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Proximal Plantar Fibroma as an Etiology of Recalcitrant Plantar Heel Pain
The Journal of Foot & Ankle Surgery 50 (2011) 153–157
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Proximal Plantar Fibroma as an Etiology of Recalcitrant Plantar Heel Pain Shaun Hafner, DPM, Nancy Han, DPM, Martin M. Pressman, DPM, Christopher Wallace, MD Department of Orthopaedics, Yale New Haven Hospital, New Haven, CT
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3 Keywords: calcaneus fascia foot neoplasm spur surgery
Prompted by repeated pathology reports of fibromas at the origin of the plantar fascia after fasciectomy for chronic plantar heel pain, this study examined the incidence of proximal plantar fibroma. A retrospective study of 100 pathology specimens from 97 patients with the preoperative diagnosis of recalcitrant plantar fasciitis was performed. Patients ranged in age from 36 to 82, and included 31 males and 66 females. The specimens consisted of medial and central bands of the fascia obtained from transverse plantar fasciectomies. The fasciectomies were performed by 4 surgeons between July 1994 and March 2008. One quarter of the cases studied had a histological appearance of plantar fibroma. This new finding has not been reported in any literature in connection with recalcitrant heel pain. Histologic findings of the specimens were placed into 3 groups: neoplastic involvement (25%, 21 female and 6 male), inflammation without neoplastic involvement (21%, 13 female and 6 male), and other, which consisted of having no inflammatory or neoplastic response (54%, 32 female and 19 male). All of the patients ailed a 3- to 6-month conservative treatment regimen, which included anti-inflammatory medication, modification of activities, injection of corticosteroids, night splints, custom molded orthotics, and physical therapy. Only 3 patients underwent bilateral plantar fasciectomies. No patient required a revisional procedure. The authors conclude that 25% of recalcitrant heel pain is neoplastic in origin, and that patients presenting with these lesions require excision and not fasciotomy. Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.
The plantar fascia is a thickened, fibrous sheet of connective tissue that originates from the plantar aspect of medial tubercle of the calcaneus, and that extends to the plantar plates of the metatarsophalangeal joints, providing a dynamic shock absorber for the foot during ambulation (1–3). Plantar heel pain was first described by Wood in 1812 (4, 5). The name plantar fasciitis is a misnomer in 2 ways: (1) the plantar fascia is actually a tendinous aponeurosis, and not a true fascial layer (6, 7), and (2) the word “fasciitis” implies that inflammation is an essential component of the disorder. However, recent histologic evidence has shown that some presentations of plantar fasciitis manifest as a noninflammatory degenerative process. Some authors have proposed that plantar “fasciosis” would be a more accurate description of this condition (1, 6, 8, 9). However, throughout this article we use the standard nomenclature of plantar fasciitis. It is estimated that plantar fasciitis engenders more than 600,000 outpatient visits per year in the United States (10, 11). Approximately 10% of the US population will suffer from plantar heel pain during the course of a lifetime (2, 12). The etiology is unknown, but it is most likely multifactorial. The typical etiology is repetitive stress overload to the origin of the plantar
fascia (10). Other causes may include weight gain, excessive pronation, occupation-related activity, anatomical variations, altered biomechanics (ie, gait abnormalities), overexertion, and inadequate foot wear (2). For the purposes of this retrospective cohort study, plantar fasciitis was defined as the following: (1) pain limited to the plantar-medial tubercle of the calcaneus and plantar aponeurosis, (2) pain with the first step in the morning, (3) pain exacerbated by previous excessive activity, (4) reduction of pain after walking, (5) symptoms not related to other systemic seropositive and negative arthropathies or neuropathies, or to specific injury or trauma (13, 14). In general, plantar fasciitis is considered a self-limiting condition. Most patients eventually improve; however, it may take several months or years to resolve (2). One long-term follow-up study found that 80% of patients treated conservatively for plantar fasciitis had complete relief of pain after 4 years, and the indolent nature of the condition is likely to be attributable to repetitive microtrauma occurring at a rate that exceeds the body’s ability to recover (15). Differential diagnoses for inferior heel pain are numerous and can be grossly subdivided into neurologic, soft tissue, skeletal, and miscellaneous causes (10).
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Martin M. Pressman, DPM, Department of Orthopaedics, Yale New Haven Hospital, 800 Howard Avenue, New Haven, CT 06511. E-mail address: [email protected] (M.M. Pressman).
