Working Healthy

Ganglion Cysts: Knots of Tissue That Cramp Your Style

Researchers have not definitively proven that repetitive stress causes ganglion cysts — fibrous lumps that often form on the hand or wrist. But judging by the number of nail techs who get them, it seems likely there’s a connection. The good news is there are many effective treatment options.

Its name in Greek means “a knot of tissue,” but when a ganglion cyst appears on a beauty professional’s wrist, hand, or fingers, it can also mean a knot in the stomach. If you’ve heard that dropping an encyclopedia on the thing will make it pop and go away, you heard right. Some doctors do recommend that weighty cure. It still appears in medical reference books and some nail technicians swear it has worked for them.

But, says Dr. Timothy McAdams of Stanford University Medical Center in Palo Alto, Calif., you also could hurt delicate blood vessels and nerves nearby. If the cyst comes back — which is likely — it could return as several smaller lumps that cause even more trouble than before. “We don’t recommend it,” says McAdams, a researcher and surgeon at the university’s Division of Hand and Upper Extremity Surgery. “There are better options now.”

The cysts form when a tiny defect in the tendons or joints of the hand allows jelly-like lubricating fluid to seep out of place, forming sacs that usually bubble up under the skin. The fibrous sacs can be simply unsightly, or can press against nerves and blood vessels to cause discomfort, pain, tingling, or even loss of feeling in the hand and fingers.

Often, however, they simply go away.

Technician Kim Flohe was surprised when a lump appeared at the base of her middle finger where it joins the hand — a common place for cysts to appear. “It felt like I had a shard of glass in it,” Flohe says. “It was uncomfortable. I just kept massaging it.”

Flohe, a tech at Fifth Avenue Salon in Indialantic, Fla., began to look into how she could get rid of the bump. A client who was an orthopedic surgeon suggested that she have it removed, but the thought of the knife left her saying, “No way!”

“Then one night my boyfriend and I had gone grocery shopping and we loaded each finger with a bag of groceries. My fingers got really stretched out,” Flohe recalls. “A few weeks later, my massage therapist asked about the cyst, and I hadn’t noticed, but it was gone.”

Some patients have reported to Dr. Dennis Phelps, a hand surgeon in Santa Barbara, Calif., that their cysts disappeared after they massaged them.

For those who are not so lucky, there are a variety of options for dealing with ganglia, ranging from techniques that relieve the discomfort to a groundbreaking surgical procedure that removes them completely with only minimal scarring and a very low rate of return.

Exercise and Relaxation May Help

“I never rush to operate,” says surgeon McAdams. “I think that any non-traditional medical treatment may be good for symptomatic relief, but people should know the risks involved.”

For Debi Daily, owner of A Touch of Elegance Nail Salon in Grass Valley, Calif., exercise and relaxation have helped her live with ganglion cysts for more than 26 years. She first noticed them long before she became a professional nail technician in 1979, and at­tributes them to her lifelong work with her hands as a writer, potter, and sketch artist. She now has a cyst inside each wrist, at the side of the joint below the base of the thumb — the second most common location for ganglia.

Discomfort flares up from time to time. “It all depends on how much I do and how much stress I have — and how much I use my hands,” says Daily.

She stretches her hands and arms throughout the day and uses relaxation techniques. “You can sit at the edge of your table, close your eyes, and visualize yourself relaxing,” Daily says. “Let your arms hang, relax your shoulders, just be. Shake your hands, pull them forward, then back. It relaxes the hand and wrist areas and improves blood circulation there.”

Although medical research hasn’t proven that exercise can prevent cysts 01 make them go away, these exercises are Daily’s way of maintaining herself pain-free. “Morning, noon, and night!” she says.

Cysts May Worsen With Work

The cysts may appear after a single injury, such as a blow to the hand or lifting of a heavy object, but more frequently seem to pop up “out of the blue.” Repetitive motion has not been proven to cause the cysts, but certainly can aggravate them, Phelps says.

Maggie Franklin, owner of The Art of Nailz in Visalia, Calif., found that a cyst popped out on the back of her left wrist — she’s a southpaw — within a few weeks of getting a new electric drill.

