- A lot of people wonder what ganglion cysts actually are. Where do they come from? How do we treat them? What's a long-term prognosis? Well, in today's podcast, we're gonna talk all about ganglion cysts, so let's dive in. Welcome back team to the Building Life-Hauling Athletes podcast. My name is Jordan Reineke. Thanks so much for stopping by. If we haven't met yet, I'm a dual board certified physician in family and sports medicine. And the goal of this podcast is to keep you active and healthy for life through actionable evidence and formal education. Today we're talking all about ganglion cysts, so let's dive into it. So ganglion cysts, what are they? They are benign soft tissue tumors that commonly occur at the wrist. We can have them in a bunch of different places. The wrist is the most common, but this lecture is gonna cover the pathophysiology, the clinical presentation, and management of the cysts. So let's go further in this. So pathophysiology-wise, what causes them? Well, the exact mechanism of cyst formation actually isn't known. The leading theory suggests that somehow these extra-articular mucin droplets, so they kind of coalesce, come together, and form a cyst body. And you might be asking, well, what the heck is mucin? Mucin's actually a type of protein called the glycoprotein, right? It's made up of a protein core with lots of sugar molecules attached. And then this structure makes mucin very good at forming viscous, gel-like substances. And if you've ever seen the inside of a cyst, and specifically looking at these ganglion cysts, it is very gel-like, very thick. And so this mucin, it's a form of hyaluron and lubricant, which these are essential for healthy joint function. So inside normal joints, we have things like hyaluron and lubricant. This provide lubrication and protects the cartilage and helps maintain the overall health of the joint. And so overall, that's one idea is that, hey, somehow this group of mucin just gets together and kind of forms this whole cyst body. And it may be due also to trauma, potentially not necessarily sure about that, maybe synovial herniation, or it's just iatrogenic, meaning we don't know what caused it. A lot of times, too, people think that there might be some underlying pathology. Like a lot of times you think about if there's underlying osteoarthritis, that can cause a cyst to come out of there. We're not entirely sure, but a lot of times there is some sort of pathology under there as well. And the origin of the fluid in the cyst actually is still debated, not necessarily sure. And as I mentioned before, we talk about why the cyst forms, where the fluid comes from. One idea is that the synovial fluid leaks into the periarticular tissue due to joint stress. Also, maybe you see mucinous, a generation of connective tissue near the joint. Maybe you have stimulation of the mucin secreted by mesenchymal cells, or you could have a pedicle kind of connecting the cyst to a nearby synovial joint, which forms afterwards. And so lots of ideas. The million dollar, I just want to step back, I have a lot of words that I said, just to pretty much tell you that we're not entirely sure where they come from. There's some ideas, though, what's going on, but the overall idea is that somehow a fluid connection forms, then a stalk forms afterwards, right? And it kind of connects it to that nearby synovial fluid. So we have that fluid, we have the stalk that kind of come together, that's what's going on. And one thing to mention, though, is that ganglion cysts actually are not true cysts. So they lack a synovial lining of epithelial cells. And so that's something that's important. They're actually pseudocysts filled with this gelatinous material composed of mainly hyaluronic acid. This is pedantic, but it's helpful to understand that they're not true cysts, they are pseudocysts. And I kind of think of it as like a water balloon versus like a blob of jelly, which sounds ridiculous, but a water balloon, right, has a nice lining. We know that if we pop that, that's what's gonna open up and it kind of contains that fluid. Whereas a blob of jelly, it can maintain a shape, but it doesn't necessarily have that definitive lining. And that's the big difference between a cyst and a pseudocyst. So I know, like I said, kind of pedantic, but that's what we're gonna go with here. So next we're gonna talk about the most common location, so clinical presentation-wise, most common location is the dorsal aspect of the wrist. I think most people come into clinic and they say, "Oh, I can see it on my wrist." That's where you mostly see it. Usually about 60 to 70% of these cysts are coming from the dorsal wrists. And that's the most common, not the only spot. There's lots of different spots that can be, there can be tons of different ones. And so these cysts usually communicate with the joint via a pedicle, usually originating from the scapho-lunate ligament. So we kind of have that main cyst coming from the scapho-lunate ligament, and then we kind of have the outpouching that comes out there. You can also have volar wrist ganglia. They account for about 13 to 