Plantar fibromatosis, also known as Ledderhose disease, is a benign but often painful condition that involves the growth of fibrous nodules within the plantar fascia — the thick band of tissue running along the bottom of the foot. These firm lumps, called plantar fibromas, are non-cancerous but can interfere with walking, cause discomfort in shoes, and significantly affect daily activities. The disease may remain stable for years or progress to involve larger areas of the foot.
How Common It Is and Who Gets It? (Epidemiology)
Plantar fibromatosis most commonly affects adults between ages 40 and 60, though it can occur at any age. It is seen more frequently in men and often affects both feet. The condition may occur alone or alongside similar fibrotic disorders such as Dupuytren’s contracture in the hands or Peyronie’s disease in men. People with diabetes, epilepsy, chronic alcohol use, or a family history of fibromatosis have a higher risk.
Why It Happens – Causes (Etiology and Pathophysiology)
The exact cause is unknown, but several contributing factors have been identified:
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Genetic predisposition: Family history strongly increases risk.
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Fibroproliferative disorders: Often associated with Dupuytren’s contracture.
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Microtrauma or repetitive stress: Chronic irritation or strain on the plantar fascia may stimulate abnormal tissue growth.
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Metabolic and endocrine factors: Diabetes, liver disease, or medications (e.g., anticonvulsants) may play a role.
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Idiopathic: Many cases develop without any clear cause.
The condition is characterized by excessive collagen deposition and fibroblast proliferation, leading to thickening of the plantar fascia and formation of nodules that may enlarge or coalesce over time.
How the Body Part Normally Works? (Relevant Anatomy)
The plantar fascia is a fibrous structure connecting the heel bone (calcaneus) to the toes, supporting the foot arch and absorbing shock during walking. In plantar fibromatosis, fibrous nodules form along this fascia, usually in the medial arch, between the heel and forefoot. When these nodules enlarge, they can press against the skin and underlying nerves, causing pain, tightness, and difficulty wearing shoes.
What You Might Feel – Symptoms (Clinical Presentation)
Symptoms vary depending on the size and number of fibromas:
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Firm lumps or nodules in the arch of the foot, typically 0.5–2 cm in size.
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Pain or tenderness when standing or walking.
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Difficulty fitting into shoes due to pressure over the fibroma.
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Tightness or limited flexibility in the foot.
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Bilateral involvement (both feet) in about 25% of cases.
The nodules are usually slow-growing and painless at first but can become tender over time as they thicken or adhere to underlying structures.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is usually made through physical examination.
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Palpation: The physician feels firm, immobile nodules along the plantar fascia.
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Ultrasound or MRI: Used to confirm the diagnosis and assess the size, depth, and extent of the fibromas. MRI shows well-defined, low-intensity lesions along the plantar fascia.
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Biopsy: Rarely needed but may be performed if malignancy or another soft-tissue mass is suspected.
Classification
Plantar fibromatosis is often classified by disease stage:
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Stage I: Small, isolated nodules.
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Stage II: Nodules coalescing into fibrous bands.
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Stage III: Advanced contracture, affecting skin and underlying muscle layers.
Other Problems That Can Feel Similar (Differential Diagnosis)
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Plantar fasciitis
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Ganglion cyst
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Lipoma or soft tissue tumor
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Neuroma (nerve tumor)
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Sarcoma (rare malignant tumor)
Treatment Options
Non-Surgical Care
Initial management focuses on reducing discomfort and preventing progression:
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Orthotics: Custom arch supports relieve pressure and redistribute weight across the foot.
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Corticosteroid Injections: May temporarily reduce pain and inflammation but do not shrink the fibroma permanently.
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Physical Therapy: Stretching, massage, and ultrasound therapy to maintain flexibility.
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Topical treatments: Verapamil gel or collagenase injections (experimental) may soften fibrous tissue.
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Footwear modification: Soft-soled or cushioned shoes with roomy toe boxes reduce friction.
Surgical Care
Surgery is considered when non-surgical treatments fail or when fibromas cause significant pain, difficulty walking, or shoe intolerance.
Surgical Options:
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Local Excision (CPT 28045):
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Removes only the fibroma.
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High recurrence rate (up to 100%).
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Wide Excision (CPT 28047):
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Removes the fibroma and surrounding fascia.
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Recurrence rate 20–65%, but may affect foot function.
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Subtotal Fasciectomy (CPT 28060):
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Removes the affected portion of the plantar fascia.
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Considered the most effective option for recurrent or extensive disease, with the lowest recurrence rates.
