Ganglion/Myxoid Cysts

This guideline applies to adults aged 18 and over.

 

Introduction

Ganglia occur most commonly at the wrist, but also around fingers, ankles and top of foot (for ankle and feet ganglion see foot and ankle Ganglion)

 

Red Flag Features

Solid swellings that do not transilluminate

• Features consistent with sarcoma, including:
  • recurrence at the site of a previously excised tumour
  • larger than 4.3cm
  • swellings that are increasing in size and/or painful
• Sarcomatous swellings can be superficial or deep to the fascia
• Epithelioid sarcoma can present as an innocuous nodule on the dorsal aspect of the foot

 

Key Features of Assessment

Nature and location of the lump and pain

• Function, work and leisure activities affected
• Transilluminate to determine ganglia from solid lesions
• Assess for nerve compression
• Exclude red flags

 

Management

Adopt a shared decision making approach with the patient

For typical ganglia with no suspicious features of sarcoma, explain to the patient that ganglia are benign, can gradually enlarge to 1 to 2cm and if not causing symptoms, they can be left alone.  Up to 50% may resolve without treatment.

Traumatic rupture is not recommended.

 

 Conservative Measures

• Reassurance should be the first therapeutic intervention
• Advise to modify activities and avoid loading the wrist in end-range positions.
• Splints or soft wrist supports can help.
• Aspiration can be performed using a green needle.  Recurrence rates after aspiration can be as high as 70%. Dorsal digital ganglion aspiration is not recommended due to the high risk of joint infection.

 

 

Referral

For red flag pathology

• Solid swellings that do not transilluminate
• Features consistent with sarcoma including recurrence at the site of a previously excised tumour, larger than 4.3cm, swellings that are increasing in size and/or painful.  Sarcomatous swellings can be superficial or deep to the fascia.
• Epithelioid sarcoma can present as an innocuous nodule on the dorsal aspect of the foot

Refer all suspected sarcoma lesions on the fast track suspected sarcoma pathway.

 

Urgent orthopaedic referral criteria

Evidence of nerve compression (numbness, paraesthesia, or motor impairment)

 

Routine orthopaedic referral criteria

• Persistent pain, i.e. pain without spontaneous resolution within 1 to 2 years or
• Significant functional impairment*

and the patient would like to proceed with surgery.

*Note significant functional impairment is defined as a restriction or interference with an individual’s capacity to meet personal, social or occupational demands. Please state the impairment the individual is experiencing.

Explain to the patient that ganglia surgery has a 1 to 2% risk of complications, such as injury to neighbouring structures, e.g. nerves, arteries.  After surgery, 10% of dorsal wrist and dorsal digital ganglions recur and 30% of palmar wrist ganglions recur.  The recurrence rate for flexor sheath ganglions is minimal.

 

Advice and Guidance

No formal advice and guidance service is available.

 

Supporting Information

For patients

Ganglion cyst - NHS

 

References

• Ganglion Excision (National Evidence Based Intervention). 
• Cornwall and IoS Commissioning Policy and Evidence Based Interventions

 

Page Review Information

Partial Review date	20 May 2025 Partial update
Next review date	20 May 2026
Clinical editor	Dr Laura Lomas, GP Sifter
Contributors	Dr Rebecca Hopkins, GP Guidelines Lead Referral Management Service, Cornwall and IoS ICB Mr Rob Poulter, Orthopaedic Surgeon, Royal Cornwall Hospitals NHS Trust