Ganglion Cyst

Most of the ganglion cysts are asymptomatic and sometimes remain undetected for long. They normally appear like a small bump, that changes in size, and usually does not move. They are normally pea sized, round or oval, an average size being about 2 cm, but their size can vary to as large as a golf ball. Cysts larger than 5 cm normally have to be surgically excised. Some cysts may appear suddenly and resolve spontaneously.

Ganglion cysts are normally painless unless they compress the adjacent nerve fibre, or restrict joint movement which results in dull aching continuous pain. Sometimes when the ganglion cyst gets attached to a tendon, it can also present with tingling numbness and muscle weakness. The cause of pain is unknown and is mainly due to adjacent nerve compression, though the most common presentation of the patient would be a non tender swelling or a mass. They never spread to other parts of the body. Along with pain, there may be slight limitation of movement of the affected joint.

Most of the ganglion cysts are easily diagnosed by a mere physical examination. They are very smooth and pliable to touch, usually 1-2 cm cystic structures that are well attached to the underlying tendon or capsule. There are no signs of inflammation and the swelling can be felt separate from the skin.

Physical examination is usually sufficient to confirm the diagnosis, but sometimes various imaging techniques to determine any underlying or adjacent pathology are carried out. Radiographs [4] are rarely suggested unless indicated, to detect any bony involvement.

Ultrasonography may be done to determine whether the swelling is cystic or solid. It may also be done to check involvement of an artery or blood vessel. Very rarely cystic fluid aspiration is necessary for further confirmation.

Magnetic Resonance Imaging (MRI) is also used nowadays for diagnosis of ganglions especially wrist ganglions. The drawback is that this procedure is very expensive. All the above mentioned imaging techniques are mainly used only for confirmation of the diagnosis.

Other than the wait and watch policy, ganglions do not require emergency treatment unless they cause severe pain or restrict movement affecting daily routine. Most disappear spontaneously. Depending upon the presentation, various treatments adopted are aspiration or surgery for removal. Aspiration involves removal of the cystic fluid by an incision with the help of a hypodermic needle, mainly ultrasound-guided. Post aspiration the site is injected with a corticosteroid mainly to reduce inflammation and prevent reoccurrence of cystic fluid. The doctor may splint the joint to provide immobilisation. Though splinting does not really help.

Surgery is mostly chosen when the mass is painful, restricting movement, or causes tingling numbness of the hand. Surgery is a simple arthroscopic or mini-open wide awake excision [5] of the ganglion cyst. Arthroscopic surgery is becoming more and more common due to minimal scar formation and faster recovery. Post-surgery doctors may advice physiotherapy or occupational therapy depending on the patient’s needs.

In comparison to aspiration, arthroscopic surgery has lesser reoccurrence and since it is minimally invasive it is more widely adopted. The prognosis of these swellings varies and chances of reappearance of these swellings are high. Normally these harmless tumours go away by themselves or may require a simple surgery. However, since they have a tendency to reappear, no single mode of treatment is enough.

The prognosis is good. It is most often a cosmetic condition and can be easily dealt with surgically.

The exact cause is uncertain. Current theories suggest herniation or out-pouching of the connective tissue through the joint capsule or tendon sheath which mainly occurs due to degeneration of the connective tissue. Excessive stress and movement of joint also tends to cause growth of these harmless tumours. Thus, a defect in the capsule of the joint or tendon sheath allows the distension and bulging. There is a lot of uncertainity regarding the origin of these soft tissue tumors [1].

The incidence is high in women; the cysts are three times more common in women than men between twenty to forty years of age and very rarely affect children below ten years of age. Most of the tumours of the hand are benign [2] with 60% being ganglion cysts.

The common sites of the ganglion cysts are joints of the wrists and fingers, especially the dorsal aspect of the wrist along the extensor carpi radialis. This accounts for 80% of all the cysts. They also affect the knee joints around the cruciate ligaments and the shoulder joints typically around the acromioclavicular joint.

Occasionally, minute ganglia occur on the flexor aspect of the fingers which although very small are very painful. Depending on the location and attachment, if the cyst occurs overlying soft tissue and bone, they are known as interosseous ganglion cysts. Very rarely, if attached to a muscle, mainly in the gastrocnemius muscle, it is known as intramuscular ganglion cyst.

Histologically, these cysts have multiple lobules separated by septae. Due to absence of epithelial lining, these are not true cysts. The cystic fluid is mainly made up of mucopolysacchrides, mainly consisting of hyaluronic acid and smaller amounts of albumen and globulin. The septae are made of loosely arranged layers of collagen fibres and fibrocytes. These cysts are connected to the joint by a pedicle or a stalk which has a tortuous lumen. The communication between the cyst and the joint is through this stalk which is one way, demonstrated by a contrast dye which travels from the joint to the cyst but not the other way, thus forming a one way valve mechanism [3]. This mechanism is facilitated by micro cysts present in the tissue around the pedicle.

Since there is no known cause for ganglion cysts, there is no method of prevention. Early detection and treatment are recommended.

Ganglion cysts are localised, tense cystic swellings, which usually occur along the joints and tendons of the appendicular skeleton. They contain a gelatinous jelly-like fluid microscopically similar to the synovial fluid; hence are also known as a synovial cyst.

They are benign and generally self limiting and tend to appear and disappear as well as change in size very rapidly. These cysts are smooth to touch and usually attached to the tendon sheath or capsule of the joint.

Ganglion cysts are harmless, non-cancerous swellings which usually occur on the joints of the hands and feet, especially on the back of the wrist. They are small, smooth, bump-like structures which usually appear attached to the tendons below.

They are painless and usually do not require any treatment unless they cause pain or restrict movement. It’s not fully understood how it occurs. The ganglion cysts tends to occur more in women than men. They never spread to other parts of the body. Although they tend to persist most often, they may intermittently appear and disappear. The cysts can be left alone if not symptomatic but if they are larger than 5 cm a surgical excision is advised.

If the cyst causes pain, it is best to seek medical care, the medical health provider will be the best to judge whether the ganglion cyst is a cause of concern or whether no treatment is needed at all.

Generally no tests are required; the doctor diagnoses it by a simple clinical physical examination. The most common treatment used which is patient friendly is a simple surgery for complete removal of the lump. This results in lesser chances of the cysts reappearing. Aspiration of the cystic fluid with the help of a needle is also done, but then the cyst tends to reoccur.
Home care treatment in the form of poultices, plasters and heat is not at all advised as it may aggravate the condition.

1. Colman MW, Lozano-Calderon S, Raskin KA, Hornicek Fj et al. Non- neoplastic soft tissue masses that mimic sarcoma. Orthop Clin North Am. 2014 Apr;45(2):245-55.
2. Darowish M, Sharma J. Evaluation and Treatment of Chronic Hand Conditions. Med Clin North Am. 98:4 2014 Jul pg 801-815
3. Craig A Camasta. Excision of the ganglion cyst. The Podiatry Institute. 1993.
4. Cooper Grant. (2006) Pocket Guide to Musculoskeletal Diagnosis. Springer. P63.
5. Bismil MSK ,Bismil QMK. The wide awake approach to hand and wrist ganglia. OA Case Reports. 2013 Nov 15;2(13):129.