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Ganglion cysts around the elbow joint are unusual, with fewer than 25 citations (most of which are case reports) in the English-language literature. Among the many causes of elbow pain, cysts are chiefly diagnosed by advanced imaging. When an elbow ganglion or perineural cyst is symptomatic, treatment has ranged from nonoperative to surgical intervention. Our case report is the first documented ultrasound-guided aspiration and cortisone injection to successfully alleviate a patient’s symptoms. The procedures and outcomes of minimally invasive ultrasound-guided aspiration and steroid injections have not been described for cysts around the elbow. The patient and patient’s guardian provided written informed consent for print and electronic publication of this case report.
Case Report
A 14-year-old female freshman varsity softball pitcher on multiple teams presented with 6 months of vague right elbow pain. She was unable to pitch and had intermittent sharp pain localized to the lateral proximal forearm. She was, however, able to bat without pain and denied any radiating paresthesias. Despite a reduction in sports activities, the symptoms did not improve.
On physical examination, there was preserved strength that was symmetric with the contralateral side of all major muscles innervated by the radial nerve in the right arm, including full wrist, thumb, and finger extension. Sensation was intact to light touch in all major nervous distributions of the right and left upper extremities. She was tender to palpation at the radiocapitellar joint anteriorly, as well as just distally. The patient was also tender with motion through the proximal radial head. She had pain with resisted finger extension; however, resisted supination elicited no discomfort or pain.
The initial diagnostic workup included radiographs of the right elbow, a magnetic resonance imaging (MRI) scan, and an ultrasound. Elbow radiographs revealed no abnormalities. The MRI scan showed a well-circumscribed ovoid T2-hyperintense structure within the supinator muscle measuring 0.6×0.6×0.4 cm (longitudinal × anteroposterior × transverse), just deep to the split of the superficial and deep radial nerves (Figures 1A-1C). A musculoskeletal ultrasound was performed to further characterize and determine the relationship to neurovascular structures. Longitudinal (Figure 2A) and transverse (Figure 2B) images showed a hypoechoic cystic structure, separate from any local nerve, and without Doppler flow, consistent with what was seen on MRI. Additionally, there was an apparent stalk communicating with the anterior margin of the radiocapitellar articulation, seen on longitudinal images, suggesting an extension of the joint capsule (Figure 3A).
We diagnosed the patient with a radiocapitellar ganglion cyst. Her symptoms continued despite several sessions of physical therapy and cessation from all throwing. Given the ultrasound and MRI findings, and continuation of the symptoms despite conservative treatment, alternative treatment plans were discussed with the patient. These included continued activity modification and nonoperative treatment, open excision of the cyst, or aspiration of the cyst under ultrasound guidance. All appropriate risks and benefits were discussed, including possibility of nerve damage given the proximity of the cyst to the radial nerve branches. After a thorough discussion with both patient and family, a plan was made to undergo aspiration under ultrasound guidance. This was carried out using a lateral-to-medial in-plane approach, transverse to the radius. Using a 19-g, 1.5-inch needle (Figure 3B), 1 mL of serosanguinous fluid was aspirated from the cyst, followed by injection of 40 mg methylprednisolone sodium succinate.
The patient made a dramatic recovery within 8 days after aspiration. On examination, she had full strength to resisted flexion, extension, pronation, and supination; had no tenderness to palpation over the supinator; and no pain with resisted finger extension. She began dedicated physical therapy and a gradual return to throwing. She was able to return to her original level of softball activities 2 months after the aspiration. The patient continued to be symptom-free 26 months after the aspiration/injection. There was no evidence of recurrence of the ganglion on repeat ultrasound at her most recent follow-up (Figures 4A, 4B).
