A Ganglion Cyst at the Foot Causing Tarsal Tunnel Syndrome Detected by Magnetic Resonance Imaging

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1 Article ID: WMC ISSN A Ganglion Cyst at the Foot Causing Tarsal Tunnel Syndrome Detected by Magnetic Resonance Imaging Corresponding Author: Dr. Iftikhar H Wani, Doctor, Emergency Hospital Orthopaedician, India Submitting Author: Dr. Iftikhar H Wani, Doctor, Emergency Hospital Orthopaedician, India Article ID: WMC Article Type: Case Report Submitted on:27-jan-2012, 04:59:48 PM GMT Article URL: Subject Categories:ORTHOPAEDICS Keywords:Tarsal Tunnel syndrome, Ganglion cyst, Medial Planter Nerve. Published on: 28-Jan-2012, 10:25:48 AM GMT How to cite the article:wani IH, Salaria AQ, Jan M. A Ganglion Cyst at the Foot Causing Tarsal Tunnel Syndrome Detected by Magnetic Resonance Imaging. WebmedCentral ORTHOPAEDICS 2012;3(1):WMC Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Source(s) of Funding: None Competing Interests: None Webmedcentral > Case Report Page 1 of 11

2 A Ganglion Cyst at the Foot Causing Tarsal Tunnel Syndrome Detected by Magnetic Resonance Imaging Author(s): Wani IH, Salaria AQ, Jan M Introduction Tarsal tunnel syndrome (TTS) is caused by compression of the posterior tibial nerve as it passes through the posterior tarsal tunnel. It is much more common in the posterior tarsal tunnel than in the anterior by compression of the deep peroneal nerve as it passes beneath the superficial fascia of the ankle [1]. TTS may be associated with exacerbation of symptoms at night, by exercise or rest, or by elevating or lowering the extremity, and symptoms confined to the lateral planter nerve, medial planter nerve, or medial calcaneal nerve [2]. Failure to diagnose and treat neuropathies effectively can cause permanent neuropathic pain and functional disability In most cases, TTS develops from unknown causes and can be treated conservatively. However, early surgical intervention is mandatory when neuropathy arises from a progressing occult pathology to avoid, repeated steroid injections, prescription of several medication for neuropathic pain, and to prevent permanent neuropathic pain. MRI and electromyography, together with clinical history and physical examination, can help to make the differential diagnosis. Case Report The patient was a 31-year-old man with a 6-month history of pain, numbness, and paresthesia on the left great toe and the first metatarsal area in the sole. The pain was constant and burning. Symptoms were aggravated by pressure on the sole such as walking and weight bearing. Symptoms had initially localized in the great toe and sole but gradually extended to the second and third toes. Patient had been prescribed lot of local steroidal injections but had no permanent relief. A physical examination did not reveal specific abnormalities except a local tenderness just below and down to the medial malleolus over the foot. There was no palpable swelling. We then performed an MRI which revealed a unilocular, ganglion cyst around the medial planter nerve in the digitorum muscles of the foot. [Fig.1 and 2]. Nerve-conduction studies showed that conduction velocity was reduced in the right medial plantar nerve. There was no apparent weakness of the intrinsic muscles of the right foot, but a subtle T2 high signal change in the abductor hallucis and flexor digitorum brevis muscle was seen on MRI. We suspected subacute muscle denervation and planned the patient for surgery. Intra-operatively, ganglion cyst was found close to the medial planter nerve and after meticulous dissection nerve was freed from the ganglion cyst [Fig. 3 and 4]. After surgery two weeks later, the patient had dramatic response with improved symptoms. Discussion The most common cause of compression of the posterior tibial nerve around the tarsal tunnel is trauma to the ankle, but any occult pathology, such as a space-occupying lesion like a ganglion cyst, can cause similar neuropathic pain [3]. Tarsal tunnel syndrome is an entrapment neuropathy caused by compression of the posterior tibial nerve and its branches, between the calcaneum and the medial malleolus under the cover of the flexor retinaculum [4, 5]. TTS can be misdiagnosed as ankle arthritis and lumbar radiculopath [6]. However, patients with ankle arthritis have radiologic evidence of it. TTS can be distinguished from lumbar radiculopathy because patients suffering from TTS have no reflex changes, and motor and sensory changes are localized to the distribution of the distal posterior tibial nerve and its branches. Secondary TTS by a ganglion is unusual,[4,5] but it can occur. Kirby and colleagues [7]) found that ganglion cysts were the most common benign lesion of the foot, accounting for nearly one-third of all cases. The size and location of the ganglion cyst is influences entrapment neuropathy because the volume of the tarsal tunnel compartment ranges from 18 cm3 to 21 cm3 in normal individuals [8]). In addition, Takakura and colleagues ([9] mentioned that a large ganglion can easily be diagnosed by MRI, but is difficult if it is smaller than cm. A cystic and completely anechoic fluid collection around the ankle detected by USG commonly represents a ganglion cyst [10]. Webmedcentral > Case Report Page 2 of 11

