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Dr Isstelle Joubert

2nd 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:

PAI
N
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

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:
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 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 movements
extension, flexion, tibial rotation: minimal
discomfort
hamstring stretch testing: marked discomfort
quad stretch testing: normal
Obers test: normal
Resisted movements
tibial rotation, knee flexion: marked discomfort

CLINICAL EVALUATION:
Functional testing
squatting and forward lunge: cause discomfort
jumping, hopping, stepping up and down step:
normal

CLINICAL EVALUATION:
Palpation
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:
Palpation
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 maneuvers
Stability testing for MCL and LCL: normal
Lachmans 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
McMurrays test
Appleys Posterior Grind test

?? medial
discomfort
medial
meniscus
aspect of knee
pathology

Tell Sally test: marked discomfort on medial


rotation

CLINICAL EVALUATION:
Referred Pain testing
Slump test

no

Neural Thomas Stretch test

pain

Straight Leg Raise with added Dorsiflexion


Lumbar Spine
Palpation + assessment: no pathology

CLINICAL EVALUATION:

Biomechanical Assessment
failed to show any signs of biomechanical
problems predisposing to pain in L knee

DIFFERENTIAL DIAGNOSIS

Bakers 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 Bakers 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
Bakers 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

Active
Bakers cyst with Pes Anserinus Bursa pressure
surgical repair indicated
Passive
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
scar fully healed

replaces the multiused


ROSlayered
(day 8system
post-op)
with the
traditional '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

Bakers Cyst
Discussion

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 Bakers cyst: diagnosed in 1840 (dr Adams)
Dr William Morrant Baker
1877,(37 y later published paper)
8 pts: peri-articular cysts caused by synovial fluid
from knee joint new sac outside joint space
associated with underlying conditions
osteo-arthritis (OA) & Charcoats 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 knee
Lindgren & Rauschning, 1980

pressure
-6mmHg

pressure
16mmHg

intra-articular pressure changes direct flow of synovial fluid


from

knee
flexion
supra-patellar

bursa

knee

knee

popliteal
cyst
extension
Lindgren & Rauschning, 1980

repeated micro-trauma of gastroc-semimem bursa:


enlargement
joint capsule herniation into popliteal fossa
trauma causative in 1/3 of cases

(Handy, 2001)

(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)

compression of popliteal vein:


venous obstruction, pseudo-thrombophlebitis,
thrombophlebitis
(Drescher & Smally, 1997)

occlusion of popliteal artery:


ischemia of lower limb
(Wachter et al, 2005)

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 Bakers cyst
presence of cystic soft tissue mass post of knee
visualising of communicating anechoic or hypoechoic fluid between semimembranosus and
medial gastrocnemius muscles
(Ward and Jacobson, 2001)

distinguish Bakers cyst from


ganglion cysts
popliteal aneurysm
other popliteal masses

gold standard: MRI

Magnetic Resonance Imaging (MRI)


Baker Cyst
diagnosis Bakers
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)

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ruptured cy

MANAGEMENT

MANAGEMENT
diagnosed incidentally: no treatment
advice:
small risk of rupture
seek medical advice if symptomatic
prevention not possible
advice on activities:
regular exercise and weight Mx for OA
no squatting, kneeling, heavy lifting, climbing

MANAGEMENT
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
Ultrasound-guided
repeat of glucocorticoid injection

direct cyst corticoid injection

arthroscopic knee surgery


indicated
non-communicating cysts:
intra-articular injection of gluco-corticoids
non-responsive to intra-articular injections
failed to relief symptoms
direct aspiration and glucocorticoid injection
non-communicating Bakers cysts
no joint pathology: surgical excision

MANAGEMENT
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 REHABILITATION

POST-OP REHAB
aim: knee function
knee immobilizer
for comfort, with weight bearing
Supportive Management:
day 1 post-op:
P.R.I.C.E. regime
isometric exercises + straight leg raises
physical therapy: pain, preserve ROM
knee range of motion exercises
muscle strengthening: quads, patellar lig
wound stable
post-op inflammation subsided (Gonzalez & Lavernia, 2010)
wound healing complete before maximal extension

PROGNOSIS
most asymptomatic NO complications
some resolve spontaneously
most respond to Mx of associated disorders of knee

differential diagnosis !!
NOT only Bakers cyst / DVT
pleomorphic sarcoma
malignant giant cell tumors
myxoid liposarcomas
(Arumilli et al, 2008)

early accurate / delayed dx


affect overall prognosis
unnecessary use of anticoagulation therapy (if mistaken
for DVT) could be dangerous!

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


Ultrasonographic assessment of Bakers cysts after inatrarticular 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 Bakers 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 Bakers 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 Bakers 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 Bakers 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
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