“The handpiece is extremely lightweight, which seemed like a good idea,” Franklin says. “Except that the cord is very heavy. I had to hold the handpiece tighter to keep the bit pointed down. I am certain that this was causing more friction on my tendons and is the primary culprit behind my cyst.”

Franklin gave up her pretty new drill and got her old one fixed. Since switching back to the old drill, she says, “The cyst has become a bit smaller and doesn’t bother me as much as it used to, but it hasn’t gone away.”

Look for other things that you could change that would reduce the stress and strain on your mitts. The keyword here is “ergonomics.” At work, make sure your chair and workstation are at comfortable heights and that you have pads to support your arms and wrists when you work. “Take more frequent breaks; pay attention to posture and the attitude of the hands and wrists. Support the wrists instead of letting them hang in the air,” says Phelps.

If you spend a lot of time in front of a computer in your leisure hours, check out jelly-pads for your mouse, wrist pads to place in front of your keyboard, and desks that let you put the keyboard closer to your waist. Your wrists should not have to bend to use the keyboard, and the arm and back of the hands should be on the same plane.

Cysts Can Be Drained

One common treatment is to insert a large needle into the cyst and suck out the gelatinous material inside. Some physicians also follow that treatment with shots of a corticosteroid — a class of drugs that fight inflammation — to shrink the sac. The procedure, called aspiration, can be done in your doctor’s office.

Pennsylvanian Lynnette Diaz-Madden developed a ganglion on the back of her right wrist—the most common location —17 years ago, long before she became a licensed nail technician. It seemed to come out of the blue and caused a constant, burning pain, Diaz- Madden says.

Her orthopedic doctor aspirated the cyst in two office sessions, numbing the area first. Although aspirated cysts will come back about half the time, Diaz- Madden’s has not returned. “I still have a little lump there, but it’s not as big,” says Diaz-Madden, who recently opened Salon 29 at Main in Pennsburg, Pa.

One caveat: Cysts that appear inside the wrist below the thumb are NOT good candidates for aspiration, surgeon McAdams says. They usually lay too close to the radial artery, a major blood vessel going into the hand.

Acupuncture May Relieve Pain

Some techs are exploring an alternative to traditional Western medicine: the ancient Chinese practice of acupuncture. Practitioners insert fine needles into the upper layers of the skin on the affected areas and on the hands, feet, ears, or along the spine. Traditionally, practitioners may also burn an herb that is twisted onto the end of the needle to generate heat; nowadays, some use electricity to do the same thing. This manipulates the energy streams that flow through the body and restores energy to areas where it had been cut off.

Unlike conventional surgery, acupuncture leaves no scar tissue that can cause further irritation, says Connie Taylor, a licensed acupuncturist and a board member of the California Association of Acupuncture and Oriental Medicine.

“The cyst prevents the proper sliding of the tendon and the muscle. It inhibits the nerves from firing properly,” Taylor says. “If you cut the cyst out, you’re still going to have obstruction because of the scar tissue.”

At her Family Acupuncture Clinic in Sacramento, Calif., she has treated ganglion cysts on the wrists of patients in trades that require fine, repetitive hand motions.

“I put three needles under the cyst and run electricity through them,” Taylor says. She also inserts needles into distal points, or related acupuncture points on the hands and feet, in a procedure that lasts about 20 minutes. “Then we usually do a little massage with a homeopathic gel that helps reduce inflammation,” Taylor says.

Her patients’ cysts shrank and stopped causing pain, although they did not disappear, Taylor says. One patient, an electrician, had a cyst on the back of his wrist. After two treatments, the man was pain-free and has remained so for two years, she says.

Only Surgery Can Remove Them

If a ganglion cyst resists all other symptomatic treatment, it can be removed by surgery done with a general anesthetic. The surgeon must work all the way down the stalk of the cyst to where it reaches into the tendon or joint capsule to get the best results.