Materials and Methods One hundred and one surgical pathology reports of resected plantar fascia with a preoperative diagnosis of recalcitrant plantar fasciitis were reviewed retrospectively. Surgeries had been performed between July 1994 and March 2008. Microscopic
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Table 1 Demographic and histologic findings of open plantar fasciectomy specimens submitted for pathological analysis as plantar fibroma and/or fasciitis (N ¼ 100 specimens in 97 patients) Specimen
Sex
Date of Birth
Date of Surgery
Pathology Lab
Fibromas
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
F F M F F F F M F F F F F M F F F F F F F F F F F
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70
F F F M M F F F F F M F F F F M F M F F M M M F M F M F M M F F M F F F F M F F F F M M F
3/12/1951 9/2/1948 12/26/2022 11/21/1941 9/19/1970 2/23/1963 4/11/1980 10/10/2029 2/20/1951 8/20/1957 8/20/1957 3/24/1964 9/17/1945 2/16/1943 4/15/1933 4/9/1958 4/9/1958 8/22/1943 8/22/1943 4/15/1935 7/17/1965 9/12/1957 9/21/1995 11/11/1949 5/10/1961 5/10/1961 3/1/1958 10/19/1952 3/10/1937 10/9/1944 11/20/1948 11/14/1946 2/23/1953 4/5/1948 4/12/1948 9/1/1948 8/15/1955 1/29/1945 7/14/1948 11/16/1956 3/22/1929 10/15/1945 2/10/1942 10/21/1961 11/22/1946 7/27/1951 7/27/1963 12/22/1957 1/10/1933 5/20/1950 10/15/1986 6/21/2029 10/13/1950 5/22/1968 6/26/1952 8/9/1957 6/1/1969 10/1/1952 3/13/1959 1/1/1966 3/9/1949 2/27/1965 8/12/1949 12/12/1963 8/22/1958 11/28/1952 2/9/1941 3/14/1972 4/19/1961 2/2/1948 5/14/1976
10/10/2002 1/17/2003 4/22/2004 2/17/2000 2/5/2004 8/10/2004 9/14/2004 3/20/1996 1/8/1997 2/7/1996 11/16/1995 4/4/2000 12/4/1998 3/31/1995 10/5/1995 7/3/1997 10/29/1997 7/9/1999 11/17/1995 1/27/2000 7/8/1997 10/31/1995 6/20/1996 7/11/1996 9/4/1997 12/5/1997 5/18/2000 9/27/2000 1/12/1999 2/22/2000 10/15/1998 7/7/1994 7/14/1994 2/11/1999 2/10/2000 1/5/2000 11/30/2000 8/24/1999 9/19/1996 5/8/1998 7/3/1996 2/20/1998 1/18/2000 9/1/1998 8/20/1999 7/8/1999 8/14/1997 9/8/2000 11/10/1998 9/5/1996 7/28/2000 8/4/1997 12/28/1995 8/24/1999 3/30/2000 6/12/1998 2/27/2004 2/19/2002 4/9/2002 6/25/2002 6/27/2002 7/24/2003 2/22/2001 3/14/2003 11/20/2001 2/15/2002 1/12/1996 2/15/2007 11/5/2007 9/8/2006 10/12/2007
MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD QUEST MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD YALE MILFORD MILFORD MILFORD MILFORD QUEST MILFORD MILFORD QUEST QUEST QUEST MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD QUEST MILFORD QUEST MILFORD MILFORD MILFORD MILFORD MILFORD ST RAPHAEL MILFORD MILFORD QUEST MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD ST RAPHAEL QUEST
Neoplastic Neoplastic Other Other Other Other Other Other Other Inflammatory Inflammatory Other Inflammatory Other Inflammatory Neoplastic Neoplastic Neoplastic Inflammatory Other Inflammatory Other Neoplastic Neoplastic Neoplastic Neoplastic Neoplastic Neoplastic Neoplastic Neoplastic Neoplastic Inflammatory Other Other Other Other Other Other Other Inflammatory Other Other Other Other Other Other Other Other Other Other Other Other Other Other Other Other Neoplastic Neoplastic Other Inflammatory Other Other Neoplastic Other Inflammatory Neoplastic Inflammatory Neoplastic Neoplastic Other Inflammatory
1 2
3 4 5
6 7 8 9 10 11 12 13 14
15 16
17
18 19 20
Table 1 (continued ) Specimen
Sex
Date of Birth
Date of Surgery
Pathology Lab
Fibromas
71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
F M F F F F M F M M F F F F F F M F F F M M M M F F M F M F
5/8/1953 11/10/1944 9/27/1954 11/27/1957 8/28/1951 12/29/1964 7/23/1952 3/25/1966 1/30/1949 8/31/1971 1/21/1952 3/20/1966 9/2/1948 7/27/1961 2/14/1915 12/19/1960 12/1/1968 9/7/1960 7/1/1968 3/24/1961 4/13/1952 9/24/1946 3/27/1969 2/21/1964 2/19/1967 7/9/1955 9/20/1947 1/2/1954 2/16/1957 11/28/1960
10/26/2007 12/26/2006 6/26/2007 8/17/2006 6/20/2006 5/15/2007 3/15/2005 3/8/2005 12/19/2006 5/24/2005 3/29/2005 7/12/2005 9/1/2005 11/12/2004 11/17/2004 7/19/2005 8/8/2006 6/27/2006 2/13/2007 4/1/2005 1/6/2006 12/28/2004 12/8/2007 4/24/2007 2/21/2008 12/20/2007 12/6/2007 2/26/2008 3/13/2008 2/5/2008
QUEST MILFORD QUEST ST RAPHAEL ST RAPHAEL ST RAPHAEL MILFORD MILFORD ST RAPHAEL MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD QUEST MILFORD QUEST QUEST QUEST QUEST QUEST QUEST
Inflammatory Neoplastic Inflammatory Other Other Other Neoplastic Other Other Other Other Other Other Other Other Neoplastic Inflammatory Other Inflammatory Other Other Inflammatory Inflammatory Other Inflammatory Other Neoplastic Neoplastic Other Inflammatory
21
22
23
24 25
analysis of these lesions was performed in 4 facilities in New Haven County, Connecticut. Analysis was carried out by board-certified pathologists in Milford Hospital, Quest Labs, The Hospital of Saint Raphael, and Yale-New Haven Hospital. Inclusion and exclusion factors were determined before the review. Inclusion criteria were met by any individual who had been diagnosed with proximal plantar fasciitis and had undergone at least 3 months of conservative therapy, and who were candidates for surgical excision. Individuals who had received a diagnosis of distal plantar fibroma or fibromatosis, or who had not received adequate conservative treatment were excluded from this study. All included patients had failed a series of conservative treatment for a minimum of 3 months before surgery. Their treatments included nonsteroidal anti-inflammatory drugs (NSAIDs), orthotics, injections, night splints, taping and strapping, and physical therapy. Following the determination that the conservative treatment had failed, surgical excision of the plantar fascia was carried out. The surgical cases of 4 surgeons were reviewed. The excision of the plantar fascia was accomplished with a transverse plantar medial incision made in the most proximal aspect of the non–weight-bearing portion of the plantar arch, just distal to the heel pad. The incision was carried down through the fat to the level of the plantar fascia. The medial, central, and lateral bands of the plantar fascia were identified. A 0.5- to 1.0-cm rectangular section of the medial and central bands of the plantar fascia was resected. This was done to remove the thickened plantar fascia and to prevent reattachment. The wedge of plantar fascia was then sent to its respective lab for analysis. Care was taken to protect the adjacent