3 Conclusion Acknowledgement In conclusion, neuropathy arising from progressing occult pathology should be diagnosed early with high degree of suspicion by modern imaging facilities and treated adequately to avoid permanent neuropathic pain and functional disability. When a suddenly exacerbated case of neuropathy is encountered, a space-occupying lesion such as a ganglion cyst should be considered and clinicians must try to detect it as soon as possible. MRI may be a helpful device for this effort. The unique clinical symptoms and signs of our diagnosis of a ganglion causing medial plantar nerve compression were confirmed by MRI and then operative findings. References Consent "Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal." Authors' contributions IHWand AQS analyzed and interpreted the patient data regarding the disease. MJ discussed the case with radiology and pathology experts and formulated the investigative and treatment plan. AQS and IHW performed the biopsy. IHW was responsible for followup and prepared the manuscript. All authors read and approved the final manuscript. 1. Waldman SD: Posterior tarsal tunnel syndrome. In: Atlas of Common Pain Syndromes. 2nd ed. Philadelphia,Saunders Elsevier. 2007,pp Greer Richardson E.:From Neurogenic disorders: Tarsal Tunnel syndrome. In Campbell s operative orthopaedics. Volume 4th. Elevanth Edition.Edited by S. Terry Canale, James H. Beaty 2008; 83: Ferraresi S, Leidi P, Leidi M, Ubiali E, Bortolotti G, Cassinari V: Tarsal tunnel syndrome. Report of a case and review of clinical and surgical aspects. Ital J Neurol Sci 1992; 13: Taguchi Y, Nosaka K, Yasuda K, Teramoto K, Mano M, Yamamoto S: The tarsal tunnel syndrome: report of two cases of unusual cause. Clin Orthop Relat Res 1987; 217: Brown RJ: Tarsal tunnel syndrome due to a ganglion: a case report. Ulster Med J 1982; 51: Lam SJ: Tarsal tunnel syndrome. J Bone Joint Surg Br 1967; 49: Kirby EJ, Shereff MJ, Lewis MM: Soft-tissue tumors and tumor-like lesions of the foot. An analysis of eighty-three cases. J Bone Joint Surg Am 1989; 71: Bracilovic A, Nihal A, Houston VL, Beattie AC, Rosenberg ZS, Trepman E: Effect of foot and ankle position on tarsal tunnel compartment volume. Foot Ankle Int 2006; 27: Takakura Y, Kumai T, Takaoka T, Tamai S: Tarsal tunnel syndrome caused by coalition associated with a ganglion. J Bone Joint Surg Br 1998; 80: Chhem RK, Beauregard G, Schmutz GR, Benko AJ: Ultrasonography of the ankle and the hindfoot. Can Assoc Radiol J 1993; 44: Webmedcentral > Case Report Page 3 of 11

4 Illustrations Illustration 1 Figure 1 MRI showing unilocular hyperintense cystic lesion in digitorum muscles of foot. Webmedcentral > Case Report Page 4 of 11

5 Illustration 2 Figure 2 MRI showing ganglion cyst. Webmedcentral > Case Report Page 5 of 11

6 Illustration 3 Figure 3 Ganglion cyst pressing on a medial planter nerve detected intraoperatively. Webmedcentral > Case Report Page 6 of 11