At McAdams’ clinic in Palo Alto, Calif., patients’ hands are immobilized with splints for one to two weeks while they heal. As soon as the stitches are cut, he sends them down the hall to the physical therapist who helps them regain motion and strength. Patients work on exercises and may get treatments with hot paraffin, hot and cold compresses, ultrasound, and other techniques that help stimulate circulation and soften the tissues. If the surgery is done properly, the cyst will return in only 1% to 5% of cases. But remember, McAdams, says, “You’re trading a bump for a scar.”

For the most common ganglia that occur on the back of the wrist, a new technique using arthroscopic surgery is being pioneered at Stanford’s Medical Center and a few others around the country. The technology has been around for decades, but has been applied to dorsal wrist ganglia only in the last couple of years.

McAdams makes two incisions only two millimeters across near the wrist joint into one, he inserts a thin telescope. “There’s a camera on the end of it. The camera shows a picture of the joint space on a TV monitor,” he says. “It’s really amazing. You can see that tear in the joint capsule and the stalk coming right down into the capsule.”

Into the second incision, he inserts a minute rotary shaver and manoeuvres it into the joint. He does not remove the cyst itself, but rather cuts off its source — the cyst’s stalk — and sucks out the synovial fluid. He then cuts a little “window” in the joint capsule. That lets the synovial fluid flow back to where it belongs. Eventually, both the window and the tear that allowed the cyst to form will heal up. The procedure leaves very small scars and the cysts return in only one case out of every 100.

What’s This Darned Thing on My Hand?

The Greek medical pioneer Hippocrates was the first to describe ganglion cysts; “knots of tissue;” that are ‘the most common type of growth on the hands.

Ganglia also appear on the top of the feet, ankles, and knees. Women are three to four times as likely as men to get them and most of those women are between 20 and 40 years of age.

But doctors are not sure what causes the cysts, which grow out of the joints and their related tendons. “They occur relatively spontaneously in the population” says Dr Dennis Phelps, a hand surgeon in Santa Barbara, Calif. “We think chat ganglion cysts may represent a degenerative process, either of the supportive tissue of the joint or the tendon sheath, and may be the result of some underlying inflammation”

A single injury, such as a blow to the hand, may cause the cysts in anywhere from 10% to 50% of cases, researchers say-Minor repeated injury may also be a factor; but researchers disagree on its role Repetitive motions like those involved in a nail technician’s work can aggravate a cyst and lead to pain, Phelps says.

The tendons are wrapped in a covering that secretes a lubricating, nourishing fluid called synovial. When you move your hand, each tendon slides inside its sheath like a length of string inside of a thick, goopy straw. Each joint also has a lubricating cover around it called a joint capsule which also contains synovia.

Researchers think ganglion cysts form when a tiny hole opens up on the tendon sheath, or sometimes both the sheath and a nearby joint capsule. The hole “works like a one-way valve,” says Dr Timothy McAdams of Stanford University Medical Center’s Division of Hand and Upper Extremity Surgery Synovial fluid seeps out. But can’t return to where it came from. The surrounding tissues try to contain it by forming a dense wall of collagen around the liquid. Usually, the cyst works its way to the layers just below the skin.

Ganglia range in size from a millimeter to three centimeters across. They may occur singly or in bunches. They may be painless. Or if they grow in areas where they compress a nerve they can have effects ranging from discomfort after a long day to a tingling sensation in the hand or fingers, to weakness to disabling pain.

When the sac’s contents are drained, the tear in the tendon heals up on its own in about one-third to one-half of all cases. But if it doesn’t, synovia may continue to leak out and the lump may return.

If You Choose Surgery

Specialists in hand surgery can be located through the American Society for Surgery of the Hand in Rosemont, Ill.

Specialists often get better results in removing ganglion cysts than general surgeons, simply because they get more practice in the procedure Talk to your prospective surgeon and find out how many operations he or she has performed and the rate of cysts returning in patients Ask the surgeon about the risks, which include infection, damage to nerves or blood vessels, and, rarely, debilitating injury. Also, ask about the different levels of anesthesia.

Trina Kleist is a freelance writer based in San Diego.


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