How To Address Ganglionic Cysts In The Tarsal Tunnel

Dina Stock, DPM, Cory Baxter, DPM, James Sferra, MD, Christopher Herbert, DPM, and Elizabeth Baracz, BS

Key Surgical Insights
The surgical procedure consisted of making a 7 cm curvilinear incision posterior to the palpable posterior tibial pulse, approximately 1 cm, and extending it distal above the abductor hallucis muscle belly and plantar to the navicular tuberosity toward the porta pedis. After significant dissection, a large fluid-filled mass was present along the medial wall of the calcaneus and was approximately 4 x 2 cm in size. The surgeon incised the encapsulated mass to allow for complete excision. A significant amount of straw-colored, thick, gelatinous fluid exuded after complete removal of the mass. The surgeon performed closure and placed a transcutaneous light suction drain within the wound due to the large dead space created.
The patient received an injection of a mixture of 0.5% marcaine plain and dexamethasone sodium phosphate 4 mg/mL at the site. The patient also wore a sterile compressive dressing and a below-knee posterior splint.
The Pathology Consultants of Cleveland received the pathology specimen. The final diagnosis from the surgical pathology report confirmed a benign ganglionic cyst.

Case Study Two: A Patient With Pain And Numbness On The Ball Of The Foot
A 48-year-old male presented with a complaint of acute pain and numbness across the ball of his right foot. The patient reported that the symptoms started suddenly exactly two weeks and one day prior to presentation, and he had more pain with rest than with activity. He noted that he felt the numbness on his first three toes and part of the fourth toe on the affected foot. The patient denied any trauma to the foot that preceded any symptoms but admitted to a recent history of increased activity on an elliptical trainer in an old pair of basketball shoes. He denied any tingling or shooting pains. The patient denied any history of back problems.
The patient’s medical history was positive for inflammatory myopathy. His medications included 200 mg hydroxychloroquine sulfate (Plaquenil). He stated an allergy to naproxen (Naprosyn, Roche Pharmaceuticals), which caused a rash. His only surgical history was a repair of a cruciate ligament in his knee.
The lower extremity examination revealed fully intact neurovascular status to the left (uninvolved) foot. Examination of the right foot revealed decreased neurological status with diminished sharp-dull and light touch to the hallux, second, third and fourth digits. The vibratory sensation was intact. The Hoffman-Tinel sign was positive with percussion of the tibial nerve at the tarsal tunnel right. There was localized edema in the right foot overlying the tarsal tunnel region. There was no pain with range of motion of the ankle, subtalar joint or MPJs.
Radiographic evaluation revealed no abnormalities. We obtained a MRI after the patient was unresponsive to conservative therapy of mechanical support and antiinflammatory therapy. Routine MRI of the right foot included T1 and T2 weighted images in all planes. Within the tarsal tunnel posterior and medial to the flexor hallucis longus, we identified a tubular cystic structure that was T2 hyperintense and was 3.2 cm x 1.2 cm x 1.4 cm in size. It appeared to have originated from the middle facet under the sustentaculum tali.

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