Transcript baker`s cyst

BAKER’S CYST
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:
• 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
• Ober’s 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
• 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
• Appley’s 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
• Baker’s Cyst
• Pes Anserinus Bursitis
• Torn Popliteus Muscle / Popliteus Tendinopathy
• Hamstring Insertional Tendinopathy
• Medial Meniscus Tear
• Posterior Cruciate Sprain
• Gastrocnemius Tendinopathy
• Synovial Plica
SPECIAL
INVESTIGATIONS
SPECIAL INVESTIGATIONS
 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
SPECIAL INVESTIGATIONS
 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
SPECIAL INVESTIGATIONS
• 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
PROBLEM LIST
PROBLEM LIST
 Active
• Baker’s 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:
replaces the multilayered system used
 not to fully extend knee – until ROS (day with
8 post-op)
the
traditional 'Robert
 scar fully healed
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 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 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 knee
pressur
Lindgren
& Rauschning, 1980
pressure
-6mmHg
e
16mmHg
 intra-articular
pressure changes direct flow of synovial fluid
knee
flexion
from 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 Baker’s 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 Baker’s cyst from
 ganglion cysts
 popliteal aneurysm
 other popliteal masses
gold standard: MRI
 Magnetic Resonance Imaging (MRI)
Baker Cyst
 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)
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
Ultrasound-guided
 ?persistent underlying
knee pathology
 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 Baker’s 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
TAKE
HOMEdiagnosis
MESSAGE
differential
!!
 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 anticoagulation therapy (if mistaken
for DVT) could be dangerous!
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