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Dorsal forefoot ganglion

Discussion in 'General Issues and Discussion Forum' started by Beth Gill, Mar 6, 2006.

  1. Beth Gill

    Beth Gill Member

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    Hi All,
    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.
  2. admin

    admin Administrator Staff Member

    Aren't you supposed to hit them with a bible?:)
  3. pgcarter

    pgcarter Well-Known Member

    Yes Craig, but that is for cranial ones....Hi Beth
  4. Beth Gill

    Beth Gill Member

    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.
  5. admin

    admin Administrator Staff Member

  6. Atlas

    Atlas Well-Known Member

    Big for a ganglion?

    Has a benign lipoma (fat cell collection) been ruled out? Has it been radiologically diagnosed?

    If, in the small possibility that it is a lipoma, the bible won't be much help unless JC pulls something out of the hat.

    I have seen podiatric surgeon(s) pimple squeeze bursa; could this be the conservative solution for whatever is going on.
  7. Scorpio622

    Scorpio622 Active Member

    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.
  8. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    I had one a couple of weeks ago coming off the 1st MTPJ with a hallux rigidus. It was causing pain with shoe gear.

    I did a small field block, put an 18guage needle into it and drained it - typical clear, jelly-like substance. A bit of force is sometime required to milk it out.

    You have to warn patients that these usually communicate with the joint, so keep the clean and well dressed for a day or two. Recurrence is high with an arthritic joint.

    Simple 5-minute procedure.

  9. Beth Gill

    Beth Gill Member

    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.
  10. NewsBot

    NewsBot The Admin that posts the news.

    A painful large ganglion cyst of the ankle treated by the injection of OK-432
    Ogose A, Hotta T, Kawashima H, Endo N.
    Mod Rheumatol. 2007;17(4):341-3
  11. Admin2

    Admin2 Administrator Staff Member

  12. NewsBot

    NewsBot The Admin that posts the news.

    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.
  13. drsarbes

    drsarbes Well-Known Member

    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)

  14. NewsBot

    NewsBot The Admin that posts the news.

    Operative Treatment for Ganglion Cysts of the Foot and Ankle
    Jae Hoon Ahn, Won-Sik Choy, Ha-Yong Kim
    Jnl Foot Ankle Surg 22 July 2010
  15. I had a good sized one of these. Considered aspiration and excision but fancied neither.

    So I thumped it one. I used the spine of "gates of fire" by Steven pressfield, a thrilling novelisation of the battle of thermopylae. 525 pages.

    Instant fix, no recurrence. Don't rule it out. I have a reference if anyone is interested.
  16. drsarbes

    drsarbes Well-Known Member

    Terrible advice Robert.....you KNOW one should always use a Bible when exorcising the devilish cystus ganglionius.

  17. W J Liggins

    W J Liggins Well-Known Member

    Well maybe....but those Greeks were creating medicine and surgery as we know it long before the Christian era! Anyway, a spartan treatment.

    Do you charge more if you use a comparatively rare book Robert? Does it work better if you believe in the book? Does it work better if the patient believes in the book?

    I feel an Isaccian research project coming on.

  18. 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.
  19. Jaimee Brent

    Jaimee Brent Active Member

    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?

    any thoughts?
  20. NewsBot

    NewsBot The Admin that posts the news.

    Preliminary report of the effectiveness of tetracycline sclerotherapy in treatment of ganglion.
    Ashindoitiang JA.
    Plast Surg Int. 2012;2012:624209.
  21. NewsBot

    NewsBot The Admin that posts the news.

    Arthroscopic ganglionectomy of the foot and ankle.
    Lui TH.
    Knee Surg Sports Traumatol Arthrosc. 2012 May 31. [Epub ahead of print]
  22. admin

    admin Administrator Staff Member

    Last edited: Sep 22, 2016
  23. drsarbes

    drsarbes Well-Known Member

    Well done:
    I have never used an #11 blade for this, usually just aspirate and or Milk it.
    An unusual location for a ganglion.

    I say 90% chance it will refill. Most likely coming of a flexor tendon sheath.


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