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American Journal of Physical Medicine & Rehabilitation:
doi: 10.1097/PHM.0b013e31825f1abb
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Medial Plantar Proper Digital Neuropathy Caused by a Ganglion Cyst

Seok, Hung Youl MD; Eun, Mi-Yeon MD; Yang, Hyun Woo MD; Lee, Ho-Joon MD

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From the Department of Neurology, The Armed Forces Yangju Hospital, Yangju-city (HYS, HWY); Department of Neurology, Korea University Medical Center, Seoul (M-YE); and Department of Radiology, The Armed Forces Yangju Hospital, Yangju-city, Korea (H-JL).

All correspondence and requests for reprints should be addressed to: Hung Youl Seok, MD, Department of Neurology, The Armed Forces Yangju Hospital, 49-1, Yongam-ri, Eunhyeon-myeon, Yangju-city, Gyeonggi-do, 482-863, Korea.

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

A 20-yr-old man presented with numbness and a tingling sensation along the medial aspect of the right great toe. His symptoms worsened during physical activities and were partially relieved by rest. During the previous few months, he had been wearing poorly fitting boots for all activities. On examination, hypesthesia to pinprick was present over the medial aspect of the right great toe. No mass was palpable, but Tinel sign was positive at the medial plantar aspect of the right hallux. Results of nerve conduction studies of the right tibial motor nerve and right medial plantar mixed nerve were normal. However, on antidromic stimulation of the right medial plantar proper digital nerve (MPPDN),1 the sensory nerve action potential was absent. A diagnosis of MPPDN neuropathy was made. He was advised to avoid lengthy walks and to wear correctly fitting shoes. During the subsequent 2 mos, no improvement occurred. Foot magnetic resonance imaging (Fig. 1A, B) revealed an elongated cystic lesion along the course of the MPPDN, close to the plantar surface of the right hallux. The lesion showed homogeneously low signal intensity on T1-weighted images and high signal intensity on T2-weighted images; these findings were consistent with a ganglion cyst.2 His symptoms and electrophysiologic findings gradually improved after surgical excision of the ganglion cyst.

FIGURE 1
FIGURE 1
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The MPPDN is the terminal sensory branch arising from the medial plantar nerve, and it subserves sensation to the medial aspect of the great toe.1 Its superficial position renders it susceptible to chronic compression, which results in MPPDN neuropathy.1 In our case, the cause of MPPDN neuropathy was initially thought to be chronic compression from ill-fitting shoes, but conservative treatment did not relieve the patient’s symptoms. Further examination indicated the presence of the ganglion cyst. We suggest that foot imaging be considered in patients with MPPDN neuropathy to exclude the possibility of a space-occupying lesion, especially when conservative treatment is unsuccessful.

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REFERENCES

1. Im S, Park JH, Kim HW, et al. : New method to perform medial plantar proper digital nerve conduction studies. Clin Neurophysiol. 2010; 121: 1059–65

2. Barrett C, Weaver TD, Schaffer SG. : Ganglion cyst of the hallux: An aberrant presentation. J Foot Ankle Surg. 1995; 34: 57–60

Copyright © 2013 by Lippincott Williams & Wilkins

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