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Postoperative Care and Recovery
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Immobilization: A splint or walking boot is worn for 4–6 weeks to protect the surgical site.
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Weight-Bearing: Typically limited for the first few weeks, gradually increased under supervision.
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Physical Therapy: Initiated once the incision heals to restore flexibility and strength.
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Recovery Time: Full recovery usually takes 6–12 weeks, depending on the extent of surgery.
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Recurrence Monitoring: Regular follow-ups are crucial due to the high recurrence risk, especially in bilateral or hereditary cases.
Possible Risks or Side Effects (Complications)
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Wound healing problems or infection
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Skin necrosis due to extensive dissection
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Nerve injury causing numbness or tingling
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Painful scar formation
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Arch flattening after fasciectomy
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Recurrence of fibromas
Long-Term Outlook (Prognosis)
Plantar fibromatosis is benign but chronic, with recurrence rates varying widely depending on the surgical approach. Subtotal fasciectomy offers the best long-term control. Even when recurrence occurs, pain can usually be managed with supportive footwear and orthotics. Most patients regain good function and return to normal activities after recovery.
Out-of-Pocket Costs
Medicare
CPT Code 28060 – Subtotal Fasciectomy: $118.09
CPT Code 28045 – Local Excision of Plantar Fibromatosis: $110.01
CPT Code 28047 – Wide Excision of Plantar Fibromatosis: $241.84
Medicare Part B generally covers 80% of the approved cost for these procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield typically cover that remaining 20%, reducing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These supplemental plans coordinate with Medicare to fill the coverage gap and minimize patient costs.
If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it serves as a secondary payer. These plans usually cover remaining coinsurance or small deductibles, which generally range between $100 and $300, depending on your plan and provider network.
Workers’ Compensation
If your plantar fibromatosis developed or was aggravated by work-related strain or standing for long hours, Workers’ Compensation will cover all associated medical expenses, including surgery, rehabilitation, and follow-up care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly covers all approved costs.
No-Fault Insurance
If your plantar fibromatosis or foot injury is related to an automobile accident, No-Fault Insurance will typically cover the total cost of treatment, including excision or fasciectomy. The only possible out-of-pocket cost may be a small deductible or co-payment depending on your policy.
Example
Patricia Gomez had painful nodules in her plantar fascia caused by plantar fibromatosis. She underwent a subtotal fasciectomy (CPT 28060) with an estimated Medicare out-of-pocket cost of $118.09. Since Patricia had supplemental coverage through Blue Cross Blue Shield, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is Subungual Exostectomy?
A. Subungual Exostectomy is a surgical procedure to remove a bony growth (exostosis) beneath the toenail, typically caused by repeated trauma or pressure, leading to pain and difficulty walking.
Q. What causes Subungual Exostosis?
A. The condition is often caused by repeated trauma to the toe or pressure from footwear, resulting in the formation of a bony lump under the toenail. Genetic factors and certain health conditions may also contribute.
Q. How is Subungual Exostectomy performed?
A. The procedure involves making a small incision in the affected toe to remove the bony growth under the nail. In some cases, the toenail may also be partially or fully removed to access the exostosis.
Q. What is the recovery time after Subungual Exostectomy?
A. Recovery typically takes 1 to 2 weeks for initial healing, with full recovery occurring within 4 to 6 weeks. Patients are advised to protect the toe and avoid pressure on the area during the recovery phase.
Q. Are there any risks associated with Subungual Exostectomy?
A. Risks include infection, bleeding, nail deformities, recurrence of the exostosis, and damage to surrounding tissues. However, these complications are rare and can usually be managed with proper care.
Q. What is the success rate of Subungual Exostectomy?
A. The procedure has a high success rate, with most patients experiencing significant pain relief and improvement in toe function. However, there is a risk of recurrence in some cases if the exostosis is not completely removed.
Q. Can Subungual Exostectomy be done on both feet at the same time?
A. While it is technically possible to perform the procedure on both feet, it is generally recommended to treat one foot at a time to allow for proper healing and minimize the risk of complications.
Q. Will I be able to walk immediately after Subungual Exostectomy?
A. You may experience some discomfort immediately after surgery, and you will need to limit weight-bearing on the affected foot for a few days. Most patients can begin walking gently after the initial recovery phase.
Q. Will I need to wear a cast or boot after Subungual Exostectomy?
A. You may be required to wear a special shoe or boot for several weeks after surgery to protect the toe and prevent pressure on the healing area, ensuring proper recovery.
