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Scientific letter
Plantar fibromatosis or Ledderhose disease: diagnosis with ultrasonography
Fibromatosis plantar o enfermedad de Ledderhose: diagnóstico ecográfico
M.F. García-Gil
Corresponding author
miguelgarciagil@outlook.com

Corresponding author.
, V. Lezcano Biosca
Servicio de Dermatología y Venereología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 66-year-old man with a history of smoking &#40;102 packs per year&#41; and alcohol use&#46; This man sought care due to some asymptomatic subcutaneous tumours which had been present for the past year on the soles of his feet&#46; Physical examination revealed firm nodules adhered to deep planes &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A-1B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">An ultrasound was performed on both feet with a high frequency linear transducer &#40;7&#46;5&#8211;13<span class="elsevierStyleHsp" style=""></span>MHz&#41;&#46; Hypoechoic and isoechoic lesions with a fusiform morphology&#44; nodular profiles and irregular borders&#44; with posterior acoustic enhancement and no colour Doppler recording&#44; were identified on the long axis&#46; All the lesions found had a similar echostructure and were located in the medial segment of the plantar fascia on the superficial and medial planes&#46; The lesions depended on the plantar fascia&#44; varied in size and measured up to 25<span class="elsevierStyleHsp" style=""></span>mm&#44; and were found to be in contact with the subcutaneous cellular tissue &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; On the short axis&#44; the lesions could be seen to be in contact with each other &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">With these findings&#44; a diagnosis was made of plantar fibromatosis or Ledderhose disease&#46; Nodules with similar characteristics&#44; but smaller in size&#44; were found on the flexor apparatus of the palms of both of the patient&#39;s hands&#46; Hence&#44; he was incidentally diagnosed with concomitant subclinical palmar fibromatosis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Ledderhose disease is a form of superficial fibromatosis caused by benign proliferation of fibroblasts of the plantar aponeurosis&#46; Even today&#44; the aetiopathogenesis of this disease is unknown&#46; It is a rare disease with a higher prevalence in males&#44; and although it may appear at any age&#44; it is more common in middle age&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Various predisposing factors have been reported&#44; such as alcohol use&#44; diabetes and epilepsy&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The plantar fascia or plantar aponeurosis is a fibrous band of connective tissue that lends support and structure to the longitudinal arch or plantar vault&#46; This fascia&#44; which is normally 1&#8211;2<span class="elsevierStyleHsp" style=""></span>mm thick&#44; consists of three compartments or bands &#40;central&#44; lateral and medial&#41;&#46; The central compartment extends from the medial tubercle of the calcaneus to its insertion in the metatarsophalangeal joints&#46; The lateral compartment originates in the lateral margin of the medial tuberosity of the calcaneus and inserts into the joint capsule of the fifth metatarsal joint&#46; Finally&#44; the medial compartment spans from its origin in the medial portion of the central band to its insertion in the first metatarsal joint&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Lesions are usually asymptomatic&#44; but may become painful or even debilitating&#46; Bilateral involvement is seen in just 25&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This fibromatosis usually does not involve retraction of anatomical structures&#44; unlike palmar fibromatosis or Dupuytren&#39;s disease&#46; Often&#44; patients with plantar fibromatosis also have other fibromatous diseases such as <span class="elsevierStyleItalic">induratio penis plastica</span> &#40;Peyronie&#39;s disease&#41; or palmar fibromatosis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Diagnosis is based on physical examination and complementary imaging tests consistent with the nature of this disease&#46; In rare cases&#44; histological confirmation is required&#46; Magnetic resonance imaging and ultrasound are the tests of choice&#44; though ultrasound is the most accessible and least costly imaging test for diagnostic confirmation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">On ultrasound&#44; lesions present as hypoechoic nodules &#40;76&#37; of cases&#41; or isoechoic nodules &#40;24&#37; of cases&#41; that are well defined with a uniform internal structure featuring sparse&#44; thin hyperechoic septa&#46; The most common site of lesions is the medial compartment or band &#40;60&#37;&#41;&#59; the second most common is the central compartment or band &#40;40&#37;&#41;&#46; Colour Doppler is usually negative&#44; shows no flow and reveals intrinsic vascularisation in just 8&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Lesions often show posterior acoustic enhancement &#40;in 20&#37;-65&#37; of cases&#44; depending on the case series&#41;&#59; posterior acoustic shadowing is more uncommon&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The differential diagnosis of plantar fibromatosis should include consideration of the following diseases of the plantar fascia&#58; diabetic fascial disease&#44; plantar fascia rupture&#44; xanthomas&#44; reactions to foreign bodies&#44; plantar infections and aggressive plantar fibromatosis presenting in the form of nodules with poorly defined margins that exhibit superficial or deep infiltration of the plantar fascia&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Magnetic resonance imaging is most useful in evaluating disease severity and in assessing the depth or extent of aggressive or wide-spreading forms of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#44; B&#41; Soles of both feet on which nodules can be seen &#40;arrows&#41;&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#41; A well-defined hypoechoic nodule with a fusiform morphology &#40;asterisk&#41; can be seen in the middle third of the medial band of the plantar fascia &#40;white arrows&#41;&#46; This lesion presses against the underlying muscle and presents posterior acoustic enhancement &#40;black arrows&#41;&#46; &#40;B&#41; Pseudonodular lesions in contact with each other with a mixed internal structure &#40;asterisk&#41;&#44; arising from the medial band of the plantar aponeurosis&#44; located in the medial to distal third thereof&#46; The lesions also show posterior acoustic enhancement &#40;black arrows&#41;&#46;</p>"
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