Many people know what a cyst is, but often times the word “cyst” can ignite fright in people, as it has developed a negative connotation to it over the years. However, when the word ganglion is used as its predecessor, the negative connotation has permission to be dropped. Ganglionic cysts are benign (non-harmful) fluid filled masses or bumps, solely involving the soft tissue that can develop on any area of the body, but of course as Podiatrists, we see them on the lower extremities!
So first, where do these ganglions come from? Well, their exact cause it unknown, but in the lower extremity they usually appear on the dorsal (top) surface of the foot, also known as the extensor surface of the foot. They are typically attached to an extensor tendon, meaning a tendon that travels across the dorsal surface of the foot, and therefore, it has been speculated that ganglions form secondary to pressure along such tendons from shoe gear, prompting the body to protect itself via creation of a ganglion.
In addition to being closely affiliated with an extensor tendon, ganglions typically form near a joint in the foot, which isn’t too difficult as the foot is filled with numerous bones and thus numerous joints. They use the joint as a place to tether themselves to (via a stalk), often making definitive removal more difficult.
For the patient, treatment isn’t sought until one of two things occurs: the ganglion becomes painful and starts to limit activity or shoe wear, or the ganglion becomes so large that patients begin to get worried about what lies beneath! Either way, when presenting to a Podiatrist, you will be evaluated in the same manner, and a diagnoses of Ganglionic Cyst will be made. Podiatrist have several ways to come to such a diagnoses including palpation of the cyst as a freely moveable mass in the first layer of tissue below the skin (subcutaneous) in addition to its location over an extensor tendon. X-rays will most likely be taken to ensure that there is no bone involvement, which with Ganglionic cysts, there typically isn’t bone involved: it’s strictly a soft tissue mass. Finally, if your Podiatrist feels as though it is necessary, you will be sent for an MRI, which can look specifically at soft tissue and determine the exact location of the mass, its attachment to surrounding structures and its overall size.
At this point, depending on the Podiatrist’s treatment choice for ganglions, they may suggest one of three treatment options:
Do nothing. If the ganglion is not painful and is not hindering daily activity it can be left alone. Sometimes they will increase in size to where they will become painful, at which time the Podiatrist will tell you to return for options 2 or 3.
Aspirate. This means that the area will be injected with a small amount of numbing medication, punctured with a sterile needle and the fluid inside, typically gelatinous and pink in color, will be “squeezed” out, flattening the cyst and providing immediate relief. After the fluid has been aspirated a small amount of cortisone will be injected into the area to decrease inflammation and prolong recurrence. However, recurrence is highly likely and in some patients the cyst will return within months, while in other patients it will not return until years later, but non-the-less, in the same location.
Surgical excision. The ganglion can be surgically excised, helping to decrease its risk of occurrence. The procedure is technically easy and requires numbing medication around the site of the ganglion, a small incision over the site and removal of as much of the ganglion as can be teased away from the extensor tendon as well as removal of the stalk. This option provides the least rate of recurrence of the ganglion, but for unknown reasons, it may still return!
Ganglions are interesting soft tissue masses, that are benign and may or may not require treatment. However, it is always best to seek the opinion of your Podiatrist rather than self-diagnose. They can provide several options that may help eliminate or relieve any symptoms you may be experiencing secondary to your ganglion, and knowing what that ‘random bump’ on your foot is, will at least put your mind at ease!
