Plantar Fibroma
In this episode of The PODdoctors podcast, Dr. Damien Dauphinee, a board-certified foot and ankle surgeon, and Dr. Raafae Hussain, a fellowship-trained foot and ankle surgeon, discuss plantar fibromas, benign tumors that form in the plantar fascia of the foot. The doctors discuss the characteristics, causes, and treatment options for these growths, emphasizing that while they can cause discomfort, they are typically not a cause for alarm. The conversation covers various diagnostic methods, including ultrasound and MRI, and explores conservative and surgical treatment approaches. Listeners will gain insights into the importance of addressing these fibromas before they lead to more serious complications, as well as the nuances of surgical intervention when necessary.
Top Takeaways:
- The evolution of advanced therapies for diabetic limb preservation showcased a significant increase in treatment options over the last two decades.
- Plantar fibromas, while often benign, can cause significant discomfort and should be evaluated through careful examination and imaging techniques like ultrasound.
- Treatment for plantar fibromas often begins conservatively with physical therapy and may escalate to injections or surgical options if necessary.
- Understanding the potential for benign versus malignant processes is crucial in managing plantar fibromas effectively and safely.
- The importance of proper post-operative care and rehabilitation after surgical removal of plantar fibromas cannot be overstated for optimal recovery.
Resources:
Visit our website: https://thepoddoctors.com/
Transcript
The POD Doctors is brought to you by the Kindle book Saving Limbs, Saving Lives.
Dr. Damian Dauphine:Advanced treatments to prevent amputations in diabetic Populations.
Dr. Damian Dauphine:This book by Dr.
Dr. Damian Dauphine:Damien Dauphine discusses specific patient cases in diabetic limb preservation which highlight the modern use of wound care technology that has exploded in the last 20 years.
Dr. Damian Dauphine: advanced therapy available in: Dr. Damian Dauphine:Dr.
Dr. Damian Dauphine:Dauphine distills these options down to show patients and physicians treating these patients how combinations of these products can be used to save limbs and save lives.
Dr. Damian Dauphine:Welcome to the Pod Doctors.
Dr. Damian Dauphine:I'm Dr.
Dr. Damian Dauphine:Damian Dauphine, board certified foot and ankle surgeon and my partner Dr.
Dr. Damian Dauphine:Rafa Hussain, fellowship trained podiatric surgeon.
Dr. Damian Dauphine:And we are the POD Doctors.
Dr. Damian Dauphine:Each week the POD Doctors will be discussing aspects of podiatric medicine and surgery to educate our audience on common foot and ankle problems and the latest treatment options available.
Dr. Damian Dauphine:We hope to bring you interesting and informative shows each week discussing all the crazy ways that our wonderful foot can malfunction and cause us problems.
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Dr. Rafa Hussain:Welcome to the Pod Doctors.
Dr. Rafa Hussain:I'm Dr.
Dr. Rafa Hussain:Damian Dauphine and I'm here.
Dr. Unknown:With my partner Dr.
Dr. Unknown:Rafi Hussain.
Dr. Rafa Hussain:And we're going to talk about the dreaded plantar fibroma.
Dr. Rafa Hussain:It's not a tumor.
Dr. Rafa Hussain:No, it actually is a tumor.
Dr. Rafa Hussain:Maybe benign.
Dr. Unknown:Benign.
Dr. Rafa Hussain:That, you know, these things pop up.
Dr. Rafa Hussain:They can be part of palmar and plantar fibromatosis where you have it on both.
Dr. Rafa Hussain:Some people get trigger finger.
Dr. Rafa Hussain:They can also get these in their arch.
Dr. Rafa Hussain:But they're painful when they're big enough.
Dr. Rafa Hussain:Some people notice them and they come in and it's not a big deal because it's the size of a pea.
Dr. Rafa Hussain:Yeah.
Dr. Rafa Hussain:But when they get big enough, they start putting pressure on sensory nerves and they become quite, quite tender.
Dr. Unknown:Yeah, it's like you're walking on a marble.
Dr. Unknown:A lot of times patients will come in and be like, I got this new bump in the bottom of my foot that I've notice over the last few months.
Dr. Unknown:I'm concerned.
Dr. Unknown:Is it something I should be worried about?
Dr. Unknown:You know, we'll go through our exam, we'll go through our X rays, we'll go through everything.
Dr. Unknown:But most of the times these are just your classic plantar fibromas which are just A benign fibrous tissue knot in the plantar fascia.
