Archive for June, 2012

Case Study: Foot pain in an avid walker/runner.

Tuesday, June 19th, 2012

Patient is a 57-year-old previously asymptomatic female, avid runner/hiker/walker who developed moderately intense pain in the bottom of her foot/arch that worsened with distance, weight bearing and improved slightly with rest.

General exam observed a slender female 5 ft 4 in, 132 lbs.

She exhibited a mild walking gait deficit that was clearly due to foot pain. Lower extremity examination found a normal ankle and Achilles tendon. The toes were normal without anatomical defects. All three arches were intact with the primary arch being moderately high.

Inspection of the sole identified a prominent marble-size, painful, firm, non-mobile nodule in the mid foot, along the arch. The skin overlying the nodule was reddened.

Compressing and to a lesser extent manipulating the nodule immediately recreated the patient’s presenting pain.

The patient was diagnosed with plantar fibromatosis, which is a fairly uncommon, slow-growing, thickening of connective tissues deep in the sole of the foot. It is a non-malignant condition that is often hereditary.

Bilateral involvement is observed in 25% of cases. Although asymptomatic in the other foot, when checked, indeed a less prominent nodule was identified.

The progress of fibromatosis is quite variable but often is dormant for many years until ‘activated’ by repetitive abrasion and microtrauma from walking and running activity by footwear or lack of footwear that increases pressure on the nodule to the point of pain and nodular growth.

Treatment in this case was straightforward. I instructed her to outline the nodule(s) with a marker and while the ink was still wet, stand in her running shoes. The resultant outline on the shoe’s insoles was cut out to leave a gap allowing the patient to run or walk without the nodules being abraded or compressed.

Early relief was significant, with the patient eventually resuming running and walking without pain.

A two month recheck did not find any significant reduction in the size of either nodule although they remained asymptomatic as long as the modified footwear was worn.

It was later discovered that the patient’s mother had a related nodular formation in the palm of her hand, but none on her feet.

Incidentally the patient went in for a general massage and the masseuse refused the patient’s request to leave the nodule alone, massaging the bottom of the foot to the point of discomfort which persisted for about a day.

Plantar fibromatosis does not respond to massage.

he prognosis is good. I do not expect the size of the nodules to decrease but with good protection the growth rate and pain should be minimal to nil.

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