Ganglions are friendly or benign soft tissue lesions and are the most common lesions we see in the upper limb. Ganglions are essentially membranous sacs filled with a jelly-like fluid, which are usually rooted in a joint and/or a sheath of a tendon. The ganglion is filled with a mucinous type of fluid, which is not the same consistency as the fluid found in the joint. The aetiology or reason why ganglions develop is still not completely understood. They usually stem from the wrist joint from the dorsal scapho-lunate ligament on the back or dorsal side, and on the front side of the wrist, they are found on the side of the thumb from the radio-scapho-capitate ligament. The other ganglions arise from a flexor sheath in the palm side of the hand. These lesions are very common and present in different ways. In some patients, it presents as a tiny lump that creates discomfort or pain, and in others, the size of the lesion creates discomfort and also becomes a functional and cosmetic issue.

The pathology of ganglions has taught us that there is some form of mucoid degeneration taking place, i.e. there is a mucoid-type fluid secreted by cells around the joint or tendon sheath that then becomes degenerative. These cells secrete this fluid, which is usually not associated with inflammatory cells.

What we have learnt over time is that ganglions usually develop in very specific ligaments and are frequently associated with ligament laxity (loose ligaments). Ganglions are more common in females, especially if they are hyper lax and after pregnancies.

This, therefore, gives us a clue that ganglions may be associated with ligament insufficiency or hyperlaxicity or the other way around, i.e. as a result of ganglions, local tissue might become weaker and hyperlax. However, we still do not fully understand this process. What we do now understand, though, is that pain at the back of the wrist, especially in the hyperextended position, like when doing a push-up or downward dog in yoga, is commonly associated with ganglions and ligament instability.

There are three types of ganglions.

Dorsal Ganglions

2Dorsal ganglions are the most common. These ganglions arise at the back of the wrist in a very specific position, with their root in the dorsal part of the scapholunate ligament. This mass can cause discomfort, as it is in the vicinity of the posterior interosseous nerve, which may be irritated by the ganglion. Furthermore, we also now know that with ganglions, the ligament dynamics within the wrist change, and the wrist then goes through motions which are beyond the normal range. This loads certain parts of the wrist with low/no cartilage, creating an inflammatory or very painful synovitis in the wrist. Treatment for dorsal ganglions associated with dorsal wrist pain is a surgical excision of the ganglion, as well as addressing the scapholunate ligament laxity at the interval between the joint capsule and the scapholunate ligament to prevent the ganglion from recurring.

Volar Ganglions

1 Volar Ganglions usually arise on the palmer or volar and radial or thumb side of the wrist. These volar ganglions have their root in the radio-scapho-capitate ligament. They are also associated with hyperlaxicity and are more common in females where the ganglions arise from this ligament zone. These ganglions may grow around the radial artery and may be very big, as there are no space limitations in this anatomical space. When these volar ganglions become symptomatic, cause pain with loaded extension of the wrist, or when resting the wrist when typing, we address this with surgery to remove the ganglion, tracing the stalk to its origin in the ligament and then tightening or reconstructing the ligament. 

Flexor Ganglions

3Flexor ganglions usually arise from the palm side of the hand and present as a very small hard node, either around the base of the fingers or in the palm. They generally arise from the flexor sheath around the A1/A2 pulley, and they can become symptomatic, especially if they are pressing onto a nerve. In the early stages, if they are small and central, away from the nerve, we can burst these ganglions with a needle and inject cortisone, as they are often associated with flexor synovitis (inflammation) in the joint. Furthermore, if they become larger and painful, a surgical excision of the ganglion can be done.

It's important to consult with our qualified healthcare professionals to ensure the appropriate diagnosis and treatment plan for your specific situation.

Volar Ganglion

Volar Ganglion