What is the appropriate evaluation and management for a tendon (ganglion) cyst?

Evaluation and Management of Tendon (Ganglion) Cysts

For classic presentations of ganglion cysts, clinical diagnosis is sufficient and observation is the preferred initial approach, with ultrasound reserved for atypical features or anatomically complex locations. 1

Diagnostic Evaluation

Clinical Assessment

• Diagnosis relies primarily on history and physical examination for typical presentations, particularly for dorsal wrist ganglions which are the most common location 1, 2
• Transillumination can confirm the cystic nature of superficial lesions 2
• Ask specifically about trauma history, as this suggests alternative diagnoses 1
• Red flags requiring urgent evaluation include rapid progression of swelling, fever, warmth, or purulent drainage—these suggest infection rather than a simple ganglion 1

Imaging Strategy

• Ultrasound is the initial imaging modality when confirmation is needed, particularly for small superficial lesions, deep-seated masses, or anatomically complex areas 1, 3
• Ultrasound has 94.1% sensitivity and 99.7% specificity for superficial soft-tissue masses, but accuracy drops considerably for deep lesions 1
• MRI should be obtained when ultrasound features are atypical, for suspected occult ganglions, or when there is concern about solid tumors 1, 3, 2
• Plain radiographs may be indicated to evaluate for associated degenerative joint disease 2
• CT is not indicated for characterizing cystic structures in joints or periarticular regions and provides inferior soft tissue characterization compared to ultrasound 1

Special Diagnostic Considerations

• When a ganglion is reported radiologically to be in close contact with tendons, maintain high suspicion for intratendinous ganglion, which poses unique diagnostic challenges and increased risk of spontaneous tendon rupture 4
• Intratendinous ganglions may not be definitively diagnosed until surgical exploration 4

Management Algorithm

Initial Conservative Management (First-Line)

• Observation is acceptable and preferred for most asymptomatic or minimally symptomatic ganglions, as 58% will resolve spontaneously over time 5, 6
• For mild tenosynovitis with ganglion, implement relative rest to reduce repetitive loading and consider physical therapy to maintain range of motion 3
• Follow-up with physical examination with or without ultrasound every 6-12 months for 1-2 years to ensure stability 1, 3

Aspiration (Second-Line for Symptomatic Relief)

• Aspiration can be offered for patients desiring symptomatic relief who do not want surgery 6
• Recurrence rate after aspiration exceeds 50% for most locations, but is less than 30% for flexor tendon sheath cysts 5
• Ultrasound guidance improves accuracy for corticosteroid injections when indicated 3

Surgical Excision (Definitive Treatment)

Indications for surgery include: 5, 7

• Pain interfering with activities of daily living
• Weakness or limited range of motion affecting function
• Nerve compression
• Imminent ulceration (mucous cysts)
• Conservative treatment failure after 3-6 months 3
• Continued growth during observation period 3

Surgical approach:

• Open excision remains the gold standard, with recurrence rates of 5-7% when the complete stalk and small portion of joint capsule are excised 5, 7, 2
• Arthroscopic excision is an alternative with similar recurrence rates (7-39%) but may provide less pain relief than open excision 7, 2
• For intratendinous ganglions, apply a lower operative threshold to prevent progression and potential tendon rupture, and be prepared for primary tendon repair 4

Critical Pitfalls to Avoid

• Do not rely solely on ultrasound for deep lesions or atypical features—obtain MRI to avoid missing solid tumors 1
• Counsel patients requiring forceful wrist extension (athletes, military personnel) about potential persistent pain and functional limitations after surgery 7
• Avoid excising the scapholunate interosseous ligament during dorsal wrist ganglion excision, as this can lead to scapholunate dissociation and instability 7
• Be aware that the posterior interosseous nerve courses past the 4th dorsal compartment and may be inadvertently resected 7
• When multiple symptomatic tendons are involved, evaluate for underlying rheumatic disease 3