Ganglion Cyst of the Hallux: An AberrantPresentationGanglion cysts are benign, thin walled, fluid-filled lesions commonly occurring in the distal extremities.Although widely debated in the literature, a true, identifiable etiology has remained elusive. The authorsreport on a ganglion cyst with a unique presentation on the hallux, and a review of the literature.

Christopher Barrett, DPM 1

Terry D. Weaver, DPM2

Sonja G. Schaffer, MD3

The ganglion cyst has been well documented in themedical literature. Although encountered more fre­quently in the hand and wrist (1-4), the number ofganglia occurring in the foot and ankle has been sub­stantial. Slavitt et al., as well as Kliman and Freiberg,each reported their findings of 33 ganglia in the foot andankle (1, 4). In a large survey of 582 foot neoplasmssubmitted to a podiatric pathology laboratory, Berlinfound that ganglion cysts accounted for 44 (7.5%) of thetumors. Ganglion cysts were second only to Morton'sneuroma in the total number of neoplasms surveyed. Ofthe 44 ganglions, only 9 were located in the digits (5).Kirby et al, in their analysis of 83 soft tissue lesions of thefoot and ankle, found ganglion cysts to be the mostcommonly encountered benign lesion, accounting for 24tumors or 29% of the total. Only three of these werelocated in the toes (6).

Case Report

A 32-year-old Caucasian male presented in June 1992with a complaint of pain and swelling to his right greattoe present since October 1991. The swelling had in­creased significantly during the previous 3 months caus­ing progressive discomfort while walking and whenwearing shoes. The patient related a history of a punc­ture wound to the right great toe while working con­struction approximately 1 1/2 years prior to this initial

From the Veterans Health Administration Medical Center, Leba­non, Pennsylvania.

1 Submitted while first year resident.2 Director of Podiatric Education. Diplomate, American Board of

Podiatric Surgery. Address correspondence to: Podiatry Section,112-A, Veterans Health Administration Medical Center, 1700 S.Lincoln Avenue, Lebanon, PA 17042.

3 Staff Radiologist.1067-2516/95/3401-0057$3.00/0Copyright © 1995 by the American College of Foot and AnkleSurgeons

presentation. The wound healed uneventfully and thepatient resumed normal activity. His past medical his­tory was remarkable for alcohol and cigarette abuse.

Physical examination revealed a soft, nontender sub­cutaneous mass along the plantar lateral aspect of theright hallux extending laterally under the base of thesecond digit. A faint bluish discoloration could be de­tected in the overlying soft tissues (Fig. 1). The mass wasfound to transilluminate with light revealing a multilocu­lated inner structure with an overall dimension of ap­proximately 3 X 2 X 1.5 em. (Fig. 2). Doppler examina­tion of both great toes demonstrated an increased pitchin the digital artery corresponding to the area of themass.

Radiographic evaluation of the right hallux demon­strated no bony changes or calcifications within the massitself. Due to suspicion of the apparent pulsatile natureofthe mass, ultrasound and computed tomography (CT)examination of the right hallux were ordered in anattempt to determine the extent of the mass as well asrule out a vascular etiology. The ultrasound study re­vealed a 2.5-cm. nonpulsatile, septated anechoic massadjacent to the interphalangeal joint of the right hallux.A CT examination again showed a nodular, nonenhanc­ing, slightly septated, soft tissue lesion of the same size.The adjacent soft tissue and bones were normal (Fig. 3).An MRI was not performed in this instance because theCT and ultrasound studies were diagnostic for a gan­glion cyst. After reviewing the results of the studies, theauthors believed the increased pitch observed with thedoppler examination was a result of the fluid filled massmagnifying the vascular sounds of the underlying digitalartery. The preoperative diagnosis was that of a ganglioncyst.

The patient was offered aspiration of the cyst, but heopted to have the cyst surgically excised. The patient wasbrought to the operating room where regional ankleblock anesthesia was administered using 15 cc. of 1%

VOLUME 34, NUMBER 1, 1995 57

Figure 1. Soft tissue mass on the plantar aspect of thehallux.

Figure 2. Transillumination of the plantar soft tissue mass.

lidocaine plain. A pneumatic ankle tourniquet was ap­plied to the right ankle and was inflated to 250 mm Hgfor hemostasis. The foot was prepared and draped in theusual sterile manner. Attention was directed to the mass

58 THE JOURNAL OF FOOT AND ANKLE SURGERY

Figure 3. CT examination of both feet at the level of thehallux revealed a 2.5-cm. nodular, nonenhancing, slightlyseptated, soft tissue mass (arrow).

Figure 4. Collapsed cystic structure, showing a multilocu­lated lumen. The cystic wall is fibrosed and occasionallylined by flattened epithelium (arrow) (H & E, original magni­fication, X25).

along the plantar aspect of the right hallux. Two con­verging, longitudinal, semi-elliptical, incisions weremade over the plantar lateral aspect of the mass to avoida painful plantar scar. The incision extended from thebase of the hallux to the midshaft level of the distalphalanx. As the skin incision was deepened, a thick,colorless gelatinous fluid began to exude from the mass.Further dissection revealed a well encapsulated, mul­tiloculated, thin walled, fibrous mass adherent to theflexor hallucis longus tendon sheath, as well as to theinterphalangeal joint capsule. The lesion was excisedfrom the tendon sheath and joint capsule and removedin toto. A small amount of redundant skin was excisedfrom both wound edges to facilitate an even closure andreturn the hallux to its normal size and appearance.Histopathology reported the lesion as a multiloculatedcystic structure consistent with a ganglion cyst (Fig. 4).The patient's postoperative course was unremarkable

and sutures were removed on day 14 with neurovascularstatus intact and normal appearance to the right hallux.At 9 months follow-up, he remains asymptomatic withno recurrence of the mass.

