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Ganglion Cyst
Matthew W. Thompson, MD
William Fiden, MD
image BASICS
  • Ganglion cysts are common benign tumors that are not related to nerve tissue (as implied incorrectly by the name).
  • Can be located anywhere throughout the body but usually adjacent to or within joints and tendons, with the most common locations being the wrist, foot, and ankle
  • Not a true cyst as microscopic examination does not show an epithelial lining
  • Most are asymptomatic except for changing size. Local nerve compression can result in pain or activity limitation.
  • Synonym(s): synovial cyst; myxoid cyst; Gideon disease; Bible bump.
  • Can affect all age groups. Unusual in children
  • Most common in ages 20 to 40 years and twice as common in women
  • Common in dorsal wrist, radial wrist, and dorsum of the distal interphalangeal (DIP) joint (referred to as a mucous cyst)
  • Mucous cysts are usually seen in older patients.
  • 60-70% of hand and wrist ganglion cysts are on the dorsal wrist; 15-20% are on the volar wrist.
  • Prevalence of wrist ganglia in patients presenting with wrist pain is as high as 19%.
  • Prevalence of ganglia in patients with a palpable mass in the wrist is as high as 27%.
  • Reported prevalence in ankles is 5.6%.
Pathogenesis is unclear. Cysts are filled with mucin and communicate with the adjacent joint space, tendon and/or tendon sheath via a stalk. Several theories about their orgin include:
  • Herniation of synovial lining creates a one-way valve. Although this is supported by dye studies, the lack of a synovial (epithelial) lining in the cyst wall makes this less likely.
  • Mucoid degeneration of connective tissue results in formation of hyaluronic acid, leading to cystic space formation. Studies haven't confirmed this hypothesis.
  • Joint stress leads to a tear in the joint capsule or tendon sheath allowing synovial fluid to leak into surrounding tissues. Local irritation leads to production of fluid and a pseudocapsule forms (explaining the lack of an epithelial lining).
  • Recurrent stress may stimulate mucin production by nearby mesenchymal cells (seen on electron microscopy) resulting in cyst formation.
No specific genetic links have been found.
  • Female > male
  • Osteoarthritis for mucoid cysts
  • Joint trauma (possible but not proven)
Mucous cysts are usually associated with osteoarthritis at the DIP joint.
Usually made on basis of history and physical examination
  • Mass
    • Rubbery
    • Subcutaneous
    • May transilluminate
    • Fixed to the tendon sheath and only slightly mobile
    • No overlying skin changes
  • Palpation may cause pain due to nerve compression.
  • Small ganglions may only be palpable in full wrist flexion or extension.
  • Occult ganglions are not palpable but can be quite painful.
  • Carpal bossing: a small, immovable mass of bone on the back of the wrist
  • Giant cell tumor, lipoma, sarcoma, hamartoma, interosseous neuroma
  • Epidermal inclusion cyst
  • True synovial cyst
  • Anomalous musculature
  • Tenosynovitis
Unless diagnosis is unclear, imaging is not necessary.
Initial Tests (lab, imaging)
  • Most are apparent clinically and do not need imaging
  • Plain films can exclude bony pathology but rarely alter the course of treatment.
  • Other options to exclude occult ganglions:
    • Ultrasound; MRI
    • Arthroscopy
  • US and MRI have similar rates of sensitivity and specificity. US is less expensive than MRI but more operator-dependent.
  • Arthroscopy is used for both diagnostic and therapeutic purposes and can be considered when initial workup is nondiagnostic and conservative treatment is not effective.
Test Interpretation
  • Gross pathologic evaluation shows that cysts are often multilobulated.
  • Microscopic exam reveals a relatively acellular outer wall with several layers of randomly oriented collagen fibers and mesenchymal cells in the collagen fibers.
  • Cyst fluid is highly viscous and contains glucosamine, albumin, globulin, and hyaluronic acid.
