Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of tarsal tunnel syndrome caused by an intraneural ganglion cyst
-
Sanjay Vishnu Phadke
and
Andrew S. Parsons
Abstract
Objectives
Intraneural ganglionic cysts are non-neoplastic cysts that can cause signs and symptoms of peripheral neuropathy. However, the scarcity of such cases can lead to cognitive biases. Early surgical exploration of space occupying lesions plays an important role in identification and improving the outcomes for intraneural ganglionic cysts.
Case presentation
This patient presented with loss of sensation on the right sole with tingling numbness for six months. A diagnosis of tarsal tunnel syndrome was made. Nerve conduction study revealed that the mixed nerve action potential (NAP) was absent in the right medial and lateral plantar nerves. The magnetic resonance imaging (MRI) found a cystic lesion measuring 1.4×1.8×3.8 cm as the presumed cause of the neuropathy. Surgical exploration revealed a ganglionic cyst traversing towards the flexor retinaculum with baby cysts. The latter finding came as a surprise to the treating surgeon and was confirmed to be an intraneural ganglionic cyst based on the histopathology report.
Conclusions
Through integrated commentary by a case discussant and reflection by an orthopedician, this case highlights the significance of the availability heuristic, confirmation bias, and anchoring bias in a case of rare disease. Despite diagnostic delays, a medically knowledgeable patient’s involvement in their own care lead to a more positive outcome. A fish-bone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic delay. Finally, this case provides clinical teaching points in addition to a pitfall, myth, and pearl related to availability heuristic and the sunk cost fallacy.
-
Research ethics: Ethical approval is not applicable: Case Report. Written Informed consent was obtained from the patient.
-
Informed consent: Written Informed consent was obtained from the patient involved in the case report.
-
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
-
Competing interests: The authors state no conflict of interest.
-
Research funding: None declared.
-
Data availability: The data generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
References
1. Panwar, J, Mathew, A, Thomas, BP. Cystic lesions of peripheral nerves: are we missing the diagnosis of the intraneural ganglion cyst? World J Radiol [Internet] 2017;9:230. https://doi.org/10.4329/wjr.v9.i5.230.Search in Google Scholar PubMed PubMed Central
2. Desy, NM, Wang, H, Elshiekh, MAI, Tanaka, S, Choi, TW, Howe, BM, et al.. Intraneural ganglion cysts: a systematic review and reinterpretation of the world’s literature [Internet]. J Neurosurg 2016;125:615–30. https://doi.org/10.3171/2015.9.jns141368.Search in Google Scholar PubMed
3. Desy, NM, Amrami, KK, Spinner, RJ. Ganglion cysts and nerves. Neurosurg Q [Internet] 2006;16:187–94. https://doi.org/10.1097/01.wnq.0000214029.54860.44.Search in Google Scholar
4. Thornburg, LE. Ganglions of the hand and wrist. [Internet]. J Am Acad Orthop Surg 1999;7:231–8. https://doi.org/10.5435/00124635-199907000-00003.Search in Google Scholar PubMed
5. Erdil, M, Ozkan, K, Ozkan, FU, Bilsel, K, Turkmen, I, Senol, S, et al.. A rare cause of deep peroneal nerve palsy due to compression of synovial cyst – case report. Int J Surg Case Rep 2013;4:515–7. https://doi.org/10.1016/j.ijscr.2012.11.028.Search in Google Scholar PubMed PubMed Central
6. Lang, CJG, Neubauer, U, Qaiyumi, S, Fahlbusch, R. Intraneural ganglion of the sciatic nerve: detection by ultrasound [Internet]. J Neurol Neurosurg Psychiatry 1994;57:870–1. https://doi.org/10.1136/jnnp.57.7.870-a.Search in Google Scholar PubMed PubMed Central
7. Bhat, AK, Madi, S, Mane, PP, Acharya, A. Bilateral tarsal tunnel syndrome attributed to bilateral fibrous tarsal coalition and symmetrical hypertrophy of the sustentaculum tali. BMJ Case Rep [Internet]. 2017;2017:bcr-2017-220087. https://doi.org/10.1136/bcr-2017-220087.Search in Google Scholar PubMed PubMed Central
8. Kim, S, Kim, H, Jo, DI, Na, SJ, Jo, YS. Isolated medial plantar neuropathy caused by a large ganglion cyst diagnosed with MRI: a case report. Int J Surg Case Rep 2018;42:200–3. https://doi.org/10.1016/j.ijscr.2017.12.016.Search in Google Scholar PubMed PubMed Central
9. Ariyaratne, S, Pathak, G, Iyengar, K, Botchu, R, Shah, A. A rare case of an intraneural ganglion cyst of the median nerve. J Ultrason [Internet] 2023;23:e161. https://doi.org/10.15557/jou.2023.0025.Search in Google Scholar PubMed PubMed Central
10. Castelli, G, Desai, KM, Cantone, RE. Peripheral neuropathy: evaluation and differential diagnosis. Am Fam Physician [Internet] 2020;102:732–9.Search in Google Scholar
11. Olivola, CY. The interpersonal sunk-cost effect. Psychol Sci [Internet] 2018;29:1072–83. https://doi.org/10.1177/0956797617752641.Search in Google Scholar PubMed
12. Nendaz, M, Perrier, A. Diagnostic errors and flaws in clinical reasoning: mechanisms and prevention in practice. Swiss Med Wkly [Internet] 2012;142:w13706. https://doi.org/10.4414/smw.2012.13706. https://smw.ch/index.php/smw/article/view/160.Search in Google Scholar PubMed
