A ganglion cyst or Bible cyst is a benign swelling or bump that usually appears around or on the joints and tendons of the hands or feet. Ganglia appear as subcutaneous claudication or nodules. The size can change over time, or disappear completely.  See illustration: In most cases (65%) Ganglions are painful, especially at first. But the severity of the pain was not related to the size of the ganglion. Ganglia in the musculoskeletal system are spherical effusions arising from adjacent joint capsules or tendon sheaths. Ganglion cysts are not cysts because Collections of clear viscous fluid are contained in cavities without epithelial lining. 
Clinically Relevant Anatomy
Ganglion cysts are most commonly located around the backs of the wrists and fingers. Along the extensor carpi radialis brevis is a common site of occurrence as it crosses the dorsum of the wrist , with 88% of cysts near the wrist and 11% near the foot and ankle. On the wrist, they appear especially in the scapholunate region.
The most common soft tissue tumor of the hand and wrist , ganglion cysts are hernias of mucus-filled synovial tissue arising from the joint capsule or tendon sheath due to a one-way valve phenomenon. The cyst enlarges in size and fluid cannot drain freely back into the synovial cavity. A sort of Ganglion cysts usually appear spontaneously without any particular reason. Anyone can be affected by ganglion cysts, but women are 3 times more likely than men. The development of ganglion cysts is associated with osteoarthritis and is therefore most common in elderly patients. Ganglion Cysts are predominantly seen in young adults and are rarely seen in children  The etiology of ganglion cysts is unknown, although prior trauma herniating internal disturbances and a degenerative process associated with mucin production are possible. Wrist ganglion cysts may be associated with Adjacent joints are more common in up to 70% of cases  Degeneration of connective tissue may be caused by irritation or chronic injury, resulting in mucin production by mesenchymal cells or fibroblasts .
Ganglia are tumors that develop near joints or tendons. The most common sites of ganglia are the dorsal side of the wrist near the scapholunate (SL) joint (60-70%), the volar side of the wrist near the radioscaphoid or pubic trigone joint (18-20%), and the volar side between A1 support band and A2 pulley (10-12%). Ganglion usually has mild symptoms. However, depending on the location of the cyst, patients may experience a variety of symptoms, such as dull pain, size change, spontaneous drainage, and sensory nerve dysfunction .
Associated Injuries/Differential Diagnosis
Tenosynovitis involves inflammation of the tendon and tendon sheath. Examples of tenosynovitis include de Quervain tenosynovitis of the volar wrist flexor tenosynovitis (i.e. trigger finger), possibly from gonococcal infection and other infectious suppurative flexor tenosynovitis Etiology . Lipomas are benign tumors composed of mature fat cells. They are the most common benign mesenchymal tumors. Lipomas are found in the subcutaneous tissue and less frequently in the viscera. Lipomas usually develop as discrete rubbery lumps in the subcutaneous tissue of the trunk and proximal limbs. Lipomas are usually only a few centimeters in size and can be removed with surgical excision or liposuction. A hamartoma is a benign (noncancerous) tumor-like malformation consisting of an abnormal mixture of cells and tissue that grows in an occurring area of the body. this is Considered a developmental error and can occur in many locations  Dupuytren’s contracture is a fixed flexion contracture of the hand in which the fingers bend toward the palm and cannot be fully extended (straightened). It is an inherited proliferative connective tissue disease, Involves the palmar fascia.
Ultrasound is used to confirm the diagnosis of a ganglion cyst and to guide needle aspiration fenestration and subsequent injection of a steroid-anesthetic mixture. Scanning was performed using a 12-5-Mhz linear transducer on an IU22 scanner . Other methods that are being used are MRI scans. It depends on the location of the ganglion cyst. The use of magnetic resonance imaging is crucial for the differential diagnosis, eg, of vascular lesions and other masses such as lipomas. Another diagnostic tool for evaluating ganglion cysts is the use of radiopaque contrast dyes. ganglionography is a method of assessing the size and extent of a ganglion cyst and may be used as an adjunct to aspiration. after several injections. Milliliters of contrast medium can be obtained on radiographs, making it easier to see the extent of the lesion .
Can be measured using the following results:
- Grip and pinch strength and wrist motion can be measured using standard assessment instruments.
