53-year-old female presented with painful (VAS: 5) palpable nodular thickening along the plantar aspect of the left foot. No progressive increase in size and mild functional limitation.
Ultrasound examination of the plantar foot demonstrates multiple sharply demarcated, oval, hypoechoic nodular thickenings within the plantar fascia.
The lesions are entirely confined to the plantar fascia, without extension into or infiltration of the adjacent soft tissues. There is no disruption of the surrounding tissue planes.
Colour Doppler examination shows no internal or peripheral neovascularisation.
The multifocal distribution, oval morphology and characteristic intrafascial location are consistent with multifocal plantar fibromatosis. There are no sonographic features suggesting invasive growth or an aggressive soft-tissue lesion.
The patient was advised to monitor the size of the nodules and to seek reassessment if the lesions increase in size or if new symptoms develop.
1. Final diagnosis
Multifocal plantar fibromatosis, consistent with Ledderhose disease, without sonographic evidence of invasive growth or increased vascularity.
2. Differential diagnosis
The characteristic intrafascial location, oval morphology and multiplicity make an alternative diagnosis less likely. In an atypical clinical course, focal nodular fasciopathy or another benign soft-tissue lesion may be considered. A malignant soft-tissue tumour is unlikely given the sharply defined, non-invasive appearance and absence of increased vascularity.
3. Teaching points
Plantar fibromatosis typically appears as one or more hypoechoic nodules arising within the plantar fascia. Careful assessment of lesion margins, adjacent soft tissues and Doppler vascularity is important to identify atypical or potentially aggressive features. MRI should be considered in cases of rapid growth, neurological symptoms, skin changes, atypical ultrasound findings or suspected extension beyond the plantar fascia.
4. Injury/disease information
Ledderhose disease is a benign fibroproliferative disorder of the plantar fascia. Asymptomatic or mildly symptomatic lesions are generally managed conservatively with patient education, pressure relief, appropriate footwear and, when required, pressure-distributing insoles. Persistent pain or functional impairment may warrant referral to a specialist foot and ankle team. Ultrasound-guided intralesional corticosteroid injection may be considered, although supporting evidence is limited. Radiotherapy may be an option for progressive and painful disease in a specialised treatment centre.
Marc is founder of, and trainer at, SonoSkills. SonoSkills is an organization dedicated to MSK ultrasound education. He's also an MSK Sonographer at EchoConsult in Roermond, the Netherlands.
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