Ledderhose disease: Causes, Symptoms, and Treatment

Ledderhose disease is a benign disease of the connective tissue of the feet. It occurs in the area of the plantar aponeuroses (= Latin term for the tendon plate of the sole). More precisely, it is a thickening of the deep connective tissue or fascia of the foot. Ledderhose disease belongs to the clinical picture of fibromatosis and is also related to Dupuytren’s disease, which is a benign disease of the connective tissue of the palm.

The nodes on the soles of the feet usually grow very slowly and are almost always centered on the plantar fascia (sole). Occasionally the growth of the nodes is delayed, and they do not grow any further. Then they can suddenly grow again rapidly and unexpectedly. A surgical intervention is only necessary in the case of painful nodes that hinder walking.

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Causes of the ledderhose disease

The causes of the disease have not yet been fully clarified. It is known that the protrusion on the sole is caused by an increase in connective tissue in the affected area. More precisely, individual cells, the myofibroblasts, are responsible for this.

There are several different theories and assumptions about which factors can influence the occurrence of Ledderhose disease. It is considered likely that a genetic component plays a role in the disease. Connective tissue changes occur when external factors such as injuries or other events of unknown nature are added. The fact that men are affected about twice as often as women also suggests a genetic influence.

Further risk factors are the simultaneous presence of other fibromatoses – especially in Dupuytren’s disease – as well as specific diseases such as diabetes mellitus or epilepsy.

There are also some different factors whose significance in the development of the disease has not yet been proven, although indications of this have been found in individual cases. These include, in particular, the consumption of stimulants such as nicotine and alcohol as well as stress, and certain metabolic and liver diseases.

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Symptoms of the ledderhose disease

With Ledderhose disease, the ability to walk is usually impaired. This is because the nodes are located on the sole, especially at the highest point of the arch of the foot in the middle of the sole. There can be only one knot, but also several knots and strand formations. If these are pronounced and distributed over the entire sole, the nodes are usually firmly attached to the muscles and the skin above them. In contrast, only a small part of the plantar fascia is affected in the mild form of Ledderhose disease, and neither the skin nor the muscles show adhesions. Approximately 25% of those affected have Ledderhose disease on both feet.

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Diagnosis

The diagnosis of Ledderhose disease begins with the patient’s medical history. Due to the complaints that typically occur when walking, which are often the first thing the person concerned notices, as well as the physical examination, the attending physician can often already make a suspected diagnosis of Ledderhose disease.

During the examination of the foot, relatively hard knots are noticeable, which are difficult to move with the hand. Diagnostic imaging equipment is used to determine the actual size of the nodes. Especially the performance of an ultrasound examination can be carried out in many practices of general practitioners. Images can also be produced with a magnetic resonance tomography (MRT) to obtain a more precise picture of the individual spread of the nodules.

Absolute certainty about the presence of Ledderhose disease can be obtained by microscopic examination of the nodes. The examined material can be taken by biopsy or during surgery to remove the nodules and examined by a specialist in pathology.

Imaging

In the magnetic resonance tomogram, the typical Ledderhose knot disease appears as a poorly defined, infiltrating mass in the tendon plate near the sole muscle.

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MRI of the foot

To exclude possible differential diagnoses of nodular changes in the foot, a magnetic resonance imaging examination, i.e., an MRI of the foot, is indicated. The MRI is particularly well suited for imaging soft tissue. Since the nodular changes in Ledderhose disease are connective tissue cell material, this can be recognized as a mass of space starting from the tendon plate of the foot (plantar aponeurosis) in the MRI. The signal intensity can be assessed in different sequences. In the possible sequences, the connective tissue-like change is poor in signal, i.e., dark, in comparison to the surrounding tissue. Furthermore, it can be seen that the fibromatous structure grows to infiltrate, i.e., pulling into surrounding structures such as muscles, tendons, fat, and skin. If contrast medium is additionally injected, an even contrast medium enrichment of the tissue can be observed.

Which doctor should I see?

As a rule, when symptoms occur for the first time or when the tumor on the sole is noticed without symptoms, the general practitioner is consulted, as the layman usually does not know what this connective tissue change may be. Depending on experience and the equipment of imaging devices (ultrasound), the family doctor can make the diagnosis himself.

For a more precise clarification, he can also issue a referral for an MRI to a radiologist (radiologist), who can ultimately confirm the diagnosis using the images. The family doctor can also be consulted for conservative therapeutic measures.

Depending on the further treatment, the nodular alteration must be surgically removed by a surgeon. These are usually foot surgeons, who operate in-patients but often also as out-patients. Since foot surgery is a specialty, it is recommended to have the operation performed in a specialized clinic.

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Therapy of the ledderhose disease

An essential guideline in the treatment of Ledderhose disease is to inhibit the inflammation and pain, as well as to maintain the ability of the affected person to walk.

Soft insoles can be prescribed, which can prevent the internal pressure on the nodes. For the inflammation and pain, non-steroidal anti-inflammatory drugs are often prescribed, as well as steroid injections into the nodes.

In the early stages, radiotherapy with soft X-rays often shows good results. Furthermore, therapy with shock waves or the injection of collagenases, which are supposed to loosen the hardened nodules, has also brought good results.

In the case of existing complaints and advanced stages, Ledderhose disease requires surgery. Radical removal of the plantar fascia is often recommended, as even faster-growing nodes often reappear with minimal surgery. However, it must also be explained to the affected person that the possibility of a return of fibromatosis is 25%. Besides, the risks of an operation on the sole must be explained. Nerves, muscles, and vision are close together and could be injured.