nerves, vessels, and underlying flexor digitorum brevis and abductor hallucis muscles. The skin was closed with 4.0 nonabsorbable vertical mattress sutures. A pneumatic ankle tourniquet was used for hemostasis throughout the procedure. Afterward, a compression dressing with a plaster slipper cast was applied, and patients were restricted to a non–weight-bearing status for approximately 3 weeks. The tissue sections were transported in formalin, which served as a fixator. A micrometer was used to shave the tissue sections to a thickness of 3 to 5 mm. All samples underwent standard staining techniques with hematoxylin and eosin (H&E). Following this procedure, a board-certified pathologist reviewed cell configuration and characteristics under 4-power and 10-power magnification. The authors reviewed all of the charts, operative reports, and pathology reports. Histologic findings were placed into 3 groups: neoplastic involvement (25%), inflammation without neoplastic involvement (21%), and other, which consisted of having no inflammatory or neoplastic response (54%). Neoplastic involvement included histologic findings of fibroma (13), fibromatosis (11), and juvenile aponeurotic fibroma (1). Inflammation without neoplastic involvement had histologic findings of fasciitis, chronic inflammation, and reactive changes of tenosynovium, bone, periosteum, and fibrotendinous tissue. The category designated other included fascia with myxoid
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Fig. 1. Low-power view demonstrating fibromatosis (neoplastic) on the right side of the figure. Circumscription of the fibroma is evident.
Fig. 3. Low-power view demonstrating fibrosis (designated in the text as other). Scattered fibroblasts noted among vascular and adipose tissue.
degeneration; mucinous changes of fascia tissue; collagenous fibrosis; cystic degeneration; bursa, neuroma; or any other normal finding of bone, fascia, skeletal muscle, or adipose tissue.
Fibroblast cells are usually delineated by their round, elongated, or, more commonly, oval hyperchromatic mononuclei. They are normally seen throughout the aponeurosis. Likewise, collagen-producing fibrocytes are found in all samples, including fascia, fibroma, and fibrosis. Figures 1 to 7 depict pathologic tissue specimens representative of the cohort. Figures 1 and 2 show samples of fibrosis and fibroma, revealing how they are often differentiated from normal fascia by their higher cellular density. Fibroma consists of delineated local areas of proliferating spindle-shaped fibroblasts, which are well defined against an acellular collagenous aponeurosis (Figures 1, 2, 5, and 6). Fibrosis is defined as a diffuse dispersion of fibroblasts throughout the acellular collagenous aponeurosis (Figures 3 and 4). White blood cell infiltrate represents either acute or chronic inflammation. Acute inflammation samples contained a predominance of neutrophils. Chronic inflammation was seen with various lymphocytes, including macrophages, mononuclear cells, and plasma cells.
Results Table 1 depicts the dataset, and depicts the results of the pathology reports of 100 specimens from 97 patients who had a preoperative diagnosis of recalcitrant plantar fasciitis, and required surgical excision between July 1994 and March 2008. The mean age of the patients was 47, 31 (31.96%) of whom were male and 66 (68.04%) of whom were female. Three (3.09%) female patients had bilateral involvement. Cases were subdivided into 3 groups based on their histopathologic diagnosis and/or description. The 3 groups included neoplastic involvement (25%), inflammation without neoplastic involvement (21%), and other, which consisted of neither inflammatory nor neoplastic response (54%). Aponeuroses are similar to broad flattened tendons; however, instead of all fibers lying in parallel arrays, the fibers of the aponeuroses are arranged in multiple layers. The bundles of collagen fibers in one layer tend to be arranged in 90 angles to the neighboring layers. The fibers within each of the layers are arranged in regular arrays; thus, it is a dense regular connective tissue (16).
Fig. 2. Low-power view demonstrating fibroma (neoplastic). Circumscription and spindle cells with elongated nuclei are noted.
Discussion Plantar fibroma as a possible cause of recalcitrant heel pain is not known to be previously reported in the literature. The purpose of this article was to share the histologic findings associated with chronic heel pain syndrome. Our findings support the addition of proximal
Fig. 4. Low-power view demonstrating fibrosis (designated in the text as other). Fibroblasts with random distribution in the collagenous stroma are noted.
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Fig. 5. Low-power view of fibroma. Note haphazard placement of uniform cells within fibrotic stroma.
plantar fibroma to the differential diagnosis of chronic heel pain and the inclusion of fasciectomy as the procedure of choice for these lesions. In a 1979 article in the Journal of the American Podiatric Medical Association, McCarthy and Gorecki (17) reported that 15% of all patients seeking podiatric treatment had a chief complaint of heel pain. The cause or causes of plantar fasciitis remain an uncertainty. Current imaging techniques offer little assistance in the diagnosis (15). We did not include a review of imaging in this article, but this is an area that provides opportunity for further study. This is evidenced by the fact that none of the 97 patients who had magnetic resonance imaging (MRI) preoperatively were diagnosed with fibroma by the MRI findings. The American College of Foot and Ankle Surgeons recommends considering surgery if the heel pain persists after 3 months of treatment (18). Conservative treatments may include steroid injections, NSAIDs, taping, night splints, physical therapy, orthotics, and cast immobilization. Conservative therapy is effective in most patients after several months. Effectiveness of surgery versus conservative measures is unproven. However, many patients who have failed conservative treatment report long-term improvement following surgery (10). The list of surgical procedures used for plantar fasciitis
Fig. 6. High-power view of fibroma. Neoplastic cells have rounded to stellate cytoplasm and hyperchromatic nuclei, and are set in a collagenous stroma.
