Ganglion: Source of Years of Symptoms

Hi Dr. Blake. I know you must be very busy but i was wondering if you could help me.

I'm a 32 year old female.

I have been seeing a podiatrist for about 4 1/2 years, Initially with big toe pain which developed into chronic plantar fasciitis, eventually resolved in one foot by ESWT, the other foot being managed by orthotics only.

 I should mention that i am a radiographer and have access to xray/ MRI at ease (although not very good quality for feet as we don't have that particular piece of equipment) and referral to ESWT (not from my podiatrist), a colleague told me they had it and it helped- and it has.

Dr Blake's comment: ESWT stands for Extracorporeal Shock Wave Therapy. It is the ultrasonic blast that is used to break down kidney stones. I am familiar, and have had patients whom have had it, but I no personal experience. Like PRP injections, I consider this on the fringes of treatment, but would definitely recommend prior to surgical treatment for plantar fasciitis. 

I also have a completely ruptured ATFL in my right foot, i believe caused by rolling my ankle once in the orthotics initially prescribed for me, and excruciating peroneus brevis tendonosis requiring a cortisone shot (different podiatrist now) (PB eventually got better now pain is only occasional- ankle instability to blame probably).
Dr Blake's comment: So, a lot has been hurting, but you tend to respond well to treatment. Good sign!! The ankle ligament tear should be coupled with daily ankle strengthening--theraband for the peroneals, and single leg flatfoot balancing. 

On several visits i mentioned pain near the fibular sesamoid right foot but more towards the the distal phalanx in the meaty space between the big toe and second toe, it was getting worse and worse,(three podiatrists all said capsulitis) eventually i got a colleague to refer me for an x ray. it basically showed nothing except a small bony bit near the fibular sesamoid not really visible on previous x ray a few years prior. So i was concerned about it (no idea whether it was a fragment or osteophyte formation but convinced it must have something to do with my pain).
Dr Blake's comment: I am assuming it is the original big toe pain that started these pain symptoms.

It was getting so annoying i pulled apart my orthotics and removed the tear drop shaped dome between the 1st and 2nd MTPJ for capsulitis. This gave some relief. I showed the podiatrist and at first he thought it was a sesamoid fracture until i showed him the MRI. MRI showed ganglionic cyst extending from tendon sheath, first and second toe.
Dr Blake's comment: This is why I love MRI so that all the bone and soft tissue is evaluated. 

Although not this patient, the MRI is able to clearly show the soft tissues of the sore area.

The much bigger ganglion has a long stalk to the first toe. i then had a doctors referral to get aspirated and injected with steroid. The second toe was too small/tricky to aspirate (a little bubble sandwiched between two tendons). After two/three weeks pain started coming back- albeit not as bad as before. After two months i got another referral for aspiration and cortisone, however they couldn't see under ultrasound enough of the one under the first toe to do anything, and the second toe- could only inject around it and not in the ganglion or the tendon sheath.
Dr Blake's comment: You have to hope that this means the cysts are calming down.

At this point in time i am trying to increase my level of exercise- and have been enjoying doing so as it has been such a chronic limitation for me these past four years. I have weight to lose and i want to start a family (i'm 32) . I feel it is important for me to fix this once and for all. At this stage it isn't so bad but feel it when walking, after increased exercise it aches, i'm scared its just going to get worse again.
Dr Blake's comment: Ganglions are common, and can re-occur post shots, but are actually not that common to remove. The shots can be repeated if bad. Surgery to remove can be a complete success, but can have complications more serious than the cyst. Now that you have identified the source of pain in this area, and you have at least a temporary fix, you can follow this closely. 

About 14 years ago when i was 18 (this might be relevant) i saw a podiatrist for pain in this area, i was prescribed orthotics under the impression it was some sort of tendon issue between first and second MTPJ- pain never really resolved- i was just putting up with it (no imaging done at this time).
Dr Blake's comment: So much depends on how long you think this has been disabling to you since you have had the shots. Definitely you want to watch over the next 2 years, have some orthotic devices made that off weight the area, get a few more shots if warranted, and ice daily to keep the inflammation under control. You are not wrong if you just have it out due to the overall time, but if you desire, you still may be able to avoid surgery.

 I am wondering what i should do next.

I was thinking orthopedic consult with view to removal because this has been such an ongoing saga for me that took forever to diagnose until i did the mri. The pain to me seems where the ganglion arises from the tendon sheath.
The thing that worried me is that both my podiatrist and radiologist injecting the cortisone seemed to not think my pain came from the ganglions (well believe me i'm not making it up!). Can you shed some light on what is going on in my foot and what i should do? Is that bony fragment anything??
Dr Blake's comment: I will try to make time to read the MRI (Dr Rich Blake 900 Hyde Street San Francisco, Ca 94109), but if the first shot into the ganglion eliminated the pain for a while that is a great sign the sesamoid is not the issue. Also, now that you have had 2 injections, how is your return to activity going?

Also i have a ganglion in my left foot too under the second proximal phalanx too (just because i felt similar pain there but much milder and got them to have a look.

I thought i was going crazy for so long because none of the podiatrists believed there was something there. I was relieved when i found the ganglions to explain the pain.
Dr Blake's comment: We doctors all function on some form of tunnel vision. What is never wrong is your body. Golden Rule of Foot: Listen to Your Body. You knew something was wrong, and it was. You have a body that heals and talks. It depends if what it says can be interpreted. 

Any advice and thoughts would be helpful because i cannot find much about ganglions under the MTPJ area anywhere except your blog (which is wonderful).
I have xray and MRI images available if required. I am not sure what to do next. Is removal the answer? Dr Blake: Maybe your best choice, and I can hear the frustration loud and clear in your words. 

