Ganglion cysts are benign (non-cancerous) lumps that are often found in the wrist or hand, on the top layer of the tendons. The exact cause is unknown and occasionally these cysts can appear around the ankle or top of the foot. Most of the time, it can be worrying to see a new growth on your skin but ganglions are harmless and the size can vary from the size of a pea, to rarely as large as a golf ball.
The majority of patients with a ganglion do not have pain, however some patients can experience pain, swelling, numbness and weakness of the joint. Research has shown that approximately 20% patients have pain associated with swelling and further evidence highlights that the fear associated with ganglion – concern about the lump being cancerous, is the primary reason for patients seeking the advice of a clinician (Suen, Fung & Lung, 2013).
Both the capsules which surround our joints and the sheath which wraps around our tendons are comprised of synovial tissue. A ganglion is essentially considered a protrusion of this tissue in which the fluid encapsulated within the joint leaks, causing fluid to collect and form the characteristic lump or ganglion cyst.
At Pure, your Physio will take a detailed history of your symptoms followed by a thorough clinical examination to establish a diagnosis and ruling out certain conditions that can cause similar symptoms such as lipomas (again a benign non cancerous growth), De Quervain’s tenosynovitis (this often comes with pain) and Dupuytren’s contracture which largely found inside the palm (Thornburg, 1999). They may consider sending you for an ultrasound scan if they are unable to give you a diagnosis with clinical examination.
A fast and accurate diagnosis will mean that the most effective treatment and management plan can be implemented straight away, helping to achieve optimal outcomes. Your Physiotherapist will want to know how your condition is effecting you day to day so that your treatment can be tailored to your needs and will mean personalised goals can be established. Regular re-assessment will ascertain if your are making progress towards your goals and will allow adjustments to your treatment to be made.
For most cases, a ganglion cyst does not need any specific management, they often disappear with time or in other words ‘wait and see’ approach is what your Physiotherapist or GP will suggest.
Based on the location and presentation, management option can vary significantly:
Dorsal or knuckle side of the wrist – typically occurs in young adults and often alleviates spontaneously. Aspiration can reduce the swelling but it often returns. The risk of recurrence after surgery is around 10%, and problems after surgery include persistent pain, loss of wrist movement and painful trapping of nerve branches in the scar.
Palm side of the wrist – may occur in young adults, but also seen in association with wrist arthritis in older individuals. Aspiration may be useful, but care is needed as the cyst is often close to the radial pulse under the thumb. There is 30% recurrence chance even after surgery, and unlike other areas that can be removed surgically, there is a bigger risk of having continuous pain, nerve damage and persistent weakness or stiffness of the wrist joint. For these reasons, many surgeons advise against operation for these cysts.
Base of the fingers – usually seen in young adults, causing pain when gripping and feeling like a dried pea sitting on the tendon sheath at the base of the finger. Puncture of the cyst with a fine needle can disperse it – like puncturing a balloon. Recurrence rate is just less than 50%. Your GP may consider sending you for an operation if the cyst is persistent and painful. Recurrence rate is quite low after surgery.
Finger joints – seen more in middle-aged or older people and associated with arthritis of the distal joint of the fingers. Occasionally the synovial fluid can leak to the surface of the skin as it makes a furrow into the nail bed. Rarely you need a surgery for this type of ganglion cyst and associated risks are infection and persistent pain.
(Peters et al., 2013)
Physiotherapy input can be very helpful for creating a bespoke exercise based rehabilitation programme. In both conservative and surgical management, exercise will be important to maintain joint mobility, function and strength.
If the ganglion is symptomatic with pain, dysfunction of the joint and numbness over the skin, your GP may offer aspiration treatment. This procedure involves drawing the fluid out using a needle and syringe.
For very persistent lesions, the ganglion can be surgically removed. The close proximity of blood vessels and tendons always leaves the possibility of significant complications. Removal of the ganglion in its entirety should be ensured, as breaking of the ganglion cyst during removal causes some of its parts to remain inside the body, and increases the risk of recurrence.
British Society for Surgery of the Hand information leaflet – click here
Suen, M., Fung, B., & Lung, C. P. (2013). Treatment of ganglion cysts. ISRN orthopedics, 2013.
Peters, F., Vranceanu, A. M., Elbon, M., & Ring, D. (2013). Ganglions of the hand and wrist: determinants of treatment choice. Journal of Hand Surgery (European Volume), 38(2), 151-157.
Thornburg, L. E. (1999). Ganglions of the hand and wrist. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 7(4), 231-238.