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Popliteal Cyst

Cysts Popliteal

A popliteal cyst is a sac filled with synovial fluid that develops in the posterior knee. In adults, this is likely associated with knee trauma or underlying disease. 


Presentation

The clinical presentation is typically mild. For example, aches and tenderness may occur with physical activity and certain positions such as knee extension. Also, the knee may feel unsteady, stiff, and limited in motion. Since these cysts develop in the context of arthritis, trauma, or mechanical injury, symptoms of these conditions may manifest. 

The fluid filled bursa is observed as a bulge on the posterior side of the knee. When the knee swells secondary to other processes, the fluid enlarges the cyst. Some cysts alternate between shrinking and growing while other spontaneously disappear. Additionally, some patients will experience recurrence.

If these sacs rupture subcutaneously, this results in pain and swelling of the calf. In this case, the clinical picture resembles that of thrombophlebitis in the lower leg. This warrants an immediate investigation to rule out a blood clot.

It is important to note that there are two types of popliteal cysts:

Primary: the cyst does not communicate with bursa or knee joint. This is more prevalent in children. There is no meniscal involvement (derangement) [8].

Secondary: the cyst communicates with the bursa and the joint. This affects adults and is much more common than the primary type [8].

Popliteal Swelling
  • Conventional radiography in the anteroposterior, lateral , and oblique projections is done to check fluid density and to rule any other lesion that might give rise to popliteal swelling.[boneandspine.com]
  • Conventional radiography in the anteroposterior, lateral, and oblique projections is done to check fluid density and to rule any other lesion that might give rise to popliteal swelling.[boneandspine.com]
  • These cysts are also referred to as Baker’s cysts, a name given to the condition after Baker’s 2 classic case description of popliteal swelling.[doi.org]
Soft Tissue Swelling
  • By Baker cyst or popliteal cyst is a soft-tissue swelling in the posterior aspect of the knee which contains gelatinous fluid. It is called Baker Cyst after Dr. William Morrant Baker who first described it.[boneandspine.com]
Constitutional Symptom
  • Abstract The gonococcal arthritis-dermatitis syndrome includes tenosynovitis, arthralgias, arthritis, skin lesions, and constitutional symptoms.[ncbi.nlm.nih.gov]
Homans' Sign
  • Abstract Rupture of a popliteal cyst and dissection of its contents into the calf may produce pain, swelling, a positive Homan's sign and other findings closely resembling thrombophlebitis of the calf.[ncbi.nlm.nih.gov]
  • Abstract Patients who present with swelling, tenderness, and inflammation in the calf of the leg, associated with a positive Homan's sign, are usually considered to have a deep vein thrombophlebitis.[annals.org]
Skin Lesion
  • Abstract The gonococcal arthritis-dermatitis syndrome includes tenosynovitis, arthralgias, arthritis, skin lesions, and constitutional symptoms.[ncbi.nlm.nih.gov]
  • In the 17th chapter of this treatise, devoted to skin lesions, the author states that steatomas appear in the popliteal fossa. However, it is no more believed to reflect the Galenic teaching and is ascribed to Pseudo-Galen.[ncbi.nlm.nih.gov]
Cutaneous Manifestation
  • Cutaneous manifestation of ruptured popliteal cyst. Clin Rheumatol . 1991; 10:340–341. doi:10.1007/BF02208705 [CrossRef] Schimizzi AL, Jamali AA, Herbst KD, Pe-dowitz RA.[doi.org]
Calf Pain
  • We present a case of a large dissecting popliteal cyst 7 years after TKA with symptoms of severe calf pain and functional disability.[ncbi.nlm.nih.gov]
  • In addition to these conditions, a dissecting or ruptured popliteal cyst should be considered in the differential diagnosis of acute calf pain and swelling following total knee arthroplasty.[ncbi.nlm.nih.gov]
  • Symptoms of a Baker's cyst include joint locking, knee, and calf pain. Baker's cyst often resolves without medication. What is a Baker's cyst Most people with Baker's cysts have an underlying illness.[medicalnewstoday.com]
  • Patients have described having a mass in the popliteal fossa that disappears as the calf pain and swelling appear. 13,25 Calf pain and swelling are also present in DVT or superficial thrombophlebitis, and the clinical imperative is to rule out DVT with[doi.org]
Knee Effusion
  • The primary physicians failed to appreciate evidence of knee disease in these patients, although the rheumatology consultant found knee effusion, and a popliteal cyst was found by arthrography or ultrasonography in every case.[ncbi.nlm.nih.gov]
  • - adults: - in adults, intra-articular pathology is common, & cyst may recur if intra-articular pathology is not corrected; - cysts are connected to the knee joint through valvular opening; - presence of knee effusion (excessive fluid pressure), allows[wheelessonline.com]
  • For patients with knee effusion, aspiration may be indicated. Physical therapy and NSAIDs may be beneficial to these individuals.[symptoma.com]
  • Examination of the joints revealed diffuse synovitis with bilateral knee effusions and a visibly enlarged left calf with a palpable mass extending inferiorly from the popliteal fossa (Panels A and B).[nejm.org]
  • Other presentations include aching, knee effusion, clicking of the knee, buckling of the knee and locking. Occasionally the cyst can rupture, resulting in pain and swelling of the calf. Exclude a DVT in patients with Baker's cyst and leg swelling .[patient.info]
Joint Swelling
  • Baker's cysts are common and can be caused by virtually any cause of joint swelling ( arthritis ).[medicinenet.com]
  • Baker’s cyst can be prevented altogether by trying to limit joint swelling if any such risk arises. Apply ice packs and compression to the site to limit swelling. Resting and elevating the affected leg above heart level is also recommended.[docpods.com]
  • Baker cysts are not uncommon and can be caused by virtually any cause of joint swelling ( arthritis ). The excess joint fluid (synovial fluid) bulges to the back of the knee to form the Baker cyst.[ipcphysicaltherapy.com]
  • Once repaired, the knee joint becomes more stable, which means no more joint swelling. This, in turn, means no more accumulated fluid and an end to the baker’s cyst! Baker’s Cyst is often caused by other problems with the knee.[caringmedical.com]

