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The Figure Skater and Ganglion Cysts of the Ankle

A survey of the Incidence and Possible Implications

April 02, 2002
Article by Sharon Walston, DPM
Copyright © The Professional Skater (PS) Magazine
Courtesy reprint authorized by the Professional Skaters Association (PSA)

It is common knowledge within the figure skating community that figure skaters have terrible feet and ankles, and the better the skater, the worse the feet. Most boot related injuries are the same injuries that wearing any tight, stiff shoe can cause, meaning corns, calluses, blisters, and bone spurs. However, one injury that seems to be particularly common to skaters, and high level skaters in particular, is a large fluid filled cyst called a ganglion cyst that occurs around the ankles. These injuries have plagued many top competitors who often have multiple cysts, some of which can be quite large containing several milliliters of fluid.

Ganglion cysts range from being non-painful to extremely painful if they become inflamed. These often pose more of a physical difficulty in getting the foot into the skate as well as being cosmetically unappealing. Other skaters find them a continual source of irritation while skating, but not painful enough to discontinue training. These cysts have been found to reduce once skating is discontinued. Silicone pads have been found to help reduce these cysts though many become permanent or continue to grow with continued abuse from daily skating. Skaters will usually put up with the cysts for months to years until they either become inflamed or just too large to continue training. Aspiration (sucking the fluid out with a syringe) can eliminate the cyst, but they usually reform in hours or a few days. The only true cure is surgical removal.

A ganglion cyst is a thin-walled cystic lesion (usually 1.5 to 2.0 cm in diameter) located just under the skin in what is called the subcutaneous tissue. It is filled with water-like fluid similar to that in joints but can also be gelatinous in nature. These cysts occur in the tissues below the skin called subcutaneous tissue as a response to repeated trauma or constant friction. These fluid cysts reduce friction of skin against the bones and/or tendons around the ankles in the case of the figure skater.

Dr. James Garrick, who has surgically removed many of these ganglion cysts from the feet of figure skaters, believes that when the skater's ankle bends and rotates, the stiff leather boots resist this motion. The skin sticks to the boot, forcing the soft tissues underneath to give way forming the cyst. Dr. Garrick states that skaters demand a great deal from their equipment. He claims that it is not that the boots are particularly ill-designed, but that the skaters demands on their feet and boots are too great and becoming even greater as skating grows technically more difficult. Skaters' boots must be flexible enough to allow extensive ankle range of motion with almost as much point and flex as ballet requires, but the boots must be stiff enough to prevent almost all side to side motion. This would indicate that those skaters putting more demands on their equipment would be more inclined to get ganglion cysts. This theory is supported by the boot manufacturer, Harlick, who said that cysts start showing up when skaters begin doing triple jumps that require increased jump height and thicker boots to support the impact coming down from those heights.

Procedure

This study included 75 figure skaters attending various freestyle and/or ice dance sessions around the San Francisco Bay Area who were asked to fill out a boot injury survey. Skaters provided information regarding age, sex, height, weight, skating level in ice dance and/or freestyle, highest jump completed, years of skating, hours/day, days/week, professional or not, and type, brand, and thickness of boots. Then, each skater was interviewed about what kinds of injuries he/she had attained as a result of wearing figure skating boots. Some skaters had been previously diagnosed as having ganglion cysts.

This data was compiled into three variants: age, skating level, and how many cysts were or had been present. Age was split into adults, with a non-growing foot, and youth, with a growing foot. This was determined by the age of fusion of the bones generally age 16-18. Age 18 or higher was considered to be an adult, and age 17 or younger a youth.

Skating ability was divided into three levels, high, intermediate, and beginner. This was determined by USFSA test level either in ice dance or freestyle and/or by highest jump. High level was determined to be any skater who had passed the junior freestyle and/or pre-gold dance test or higher. Jump level was ability to complete a double Axel or higher. Intermediate included Bronze dance and/or juvenile freestyle test up to silver dance and/or novice freestyle test. Jump level included Axel through double Lutz. Beginner was determined to be test level up to pre-bronze dance or pre-juvenile freestyle. Jump level no higher than a Lutz.

Discussion

Based on the above data, ganglion cysts happen to higher level skaters more often than their lower level counterparts, 46.7% of high level adults versus 12.5% of intermediate level adults, and only 10% of low level adults. The majority, 24 of the 29 cysts seen, were over the tendon in the front of the ankle. However, the largest variance was by age. These cysts are an injury of the skeletally mature skater. 100% of the cysts surveyed occurred in skaters, age 18 or older. In fact, the youngest skater to have or have had a cyst was a high level 23 year old.

