Ganglion Cysts in the Foot and Ankle

Ganglion Cysts - A Painful Bump On the Top of The Foot.

 

What is a ganglion cyst?

A ganglion cyst is fluid filled sack that appears a lump or bump under the skin. In the foot this most often occurs on the top of the foot or at the big toe joint. The fluid within a ganglion cyst is actually synovial fluid (the fluid that lubricates your joints). The ganglion itself is a little balloon of synovial tissue that has squeezed out of the joint capsule. Because of this, a ganglion cysts is always a little mass attached to or extending from a joint or tendon sheath. 

The most common location for a ganglion is actually the wrist. But ganglion cysts also frequently occur on the top of the foot, at the base of the big toe (or at the big toe joint), or around the ankle. Ganglion cysts are also sometimes called a “ganglionic cyst” or a “Bible cyst.”

 

 

Why do ganglion cysts cause foot pain?

A ganglion cyst in the foot will start to become painful only when it gets compressed between the bones on the top of your foot and the shoe that you wear. It can certainly become more painful if your laces are tight. Dress shoes, cycling shoes and ski boots also cause pain simply because they may be tight and stiff, which squishes the ganglion inside the shoe. The skin can become irritated and red. Any nerve that is close to the ganglion cyst might also become impinged and cause pain. 

How to diagnoses a ganglion cyst in the foot.

Basically if you are between 20 and 50 years old, and the lump is soft, slightly mobile and located right next to a tendon sheath or joint, it is probably a ganglion. This is just based on statistical probability.  After all, the vast majority of lumps and bumps on the top of the foot are ganglions. 

Of course, not all lumps and bumps in the foot are ganglions. Osteophytes are hard growths of bone that occur around arthritis joints. They are common at the big toe joint and on the top of the midfoot. Because they are related to osteoarthritis, they more often occur in older adults. The bump in this case is much harder than a ganglion. Unlike a ganglion that is slightly mobile little sack that you can move slightly, osteophytes are bone that won’t budge because it is actually part of the underlying bone. 

Another mass that might appear to be a ganglion is pigmented villonodular synovitis (PVNS). This is also sometimes called a “giant cell tumor.” PVNS also happens in young adults. It is also often frequently misdiagnosed as a ganglion. PVNS is more dangerous than ganglion cysts because it invades tissues and causes damage. 

In 2005, I was co-author of a report of PVNS in two you women, both of whom had been misdiagnosed. In both cases their doctors incorrectly thought they had a ganglion. We had to do surgery to remove all of the damaged tissue that was invaded by the PVNS. PVNS has a characteristic appearance on MRI and so MRI is the very best way to diagnose PVNS. PVNS requires surgery.  It is so invasive that I actually recommended a new treatment including irradiation of the mass to prevent its return. This was also published another medical journal. The good thing is that PVNS is very rare compared to ganglion cysts.

The best way to tell for sure whether or not you have a ganglion is to have a doctor drain it. As soon as the thick, straw-colored synovial fluid comes out, we know it is a ganglion cyst.

If your podiatrist does drain it, then he can also inject some corticosteroids that cause the ganglion to shrink.  This will increase the chances that it will get smaller and quit bothering you.

What is the best way to treat a ganglion cyst in the foot?

One of the earliest mentions of ganglion cyst treatment in a medical text went something like this: “The physician places the patient’s extremity on a table. The physician then firmly strikes the ganglion with a King James Bible.” Obviously striking patients with any object, no matter how enlightened that object might be, is no longer performed by most doctors. But this archaic treatment recommendation is the origin of the term “Bible cyst.”

The first real question when treating a ganglion is to decide whether you just want it to stop hurting, or do you really want the mass to go away completely.

If it is big and unsightly, you have tried the standard treatments, it has been present for months or years and you want it to go away, you really only have two choices 1) drain it and hope it won’t come back 2) surgically remove it.

Ganglion surgery becomes necessary when other treatments fail. 

The standard self-treatments for ganglion cysts of the foot are as follows:

1. Wait to see if the cyst will go away on its own. Foot surgeons call this spontaneous resolution.  Believe it or not this actually happens fairly often. Because of this, it may be worth waiting to see if the ganglion cyst will go away on its own. The exception to this is if yo have burning or tingling pain. Burning/tingling in the foot can be a sign of nerve compression that might cause permanent nerve injury.  

