Ledderhose disease (plantar fibromatosis): 2026 update

A hard lump under the arch of the foot, which does not always hurt, which grows slowly, and which almost everyone first takes for plantar fasciitis. It is in fact another disease, a first cousin of Dupuytren's disease, of which only one treatment has been validated against placebo, and it is neither surgery nor physiotherapy.

Summary written from primary sources verified one by one on PubMed: identifier resolved, journal and year checked, abstract read before citation. Full bibliography at the end of the article.

Clinical summary

What is Ledderhose disease, and what is it a cousin of?

Understanding what this disease makes saves a long detour: it is the same tissue as in the palm, at the same cellular stage, but in a foot that carries the body's weight, and that last point changes almost everything else.

A superficial fibromatosis, cousin of Dupuytren's disease

Ledderhose disease belongs to the group of superficial fibromatoses, alongside Dupuytren's disease (palmar fibromatosis) and Peyronie's disease (penile involvement). All rest on the same process: a benign proliferation of fibroblasts and myofibroblasts, producing excess collagen.

A pathology review of the two sites describes a shared histology: an unremarkable spindle-cell proliferation, bluish in appearance, with a variable amount of background collagen depending on the age of the lesion1. The authors stress above all the decisive clinical difference: palmar fibromatosis leads to nodules and then to digital contracture, whereas plantar fibromatosis produces nodules that are often painful but does not usually end in contracture1.

That is the nuance to explain to the patient who has a relative operated on for the hand and fears “no longer being able to straighten their toes”. Toe contracture does exist, but it is rare2 ; what is troublesome is the lump under the foot.

Where exactly the nodules sit

The topography is stereotyped and is a diagnostic argument. The nodules sit in the medial part of the plantar fascia, on the central or medial band. An ultrasound series of 57 fibromas in 43 patients measured their distribution: 84 % were at the middle third of the plantar fascia3.

That detail explains two things. First, why the pain is not in the heel: it sits under the arch, in front of the heel, exactly where plantar fasciitis does not hurt. Second, why footwear and weight bearing govern the complaint: a nodule in the middle of the arch is crushed at every step between the ground and the bone.

A cause that remains unknown, and associations that do not

No aetiology is established, and the reviews say so plainly: there is no causal treatment, management remains symptomatic2. The associations reported in the literature are, for their part, fairly consistent from one review to another: trauma, diabetes, anticonvulsant use, frozen shoulder, alcohol consumption and liver disease4.

They have to be handled with the caution appropriate to associations drawn from case series: they guide the history, they do not explain the disease and they cannot be treated. The only link whose size has been measured in a cohort with a control group is that with Dupuytren's disease, and that is the subject of the next chapter.

Ledderhose disease is not a plantar fasciitis that has gone wrong: it is a disease of the hand that has come out on the wrong floor.

Who is affected, and what is the link with Dupuytren's disease?

This is the most useful chapter in the clinic, because it turns a curiosity into an examination reflex: two areas to look at in the same patient, in both directions.

A rare disease, whose exact prevalence remains poorly known

We should start with a methodological honesty: no general population study has measured the prevalence of Ledderhose disease. The reviews quote incidence figures of the order of one to two cases per hundred thousand people, but those values come from hospital series and not from a representative sample4. What is established, on the other hand, is the profile: a middle-aged or older adult, with a male predominance.

The surgical series give consistent markers. In a British series of 18 patients operated on with partial fasciectomy, the mean age was 41.3 (range 20 to 57), with 12 men out of 18, and 17 % of patients had multiple nodules at their first consultation5. Cohen's ultrasound series covered 43 patients aged 26 to 77, mean age 543.

The link with the hand, measured in a cohort with controls

This is the most solid datum in the whole chapter, and it comes from the Reykjavík study. One hundred and twenty-two men with Dupuytren's disease were invited back eighteen years after their original enrolment, along with the same number of controls matched for age and smoking. Ninety-two patients and 101 controls attended and were examined for plantar nodules6.

Ledderhose disease was identified in 14 of the 92 men with Dupuytren's (15.2 %), against 4 of the 101 controls (3.9 %), an odds ratio of 4.35 (95 % confidence interval: 1.3 to 16.7; p < 0.01). Two secondary results deserve just as much attention:

• Men who had been operated on for their Dupuytren's disease, or who had a digital contracture, were six times more likely to have plantar nodules than those who had only palmar nodules or cords (odds ratio 6.1; 1.8 to 27.1; p < 0.001)6.
• Plantar involvement was linked to a family history of Dupuytren's disease (odds ratio 3.1; 1.1 to 8.5; p = 0.02)6.

