Most patients walk into clinic worried that any lump in the foot means cancer. The truth is, the vast majority of foot and ankle masses are benign. That does not make them trivial. The foot’s tight compartments, small nerves, and constant load mean even a harmless lesion can be painful, deforming, or functionally limiting. Distinguishing benign from malignant, choosing the right imaging, and planning treatment without jeopardizing function takes judgment that comes from years working as a foot and ankle specialist.
I am writing from the perspective of an orthopedic foot and ankle surgeon who has resected neuromas that felt like pebbles in a shoe, excised ganglion cysts that refilled after needle aspiration, and coordinated limb salvage for sarcomas that masqueraded as stubborn “sprains.” The stakes vary from nuisance to life changing. Getting the first steps right often determines the long‑term outcome.
Why foot masses behave differently
The foot is compact. Skin, subcutaneous tissue, tendons, fascia, nerves, vessels, and bone lie in millimeters of each other. A mass that grows in the thigh can expand for months without causing much trouble. A mass in the tarsal tunnel, or between metatarsal heads, can irritate a digital nerve with each step. Weightbearing pressures drive symptoms even when the lesion is small. Shoes act like external splints that can push a benign lump into a painful prominence. Blood supply in the distal foot can complicate healing, especially in smokers and patients with diabetes or peripheral vascular disease. These anatomic facts shape decisions that a foot and ankle doctor makes at the first visit.
First questions I ask when someone finds a lump
On day one, I want the story, not just the image. When did you notice it? Is it growing, staying the same size, or waxing and waning? Tender with shoes or touch? Any night pain that wakes you, unexplained weight loss, fevers, or a history of cancer? Have you had trauma or repetitive stress from running, dance, soccer, or a job that keeps you on concrete floors? Does the mass change with activity or elevation? Does it transilluminate with a light, suggesting fluid? These clues steer me toward or away from certain diagnoses well before we scan.
I also examine shoes, orthotics, and gait. A forefoot lump that only hurts in a narrow toe box behaves differently from a lesion that causes pain barefoot on a hard floor. With a Morton’s neuroma, for example, forefoot squeeze can reproduce a shocky nerve pain. A ganglion off the dorsum of the midfoot may move with tendon excursion. A plantar fibroma feels like a firm nodule within the plantar fascia band. A glomus tumor under a nail produces exquisite cold sensitivity and point tenderness. Pattern recognition matters, but we still confirm with imaging when needed.
Benign versus malignant: clinical signals that count
Most foot masses are benign cysts, benign nerve lesions, fibromas, lipomas, or post‑traumatic changes. Malignant tumors, including soft tissue sarcomas and bone malignancies, are rare in the foot, far rarer than around the thigh or shoulder. Rarity does not mean impossible, so our triage blends probability with red flags.
Features that make me more concerned about malignancy include rapid growth over weeks to a few months, size greater than about 5 cm in soft tissue, a mass that is deep to fascia or fixed to surrounding structures, unexplained pain at night, and associated systemic symptoms such as unintentional weight loss. Prior radiation or a known cancer elsewhere also shifts the calculus. A mass that ulcerates through skin without trauma deserves urgent evaluation. Benign lesions can still be deep or firm, so none of these signs is definitive on its own. It is the pattern that urges caution.
Common benign foot and ankle masses, in plain language
I tend to explain lesions using lay terms first, then anatomical nuance.
A ganglion cyst is essentially a small balloon of joint or tendon sheath fluid that has herniated through a thin spot in the capsule. They often sit on the top of the foot near the midfoot joints or in the ankle. They fluctuate in size and may transilluminate. They can be aspirated, though about half recur over time. When they cause nerve irritation or repeated shoe pressure, a minimally invasive foot surgeon may remove the stalk and capsule to reduce recurrence.
A Morton’s neuroma is not a true tumor. It is a thickening of tissue around the digital nerve between metatarsal heads, most often between the third and fourth toes. Patients describe burning, tingling, or a sensation of a sock bunched under the toes. We start with shoe modifications, orthotics, and sometimes an ultrasound‑guided injection. Surgery, if needed, removes the diseased segment, which usually relieves pain but can leave a numb patch in the web space.
