Tarsal Cyst: Symptoms, Types, Causes and Treatment

Tarsal cysts are uncommon but significant lesions that can develop in or around the tarsal structures of the foot or eyelid, often leading to discomfort, pain, and functional impairment. While sometimes mistaken for more common conditions, such as chalazia or simple ganglia, tarsal cysts may require a nuanced approach for accurate diagnosis and effective management. This article explores their symptoms, various types, underlying causes, and evidence-based treatment options, drawing on the latest research and clinical experience.

Symptoms of Tarsal Cyst

Tarsal cysts, whether in the foot or eyelid, often present with subtle but progressive symptoms. Recognizing these early warning signs is key to timely intervention and optimal outcomes. Many tarsal cysts mimic other conditions, making awareness of their core symptoms essential for patients and clinicians alike.

Symptom	Description	Occurrence/Context	Source(s)
Mass	Localized swelling or lump	Eyelid or tarsal tunnel area	2 3 4 5 7
Pain	Discomfort, often with movement or pressure	Heel, plantar foot, or eyelid	1 4 5 6 7
Recurrence	Lesions reappear after initial treatment	Especially eyelid cysts	2 3
Neuropathy	Numbness, tingling, or weakness	Tarsal tunnel/foot cysts	1 4 5 6

Table 1: Key Symptoms

Understanding the Symptoms

Mass Formation

• Eyelid Cysts: Present as a firm, non-tender mass fixed to the tarsal plate, with the skin freely mobile over it. These are often initially mistaken for chalazia but lack significant inflammation and may not fluctuate in size 2 3.
• Foot Cysts: Tarsal tunnel or calcaneal cysts can cause palpable swelling or fullness in the ankle or heel area 5 7.

Pain and Discomfort

• Localized Pain: Calcaneal bone cysts typically cause heel pain, which may worsen with weight-bearing activities 7.
• Nerve Compression: Ganglion or synovial cysts in the tarsal tunnel can compress nerves, causing not only pain but also burning, tingling, or shooting sensations along the sole of the foot 1 4 5 6.

Recurrence

• Eyelid Lesions: Cysts such as epidermal inclusion cysts often recur after incision and curettage, necessitating more definitive surgical excision 2 3.

Neurological Symptoms

• Tarsal Tunnel Syndrome: Neuropathy symptoms—numbness, tingling, or weakness—are hallmark signs of cysts compressing the posterior tibial nerve within the tarsal tunnel 1 4 5 6.

Types of Tarsal Cyst

The term "tarsal cyst" encompasses several distinct pathological entities affecting either the eyelid tarsus or the tarsal bones and soft tissues of the foot. Each type has unique features, implications, and management needs.

Type	Key Features	Common Location	Source(s)
Epidermal Inclusion	Keratin-filled, slow-growing, eyelid-based	Eyelid tarsus	2 3
Keratinous	Intratarsal, firm, often recurrent	Eyelid tarsus	3
Ganglion	Mucinous, compresses nerves, may be intraneural or epineural	Tarsal tunnel (foot)	1 4 5 6
Synovial	Joint fluid-filled, causes tarsal tunnel syndrome	Tarsal tunnel/ankle	5
Bone (UBC)	Unicameral, fluid-filled within calcaneus	Calcaneus (heel bone)	7

Table 2: Major Types of Tarsal Cyst

Exploring the Major Types

Epidermal Inclusion and Keratinous Cysts

• Eyelid Tarsus: These cysts arise within the tarsal plate of the eyelid, lined with keratinized epithelium and filled with keratin debris. They grow slowly and can be mistaken for chalazia, but lack inflammation and tend to recur unless completely excised 2 3.
• Keratinous Cysts: Similar in presentation, often recurring after incomplete removal. Histopathology is vital for differentiation 3.

Ganglion Cysts

• Intraneural/Epineural: Ganglion cysts may form within the nerve (intraneural) or around it (epineural). Intraneural ganglia can cause direct nerve fiber destruction, while epineural cysts compress the nerve externally. Both may present with tarsal tunnel syndrome symptoms 1 4 6.
• Foot and Ankle: Typically found around the tarsal tunnel, leading to nerve compression 1 4 5 6.

Synovial Cysts

• Joint Origin: These cysts arise from defects in the joint capsule, allowing synovial fluid to track into adjacent soft tissue, sometimes compressing neurovascular structures within the tarsal tunnel 5.

Unicameral Bone Cysts (UBCs)

• Calcaneus: UBCs are benign, fluid-filled lesions within the calcaneus (heel bone), more common in children and adolescents, and can cause chronic heel pain or be discovered incidentally 7.

Causes of Tarsal Cyst

Understanding the origins of various tarsal cysts is essential for both prevention and targeted therapy. The causes range from mechanical and developmental factors to post-traumatic or degenerative changes.