Dr. Rafa Hussain:And we can't know absolutely whether or not these are benign or malignant unless we biopsy them.
Dr. Rafa Hussain:But having said that, primary malignancies in the foot are very rare, and these are almost always a benign process.
Dr. Rafa Hussain:Yeah, so that's just the caveat there.
Dr. Rafa Hussain:The disclaimer is we can't know for sure unless we actually take some tissue, send it to pathology, let them study it.
Dr. Unknown:Yeah, sometimes they'll have them bilaterally.
Dr. Unknown:They're literally, like I said, a scar tissue knot.
Dr. Unknown:It could be due to overuse, it could be due to trauma.
Dr. Unknown:It could just be genetics.
Dr. Unknown:We don't really know exactly why they form, but you know what to treat them.
Dr. Unknown:Imaging.
Dr. Unknown:So a lot of patients are like, oh, can we get X rays and see what's going on?
Dr. Unknown:We'll get X rays, but it's a soft tissue pathology, and very rarely do you see it on X rays unless it's like, calcified or something extreme.
Dr. Unknown:But 99% of the time, you're barely seeing a shadow on the X rays.
Dr. Unknown:But we have ultrasound in office, in which most clinics do, we can get an ultrasound, see exactly what it is, and you'll see it in line with the plantar fascia.
Dr. Unknown:We'll do our full exam.
Dr. Unknown:And, yeah, they're usually benign.
Dr. Unknown:And if we need to, we can get more aggressive with treatments, but we start off with simple things.
Dr. Unknown:And if you don't have ultrasound in your office, you can get MRIs and such also.
Dr. Rafa Hussain:Well, you know, an MRI is nice to be able to study the density.
Dr. Rafa Hussain:You get a better idea of what it's made of.
Dr. Rafa Hussain:Just make sure that it's not affecting bone because the bone will light up.
Dr. Rafa Hussain:If this was some sort of invasive sarcoma, you'd see it investing into the other tissue layers or into other tissues like bone and muscle.
Dr. Rafa Hussain:So this clearly is well encapsulated.
Dr. Rafa Hussain:It's pushing on those tissues, but it's not invested in those tissues.
Dr. Rafa Hussain:Yeah, generally that would be considered a benign process.
Dr. Unknown:Yeah.
Dr. Unknown:And the reason this is white and this is black is just based on the type of MRI we did here.
Dr. Unknown:This is a T1, this is a T2.
Dr. Rafa Hussain:Right.
Dr. Rafa Hussain:So you're blocking out the water content.
Dr. Rafa Hussain:Yeah, the fat.
Dr. Rafa Hussain:The fat is being blacked out.
Dr. Rafa Hussain:So then you're going to show inflammation better that way.
Dr. Unknown:All right, so simple treatments.
Dr. Unknown:Right.
Dr. Unknown:Initially, we'll start off with pretty much kneading the area on the patient's end.
Dr. Unknown:I'm not going to do the area for you, you can do your hands, you can do your thumbs, you can use tools, spoons, the back of a wooden label, you can use those massage guns.
Dr. Unknown:Some people like to do it on a golf ball, but the goal being that you're breaking down that fibrous tissue so the body can lay down new straight collagen so it comes out nice and straight and hopefully fades away into the background.
Dr. Unknown:This is easier said than done because a lot of these do tend to be a little painful to push on there quite often.
Dr. Unknown:We'll recommend simple stretching exercises.
Dr. Unknown:Also, like I said, it's in line with your plantar fascia.
Dr. Unknown:So if your plantar fascia keeps on dropping, right, and you're putting micro tears in the fascia bands, that can be one of the causes for getting that fibrom to form there.
Dr. Unknown:So the same stretches that you do for your plantar fasciitis, you can do for your plantar fibroma.
Dr. Unknown:So there's insoles, there's night splints, there's heel rockers that you can use to help out with the stretching and support.
Dr. Unknown:So the plantar fascia aspect of this does not play a part.
Dr. Rafa Hussain:That's.
Dr. Rafa Hussain:And as far as the orthotics are concerned, sometimes it's difficult because it ends up putting pressure on the, on the lesion, which makes things worse.
Dr. Rafa Hussain:But you could do things like Plastazote, which is a foam that will mold around prominences, heat mold itself.
Dr. Rafa Hussain:Just the, the daily wear of those can be helpful.
Dr. Rafa Hussain:So I've done that from time to time.
Dr. Rafa Hussain:But yeah, just the regular polypropylene orthotics usually makes this worse.
