Management of MRI-Identified Plantar Fibroma in a 67-Year-Old Male
For a 67-year-old male with an MRI-identified plantar fibroma, the recommended first-line approach is a conservative "watch and wait" strategy for 1-2 years, with regular MRI follow-up to monitor for progression. 1
Initial Management Approach
- A conservative "watch and wait" strategy is the recommended first-line approach for newly diagnosed plantar fibromas, regardless of whether the patient is experiencing pain or other clinical symptoms 1
- This observation period allows clinicians to understand the natural behavior of the lesion and tailor subsequent treatment steps accordingly 1
- The recommended observation period is 1-2 years with regular follow-up using contrast-enhanced MRI 1
Follow-up Schedule
- First clinical and radiologic re-evaluation should be performed within 8-12 weeks after diagnosis 1
- Subsequent evaluations should be conducted every 3 months during the first year 1
- Follow-up can then be reduced to every 6 months up to the fifth year, and yearly thereafter 1
When to Consider Active Treatment
Active treatment should be considered when:
- There is objective tumor size progression in multiple (typically three) consecutive imaging studies 1
- The patient experiences worsening pain or functional limitation 1
- The lesion shows rapid growth or compression of adjacent structures 1
When determining the need for active treatment, several factors should be evaluated:
- Initial tumor size
- Growth rate
- Anatomical location
- Risk to adjacent nerves and structures
- Functional impairment 1
Treatment Options for Progressive Disease
If the plantar fibroma shows progression during the observation period, treatment options include:
Conservative Treatments
- Steroid injections to reduce inflammation and pain 2
- Verapamil injections to inhibit collagen production 2
- Extracorporeal shock wave therapy 2
- Radiation therapy, which has shown promising results in plantar fibromas 3
Surgical Management
- Surgery should be considered only when conservative measures fail 2
- Wide excision of the fibroma with adjacent normal-appearing plantar fascia is the preferred surgical approach 4
- Patients should be informed about the high recurrence rate following surgery, which can be as high as 100% depending on the type of fasciectomy performed 3
Important Considerations
- Plantar fibromatosis is a benign condition, but it can be locally aggressive and result in pain, functional disability, and decreased quality of life 2
- Spontaneous regression occurs in approximately 20-30% of cases, which further supports the initial "watch and wait" approach 1
- Recurrence rates after surgical intervention are high, making it crucial to exhaust conservative options before considering surgery 5
- MRI is the preferred imaging modality for diagnosis and follow-up of plantar fibromatosis 1
Common Pitfalls to Avoid
- Rushing to surgical intervention before adequate trial of conservative management 2
- Performing local excision without adequate margins, which significantly increases recurrence risk 6
- Failing to recognize that plantar fibromatosis can be bilateral, requiring examination of both feet 4
- Underestimating the impact of post-surgical complications such as neuroma formation, which can lead to unsatisfactory outcomes 6