Ganglion: Description, causes, symptoms, therapy
A ganglion is a somewhat misleading term: it is not an ossification, but a fluid-filled bagging of a joint or tendon sheath. Mostly it forms in the area of the hand. It can also occur on the foot or knee. Apart from the fact that a ganglion does not look so beautiful, it usually does not cause any complaints. Read here, among other things, how an overleg is created, how to recognize it and how to get rid of it!
- What is a ganglion? A fluid-filled, sack-like cavity in the joint, usually in the hand, less frequently in the knee, foot or spine
- Symptoms: bulging of a few millimetres to a few centimetres in diameter, possibly pressure pain, restricted movement or numbness, but often no symptoms at all
- Causes: Not exactly known. Connective tissue weakness and risk factors such as joint diseases or increased joint stress probably play a role.
- Attending physician: Orthopaedic surgeon
- Diagnosis: patient interview, physical examination, possibly imaging procedures and fine needle aspiration
- Treatment: if necessary only observation and physiotherapy, otherwise surgery or aspiration possible
- Prognosis: mostly favourable course, but ganglia often return
This designation “ganglion” is a relic from the time when it was thought to be a bony structure. In fact, a ganglion is a cystic bulge, i.e. a cavity filled with fluid, which usually occurs at joints (arthrogenic). Ganglia are connected to the joint by a kind of grommet, which is why they can hardly be moved.
The hand is where ganglions occur most frequently (in about 65 percent of cases): The ganglion develops here especially on the back of the hand. However, sometimes fingers or wrist are also affected. Less often, an oversized leg develops on the hip, knee, feet or spine. A fluid-filled sac around a joint or tendon sheath forms in the ganglion
More rarely, a ganglion can also occur at the tendon sheaths (tendinogen). In this case one also speaks of a tendon sheath ganglion. Another special form of ganglion is the so-called intraosseous ganglion, which is formed in a bone. So it arches inwards instead of outwards.
In principle, people of all ages can get an overleg, even children. However, it occurs most frequently between the ages of 20 and 30. Women are more frequently affected than men. The reasons for this are naturally weaker connective tissue and more flexible joint capsules.
Affected persons usually notice a bump on the wrist or back of the hand, less frequently on other parts of the body. Several ganglions can also develop.
The “lump” on the wrist or other parts of the body is typically bulging. It has an average diameter of a few millimetres to two centimetres. However, there are also ganglia that grow up to eight centimetres in size. Some remain so small that the affected person does not even notice the bulge and it is only discovered by chance.
Typically, a ganglion causes no pain and is hardly noticeable in other ways. Depending on the size and location, however, it can restrict or hurt the mobility of joints and muscles when the person concerned relies on it. The (pressure) pain can also radiate. The ganglion can also hurt when moved or touched.
If an overleg presses on tendons, it can squeeze them and possibly cause an inflammation (tendon sheath inflammation) due to the permanent strain.
Numbness, tingling or weakness in the hand may indicate that the ganglion is “pinching” a nerve. Often the nerves are affected in so-called ring ganglia. These are small overlegs on the ring bands of the fingers, which can make bending and stretching difficult. But also wrist or foot (back) are susceptible to depressed nerve paths and vessels. The pressure on vessels can lead to bleeding. In addition, infections can spread in the fluid-filled space of the ganglion.
Ganglion: causes and risk factors
The exact causes of a ganglion are not yet known. Probably several factors play a role in the development of a ganglion. This could be a weakness of the connective tissue, for example:
Around the joints lies (solid) connective tissue, the so-called joint capsule. This holds the joint in position and ensures that it moves only in the desired direction. In the joint, a soft layer of connective tissue (synovial membrane) lines the joint cavity like wallpaper. The joint cavity contains bile-like fluid (“synovial fluid”), without which the bony parts of the joints would rub against each other.
In case of a weakness of the connective tissue, in connection with an overloading of the joint, it can happen that joint fluid leaks out of the joint cavity and collects in the surrounding soft tissue. This way a ganglion is created, experts assume.
Among the risk factors for a ganglion are
- increased joint stress such as that caused by repeated minor injuries to the capsule and ligamentous apparatus
- Disturbances in the biomechanics of the joint or tendon
- Joint diseases and rheumatic diseases (such as arthrosis, lupus erythematosus, gout)
About ten percent of patients report having previously injured themselves at the site of the ganglion. In addition, the connective tissue cells (fibroblasts) of a ganglion probably stimulate the production of synovial fluid. Its components hyaluronic acid and so-called mucopolysaccharides form a viscous fluid, which then accumulates in the ganglion.
In addition, wear-related tissue damage probably also plays a role in the formation of a ganglion.
Ganglion: examinations and diagnosis
If you suspect a ganglion, go to an orthopaedic surgeon or surgeon. It can possibly exclude basic diseases such as arthrosis as a trigger for the lump. It is best to consult a doctor who specialises in the affected area of the body, for example a hand surgeon in the case of an over-the-knee injury.
To clarify the suspected ganglion, the doctor usually proceeds as follows:
Collection of the medical history: In conversation with the patient, the doctor will inquire about the exact symptoms as well as possible injuries and basic or previous illnesses. Possible questions from the doctor in this anamnesis interview are, for example
- When did you first notice the swelling?
- Does the swelling impair the mobility of the affected body part or does it cause pain?
- Have you ever injured yourself in the affected area?