Fig. 7. High-power view of fibroma. Neoplastic cells have uniform, rounded nuclei and are distributed within a collagenous stroma in a haphazard fashion.
includes variations of open or closed fascia release, with or without calcaneal spur resection, excision of abnormal tissue, and nerve decompression (15). Potential complications include transient swelling of the heel pad, calcaneal fracture, injury to the posterior tibial nerve or its branches, and flattening of the longitudinal arch with resultant midtarsal pain (15, 19, 20). Malay et al (21) concluded that postoperative complications such as recurrent pain, nerve injury, infection, and tarsal instability detract from the usefulness of surgical interventions. Plantar fibromatosis occurs most often on the medial half of the midtarsal region (22). A 1955 study by Allen (23) reported that 72% of the 54 patients examined demonstrated the presence of the plantar fibroma on the medial half of the midtarsal region. According to Allen, “the microscopic appearance of the lesion [plantar fibroma] is so distinctive as to be diagnostic” (23). The nodules consist of islands of proliferating spindle-shaped fibroblasts, which contrasts sharply with the relatively acellular collagenous aponeurotic background (23). The growth exhibited by plantar fibromatosis can be classified into 2 stages. The active stage is consistent with fibroblastic activity and abundant cellular proliferation. The second, resting stage is evidenced by fascial scarring and contraction of the plantar fascia. The distinct histologic appearance is almost pathognomonic for this lesion (24). Of the 3 patients with bilateral involvement, one had bilateral inflammatory involvement only, the second had bilateral neoplastic involvement (both were treated surgically less than a year apart), and the third had a neoplastic involvement of one side with an inflammatory involvement of the other side. In this last patient, the inflammatory side was treated 4 years earlier than the neoplastic side. This suggests the possibility that proximal plantar fibroma develops in response to long-standing inflammation. Barret and Day have reported favorable results from the use of endoscopic techniques for a plantar fasciotomy, which relieved pain in 80% to 90% of patients (25, 26). Benton-Weil et al showed 83% satisfaction rate with percutaneous plantar fasciotomy and Berlin reported 89% good to excellent results with percutaneous plantar fasciotomy (27–29). Vohra has shown an 85% patient satisfaction rate in a study comparing open versus endoscopic fasciotomies, whereas Barrett and associates reported an 87% improvement with an endoscopic plantar release (EPF) (27, 30, 31). Lundeen et al had an 81.1% patient satisfaction rate with EPF, whereas Urovitz et al described an 82% satisfaction rate; however, the procedure was not a panacea (32, 33). Perelman and associates have reported that at least 90% of the patients were satisfied with the instep plantar fasciotomy procedure
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(27, 34). Brekke and Green performed a retrospective analysis of minimal incision, endoscopic, and open procedure for heel spur syndrome. They found that the overall satisfaction rates were highest among the open group (78.8%), followed by the minimal incision group (71.4%), and were least among the endoscopic group (67.7%) (35). These results suggest that satisfaction for plantar fasciotomies is less than ideal. It is possible that the unsatisfactory results are related to the undiagnosed presence of a proximal plantar fibroma, which caused the chronic heel pain and remained unresolved after fasciotomy. Further, long-term prospective outcome comparative studies with inclusion of histologic examination are needed. In conclusion, the purpose of this study was to examine the histology of resected plantar fascia removed for the treatment of recalcitrant plantar fasciitis. Twenty-five percent of the 100 specimens collected from 97 patients were fibromas. The presence of a proximal plantar fibroma as an etiology of recalcitrant heel pain has not been previously reported. These findings suggest that fasciectomy rather than fasciotomy is the most appropriate procedure for the removal of this benign neoplasm. For the approximately 25% of recalcitrant heel pain cases that are caused by plantar fibromas, procedures such as endoscopic plantar fasciotomy or open fasciotomies would be poor surgical choices. A study of preoperative MRI or ultrasound findings with histopathology of the fascial specimens, possibly from needle biopsy, would be helpful to determine the role of imaging in the preoperative diagnosis of proximal plantar fibroma. If imaging of the fascia does not provide for the diagnosis, perhaps needle biopsy of the fascia alone is warranted before the definitive surgery. References 1. Karabay N, Toros T, Hurel C. Ultrasonographic evaluation in plantar fasciitis. J Foot Ankle Surg 46:442–446, 2007. 2. Roxas M. Plantar fasciitis: diagnosis and therapeutic considerations. Altern Med Rev 10(2):83–93, 2005. 3. Cornwall MW, McPoil TG. Plantar fasciitis: etiology and treatment. J Orthop Sports Phys Ther 29:756–760, 1999. 4. Green D, Kim PS. Surgical pearls: plantar calcaneal spurs: is surgery necessary? Podiatry Today 19:30–35, 2006. 5. McGarvey WC, Sparks M, Baxter DE. Causes of heel pain. FAClinics 3(1):175–187, 1998. 6. Barrett SL, Erredge SE. Growth factors for chronic plantar fasciitis? Podiatry Today 17:36–42, 2004. 7. Gibbon W, Long G. Ultrasound of the plantar aponeurosis (fascia). Skeletal Radiol 28:21–26, 1999. 8. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Pod Med Assoc 93:234–237, 2003. 9. Aldrige T. Diagnosing heel pain in adults. Am Fam Physician 70:332–338, 2004. 10. Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-base review of diagnosis and therapy. Am Fam Physician 72:2237–2242, 2005.