Discussion
Our review of the English-language literature identified 23 reports of cysts in and around the supinator muscle. Ganglion cysts are benign lesions that are uncommonly seen about the elbow. This highlights the rarity of this diagnosis, as well as the need for recognition of its existence. Cysts located in the substance of the nerve1-5 and extraneural ganglia causing symptomatic nerve compression have been described. These extraneural ganglia have been reported to cause compression of the ulnar nerve,1-4,6 posterior interosseous nerve (PIN),5,7-12 and radial nerve,13 and isolated compression of the radial sensory branch.14-17 Ganglion cyst compression in the elbow can result in pain, decreased motor function, and decreased sensation. The PIN syndrome is primarily a motor deficiency, whereas isolated compression of the sensory branches of the radial nerve presents as pain along the radial tunnel and extensor muscle mass.17
Most ganglion cysts are formed when joint fluid extrudes through a defect in the joint capsule; they have also been described originating from a nonunion site.18 When conservative treatment fails, surgical excision has been recommended.5,6,8-10,12-16 We present the first known case of successful ultrasound-guided aspiration and injection of a ganglion cyst from the proximal radiocapitellar joint.
In the earliest described case in 1955, Broomhead19 noted exploration was essential to establish the diagnosis of nerve palsy. In 1966, Bowen and Stone7 were the first to report PIN compression by a ganglion and that compression was likely where nerves pass through confined spaces. In keeping with the known potential for compression of the common peroneal nerve around the fibular head, Bowen and Stone7 posited that the same could be true of the PIN coursing through the supinator and around the radial neck.
Many authors have noted that nerve palsy either improves with rest or worsens with heavy manual work.3,20,21 These observations suggest that dynamic factors in addition to compression of the nerve by the ganglion may influence the occurrence of the nerve palsy.14 This is in line with our patient whose symptoms worsened after pitching.
Ogino and colleagues20 reported on the first use of ultrasonography as a screening examination for a ganglion, particularly when palpation was difficult. Ultrasound allows a detailed assessment of peripheral nerve continuity with a mass, differentiating an intraneural lesion from an adjacent extrinsic ganglion.13 Tonkin10 published the first description of MRI used for the diagnosis of an elbow cyst, and its use has been supported by others.5,8,20 The typical appearance of ganglion cysts on MRI include low signal on T1-weighted images and very high signal on T2-weighted images. Only the periphery of the mass is enhanced by gadolinium, if used.
As recently as 2009, Jou and associates13 suggested that surgical excision should be performed promptly to ensure optimal recovery from a nerve palsy. Many authors agree that early diagnosis and careful surgical excision is associated with a satisfactory outcome without recurrence of the cyst.5,6,8-10,12-15 There are only 4 published case reports14-17 of ganglions causing isolated compression of the superficial radial sensory nerve, as in our case. Their patients had pain with exertional trauma14 as did our patient, a positive Tinel sign,15 and resolution of symptoms after surgical excision without recurrence.14-16 Mileti and colleagues16 state that standard management for resistant radial tunnel syndrome is open decompression of the radial nerve.
In the last decade, a few reports of arthroscopic excision being a viable and safe alternative to open excision have been published.16,22,23 In 2000, Feldman22 described the benefits of an arthroscopic approach as decreased soft-tissue dissection, increased ability to identify intra-articular pathology, and similar recurrence rates to open procedures. He reported 1 transient neurapraxia of the superficial radial nerve from the arthroscopy, highlighting a risk of arthroscopic treatment.
An alternative to open or arthroscopic cyst decompression is aspiration. The only mention of aspiration in the literature comes from Broomhead19 in 1955 when he described 2 patients in whom treatment by aspiration was unsuccessful in relieving their symptoms. Yamazaki and colleagues12 noted that 1 of their 14 patients with PIN palsies caused by ganglions at the elbow underwent puncture of the ganglion with recovery of the paralysis. With the aid of ultrasound guidance, we were able to accurately locate the ganglion cyst, aspirate its contents, and inject methylprednisolone sodium succinate. Our patient continued to be symptom-free and was an active pitcher on a varsity softball team 26 months after aspiration.
Conclusion
This case report describes a rare location for a ganglion cyst in a high-level softball player. To our knowledge, successful treatment with ultrasound-guided aspiration and injection of a supinator cyst has not been reported in the literature. This case report highlights the importance of a careful diagnosis of this condition and an alternative treatment algorithm.
1. Boursinos LA, Dimitriou CG. Ulnar nerve compression in the cubital tunnel by an epineural ganglion: a case report. Hand (N Y). 2007;2(1):12-15.