Discussion

Ganglions are thin-walled, cystic lesions approxi­mately 1.5 to 2.0 em, in diameter, generally located inthe subcutaneous tissue and are almost invariably incontact with a joint capsule or tendon sheath (1-3,7-11). They are filled with a thin, synovial-like fluid thatis occasionally gelatinous in nature. This fluid, mostoften colorless, may sometimes appear tinged yellow orreddish-brown secondary to hemorrhage (1, 2, 8, 11).Ganglions consist of three components: 1) an encapsu­lated cyst or main cyst; 2) offshoots of the main cyst,known as ganglial pseudopods; and 3) capsule cysts thatare microcysts at the site of contact between ganglionand fibrous capsule of tendon sheath (1, 2, 11). Berlinhas noted that ganglion cysts, as well as synovial cysts,are characterized by a secretory lining of mesothelial­like cells that lie on a stroma of collagen-rich connectivetissue (8). This mesothelial-like lining is similar in struc­ture to the lining of tendon sheath and the synovium ofjoint capsule (7).

The term ganglion cyst is often used interchangeablywith synovial cyst because both have similar histopathol­ogy (12, 13). However, the location of the cyst deter­mines whether it is referred to as a ganglion or synovialcyst. Ganglia in the lower extremities occur most fre­quently on the ankle and dorsum of the foot. Accordingto Kirby et at. in their study of soft tissue tumors of thelower extremities, 32% occurred about the ankle and48% on the dorsum of the foot (6). True synovial ormucoid cysts usually present intradermally on the dorsalaspect of the fingers and toes between the distal inter­phalangeal joint and the posterior nail fold (12-14).

There are many theories on the etiology of ganglioncysts (1) and a thorough discussion is beyond the scopeof this report. Although these theories are subject todebate and the true etiology unknown (1, 8, 10), traumahas been a commonly accepted factor in the pathogen­esis of a ganglion cyst, as demonstrated by this casereport (8-10). The diagnosis of ganglion cysts is basedprimarily on clinical suspicion. Presence of a dense,freely movable subcutaneous mass in one of the morecharacteristic locations (wrist, ankle, dorsum of the foot)is highly suggestive. Plain film studies, while not diag­nostic, will demonstrate a nonspecific soft tissue density,and adjacent bony involvement is characteristically ab­sent (1, 2). Ultrasound evaluation shows a nonspecific

fluid collection adjacent to the tendon (15). CT exami­nation usually reveals a well defined water density masswith normal surrounding soft tissues (16). Ganglion cystsare seen on magnetic resonance characteristically ashomogeneous, low intensity lesions on T1-weighted im­ages with markedly increased signal on Tz-weightedimages. The borders of these lesions are smooth. Thesebenign soft tissue tumors can readily be differentiatedfrom the surrounding soft tissues and images in multipleplanes are also readily made available (17, 18).

There are various methods of treatment for ganglioncysts. Rupturing the cyst results in a cure rate of 50-78%(19-21). Interestingly enough ganglions have been re­ported to resolve spontaneously at a rate of 52-58%without treatment (19, 22). Slavitt and associates re­ported poor results with aspiration of cysts. All theganglions in their study treated with this method re­curred within 3 years (1). Aspiration of the cyst withinfiltration of a long-acting steroid fared better thanaspiration alone. Kliman and Freiberg reported a 70%success rate in treating ganglions of the wrist withaspiration and injection of 0.5 cc. of triamcinoloneacetonide 10 mg./ml. (4). Surgical excision produced thebest results. Nelson et at. reported a success rate of up to84% in their experience with excision of ganglion cystsfrom the hand and wrist (23). Surgical excision offers thehighest success rates and is generally accepted as thetreatment of choice at the present time (1, 10, 11).Successful surgical excision is dependent on a bloodlessfield with good visualization and meticulous dissectionof all portions of the cyst, including the cystic offshoots,or pseudopods, extending outward from the main cyst(1, 11). Johnston believes that in addition to removingthe cyst, it is important to remove most of the surround­ing degenerative capsular or tendon sheath collagentissue to help prevent recurrence (24).

Summary

Ganglion cysts are one of the most commonly isolatedbenign soft tissue lesions in the foot and ankle. Theauthors present a case report and review of ganglioniccysts. To the best of our knowledge, a ganglion with thispresentation has not been previously reported in theliterature.

Acknowledgments

The authors express their appreciation to Dr. Lee J.Sanders, Chief, Podiatry Section, VA Medical Center,Lebanon, Pennsylvania, for his assistance in editing thismanuscript. In addition, we would like to acknowledge

VOLUME 34, NUMBER 1, 1995 59

Mrs. Barbara E. Deavon, medical librarian, Mrs. Rox­anne Felli, and Mrs. Dorothy Melan. Their assistance isappreciated in performing the computer search andobtaining reference materials.

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