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Proximal Plantar Fibroma as an Etiology of Recalcitrant Plantar Heel Pain Shaun Hafner, DPM, Nancy Han, DPM, Martin M. Pressman, DPM, Christopher Wallace, MD Department of Orthopaedics, Yale New Haven Hospital, New Haven, CT
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3 Keywords: calcaneus fascia foot neoplasm spur surgery
Prompted by repeated pathology reports of fibromas at the origin of the plantar fascia after fasciectomy for chronic plantar heel pain, this study examined the incidence of proximal plantar fibroma. A retrospective study of 100 pathology specimens from 97 patients with the preoperative diagnosis of recalcitrant plantar fasciitis was performed. Patients ranged in age from 36 to 82, and included 31 males and 66 females. The specimens consisted of medial and central bands of the fascia obtained from transverse plantar fasciectomies. The fasciectomies were performed by 4 surgeons between July 1994 and March 2008. One quarter of the cases studied had a histological appearance of plantar fibroma. This new finding has not been reported in any literature in connection with recalcitrant heel pain. Histologic findings of the specimens were placed into 3 groups: neoplastic involvement (25%, 21 female and 6 male), inflammation without neoplastic involvement (21%, 13 female and 6 male), and other, which consisted of having no inflammatory or neoplastic response (54%, 32 female and 19 male). All of the patients ailed a 3- to 6-month conservative treatment regimen, which included anti-inflammatory medication, modification of activities, injection of corticosteroids, night splints, custom molded orthotics, and physical therapy. Only 3 patients underwent bilateral plantar fasciectomies. No patient required a revisional procedure. The authors conclude that 25% of recalcitrant heel pain is neoplastic in origin, and that patients presenting with these lesions require excision and not fasciotomy. Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.
The plantar fascia is a thickened, fibrous sheet of connective tissue that originates from the plantar aspect of medial tubercle of the calcaneus, and that extends to the plantar plates of the metatarsophalangeal joints, providing a dynamic shock absorber for the foot during ambulation (1–3). Plantar heel pain was first described by Wood in 1812 (4, 5). The name plantar fasciitis is a misnomer in 2 ways: (1) the plantar fascia is actually a tendinous aponeurosis, and not a true fascial layer (6, 7), and (2) the word “fasciitis” implies that inflammation is an essential component of the disorder. However, recent histologic evidence has shown that some presentations of plantar fasciitis manifest as a noninflammatory degenerative process. Some authors have proposed that plantar “fasciosis” would be a more accurate description of this condition (1, 6, 8, 9). However, throughout this article we use the standard nomenclature of plantar fasciitis. It is estimated that plantar fasciitis engenders more than 600,000 outpatient visits per year in the United States (10, 11). Approximately 10% of the US population will suffer from plantar heel pain during the course of a lifetime (2, 12). The etiology is unknown, but it is most likely multifactorial. The typical etiology is repetitive stress overload to the origin of the plantar
fascia (10). Other causes may include weight gain, excessive pronation, occupation-related activity, anatomical variations, altered biomechanics (ie, gait abnormalities), overexertion, and inadequate foot wear (2). For the purposes of this retrospective cohort study, plantar fasciitis was defined as the following: (1) pain limited to the plantar-medial tubercle of the calcaneus and plantar aponeurosis, (2) pain with the first step in the morning, (3) pain exacerbated by previous excessive activity, (4) reduction of pain after walking, (5) symptoms not related to other systemic seropositive and negative arthropathies or neuropathies, or to specific injury or trauma (13, 14). In general, plantar fasciitis is considered a self-limiting condition. Most patients eventually improve; however, it may take several months or years to resolve (2). One long-term follow-up study found that 80% of patients treated conservatively for plantar fasciitis had complete relief of pain after 4 years, and the indolent nature of the condition is likely to be attributable to repetitive microtrauma occurring at a rate that exceeds the body’s ability to recover (15). Differential diagnoses for inferior heel pain are numerous and can be grossly subdivided into neurologic, soft tissue, skeletal, and miscellaneous causes (10).
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Martin M. Pressman, DPM, Department of Orthopaedics, Yale New Haven Hospital, 800 Howard Avenue, New Haven, CT 06511. E-mail address: [email protected] (M.M. Pressman).
