Initial Treatment for Plantar Fascia Fibromatosis
The initial treatment for plantar fascia fibromatosis (Ledderhose disease) is active surveillance with clinical and radiologic monitoring, combined with conservative symptomatic management including appropriate footwear, physiotherapy, and pain control. 1
Treatment Algorithm
First-Line Approach: Active Surveillance and Conservative Management
The most recent high-quality guidelines from the British Journal of Cancer (2025) establish that active surveillance with regular MRI scans and clinical review is the standard first-step management for fibromatosis, given its unpredictable natural history with potential for spontaneous regression and lack of metastatic potential. 1
Conservative measures to implement during surveillance include:
- Appropriate footwear that accommodates foot shape to relieve pressure on nodules 2
- Physiotherapy with structured exercise programs targeting the foot and ankle over 8-12 weeks under professional supervision 2
- Pain management with nonsteroidal anti-inflammatory drugs 3, 4
- Orthotic devices to redistribute plantar pressure 3, 4
- Avoidance of barefoot walking or thin-soled footwear to prevent symptom aggravation 2
When to Escalate Treatment
Treatment escalation is reserved specifically for progressive disease with worsening symptoms or functional impairment. 1 The rationale for this conservative initial approach is that plantar fibromatosis is a benign condition with variable behavior—some cases remain stable or even regress spontaneously, making aggressive early intervention unnecessary and potentially harmful. 1, 4
Additional Conservative Options for Symptomatic Cases
If symptoms persist despite initial conservative measures but disease is not clearly progressive, consider:
- Corticosteroid injections locally into symptomatic nodules 3, 4
- Verapamil injections (calcium channel blocker with antifibrotic properties) 4
- Collagenase injections 4
- Extracorporeal shock wave therapy 4
- Tamoxifen (hormonal therapy with antifibrotic effects) 4
- Radiation therapy for critical sites where other options have failed 1
Diagnostic Imaging During Initial Management
Ultrasound is the reasonable and cost-effective initial imaging modality for patients whose pain persists beyond three months despite treatment. 2 MRI provides superior characterization of the plantar fascia and adjacent soft tissues and bone, and is recommended for surveillance monitoring. 1, 2
Critical Pitfalls to Avoid
Do not rush to surgery as initial treatment. The evidence strongly supports that surgery should be reserved for cases failing conservative management, as recurrence rates after surgical excision can reach 60%, with increased risk of complications and more aggressive tissue ingrowth after partial resection. 3, 5, 6 Even when surgery becomes necessary, the timing and extent require careful consideration—complete fasciectomy may be preferable to partial excision to reduce recurrence risk. 3, 5
Do not confuse plantar fibromatosis with plantar fasciitis. While both affect the plantar fascia, fibromatosis involves nodular fibrous proliferation requiring different management than the inflammatory condition of fasciitis. 4
Ensure genetic screening is considered. In younger patients, male gender, or those with family history of cancer, investigate for familial adenomatous polyposis (FAP) or Gardner syndrome, as plantar fibromatosis can be associated with germline APC mutations. 1
Monitoring During Initial Treatment
Daily foot examination is essential, particularly in patients with diabetes or other risk factors for ulceration. 2 Clinical reassessment should occur at regular intervals (typically every 3-6 months) to evaluate for disease progression, symptom burden, and functional impairment. 1