- Have you ever had similar “lumps” before?
- Are there similar swellings elsewhere?
Physical examination: Afterwards the doctor examines the swelling to be able to assess it more precisely. A ganglion feels tightly elastic, similar to a solid rubber ball. It can only be moved slightly due to its anchorage to the joint or tendon sheath. In contrast to highly inflammatory processes, the affected region is neither overheated nor reddened. Maybe the doctor will take some photos for documentation.
He will also test blood circulation, motor skills and sensitivity in the area of the affected body region. For example, he can detect movement restrictions caused by the ganglion, circulatory disorders and nerve damage. It is also possible to “transilluminate” the swelling (transillumination): By transilluminating the ganglion with a light source from the side, the doctor can determine whether the interior is liquid (indication of a ganglion or cyst) or solid.
Imaging: Imaging procedures are unusual in ganglia. They are only used if the case is unclear and, for example, if there is a suspicion of a malignant process or arthritis. Even if the doctor suspects a “hidden” ganglion, ultrasound and magnetic resonance imaging (MRI) can confirm or invalidate this suspicion.
Fine needle aspiration: For diagnostic and also therapeutic purposes, the physician can use a very thin, hollow needle to pierce the ganglion ultrasound-guided with a very thin, hollow needle in order to extract fluid from the interior. This usually viscous but clear liquid is then examined by a pathologist in the laboratory. In this way, inflammations or even malignant processes can be ruled out. Draining fluid from the ganglion causes it to visibly shrink. In most cases, however, this is not a permanent solution.
If a ganglion does not cause any complaints, it does not necessarily have to be treated. Some ganglions also disappear again on their own after a while.
However, many affected people find an extra leg to be cosmetically uncomfortable or it causes them discomfort (e.g. pain during certain movements, limited mobility). Then treatment is advisable. Basically there are three ways to treat an oversized leg: conservative treatment, aspiration and surgery. Which method is used in each individual case depends on several factors, such as the position of the ganglion. The wishes of the patient are also taken into account when planning the ganglion therapy.
The so-called Bible or hammer therapy is not recommended! This brute (self-therapy) method was often used for ganglia in the past. One tries to smash the overleg with a Bible or a hammer. This is where the name “biblical cyst” for ganglia comes from. In the worst case, bones break.
A ganglion that does not affect the affected person can initially simply be observed. It is possible that the ganglion will regress spontaneously or with the help of physiotherapy. By immobilising it, it can be prevented from growing larger. It is also important to avoid incorrect loading of the affected joint. After about three months of conservative treatment, the doctor discusses with the patient in most cases how the therapy should be continued.
An aspiration, which the doctor may already have used to make a diagnosis, can also be used therapeutically. In this form of ganglion treatment, the doctor inserts a fine hollow needle into the ganglion and sucks out the fluid contained in the ganglion (needle puncture). However, new fluid usually accumulates within a short time (ganglion recurrence).
Therefore, the doctor sometimes injects corticosteroids (cortisone) into the “drained” ganglion after aspiration. It should prevent further swelling.
Another possibility is to inject the enzyme hyaluronidase into the ganglion. It decomposes the main component of the contained liquid (hyaluronic acid). The doctor then aspirates the liquid by means of aspiration.
The surgical removal of a ganglion is considered very promising if it is performed by an experienced specialist. During this procedure, the surgeon removes the ganglion and tries to close the joint so that no more fluid escapes. In principle, a ganglion operation can be performed open (via a larger skin incision) or minimally invasive (arthroscopic). As a rule, only a local or regional anaesthetic is required for the surgery on the ganglion.
In some cases such as a ganglion finger, a ganglion wrist or a ganglion foot or a ganglion arch, a so-called tourniquet can be applied during the procedure. It reduces the blood flow into the affected area and thus the risk of major bleeding. During the operation, care must be taken to ensure that the ganglion is removed completely (without leaving any residue) and that important surrounding structures such as vessels, nerves or tendons remain unharmed.
After the operation, the operated area should first be spared and immobilised. The patient may have to wear a splint for some time. Accompanying physiotherapy can help to prevent stiffening of the joint.
Complications of ganglion surgery
Every tenth open surgery is associated with complications. Arthroscopic interventions and aspiration procedures, on the other hand, lead to problems much less frequently, at four and two percent respectively. Especially vascular (bleeding) and nerve injuries (numbness, paralysis) are more common in open surgery. There is also the risk of infections, wound healing disorders and the development of Sudeck’s disease (a chronic pain syndrome). Furthermore, as after every operation, a (small) scar remains.
Ganglion: course of disease and prognosis
A ganglion is a benign protrusion with a favorable course. It can spontaneously regress, but also enlarge. Mostly it does not cause any complaints. Depending on the position, however, it can cause (pressure) pain or numbness or limit the mobility of the affected joint.
If a ganglion has been successfully treated, there is a risk of relapse (recurrence): a new ganglion may form at the same or a different site. Surgery seems to be most sustainable in the case of a ganglion: Only in about every fifth patient a cystic protrusion forms again in the same place after open surgery. With a minimally invasive operation, the risk of relapse is even lower. After aspiration treatment, on the other hand, half of the patients again develop an extra leg.
To prevent relapses, risk factors for ganglia should be reduced and the muscles should be relaxed and loosened during the day. This prevents overloading, which can favour a ganglion.