Dr Isstelle Joubert2nd yr M Sports and Exercise Medicine

September 2012

PATIENT COMPLAINT

• Mr. CG, 27yo

• rugby player playing lock forward – 1st team,

senior club level

• pain at medial aspect of left knee – 6/52 Hx

• pain progressed last 3/52 - VAS 6-7/10

 

PATIENT COMPLAINT:

• gradual in onset

• daily when standing or sitting for extended periods

• irritated when driving long distances: knee flexed

• aggravated: bending to engage in scrums

• relieved with occasional NSAIDs - returned within

day 

PAINPAIN

PATIENT COMPLAINT:

• slight instability in L knee

• “fullness”, especially in fully flexed position

• mid-season - over-reaching during period before

onset of pain

• playing surfaces – not changed

• footwear – not changed

PREVIOUS HISTORY:

partial tear in ACL of L knee – 2 seasons before

• Rx: conservative, limited ROM brace

• no meniscal injuries

 

No other medical history

CLINICAL EVALUATION:

Observation:Observation:

• standing + supine:

visible diffuse swelling

postero-lateral aspect of popliteal fossa of L

leg

• walking: not much change in size / position

• swelling visible bilateral to patellar tendon ant

 

CLINICAL EVALUATION:

Active movementsActive movements

• straight leg raise: normal

• knee extension, flexion, tibial rotation: normal

ROM

• some discomfort:

on full extension

medially with tibial rotation

“fullness”: knee full flexed position

 

 

CLINICAL EVALUATION:

Passive movementsPassive movements

• extension, flexion, tibial rotation: minimal

discomfort

• hamstring stretch testing: marked discomfort

• quad stretch testing: normal

• Ober’s test: normal

 

Resisted movementsResisted movements

• tibial rotation, knee flexion: marked discomfort

CLINICAL EVALUATION:

Functional testingFunctional testing

• squatting and forward lunge: cause discomfort

• jumping, hopping, stepping up and down step:

normal

 

CLINICAL EVALUATION:

PalpationPalpation

• gluteus medius: no trigger points

• patellar tapping: mild ballotability - small

effusion

• patella glide test (all directions): no pain

• palpation of patellar fat pad: normal

• no synovial plica palpable

• patella tracked perfectly within femoral trochlea

• both VMO muscles palpated evenly in mass

CLINICAL EVALUATION:

PalpationPalpation

• posterior popliteal fossa: diffuse swelling noted

• direct pressure:

elicited pain, mainly centrally in fossa

radiated towards medial aspect of knee to

point of pes anserinus bursa

• not pulsating

• auscultation: no vascular bruits

CLINICAL EVALUATION:

Special maneuversSpecial maneuvers

• Stability testing for MCL and LCL: normal

• Lachman’s test

• Anterior Drawer test normal bilateral = ACL normal

• Pivot Shift tests

• Posterior Drawer test + with External Rotation

reproduced pain - stability normal acc to R side

• no posterior sagging

CLINICAL EVALUATION:

• Reverse Lachman: negative - normal PCL

• Patellar Apprehension testing: negative

• Medial and Lateral Translations: not reproduce pain

• McMurray’s test discomfort medial

• Appley’s Posterior Grind test aspect of knee

• Tell Sally test: marked discomfort on medial

rotation

?? medial meniscus pathology

CLINICAL EVALUATION:

Referred Pain testingReferred Pain testing

• Slump test no

• Neural Thomas Stretch test pain

• Straight Leg Raise with added Dorsiflexion

Lumbar SpineLumbar Spine

• Palpation + assessment: no pathology

CLINICAL EVALUATION:

Biomechanical AssessmentBiomechanical Assessment

• failed to show any signs of biomechanical

problems predisposing to pain in L knee

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

• Baker’s Cyst

• Pes Anserinus Bursitis

• Torn Popliteus Muscle / Popliteus Tendinopathy

• Hamstring Insertional Tendinopathy

• Medial Meniscus Tear

• Posterior Cruciate Sprain

• Gastrocnemius Tendinopathy

• Synovial Plica

Soft tissue Ultra-sound

• large cystic mass - typical of Baker’s cyst

• centrally in popliteal fossa

• extending medially towards medial collateral

lig area

X-rays

• no abnormalities detected 

MRI

• oval shaped, multi-lobulated cyst

• medial in fossa

• small neck: between medial gastroc head

and semi-membranosis tendons

• pressure on Pes Anserinus bursa

• size:

axially 36x15mm

cross sectionally 35mm

• no free fluid accumulation in knee joint

• no bone marrow edema or contusion

• medial and lateral menisci: normal, no tears

• medial and lateral collateral ligaments: normal

• anterior and posterior cruciate ligaments:

normal

• quadriceps tendon, patellar tendon, other:

normal

3 STAGE SUMMARY

3 STAGE SUMMARY

Biological / Clinical

• Baker’s cyst due to unknown cause

 