A plantar fibroma is a firm nodule within the plantar fascia. It can be small and painless or large and bothersome. These rarely transform into cancer. They can be stubborn. We try orthotics, topical agents, and shockwave in selected cases. Wide excision lowers recurrence but increases the risk of arch pain. This is where judgment and exacting technique from a foot and ankle care surgeon matter.
An inclusion cyst can form after minor trauma, sometimes from a puncture wound or nail salon injury. It feels like a firm pearl under the skin. These are usually straightforward to remove, but we respect scar placement in weightbearing zones to avoid painful scars.
A lipoma is a fatty, soft mass that is usually mobile and painless. They are less common in the foot than elsewhere because there is less subcutaneous fat. When symptomatic or suspicious, we remove them and send them for pathology.
A glomus tumor under a toenail is tiny, often just a few millimeters, yet disproportionately painful. Cold sensitivity and pinpoint tenderness are classic. MRI can help localize it before surgery. Relief after excision is immediate and gratifying.
In children, osteochondromas near the toes or midfoot can create lumps over time. Pediatric foot surgeons watch these closely and remove them if they irritate the skin or deform nearby toes.
What images tell us, and what they cannot
Plain X‑rays are a low radiation, low cost baseline. They reveal bone lesions, calcifications, erosion from a pressure effect, or hardware issues in a post‑surgical foot. Most soft tissue masses will not show on X‑ray, but bone changes around a soft mass can.
Ultrasound is an excellent bedside test for cystic versus solid lesions, and for guiding injections or aspirations. A foot and ankle specialist with ultrasound in clinic can answer key questions in minutes. Ultrasound also shows vascularity with Doppler, which helps characterize a lesion.
MRI is the workhorse when we need detail. It shows size, depth, relationship to fascia, nerves, and vessels, and signal characteristics that suggest certain diagnoses. A benign cyst has a classic bright fluid signal. A plantar fibroma has a low signal band within the fascia. Morton’s neuroma has a characteristic teardrop appearance between metatarsal heads. Sarcomas often appear heterogenous and infiltrative. That said, MRI is suggestive, not definitive. Pathology remains the gold standard.
CT scans have a role when bone involvement is suspected, such as a tarsal bone lesion, or when hardware from prior surgery distorts MRI images. For suspected infection or aggressive bone lesions, CT can map cortical involvement with precision.
If malignancy is on the table based on imaging or clinical features, we pause. The next step is not a casual in‑office excision. It is a planned image‑guided core needle biopsy performed in a way that does not contaminate compartments we might need to spare in a future resection. This is where coordination between a foot and ankle orthopedic specialist and a sarcoma center matters.
The art of biopsy in the foot and ankle
Biopsy is deceptively simple. Any podiatric surgeon or orthopedic foot surgeon can remove a lump. Doing it in the wrong plane or with the wrong incision can turn a contained tumor into one that seeded along the skin track, forcing a larger resection to secure margins. We always plan the biopsy track as if it will need to be removed in a definitive surgery.
For superficial, small, clearly benign‑appearing lesions that affect shoe wear, an excisional biopsy can be both diagnostic and therapeutic. For deeper masses, especially if MRI raises concern, the safer course is a percutaneous core needle biopsy performed or planned in conjunction with a sarcoma team. Fine needle aspiration alone is often inadequate for soft tissue tumors. Core biopsy gives architecture and is usually preferred. If a nail unit tumor is suspected, mapping the exact matrix involvement makes a difference in preserving nail function.
When we reassure and when we escalate
A sizable fraction of patients leave the first visit with reassurance and a plan centered on monitoring or symptom relief. If imaging shows a simple ganglion in a convenient location, we can aspirate and brace activity for a week. If a plantar fibroma is small, we use orthotics to offload the band and revisit in 3 to 6 months. If a Morton’s neuroma responds to shoe changes and one guided injection, no surgery is needed.
We escalate when the mass is enlarging, symptomatic despite conservative measures, causing nerve dysfunction, or has features worrisome for malignancy. Escalation can mean advanced imaging, biopsy, or a surgical excision. In children, rapid growth around growth plates requires earlier imaging. In patients with diabetes, even benign lesions can ulcerate under pressure, so a diabetic foot surgeon weighs skin integrity more heavily.
