A 45-year-old male recreational football player presents with a four month history of swelling over the dorsum of his right foot. He cannot identify any significant cause for this. He reported increasing difficulty wearing tightly fitting shoes as well as altered sensation over his great toe.
On examination there was a visible, and palpable, mass over the dorsum of the right foot. This was located in the region of the Lisfranc ligament. The mass was tender, firm and cystic to palpation.
X-rays of the foot and ankle were normal. The palpable abnormality over the dorsal surface of the midfoot represents a reasonably substantial multiloculated fluid signal structure. The lesion has a long axis measurement of 2.9 cm with maximum depth and transverse measurements of 1.6 x 1 cm. It lies deep to the tendon of extensor hallucis and extensor digitorum longus, which it displaces and distorts, and extends deeply between the first and second metatarsals. It appears to be related to the Lisfranc joint (which is otherwise clinically and radiologically normal). It is in close proximity to the deep peroneal nerve.
This player was treated with aspiration of the ganglion and infiltration of corticosteroid. He has remained symptom-free for six months.
Ganglia around the foot are often not well tolerated. Compared with other sites, for example the wrist, they are generally larger. There are also region-specific issues for example the pain is often provoked by wearing shoes because of the added pressure and irritation created by the mass of the cyst. Sensory symptoms are relatively common. This is often due to compression of the medial branch of the deep peroneal nerve. This structure runs distally on the dorsum of the foot and innervates the first web space.
In most cases the initial treatment for this type of ganglion involves a trial of non-surgical treatment, including aspiration. When the lesion is recurrent or painful, surgical excision can be a good option. Larger lesions and those that are located at a deeper site may be more likely to require resection. Nerve injuries occur in up to 10% of such resections and can lead to lifelong sensory changes.
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