2. Ferlic DC, Ries MD. Epineural ganglion of the ulnar nerve at the elbow. J Hand Surg Am. 1990;15(6):996-998.
3. Ming Chan K, Thompson S, Amirjani N, Satkunam L, Strohschlein FJ, Lobay GL. Compression of the ulnar nerve at the elbow by an intraneural ganglion. J Clin Neurosci. 2003;10(2):245-248.
4. Sharma RR, Pawar SJ, Delmendo A, Mahapatra AK. Symptomatic epineural ganglion cyst of the ulnar nerve in the cubital tunnel: a case report and brief review of the literature. J Clin Neurosci. 2000;7(6):542-543.
5. Hashizume H, Nishida K, Nanba Y, Inoue H, Konishiike T. Intraneural ganglion of the posterior interosseous nerve with lateral elbow pain. J Hand Surg Br. 1995;20(5):649-651.
6. Kato H, Hirayama T, Minami A, Iwasaki N, Hirachi K. Cubital tunnel syndrome associated with medial elbow Ganglia and osteoarthritis of the elbow. J Bone Joint Surg Am. 2002;84(8):1413-1419.
7. Bowen TL, Stone KH. Posterior interosseous nerve paralysis caused by a ganglion at the elbow. J Bone Joint Surg Br. 1966;48(4):774-776.
8. Ly JQ, Barrett TJ, Beall DP, Bertagnolli R. MRI diagnosis of occult ganglion compression of the posterior interosseous nerve and associated supinator muscle pathology. Clin Imaging. 2005;29(5):362-363.
9. McCollam SM, Corley FG, Green DP. Posterior interosseous nerve palsy caused by ganglions of the proximal radioulnar joint. J Hand Surg Am. 1988;13(5):725-728.
10. Tonkin MA. Posterior interosseous nerve axonotmesis from compression by a ganglion. J Hand Surg Br. 1990;15(4):491-493.
11. Tuygun H, Kose O, Gorgec M. Partial paralysis of the posterior interosseous nerve caused by a ganglion. J Hand Surg Eur. 2008;33(4):540-541.
12. Yamazaki H, Kato H, Hata Y, Murakami N, Saitoh S. The two locations of ganglions causing radial nerve palsy. J Hand Surg Eur. 2007;32(3):341-345.
13. Jou IM, Wang HN, Wang PH, Yong IS, Su WR. Compression of the radial nerve at the elbow by a ganglion: two case reports. J Med Case Rep. 2009;3:7258.
14. Hermansdorfer JD, Greider JL, Dell PC. A case report of a compressive neuropathy of the radial sensory nerve caused by a ganglion cyst at the elbow. Orthopedics. 1986;9(7):1005-1006.
15. McFarlane J, Trehan R, Olivera M, Jones C, Blease S, Davey P. A ganglion cyst at the elbow causing superficial radial nerve compression: a case report. J Med Case Rep. 2008;2:122.
16. Mileti J, Largacha M, O’Driscoll SW. Radial tunnel syndrome caused by ganglion cyst: treatment by arthroscopic cyst decompression. Arthroscopy. 2004;20(5):e39-e44.
17. Plancher KD, Peterson RK, Steichen JB. Compressive neuropathies and tendinopathies in the athletic elbow and wrist. Clin Sports Med. 1996;15(2):331-371.
18. Chim H, Yam AK, Teoh LC. Elbow ganglion arising from medial epicondyle pseudarthrosis. Hand Surg. 2007;12(3):155-158.
19. Broomhead IW. Ganglia associated with elbow and knee joints. Lancet. 1955;269(6885):317-319.
20. Ogino T, Minami A, Kato H. Diagnosis of radial nerve palsy caused by ganglion with use of different imaging techniques. J Hand Surg Am. 1991;16(2):230-235.
21. Spinner M, Spencer PS. Nerve compression lesions of the upper extremity. A clinical and experimental review. Clin Orthop Relat Res. 1974;(104):46-67.
22. Feldman MD. Arthroscopic excision of a ganglion cyst from the elbow. Arthroscopy. 2000;16(6):661-664.
23. Kirpalani PA, Lee HK, Lee YS, Han CW. Transarticular arthroscopic excision of an elbow cyst. Acta Orthop Belg. 2005;71(4):477-480.