Q. Can I drive after Subungual Exostectomy surgery?
A. Most patients can drive once they are no longer taking pain medications and feel comfortable moving their foot. This typically happens after a few days to a week, depending on the individual’s healing process.
Q. Will the excised area leave a scar?
A. Yes, there will be a small scar where the incision was made to remove the exostosis, but it typically heals well and becomes less noticeable over time.
Q. How soon can I return to normal activities after Subungual Exostectomy?
A. Most patients can return to normal, non-strenuous activities within 1 to 2 weeks, but high-impact activities or those that put pressure on the toe should be avoided for several weeks.
Q. Can the excision of Subungual Exostosis affect my toenail?
A. In some cases, the toenail may be temporarily or permanently altered, especially if it is removed to access the exostosis. However, this is generally not a significant issue for most patients.
Q. Are there any long-term effects of Subungual Exostectomy?
A. The long-term effects are generally positive, with most patients experiencing relief from pain and improved toe function. However, there is a risk of recurrence, especially if the growth was not completely excised.
Q. Is physical therapy required after Subungual Exostectomy surgery?
A. Physical therapy is usually not required after Subungual Exostectomy unless there is significant post-surgical stiffness or weakness. However, patients may benefit from exercises to improve mobility and strength in the foot during recovery.
Q. What is plantar fibromatosis?
A. A benign overgrowth of fibrous tissue in the plantar fascia, forming nodules that may cause pain and discomfort in the arch of the foot.
Q. Can plantar fibromatosis go away on its own?
A. No. The nodules may remain stable or grow slowly, but they do not disappear without treatment.
Q. Is surgery always required?
A. Not always. Many cases are managed successfully with orthotics, stretching, and injections. Surgery is reserved for painful or recurrent lesions.
Q. How high is the recurrence rate after surgery?
A. Recurrence ranges from 25–100%, depending on the procedure and patient risk factors. Subtotal fasciectomy offers the lowest recurrence rate.
Q. How long will recovery take after surgery?
A. Most patients recover within 6–12 weeks but may require several months for complete healing if skin grafting is needed.
Q. Is plantar fibromatosis related to Dupuytren’s disease?
A. Yes. Both involve fibrous tissue overgrowth and may occur together, especially in individuals with a genetic predisposition.
Summary and Takeaway
Plantar fibromatosis is a benign but potentially painful condition of the plantar fascia that can limit mobility and quality of life. While non-surgical management often controls symptoms, surgery—particularly subtotal fasciectomy—may be necessary for severe or recurrent cases. Although recurrence remains a challenge, careful surgical technique and follow-up can provide lasting pain relief and improved foot function.
Clinical Insight & Recent Findings
Recent studies confirm that subtotal fasciectomy remains the most reliable surgical treatment, with recurrence rates under 40% compared to nearly 100% after local excision. Emerging therapies such as collagenase injections and radiotherapy are being studied as less invasive alternatives for early-stage disease.
Who Performs This Treatment? (Specialists and Team Involved)
Treatment is managed by an orthopedic foot and ankle surgeon or a podiatric surgeon. The care team may include a physical therapist and wound care specialist to assist in rehabilitation and recovery.
When to See a Specialist?
You should see a specialist if you notice persistent lumps in your arch, experience foot pain that interferes with walking, or cannot wear normal footwear comfortably.
When to Go to the Emergency Room?
Go to the emergency room if you experience severe foot swelling, redness, fever, or drainage after surgery, which could indicate infection.
What Recovery Really Looks Like?
Postoperative recovery involves several weeks of limited activity followed by physical therapy. Most patients regain full function within a few months, though mild stiffness or tenderness may persist initially.
What Happens If You Ignore It?
Without treatment, fibromas may enlarge, causing chronic pain, restricted mobility, and difficulty walking. However, the condition is benign and not life-threatening.
How to Prevent It?
While there is no known prevention, using proper footwear, maintaining a healthy weight, and avoiding repetitive foot trauma may reduce the risk of progression.
Nutrition and Bone or Joint Health
A balanced diet with adequate vitamin C, protein, and collagen-supporting nutrients promotes soft tissue healing after surgery. Avoid smoking, as it delays wound healing.
Activity and Lifestyle Modifications
After recovery, wear supportive shoes with cushioned soles and avoid walking barefoot on hard surfaces. Gentle stretching and maintaining foot flexibility can help prevent recurrence and maintain long-term comfort.
Dr. Mo Athar
