REMEDY : BNSSG referral pathways & Joint Formulary

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Checked: 25-06-2024 by Rob Adams Next Review: 25-06-2026


A ganglion is a fluid-filled lump which can occur near joints or tendons. It is most commonly found on the wrist or hands. It is usually harmless and often, no treatment is needed. If required and criteria are met (1) , a ganglion can be injected, aspirated or removed surgically.

A ganglion is a swelling that contains a thick jelly-like material and is usually attached to a joint or tendon . The fluid inside is a thicker version of the synovial fluid. It looks and feels like a smooth lump under the skin. It is not fully understood how it occurs. In some cases they occur after an injury but in most there is no obvious cause.

The most common site for a ganglion to be found is on the back of the wrist. It can also occur on the other side of the wrist, on the hand, and on the top of the foot. Other sites of the body are affected less commonly (2).

Who to Refer

In most cases a ganglion can be diagnosed clinically and reassurance given (3). Referral or imaging are not usually required.

In some cases a referral to MSK can be made to consider a guided injection or aspiration or for surgical excision. Referrals should only be considered if the following criteria are met:

1. Conservative measures (over 6 months) have been exhausted including rest, activity modification, pain relief, NSAIDS, splinting, exercises, as appropriate.


2. Patients with:
a) Significant neurovascular compromise (mild discomfort or localised numbness would not be considered significant)
b) Where ganglion only forms part of or maybe is secondary to the diagnosis (i.e.underlying OA or instability) where the underlying problem can only be resolved by removal of the ganglion.
c) Patients with persistent foot and ankle ganglia (over 6 months)  causing pain and significant functional limitation (difficulty working, or doing everyday activities, wearing normal footwear).

Red Flags

If a lump is suspicious and there are concerns about malignancy please consider using the Bone & Soft Tissue - USC (2WW) referral pathway.

What to do before referral

Please state clearly in a referral how criteria are met (as above).

Please also consider the following prior to referral:


If possible, please include photos of the ganglion with a referral (although this is not mandatory)


Most ganglia can be diagnosed clinically and imaging it not routinely required. Consider imaging (USS or MRI) if there is diagnostic uncertainty or if there is significant neurovascular compromise. Imaging can be considered and requested on ICE but please include clinical details and indication for imaging as otherwise requests may be returned.

Prior Approval

Applications for Prior Approval are not required if referring from primary care. This policy is intended for use by the MSK team.


Patients who meet criteria for referral should be referred via the community Musculoskeletal (MSK) Interface Service.

Direct referrals for surgery (i.e.  to plastics or hand surgeons, etc) should not be made and will be returned.

Patients who are seen by the MSK team will be reviewed and treated as appropriate if funding criteria are met (1). Please manage patient expectation, as not all patients will meet criteria for surgical management and may be discharged without any further treatment.


(1) Ganglion Referral and Removal - NHS BNSSG ICB

(2) Ganglion (Causes, Symptoms, and Treatment) (

(3) Ganglion cyst - NHS (

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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