Ganglion cysts around the elbow joint are unusual, with fewer than 25 citations (most of which are case reports) in the English-language literature. Among the many causes of elbow pain, cysts are chiefly diagnosed by advanced imaging. When an elbow ganglion or perineural cyst is symptomatic, treatment has ranged from nonoperative to surgical intervention. Our case report is the first documented ultrasound-guided aspiration and cortisone injection to successfully alleviate a patient’s symptoms. The procedures and outcomes of minimally invasive ultrasound-guided aspiration and steroid injections have not been described for cysts around the elbow. The patient and patient’s guardian provided written informed consent for print and electronic publication of this case report.
Case Report
A 14-year-old female freshman varsity softball pitcher on multiple teams presented with 6 months of vague right elbow pain. She was unable to pitch and had intermittent sharp pain localized to the lateral proximal forearm. She was, however, able to bat without pain and denied any radiating paresthesias. Despite a reduction in sports activities, the symptoms did not improve.
On physical examination, there was preserved strength that was symmetric with the contralateral side of all major muscles innervated by the radial nerve in the right arm, including full wrist, thumb, and finger extension. Sensation was intact to light touch in all major nervous distributions of the right and left upper extremities. She was tender to palpation at the radiocapitellar joint anteriorly, as well as just distally. The patient was also tender with motion through the proximal radial head. She had pain with resisted finger extension; however, resisted supination elicited no discomfort or pain.
The initial diagnostic workup included radiographs of the right elbow, a magnetic resonance imaging (MRI) scan, and an ultrasound. Elbow radiographs revealed no abnormalities. The MRI scan showed a well-circumscribed ovoid T2-hyperintense structure within the supinator muscle measuring 0.6×0.6×0.4 cm (longitudinal × anteroposterior × transverse), just deep to the split of the superficial and deep radial nerves (Figures 1A-1C). A musculoskeletal ultrasound was performed to further characterize and determine the relationship to neurovascular structures. Longitudinal (Figure 2A) and transverse (Figure 2B) images showed a hypoechoic cystic structure, separate from any local nerve, and without Doppler flow, consistent with what was seen on MRI. Additionally, there was an apparent stalk communicating with the anterior margin of the radiocapitellar articulation, seen on longitudinal images, suggesting an extension of the joint capsule (Figure 3A).
We diagnosed the patient with a radiocapitellar ganglion cyst. Her symptoms continued despite several sessions of physical therapy and cessation from all throwing. Given the ultrasound and MRI findings, and continuation of the symptoms despite conservative treatment, alternative treatment plans were discussed with the patient. These included continued activity modification and nonoperative treatment, open excision of the cyst, or aspiration of the cyst under ultrasound guidance. All appropriate risks and benefits were discussed, including possibility of nerve damage given the proximity of the cyst to the radial nerve branches. After a thorough discussion with both patient and family, a plan was made to undergo aspiration under ultrasound guidance. This was carried out using a lateral-to-medial in-plane approach, transverse to the radius. Using a 19-g, 1.5-inch needle (Figure 3B), 1 mL of serosanguinous fluid was aspirated from the cyst, followed by injection of 40 mg methylprednisolone sodium succinate.
The patient made a dramatic recovery within 8 days after aspiration. On examination, she had full strength to resisted flexion, extension, pronation, and supination; had no tenderness to palpation over the supinator; and no pain with resisted finger extension. She began dedicated physical therapy and a gradual return to throwing. She was able to return to her original level of softball activities 2 months after the aspiration. The patient continued to be symptom-free 26 months after the aspiration/injection. There was no evidence of recurrence of the ganglion on repeat ultrasound at her most recent follow-up (Figures 4A, 4B).