Surgical planning in the tight spaces of the foot
Surgery on the foot rewards precision. Incisions follow skin lines and avoid high pressure areas when possible. We protect sensory nerves that run close to almost every approach. For a dorsal midfoot ganglion, a small transverse incision in a shoelace crease can hide the scar and reduce postoperative irritation. For a Morton’s neuroma, the web space incision must preserve digital nerves and small arteries. For plantar fibromas, a curved incision just medial to the weightbearing plantar surface can avoid a painful plantar scar.
Minimally invasive options exist for selected lesions, including endoscopic decompression of a tarsal tunnel cyst or arthroscopic excision of certain intra‑articular ganglia. An arthroscopic ankle surgeon may address a cyst that communicates with the ankle joint from inside the joint, reducing soft tissue trauma. These choices depend on lesion location, size, and surgeon experience.
Margins matter in suspected malignancy. A foot and ankle tumor surgeon will plan a wide resection around a sarcoma, sometimes in combination with a plastic surgeon for soft tissue coverage or a microvascular flap. Limb salvage rates for foot sarcomas have improved when cases are centralized and protocols followed. It is rarely a solo effort. Radiology, pathology, medical oncology, and reconstructive partners make a difference.
Recovery, recurrence, and the long game
After excising a benign mass, recovery usually involves a short period in a postoperative shoe or boot, elevation to limit swelling, and suture removal at about 2 weeks. Return to desk work can be quick, often a few days, while manual labor may need 3 to 6 weeks. Athletes can start gentle activity after wound healing, then rebuild load over 4 to 8 weeks depending on the location.
Recurrence rates vary. Ganglion cysts can recur even after meticulous resection if a small joint communication persists. Plantar fibromas have a meaningful recurrence risk, higher when excision is limited and lower with wider excision, but wider excision carries more risk of arch discomfort. Neuromas, once removed, typically do not come back in the same spot, though a stump neuroma can occur if the nerve end forms a painful neuroma. Good technique reduces this risk.
If pathology shows malignancy, the plan pivots to staging. We obtain chest imaging to look for metastasis, usually a CT chest for soft tissue sarcomas. We discuss margins achieved and whether re‑excision is needed. Radiotherapy is considered based on size, depth, grade, and margin status. These decisions are nuanced and follow established oncologic pathways. The foot is a special site where radiotherapy can complicate wound healing. That makes margin‑negative surgery at the outset all the more valuable.
Stories that stick
Two examples illustrate how small details change outcomes. A 42‑year‑old runner presented with a “marble” on the dorsum of her midfoot that grew and shrank with mileage. Ultrasound showed a cyst with a neck to the intercuneiform joint. Aspiration relieved her for three months, then it refilled. We scheduled arthroscopic debridement of the joint synovium and open excision of the stalk. She was back to easy runs at six weeks, and the cyst did not recur.
Another patient, a 58‑year‑old carpenter, had a firm mass along the lateral plantar foot that he thought was a callus. It grew from 1 to 3 cm over four months. MRI showed a deep mass within the abductor digiti minimi muscle with irregular borders. Rather than excise it in clinic, we arranged a core needle biopsy through a planned lateral incision path. Pathology revealed a myxofibrosarcoma, low grade. With the sarcoma team, we performed a wide resection and a rotational flap for coverage. He kept his foot, returned to light duty by three months, and remains disease‑free at his two‑year visit. Planning the biopsy track correctly spared him a more radical surgery.
The role of the broader foot and ankle team
Not every lump is a job for a tumor specialist. A foot cyst surgeon handles many dorsal ganglia. An ankle cyst surgeon treats anterolateral ankle ganglia that impinge during dorsiflexion. A surgeon for hammertoes may encounter small inclusion cysts at the tip of clawed toes during corrective surgery. An ankle instability surgeon might find a peroneal tendon sheath ganglion during a Broström repair. A diabetic foot surgeon balances mass removal with pressure distribution to prevent ulcer recurrence. A pediatric ankle surgeon watches osteochondromas and nonossifying fibromas differently than in adults.
The unifying principle is matching the lesion to the right skill set. Orthopedic foot and ankle surgeons and podiatric surgeons share many of these competencies. Board‑certified foot and ankle surgeons bring additional training in complex reconstruction. For lesions that cross boundaries, we coordinate. Sports foot surgeons work with radiologists for ultrasound‑guided procedures. Foot and ankle reconstructive surgeons work with plastic surgeons for coverage. Trauma foot surgeons keep malignancy in mind when a “hematoma” after an injury does not resolve as expected.