20% of cases. And other locations include flexor tendon sheets in the hand, about 10%, other joints, and really can be anywhere where you have a synovial fluid. That can happen. And ganglion cysts typically present as about one to two centimeter firm, rubbery, and well circumscribed mass. They are usually not associated with warmth or athena, and they readily trans-luminate. So if you were to put a light on the cyst, it should trans-luminate, which is kind of interesting thing to see. From a symptoms perspective, you can maybe complain of an aching wrist pain that can radiate to the arm, pain with activity or palpation. Maybe they're gonna have decreased range of motion and grip strength. And you also may have parasthesias from nerve compression and the volar ganglia. So essentially if the ganglia is somehow on a nerve, that can lead to parasthesias as well. May also have pain and other reasons. We're not necessarily sure why. Could be due to nerve compression. Could be due to restricted range of motion. I'm not sure why the pain happens, but we definitely see pain quite frequently. And the frequency of pain though is debated in literature with some studies reporting that it's in most patient while others suggest it's less common. So the big takeaway is that you can have lots of things. The one thing that will be similar is you'll have a nodule there. You can have these small enough where you won't necessarily see them to the eye, but then you don't know that they're there and they're not gonna come into your clinic. But most of the time it's gonna start with people, "Hey, I have this thing on my wrist. What is it?" That's usually the main presenting symptom. May or may not have pain, may have decreased grip strength, range of motion, those things. So those are the big things we're thinking about there specifically. And then moving on to diagnosis. Well, how do you diagnose this? Well, it's a clinical diagnosis. And the first thing is imaging is not required. You definitely can make this diagnosis in your clinic. You can look at someone's wrist and be like, "That is a gangly cyst. There we go. If it walks like a duck, quacks like a duck." You definitely don't need that. It can be made clinically. If imaging is needed, however, you can use ultrasound or MRI preferred. You could get an X-ray to show some underlying pathology, right? If you think you're worried about OA, there's lots of OA somewhere, you can get an X-ray, and that may help you understand, "Okay, yep, maybe coming from that OA." But overall, X-rays aren't gonna show you the cyst necessarily. Ultrasound or MRI is gonna be preferred, with ultrasound being less invasive, less costly, and quicker to get. So usually that's where we start. And if we're still kind of confused, we go to MRI. How I typically approach this is I will ultrasound it just 'cause I can do that. Ultrasound will make the diagnosis. But if there's something going on that doesn't look quite right, or it's really loculated, or I'm not quite sure, then I'll get an MRI to take a further look. But overall, if you're seeing a dorsal wrist one, and it's a slam dunk, you feel it, it trans-eliminates, and the story's convincing, you can make that diagnosis clinically. You do not need any additional imaging, that's for sure. So just something to consider there as well. And then moving on next here, we talked about management. How do we manage this thing? Well, there's lots of different options. The first one is watchful waiting. Most cysts, or I should say many cysts, spontaneously resolve, so about 50%. So a lot of coin flip, right? So flip it, may resolve, may not. So watchful waiting is a very reasonable approach to take. There are also different non-operative routes you can take. You can do aspiration or injection. So a lot of times you go in there, this involves how this process works is you aspirate the cyst contents, and then it may or may not include a steroid injection. So essentially you go in there, a lot of times I use ultrasound, you can do this landmark. If it's big enough, you can absolutely aspirate it, but a lot of times you use the ultrasound, go in there, try to aspirate out the contents. This is where you know you're right if you aspirate out, and it's just this thick jelly. That's how you know, yep, that is a ganglion cyst. So that is something you can do, and plus or minus putting a steroid injection in there as well. Some people say that that kind of helps calm things down. Debates out there, not necessarily sure, but aspiration can be done. It has variable success rates though, can be anywhere from like 30 to 50%, and that's not necessarily great. It has a high recurrence rate as well. Steroid injection have not been shown to have added benefit over aspiration alone. That's why I say it's kind of hit or miss. And then another idea that's kind of floating around is called sclera therapy. So essentially you use injecting agent like dextrose, so sugar, right, to try to sclera roast down the cyst so it can't reaccumulate. So you go in there, you puncture it, you try to aspirate it, and then you try to re-inject that dextrose or