  • Histopathologically identical regardless of anatomic location

Four primary treatment options include:
  • Reassurance and observation: Ganglia are not likely to be malignant or to cause damage. May treat with splinting and NSAIDs if desired for comfort
    • Multiple studies suggest spontaneous cyst resolution in half of patients over 5 years (1,2)[A].
  • Closed rupture: historically done by hitting cyst with a book (“King James Bible treatment”)
    • Results in initial treatment decreased clinical symptoms by 22-66%, recurrence is common.
    • Typically a home remedy.
  • Aspiration: can be done in the office under local anesthesia with a 16-gauge needle at base of the cyst. Studies demonstrate mixed results on aspirations with 30-85% success with multiple aspirations (1,2)[A]. Volar wrist ganglia should not be aspirated without US guidance due to risk of damage to neurovascular structures. Mucous cysts can be aspirated, but recurrence is >50% and pain may not resolve if due to underlying osteoarthritis.
    • Concurrent injection of steroids or hyaluronidase have mixed results and are not clearly more effective than aspiration alone. Steroids have the additional risk of fat atrophy and skin depigmentation.
    • Multiple cyst punctures are not more effective than simple aspiration.
    • Sclerotherapy or injections that increase inflammation and cause fibrosis to reduce recurrence are less common due to concerns for joint damage.
  • Surgical excision
First Line
  • NSAIDs for pain relief
  • No other medications have been shown to be effective.
  • Recurrence rates vary among studies but have been as low as 0-28%. Results better at high-volume centers and actual recurrence rates are likely higher.
    • Arthroscopic excision is as good as open excision with better cosmetic outcomes and a faster return to normal function (3)[A].
  • A 6-year study comparing blind aspiration, surgery, and watchful waiting showed:
    • Recurrence rates of 58% after aspiration, 39% after surgery, and 58% in untreated patients.
    • Patient satisfaction was 81% with aspiration, 83% with surgery, and 53% with reassurance.
    • There was no significant difference in pain, weakness, or stiffness between groups.
    • Pain was reduced significantly in all groups.
    • Time away from work is greater with excision compared to aspiration and reassurance.
    • Neither aspiration nor surgical excision provides a clear long-term benefit over simple observation. The primary benefit of surgery is early cosmetic resolution (4)[B].
  • Bottom line
    • Surgery appears to provide the lowest rates of cyst recurrence but does not provide significantly higher pain reduction or patient satisfaction.
    • Determine the patient's reasons for seeking medical attention. Education alone can provide adequate treatment.
May require supervised hand therapy after surgical repair to improve stiffness and function
  • Hand/occupational therapy may be helpful if ganglion symptoms persist despite rest.
  • Manage expectations about recurrence.
  • Generally very good
  • Up to 50% will resolve with watchful waiting.
  • Higher rate of resolution in children
1. Suen M, Fung B, Lung CP. Treatment of ganglion cysts. ISRN Orthop. 2013;2013:940615.
2. Meena S, Gupta A. Dorsal wrist ganglion: current review of literature. J Clin Orthop Trauma. 2014;5(2):59-64.
3. Bontempo NA, Weiss AP. Arthroscopic excision of gangion cysts. Hand Clin. 2014;30(1):71-75.
4. Dias JJ, Dhukaram V, Kumar P. The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. J Hand Surg Eur Vol. 2007;32(5):502-508.
Additional Reading
Gant J, Ruff M, Janz BA. Wrist ganglions. J Hand Surg Am. 2011;36(3):510-512.
See Also
Algorithm: Pain in Upper Extremity
  • M67.40 Ganglion, unspecified site
  • M67.48 Ganglion, other site
  • M67.439 Ganglion, unspecified wrist
Clinical Pearls
  • Ganglion cysts (technically not true cysts) are the most common wrist masses.
  • Diagnosis is based on history and physical examination.
  • Treatment options include observation, aspiration, and excision. Long-term outcomes are generally similar with all three approaches.
  • Volar wrist ganglia should not be aspirated without ultrasound guidance due to the risk of damage to neurovascular structures from blind aspiration.