Baker’s cysts

Baker’s cysts

 

Steve Ramsey,PhD -Public Health MSc(hon) in Med Ultrasound

Steve Ramsey,PhD -Public Health MSc(hon) in Med Ultrasound

Baker’s cysts are not technically true cysts; they represent distention of the gastroc.-semimembr Bursa through accumulation of fluid, which communicates with the knee joint. Baker’s cysts are usually most prevalent in patients with preexisting intra-articular knee joint pathology such as arthritis (degenerative or inflammatory) or internal derangement (meniscal or anterior cruciate ligament tears, loose bodies, etc). Although Baker’s cysts are most frequently asymptomatic, they may cause posterior knee pain, joint stiffness, and reduced range of motion.

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A popliteal cyst, better known as Baker’s cyst, is a fluid-filled swelling that is developed at the back of the knee in the popliteal fossa region. Ganglia which are benign cystic tumors, originate from synovial tissue. Common areas for cyst can occur at the wrist, hand, foot, and knee. Baker’s cysts may rupture and cause acute leg pain and swelling, mimicking deep venous thrombosis.

The cyst can exercise pressure on some anatomical structures, in most cases; the affected anatomical structure is the popliteal vein. Which can develop into thrombophlebitis?

A Baker’s cyst is an enlarged bursa that is normally located between the medial head of the gastrocnemeius and a capsular reflection of the semimembranosus, named oblique popliteal ligament. The two requirements for a cyst formation are the anatomical communication and a chronic effusion. Knee joint effusions may replete the gastrocnemeius-semimembranosus bursa with synovial fluid and if the fluid outflow is hindered by a unidirectional mechanism, the gastrocnemeius-semimembranosus bursa enlarges giving rise to a pseudocystic cavity, referred to as a Baker’s cyst.

A Baker’s cyst, or a popliteal cyst, occurs if there is an underlying intraarticular problem with the knee or and inflammatory reactions, commonly as a result of losing bodies formed in conditions such as osteoarthritis, gout, rheumatoid arthritis, ACL tears, meniscal tears or because of particles following knee arthroplasty, mostly from the polyethylene liner.

Primary Cyst: An expansion arising independently from the joint and there is no knee derangement.

Secondary Cyst: A distension of the bursa located between the gastrocnemeius and semimembranosus tendons: fluid finds its way through the channel the normal bursa communicates with the joint. This is the most common occurrence

The cyst can vary in size; from a very small (asymptomatic) to a large one but a change in size is very common. Especially in smaller cysts a septum may exist separating the semimembranosus and gastrocnemeius components. This may function as a flap valve allowing fluid to enter a popliteal cyst and not to exit it.

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There are differences between a popliteal cyst in children and in adults. In children, there are cystic masses filled with gelatinous material that develop in the popliteal fossa, are usually asymptomatic, and are not related to intra-articular pathology. Spontaneous resolution usually occurs, although the process can take several years. In adults, a Baker’s cyst is often found in combination with other intra-articular pathologies and inflammatory conditions. 

Symptoms can include

vague posterior pain

swelling and a mass in the popliteal space

limited range of motion

stiffness in the back of the knee sometimes increased by activity

Tightness behind the knee.

Most cysts are found on the medial side of the popliteal space in the gastrocnemeius-semimembranosus bursa, but they could be found in the popliteal bursa so the mass will be found on the lateral side of the popliteal space. Also, there are some rare cases in which popliteal cyst extend superiorly or anteriorly

Cysts may range in size from small, from clinically, asymptomatic and not palpable, to large masses causing visible swelling of the patient’s knee. The size of the cyst or pain can cause limitations in range of motion. If the cyst is large, it may result in mechanical problems in knee flexion and limiting mobility. In rare cases there will be signs and symptoms of a meniscal tear which can be tested by McMurray test.

Popliteal cysts can give pressure against other anatomic structures. Compression of the popliteal artery or vein can cause ischemia or thrombosis, respectively, whereas compression of the tibial or peroneal nerve can cause peripheral neuropathy.