Personal / Psychological

• away from work due to post-operative pain

• might be a career-ending injury

 

Social / Contextual

• letting his team down mid-season

ActiveActive

• Baker’s cyst with Pes Anserinus Bursa pressure

• surgical repair indicated

PassivePassive

• None at this stage

PLAN & PROGRESSION

PLAN

• patient discussed with orthopedic surgeon

• plan: formal excision of cyst

• surgery done in July 2012

• cyst found to be much larger than on MRI report

PROGRESSION

• discharged 1-day post-op with Robert Jones bandage

• referred to physiotherapist

• walking crutches for 5 days

• during this period physiotherapist:

isometric contraction exercises

proprioceptive work

• instructions:

not to fully extend knee – until ROS (day 8 post-op)

scar fully healed

replaces the multi-layered system used

with thetraditional 'Robert Jones Dressing'

PROGRESSION

Week 2 post-op:

• physiotherapist: with Range of Motion (ROM) exercises

• aim: to re-establish full knee extension

active assisted knee slides against wall

progressed to knee flexor stretching

using sport cord and knee flexor stretch against a wall

• after full ROM:

active cycling to maintain aerobic fitness

Isotonic Open-Chain-Kinetic Exercise - straight leg raises

PROGRESSION

Week 3 post-op:

• Closed-Kinetic-Chain Strengthening Exercises

• initial mini squats performed in 0-40 degree range

• progressing to standing wall slides

• followed by straight line lunges

• lunges done at different angles 

PROGRESSION

Week 4 post-op:

• start light leg presses in gym

• incorporation of plyometric exercises

Week 5 post-op:

• discharged to biokineticist

• aim:

maintain strength, proprioception and flexibility

testing to return to play

Baker’s CystBaker’s CystDiscussion

DEFINITION

• synovial fluid filled mass

• in popliteal fossa

• enlarged bursa located beneath medial head of gastroc +

semimembranosus muscles

• type of chronic knee joint effusion:

herniates between two heads of gastroc

Brukner & Khan, 2012

DEFINITION

• 1st Baker’s cyst: diagnosed in 1840 (dr Adams)

• Dr William Morrant Baker

1877,(37 y later – published paper)

8 pt’s: peri-articular cysts caused by synovial fluid

from knee joint new sac outside joint space

associated with underlying conditions

osteo-arthritis (OA) & Charcoat’s joints

Baker, 1994

INCIDENCE

INCIDENCE

• 2 peaks of age-incidence: 4-7y and 35-70y (Handy, 2001)

• general population:10-41% (Janzen et al, 1994)

• depends on diagnostic imaging:

5-40% (MRI) in pt with OA or ?internal derangement

23-32% with arthrography in similar population

(Fielding et al, ‘91; Sansone et al, ‘95; Miller et al, ‘96; Hayashi et al, ‘10)

•  common associated meniscal lesions (83%)

43% were associated with articular cartilage damage

32% associated with ACL tears (Sansone et al 1995)

factors in development + maintenance of pop cyst

communication between joint and cyst (valve-like effect)

influenced by gastrocnemius-semimembranosus muscle

changes during flexion-extension of kneeLindgren & Rauschning, 1980

intra-articular pressure changes direct flow of synovial fluid

from supra-patellar bursa knee popliteal cystLindgren & Rauschning, 1980

pressure -6mmHg

knee flexion

pressure

16mmHg

knee

extension

repeated micro-trauma of gastroc-semimem bursa:

enlargement

joint capsule herniation into popliteal fossa (Handy, 2001)

trauma causative in 1/3 of cases (Miller et al, 1996)

co-existent joint disease in 2/3 of cases (Miller et al, 1996)

osteo-arthritis

rheumatoid arthritis

meniscal tears

infectious arthritis

most cases:

small, asymptomatic, not found o/e

dx imaging studies for other indications

Sx from associated joint disorders / Kx

Sx & Tx of Cyst itself:

posterior knee pain

knee stiffness

swelling / mass palpable post – in extension

discomfort - prolonged standing / hyperflexion

symptoms worsened by physical activity

due to Kx of the Cyst:

enlargement into lower leg - DVT

nerve entrapment: tibial and peroneal nerve (Jong-Hun Ji and Shafi et al, 2007)

compartment syndrome, ant or post involvement (Klovning and Beadle, 2007)

occlusion of popliteal artery:ischemia of lower limb

(Wachter et al, 2005)

compression of popliteal vein:venous obstruction, pseudo-thrombophlebitis,

thrombophlebitis (Drescher & Smally, 1997)

due to Underlying joint disorders:

instability of knee joint

due to internal derangement:

meniscal tears

+/- ACL deficiencies

joint pain

inflammatory arthritis

osteo-arthritis

cartilage damage

 