13. Taber, JM, Leyva, B, Persoskie, A. Why do people avoid medical care? A qualitative study using national data. J Gen Intern Med [Internet] 2015;30:290. https://doi.org/10.1007/s11606-014-3089-1.Search in Google Scholar PubMed PubMed Central
14. Krist, AH, Tong, ST, Aycock, RA, Longo, DR. Engaging patients in decision-making and behavior change to promote prevention. Stud Health Technol Inform [Internet] 2017;240:284.10.3233/ISU-170826Search in Google Scholar
15. Saposnik, G, Redelmeier, D, Ruff, CC, Tobler, PN. Cognitive biases associated with medical decisions: a systematic review. BMC Med Inform Decis Mak [Internet] 2016;16:1–14. https://doi.org/10.1186/s12911-016-0377-1.Search in Google Scholar PubMed PubMed Central
© 2024 Walter de Gruyter GmbH, Berlin/Boston
Articles in the same Issue
- Frontmatter
- Editorial
- The growing threat of hijacked journals
- Review
- Effects of SNAPPS in clinical reasoning teaching: a systematic review with meta-analysis of randomized controlled trials
- Mini Review
- Diagnostic value of D-dimer in differentiating multisystem inflammatory syndrome in Children (MIS-C) from Kawasaki disease: systematic literature review and meta-analysis
- Opinion Papers
- Masquerade of authority: hijacked journals are gaining more credibility than original ones
- FRAMED: a framework facilitating insight problem solving
- Algorithms in medical decision-making and in everyday life: what’s the difference?
- Original Articles
- Computerized diagnostic decision support systems – a comparative performance study of Isabel Pro vs. ChatGPT4
- Comparative analysis of diagnostic accuracy in endodontic assessments: dental students vs. artificial intelligence
- Assessing the Revised Safer Dx Instrument® in the understanding of ambulatory system design changes for type 1 diabetes and autism spectrum disorder in pediatrics
- The Big Three diagnostic errors through reflections of Japanese internists
- SASAN: ground truth for the effective segmentation and classification of skin cancer using biopsy images
- Computable phenotype for diagnostic error: developing the data schema for application of symptom-disease pair analysis of diagnostic error (SPADE)
- Development of a disease-based hospital-level diagnostic intensity index
- HbA1c and fasting plasma glucose levels are equally related to incident cardiovascular risk in a high CVD risk population without known diabetes
- Short Communications
- Can ChatGPT-4 evaluate whether a differential diagnosis list contains the correct diagnosis as accurately as a physician?
- Analysis of thicknesses of blood collection needle by scanning electron microscopy reveals wide heterogeneity
- Letters to the Editor
- For any disease a human can imagine, ChatGPT can generate a fake report
- The dilemma of epilepsy diagnosis in Pakistan
- The Japanese universal health insurance system in the context of diagnostic equity
- Case Report – Lessons in Clinical Reasoning
- Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of tarsal tunnel syndrome caused by an intraneural ganglion cyst
Articles in the same Issue
- Frontmatter
- Editorial
- The growing threat of hijacked journals
- Review
- Effects of SNAPPS in clinical reasoning teaching: a systematic review with meta-analysis of randomized controlled trials
- Mini Review
- Diagnostic value of D-dimer in differentiating multisystem inflammatory syndrome in Children (MIS-C) from Kawasaki disease: systematic literature review and meta-analysis
- Opinion Papers
- Masquerade of authority: hijacked journals are gaining more credibility than original ones
- FRAMED: a framework facilitating insight problem solving
- Algorithms in medical decision-making and in everyday life: what’s the difference?
- Original Articles
- Computerized diagnostic decision support systems – a comparative performance study of Isabel Pro vs. ChatGPT4
- Comparative analysis of diagnostic accuracy in endodontic assessments: dental students vs. artificial intelligence
- Assessing the Revised Safer Dx Instrument® in the understanding of ambulatory system design changes for type 1 diabetes and autism spectrum disorder in pediatrics
- The Big Three diagnostic errors through reflections of Japanese internists
- SASAN: ground truth for the effective segmentation and classification of skin cancer using biopsy images
- Computable phenotype for diagnostic error: developing the data schema for application of symptom-disease pair analysis of diagnostic error (SPADE)
- Development of a disease-based hospital-level diagnostic intensity index
- HbA1c and fasting plasma glucose levels are equally related to incident cardiovascular risk in a high CVD risk population without known diabetes
- Short Communications
- Can ChatGPT-4 evaluate whether a differential diagnosis list contains the correct diagnosis as accurately as a physician?
- Analysis of thicknesses of blood collection needle by scanning electron microscopy reveals wide heterogeneity
- Letters to the Editor
- For any disease a human can imagine, ChatGPT can generate a fake report
- The dilemma of epilepsy diagnosis in Pakistan
- The Japanese universal health insurance system in the context of diagnostic equity
- Case Report – Lessons in Clinical Reasoning
- Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of tarsal tunnel syndrome caused by an intraneural ganglion cyst
