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I've been taking in all your advice anonomously, and finally decided to take part and ask a question!
I'm a podiatrist in Australia, and I'm looking for advice on conservative treatment options for a ganglion. It is on the dorsum of base of left metatarsals 1 and 2. No pain on palpation or from shoes. Size: 4cm in diameter, 0.5 cm height. It is soft and slightly movable under the skin. Duration: 4 weeks.
The GP has recommended surgical excision, but my patient (74 year old female with no outstanding medical history and no medications) is hesitant to undergo such a procedure. However, we are concerned that if the ganglion continues to increase in size it may cause pain from footwear pressure.
I have read that aspiration is possible, followed by compressive taping to prevent the ganglion 'refilling'. If so, from which angle should I aspirate, and what precautions are necessary.
I also have a friend who had a ganglion and the GP recommended him to use an anti inflammatory gel on it for 2 weeks, and it resolved.
Any suggestions of treatments, apart from throwing a bible at it, :) would be much appreciated.
Hello to you both and thanks for replying.
Thanks Craig. I did actually mention the bible treatment, but I think that worried her more than the prospect of surgery, until she realised I was joking.
I think you're right Phil, sounds like it could cause a headache, or footache.
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After assuring that it is a ganglion, I often fill the ganglion to maximum tension with a large amount of Marcaine and a little bit of steroid. Then, I simply pop it like a pimple. I then apply a compressive dressing, but I don't think this does much because these things recur slowly with time and not over the next week, when we usually stop the compressive dressing. I find that the recurrence rate with this technique is lower than aspiration.
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Thanks to all of you for your replies. I spoke to the lady today and apparently it hasn't increased in size, and is still painless.
Unfortunately, as I'm a podiatrist in Australia, I'm not allowed to inject steroid and marcaine, but thanks for the suggestion.
I'm going to get her to come in again and I'll refer her for xrays to confirm diagnosis (originally from GP). :) . I'll let you all know the outcome. thanks again.
Despite its benign nature, a ganglion can be problematic. We successfully treated a patient with large painful ganglion in his ankle by OK-432 (lyophilized incubation mixture of group A Streptococcus pyogenes of human origin) injection. OK-432 injection seems to be a safe, convenient, and effective alternative to surgical treatment for either symptomatic or recurrent ganglia.
Paresthesia and hypesthesia in the dorsum of the foot as the presenting complaints of a ganglion cyst of the foot.
Casal D, Bilhim T, Pais D, Almeida MA, O'Neill JG. Clin Anat. 2010 Jul;23(5):606-10.
Although ganglion cysts of the foot represent a substantial amount of lumps in this region, they rarely cause peripheral nerve symptoms. We describe the clinical case of a 43-year-old female with complaints in the previous three months of hypesthesia and paresthesia in the anterior portion of the medial half of the dorsum of her left foot that extended into the first interdigital cleft. She associated the start of her neurological symptoms to the appearance of a lump in the dorsum of the foot. A presumptive diagnosis of compression of the medial branch of the deep fibular nerve and of the medial dorsal cutaneous nerve in the dorsum of the foot by a ganglion cyst was made. Ultrasonography confirmed the cystic nature of the lesion and surgery allowed complete excision of a mass arising from the joint between the medial and intermediate cuneiform bones that was compressing the deep fibular nerve and the medial dorsal cutaneous nerve. Pathological examination confirmed that the lesion was a cystic ganglion. As far as the authors know, the simultaneous compression of the medial branch of the deep fibular nerve and of the medial dorsal cutaneous nerve in the dorsum of the foot by a ganglion cyst has not been described before.
You shouldn't really need an xray to Dx a ganglion. If you are concerned that possibly an underlying osseous pathology (osteophyte) is causing irritation, then perhaps it's indicated but unless you are going to perform the surgery, not really necessary.
Most ganglions are very easily diagnosed via physical examination. Aspiration is the conservative treatment of choice. It's very easy to do, in fact just inserting and removing an 18 g needle many times will allows one to "milk" it.