Discussion
Our review of the English-language literature identified 23 reports of cysts in and around the supinator muscle. Ganglion cysts are benign lesions that are uncommonly seen about the elbow. This highlights the rarity of this diagnosis, as well as the need for recognition of its existence. Cysts located in the substance of the nerve1-5 and extraneural ganglia causing symptomatic nerve compression have been described. These extraneural ganglia have been reported to cause compression of the ulnar nerve,1-4,6 posterior interosseous nerve (PIN),5,7-12 and radial nerve,13 and isolated compression of the radial sensory branch.14-17 Ganglion cyst compression in the elbow can result in pain, decreased motor function, and decreased sensation. The PIN syndrome is primarily a motor deficiency, whereas isolated compression of the sensory branches of the radial nerve presents as pain along the radial tunnel and extensor muscle mass.17
Most ganglion cysts are formed when joint fluid extrudes through a defect in the joint capsule; they have also been described originating from a nonunion site.18 When conservative treatment fails, surgical excision has been recommended.5,6,8-10,12-16 We present the first known case of successful ultrasound-guided aspiration and injection of a ganglion cyst from the proximal radiocapitellar joint.
In the earliest described case in 1955, Broomhead19 noted exploration was essential to establish the diagnosis of nerve palsy. In 1966, Bowen and Stone7 were the first to report PIN compression by a ganglion and that compression was likely where nerves pass through confined spaces. In keeping with the known potential for compression of the common peroneal nerve around the fibular head, Bowen and Stone7 posited that the same could be true of the PIN coursing through the supinator and around the radial neck.
Many authors have noted that nerve palsy either improves with rest or worsens with heavy manual work.3,20,21 These observations suggest that dynamic factors in addition to compression of the nerve by the ganglion may influence the occurrence of the nerve palsy.14 This is in line with our patient whose symptoms worsened after pitching.
Ogino and colleagues20 reported on the first use of ultrasonography as a screening examination for a ganglion, particularly when palpation was difficult. Ultrasound allows a detailed assessment of peripheral nerve continuity with a mass, differentiating an intraneural lesion from an adjacent extrinsic ganglion.13 Tonkin10 published the first description of MRI used for the diagnosis of an elbow cyst, and its use has been supported by others.5,8,20 The typical appearance of ganglion cysts on MRI include low signal on T1-weighted images and very high signal on T2-weighted images. Only the periphery of the mass is enhanced by gadolinium, if used.
As recently as 2009, Jou and associates13 suggested that surgical excision should be performed promptly to ensure optimal recovery from a nerve palsy. Many authors agree that early diagnosis and careful surgical excision is associated with a satisfactory outcome without recurrence of the cyst.5,6,8-10,12-15 There are only 4 published case reports14-17 of ganglions causing isolated compression of the superficial radial sensory nerve, as in our case. Their patients had pain with exertional trauma14 as did our patient, a positive Tinel sign,15 and resolution of symptoms after surgical excision without recurrence.14-16 Mileti and colleagues16 state that standard management for resistant radial tunnel syndrome is open decompression of the radial nerve.
In the last decade, a few reports of arthroscopic excision being a viable and safe alternative to open excision have been published.16,22,23 In 2000, Feldman22 described the benefits of an arthroscopic approach as decreased soft-tissue dissection, increased ability to identify intra-articular pathology, and similar recurrence rates to open procedures. He reported 1 transient neurapraxia of the superficial radial nerve from the arthroscopy, highlighting a risk of arthroscopic treatment.
An alternative to open or arthroscopic cyst decompression is aspiration. The only mention of aspiration in the literature comes from Broomhead19 in 1955 when he described 2 patients in whom treatment by aspiration was unsuccessful in relieving their symptoms. Yamazaki and colleagues12 noted that 1 of their 14 patients with PIN palsies caused by ganglions at the elbow underwent puncture of the ganglion with recovery of the paralysis. With the aid of ultrasound guidance, we were able to accurately locate the ganglion cyst, aspirate its contents, and inject methylprednisolone sodium succinate. Our patient continued to be symptom-free and was an active pitcher on a varsity softball team 26 months after aspiration.
Conclusion
This case report describes a rare location for a ganglion cyst in a high-level softball player. To our knowledge, successful treatment with ultrasound-guided aspiration and injection of a supinator cyst has not been reported in the literature. This case report highlights the importance of a careful diagnosis of this condition and an alternative treatment algorithm.