Dr. Rafa Hussain:Yeah, they just, they have too much discomfort.
Dr. Unknown:All right.
Dr. Unknown:The stuff that we do on our end.
Dr. Unknown:So quite often we'll inject these.
Dr. Unknown:Steroids will help shrink these away.
Dr. Unknown:The goal being that we're breaking down that fibrous tissue in there and you'll see we'll typically pierce it a couple of times.
Dr. Unknown:We're not just dropping steroid around it, we're trying to pierce it, which will hopefully add to the breaking down of that fibrous tissue.
Dr. Unknown:We have the ultrasound in the office, so we do them ultrasound guided and we make sure that we hit that.
Dr. Unknown:Exactly.
Dr. Unknown:Steroids the doctors will use is very user dependent.
Dr. Unknown:Typically in our office we like to use dexamethasone and Kenalog 40.
Dr. Unknown:It works well.
Dr. Unknown:The kenalog especially, it's crystalline.
Dr. Unknown:I'll get into that fibroma and hopefully add to the breakdown process and it lasts longer.
Dr. Unknown:Too.
Dr. Unknown:And sometimes it takes a shot, sometimes it takes a series.
Dr. Unknown:I don't know.
Dr. Unknown:What do you do?
Dr. Unknown:Three to five shots if needed.
Dr. Rafa Hussain:Yeah.
Dr. Rafa Hussain:I mean, I would do at least two if they wanted to go that route.
Dr. Unknown:Yeah.
Dr. Rafa Hussain:You know, and then there, you know, there are off label uses of the collagenases I think you're going to get into.
Dr. Unknown:Yeah, exactly.
Dr. Rafa Hussain:So the Xiao Flex stuff, so that stuff's really approved for the hand.
Dr. Rafa Hussain:None of these have been approved for the foot.
Dr. Rafa Hussain:But it's the same process.
Dr. Unknown:Yeah.
Dr. Rafa Hussain:So the.
Dr. Rafa Hussain:That's an easy way for the insurers to not pay for it.
Dr. Unknown:It's experimental at this point.
Dr. Rafa Hussain:These can work.
Dr. Rafa Hussain:And the downside is they're like two or three thousand dollars.
Dr. Rafa Hussain:I don't know that they've come down in price tremendously in the last year.
Dr. Rafa Hussain:It's probably the last time I actually looked at the price.
Dr. Rafa Hussain:But they tend to price people out who want to use it off label.
Dr. Unknown:Yeah.
Dr. Rafa Hussain:The topical verapamil.
Dr. Rafa Hussain:There's a pharmacy in San Antonio that has created a sort of a proprietary version of topical verapamil.
Dr. Rafa Hussain:It's calcium channel blocker.
Dr. Rafa Hussain:And the theory is that it'll.
Dr. Rafa Hussain:It'll help break down the fibroma and help it remodel.
Dr. Rafa Hussain:I've seen that work in some cases.
Dr. Unknown:Yeah.
Dr. Rafa Hussain:Has it been like this amazing go to.
Dr. Rafa Hussain:No, no.
Dr. Unknown:Extracorporeal shockwave therapy.
Dr. Rafa Hussain:Another thing that can help in some cases.
Dr. Rafa Hussain:I guess.
Dr. Rafa Hussain:Haven't seen tremendous results with that.
Dr. Unknown:Yeah.
Dr. Unknown:Plus you have to invest in this giant machine that isn't covered by insurance and it's a hit or miss.
Dr. Unknown:I think it works great for certain things, but I don't have one.
Dr. Unknown:I couldn't tell you from personal use.
Dr. Unknown:According to literature, it works decent.
Dr. Rafa Hussain:I mean, and then, you know, exciting these surgically and I think we're surgeons, that's what we do for a living.
Dr. Rafa Hussain:I've had good success in removing these.
Dr. Rafa Hussain:Sometimes you have to do that radical fasciectomy where you're taking the.
Dr. Rafa Hussain:Almost the entire plantar fascia out.
Dr. Unknown:So this incision is much bigger than what you'll see Dr.
Dr. Unknown:D or I do.
Dr. Unknown:You'll see us get to the end roughly a little bit shorter than what the actual size of the mass is.
Dr. Unknown:And you just tent the skin and you take the samples.
Dr. Unknown:Now the key thing is when we take these samples, we'll send them off for pathology and we'll label, you know, north, south, east, west, we do with sutures and we'll send them off.
Dr. Unknown:God forbid.