Physical Examination:

palpable fullness

at medial aspect of popliteal fossa

at or near origin of medial head of gastroc muscle

if injured medial meniscus: McMurray test positive

Plain radiography

is not modality of choice

other intra-articular pathologies, i.e.

calcification / loose bodies in joint space(Brukner & Khan, 2012)

Ultrasonography

great value (size1-2 cm)

easy, quick, inexpensive, non-invasive

not Dx of other intra-articular pathology (B & K, 2012)

1st U/S-dx: 1972 (McDonald & Leopold, 1972)

Baker Cyst

Ultrasonography

sonographic diagnosis of Baker’s cyst

presence of cystic soft tissue mass post of knee

visualising of communicating anechoic or hypo-

echoic fluid between semimembranosus and

medial gastrocnemius muscles

(Ward and Jacobson, 2001)

distinguish Baker’s cyst from

ganglion cysts

popliteal aneurysm

other popliteal masses

Magnetic Resonance Imaging (MRI)

diagnosis Baker’s cyst

and intra-articular pathologies (Brukner & Khan, 2012)

indicated

if ?internal derangement

evaluate anatomical relationship to joint and

surrounding tissues

surgery is considered

uncertain ultrasound-diagnosis (Marra et al, 2008)

gold standard: MRI

Baker Cyst

Baker Cyst

Baker Cyst

intra-articular body in cyst

Baker Cyst

ruptured cyst

MANAGEMENT

diagnosed incidentally: no treatment

advice:

small risk of rupture

seek medical advice if symptomatic

diagnosed incidentally: no treatment

advice:

small risk of rupture

seek medical advice if symptomatic

MANAGEMENT

prevention not possible

advice on activities:

regular exercise and weight Mx for OA

no squatting, kneeling, heavy lifting, climbing

prevention not possible

advice on activities:

regular exercise and weight Mx for OA

no squatting, kneeling, heavy lifting, climbing

initial Rx:

arthrocentesis of knee

aspiration

intra-articular glucocorticoid injection of cyst

expect ↓ in size and discomfort of cyst (two-thirds of pt) within 2 to 7 days

• ↓ risk of recurrence

• improvement of symptoms

• controlling inflammation by glucocorticoid injections (Acebes et al, 2006)

initial Rx:

arthrocentesis of knee

aspiration

intra-articular glucocorticoid injection of cyst

expect ↓ in size and discomfort of cyst (two-thirds of pt) within 2 to 7 days

• ↓ risk of recurrence

• improvement of symptoms

• controlling inflammation by glucocorticoid injections (Acebes et al, 2006)

MANAGEMENT

review diagnosis

?persistent underlying knee pathology

repeat of glucocorticoid injection

arthroscopic knee surgery

non-communicating cysts:

non-responsive to intra-articular injections

direct aspiration and glucocorticoid injection

no joint pathology: surgical excision

review diagnosis

?persistent underlying knee pathology

repeat of glucocorticoid injection

arthroscopic knee surgery

non-communicating cysts:

non-responsive to intra-articular injections

direct aspiration and glucocorticoid injection

no joint pathology: surgical excision

MANAGEMENT

Ultrasound-guided

direct cyst corticoid injection indicated

intra-articular injection of gluco-corticoids

failed to relief symptoms

non-communicating Baker’s cysts

indicated (if injections):

++ painful

↓ joint mobility

lengthy procedure

open procedure to excise cyst (Fritschy et al, 2006)

arthroscopic procedures

repair of intra-articular pathology

removal of cyst

debridement of capsular openings (Ahn et al, 2010)

indicated (if injections):

++ painful

↓ joint mobility

lengthy procedure

open procedure to excise cyst (Fritschy et al, 2006)

arthroscopic procedures

repair of intra-articular pathology

removal of cyst

debridement of capsular openings (Ahn et al, 2010)