Workup

A clinician should obtain a thorough history including identification of coexisting knee pathology, physical exam, and imaging to arrive at the correct diagnosis. It is crucial to rule out destructive processes as knee diseases can be devastating.

Imaging

Radiography can identify any calcifications, soft tissue masses, or rare bone involvement from cysts [9].

Ultrasonography is useful to detect a popliteal mass. Further, it elucidates the characteristics of the mass which may be a simple or complex cyst or a solid structure. Doppler imaging with color is useful to detect blood flow in the mass. Specifically, this is helpful for ruling out an aneurysm or degeneration of the popliteal artery [10]. Another crucial benefit of ultrasound examination is to evaluate for thromboembolism. A shortcoming of ultrasonography is its ineffectiveness in demonstrating a connection between the cyst and the joint properly. Thus, it is not helpful in distinguishing popliteal cysts from other pathologies.

If using arthrography, iodide contrast is injected directly into the joint to display a connection [11].

CT demonstrates a mass in the posteromedial popliteal space. Further it shows other findings such as wall thickening, bone erosion, bone fragments within the cyst, etc.

MRI provides valuabe details regarding the characteristics and composition of popliteal cysts. It offers multiple plane views and excellent contrast of the soft tissue. Furthermore, this modality can be performed for any knee complaints or presentations.

Soft Tissue Calcification
  • tissue calcification in the mass, which may indicated synovial cell sarcoma or hemangioma ; - in children, surgical excision of popliteal cysts is rarely indicated. - most authors report spontaneous resolution of cysts in 10-20 months; - therefore, a[wheelessonline.com]

Treatment

The therapeutic approach is tailored to the severity of symptoms and whether the patient has failed another mode of treatment. Of importance, patients with underlying disease should also have that addressed as well.

In asymptomatic patients, treatment is not indicated. However, imaging may be warranted to diagnose any existing pathologies.

Symptomatic: first time treatment
Mild complaints and benign presentations are usually managed conservatively through non-steroidal anti-inflammatory drugs (NSAIDs) and/or physical therapy.