Dr. Unknown:This comes back as something questionable.
Dr. Unknown:They'll let us know what margins are clean and which margins are dirty.
Dr. Unknown:So when we, you know, have to go back in or send them to oncology or whatever it might be, they'll know, hey, look, the proximal margin and the medial lateral border came back clean, but the distal margin came back questionable.
Dr. Unknown:And it doesn't look like you excised the whole thing, whatever it might be.
Dr. Unknown:So they can take over from there.
Dr. Unknown:They're not completely starting from scratch all over again.
Dr. Rafa Hussain:Thankfully, I've never had one of these.
Dr. Unknown:Yeah, knock on wood.
Dr. Unknown:Yeah.
Dr. Rafa Hussain:They have always been benign plantar fibroma.
Dr. Rafa Hussain:That one in the middle looks really weird.
Dr. Rafa Hussain:Like that one.
Dr. Rafa Hussain:I would be worried about that one.
Dr. Unknown:I don't know about Dr.
Dr. Unknown:D, but I will put a graft over that area to prevent any adhesions or anything afterwards.
Dr. Unknown:So right underneath this layer is your muscles.
Dr. Unknown:And the last thing we want to do is cause that muscle to skin adhesion.
Dr. Unknown:If you've seen anyone who've had really bad trauma or car accidents or anything like that, fractures where the skin was compromised and then they get that adhesion of the skin.
Dr. Unknown:So when they move their tissue, you can see the skin move with them.
Dr. Unknown:That's what we're trying to avoid.
Dr. Unknown:So quite often I'll put a graft, I'll use an umbilical cord or something along those lines.
Dr. Unknown:And I'll literally just put some tiny tags in over the size of the wound.
Dr. Unknown:I mean, sorry, the size of the fibromyalgia that excised.
Dr. Unknown:And then I'll just stitch it in observable stitches and then eventually it'll incorporate itself and hopefully.
Dr. Rafa Hussain:I totally agree.
Dr. Rafa Hussain:I do that as well.
Dr. Rafa Hussain:I think the benefits of the umbilical cord are unique.
Dr. Rafa Hussain:Whether it's the dehydrated version of the crowd preserved version.
Dr. Rafa Hussain:I.
Dr. Rafa Hussain:If I can use the crowd preserved version, I like that better because it's got stem cells and lots of growth factors.
Dr. Rafa Hussain:But I think covering the muscle layer where you've got the nerves and I know you're going to get into that.
Dr. Rafa Hussain:Oh, yeah.
Dr. Rafa Hussain:Probably right after this, that happens.
Dr. Rafa Hussain:Yeah.
Dr. Rafa Hussain:So those.
Dr. Rafa Hussain:You're exposing the medial lateral plantar nerve.
Dr. Rafa Hussain:If you're doing a complete fasciotomy.
Dr. Unknown:Yeah.
Dr. Unknown:This is the tarsal tunnel here, coming down to your toes.
Dr. Unknown:And if you imagine if you're taking a fibroma along that medial band or that lateral band, you're exposing that nerve, you'll see the nerve.
Dr. Unknown:And I have had one or two patients who have had the fibromyalgia excised and talk about that.
Dr. Unknown:They still have nerve pain or whatever.
Dr. Unknown:Not from us.
Dr. Unknown:Yeah, from other.
Dr. Rafa Hussain:Somebody bagged the nerve.
Dr. Rafa Hussain:Yeah.
Dr. Rafa Hussain:And it's very easy to do because the nerve is literally on the other side.
Dr. Unknown:It's literally touching that fibromyalgia.
Dr. Unknown:Yeah.
Dr. Rafa Hussain:So, yeah, it's not a.
Dr. Rafa Hussain:It's not a benign process taking that fascia out.
Dr. Rafa Hussain:And it does have a.
Dr. Rafa Hussain:It does have a.
Dr. Rafa Hussain:Have a purpose.
Dr. Rafa Hussain:I mean, it's a suspension bridge.
Dr. Unknown:Yeah.
Dr. Rafa Hussain:So I would imagine that when you have to do a radical fasciactomy, you're probably putting those people in orthotics trying to.
Dr. Rafa Hussain:Yeah.
Dr. Rafa Hussain:So the.
Dr. Rafa Hussain:I think the goal would be you need to start to think about the biomechanical repercussions of taking that structure out.
Dr. Rafa Hussain:There are certainly biomechanical repercussions and you can jump all over that by getting people into custom orthotics now that the fibroma's gone.
