A Cyst in the Wrist is Easy to Miss
Simple ideas on the management of Ganglion Cysts in the Wrist/Hand
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For those who don’t know me, I’m a Dad with two kids under 6yrs (2022), Dr Seuss is currently a book-before-bed staple in my house, I am Dr Seuss rhyming all day long in my head at the moment. Apologies in-advance to the estate of Dr Seuss for the title graphic.
Musculoskeletal Clinicians (GPs, Physios, Specialists) learn about many possible diagnoses for wrist pain. Ganglion Cysts were not taught at University, they were one of those issues that you picked up on-the-job (so the speak). Before diving into Hand/Wrist issues it’s nice to get re/acquainted to some terminology so we can navigate around this complex structure. We broadly classify wrist issues as radial-sided (thumb side) and ulnar-sided (little finger side), and Volar (palm side) or Dorsal (back of hand) sided.
Ganglion cysts can form anywhere in the body however they are commonly seen in hands and feet. When they grow near joints, soft-tissues and nerves they can cause problems.
Many of you, dear readers, will be familiar with Ganglion Cysts. They can occur quite obviously in the wrist as a visible squishy lump.
Back in the day… (perhaps sometimes still)… Clinicians used to ‘throw the book at them’.
Quite literally. The ‘Good Book’. …. The Bible… in fact some people (in the Mid USA ‘Bible Belt’ perhaps) still call it “The Bible Bump”.
A simple, yet draconian, procedure involving the patient exposing the wrist with the cyst poking up, and someone bashing it hard with a big book. For those who aren’t squeamish, here’s an example: https://youtu.be/AJFdx1fPLlA
These Very-Obvious-Cysts rarely present to the clinic, as they look a lot worse then they are, as they sit in a ‘no mans land’ near the wrist and don’t affect function such as gripping tasks and hands-on-ground (weight bearing) tasks. It is usually because the balloon-part of the cyst sits outside of a functional weight-bearing area such as a joint, making them ‘extra-articular’ (outside of, joint). They are probably more likely to go to a GP who can send them down the clinic corridor to the procedure room and aspirate (suck out) the fluid.
In the wrist, when these cysts are ‘Intra-articular’ (inside the joint) they leave no room for function without pain and these can cause more issues long-term for those who have a high demand on wrist function for work (eg: mechanics) or sport (eg: gymnasts, tennis players) (Suen, Fung, & Lung, 2013).
But first, let’s rewind explore something very important:
What the heck is a Ganglion Cyst?
A cyst is a ‘gelatinous mucoid material’ filled sac (Suen et al., 2013), sort of a watery jelly-type substance inside a mini-balloon.
We have the Greeks to thank for the word “Ganglion”, first described by Galen as ganglion ‘tumour on or near sinews or tendons’. A Ganglion Cyst is a tumour or a ‘growth’ but fortunately it is benign. (“benign… benign and a half”…. A ‘Scrubs’ joke that goes through my head EVERY SINGLE TIME I hear the word ‘benign’: https://www.youtube.com/watch?v=q_0t3itWLw0
They can occur across the lifespan but are more common in 20–50year olds, They more often occur on the ‘volar’ (palm) side than the ‘dorsal’ (back of hand) side (Suen et al., 2013; Zhang et al., 2019).
Only a small amount of cases (10%) have a traumatic mechanism involved, they are more likely to form with repetitive loads through the hand/wrist (e labouring, tennis/gymnastics etc) but what causes the formation of Ganglion Cysts in general is still unclear. Ganglion cysts occur in 19% of patients with wrist pain but 50% of us have them and can’t feel them at all, 50% of us that us do feel them self-resolve over time (Lowden et al., 2005).
When they do form, they usually have a stalk (neck of balloon) which feeds the cyst (balloon).
How to assess a Cyst in the Wrist
A ganglion cyst, in the absence of diagnostic imaging which confirms it or in the absence of a clearly observable cyst, is mainly a diagnosis of exclusion (ie: a diagnosis of nothing else fits or doesn’t make sense).
In traumatic wrist injuries (high force or impact injuries) there are probably other injured structures that take more of a priority, are more sensitised and cause more issues in the hand/wrist. For example: scaphoid fracture, distal radius fracture, scapholunate joint injury, ulnar sided wrist injury (ECU, TFCC etc) and many others.