Materials and Methods One hundred and one surgical pathology reports of resected plantar fascia with a preoperative diagnosis of recalcitrant plantar fasciitis were reviewed retrospectively. Surgeries had been performed between July 1994 and March 2008. Microscopic
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Table 1 Demographic and histologic findings of open plantar fasciectomy specimens submitted for pathological analysis as plantar fibroma and/or fasciitis (N ¼ 100 specimens in 97 patients) Specimen
Sex
Date of Birth
Date of Surgery
Pathology Lab
Fibromas
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
F F M F F F F M F F F F F M F F F F F F F F F F F
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70
F F F M M F F F F F M F F F F M F M F F M M M F M F M F M M F F M F F F F M F F F F M M F
3/12/1951 9/2/1948 12/26/2022 11/21/1941 9/19/1970 2/23/1963 4/11/1980 10/10/2029 2/20/1951 8/20/1957 8/20/1957 3/24/1964 9/17/1945 2/16/1943 4/15/1933 4/9/1958 4/9/1958 8/22/1943 8/22/1943 4/15/1935 7/17/1965 9/12/1957 9/21/1995 11/11/1949 5/10/1961 5/10/1961 3/1/1958 10/19/1952 3/10/1937 10/9/1944 11/20/1948 11/14/1946 2/23/1953 4/5/1948 4/12/1948 9/1/1948 8/15/1955 1/29/1945 7/14/1948 11/16/1956 3/22/1929 10/15/1945 2/10/1942 10/21/1961 11/22/1946 7/27/1951 7/27/1963 12/22/1957 1/10/1933 5/20/1950 10/15/1986 6/21/2029 10/13/1950 5/22/1968 6/26/1952 8/9/1957 6/1/1969 10/1/1952 3/13/1959 1/1/1966 3/9/1949 2/27/1965 8/12/1949 12/12/1963 8/22/1958 11/28/1952 2/9/1941 3/14/1972 4/19/1961 2/2/1948 5/14/1976
10/10/2002 1/17/2003 4/22/2004 2/17/2000 2/5/2004 8/10/2004 9/14/2004 3/20/1996 1/8/1997 2/7/1996 11/16/1995 4/4/2000 12/4/1998 3/31/1995 10/5/1995 7/3/1997 10/29/1997 7/9/1999 11/17/1995 1/27/2000 7/8/1997 10/31/1995 6/20/1996 7/11/1996 9/4/1997 12/5/1997 5/18/2000 9/27/2000 1/12/1999 2/22/2000 10/15/1998 7/7/1994 7/14/1994 2/11/1999 2/10/2000 1/5/2000 11/30/2000 8/24/1999 9/19/1996 5/8/1998 7/3/1996 2/20/1998 1/18/2000 9/1/1998 8/20/1999 7/8/1999 8/14/1997 9/8/2000 11/10/1998 9/5/1996 7/28/2000 8/4/1997 12/28/1995 8/24/1999 3/30/2000 6/12/1998 2/27/2004 2/19/2002 4/9/2002 6/25/2002 6/27/2002 7/24/2003 2/22/2001 3/14/2003 11/20/2001 2/15/2002 1/12/1996 2/15/2007 11/5/2007 9/8/2006 10/12/2007
MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD QUEST MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD YALE MILFORD MILFORD MILFORD MILFORD QUEST MILFORD MILFORD QUEST QUEST QUEST MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD QUEST MILFORD QUEST MILFORD MILFORD MILFORD MILFORD MILFORD ST RAPHAEL MILFORD MILFORD QUEST MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD ST RAPHAEL QUEST
Neoplastic Neoplastic Other Other Other Other Other Other Other Inflammatory Inflammatory Other Inflammatory Other Inflammatory Neoplastic Neoplastic Neoplastic Inflammatory Other Inflammatory Other Neoplastic Neoplastic Neoplastic Neoplastic Neoplastic Neoplastic Neoplastic Neoplastic Neoplastic Inflammatory Other Other Other Other Other Other Other Inflammatory Other Other Other Other Other Other Other Other Other Other Other Other Other Other Other Other Neoplastic Neoplastic Other Inflammatory Other Other Neoplastic Other Inflammatory Neoplastic Inflammatory Neoplastic Neoplastic Other Inflammatory
1 2
3 4 5
6 7 8 9 10 11 12 13 14
15 16
17
18 19 20
Table 1 (continued ) Specimen
Sex
Date of Birth
Date of Surgery
Pathology Lab
Fibromas
71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
F M F F F F M F M M F F F F F F M F F F M M M M F F M F M F
5/8/1953 11/10/1944 9/27/1954 11/27/1957 8/28/1951 12/29/1964 7/23/1952 3/25/1966 1/30/1949 8/31/1971 1/21/1952 3/20/1966 9/2/1948 7/27/1961 2/14/1915 12/19/1960 12/1/1968 9/7/1960 7/1/1968 3/24/1961 4/13/1952 9/24/1946 3/27/1969 2/21/1964 2/19/1967 7/9/1955 9/20/1947 1/2/1954 2/16/1957 11/28/1960
10/26/2007 12/26/2006 6/26/2007 8/17/2006 6/20/2006 5/15/2007 3/15/2005 3/8/2005 12/19/2006 5/24/2005 3/29/2005 7/12/2005 9/1/2005 11/12/2004 11/17/2004 7/19/2005 8/8/2006 6/27/2006 2/13/2007 4/1/2005 1/6/2006 12/28/2004 12/8/2007 4/24/2007 2/21/2008 12/20/2007 12/6/2007 2/26/2008 3/13/2008 2/5/2008
QUEST MILFORD QUEST ST RAPHAEL ST RAPHAEL ST RAPHAEL MILFORD MILFORD ST RAPHAEL MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD MILFORD QUEST MILFORD QUEST QUEST QUEST QUEST QUEST QUEST
Inflammatory Neoplastic Inflammatory Other Other Other Neoplastic Other Other Other Other Other Other Other Other Neoplastic Inflammatory Other Inflammatory Other Other Inflammatory Inflammatory Other Inflammatory Other Neoplastic Neoplastic Other Inflammatory
21
22
23
24 25
analysis of these lesions was performed in 4 facilities in New Haven County, Connecticut. Analysis was carried out by board-certified pathologists in Milford Hospital, Quest Labs, The Hospital of Saint Raphael, and Yale-New Haven Hospital. Inclusion and exclusion factors were determined before the review. Inclusion criteria were met by any individual who had been diagnosed with proximal plantar fasciitis and had undergone at least 3 months of conservative therapy, and who were candidates for surgical excision. Individuals who had received a diagnosis of distal plantar fibroma or fibromatosis, or who had not received adequate conservative treatment were excluded from this study. All included patients had failed a series of conservative treatment for a minimum of 3 months before surgery. Their treatments included nonsteroidal anti-inflammatory drugs (NSAIDs), orthotics, injections, night splints, taping and strapping, and physical therapy. Following the determination that the conservative treatment had failed, surgical excision of the plantar fascia was carried out. The surgical cases of 4 surgeons were reviewed. The excision of the plantar fascia was accomplished with a transverse plantar medial incision made in the most proximal aspect of the non–weight-bearing portion of the plantar arch, just distal to the heel pad. The incision was carried down through the fat to the level of the plantar fascia. The medial, central, and lateral bands of the plantar fascia were identified. A 0.5- to 1.0-cm rectangular section of the medial and central bands of the plantar fascia was resected. This was done to remove the thickened plantar fascia and to prevent reattachment. The wedge of plantar fascia was then sent to its respective lab for analysis. Care was taken to protect the