The converse was observed in a Dutch prevalence study of 763 randomly selected subjects aged 50 to 89: the prevalence of Dupuytren's disease there reached 22.1 %, and the presence of Ledderhose disease was among the significant risk factors for Dupuytren's disease, alongside a history of hand trauma, excessive alcohol consumption and family history7.

The nuance about “diathesis”, which needs quoting correctly

The notion of a Dupuytren's diathesis denotes the clinical features that identify aggressive forms at high risk of recurrence. Its historical version counted ectopic involvement (that is, outside the palm, so plantar or penile), among its four factors.

A reappraisal in 322 patients modified that definition, and the detail matters: the factors were widened to male sex and onset before the age of 50, but ectopic involvement was restricted to knuckle pads over the interphalangeal joints (Garrod's pads) alone. The presence of all the revised factors takes the risk of recurrence to 71 %, against 23 % in a patient with none of them8.

In other words: Ledderhose disease is not, in the revised version, a formal diathesis criterion. But the Reykjavík study shows that it preferentially accompanies the most severe palmar forms6. The practical course is the same on both readings, look at the other site, but the exact wording avoids making a score say what it does not.

What difference does involvement at several sites make?

Some patients do not have Ledderhose disease: they have a fibromatous disease expressing itself in several places. That subgroup is worth identifying, because it changes the examination, the outlook and what you say.

Three sites, one single process

The superficial fibromatoses form a coherent group histologically. A pathology review of the palmar and plantar forms describes in both cases the same proliferation of fibroblasts and myofibroblasts, with a shared microscopic appearance: unremarkable bluish spindle cells, with a background amount of collagen varying with the age of the lesion1. The clinical reviews add the third site, penile, under the name Peyronie's disease4.

What distinguishes these three expressions is the mechanical behaviour of the tissue concerned, not the nature of the lesion:

The difference between the hand and the foot is worth explaining to the patient, because it explains why the treatment differs. In the palm, the cord pulls on a mobile finger and surgery has a geometric aim: to restore extension. Under the foot, the nodule is crushed against the ground and surgery has an analgesic aim: to remove the compression. The two diseases share a histology and not a therapeutic logic.

How to spot this patient in the clinic

Three things are enough, and none takes more than a minute:

• Take the shoes off any patient who comes about a hand. In the Reykjavík cohort, 15.2 % of the men with Dupuytren's disease had plantar nodules, against 3.9 % of matched controls6.
• Look at the palms of any patient who comes about a foot. The converse is documented at population level: in a Dutch study of 763 subjects aged 50 to 89, the presence of Ledderhose disease was among the significant risk factors for Dupuytren's disease7.
• Ask about family history. Plantar involvement was linked to a family history of Dupuytren's disease with an odds ratio of 3.1 (1.1 to 8.5; p = 0.02)6.

The strongest signal, however, is not simply the presence of palmar involvement: it is its severity. Men operated on for their Dupuytren's disease, or with an established digital contracture, were six times more likely to have plantar nodules than those who had only nodules or cords (odds ratio 6.1; 1.8 to 27.1; p < 0.001)6. In other words, the patient whose shoes should come off first is the one who has already been operated on for the hand.

What this changes, and what it does not

What it changes. The examination becomes routinely bilateral and multi-site. Follow-up lengthens, because one site can appear years after the other: the Icelandic cohort re-examined its patients eighteen years after enrolment6. And what you say changes: you no longer talk about an isolated nodule but about a predisposition, which helps the patient understand why the disease comes back after surgery.

What it does not change. The treatment of each site remains the treatment of that site. No data indicate that a systemic treatment acts on all of them, and the drugs cited in the reviews (verapamil, tamoxifen, imatinib, sorafenib, mitomycin C) are cited at descriptive levels of evidence, with no established indication49.

How do you recognise a plantar nodule at examination?

The diagnosis is clinical. It comes down to a well-conducted palpation and three questions: provided you have in mind what it must on no account be confused with.

What the patient describes

Three complaints recur, in this order of frequency: a lump under the foot that the patient discovered while washing or walking barefoot, pain on weight bearing that increases with prolonged standing and walking barefoot on hard ground, and difficulty with footwear. Kadir's surgical series sums up the reasons for consulting in three items: pain, swelling, and functional difficulty5.

What is not the picture: pain on the first steps in the morning, maximal under the heel, easing after a few minutes of walking. That is the picture of plantar fasciopathy, and the distinction is the first one to make.