However in those cases of “niggling” wrist pain where there hasn’t been a fall onto the hand or another similar high-force injury, the clinician has so ‘hunt’ down a diagnosis during the subjective and objective assessment.
Here is what I think would suggest a possible symptomatic (painful) Ganglion Cyst being the primary cause of wrist pain:
- Hand/Wrist with repetitive use in sport/occupation requiring repetitive gripping/twisting or weightbearing (eg: gymnastics).
- Absence of other clear pathology (eg: scapholunate joint pain)
- Unreliable on physical assessment (sometimes painful/not painful with the same test)
The best test to use for assessment/reassessment is the test that is provocative but also measurable. I like the Hands Weight-Bearing test, which seeks the pain-free weight-bearing tolerance of the wrist.
A grip strength dynamometer in different wrist/forearm positions (neutral, flexion, extension, pronated, supinated, ulnar/radial deviated) can also be used if grip strength is provocative in any of these positions, to find their pain-free number.
A handheld dynamometer might also be handy to test resisted isometric wrist strength, if it’s painful, find the pain-free number and use that for assessment/reassessment.
If imaging is needed, an ultrasound with a switched-on Sonographer can assess it but those tricky to find intra-articular cysts might need a 3T MRI to find them, especially those inside the scapholunate or radiocarpal joints.
What do we do about it
Ganglion cysts never go away, they are forever.
If you imagine a ganglion cyst being a water balloon sitting in a tight space of other structures, when they fill up they expand and the rubber of the balloon is painful itself but it also pushes on other structures irritating them. The fluid inside the water balloon may come (bigger) and go (gets smaller) but the water balloon itself will always remain, shrivelled up when it’s not active.
Here are the four treatment options in order of least invasive/inexpensive to most invasive/expensive:
1. Rest — Stop doing the things that makes it worse…. Commonly weightbearing or forceful grip/twist tasks (eg: Gardening, Tennis, Golf etc)
2. Immobilise — Immobilise the wrist in a custom thermoplastic splint or a pre-fabricated wrist brace. If it’s a long-term cyst (>6 weeks) this will probably mean 24hrs/day — 7 days/week immobilisation for at least 2 weeks, weaning into nights-only for a week, but reassessment at 2 weeks will determine whether another 2 weeks (4 weeks total, 24/7 wear) is required.
3. Cortisone (& splint) — Some Physicians will recommend a cortisone injection to help reduce the inflammation and related swelling, in my experience working in Hand Therapy it is best practice for the wrist to then be immobilised for at least 2 weeks following this injection.
4. Aspiration — See a Physician and have the fluid from the ganglion cyst sucked out with a syringe. The ‘water balloon’ will remain however….
5. Surgical Excision — See a Hand Specialist (Orthopaedic Surgeon) to have the cyst surgically removed, this will remove the whole cyst and usually requires wrist immobilisation for at least 2 weeks (sometimes up to 4–6 weeks) with a very gradual return to the activity/sport that was irritating it in the first place.
As always, if you have ongoing musculoskeletal pain or dysfunction giving you grief with every day activities, occupation or sports, please seek out the services of a Regulated and Registered Healthcare Professional with experience in management of your issue.
For Clinicians, if you don’t have a trusted Hand Therapist colleague in your life, reach out in your local area and find one, they are amazing and usually very approachable to help you manage your tricky hand/wrist patients.
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References
Lowden, C., Attiah, M., Garvin, G., Macdermid, J., Osman, S., & Faber, K. (2005). The prevalence of wrist ganglia in an asymptomatic population: magnetic resonance evaluation. Journal of Hand Surgery, 30(3), 302–306.
Suen, M., Fung, B., & Lung, C. (2013). Treatment of ganglion cysts. International Scholarly Research Notices, 2013.
Zhang, A., Falkowski, A. L., Jacobson, J. A., Kim, S. M., Koh, S. H., & Gaetke‐Udager, K. (2019). Sonography of wrist ganglion cysts: which location is most common? Journal of Ultrasound in Medicine, 38(8), 2155–2160.
