Ganglion Cyst of the Foot

ganglion

A ganglion cyst is a mass or lump that forms below the surface of the skin. It is a benign cyst that is filled with a jelly-like fluid. The term ganglion means “knot”. It is not a malignant tumor, but a soft tissue benign mass. Ganglion cysts can occur anywhere; however, they usually occur at the wrist area and may occur at the foot (usually on top). This mass can change in size, vary in size, and may grow slowly.

wrist and footPresentation

The mass is usually asymptomatic and typically, the patient will find the mass at the top of the foot. The patient may have a burning sensation due to nerve irritation or compression of the nerve. Sometimes, a ganglion cyst mass occurs in the tarsal tunnel area, causing tarsal tunnel syndrome. If this is the case and the pain and burning sensation is not resolved with in tarsal tunnelconservative treatment, excision of the mass is probably the best option. The patient may have skin irritation, as well as difficulty in walking and wearing shoes. If the ganglion is pushing on a nerve and causing irritation, something surgical needs to be done, such as aspiration or removal. Usually, the patient’s symptoms become better after these treatments.

The physician will need to differentiate a ganglion cyst from plantar fibromatosis. Remember, ganglion cysts tend to occur at the top of the foot. Plantar fibromatosis occurs at the bottom of the foot. A ganglion cyst will transilluminate, while plantar fibromatosis will not.

tansilluminateTreatment

Treatment typically consists of observation, shoe modification, and aspiration/injection of steroids. Surgery is performed as the last resort.

The Accessory Navicular Bone

What is an accessory Navicular Bone?

accessoryAn Accessory Navicular Bone is an extra bone that may be attached or detached from the navicular bone. It is considered a normal variant and is present in approximately 10% of people. This accessory bone is usually located under the plantar medial aspect of the navicular and is often associated with a pes planus (flatfoot) deformity. Ossification of the navicular bone occurs at three years of age in females and five years of age in males. However, the accessory navicular bone does not begin ossification before eight years of age.

flatfoot

The majority of patients are asymptomatic but, females tend to be more symptomatic. The patient may present with an activity related limp and pain in the arch area. The condition may also be bilateral. During examination, there may be swelling, tenderness, warmth, or redness in the plantar medial aspect of the arch. Relative to a normal foot, a plain x-ray AP view can detect the accessory navicular. An external oblique view is considered to be the best imaging position to detect an accessory navicular bone. An MRI may also be obtained in order to determine the size and type of the accessory navicular as well as assess the posterior tibial tendon.

radiologyThe accessory navicular is classified into three types. In Type I classifications, the accessory ossicle is mainly in the substance of the posterior tibial tendon and is not attached to the navicular. In Type II, the accessory bone resides very close to the navicular tubercle and is connected to the navicular by a thick layer of cartilage. In Type III classifications, the accessory bone is considered an enlarged navicular tubercle. Type IIIs are essentially a type II that is fused with the navicular by a bony bridge.

accessory typesIn regards to prognosis, when skeletal maturity has been reached, almost all patients become asymptomatic.

Treatment

Nonoperative treatment usually consists of activity modification, orthotics, or a short leg walking cast. Surgical excision is indicated only after all conservative treatment options have failed.

 

 

Dislocations of the Talus

dislocationtalusA dislocation of the talus can be a total dislocation or a subtalar dislocation. There are two different main types of dislocations, total and subtalar. Subtalar dislocations are further categorized into lateral and medial dislocations.

A total dislocation of the talus that is not accompanied by a fracture is a very rare injury. Most of the injuries are open and urgent care is necessary totalin order to avoid any soft tissue complications. There is a high risk of avascular necrosis of the talus, as well as arthritis and soft tissue infection.

Subtalar dislocations of the talus are rare injuries that result from either excessive supination or from excessive pronation. It involves a simultaneous dislocation of the distal articulations of the talus at the talocalcaneal and talonavicular joints. A lateral subtalar dislocation is often the result of a high energy trauma. These dislocations have a worse long-term prognosis. Irreducible lateral dislocation due to interposed tibialis posterior tendon. Lateral subtalar dislocations can be unstable and may sublux. The physician may need a CT scan to check for fractures. 85% of the dislocations are medial and subtalaroften result from low energy trauma. Irreducible medial dislocations can be due to the interposed extensor digitorum brevis or extensor retinaculum. The direction of subtalar dislocation has important effects with respect to management and outcome. Complications of subtalar dislocations may include stiffness and subtalar arthritis.

