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Hi all,
wondering if i can pick your brains knowledge and experience of plantar fibromatosis.

Case
32 yo female mechanic develops pain in medial band of p/fascia, GP gave oral anti inflams and sent pt away, saying pt was just overweight. X-rays then obtained, no sign of spurs present. Pt having great difficulty walking at this stage, with sharp stabbing pains at med calc tubercule and along med band p/fascia, worst in the morning. New footwear obtained and pain reduced slightly in day to day work. , where pt is standing for long hours on concrete floor.

At this point, sees pod, begins strapping regime of j strap and low dye, gives great reief of syptoms, , starts exercise therapy of ice/massage, stretching. Pain continues to improve with repeatd strapping, casted for custom made orthoses, help but do not produce the same results as strapping. Pt takes two weeks off work and at end of period is pain free all day. A further review shows pain has returned and much more severe.

another x-ray is taken and small spurs are seen to be forming to both med calc tubercle and post calc. Pts GP conducts cortisone injections into both plantar calc regions, through palpation. After the second injection in the left, pt is advised to discontinue by pod

This is where I step in having consultation with pt. I have ordered an ultrasound, which showed a 11mm difference in thickness of plantar fascia from the left to the right, plantar fibromatosis, inflammmation of both plantar fascia and overlying bursitis.

A night splint was ordered for the pt before i consulted, and pt has begun to use this on a nightly basis. I have also begun weekly massage, and ultrasound regime, and monitoring of situation.

Pt is at a point she can barely bear weith on calcs, left much worse than right and at the end of her tether. I have also suggested consult with a sx to look into cortisone injection under ultrasound guidance, though am wary of this as she has already had no luck, though intial injections were only with palpation.

Can anyone suggest further ideas of intervention.. am also tossing up idea of Extracorpel wave therapy, any suggestions of where I could approach to look into this servie in Melbourne?

I appreciate any comments or suggestions you can offer.
Thanks for you time, i know it has been long winded- have a nice day!
Liz

Ultrasound is referred for and

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Hi Liz

Think I'd be looking carefully at the existing orthotic - perhaps the prescription isn't right? What foot type does she have? What other biomechanical detail can you give us? I'd also be looking into specific actions she is having to do at work ie. a lot of stamping on things etc?

E

Related threads:
Recurrence of Plantar Fibromatosis after Plantar Fasciectomy
Painful palpable midfoot lesion
Plantar fibroma

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I would get a second opinion on that. The rest of the history does not support the diagnosis of plantar fibromatosis.

If strapping helped and orthotic's didn't, then do as Ella said and re-evaluate the orthotic prescription.

looking at the foot in weightbearing, it is held well by the orthoses, though if prescribed again, i would probably use a more forgiving material.

There is no fibroma hardening to be palpated, infact not much palpation can be carried out due to the patient's discomfort. The region of more severe discomfort is just anterior to the med calc tubercle, in the med band of p/fascia. Increasing the rearfoot inversion was tried, without success in terms of pain reduction, the patient was unable to bear weight.

No specific work actions have been elicited apart from standing on concrete floors for long periods in the workshop.

Hi Liz:
Classically, plantar Fibromatosis means having fibromas (one or more) on the plantar aspect, i.e., a well circumscribed, often intra-fascial, fibrous mass. These are quite common and I'm sure we've all seen them.

I think it is inaccurate to refer to a fibrosed plantar fascia as plantar fibromatosis.

That being said, chronic fasciitis does not always (contrary to some opinions) respond to orthotic therapy. Frequently there comes a point when all conservative treatments have been tried and the patient wants a cure.

ECSW, endoscopic fasciotomy, MIS procedures, flouroscopic aided fasciotomy/spur resection, etc..... are all treatment options.

Steve

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Thankyou, yes, i am in agreeance the diagnosis is not fully supported by the evidence, it was an ultrasonographer who used the term, I have had minimal experience with these cases and any outside the 'norm' of diagnostic signs and symptoms.

Will take it further regading diagnostic examination.
Thanks for your help

Hi Liz,

Does this mean the prescription is appropriate? Good visual alignment (kinematics) does not necessarily suggest that the pathological force within the injured structure is being addressed (kinetics). Perhaps some more information on the dynamic foot function with/without orthoses?

Ian