How To Address Ganglionic Cysts In The Tarsal Tunnel
A Guide To The Surgical Procedure
In regard to the surgical procedure, we initially made a 10 cm incision, beginning behind the medial malleolus over the palpable posterior tibial artery, and extending down to the plantar fascia region along and throughout the course of the neurovascular bundle. A palpable ganglion cyst deep in these tissues was present at the mid-aspect of the incision.
After deep dissection, the surgeon identified a large cyst approximately 3 cm in length and 1.5 cm in width, and the surgeon circumferentially separated it from the surrounding soft tissues. The cyst was overlying the tibial nerve and was slightly anterior to this nerve. A stalk from the cyst led down to the sinus tarsi region. We closed off the stalk with a suture and cut just superficial to the stalk so we could remove the cyst in toto.
After closing the wound, the surgeon injected an ankle block using 30 cm3 of 0.5% plain marcaine. The patient received a modified Jones dressing.
The Cleveland Clinic received the specimen. The diagnosis confirmed a ganglionic cyst.
Pertinent Perspectives On The Case Studies
These two cases offered interesting examples of when the etiology of tarsal tunnel is difficult to assess clinically. In both instances, the patients’ symptoms were quite severe and began very abruptly. Both patients had local deficits of sensation and one had a positive Tinel’s sign. The symptoms and findings were very general upon clinical examination and fell short of the information needed to properly diagnose and treat the patients.
We have detailed the importance of using accessory diagnostic tools in these instances. Timely and appropriate treatment of ganglion cysts within the tarsal tunnel causing nerve compression is vital and will limit the potential damage done to the nerve and the need for further intervention.
The diagnosis of tarsal tunnel syndrome must rely strongly upon the clinical presentation and evaluation. There is evidence to show that a patient has a statistically higher chance of a better outcome if the Tinel’s sign is positive.8 However, ganglions are not always palpable within the fibro-osseous tarsal tunnel. Accordingly, adjunctive imagery such as MRI and ultrasonography may be useful tools. Electrodiagnostic nerve conduction velocity studies may be another useful means to determine nerve latency.
When it comes to decreasing recurrence rates, complete surgical excision is the gold standard of treatment for space-occupying lesions within the tarsal tunnel.9 The aforementioned case studies provide examples of using both clinical examination and advanced imagery to diagnose tarsal tunnel syndrome.
Dr. Stock practices at the Cleveland Clinic in Cleveland.
Dr. Baxter completed her PGY1 year at the Cleveland Clinic followed by a surgical residency in Salt Lake City. She is currently doing a fellowship in Texas.
Dr. Herbert practices at the Cleveland Clinic.
Dr. Sferra is a foot and ankle orthopedic surgeon practicing at the Cleveland Clinic.
Dr. Burks is a Fellow of the American College of Foot and Ankle Surgeons, and is board certified in foot and ankle surgery. Dr. Burks practices in Little Rock, Ark.
Editor’s note: For related articles, see “A Closer Look At Tarsal Tunnel Syndrome” in the November 2003 issue, “Rethinking Tarsal Tunnel Syndrome” in the December 2004 issue or “Expert Insights On Peripheral Nerve Surgery For Tarsal Tunnel Syndrome” in the September 2003 issue. For other articles, visit the archives at www.podiatrytoday.com.