Ganglion cysts around the elbow joint are unusual, with fewer than 25 citations (most of which are case reports) in the English-language literature. Among the many causes of elbow pain, cysts are chiefly diagnosed by advanced imaging. When an elbow ganglion or perineural cyst is symptomatic, treatment has ranged from nonoperative to surgical intervention. Our case report is the first documented ultrasound-guided aspiration and cortisone injection to successfully alleviate a patient’s symptoms. The procedures and outcomes of minimally invasive ultrasound-guided aspiration and steroid injections have not been described for cysts around the elbow. The patient and patient’s guardian provided written informed consent for print and electronic publication of this case report.
Case Report
A 14-year-old female freshman varsity softball pitcher on multiple teams presented with 6 months of vague right elbow pain. She was unable to pitch and had intermittent sharp pain localized to the lateral proximal forearm. She was, however, able to bat without pain and denied any radiating paresthesias. Despite a reduction in sports activities, the symptoms did not improve.
On physical examination, there was preserved strength that was symmetric with the contralateral side of all major muscles innervated by the radial nerve in the right arm, including full wrist, thumb, and finger extension. Sensation was intact to light touch in all major nervous distributions of the right and left upper extremities. She was tender to palpation at the radiocapitellar joint anteriorly, as well as just distally. The patient was also tender with motion through the proximal radial head. She had pain with resisted finger extension; however, resisted supination elicited no discomfort or pain.
The initial diagnostic workup included radiographs of the right elbow, a magnetic resonance imaging (MRI) scan, and an ultrasound. Elbow radiographs revealed no abnormalities. The MRI scan showed a well-circumscribed ovoid T2-hyperintense structure within the supinator muscle measuring 0.6×0.6×0.4 cm (longitudinal × anteroposterior × transverse), just deep to the split of the superficial and deep radial nerves (Figures 1A-1C). A musculoskeletal ultrasound was performed to further characterize and determine the relationship to neurovascular structures. Longitudinal (Figure 2A) and transverse (Figure 2B) images showed a hypoechoic cystic structure, separate from any local nerve, and without Doppler flow, consistent with what was seen on MRI. Additionally, there was an apparent stalk communicating with the anterior margin of the radiocapitellar articulation, seen on longitudinal images, suggesting an extension of the joint capsule (Figure 3A).
We diagnosed the patient with a radiocapitellar ganglion cyst. Her symptoms continued despite several sessions of physical therapy and cessation from all throwing. Given the ultrasound and MRI findings, and continuation of the symptoms despite conservative treatment, alternative treatment plans were discussed with the patient. These included continued activity modification and nonoperative treatment, open excision of the cyst, or aspiration of the cyst under ultrasound guidance. All appropriate risks and benefits were discussed, including possibility of nerve damage given the proximity of the cyst to the radial nerve branches. After a thorough discussion with both patient and family, a plan was made to undergo aspiration under ultrasound guidance. This was carried out using a lateral-to-medial in-plane approach, transverse to the radius. Using a 19-g, 1.5-inch needle (Figure 3B), 1 mL of serosanguinous fluid was aspirated from the cyst, followed by injection of 40 mg methylprednisolone sodium succinate.
The patient made a dramatic recovery within 8 days after aspiration. On examination, she had full strength to resisted flexion, extension, pronation, and supination; had no tenderness to palpation over the supinator; and no pain with resisted finger extension. She began dedicated physical therapy and a gradual return to throwing. She was able to return to her original level of softball activities 2 months after the aspiration. The patient continued to be symptom-free 26 months after the aspiration/injection. There was no evidence of recurrence of the ganglion on repeat ultrasound at her most recent follow-up (Figures 4A, 4B).
Discussion
Our review of the English-language literature identified 23 reports of cysts in and around the supinator muscle. Ganglion cysts are benign lesions that are uncommonly seen about the elbow. This highlights the rarity of this diagnosis, as well as the need for recognition of its existence. Cysts located in the substance of the nerve1-5 and extraneural ganglia causing symptomatic nerve compression have been described. These extraneural ganglia have been reported to cause compression of the ulnar nerve,1-4,6 posterior interosseous nerve (PIN),5,7-12 and radial nerve,13 and isolated compression of the radial sensory branch.14-17 Ganglion cyst compression in the elbow can result in pain, decreased motor function, and decreased sensation. The PIN syndrome is primarily a motor deficiency, whereas isolated compression of the sensory branches of the radial nerve presents as pain along the radial tunnel and extensor muscle mass.17
Most ganglion cysts are formed when joint fluid extrudes through a defect in the joint capsule; they have also been described originating from a nonunion site.18 When conservative treatment fails, surgical excision has been recommended.5,6,8-10,12-16 We present the first known case of successful ultrasound-guided aspiration and injection of a ganglion cyst from the proximal radiocapitellar joint.