2. Wear shoes that don’t push on the cyst. If you just want it to stop hurting, you can simply pay close attention to the shoes you wear, making sure that your shoes don’t press on the mass. Ganglions usually hurt because they get squished in between a shoe and the bones on the top of the foot. In cases of midfoot ganglions, there is usually a nerve nearby that makes the pain more noticeable. If the ganglion doesn’t have pressure on it it probably won’t hurt..

3. Apply pads next to the ganglion. Padding can sometimes help simply by moving some of the pressure from the mass, to the area around the mass. You can’t remove pressure, but you can put is someplace else.  This is how padding works. Just make sure you place the pads around (and not directly on) the mass. If you put a pad directly on top if the mass, it will hurt worse. You can find gel or felt pads at the drug store.

4. Adjust your shoelaces by changing your lacing pattern. If you lace your shoes so that you skip one hole right at the location of the ganglion on the top of your foot, it will significantly decrease the amount of pressure and irritation to the ganglion. This may be enough to allow you to run without pain. If you are wearing cycling shoes that press on the ganglion, make sure that the strap that goes over the ganglion is loose. The goal is to simply decrease the amount of pressure from your shoes on top of the ganglion.

If none of these treatments work then you can see a foot surgeon who is experienced in treating ganglions and other masses like PVNS. 

Nonsurgical treatment of ganglions cysts in the foot by Podiatrists

One of the first treatments that any podiatrist or foot surgeon will try is to drain the ganglion. A small amount of local anesthetic will be injected to make the area numb. A needle is then inserted into the ganglion in order to try to drain the fluid. At the same time, a small amount of steroid is injected into the ganglion to get it to stick together and shrink down and shrivel up and go away. This does not work all of the time but it is certainly worth a try because it is a quick fix when it works.

When should I have surgery to remove a ganglion cyst in the foot?

If the ganglion is so big that it becomes difficult to wear shoes, surgery might be necessary. If the ganglion is drained and it comes back, you may want to consider surgery.  Surgery is much more reliable treatment than draining the ganglion. The reason that you shouldn’t consider it initially is that it is more expensive and requires more downtime.  You will have stitches in your foot for about 2 weeks after your surgery. You’ll have to decrease activity and keep the foot dry while you have stitches.

The only time you really must surgically remove a ganglion is if it is pushing on against nerve. Nerve compression can lead to permanent numbness, tingling and chronic pain. 

Unfortunately ganglions often occur on the midfoot or at the big toe joint right next to nerves. When the ganglion gets big enough to push against the nerve you get numbness tingling or burning pain. This can produce permanent nerve damage if ignored. If you have numbness tingling or burning pain, you may need to consider having ganglion surgery. 

If you do decide to have the ganglion surgically removed you want to time this so that it won’t disrupt your lifestyle. You should also make sure that you get a second opinion and see at least one foot surgeon who is an expert with ganglions and PVNS. The goal of ganglion treatment should be to allow you to return to which ever shoes and activities you need  to enjoy life, and your lifestyle to its fullest. 

Learn more...

If you are a runner, cyclist or triathlete, you can learn more specifics about ganglions in athletes at www.DocOnTheRun.com . 

Call to schedule a housecall to have your ganglion evaluated today! - 415-308-0833

Dr. Christopher Segler is a nationally recognized foot surgeon and sports medicine podiatrist. He is an internationally recognized expert in PVNS and soft tissue masses that may appear to be ganglion cysts. His research and theories on PVNS have been published in the medically journals and were used as the basis for new treatment methods of these soft tissue masses. He practices podiatry, sports medicine and surgery in San Francisco. His practice focuses on runners, triathletes and complicated reconstructive foot and ankle surgery cases. He lectures worldwide at medical conferences to audiences of podiatrists, sports medicine physicians and foot surgeons about complicated running injuries and his patented and published methods to speed up surgery and reduce pain after foot and ankle surgery. if you have a question about a ganglion you can call him directly at (415) 308-0833