MANAGEMENT

Post-op Risks:

wound sepsis

synovial fistulae

recurrence: 2y post-op f/u on MRI-study (Calvisi et al, 2007)

disappeared: 64%

reduced: 27%

persisted: 9%

Post-op Risks:

wound sepsis

synovial fistulae

recurrence: 2y post-op f/u on MRI-study (Calvisi et al, 2007)

disappeared: 64%

reduced: 27%

persisted: 9%

MANAGEMENT

POST-OP REHABILITATION

aim: ↑ knee function

knee immobilizer

for comfort, with weight bearing

day 1 post-op:

isometric exercises + straight leg raises

knee range of motion exercises

wound stable

post-op inflammation subsided (Gonzalez & Lavernia, 2010)

wound healing complete before maximal extension

aim: ↑ knee function

knee immobilizer

for comfort, with weight bearing

day 1 post-op:

isometric exercises + straight leg raises

knee range of motion exercises

wound stable

post-op inflammation subsided (Gonzalez & Lavernia, 2010)

wound healing complete before maximal extension

POST-OP REHAB

Supportive Management:

P.R.I.C.E. regime

physical therapy: ↓ pain, preserve ROM

muscle strengthening: quads, patellar lig

PROGNOSIS

most asymptomatic – NO complications

some resolve spontaneously

most respond to Mx of associated disorders of knee

most asymptomatic – NO complications

some resolve spontaneously

most respond to Mx of associated disorders of knee

differential diagnosis !!differential diagnosis !!NOT only Baker’s cyst / DVT

• pleomorphic sarcoma

• malignant giant cell tumors

• myxoid liposarcomas (Arumilli et al, 2008)

early accurate / delayed dx

affect overall prognosis

unnecessary use of anti-

coagulation therapy (if mistaken

for DVT) could be dangerous!

1. Acebes JC, Sanchez-Pernaute O, Diaz-Oca A, et al.

Ultrasonographic assessment of Baker’s cysts after inatr-

articular corticosteroid injection in knee osteoarthritis. J

Clin Ultrasound. 2006;34:113

2. Ahn JH, Lee SH, Yoo JC, et al. Arthroscopic treatment of

popliteal cysts: clinical and magnetic resonance imaging

results. Arthroscopy. 2010;26:1340

3. Arumilli BRB, Babu VL, Paul AS. Painful swollen leg -

think beyond deep vein thrombosis or Baker’s cyst.

World Journal of Surgical Oncology. 2008;(6):6

4. Baker WM. On the formation of the synovial cysts in the

leg in connection with disease of the knee joint. 1877.

Clin Orthop Relat Res. Feb 1994;(299):2-10

5. Calvisi V, Lupparelli S, Giuliani P. Arthroscopic all-inside

suture of symptomatic Baker’s cysts: a technical option for

surgerical treatment in adults. Knee Surgery, Sports

Traumatology, Arthroscopy. 2007;15(12):1452-1460

6. Brukner P, Khan K. Clinical Sports Medicine.4th Ed. 2012. p

731-732

7. Drescher MJ, Smally AJ. Thrombophlebitis and

pseudothrombo-phlebitis in the emergency department. Am J

Emerg Med. 1997;15:683-685

8. Fielding JR, Franklin PD, Kustan J. Popliteal cysts: a

reassessment using magnetic resonance imaging. Skeletal

Radiol. 1991;20:433

15.Miller TT, Staron RB, Koenigsberg T, et al. MR imaging of Baker

cysts: association with internal derangement, effusion, and

degenerative arthropathy. Radiology. 1996;201:247

16.Hayashi D, Roemer FW, Dhina Z, et al. Longitudinal assessment

of cyst-like lesions of the knee and their relation to radiographic

osteoarthritis and MRI-detected effusion and synovitis in patients

with knee pain. Arthritis Res Ther. 2010;12:R172

17.Klovning J, Beadle T. Compartment Syndrome secondary to

spontaneous rupture of a Baker’s cyst. J La State Med Soc.

2007;159(1):43-44

18.Lindgren PG, Rauschning W. Radiographic investigation of

popliteal cysts. Acta Radiol Diagn (Stockh). 1980;21:657

19.Marra MD, Crema MD, Chung M, et al. MRI features of cystic

lesions around the knee. Knee. 2008;15:423

20.McDonald DG, Leopold GR. Ultrasound B-scanning in the

differentiation of Baker’s cyst and thrombophlebitis. Br J Radiol.

1972;45:729

21.Sansone V, De Ponti A, Palluello GM, et al. Popliteal cysts and

associated disorders of the knee. Critical review with Magnetic

Resonance Imaging. Int Orthop. 1995;19(5):275-9

22.Ward EE, Jacobson JA. Sonographic detection of Baker’s cysts:

Comparison with MR imaging. Am J Roëntgenol.

2001;176(2);373-80