In the earliest described case in 1955, Broomhead19 noted exploration was essential to establish the diagnosis of nerve palsy. In 1966, Bowen and Stone7 were the first to report PIN compression by a ganglion and that compression was likely where nerves pass through confined spaces. In keeping with the known potential for compression of the common peroneal nerve around the fibular head, Bowen and Stone7 posited that the same could be true of the PIN coursing through the supinator and around the radial neck.
Many authors have noted that nerve palsy either improves with rest or worsens with heavy manual work.3,20,21 These observations suggest that dynamic factors in addition to compression of the nerve by the ganglion may influence the occurrence of the nerve palsy.14 This is in line with our patient whose symptoms worsened after pitching.
Ogino and colleagues20 reported on the first use of ultrasonography as a screening examination for a ganglion, particularly when palpation was difficult. Ultrasound allows a detailed assessment of peripheral nerve continuity with a mass, differentiating an intraneural lesion from an adjacent extrinsic ganglion.13 Tonkin10 published the first description of MRI used for the diagnosis of an elbow cyst, and its use has been supported by others.5,8,20 The typical appearance of ganglion cysts on MRI include low signal on T1-weighted images and very high signal on T2-weighted images. Only the periphery of the mass is enhanced by gadolinium, if used.
As recently as 2009, Jou and associates13 suggested that surgical excision should be performed promptly to ensure optimal recovery from a nerve palsy. Many authors agree that early diagnosis and careful surgical excision is associated with a satisfactory outcome without recurrence of the cyst.5,6,8-10,12-15 There are only 4 published case reports14-17 of ganglions causing isolated compression of the superficial radial sensory nerve, as in our case. Their patients had pain with exertional trauma14 as did our patient, a positive Tinel sign,15 and resolution of symptoms after surgical excision without recurrence.14-16 Mileti and colleagues16 state that standard management for resistant radial tunnel syndrome is open decompression of the radial nerve.
In the last decade, a few reports of arthroscopic excision being a viable and safe alternative to open excision have been published.16,22,23 In 2000, Feldman22 described the benefits of an arthroscopic approach as decreased soft-tissue dissection, increased ability to identify intra-articular pathology, and similar recurrence rates to open procedures. He reported 1 transient neurapraxia of the superficial radial nerve from the arthroscopy, highlighting a risk of arthroscopic treatment.
An alternative to open or arthroscopic cyst decompression is aspiration. The only mention of aspiration in the literature comes from Broomhead19 in 1955 when he described 2 patients in whom treatment by aspiration was unsuccessful in relieving their symptoms. Yamazaki and colleagues12 noted that 1 of their 14 patients with PIN palsies caused by ganglions at the elbow underwent puncture of the ganglion with recovery of the paralysis. With the aid of ultrasound guidance, we were able to accurately locate the ganglion cyst, aspirate its contents, and inject methylprednisolone sodium succinate. Our patient continued to be symptom-free and was an active pitcher on a varsity softball team 26 months after aspiration.
Conclusion
This case report describes a rare location for a ganglion cyst in a high-level softball player. To our knowledge, successful treatment with ultrasound-guided aspiration and injection of a supinator cyst has not been reported in the literature. This case report highlights the importance of a careful diagnosis of this condition and an alternative treatment algorithm.
1. Boursinos LA, Dimitriou CG. Ulnar nerve compression in the cubital tunnel by an epineural ganglion: a case report. Hand (N Y). 2007;2(1):12-15.
2. Ferlic DC, Ries MD. Epineural ganglion of the ulnar nerve at the elbow. J Hand Surg Am. 1990;15(6):996-998.
3. Ming Chan K, Thompson S, Amirjani N, Satkunam L, Strohschlein FJ, Lobay GL. Compression of the ulnar nerve at the elbow by an intraneural ganglion. J Clin Neurosci. 2003;10(2):245-248.
