Ganglion Cysts of the Foot & Ankle
A Ganglion cyst is a fluid filled swelling that usually occurs near a joint or tendon in the foot or ankle. They are non-cancerous, benign lesions that are outpouchings of the capsule or sheath that surrounds a joint or tendon. They are filled with a clear jelly like substance called synovial fluid.
- A Ganglion appears as a smooth lump just under the skin that can feel quite tense yet indentable.
- Ganglions can be singular or multi-lobular giving a ‘bunch-of-grapes’ feel and appearance
- They can fluctuate in size daily or weekly.
- A ganglion can resolve completely on its own, though no timetable or natural history for this is predictable.
What symptoms do they cause?
- Pressure pain from the lump rubbing in shoewear.
- Throbbing pain centred over the lump radiating into the underlying foot area.
- Joint pains away from the foot as you alter your walking gait to prevent aggravating the cyst.
- Skin redness or sores from rubbing in footwear.
What Investigations can be needed?
- Usually ganglions are clinical diagnosis where my high suspicion based on the examination and symptoms is enough to prompt treatment.
- If uncertain then an Ultrasound test or rarely an MRI can be used for more detail.
What are the treatment options?
A Ganglion cyst is entirely benign and therefore can just be left alone if it doesn’t bother you. If however you are experiencing persistent symptoms the systematic options include:-
Accommodate and Live with Ganglion
- Adjustments to shoewear or even a bespoke insole can be made to accommodate the lump and live with it.
- Time can occasionally see these resolve spontaneously, but it is not for certain.
Aspirate the Ganglion
- This is done in the Outpatient clinic
- The skin overlying is cleaned with antiseptic
- A single needle is passed into the ganglion
- An attached syringe is used to suck out the fluid and try to empty the sac.
- A bandage is wrapped around the foot to compress the sac flat and encourage it to stick together and not refill.
- You should not drive home immediately afterwards but should be OK later that day.
- Risks of the procedure
- Bleeding – Rare and should stop with pressure
- Infection – Rare and an aseptic technique will be used. If the area becomes red and hot then some antibiotics may be indicated
- Nerve Damage – Unusual but the needle passing in could catch a local nerve leaving a sensitive patch or an area with no feeling that usually resolves.
- Further Investigation – Occasionally no fluid is found or it appears not to be ganglionic fluid and then further investigations and possibly surgery are required.
- A sample of the unsuspected fluid is usually sent to the laboratory for microscopic examination
Approximately a 50/50 success rate with this technique is recognised in preventing recurrence.
Surgical excision of Ganglion
This is a daycase procedure usually undertaken under general anaesthetic or occasionally Local Anaesthetic with sedation.
You will have a tourniquet around your ankle or thigh depending on the location of the ganglion
- This area may feel a little bruised for a day or 2 afterwards
A cut is made directly over the ganglion and the sac excisied along with its contents.
The ganglion sac is usually attached to a capsule of joint or tendon and apiece of that is excised also along with any underlying bone prominence if present (Osteophyte).
The wound is closed with absorbable sutures and wrapped in a bulky compressive bandage.
The recovery period from surgery
Allow 2 weeks off work & driving to rest and get the wound healed
You should go home the same day as the surgery
You should rest and elevate your foot “Toes above your Nose” for the 1st few days.
You will be able to Fully Weightbear immediately after the surgery when necessary wearing the surgical sandal provided.
Likely Follow-Up arrangements
- At 2 weeks you will return to clinic for a wound check
- If all is well you will be encouraged to bathe and massage the scar to optimise healing.
- No further routine follow-up is usually required.
Bleeding : A Small amount of bleeding is to be expected following surgery. A small patch of blood on the dressing is not uncommon. There is usually nothing to worry about if this happens.
- Bleeding seen to drip from the toe or be soaking the dressing should be immediately reported
Infection: A localised infection to the skin occurs in my experience in about 1:20 cases of foot surgery and requires a course of tablet antibiotics. A deeper infection of the joint, bone or tendons can be more serious but fortunately is very rare.
- Infection appears as increasing pain, redness, pus or feeling unwell – please report any concerns of this to a nurse or doctor.
Scar pain – A local nerve response felt as soreness when the scar is touched or rubbed particularly inside shoes
Nerve Damage – To cut get around the Ganglion and excise it the local fine nerves will be pulled and dissected. This will leave the area a little numb to start with. Occasionally a larger nerve can be damaged leaving a permanent area of numbness or heightened sensitivity.
Recurrence – Reading of the evidence suggests approximately a 20% chance of recurrence of a ganglion at the same site
Persistent Pain – It is possible that despite removing the lump any underlying joint or tendon irritation may remain and hence the pain remain
GENERAL RISKS OF ANY SURGICAL PROCEDURE
- Small areas of the lung may collapse, which increases the risk of a chest infection.
- If you develop shortness of breath or start coughing up blood or yellow sputum – Seek medical attention
- Stress of surgery can cause a heart attack or stroke.
- If you develop chest pain / sudden weakness or collapse - Seek medical attention
- Immediate life-threatening events may occur during any surgical procedure, which may require life saving interventions.
- Increased risk of wound infection, heart and lung complications, and thrombosis are associated with OBESITY and/or SMOKING.
Removing a ganglion is choice you and Mr. Williams make together based on your symptoms and how much it bothers you along with pragmatic trialling of alternatives. Always ask questions you may have before the treatment, any member of the team will help with these at any stage.