Ganglion cysts:
to smash or not to smash?

Ganglion cysts used to be called Bible cysts. If you had one of these cysts, the at-home treatment was to smash it with a book. And since the largest and most commonly found book in most households was a Bible, they were called Bible cysts. Some old-timey remedies (like drinking out of the other side of the cup to stop the hiccups) have an element of wisdom to them. Others (like treating a fever with leeches) haven’t held up very well. So what about ganglion cysts? Should you smash them with a book? And what are they anyway?

Engines need lubrication, just like jointsMoving parts need lubrication

What exactly is a ganglion cyst?

The joints in your body have lubricating fluid in them – it keeps the joints moving smoothly. It’s like engine oil – thick and viscous. A thick capsule of tissue around the joint makes sure the lubricating fluid stays where it is needed. Sometimes, a little hole can develop in the capsule of tissue, and lubricating fluid escapes. Because the fluid is so thick, it escapes slowly, and the body creates a cyst around the escaped fluid. These cysts of joint fluid are called ganglion cysts. They can occur anywhere in the body, but are pretty common in the wrists and fingers.

What causes ganglion cysts?

The cyst is caused by a tiny hole in the joint capsule. Interestingly, because the hole is small, it acts a bit like a valve. It lets fluid out of the joint quite easily, but getting the fluid back in is hard. Escaped fluid forms a cyst, but occasionally fluid may leave the cyst and go back into the joint. As a result, ganglion cysts can sometimes get smaller all by themselves. The tiny hole in the capsule can be caused by many different things. Arthritis in the joint can cause sharp edges of bone that can poke a hole in the joint. Trauma (like a fall, or a car wreck) could make a hole in the capsule. And sometimes the hole just appears for no apparent reason.

What are the types of ganglions?

Ganglion cysts are called by different names depending on where they appear. There are a few different types in the hand and wrist:

Dorsal wrist ganglion cystsA dorsal wrist ganglion cyst

Wrist ganglion cysts

These are either volar (on the palm side) or dorsal (on the back side) of the wrist. Dorsal cysts are more common than volar cysts. Some ganglion cysts are “occult”. This means that they are not obviously visible from the outside. Occult ganglion cysts can be quite painful. You might only notice that your wrist hurts without seeing any type of bump on it. However a detailed hand and wrist examination (and occasionally an MRI) will find the cyst.

Volar retinacular cysts

When lubricating fluid around the finger tendons escapes, it forms these little ganglion cysts. They usually occur on the palm of the hand where the fingers meet the palm.

Ganglion cysts of the DIP joints (mucous cysts)Arthritic hands with mucous cysts

Mucous cysts

These are the bumps people get on the last knuckle of their fingers (just behind the fingernail). They are very common in people with arthritis of the hands. In fact, they are usually caused by arthritis of the last knuckle joint. Sometimes you will see them in the next knuckle, but this is much less common.

What are your options?

Ganglion cysts aren’t an emergency – they’re not cancer, and they aren’t dangerous in any way. However, they can be painful and annoying. For example, a cyst on the back of the wrist can be constantly irritated by your wristwatch or jewelry. Many patients with ganglion cysts have wrist pain with activities like yoga, exercise, or playing sports. Fortunately there are a few simple treatment options.

Do nothing

If the cyst is just something you noticed, but it really doesn’t bother you, it’s very reasonable to do absolutely nothing. If it ever does bother you in the future, you still have all the options available.

Smash it (with a book)

The old-timey solution. This is like sweeping it under the rug. It’ll work very temporarily, but the cyst will almost certainly come back. And each time it is smashed, you get internal bleeding and scarring. This makes the other options more difficult, and less likely to work in the future.

Aspirate it

Or in other words, pull the fluid out with a needle and syringe. This is a more civilized version of the book-smash technique. It hurts less, and causes less bleeding and scarring. This is the preferred treatment for volar retinacular cysts. For the other types, this option is not very effective in the long term.

Inject with steroids

In this option, the fluid from the cyst is pulled out first. Then, the tiny hole in the joint capsule that caused the problem is injected with a little bit of steroid. This decreases the inflammation in the area (reducing the pain). And it reduces the chances that the cyst comes back. The odds that a cyst comes back after this treatment are about 50/50. But, since it is such an easy treatment (it takes about 30 seconds to do it in the office), I usually recommend it as a first step.
Volar wrist cysts often cannot be treated with this option. These cysts are very close to arteries and nerves, and sticking sharp objects into them can be dangerous.

Surgery

Surgery basically removes the whole cyst and makes the hole in the capsule a bit bigger. By making the hole bigger, it allows fluid to escape but also to go back into the joint. Fluid will no longer collect and form a cyst. This does not cause any problems for the joint itself. It is rare for a cyst to come back if it was surgically removed. the recovery is usually quick. Patients spend a few days in a light dressing. You cannot do any heavy lifting for 2-3 weeks, but you can resume normal activities (driving, writing, typing, etc.) immediately after surgery.

reading a bookSave your books for reading

So.. should you smash your cyst with a Bible?

As you can tell, I’m not a big fan of the book-smashing technique. There are less painful and more effective ways to get rid of these cysts. Reserve the Bible (or the complete works of Shakespeare, or your encyclopedia) for reading.