Palpation, step by step

• Patient prone, knee flexed to 90°, foot relaxed: that is the position giving the best access to the sole without putting the fascia on tension.
• Palpate the medial border of the fascia from the heel towards the toes. The nodule is firm, well defined, from a few millimetres to a few centimetres, often at the middle third: 84 % of lesions in the reference ultrasound series3.
• Assess mobility. The nodule is part of the fascia : it does not roll under the finger like a lipoma and does not move with the skin, which stays free above it.
• Put the fascia on tension with passive dorsiflexion of the toes (the windlass manoeuvre). The nodule becomes more prominent and harder, which confirms that it belongs to the fascia.
• Count and map. Multiple nodules are not rare: 17 % of the patients in Kadir's series had several from the outset5. Recording the number, the size and the distance from the heel allows progression to be followed without repeated imaging.
• Examine the other foot, then both hands. Bilateral involvement is frequent4, and looking for an associated Dupuytren's disease is not a curiosity: it concerns one man in seven in the Reykjavík cohort6.
• Look for toe contracture: rare, but it changes what to do because it marks an advanced form1.

What it gets confused with

Which imaging, and when should something else be feared?

Imaging does not make the diagnosis, it confirms it and above all it rules things out. Two publications are enough to know what to request and how to read the report.

Ultrasound first line

The reviews agree: the diagnosis is clinical, ultrasound and MRI are confirmatory adjuncts, with MRI reserved for aggressive or advanced forms49. Ultrasound has the advantage of being dynamic, comparative and immediate.

The reference series described 57 fibromas in 43 patients and quantified the ultrasound features3 :

Two points of interpretation deserve emphasis, to the patient as much as to the requesting doctor. First, intralesional vascularity on Doppler is not a sign of malignancy here : it is present in more than half the benign fibromas in that series3. Second, the comb sign, that alternation of hypoechoic and isoechoic bands described by these authors, appears all the more readily the larger the nodule, which makes it a useful but not an essential sign.

MRI, and the trap it holds

MRI is requested when the lesion is large, deep, atypical, or when doubt about a tumour persists. It does however have a shortcoming worth knowing before reading an alarming report.

A case published in The Foot reports a 42-year-old man with a histologically provenplantar fibromatosis, whose MRI showed a so-called “brain gyriform” pattern: an appearance until then described as specific to low-grade fibromyxoid sarcoma. Posterior acoustic enhancement on ultrasound, T2 hyperintensity and contrast enhancement were all atypical, and corresponded histologically to areas of high cellularity alternating with cell-poor fibrous areas20.

The practical message runs in both directions: a genuine plantar fibroma can look like a sarcoma on MRI, and a sarcoma can be taken for a plantar fibroma19. No imaging replaces histopathology when the presentation falls outside the usual frame. It is not for the physiotherapist to decide, it is for them to know when not to treat.

What can physiotherapy do, and what belongs elsewhere?

This is a disease in which the physiotherapist is often the first to be consulted and rarely the one who will treat it. Knowing what can be offered, and when to hand over, is better than multiplying sessions on a nodule that will not move.

The state of the evidence, without arrangement

The most complete systematic review of treatments gathered 25 studies and 233 patients. Across that whole set, only five studies concerned a conservative treatment, totalling 35 patients, against 178 patients operated on15. The authors conclude that clinical trials with standardised outcomes are still needed to evaluate the success rate and the complications of each procedure seriously.

An older review already wrote it: no causal treatment exists, management is symptomatic and graded by severity, and no long-term randomised controlled study was available for the conservative options2. Since then one exception has appeared, and only one: radiotherapy, which has its own chapter below.

What rehabilitation actually aims at

Aim no. 1, take the load off the nodule. This is the measure whose effect is the most immediate and the most reproducible in practice. A foot orthosis with a hollow over the nodule, a cushioning insole, footwear with a thick, rigid sole: anything that stops the nodule being crushed between the ground and the bone reduces weight-bearing pain. No trial has measured that effect in this condition: it is mechanical reasoning, and it must be presented as such.

Aim no. 2: maintain the flexibility of the posterior chain. A short triceps surae increases the load on the fascia. Stretching of the gastrocnemius and soleus, and specific plantar fascia stretching, are commonly proposed. Here again, no data specific to Ledderhose disease: the transposition comes from plantar fasciopathy, which is another disease of the same tissue.