7 Illustration 4 Figure 4 Removed ganglion cyst Webmedcentral > Case Report Page 7 of 11

8 Reviews Review 1 Review Title: A ganglion cyst at teh foot causing tarsal tunnel syndrome detected by magnetic resonance imaging. Posted by Dr. Yoichi Aota on 22 Apr :29:41 PM GMT 1 Is the subject of the article within the scope of the subject category? Yes 2 Are the interpretations / conclusions sound and justified by the data? Partly 3 Is this a new and original contribution? No 4 Does this paper exemplify an awareness of other research on the topic? Yes 5 Are structure and length satisfactory? Yes 6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? 7 Can you suggest any reductions in the paper, or deletions of parts? No 8 Is the quality of the diction satisfactory? Yes 9 Are the illustrations and tables necessary and acceptable? No 10 Are the references adequate and are they all necessary? Yes 11 Are the keywords and abstract or summary informative? Yes Rating: 5 Comment: MR images were blurred and poor in quality. Aouthors should better to indicate MR planes (sagittal or axaila) and explain the raiological findings in figure legends. Competing interests: no Invited by the author to make a review on this article? : No Experience and credentials in the specific area of science: I have few experiences in tarsal tunnel syndrome because I am a spine surgeon. Publications in the same or a related area of science: No How to cite: Aota Y.A ganglion cyst at teh foot causing tarsal tunnel syndrome detected by magnetic resonance imaging.[review of the article 'A Ganglion Cyst at the Foot Causing Tarsal Tunnel Syndrome Detected by Magnetic Resonance Imaging ' by ].WebmedCentral 1970;3(4):WMCRW No Webmedcentral > Case Report Page 8 of 11

9 Review 2 Review Title: Medial plantar nerve compression by an extraneural ganglion cyst Posted by Dr. Robert J Spinner on 07 Feb :31:19 AM GMT 1 Is the subject of the article within the scope of the subject category? Yes 2 Are the interpretations / conclusions sound and justified by the data? Yes 3 Is this a new and original contribution? Yes 4 Does this paper exemplify an awareness of other research on the topic? No 5 Are structure and length satisfactory? Yes 6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? 7 Can you suggest any reductions in the paper, or deletions of parts? No 8 Is the quality of the diction satisfactory? No 9 Are the illustrations and tables necessary and acceptable? No 10 Are the references adequate and are they all necessary? Yes 11 Are the keywords and abstract or summary informative? Yes Rating: 3 Comment: The authors discuss a case of an extraneural ganglion cyst in the foot producing medial plantar nerve compression. No While this is an established cause of nerve compression within the tarsal tunnel, it is a relatively rare cause. The case itself is relatively straight forward. A few minor additions would be helpful: 1. The MRI legends should include sequences. 2. The specific joint origin of the cyst should be included. Was pedicle of cyst traced to the joint? How was joint connection treated? 3. There are several misspellings and syntactical lapses: a. Title; ganglion cyst of the foot b. plantar rather than planter in several locations c. posterior tibial nerve should be tibial nerve d. 2nd sentence of introdcution is awkward. e. Introduction beginning "Failure to diagnose and treat neuropathies...should be rewritten. Add period after disability. f. introduction medications g. introduction to make the diagnosis h. case report, line 2 paresthesias i. case report. The patient j. case report prescribed local steroid injections k. An MRI revealed Webmedcentral > Case Report Page 9 of 11

10 l. flexor digitorum muscles in case report and fig legend m. discussion, calcaneus n. discussion, radiculopathy o. discussion ganglion cyst influences p. conclusion, 1st sentence should be rewritten. Competing interests: No Invited by the author to make a review on this article? : Yes Experience and credentials in the specific area of science: I am a peripheral nerve surgeon with particular interest in nerve compression by ganglion cysts. Publications in the same or a related area of science: Yes How to cite: Spinner R.Medial plantar nerve compression by an extraneural ganglion cyst [Review of the article 'A Ganglion Cyst at the Foot Causing Tarsal Tunnel Syndrome Detected by Magnetic Resonance Imaging ' by ].WebmedCentral 1970;3(2):WMCRW Webmedcentral > Case Report Page 10 of 11

11 Disclaimer This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party. Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website. Webmedcentral > Case Report Page 11 of 11