If it is non painful, your patient certainly has the option of no treatment. They usually get larger and more firm with time (as the contents become more viscous)
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
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The authors analyzed the clinical results of surgical excision for symptomatic or recurrent ganglion cysts of the foot and ankle, and tried to elucidate the prognostic factors. Fifty-three cases of ganglions in the foot and ankle were followed for more than 24 months after excision. The mean duration of follow-up was 3.7 years. As a preceding treatment, 17 cases received a mean of 1.3 aspirations, and 16 cases recurred after a mean of 1.7 operations. The cyst was most common in the dorsum of the foot and ankle, where 35 cases were found. Thirty cases originated from the tendon sheath, 19 cases from the joint, and 4 cases from others. Preoperative mean AOFAS foot scores were low in the cysts associated with the tarsal tunnel syndrome, and in the cysts of the plantar aspect of the first toe. Postoperative mean AOFAS foot scores were significantly increased in the preceding 2 groups. There were 3 (5.7%) cases of recurrence, all of which originated from the tendon sheath. In the case of ganglion cysts originating from the tendon sheath, careful attention should be paid to locate satellite masses to avoid recurrence.
Isaacs R G, A Pragmatic Randomised Controlled Trial of Book Types used for treatment of Dorsal ganglia. JIR, Vol 84, P937-P941
Dorsal Ganglions of the foot are a common affliction, affecting people of all ages and demographic groups. Various treatment methods are available, including surgical excision and aspiration. A third method is traumatic hypertensioning and rupture of the ganglion by the forcible application of a book. Empirically, good results have been reported using The Bible, however no data presently exists on whether the type of book is significant. A randomised controlled trial was carried out, using 4 documents, the King james bible (with annotations and concordance) the Torah, The Holy Qur'an and the control, a pamphlet entitled "Homeopathy and You". The control weighed less than 10 grams, so the mechanical effect of this can be considered negligable.
The books were all wrapped in plain brown paper to conceal their nature from the tester and the subject, and applied with a consistant force, so far as was possible, to the lesion. The results were then recorded as either a positive or nagative treatment outcome. 139 subjects were recriuted to the trial, with a dropout rate of 12 who ran when they saw the size of the books.
The results showed that the Holy Quran and the Holy Bible performed better than the placebo and the Torah (P=<0.02). There was no significant difference between the Qu'an and the Bible, however there was a statistically insignificantly better result for the Torah against the control. It is hypothesised that the fact that the Torah is a scroll increased the difficulty of accurately hitting the Ganglion. Further research is needed to test the Bible and the Qur'an against secular titles, Richard Dawkin's "The God Delusion" being the obvious choice.
Vested interest Declaration.
Mr Isaacs declares vested interest in the religion of the emergant church, a subset of Christianity.
I was just reading this thread and wanted to ask about a patient i habvve been seeing.
He has a Large protruding bump on the base of his forefoot. It's well demarcated and does have a viscous feel to it, but possibly larger and a bit more solid than any ganglion i have encountered but he has had it (and it has increased in size) over the last year. It's not painful for him, however he is having to alter his gait to walk comfortably as it is "noticable".
I have sent him for an MRI just to make sure it isn't a Lipoma etc.
basically the question is... if it is a ganglion, will aspiration of this site be best achieved from a dorsal or plantar aspect? Obviously under LA, but would there be high pain once it wore off if i went from the plantar? and as it is a large area (4cm by 2cm) would i be able to get enough movement from the dorsum due to the possible blocking of MPJ's?
Ganglion, a benign cyst, most common soft tissue tumor of the hand, usually occurs in the hand, wrist, and foot. It is difficult to treat as reoccurrence is common after surgery and also following other treatment procedures. In this study, sclerotherapy technique in 20 patients treated using a solution of tetracycline after aspiration is described. Most of the patients in this study were between the ages of 20 and 35 years. 16 patients had ganglion on the dorsum of the wrist, 2 patients had bilateral ganglion, and 2 patients had ganglion on the dorsum of the foot. Under aseptic conditions, the ganglions were aspirated using size 21 G needles, and then 1 mL equivalent to 100 mg/mL solution of tetracycline was injected. In the postoperative followup ranging between 18 months to 5 years, 2 reoccurrences were noticed that required the same technique. This procedure is simple, safe, effective, and cheap when compared to surgery and other nonsurgical procedure of treating ganglion.
To study the efficacy of arthroscopic ganglionectomy in the management of ganglia of the foot and ankle.
From 2006 to 2010, arthroscopic ganglionectomy was performed for 89 ganglia in the foot and ankle of 88 patients. Clinical and intra-operative details were reviewed retrospectively.
Ganglion stalk was identified in 6 % of the cases. The overall rate of presence of pathology was 26 %. The overall rate of recurrence or residual lesion was 12 % with high recurrent rate for extensor tendon ganglia and toe pulp ganglia.
Arthroscopic ganglionectomy of the foot and ankle ganglion by either internal drainage or complete resection is a feasible approach. Good results can be achieved in case of adequate internal drainage of the ganglion to the joints or fibrous tendon sheath.