Thank you if you have the time to respond,
Marie (name changed due to climate change)

Ganglion Cyst Mimicking Sesamoid Injury: The Positive Role of an MRI

This young lady emailed me back in Dec 2012 to let me know that she fractured her sesamoid bone and was scheduled for surgery and should she seek another opinion. Her original email is at the bottom of this post. I encouraged her to get a second opinion. She cancelled the upcoming surgery and followed her gut. What was so different from other cases of sesamoid injuries was her feeling she was stepping on a golf ball. She was able to get another opinion and a MRI documenting the ganglion cyst with no fracture to the sesamoid. 

Dr. Blake,

 I am so sorry that is has taken so long to get back to you but I had an MRI yesterday and I am attaching 2 images. The Dr. suspected and the MRI confirmed that I don't have a sesamoid fracture but a very large ganglion cyst in my foot. I have been scheduled for surgery the end of May to remove the cyst and start the recovery process. Thank you so much for your encouragement to seek a third opinion, I consider you my second opinion,  I truly believe you have saved me a lifetime of suffering. 

Sincerly,

Large Ganglion Cyst is seen next to a totally normal sesamoid

Large  Ganglion Cyst noted on MRI under the first metatarsal near the sesamoids

Dr. Blake,

I was diagnosed with a fibula sesamoid fracture on my left foot. I feel like I am walking on a golf ball and that is what I call it now. I walk on the side of my foot to keep the pressure off of the ball of my foot but that is causing knee pain and hip pain.  The podiatrist that I saw took one set of x-rays sold me cushions for my shoes and arch supports to wear. I tried those for 2 weeks and no relief. When I returned to the podiatrist he suggested since the arch supports provided no relief that I try a cortisone shot. The shot took the inflammation out of my foot, for about a week,  so it felt like the golf ball went away but the pain was more severe since there was not any extra padding on the ball of my foot. I returned to the Dr. 2 weeks later and he said there is nothing else he can do surgery is my only option and sent me home. I feel after reading your blog that I really need a second opinion before I let anyone do surgery on my foot. My question is do I get that second opinion from another podiatrist or do I try to see an orthopedic doctor? I am scheduled for surgery on December 28, 2012. Any help or advice is very much appreciated. I have cried with my husband over this whole situation and how frustrated I am please help. 

Sincerely,

Ganglion Cyst/Bursitis Medial Ankle Area with MRI Image Presentation

This video shows a fluid filled ganglion cyst or bursitis on the inside part of the lower ankle area. The MRI views clearly show that the mass the patient presented with was indeed fluid filled and not a dangerous tumor. The patient is using ice massage techniques three times daily to reduce the swelling, and I will consider injection with drainage if it does not respond. Unfortunately, some of these cysts need to be surgically removed. 

Ganglion Cysts

Many patients present to my office with lumps on their foot that either appeared suddenly or gradually grew. These are normally ganglion cysts, formed by fluid leaking from tendons or joints. They are totally benign, and occasionally have to be surgically removed. But most patients are told to ice massage them in a circular manner 2 times per day to see if they can break them done. Before any thought of surgery, the ganglions should be drained in an office setting, one or two times. If the ganglions are not superficial, then cortisone can be injected after the draining to further increase the chance that they will not return. If you do get them drained, you need to spend one month with a compression wrap and extra padding over the ganglion to help prevent it from refilling up again. Here is an example of a ganglion from a recent patient. Like some patients, this patient also had a ganglion on his wrist that did need surgery. Ganglion patients can get other ganglions. 

These benign lumps are not attached to the skin, are soft to pressure, and can only be documented on MRI or ultrasound. X-rays should be negative. Since ganglion cysts can develop from herniations in the ligaments of an arthritic joint, X-rays may show boney changes under the ganglion. If you can use ice massage to shrink them, routine ice massage 2 to 3 times per week may help keep them from coming back. 

Ganglions: Soft Tissue Masses often seen in the Foot



Patient presents with painful swollen big toe joint

  Patient Carleen presented to my office yesterday with a swollen big toe joint. These first two photos show how swollen the area looked. Compare the swollen right big toe joint with the uninvolved left big toe joint seen in the third photo.



Side View of the Swollen Right Big Toe Joint



Non Swollen, yet prominent, uninvolved left big toe joint

MRI showing Probable Ganglion Cyst not involving the Joint

MRI Image of the Sideview of the Big Toe Joint

After getting the MRI imaging, I drained the cyst of 5 ml of bloody fluid and sent it to the lab. The lab did not identify any bacteria. Hooray!! Carleen was started on icing and contrast bathing to reduce the swelling (minimum of 3 daily of the combination). She was given a hapad arch support to transfer weight into the arch and dancer's pad to float the painful toe. See the padding used in the following post link.

http://www.drblakeshealingsole.com/2010/09/sesamoid-fractures-advice-when-not.html

 I will follow her in two weeks. Ganglions may resorb, but some have to be surgically removed. I would inject 3 plus times with cortisone before considering surgery. She will need some form of orthotic device designed for her shoes to prevent pressure. The biomechanics of her foot is of a plantarflexed first ray which sticks out like a sore thumb and gets easily bruised. This bruising over time can lead to the gradual development of a cyst.

Carleen first felt symptoms 3 months ago, but does not recall bruising her foot. It is probably her biomechanics coupled with unpadded shoes, or the normal stress of activity, that causes the tissue to be initially traumatized. Ganglions are normally produced by normal joint or tendon fluid, that due to a weak spot in the lining of the joint or tendon sheath, allows the fluid to begin to seep out of the joint/tendon and into the surrounding tissue. The body attempts to wall off the fluid, but the hernia formed causes a gradual cyst formation. The biggest cyst of this type is called a Baker's Cyst off the back of the knee joint. Hopefully, with Carleen, we will be able to prevent surgery.