adjacent nerves, vessels, and underlying flexor digitorum brevis and abductor hallucis muscles. The skin was closed with 4.0 nonabsorbable vertical mattress sutures. A pneumatic ankle tourniquet was used for hemostasis throughout the procedure. Afterward, a compression dressing with a plaster slipper cast was applied, and patients were restricted to a non–weight-bearing status for approximately 3 weeks. The tissue sections were transported in formalin, which served as a fixator. A micrometer was used to shave the tissue sections to a thickness of 3 to 5 mm. All samples underwent standard staining techniques with hematoxylin and eosin (H&E). Following this procedure, a board-certified pathologist reviewed cell configuration and characteristics under 4-power and 10-power magnification. The authors reviewed all of the charts, operative reports, and pathology reports. Histologic findings were placed into 3 groups: neoplastic involvement (25%), inflammation without neoplastic involvement (21%), and other, which consisted of having no inflammatory or neoplastic response (54%). Neoplastic involvement included histologic findings of fibroma (13), fibromatosis (11), and juvenile aponeurotic fibroma (1). Inflammation without neoplastic involvement had histologic findings of fasciitis, chronic inflammation, and reactive changes of tenosynovium, bone, periosteum, and fibrotendinous tissue. The category designated other included fascia with myxoid
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Fig. 1. Low-power view demonstrating fibromatosis (neoplastic) on the right side of the figure. Circumscription of the fibroma is evident.
Fig. 3. Low-power view demonstrating fibrosis (designated in the text as other). Scattered fibroblasts noted among vascular and adipose tissue.
degeneration; mucinous changes of fascia tissue; collagenous fibrosis; cystic degeneration; bursa, neuroma; or any other normal finding of bone, fascia, skeletal muscle, or adipose tissue.
Fibroblast cells are usually delineated by their round, elongated, or, more commonly, oval hyperchromatic mononuclei. They are normally seen throughout the aponeurosis. Likewise, collagen-producing fibrocytes are found in all samples, including fascia, fibroma, and fibrosis. Figures 1 to 7 depict pathologic tissue specimens representative of the cohort. Figures 1 and 2 show samples of fibrosis and fibroma, revealing how they are often differentiated from normal fascia by their higher cellular density. Fibroma consists of delineated local areas of proliferating spindle-shaped fibroblasts, which are well defined against an acellular collagenous aponeurosis (Figures 1, 2, 5, and 6). Fibrosis is defined as a diffuse dispersion of fibroblasts throughout the acellular collagenous aponeurosis (Figures 3 and 4). White blood cell infiltrate represents either acute or chronic inflammation. Acute inflammation samples contained a predominance of neutrophils. Chronic inflammation was seen with various lymphocytes, including macrophages, mononuclear cells, and plasma cells.
Results Table 1 depicts the dataset, and depicts the results of the pathology reports of 100 specimens from 97 patients who had a preoperative diagnosis of recalcitrant plantar fasciitis, and required surgical excision between July 1994 and March 2008. The mean age of the patients was 47, 31 (31.96%) of whom were male and 66 (68.04%) of whom were female. Three (3.09%) female patients had bilateral involvement. Cases were subdivided into 3 groups based on their histopathologic diagnosis and/or description. The 3 groups included neoplastic involvement (25%), inflammation without neoplastic involvement (21%), and other, which consisted of neither inflammatory nor neoplastic response (54%). Aponeuroses are similar to broad flattened tendons; however, instead of all fibers lying in parallel arrays, the fibers of the aponeuroses are arranged in multiple layers. The bundles of collagen fibers in one layer tend to be arranged in 90 angles to the neighboring layers. The fibers within each of the layers are arranged in regular arrays; thus, it is a dense regular connective tissue (16).
Fig. 2. Low-power view demonstrating fibroma (neoplastic). Circumscription and spindle cells with elongated nuclei are noted.
Discussion Plantar fibroma as a possible cause of recalcitrant heel pain is not known to be previously reported in the literature. The purpose of this article was to share the histologic findings associated with chronic heel pain syndrome. Our findings support the addition of proximal
Fig. 4. Low-power view demonstrating fibrosis (designated in the text as other). Fibroblasts with random distribution in the collagenous stroma are noted.
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Fig. 5. Low-power view of fibroma. Note haphazard placement of uniform cells within fibrotic stroma.
plantar fibroma to the differential diagnosis of chronic heel pain and the inclusion of fasciectomy as the procedure of choice for these lesions. In a 1979 article in the Journal of the American Podiatric Medical Association, McCarthy and Gorecki (17) reported that 15% of all patients seeking podiatric treatment had a chief complaint of heel pain. The cause or causes of plantar fasciitis remain an uncertainty. Current imaging techniques offer little assistance in the diagnosis (15). We did not include a review of imaging in this article, but this is an area that provides opportunity for further study. This is evidenced by the fact that none of the 97 patients who had magnetic resonance imaging (MRI) preoperatively were diagnosed with fibroma by the MRI findings. The American College of Foot and Ankle Surgeons recommends considering surgery if the heel pain persists after 3 months of treatment (18). Conservative treatments may include steroid injections, NSAIDs, taping, night splints, physical therapy, orthotics, and cast immobilization. Conservative therapy is effective in most patients after several months. Effectiveness of surgery versus conservative measures is unproven. However, many patients who have failed conservative treatment report long-term improvement following surgery (10). The list of surgical procedures used for plantar fasciitis
Fig. 6. High-power view of fibroma. Neoplastic cells have rounded to stellate cytoplasm and hyperchromatic nuclei, and are set in a collagenous stroma.