Aim no. 3: monitor. This is a physiotherapist's job in its own right and it is underrated. Mapping the nodules, measuring them, recording their number: that is what will make it possible to say in six months whether the disease is progressing, and that is what will trigger referral.

What to avoid. Aggressive techniques applied directly to the nodule (heavy deep transverse friction, prolonged ischaemic pressure, radial shockwaves aimed at “breaking it up” without an established protocol) have no data in their favour and risk aggravating the pain of a lesion which, for its part, does not dissolve under the finger. That point is reasoning, not a trial: there is no trial.

The table of modalities, with the level of evidence actually available

The ranking below applies GRADE principles to the precise question of symptomatic treatment of Ledderhose disease. It is an editorial appraisal : no published GRADE assessment and no learned society guideline exists for this condition.

Does radiotherapy really work?

It is the only question in this article that a randomised trial against placebo answers. It deserves detailed treatment, because it is also the treatment patients are most afraid of.

The LedRad trial, and why it counts

The LedRad study is a prospective multicentre double-blind randomised phase 3 trial. Patients were allocated between radiotherapy and sham radiotherapy: a placebo, therefore, which is exceptional in this field. The primary outcome was the reduction in pain at twelve months on a numerical rating scale10.

Eighty-four patients were included. The results:

• Pain at 12 months : 2.5 in the irradiated group against 3.6 in the placebo group (p = 0.03).
• Pain at 18 months : 2.1 against 3.4 (p = 0.008): the gap widens with time rather than fading.
• Pain relief at 12 months : 74 % against 56 % (p = 0.002).
• Quality of life significantly better in the irradiated group (p < 0.001), and barefoot walking speed and cadence higher (p = 0.02).
• Adverse effects : erythema, dry skin, burning sensations and a transient increase in pain, mild in grade in 95 % of cases, and resolved in 87 % of patients at eighteen months10.

What becomes of the effect in the long term

The same team surveyed by questionnaire all the patients treated with radiotherapy in their centre between 2008 and 2017. One hundred and two feet were irradiated in 67 patients (28 men, 39 women), on a protocol of two series of five daily fractions of 3 Gy11.

Mean pain fell from 5.7 before treatment to 1.7 at the time of assessment (p < 0.001). The detail of the response is more instructive than the mean: a complete response, pain gone, for 42 feet (41 %), a partial response for 38 feet (37 %), no change for 22 feet (22 %), and worsening for none. Seventy-eight per cent of patients said they were satisfied, 57 % did not find the treatment burdensome, and quality of life scores were comparable to those of the Dutch population of the same age. The most frequent residual adverse effect was dry skin, in 10 patients (15 %)11.

One patient in five gets nothing from radiotherapy, none comes out worse, and two in five have no pain at all: it is the only treatment for this disease of which that can be said with a figure.

When do you operate, and why is recurrence the rule?

Surgery relieves, and it recurs. Those two facts do not contradict each other: they are explained by a single variable, the extent of what is removed.

Recurrence depends on the width of the resection, and on nothing else

This is the most useful result in the whole surgical literature on this disease. A systematic review coupled with a personal series compiled six studies covering 109 feet in 92 patients, and classified recurrence by the procedure performed16 :

The authors draw an explicit recommendation from it: prefer wide excision or fasciectomy to local excision, because of the markedly lower recurrence rate16. Their own series of 12 patients reviewed between 2 and 13 years after a wide excision shows 2 recurrences (17 %) at a mean follow-up of 7.8 years, with a median Foot Functional Index (Foot Functional Index) of 1 and a median AOFAS score of 95, in other words excellent functional results in those who do not recur.

A British series offers a useful counterpoint. Eighteen patients, nineteen partialfasciectomies, with up to five years of follow-up: a single recurrence (6 %), but 17 % scar problems: two cases of scar pain and one hypersensitive scar that resolved at twelve months5. That last point is not trivial in a region that carries the body's weight: a painful plantar scar can be more disabling than the nodule it replaced.

Who to operate on, and when

The rule accepted by all the reviews is simple: surgery comes after conservative treatment has failed, never before915. The criteria that tip the balance:

• disabling weight-bearing pain despite offloading, an adapted orthosis and modified footwear;
• a large nodule, or documented progression over several months;
• an established toe contracture: rare, but it changes the functional picture;
• persistent diagnostic doubt, where excision also has histopathological value.

And a common-sense contraindication that the literature suggests through its figures: an asymptomatic nodule is not operated on. Two thirds recurrence after local excision is not a reasonable price for removing a lump that does not hurt.

What do real case reports teach us?