Irradiation

The use of radiotherapy in the treatment of Ledderhose disease is particularly widespread in the early stages. The effectiveness of radiotherapy has been shown in several studies.

Concerning the radiation used, a distinction must be made between two different forms of radiation. Mild X-rays (orthovoltage therapy) and electron beams are used.

The radiation energy used in these treatments of Ledderhose disease is only a fraction of that used for malignant, solid tumors, for example. Nevertheless, there is a particular risk for the treated person, which is why, as a rule, only persons over 45 years of age receive radiation therapy.

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Operation of the ledderhose disease

If conservative therapy does not help, the nodes can be removed surgically.

The treatment options for Ledderhose disease can be divided into conservative and surgical treatment options. If conservative methods are not successful, surgery may be considered.

There are two different options for operating on the nodes on the sole. On the one hand, only the nodes can be removed. This initially provides freedom from symptoms but is associated with a high probability that further, even more, aggressive and larger nodes will develop in the course of the operation. The probability of recurrence with this type of removal is up to 85%.

The second possibility is the removal of the nodules and the simultaneous removal of the so-called plantar fascia (plantar fasciotomy). This fascia is a tendon plate which is located on the sole and is the starting point for the development of the nodes. But even after the removal of the plantar fascia, recurrences can occur. The probability of recurrence after this operation is about 25%.

Since the probability of recurrence is much lower, many doctors advise the latter when choosing between the two operations. This is also because the recurrences that occur are more aggressive, and a second operation has a higher risk of complications due to the scar tissue that has formed.

It should be mentioned, however, that the removal of the plantar fascia is not without consequences for the affected person. Thus, further complaints can occur while walking, which the attending physician must inform about before the operation is performed.

If the connective tissue growths so severely damage the skin that it must be removed over a large area, it may be necessary to perform a skin transplant on the sole.

In both operations, the affected foot should be protected for up to three weeks. On the one hand, this is necessary to allow the wound to heal as quickly as possible and to reduce the probability of recurrence.

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Homeopathy

In addition to the classical treatment approaches, such as conservative or surgical care and radiotherapy, homeopathy is becoming more and more popular. With different homeopathic remedies, homeopathy aims above all at relieving pain and inflammation.

One substance that is supposed to help in the homeopathic treatment of Ledderhose disease is formic acid (Acidum formicicum). The treatment involves injecting the formic acid in the area of the plantar aponeurosis, i.e., at the site of manifestation. Patients describe this procedure as very painful, but it must be repeated several times for the therapy to be successful. Currently, however, there are no studies that confirm the benefit or effectiveness of homeopathic treatment. Therefore, if the therapeutic benefit is insufficient and the pain during the application of formic acid injections is too severe, it is not uncommon for patients to resort to drug or surgical treatment.

Healing of the ledderhose disease

M. Ledderhose is a benign connective tissue proliferation that can be treated with various therapeutic approaches. Conservative treatments make it possible to prevent or even eliminate the progression of the nodular growths.

However, M. Ledderhose has the characteristic to appear in relapses and to follow a progressive (= progressing) course. This means that even after successful therapy and after phases of freedom from symptoms, a new episode occurs, and the nodular changes become symptomatic again. Even surgical removal cannot provide a lifelong guarantee that the disease will not reoccur. The recurrence rate is very high, as with the similar clinical picture of Dupuytren’s disease.

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Risk factors

Why Ledderhose disease occurs at all is unfortunately still not known precisely. At present, there are already defined risk factors that favor the occurrence of plantar fascial fibromatosis.

These include:

  • Familial frequency of the disease
  • Gender (men are more often affected than women)
  • Fibromatosis in hand (thus the risk increases to 10-65%)
  • Peyronie’s disease
  • Epilepsy
  • Diabetes mellitus
  • Other factors with no direct link: smoking, alcoholism, liver disease, thyroid disease, stress.

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Analogies to Dupuytren’s disease

The clinical picture of M. Ledderhose, just like Dupuytren’s contracture, belongs to the group of benign connective tissue growths, the so-called fibromatosis. Ledderhose disease is a connective tissue disease of the tendon plate (aponeurosis) of the feet, the plantar aponeurosis. Similarly, the disease on the hands is called Dupuytren’s disease and affects the tendon plate of the hand, the palmar aponeurosis.

What both have in common is that it is a benign, connective tissue proliferation that can grow into the surrounding tissue and is primarily based on the proliferation of specialized cells called myofibroblasts. Also, both diseases have a high risk of recurrence after surgical removal, i.e., even after complete removal, the nodular changes can recur again and again.

A third related disease affects the penis and is called “Peyronie’s disease,” a scarring of specific skin layers, which is associated with a painful curvature of the penis during erection and the risk of erectile dysfunction.

Of the 3 fibromatoses mentioned above, Dupuytren’s contracture is the most common and best known clinical picture. Despite the many similarities, M. Ledderhose and M. Dupuytren differ in a few aspects. On the one hand, Dupuytren’s disease leads to an inhibition of stretching of the fingers, hence the synonym Dupuytren’s contracture (contracture = shortening of muscles and tendons). However, this symptom does not occur on foot, as the toes are usually not affected to this extent. On the other hand, the nodular changes in the plantar aponeurosis of the foot tend to be much larger than those in the palmar aponeurosis of the hand.

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