4. Sharma RR, Pawar SJ, Delmendo A, Mahapatra AK. Symptomatic epineural ganglion cyst of the ulnar nerve in the cubital tunnel: a case report and brief review of the literature. J Clin Neurosci. 2000;7(6):542-543.
5. Hashizume H, Nishida K, Nanba Y, Inoue H, Konishiike T. Intraneural ganglion of the posterior interosseous nerve with lateral elbow pain. J Hand Surg Br. 1995;20(5):649-651.
6. Kato H, Hirayama T, Minami A, Iwasaki N, Hirachi K. Cubital tunnel syndrome associated with medial elbow Ganglia and osteoarthritis of the elbow. J Bone Joint Surg Am. 2002;84(8):1413-1419.
7. Bowen TL, Stone KH. Posterior interosseous nerve paralysis caused by a ganglion at the elbow. J Bone Joint Surg Br. 1966;48(4):774-776.
8. Ly JQ, Barrett TJ, Beall DP, Bertagnolli R. MRI diagnosis of occult ganglion compression of the posterior interosseous nerve and associated supinator muscle pathology. Clin Imaging. 2005;29(5):362-363.
9. McCollam SM, Corley FG, Green DP. Posterior interosseous nerve palsy caused by ganglions of the proximal radioulnar joint. J Hand Surg Am. 1988;13(5):725-728.
10. Tonkin MA. Posterior interosseous nerve axonotmesis from compression by a ganglion. J Hand Surg Br. 1990;15(4):491-493.
11. Tuygun H, Kose O, Gorgec M. Partial paralysis of the posterior interosseous nerve caused by a ganglion. J Hand Surg Eur. 2008;33(4):540-541.
12. Yamazaki H, Kato H, Hata Y, Murakami N, Saitoh S. The two locations of ganglions causing radial nerve palsy. J Hand Surg Eur. 2007;32(3):341-345.
13. Jou IM, Wang HN, Wang PH, Yong IS, Su WR. Compression of the radial nerve at the elbow by a ganglion: two case reports. J Med Case Rep. 2009;3:7258.
14. Hermansdorfer JD, Greider JL, Dell PC. A case report of a compressive neuropathy of the radial sensory nerve caused by a ganglion cyst at the elbow. Orthopedics. 1986;9(7):1005-1006.
15. McFarlane J, Trehan R, Olivera M, Jones C, Blease S, Davey P. A ganglion cyst at the elbow causing superficial radial nerve compression: a case report. J Med Case Rep. 2008;2:122.
16. Mileti J, Largacha M, O’Driscoll SW. Radial tunnel syndrome caused by ganglion cyst: treatment by arthroscopic cyst decompression. Arthroscopy. 2004;20(5):e39-e44.
17. Plancher KD, Peterson RK, Steichen JB. Compressive neuropathies and tendinopathies in the athletic elbow and wrist. Clin Sports Med. 1996;15(2):331-371.
18. Chim H, Yam AK, Teoh LC. Elbow ganglion arising from medial epicondyle pseudarthrosis. Hand Surg. 2007;12(3):155-158.
19. Broomhead IW. Ganglia associated with elbow and knee joints. Lancet. 1955;269(6885):317-319.
20. Ogino T, Minami A, Kato H. Diagnosis of radial nerve palsy caused by ganglion with use of different imaging techniques. J Hand Surg Am. 1991;16(2):230-235.
21. Spinner M, Spencer PS. Nerve compression lesions of the upper extremity. A clinical and experimental review. Clin Orthop Relat Res. 1974;(104):46-67.
22. Feldman MD. Arthroscopic excision of a ganglion cyst from the elbow. Arthroscopy. 2000;16(6):661-664.
23. Kirpalani PA, Lee HK, Lee YS, Han CW. Transarticular arthroscopic excision of an elbow cyst. Acta Orthop Belg. 2005;71(4):477-480.
1. Boursinos LA, Dimitriou CG. Ulnar nerve compression in the cubital tunnel by an epineural ganglion: a case report. Hand (N Y). 2007;2(1):12-15.
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