Conway McLean, DPM, Journal columnist

EDITOR’S NOTE: This column originally appeared in The Mining Journal on June 2, 2020.

Bob was a hard working fellow, with a job requiring demanding, physical labor, and therefore considerable pounding to his body. He took pride in doing a good job and was glad he was able to. Thankfully, he was in good shape and overall, was quite healthy. The work was tiring but not pain inducing. Until his foot started hurting, that is.

Because he had no pain when not working, he thought little of it. He was performing significant physical acts in his occupation; his feet should hurt, or so he assumed. Following his average workday, he was happy to relax with the family, drink a cold beer, watch a little tv before falling asleep on the couch. This went on for months before he started to take it more seriously.

A self-exam after his shower revealed a lump on the top of his foot, directly in the area of pain. Now this was concerning, disconcerting even. The first thought that came to mind, as should be predictable, was he had a tumor. The next thought was what his life would be like in a wheelchair. He realized that probably was unlikely, but still, he was concerned. Indeed, Bob did have a tumor, which simply means a growth. While it is true some tumors are malignant, this is not typical. Most of these lumps are benign, meaning they won’t spread aggressively to other structures or tissues via metastases.

Bob eventually went to his primary care provider who made some educated guesses about an explanation but knew a referral was in order. Which brought him to my doorstep. An appropriate evaluation for such a condition would naturally include a thorough physical exam, as well as x-rays of the part. I am also able to exam various soft tissue structures with the use of an ultrasound device. Additionally, I can give myself x-ray vision with my fluoroscopy unit, a real time x-ray imaging modality (meaning I can watch the bones move as the foot is moved).

Many of these techniques were utilized in Bob’s case, with the final diagnosis being that of a ganglionic cyst. Sounds rather benign, doesn’t it? These are common lesions and many have heard of them. But how many know any specifics, the interesting details? I would be happy to provide.

A ganglionic cyst is a benign growth, most commonly developing along tendons or joints, often on the hands, occasionally on the feet and ankles. They are non-cancerous and have no predilection for becoming so. About half of all masses at those locations are of this type. Although we don’t understand the exact mechanism for their formation, trauma or repetitive motion seem often to be associated with the development of one of these.

A ganglion grows out of the joint capsule, which is the structure covering a joint. It rises up from a joint like a balloon on a stalk. They also can, and often do, originate from such structures as ligaments or tendon sheaths. Inside the balloon is the thick, slippery fluid which fills the joint space. Early in the genesis of a ganglionic cyst, the stalk communicates with the joint or tendon sheath, which allows the mass to “disappear” as the fluid re-enters the joint space. To many uninitiated, this disappearing act is a great mystery. Where did it go? What was it? Then, the next day, it’s back!

This magic act becomes less common over time, because the stalk connecting the cyst to the joint will eventually “scar in”. This means the gelatinous content will no longer be able to leave the cyst. At this point, the cyst tends to become harder, more rigid and unyielding. Although rare, they can even calcify, becoming almost bony.

Since they don’t spread, what is the danger? And why the symptoms? Many who develop a ganglionic cyst experience a burning pain as the mass matures. This is a frequent sensation when a nerve is pressured or pinched. A ganglion located on top of a foot will often do just that. As the cyst hardens, it can impinge on any number of structures located there. In addition, shoes tend to be a source of significant pressure to the cyst, and consequently to neighboring structures.

In Bob’s case, we decided on the typical initial treatment, which is administration of a steroid, often referred to as cortisone. The concept is simple: corticosteroids can cause tissues to shrink, technically termed atrophy. Although a single injection rarely will produce sufficient changes in the size of the mass, several of them, performed over time (weeks), have a good success rate. But not a great one.

Because Bob had procrastinated long enough prior to seeing me, the cyst had scarred in. The result is two steroid injections helped only mildly, and the benefits were transient. Most physicians at this point would recommend surgical excision, the typical course of treatment. But surgery requires some “down time”, ie recovery time, and Bob could not take any days off. He asked about any and all possible alternatives.

There are home therapies for symptomatic relief. Some examples include immobilization, use of an anti-inflammatory medication. But once a ganglionic cyst becomes firm, dense and fibrotic (which means there’s too much scar tissue), the standard methods of conservative treatment usually fail. An alternative treatment, first discovered in a recent medical journal article, involved the use of high intensity radiowaves. This is a familiar technology, having been in use for years. Radiowave coblation, as it is called, has been found beneficial for a variety of different surgical procedures, from a minimally invasive solution for heel pain, to providing permanent relief from ingrown nails.

There are many benefits to the use radiowave coblation for soft tissue problems. One is that, unlike other technologies using electricity surgically, this does not burn tissue. The result is easier healing. Several studies had looked at sclerotherapy for ganglion cysts, that being the term for the controlled destruction of soft tissues. Sclerotherapy has been in use for decades using some caustic agent, but more recent research has been directed at the use of electrical devices like radiowave coblation.

Bob understood this was a new procedure, although both the technology and the pathology were well known. I am happy to say Bob didn’t miss a day of work after the procedure and has had complete resolution of his pain. A tiny bump remains where the ganglion once was. But this speaks to the importance of new uses for old technologies, about keeping an open mind to a different approach. Our system of medicine has been accused of many failures of late. More people than ever want a change to Western health care. There are many ways to treat any condition and many ways to practice medicine. Certainly, we must be open to a better way. But that is not enough, we must look harder.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula. Dr. McLean’s practice, Superior Foot and Ankle Centers, has offices in Marquette and Escanaba, and now the Keweenaw following the recent addition of an office in L’Anse. McLean has lectured internationally, and written dozens of articles on wound care, surgery, and diabetic foot medicine. He is board certified in surgery, wound care, and lower extremity biomechanics.