When to get a foot and ankle specialist involved early
Early referral helps in a few scenarios that show up often in primary care or urgent care.
A mass that appears after a sprain and persists beyond normal healing deserves an exam and likely an ultrasound or MRI. Not every post‑injury lump is a hematoma. An enlarging mass deep to the plantar fascia, especially if firmer than the surrounding band, warrants imaging rather than repeated steroid injections. Recurrent “bursitis” on the dorsum of the foot that refills after aspiration should be evaluated for a joint‑connected ganglion. Any nail unit lesion with discoloration, bleeding, or a subungual mass that does not respond to typical care should be assessed by a toe surgery surgeon with experience in nail bed tumors.
Patients who are immunosuppressed, have a history of cancer, or have poorly controlled diabetes benefit from earlier imaging. With diabetes, offloading and skin care are as important as mass management. With prior cancer, a small metastasis can mimic a benign cyst. Nuance protects patients.
Living with a benign mass versus removing it
I often frame the choice pragmatically. If a benign lesion is small, not growing, and painless in your usual shoes, watching it is sensible. If it interferes with work boots, dance shoes, or daily walks, and nonoperative measures fail, removal is reasonable. Surgical risks are not negligible in the foot: wound issues, nerve irritation, scar sensitivity, and recurrence. In weightbearing areas, even a perfect incision can feel tender for a few months. Clear expectations help. Many patients choose to live with a stable lipoma or a plantar fibroma they can pad around, and that is a perfectly fine outcome.
Technology helps, judgment decides
Ultrasound in clinic has shortened time to answers for many patients. High field MRI shows lesions we used to miss. Arthroscopy allows us to address certain cysts without a big incision. None of these replaces clinical judgment. A foot and ankle consultant balances the allure of intervention against the reality of shoes, floors, and miles walked every week. Every decision returns to function, comfort, and safety.
A concise guide for patients noticing a new foot lump
- Track size and symptoms over weeks. Note pain with shoes, at night, or with activity. Avoid repeated “popping” or massage if it worsens pain or swelling. Seek evaluation if the mass is enlarging, deeper than the skin, painful at rest, or associated with numbness, weakness, fever, or weight loss. Bring your most worn shoes to the visit. Wear marks and pressures map your foot better than words. If a biopsy is advised for a suspicious lesion, ask who will perform it and how the incision or needle track will be planned for a possible definitive surgery.
How we keep you moving
For many patients, the Click here for info right solution mixes small interventions that add up. A met pad can unload a Morton’s neuroma, and one ultrasound‑guided injection can calm it. A dorsal midfoot ganglion might be aspirated once before a wedding trip, then definitively treated later. A plantar fibroma can be offloaded with a custom orthotic cutout, avoiding surgery for years. When surgery is needed, meticulous handling of tissue, careful closure, and a shoe strategy reduce downtime. A foot surgery specialist aims to remove the problem without creating a new one.
For complex cases, such as tumors entwined with nerves or arteries, a foot and ankle microsurgery specialist may assist with nerve grafts or vascular repair. When bone is involved, an orthopedic surgeon for foot lesions plans resections that preserve alignment, sometimes using small plates, screws, or, rarely, foot implants to rebuild stability. An ankle surgeon coordinates when tumors extend into the hindfoot or ankle joint. Whatever the path, the goal is straightforward: relieve pain, protect function, and, when cancer is present, secure durable control of disease.
Final thoughts from years in the trenches
I have learned to respect small masses and to be skeptical of big promises. A painless lump that behaves for years may never need the knife. A dime‑sized lesion under a nail can steal sleep until we find it on MRI and cure it with a 20‑minute procedure. The rare sarcoma in the plantar foot is unforgiving of shortcuts, yet with the right plan the majority of patients keep their limb and return to daily life.
If you or a family member has found a mass in the foot or ankle, start with a thorough exam by a foot and ankle doctor. Ask direct questions. What is the likely diagnosis? What features make it more or less concerning? If imaging is needed, which modality and why? If a biopsy is proposed, how will it be done to preserve options if it proves malignant? If surgery is advised for a benign lesion, what is the plan for scar placement, nerve protection, and recurrence prevention?
Good care often looks like patience at the beginning and precision at the end. That balance, more than any single test or technique, is what keeps people walking comfortably after a foot mass is found.