A ruptured cyst can manifest as calf pain or even swelling, it can also cause an itching feeling in the calf. There are more common in patients with an inflammatory pathology than in patients with a degenerative pathology.

Baker’s cyst can be mistaken for several other injuries in the knee. The patient’s history, as well as the clinical investigation and imaging allow for .

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If the popliteal cyst becomes infected, this can often result in a painful mass behind the knee. In such cases, it could be difficult to make a diagnosis and the infected cyst can be mistaken for a neoplasm. The cyst can rupture (split open) resulting in severe calf pain, decreased motion at the ankle and cause similar symptoms as a deep vein thrombosis (evident on ultrasound or venograpm).

It is important to diagnose a ruptured Baker’s cyst early in order to determine the best treatment and avoid complications, such as compartment syndrome and to differentiate from:

thrombophlebitis

a popliteal aneurysm

inflammatory arthritis

medial gastrocnemeius strain

soft-tissue tumor or muscle tear

It must be considered, that Popliteal cyst can rarely present as a swelling on the anterior surface of the proximal tibia as part of the differential diagnoses when faced with a patient with a previous history of an ipsilateral total knee arthroplasty

The imaging workup of knees with suspected popliteal cysts can include plain radiographs, arthrography, ultrasound, and MRI. Early in the evaluation it can be useful to obtain plain radiographs (as poster anterior Rosenberg, lateral, and patellofemoral axial views) for detecting other conditions found in association with popliteal cysts, such as osteoarthritis, inflammatory arthritis, and loose bodies. In addition, loose bodies may be seen in a Baker’s cyst on plain radiographs.

At first, direct arthrography was used for detecting popliteal cysts. Direct arthrography involved intra-articular injection of the knee with gas or an iodinated contrast medium, followed by mobilization of the joint to force the contrast into the cyst. Afterwards, spot radiographs or fluoroscopy were used to detect the presence of the contrast in the cysts. The disadvantages of this technique include the use of ionizing radiation and the use of invasive techniques to inject the contrast.

The advantages of ultrasound provide a replacement of arthrography by ultrasound. The advantages are its low cost, noninvasive usage and the absence of radiation. The main disadvantage is the fact that it is user dependent. Ultrasound is able to detect Baker’s cysts near 100% but lacks to differentiate from other conditions, such as meniscal cysts or myxoid tumors, it also doesn’t visualize other conditions in the knee that are often associated with these cysts.

The gold standard for diagnosis of Baker’s cysts and differentiating them from other conditions remains magnetic resonance imaging. It allows assessing soft tissue abnormalities and has the added advantage of being accurate at diagnosing associated joint disorders so the entire spectrum of related disorders is possible to assess

Conditions such as meniscal cysts are more easily differentiated from Baker’s cysts with MRI than ultrasound. This may be the gold standard but is also a high-cost technique, therefore, ultrasound should be considered as a screening modality if the evaluation of the intra-articular structures is not necessary.

Baker’s cyst on axial MRI with communicating channel between the semimembranosus muscle and the medial head of the gastrocnemeius muscle

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The cyst can be removed with surgery if it becomes very large or causes symptoms such as discomfort, stiffness or painful swelling. There are three surgical techniques available to treat the cyst: common posterior approach, the poster medial approach, and the medial intra-articular approach. The first two techniques are techniques where the cyst is going to be removed. In the last technique, they make an opening in the cyst and close it afterward. The popliteal cyst will eventually disappear.

An ice massage of 15 minutes every 4-7 hours will reduce the inflammation. The treatment is based on the principles of R.I.C.E (rest, ice, compression, and elevation) followed by some muscle-conditioning exercises.

A rehabilitation program can improve the control of the knee joint by range of motion exercises. It will increase the motion of the joint as well as increase flexibility. The physiotherapist will give mobility, a hamstring stretching program and a concurrent quadriceps strengthening program that has to repeat several times a day. This will result in less pain at about 6-8 weeks.

Steve Ramsey. Okotoks- Alberta.

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