Professional Documents
Culture Documents
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
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
CLINICAL EVALUATION:
Referred Pain testing
Slump test
no
pain
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
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
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
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
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)
(Sansone et al 1995)
pressure
-6mmHg
pressure
16mmHg
knee
flexion
supra-patellar
bursa
knee
knee
popliteal
cyst
extension
Lindgren & Rauschning, 1980
(Handy, 2001)
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
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)
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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
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)