There are several possibilities as to why this is the case. These include increased weight and height, however these would suggest a gradual increase in cyst numbers with increasing age versus such a sharp contrast. One factor that changes with aging is the lack of growth of the mature foot. The reason this is significant is that young skaters will often go through at least one pair of skating boots each year replacing them because they have outgrown them rather than having broken them down. Once the foot is mature, the only factor sending a skater to the boot manufacturer for new boots is the breakdown of old boots. Many adult and professional skaters will keep skating on old broken down boots lovingly referred to as "bedroom slippers," because new boots are so expensive, and the skater does not want to endure the countless blisters and sore spots of breaking in a new pair. Some skaters will get their current boots rebuilt meaning the manufacturer reglues the leather, building back up the sides of the boot giving it renewed support.

It is the author's belief that it is not necessarily the broken down boots that cause these cysts, but more the wearing down of the tongues of the old boots. When skaters are replacing their boots for growth, the tongues do not have a chance to breakdown or wear through. Lacking the need for larger boots, the skaters will often go up to several years in one pair of boots. The part that wears out first is the tongue. What was once a thick piece of leather with a good half inch of soft foam or lamb's wool padding protecting the skaters' ankle region from direct abrasion from the laces turns into nothing more than a very thin, soft piece of leather.

It is the top lace that takes the majority of the downward forces created during ankle flexion while skating. This is seen when the skater does any deep knee bend such as while landing a jump. However this force is dispersed over the entire front of the ankle area by the stiff, thick, padded tongue. As the tongue leather thins and the padding wears out under the top lace, it leaves little between the skater's skin and the top lace focusing the downward force onto the most prominent structure, the anterior tibial tendon. When flexing, skaters actively utilize the muscles in the front of their ankles to push against the boot while stabilizing this flexion with the muscles in the back of the calf. With this muscle contraction, the tendon in front of the ankle stands out as a prominent tight cord that supports the body weight against the tongue and lacing of the boot. Missing the protection from the tongue, the top lace acts like a tight cord supporting the skater's weight and rubbing up and down the tendon each time the skater flexes. What breaks down is the tendon sheath of this tendon forming the ganglion cyst. Supporting this theory is the fact that putting more dense padding between the ankle region and tongue of the boot can help distribute the forces over a larger area reducing the pain of tendonitis and/or cysts. Skaters interviewed in this study also found silicone padding to be of help in this area as well. These silicone pads help the tongue to move easily over the front of the ankle without dragging the skin along with it.

The theory of higher level skaters getting more ganglion cysts was found to be correct. Disregarding age, 38.9% of high level skaters had cysts, versus the decrease to 9.5% of intermediate level skaters, and 6.7% of beginning level skaters. This is simply because high level skaters have greater ankle range of motion, against stiffer boots, and more often. They also replace their worn out triple and quadruple strength boots as often as twice a year for elite competitors. This is supported by the fact that the skater with four cysts is an elite skater.

High level skaters utilize almost as much ankle range of motion as a ballet dancer. The skating ankle will be maximally flexed for a "down in the knees" position in which the ankle and knee are maximally flexed, and the trunk in upright. The free leg will be extended with the free foot and ankle maximally pointed against the boot for a "pointed toe." This pointing pulls the heel and ankle bones forward putting a great deal of rubbing on the skin on top of the ankle bones and over the tendon in front of the ankle. Beginning and intermediate skaters tend to flex more at the waist with little bend in the ankles. Proper down in the knees position must be achieved in order to do high level double and triple jumps or high level ice dancing. These skaters demand a lot of support from their boots. Jumping wears out skates the fastest. The skater utilizes the boot's stiffness as a spring to help take off and as a shock absorber landing on one foot. The higher the jump the more downward force put on the boot, and as rotations increase in number and velocity, the more torque put on the boot. These skaters also spend more time doing on-ice training, often skating two or three times each day. Also, the softer the boot gets, the tighter the laces have to be to get the same amount of support. Hence, in a worn out pair of boots, the skater's top lace is tighter, with very little padding between the top laces and the skater's tendons.

Cysts over the ankle bones have been found to be the result of the purchase of new boots or an increase in training. New boots, and especially triple and quadruple strength boots like those used by higher level skaters, have very stiff, flat sides that are forced to bend and form around the prominent ankle bones. Over the course of several weeks of continuous skating, the boot contours to the ankle bones. It can be a very painful process, and any skater who has broken in new boots knows the pain involved in breaking them in. Blisters, calluses, and occasionally, ganglion cysts can be the result. This study only found five skaters to have cysts over their ankle bones, so few conclusions can be drawn. Things that have been found to help ankle bone pain and cysts include having the uppers of the boot punched out using a ball and ring device, or using dense foam or silicone padding either whole or in a ring around the ankle bone.

As for beginning level skaters with ganglion cysts, this may be the result of over zealousness. Some beginning adults tend to take up skating with a vengeance, skating hours every day. Other beginning adults like to buy the "best" most expensive equipment, meaning the stiffest skates, regardless of whether or not they need them for support. Both of these factors could lead to cysts. These adults probably have tender skin around their ankles, unlike higher level skaters who have built up tough scarred skin over years of abuse in boots. Possible future studies could include other sports activities involving tight fitting stiff boots such as skiing, ice hockey, or in-line skating.