- Visual Analogue Pain Scale
- Arm Shoulder and Hand Disability Questionnaire 
A ganglion cyst is diagnosed by a doctor based on clinical tests or based on a medical history. If we think abrasion or trauma is the cause, we do some additional tests: ultrasound, x-ray, or MRI. These studies are not painful. The sensitivity of MRI is About 80% en has about 50% specificity. These results are given by the criteria for determining the disease intraoperatively . MRI is performed when atypical features or neurologic symptoms are present and in specific preoperative settings. Cysts are hypointense on MRI Strength compared to muscle. Ultrasound is usually sufficient to evaluate typical cysts. It can be used to detect the presence of occult cysts. To rule out any more serious underlying pathology radiographs, anteroposterior and lateral views were obtained. A simple cyst is fine on an ultrasound Confined and anechoic, with enhanced rear acoustics. The orthopedic surgeon will also investigate the physical phenomenon of possible trigger finger . Doctors can often make a diagnosis based on the symptoms. These phenomena are subcutaneous lumps or lumps That size nodule can vary. It’s usually a soft bump the size of a pea. Ganglion cysts are painful at first. In addition to pain, restricted movement of ganglia can lead to loss of strength, primarily due to pressure from swelling of adjacent tendons or nerves. In most cases, additional research  can be omitted.
Many ganglion cysts (38%-58%) disappear without any treatment. Various treatments have been proposed over the years. These include telling people with cysts who are asymptomatic not to worry about using a needle to remove the cyst contents (aspiration) or surgery.  Suction usually This involves inserting a needle into the cyst, withdrawing fluid material and injecting a steroid compound into the cavity (as an anti-inflammatory agent).  Aspiration is a beneficial and simple option for acute management but appears to have little long-term effect on patients resolution. Aspiration of the flexor sheath ganglion of the hand seems to be more successful, up to 60 or 70% of the time.  Surgical resection remains the gold standard for the treatment of ganglion cysts. Surgical techniques include resection of the entire The ganglion complex includes the capsular pedicle and the cuff of the adjacent articular capsule. After surgery, the wrist is sometimes splinted to prevent it from moving . This is to prevent wrist movement from pumping synovial fluid through the one-way valve mechanism and refilling the cyst. this Has been shown to be no more effective than simple suction and can cause prolonged joint stiffness and reduced range of motion in postoperative patients.  Most studies show that even repeated wishes have only a 30-50% success rate. If you compare aspiration/injection vs surgical excision Generally, cysts rarely recur after surgery.  A higher rate of recurrence was found in patients with a longer history, larger ganglia, and less experienced surgeons. Ganglion location Age and sex had no effect on recurrence rate .
Physical Therapy Management
Ganglion cysts can interfere with daily activities. Surgical removal is not always complete, and sometimes cysts disappear without any treatment or with treatment alone. The therapy is aimed at normal use of the hands. If treatment is given after surgical resection, then the stress Edema is relieved and scar tissue is reduced during sports splint therapy. As noted above, the main goal of physical therapy is to restore normal use of the hand. Therefore, we need to restore full mobility in all joints of the hand. In most protocols, the following exercises are used to implement Full Mobility :
- PROM (Passive ROM) exercise: There are 3 finger joints (MCP PIP and DIP joints) and 2 wrist joints (radiocarpal and midcarpal). It is important to train all possible movements.
- PNF (proprioceptive neuromuscular facilitation) exercise: The therapist holds the fingers in flexion. After the patient relaxes the fingers, the patient needs to remain in this position for a while (mobility). Repeat for all fingers.
- Tendon sliding exercise: From wrist flexion and finger extension to wrist extension and finger flexion.
- Blocking Exercise: Place your palms facing up on a table. With the other hand, grab and hold the affected finger in the middle just below the terminal knuckle. Bend and straighten the fingers only at the end joints while keeping the rest of the fingers straight. Repeat for all joints and fingers.
It is also important to reduce scar tissue to restore functional mobility, improve range of motion, and reduce pain. Scar tissue remodeling occurs when you start stretching and pulling on the scar tissue. In this case, hand stretching helps align the collagen fibers, allowing them to return to their original shape normal. This rearrangement of collagen fibers allows the tissue to better withstand the forces placed on it during the day. Another way to help reshape scar tissue in your skin is massage. This also helps loosen any adhesions between the scar and the underlying tissue and fascia. Stretching scar massage along with flexibility and strength exercises can help loosen scar tissue and ensure proper remodeling. 
With professional treatment, the recurrence rate is lower and recovery is faster. People with ganglion cysts can use the back of their hands 2 weeks after surgical removal.
