What is a Ganglion?
A ganglion is a collection of fluid that forms a swelling under the skin. In the foot, they can make shoes uncomfortable, or they can burst and cause a discharge. They often change in size over time, getting bigger as well as smaller.
Ganglions most frequently occur near joints where there has been some wear and tear, or near a tendon sheath. Joints and tendon sheaths produce fluid, and this can be forced out into an area under the skin where it collects. There is normally a rent in the joint lining or tendon sheath to allow the fluid to escape.
Sometimes, the fluid nature of the ganglion allows light to transilluminate it – as demonstrated on the left.
There is often deep pain associated with a ganglion. This is caused by the underlying wear and tear arthritis, rather than the ganglion. This means it may not settle if the ganglion is removed.
Some ganglions are very small, but very painful. These often occur near the small joints of the toes. These are often referred to as seed ganglions.
If you have a ganglion of the foot, it is best to see an orthopaedic surgeon who specialises in foot and ankle surgery. You should have x-rays taken in a standing position – if your ganglion is related to any joint arthritis, this may require treatment to get rid of any associated pain.
How is the Surgery Performed?
The ganglion usually arises from a stalk that connects it to a tendon or a joint. The fluid in the ganglion is pumped out of the bag that encloses the tendon which provides lubrication, or from the lining of the joint. The surgery aims to take away the sac of fluid, and also to prevent the ganglion from re-arising by removing some of the lining of the joint to encourage scarring, which usually prevents the fluid escaping again.
A cut is made in the skin and the bag of fluid is removed. Sometimes, there are nerves or blood vessels stretched under the ganglion and all attempts are made to preserve these.
The chances of a ganglion reoccuring are around 5%, so there is a 95% chance that the ganglion will not recur.
If there is a worn out joint nearby, then the pain associated from a ganglion may be coming from the joint, and sometimes it is necessary to fuse the joint to deal with the cause of the pain. This can make the procedure bigger.
Surgery is carried out under general anaesthetic, but can be carried out with local anaesthetic injections behind the knee or around the ankle. The injections are normally given while you are asleep for your comfort. They can give good pain relief for the first day after the operation. You can go home the same day in the evening.
Risks of Surgery
Bleeding, infection, poor bone healing, poor skin healing, injury to tendons, injury to nerves, recurrence, and a need for further surgery.
There is a small risk of blood clots in the legs or lungs (DVT and PE), and there are also risks from anaesthesia – the process of being put to sleep for your operation.
Risks of Anaesthesia
The injection behind your knee is given using an ultrasound machine to guide the needle. There is a less than 1% chance of injury to the nerve. General anaesthetic also carries risks. These risks are proportional to your general health. You will need to be assessed for your fitness for surgery and an Anaesthetist will be able to advise you on your individual risk.
What Happens After Surgery?
You will have had injections to numb your foot so that you are not in pain after the operation. This injection will wear off after 18-24 hours, so you must take regular painkillers so that you are not in severe pain when the injection wears off.
The pain will settle over a few weeks. You may see blood stains on the dressings. This is normal and not a cause for alarm. If blood is dripping from the dressings however, return to hospital.
The foot will be swollen as well as sore. You should keep the foot elevated as much as possible for the first two weeks. Keep walking down to a minimum – going to the toilet or for meals. Letting the leg hang down will cause the foot to become more swollen.
If you are resting on your sofa, keep your foot elevated on the back rest or arm rest. If you are resting in bed, then place a few pillows under the foot to keep it elevated.
You have been given a postoperative shoe that is for your comfort when you walk, as you will not be able to fit into a normal shoe with heavy dressings applied. Crutches are for balance only.
You should keep all the joints as mobile as possible. Drawing the alphabet in the air with your foot should move all the joints adequately to prevent stiffness.
RETURNING TO WORK
You will be wearing the special shoe for two weeks. I advise that you do not return to work before this, especially if you are on your feet all day at work. We will remove your stitches and we should have a lab report to confirm that the lump taken out was indeed a ganglion. Most people can return to work after that and drive once they are able to fit back into a normal shoe. Remember that not everyone is the same, and some people take a longer time to recover from their surgery. Please request a sick note before you leave hospital, if you need one.