Journal of Orthopaedic Surgery 2005:13(2):181-185
Ganglion cyst of the anterior cruciate
ligament: A case report
B Dinakar, T Khan, AC Kumar, A Kumar
Fujairah Hospital, Fujairah, UAE
ABSTRACT
A ganglion is a cystic swelling that usually arises
close to tendons or joints. Its occurrence inside a joint
is rare, and its diagnosis is usually incidental during
magnetic resonance imaging or arthroscopy. It may
be painful or asymptomatic. Some patients may
have a trauma history. Ganglia may mimic intra-
articular lesions like tears of the anterior cruciate
ligament or meniscus. Magnetic resonance imaging
is the investigation of choice for diagnosis. Ganglia
commonly arise from the anterior cruciate ligament,
but can also arise from other structures such as the
posterior cruciate ligament or meniscus. Ganglia
are typically treated by arthroscopic excision and
debridement. We report a case of ganglion cyst of
the anterior cruciate ligament in a 16-year-old man.
Key words: anterior cruciate ligament; arthroscopy; ganglion cysts
Address correspondence and reprint requests to: Dr B Dinakar, Specialist Orthopaedic Surgeon, P.O. Box 10, Fujairah Hospital,
Fujairah, UAE. E-mail: begurdinakar@yahoo.com
CASE REPORT
A 16-year-old man presented to Fujairah Hospital in
March 2004 with pain in his right knee joint for the
previous 8 months. He was serving in the military and
engaged in regular heavy physical activity. He had
mildly twisted his right knee joint one year earlier and
had been treated with anti-inflammatory medications.
He recovered well and continued with his regular
activities.
On presentation, the patient had difficulty
bending his right knee. He had no history of locking
or giving way of the knee, but had pain on standing.
On clinical examination, there was mild wasting of the
quadriceps muscle, some swelling of the right knee
joint, and local tenderness over the medial joint line.
The range of movement of his knee was full, with no
loss of extension, but the terminal knee flexion (the
final 10 to 15 degrees) was painful. McMurray’s test
was negative, and the collateral and cruciate ligaments
were clinically stable. The patellar articular surface was
not tender, and patellar movements were normal. The
182 B Dinakar et al.
(a) (b)
Figure 1 Magnetic resonance images of the knee showing (a) the extension of the cyst, (b) the posterior cruciate ligament in
between, and (c) the cyst in the intercondylar fossa.
Cyst
ACL
ACL
(a) (b)
Figure 2 Arthroscopic photographs of the knee showing the cyst (a) in front of, (b) arising from, and (c) beside the anterior
cruciate ligament.
cause of his pain was presumed to be due to internal
derangement of the knee, probably caused by a mild
meniscal injury.
Magnetic resonance imaging (MRI) of the right
knee showed a moderate amount of loculated fluid
in the intercondylar fossa, with septations. The
radiologist interpreted the MRI as a cyst involving the
posterior horn of the medial meniscus. The swelling
extended in front of the anterior cruciate ligament
(ACL), in between the ACL and the posterior cruciate
ligament (PCL), and further extended posterior to the
PCL (Fig 1).
The patient underwent arthroscopy of his right
knee joint under general anaesthesia through the
standard anteromedial and anterolateral portals. The
posterior portal was once considered an option while
planning the procedure. As we were able to visualise
the swelling clearly and were also able to excise a major
part of it through the anterior portals, a further
posterior approach was not considered.
During the procedure, the cyst was visualised well;
it was located in front of the ACL and partially within
Journal of Orthopaedic Surgery
(c)
Cyst Cyst
ACL
(c)
the ACL close to the femoral attachment. It was ovoid
in shape measuring about 15 mm in diameter. The cyst
was well demarcated and its origin from the ACL was
clearly visualised (Fig. 2). It was transparent and
freely mobile. There were no adhesions or signs of
inflammation surrounding the swelling. The cyst was
thin-walled and easily punctured by the probe. The
wall of the cyst lying posterior to the PCL was broken
by the probe, and approximately three quarters of the
cyst and its wall were excised.
A diagnosis of a cyst arising from the ACL was
made. The medial and lateral menisci were normal.
Transparent gelatinous fluid came out of the cyst when
it was punctured. The major portion of the cyst wall
was resected using the arthroscopy resector. The area
around the ACL was probed, and all the septa were
broken. The knee was then put through a full range of
motion. All other structures within the knee joint
were found to be normal.
The cyst wall was sent for histopathological
examination. The postoperative course was
uneventful. The patient was mobilised in hospital
Vol. 13 No. 2, August 2005
Figure 3 Magnetic resonance image of the knee 3 months
after surgery showing no evidence of the cyst
and discharged home the next day. The histopathology
report showed greyish-white membranous bits
measuring 1.3x0.6x0.3 cm. Microscopic sections
showed lobulated fibro-fatty tissue covered
superficially by flattened synovial cells. A confluent
area of fibrinoid/hyaline change of the stroma
was observed, as well as a moderate infiltration by
mononuclear leukocytes. Multinucleated giant
cells were not seen. All these features were
suggestive of a ganglion cyst.
The patient was followed up in an orthopaedic
out-patient regularly. At the final follow-up of
postoperative 6 months, the patient did not have any
complaints and the follow-up MRI showed no
signs of any residual cyst (Fig. 3).