sclera roasting agent to hopefully bring down that cyst, and it kind of sits together and doesn't reaccumulate. That's the idea behind it, but it's variable how much it works, and recurrence is pretty high regardless. The kind of gold standard for if you want this gone though, is actually surgical removal. And it's gold standard because it has lower recurrence rate, but it does have a higher rate of complications, right? So historical treatments include things like rubbing the cyst with a book on the back, or some people call it a Bible cyst where you bump with a Bible. That's not necessarily part of standard management. So the big three options we typically have are just watch waiting, some sort of injection, or surgery. That's kind of how I go to. I mean, I have had people tell me that they've gone and like just took a book and just whacked it, and it's gone there, but that's what it is. But overall, those are kind of the big three ones. And as I mentioned with surgery, surgical excision seems to be the best in terms of recurrence rates are, can be as low as potentially one to 5% for Volar, but around seven, maybe 10% for Dorsal. So more likely to have long-term resolution with a surgery versus injection. But once again, anytime you're doing that, you never know. Those are what the studies say, other studies that I have seen saying clinically, it's more around like 16 to maybe even 30%, who knows what. Long story short though, seems to be better than injections, but you're still kind of never guaranteed to have a outcome that is awesome. And then on top of that, you also have high risk for complications, right? So anywhere for, in terms of maybe you hit a nerve, decreased range of motion afterwards, post-operative pain, stiffness, lots of things like that. So as we know, surgery is a surgery, right? So we can never just say, hey, it's gonna be totally fine. That's an option that we have, but that's a risk that we do run as well. So patient considerations, I just wanna talk about that next. So patient satisfaction typically often higher than the actual rate of ganglion resolution, which is surprising, right? So a lot of times you think, hey, the patient's only gonna be happy if we go and completely remove it and it's gone forever. That's not necessarily the case. A lot of times patients seek medical attention for cosmetic concerns, they say about 38% of the time. So that could be one thing, but also a lot of times they show up 'cause they're worried about it being cancer, right? About 28% of the time, people worry about that or pain about 26% of the time. And so pain once again, although commonly reported is often not severe and may not be the primary reason for people seeking care. And many patients with recurrent cysts after this aspiration or surgery actually opt to not undergo any further procedures. They say, okay, cool, it's good. I just wanna know what it is. And so, yeah, that's kind of what we think about. So given the high rate of spontaneous resolution, conservative management with patient education of the benign nature and natural history of the cyst is often appropriate. A lot of times I've had patients come to me say, hey, I just wanna know what it is. You tell them, talk about it, say, hey, you're the option. They say, okay, cool, I'm good, I'm good. I just wanna know it wasn't cancer and that it's okay if I have this and it doesn't really bother me. So I've done many times where people have come in and it's kind of a small cyst, I don't aspirate it and we just kind of let it be and give it a little ride and see what happens there. But overall patient satisfaction, I think a lot of times comes from just reassurance and not necessarily saying, hey, it has to be 100% resolved, but it's just, yeah, understanding the context behind it. So I think that can be helpful. So overall, the conclusion here, ganglion cysts are a common and usually benign condition. Management should be individualized based on patient symptoms and concerns and conservative treatment with watchful waiting or aspiration is often a very appropriate place to start. However, if we want to go more aggressive, surgical excision is reserved for cases with persistent symptoms, functional limitations or cosmetic concerns, or they just want it gone. And overall primary care physicians, they play a crucial role in patient education, shared decision-making and appropriate referral. So you can see this in the front line in primary care, you can identify it, you can diagnose it clinically, you can treat it, you can do a lot here. So you don't necessarily have to refer this out, but just understanding what the options that we have there. And so hopefully next time you see this in clinic, you feel much more confident, ready to tackle it. And that's gonna do it today for the podcast. Thanks so much for stopping by. If you liked this information, it would mean the world to me if you shared this with someone, or if you liked, commented or subscribed on YouTube. But that's it for today. Thanks so much for stopping by. Now get off your phone, get outside, have a great rest of your day. We'll see you next time.