Four published situations, taken as they stand with their identifiers. Two show what treatment can do, two show what imaging cannot.

How do you apply all this on Monday morning?

A rare disease, with no guideline, whose best treatment does not fall to us: the physiotherapist's role in it is real, but it has to be defined precisely so as not to be lost in pointless sessions.

The first session, in six points

1. Name it and distinguish it. Tell the patient that this is not plantar fasciitis, that it is the plantar cousin of Dupuytren's disease, and that the toe contracture they fear is the exception and not the rule1.
2. Map it. Number of nodules, size in millimetres, distance from the back of the heel, side. It is the only datum that will allow progression to be followed without multiplying imaging.
3. Examine the hands, and the other foot. One man in seven with Dupuytren's disease has plantar nodules6 ; the converse justifies inspecting the palms of every Ledderhose patient.
4. Rule out the red flags before laying a hand on it: rapid growth, size over 5 cm, night pain, deep fixation.
5. Offload. A foot orthosis with a hollow over the nodule, a cushioning insole, footwear advice. It is the intervention with the most direct effect on the complaint.
6. Explain the whole pathway. Including radiotherapy, which the patient will not consider spontaneously and which is nevertheless the only treatment validated against placebo10.

What you follow up, and how often

Who to refer to, and when

• Orthopaedic foot surgeon, for disabling pain despite offloading, a large or progressing nodule, a toe contracture, or diagnostic doubt. Reminding them that the extent of the resection governs recurrence16 is legitimate: it is published.
• Radiotherapist, through the family doctor or the specialist: it is the treatment with the best level of evidence, and the patient will never ask for it themselves.
• Orthotist or podiatrist, for the foot orthosis with selective offloading, which requires a cast or scan adapted to the exact site of the nodule.
• Specialist opinion without delay, for any red flag. A reminder: sarcomas present under the exact mask of a plantar fibroma19.

Frequently asked questions

Can this lump disappear on its own?

That is unlikely. Ledderhose disease is a fibrous proliferation; no regular spontaneous regression is described, and no causal treatment exists2. On the other hand, a nodule can stay stable and painless for years, in which case there is nothing to do, and that is good news which should be delivered as such.

Am I going to get the same thing in my hands?

The link exists and it has been quantified: in the Reykjavík cohort, 15.2 % of the men with Dupuytren's disease had plantar nodules against 3.9 % of controls6, and the presence of Ledderhose disease is among the risk factors for Dupuytren's in a Dutch population study7. That justifies examining the palms, not being alarmed: most patients will not have both.

Is it cancer?

No: it is a benign lesion1. But the question is legitimate, because rare malignant tumours can present in exactly the same way19. That is precisely why a mass that grows quickly, that exceeds a few centimetres or that wakes you at night is investigated before it is treated.

Should it be operated on?

Only after conservative treatment has failed915, and never on a painless nodule. The point to know before deciding: recurrence depends on the extent of the resection: 67 % after removing the nodule alone, 42 % after wide excision, 27 % after fasciectomy16. A partial fasciectomy also led to 17 % scar problems in a series of 18 patients5, which is no small thing under a foot.

Are insoles of any use?

No study has measured it in this disease. The mechanical reasoning is solid (a nodule at the middle third of the arch is compressed at every step between the ground and the bone, and a hollow removes that compression) and the risk is nil. It is a common-sense intervention, to be offered as such and not as a validated treatment.

Can I keep running?

Nothing forbids it and nothing encourages it: the question has not been studied. The practical marker is weight-bearing pain, which governs. Change the surface, the shoe and the volume before stopping, and adapt the orthosis to the sports shoe, which does not have the same internal volume as a street shoe.

Radiotherapy, isn't that dangerous?

In the randomised phase 3 trial, the adverse effects (erythema, dry skin, burning sensations, a transient increase in pain) were mild in grade in 95 % of cases and resolved in 87 % of patients at eighteen months10. In the long follow-up cohort, the most frequent residual effect was dry skin in 15 % of patients11. The decision rests with the doctor; the factual information can be given in a session.

Do shockwaves work?

The available literature is a prospective series of six patients and one case report, both without a control group1213. The reported results are favourable and the parameters are published (high-energy focused waves, not radial ones), but the sample size rules out any conclusion. To be offered, where appropriate, as a therapeutic trial whose level of evidence is stated.

Bibliography

Every reference was verified individually in PubMed: identifier resolved, journal, year, volume and author list checked, abstract read to make sure the source does establish what is attributed to it.

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