- ↑ Jump up to:1.0 1.1 @inproceeding Camasta 2012 EXCISIONOT, EXCISION OF THE GANGLION CYST, Craig A. Camasta 2012 Available from: https://www.semanticscholar.org/paper/EXCISION-OF-THE-GANGLION-CYST-Camasta/67d2f2944bbe3a87f570fcf41ff1d4e92cc92467 (last accessed 11.10.2019)
- ↑ Syed M. et al. Comparative study of two methods for treatment of dorsal wrist ganglion, the journal of Pakistan orthopaedic association, February 2010 vol. 22 No.1 53-57
- ↑ McNabb JW. A practical guide to joint & soft tissue injection & aspiration: an illustrated text for primary care providers. Lippincott Williams & Wilkins; 2009 Nov 1. Available from: https://shop.lww.com/Practical-Guide-to-Joint—Soft-Tissue-Injections/p/9781451186574 (last accessed 11.10.2019)
- ↑ Jump up to:4.0 4.1 4.2 Thornburg LE. Ganglions of the hand and wrist. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 1999 Jul 1;7(4):231-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10434077 (last accessed 11.10.2019)
- ↑ Wang G, Jacobson JA, Feng FY, Girish G, Caoili EM, Brandon C. Sonography of wrist ganglion cysts: variable and noncystic appearances. Journal of ultrasound in medicine. 2007 Oct;26(10):1323-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17901135 (last accessed 11.10.2019)
- ↑ Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS, Wolfe SW. Green’s Operative Hand Surgery, 2-Volume-Set. Elsevier; 2017.Available from: https://www.elsevier.com/books/greens-operative-hand-surgery-2-volume-set/wolfe/978-1-4557-7427-2 (last accessed 13.10.2019)
- ↑ Peters F, Vranceanu AM, Elbon M, Ring D. Ganglions of the hand and wrist: determinants of treatment choice. Journal of Hand Surgery (European Volume). 2013 Feb;38(2):151-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22508801 (last accessed 13.10.2019)
- ↑ Marx J, Walls R, Hockberger R. Rosen’s Emergency Medicine-Concepts and Clinical Practice E-Book. Elsevier Health Sciences; 2013 Aug 1. Available from: https://www.worldcat.org/title/rosens-emergency-medicine-concepts-and-clinical-practice-vol-3/oclc/278499349 (last accessed 13.10.2019)
- ↑ Hanssen AM, Fryns JP. Cowden syndrome. Journal of medical genetics. 1995 Feb 1;32(2):117-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20580873 (last accessed 13.10.2019)
- ↑ Saboeiro GR, Sofka CM. Ultrasound-guided ganglion cyst aspiration. HSS journal. 2008 Sep 1;4(2):161-3. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2553163/ (last accessed 13.10.2019)
- ↑ Suen M, Fung B, Lung CP. Treatment of ganglion cysts. ISRN orthopedics. 2013 May 28;2013. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4045351/ (last accessed 13.10.2019)
- ↑ Scott G. Edwards, Prospective Outcomes and Associations of Wrist Ganglion Cysts Resected Arthroscopically, American Society for surgery of the Hand, 2009;34A:395-400
- ↑ Goldsmith, S et all. Magnetic resonance imaging in the diagnosis of occult dorsal wrist ganglions. Journal of hand surgery-european volume. October 2008, vol: 33E issue 5, p595-599
- ↑ Freire V, et All, Imaging of hand and wrist cysts: A clinical approach. American journal of roentgenology. November 2012, volume 199 number 5
- ↑ http://www.handclinic.nl/content.asp?id=299
- ↑ Jump up to:16.0 16.1 16.2 16.3 Elisa E. Aumont, MD, Ganglion Cyst, emedicinehealth
- ↑ Jump up to:17.0 17.1 17.2 17.3 Harvey V. Thommasen et al. Management of the occasional wrist ganglion, society of Rural Physicians of Canada, 2006
- ↑ Jump up to:18.0 18.1 Warren Gude, Morelli Vincent, Ganglion cysts of the wridt: pathophysiology, clinical picture and management, Curr Rev Musculoskelet Med. 2008 December; 1 (3-4): 205-211
- ↑ Schicke, S. H. et All. Ganglia of the hand and wrist: a retrospective study on the origination of recurrences. Handchirurgie mikrochirurgie plastische chirurgie. Oct 2011 Volume: 43 Issue: 5, pages: 298-301
- ↑ Evelyn J. Mackin, Anne D. Callahan, Terri M. Skirven, Lawrence H. Schneider, and A. Lee Osterman, editors; and James M. Hunter, editor emeritus. St. Louis: Mosby; 2002. 2109 pages.
- ↑ Kisner, C., & Colby, L. A. (1996). Therapeutic exercise: Foundations and techniques. (3 ed.). Philadelphia: FA Davis.
- ↑ Hertling, D. (2006). Management of common musculoskeletal disorders. (4th ed.). Philadelphia: Lippincott Williams & Wilkins