Dr. Rafa Hussain:They're going to tolerate those better once the incision heals.
Dr. Unknown:Yeah, the incision, that's another point.
Dr. Unknown:The incision's on the bottom of your foot.
Dr. Unknown:So we really have to be careful on our closure.
Dr. Unknown:We don't want to put anything aggressive.
Dr. Unknown:Stitches.
Dr. Unknown:You'll see that.
Dr. Unknown:We'll put smaller stitches, but a lot more because we really want that edge to edge healing so you don't get a hypertrophic scar or keloid.
Dr. Rafa Hussain:But having said that, the thick skin on the bottom of the foot heals beautiful.
Dr. Unknown:It does.
Dr. Rafa Hussain:If you put it together correctly, it heals great.
Dr. Rafa Hussain:You can barely even find these scars.
Dr. Rafa Hussain:Yeah, I like that big lazy ass.
Dr. Unknown:Lazy ass style.
Dr. Rafa Hussain:Yeah, that's my favorite.
Dr. Unknown:I try to trace some of the skin lines in the foot.
Dr. Unknown:Yeah.
Dr. Unknown:The lines here still be lazy.
Dr. Rafa Hussain:You're going to violate them no matter what you do.
Dr. Unknown:Yeah.
Dr. Unknown:I don't do straight incisions along the bottom of the foot because that.
Dr. Unknown:You're just asking for a thicker scar.
Dr. Rafa Hussain:Yeah, I totally agree with you.
Dr. Unknown:But yeah, these, if you do them right, they heal up.
Dr. Unknown:And I know some people are like, oh, a scar on the bottom of the foot, we really try to avoid it, which is true.
Dr. Unknown:But if you do them right, and.
Dr. Rafa Hussain:Typically we're leaving this particular scar in the arch between the heel.
Dr. Rafa Hussain:Weight bearing heel and weight bearing ball of the foot.
Dr. Unknown:Yeah.
Dr. Rafa Hussain:So, yeah, you're.
Dr. Rafa Hussain:You're typically going to be able to ambulate without putting direct pressure on that scar.
Dr. Rafa Hussain:Unless you have an incredibly flat foot.
Dr. Unknown:Recovery, your per doctor, you'll be partial weight bearing or completely weight off weight bearing for the first few weeks.
Dr. Unknown:Once that incision heals, then you're back to normal.
Dr. Unknown:I typically say a week to three weeks.
Dr. Unknown:You're just doing protective weight bearing to my patients.
Dr. Unknown:Depends on, you know, how big the incision has to be also and, and the, the gravity of it all.
Dr. Rafa Hussain:I'm keeping them off of it for probably three to five days with crutches or a knee scooter.
Dr. Unknown:Yeah.
Dr. Rafa Hussain:And then once you've given the skin kind of a head start, then they can start being a little more weight bearing on it.
Dr. Rafa Hussain:But yeah, these typically heal up, heal up great.
Dr. Rafa Hussain:So the, I think the catch all take home is that these are benign process.
Dr. Rafa Hussain:Yes, they're very common.
Dr. Rafa Hussain:They can be more common in patients who have already had problems with trigger finger.
Dr. Unknown:Yeah.
Dr. Rafa Hussain:Because you can get palmar plantar fibromatosis.
Dr. Rafa Hussain:We don't exactly know why they show up.
Dr. Rafa Hussain:They can be addressed in some cases with conservative non surgical care, but when they're, when they're big enough, you generally just need to remove them surgically.
Dr. Unknown:Yeah.
Dr. Unknown:And it's a very in and out day procedure.
Dr. Rafa Hussain:Yep.
Dr. Damian Dauphine:Awesome.
Dr. Rafa Hussain:Well, that was a great complete discussion of the notorious plantar fibroma.
Dr. Rafa Hussain:And if you have any questions or you guys want us to dig a little deeper in plantar fibromas or other soft tissue lesions like that, then shoot us a note and we'll go after those as well.
Dr. Rafa Hussain:Thanks Dr.
Dr. Rafa Hussain:Hussain, for putting that together.
Dr. Rafa Hussain:That was a great job and we will see you guys next time on the podcast.
Dr. Unknown:Thank you for listening to the pod doctors.
Dr. Unknown:We appreciate all of our listeners and subscribers.
Dr. Unknown:If you'd like to hear more, follow us on Facebook, Twitter and watch our videos on YouTube like thumbs up, subscribe, be safe.
Dr. Unknown:See you all next time.
Dr. Unknown:Bye bye.