Treatment

Stable dislocations will be treated with a closed reduction. The patient should have 3-4 weeks of immobilization, followed by physical therapy. Unstable fractures will require a closed reduction; an internal fixation may be required. An anteromedial incision is used for medial dislocations and a lateral approach is used for lateral dislocations.

 

Common Foot Conditions and Injections

 

Conditions which cause pain and inflammation are treatable with the use of diagnostic and therapeutic injections. The purpose of this article is to shed some light on common ankle and foot conditions that may require injections and where the proper sites to perform these injections are located.

anklejoint

Ankle Joint

The ankle joint is formed by articulation of the tibia and talus. Injections are performed here to alleviate pain occurring from trauma, arthritis, gout, or other ankleeeeinflammatory conditions. Anterolateral Ankle Impingement can occur due to the build-up of scar tissue in the ankle joint or from the presence of bony spurs. When executing an injection here, the ankle will need to be in a neutral position. The physician will mark the injection site just above the talus and medial to the tibialis anterior tendon. The injection site should be disinfected with betadine. Then, the needle is inserted into the identified site and directed posterolaterally. The solution is injected into the joint space and should flow smoothly without resistance. It may be helpful to pull on the foot in order to distract the ankle joint.

First Metatarsophalangeal Joint

The MTP joint is a common injection site frequently affected by gout and firstmetaosteoarthritis. The injection site is first disinfected with betadine and then the needle is inserted on the dorsomedial or dorsolateral surface. The needle is angled at 60-70° of the plane to match the slope of the joint. The solution is injected into the joint space and should flow smoothly without resistance. Pulling on the big toe is sometimes helpful in distracting the joint.

 

Peroneal Tendonitis

Peroneal Tendonitis is an irritation to the tendons that run on the outside area of the ankle, the peroneus longus and peroneus brevis. First, the injection site is disinfected with betadine. Then, the needle should be carefully inserted in a proximal direction when injecting the peroneus brevis and longus tendon sheath. The needle will need to advance distally to inject the peroneus brevis alone at its bony insertion.

peroneal

Achilles Tendonitis

Achilles Tendonitis is an irritation and inflammation of the large tendon in the back of the ankle. Achilles tendonitis is a common overuse injury that occurs in athletes. needlingInjections of steroids should be given around the tendon, not through the tendon. The injections inserted directly into the tendon is not recommended due to the increased risk of tendon rupture. A platelet injection can be done through the tendon with needling and fenestration.

 

Tarsal Tunnel Syndrome

Tarsal Tunnel Syndrome is a condition of pain and paresthesia caused by irritation to the posterior tibial nerve. When performing an injection for this condition, the tarsal tunnelphysician will want to feel the pulse of the posterior tibial artery. The nerve is posterior and the physician will want to find the area of maximum tenderness. The injection site should be 1-2cm above the tender area, which is marked on the medial side of the foot and disinfected with betadine. The solution is injected at a 30° angle and directed distally. It is important to inform the patient that the foot may become numb and that care should be taken when walking and driving. Injections for Tarsal Tunnel Syndrome are usually performed after a treatment program which can include rest stretching and the use of shoe inserts.

 

Plantar Fasciitis

The plantar fascia is a band of connective tissue deep to the fat pad on the plantar aspect of the foot. Patients with plantar fasciitis complain of chronic pain symptoms that are often worse in the morning with walking. The injection site is identified and marked on the medial side of the foot and betadine is used as a disinfectant. The physician will need to avoid injecting through the fat pad at the bottom of the foot to avoid fat atrophy. The needle is inserted in a medial to lateral direction one finger breath above the sole of the foot, in a line that corresponds to the posterior aspect of the tibia. The solution is injected past the midline of the width of the foot.plantar