Fig. 7. High-power view of fibroma. Neoplastic cells have uniform, rounded nuclei and are distributed within a collagenous stroma in a haphazard fashion.
includes variations of open or closed fascia release, with or without calcaneal spur resection, excision of abnormal tissue, and nerve decompression (15). Potential complications include transient swelling of the heel pad, calcaneal fracture, injury to the posterior tibial nerve or its branches, and flattening of the longitudinal arch with resultant midtarsal pain (15, 19, 20). Malay et al (21) concluded that postoperative complications such as recurrent pain, nerve injury, infection, and tarsal instability detract from the usefulness of surgical interventions. Plantar fibromatosis occurs most often on the medial half of the midtarsal region (22). A 1955 study by Allen (23) reported that 72% of the 54 patients examined demonstrated the presence of the plantar fibroma on the medial half of the midtarsal region. According to Allen, “the microscopic appearance of the lesion [plantar fibroma] is so distinctive as to be diagnostic” (23). The nodules consist of islands of proliferating spindle-shaped fibroblasts, which contrasts sharply with the relatively acellular collagenous aponeurotic background (23). The growth exhibited by plantar fibromatosis can be classified into 2 stages. The active stage is consistent with fibroblastic activity and abundant cellular proliferation. The second, resting stage is evidenced by fascial scarring and contraction of the plantar fascia. The distinct histologic appearance is almost pathognomonic for this lesion (24). Of the 3 patients with bilateral involvement, one had bilateral inflammatory involvement only, the second had bilateral neoplastic involvement (both were treated surgically less than a year apart), and the third had a neoplastic involvement of one side with an inflammatory involvement of the other side. In this last patient, the inflammatory side was treated 4 years earlier than the neoplastic side. This suggests the possibility that proximal plantar fibroma develops in response to long-standing inflammation. Barret and Day have reported favorable results from the use of endoscopic techniques for a plantar fasciotomy, which relieved pain in 80% to 90% of patients (25, 26). Benton-Weil et al showed 83% satisfaction rate with percutaneous plantar fasciotomy and Berlin reported 89% good to excellent results with percutaneous plantar fasciotomy (27–29). Vohra has shown an 85% patient satisfaction rate in a study comparing open versus endoscopic fasciotomies, whereas Barrett and associates reported an 87% improvement with an endoscopic plantar release (EPF) (27, 30, 31). Lundeen et al had an 81.1% patient satisfaction rate with EPF, whereas Urovitz et al described an 82% satisfaction rate; however, the procedure was not a panacea (32, 33). Perelman and associates have reported that at least 90% of the patients were satisfied with the instep plantar fasciotomy procedure
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(27, 34). Brekke and Green performed a retrospective analysis of minimal incision, endoscopic, and open procedure for heel spur syndrome. They found that the overall satisfaction rates were highest among the open group (78.8%), followed by the minimal incision group (71.4%), and were least among the endoscopic group (67.7%) (35). These results suggest that satisfaction for plantar fasciotomies is less than ideal. It is possible that the unsatisfactory results are related to the undiagnosed presence of a proximal plantar fibroma, which caused the chronic heel pain and remained unresolved after fasciotomy. Further, long-term prospective outcome comparative studies with inclusion of histologic examination are needed. In conclusion, the purpose of this study was to examine the histology of resected plantar fascia removed for the treatment of recalcitrant plantar fasciitis. Twenty-five percent of the 100 specimens collected from 97 patients were fibromas. The presence of a proximal plantar fibroma as an etiology of recalcitrant heel pain has not been previously reported. These findings suggest that fasciectomy rather than fasciotomy is the most appropriate procedure for the removal of this benign neoplasm. For the approximately 25% of recalcitrant heel pain cases that are caused by plantar fibromas, procedures such as endoscopic plantar fasciotomy or open fasciotomies would be poor surgical choices. A study of preoperative MRI or ultrasound findings with histopathology of the fascial specimens, possibly from needle biopsy, would be helpful to determine the role of imaging in the preoperative diagnosis of proximal plantar fibroma. If imaging of the fascia does not provide for the diagnosis, perhaps needle biopsy of the fascia alone is warranted before the definitive surgery. References 1. Karabay N, Toros T, Hurel C. Ultrasonographic evaluation in plantar fasciitis. J Foot Ankle Surg 46:442–446, 2007. 2. Roxas M. Plantar fasciitis: diagnosis and therapeutic considerations. Altern Med Rev 10(2):83–93, 2005. 3. Cornwall MW, McPoil TG. Plantar fasciitis: etiology and treatment. J Orthop Sports Phys Ther 29:756–760, 1999. 4. Green D, Kim PS. Surgical pearls: plantar calcaneal spurs: is surgery necessary? Podiatry Today 19:30–35, 2006. 5. McGarvey WC, Sparks M, Baxter DE. Causes of heel pain. FAClinics 3(1):175–187, 1998. 6. Barrett SL, Erredge SE. Growth factors for chronic plantar fasciitis? Podiatry Today 17:36–42, 2004. 7. Gibbon W, Long G. Ultrasound of the plantar aponeurosis (fascia). Skeletal Radiol 28:21–26, 1999. 8. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Pod Med Assoc 93:234–237, 2003. 9. Aldrige T. Diagnosing heel pain in adults. Am Fam Physician 70:332–338, 2004. 10. Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-base review of diagnosis and therapy. Am Fam Physician 72:2237–2242, 2005.
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