Cause	Mechanism or Pathway	Associated Cyst Type	Source(s)
Trauma	Inclusion of epidermal cells	Epidermal inclusion	2 3
Articular Defect	Synovial fluid egress via capsular defect	Ganglion/synovial	1 5
Degeneration	Intraneural cyst formation	Ganglion	6
Developmental	Abnormal cavity in bone	Unicameral bone cyst	7
Iatrogenic	Surgery or incomplete curettage	Epidermal inclusion	2 3

Table 3: Principal Causes of Tarsal Cyst

Unpacking the Causes

Trauma and Surgical Interventions

• Eyelid Cysts: Trauma or previous surgery (e.g., chalazion curettage) can lead to the implantation of epidermal cells into the tarsus, resulting in inclusion cysts. These cells proliferate, producing keratin and forming a cystic mass 2 3.

Joint Capsule Defects

• Ganglion/Synovial Cysts: The most widely accepted theory for ganglion cyst formation is the articular (synovial) theory. A defect in a neighboring joint capsule allows synovial fluid to leak out, tracking along adjacent tissue planes or nerves 1 5.

Nerve Degeneration

• Intraneural Cysts: Degenerative processes within nerves themselves can lead to cyst development, occasionally compressing nerve fibers and causing neuropathic symptoms 6.

Developmental Factors

• Unicameral Bone Cysts: These benign bone cavities are believed to result from developmental anomalies, which may disrupt bone formation and result in fluid-filled spaces within the calcaneus 7.

Iatrogenic Factors

• Recurrence: Incomplete removal or curettage of a cyst, especially in the eyelid, can leave behind cystic tissue, leading to recurrence 2 3.

Treatment of Tarsal Cyst

Management of tarsal cysts is tailored to the type, size, location, and symptoms. While some cysts may resolve spontaneously or be managed conservatively, others require surgical intervention for definitive cure and symptom relief.

Treatment	Approach/Technique	Indications/Notes	Source(s)
Complete Excision	Surgical removal, often with tarsus base	Eyelid inclusion/keratinous cysts	2 3
Curettage	Incision and scraping	Often ineffective for recurrence	2 3
Nerve Decompression	Cyst excision, nerve release	Ganglion/synovial cysts, tarsal tunnel syndrome	1 4 5 6
Bone Curettage & Grafting	Open curettage and bone augmentation	Calcaneal bone cysts	7
Observation	Watchful waiting, activity modification	Small, asymptomatic cysts	7

Table 4: Main Treatments for Tarsal Cysts

Treatment Strategies in Detail

Eyelid Tarsal Cysts

• Complete Excision: For intratarsal epidermal inclusion and keratinous cysts, complete surgical excision, including removal of the full-thickness tarsal plate at the cyst’s base, is recommended for definitive treatment. Incision and curettage alone are often insufficient and result in recurrence 2 3.
• Histopathology: Examination of excised tissue is vital to confirm the diagnosis and exclude other pathologies 3.

Ganglion and Synovial Cysts of the Tarsal Tunnel

• Surgical Removal: Symptomatic cysts compressing nerves require surgical excision. The distinction between intraneural and epineural ganglia is critical, as intraneural cysts may cause more extensive nerve involvement and require more delicate dissection 1 4 6.
• Decompression: Removal of the cyst, along with decompression of the tarsal tunnel, often leads to symptom resolution 1 4 5 6.

Unicameral Bone Cysts (UBCs)

• Open Curettage and Bone Grafting: The best outcomes for calcaneal UBCs are achieved with open curettage (scraping out the cyst lining) and bone augmentation, ideally using autograft material. This approach relieves pain and promotes bone healing 7.
• Conservative Management: Observation may be considered for small, asymptomatic cysts, but most require surgical intervention due to risk of fracture or persistent pain 7.

General Principles

• Recurrence Prevention: Ensuring complete cyst removal reduces recurrence risk, especially in eyelid and tarsal tunnel cysts 2 3 4.
• Postoperative Follow-up: Regular monitoring is crucial to detect recurrence or complications early 3 7.
• Multidisciplinary Care: Complex cases, especially those involving nerve or bone, may benefit from coordinated care between ophthalmology, orthopedics, and neurology.

Conclusion

Tarsal cysts, though relatively rare, present unique diagnostic and therapeutic challenges. Their varied presentation—ranging from eyelid masses to painful foot lesions—demands careful clinical evaluation, histopathological confirmation, and tailored treatment strategies.

Key Takeaways:

• Tarsal cysts commonly present as painless masses, but can cause pain, recurrence, or nerve symptoms depending on location and type.
• Main types include eyelid epidermal inclusion/keratinous cysts, ganglion and synovial cysts in the tarsal tunnel, and unicameral bone cysts in the calcaneus.
• Causes range from trauma and surgical intervention to joint defects and developmental anomalies.
• Treatment is primarily surgical, with complete excision or decompression essential for cure and prevention of recurrence.
• Accurate diagnosis and individualized management are crucial for optimal outcomes.

If you experience persistent lumps or nerve symptoms in the eyelid or foot, prompt medical evaluation is recommended to rule out tarsal cysts and ensure appropriate care.