Clinical features
Intra-articular swellings such as ganglion cysts
may present with pain and/or limitation of the
movements of the joint. These may be due to
mechanical blocking effects. Some patients present
with a clicking sensation and interference during
extreme flexion and extension movement. Cysts
anterior to ACL tend to limit extension, whereas
those posterior to the PCL tend to limit flexion. There
maybe joint line tenderness and retropatellar pain.
Ganglion cysts may present as palpable masses
around the knee joint. Symptoms may grow worse
with activity, especially running, jumping, or
squatting. The duration of symptoms may last from
a few weeks to as long as 5 years. The symptoms are
non-specific, and investigations are needed to
Ganglion cyst of the anterior cruciate ligament 183
diagnose the lesion, which usually be found
incidentally during MRI or arthroscopy.
Ganglion cysts are differentiated from pigmented
villo-nodular synovitis, fibroma, haemangioma,
synovial sarcoma, synovial proliferation, myxoma,
synovial chondromatosis, aneurysm, and intra-
articular lipoma.1
Investigations
MRI and arthroscopy are the usual tools for diagnosing
ACL cysts. MRI is the most sensitive, specific, accurate,
and non-invasive method for diagnosing these
lesions. It can also detect other intra-articular lesions.
The ganglion cysts are usually ovoid and well
circumscribed on MRI. They have homogeneously
low signal intensity on T1-weighted images and high
signal intensity on T2-weighted images. They can
extend towards the joint line and around the knee joint.
MRI is also useful in detecting any associated internal
derangement of the knee, such as ACL or meniscal
tears. Other diagnostic modalities such as ultrasound,
computed tomography (CT), and arthrography have
also been used.
Treatment
Asymptomatic cysts need to be treated and excised;
otherwise, they may become symptomatic
later. Arthroscopic resection, debridement, and
excision are the treatments of choice for ganglion
cysts. Other treatment methods include ultrasound-,
CT-, and arthroscopic-guided needle aspiration, but
these are usually associated with a higher rate of
recurrence.
DISCUSSION
Caan first described the ACL ganglion cyst during a
routine autopsy in 1924. In the early 1990s, only a few
sporadic cases and one main case report were found
in the literature.2–12 With widespread use of MRI and
arthroscopy in daily practice, an increasing number
of cases have been discovered.
Ganglion is a cystic swelling that usually
arises close to the tendons or joints. Most often it is
encountered over the dorsum of the hand, but it can
occur in any part of the body. Its occurrence inside a
joint is very rare. The incidence of finding intra-
articular cystic masses is 1.3% by MRI and 0.6% during
arthroscopy. They may be single or multiple,13 as well
as unilateral or bilateral.14 The cysts could be ganglia
or synovial cysts. The term ganglion cyst is used to
184 B Dinakar et al.
include both lesions. The common site for cystic lesions
inside the knee joint is the ACL, followed by PCL, then
menisci, especially the medial meniscus. Other rare
sites of occurrence are at the infrapatellar fat pad,
medial plica, from a subchondral cyst, popliteus
tendon, from chondral fractures or subchondral bone
cysts. They may arise from alar folds that cover either
the infrapatellar fat pad15 or the cruciate ligaments.
The cysts of the cruciate ligaments can distend
outside along the fibres (anterior to the ACL and
posterior to the PCL), between the 2 cruciate
ligaments (intercruciate distension—as in our case),
or interspersing within the fibres. Nearly two thirds
of all ganglion cysts originate from the ACL. They
usually arise from tibial insertion. In our case, it was
from the substance of the ACL close to the femoral
attachment. Meniscal cysts arise both from anterior
and posterior horns. Cystic lesions posterior to PCL
require additional portals such as posteromedial and
posterolateral portals for access during arthroscopy.
Intra-ligamentous ganglion cysts are detectable by
intra-fibrous probing during surgery, which yields an
outflow of whitish or yellowish gelatinous material.
The shape of ganglion cysts could be fusiform, spindle-
shaped, rounded, ovoid, and well-demarcated outlines
with a normal size of 5 to 30 mm, rarely up to 40 mm
in diameter. They appear uni- or multi-locular and are
usually found alone in each knee.16
The cause of ganglion cyst may be due to synovial
tissue herniation, connective tissue degeneration after
trauma, mucin deterioration of connective tissue,
ectopia of synovial tissue, or proliferation of
pluripotential mesenchymal stem cells. Patients may
have a history of knee trauma.
The clinical features may suggest internal
derangement of the knee. Pain is the most common
symptom. There are often fusiform swellings on MRI
examination. Intra-articular ganglion cysts can be
symptomatic or asymptomatic. Krudwig et al. 16
reported 85 cases of intra-articular ganglion cysts, of
which 9 were symptomatic and 76 were asymptomatic.
All the 9 symptomatic patients had no history of
trauma. The definite history of trauma in our patient
is a significant finding. The possible aetiology may be
connective tissue degeneration or re-activation of
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Journal of Orthopaedic Surgery
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Diagnosis of intra-articular ganglion cysts should be
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ACKNOWLEDGEMENTS
We wish to thank Dr Kavya Dinakar for her assistance
in preparing this manuscript, Dr Mohammed Haroon
for interpreting the MRI, Mr Shakeeb Mohammed for
preparing the pictures, and Dr Issac Olude for
interpreting the histopathological slides.
Vol. 13 No. 2, August 2005 Ganglion cyst of the anterior cruciate ligament 185

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