For patients with knee effusion, aspiration may be indicated. Physical therapy and NSAIDs may be beneficial to these individuals.

Symptomatic: failed initial treatment
Studies have reported that corticosteroid intra-articular injection is effective in popliteal cyst therapy [4]. This treatment could be employed in cases refractory to conservative measures.

Surgical intervention is uncommon. It is reserved for individuals with complicated and severe symptoms that are unresponsive to conservative treatment or knee aspiration although surgical excision is associated with increased recurrence rates.

Procedures such as arthroscopic synovectomy, capsulectomy, and capsuloplasty with grafting have demonstrated successful results. Also, good results have been observed with arthroscopic cyst resection [12]. Another procedure utilized intra-articular injection of ethanol and sodium morrhuate. This was associated with improvement and low recurrence rates [7] [13].

The above procedures are not routinely performed but could be promising for complicated or recurrent cysts.

Prognosis

Some patients experience intermittent symptoms and discomfort, but a popliteal cyst is not commonly associated with long-standing disability

Popliteal cysts may resolve spontaneously or improve with surgical intervention [7]. Recurrence has been associated with cyst excision but there are emerging procedures that may reduce further episodes. 

Etiology

Synovial fluid is found in the cavities of the joint. When the knee joint synthesizes excess fluid, pressure increases. This results in subsequent accumulation of fluid in the posterior knee. Hence, a bulge is formed in the popliteal fossa.

The most common etiologies are osteoarthritis, Rheumatoid arthritis [1] meniscal tears, and inflammatory knee diseases.

It is important to note that the knee is a complex joint and is prone to injuries and damage. The American Academy of Orthopedic Surgeons reports that approximately 19 million people presented with knee complaints in 2003. Additionally, most referrals to orthopedic specialists are due to knee signs and symptoms.

Epidemiology

Epidemiological data regarding popliteal cysts are based on the populations investigated and the modes of imaging utilized for diagnosis. One study observes that 19% of patients who underwent MRI for knee evaluation were diagnosed with popliteal cysts [2]. Another study evaluating patients for DVT with doppler ultrasound found popliteal cysts in 3% to 4% of these patients [3].

Gender: Both genders are affected.

Age: Popliteal cysts are observed more as age increases. For example, it is reported that in the 31 to 50 years old group, 26% develop popliteal cysts whereas this number is doubled in the age range of 51 to 90 years of age [4]. Furthermore, the same study recognizes that the highest incidence occurs in two main age groups which are: [4]

  • 4 to 7 years: Cysts in this age range are most likely secondary to normal bursa processes. Trauma and joint disease rarely cause cyst development in this group.
  • 35 to 70 years: In this group, trauma or underlying joint diseases such as arthritis and other etiologies account for these cysts. 
Sex distribution
Age distribution

Pathophysiology

Understanding the physiology of synovial fluid helps clarify the mechanism of popliteal cyst development. The articular joint is lined by the synovium, which consists of a complex fibrillar interstitial matrix. As part of an ongoing process, blood vessels in the synovium produce fluid secondary to an osmotic gradient between vasculature of the synovial capsule and the intra-articular space [5]. Furthermore, when filtration of the fluid exceeds absorption, this results in effusions. Conditions that cause this excessive fluid volume include knee injuries, infection, and arthritis [5]. 

Lack of adequate anatomic support can also contribute to the development of these cysts [6]. Moreover, the site located between the posterior cruciate ligament and the expansion of the semimembranous muscle is only supported by a segment of the medial meniscus; hence, it is a weak area. Thus any insult to the medial meniscus coupled with pressure elevation cause the articular capsule to extend outwards. Consequently, a popliteal cyst forms [6].

Prevention

Preventing knee injuries reduces the risk of developing a popliteal cyst. Recommendations include wearing proper footwear. Also, it is advisable to exercise with appropriate warm-up and cool down periods. Applying caution with physical activity is pertinent as well. Finally, in the event of a knee injury, the individual should seek care for evaluation and possible treatment.

Since popliteal cysts occur with coexisting diseases, patients should be screened for these. Treating the underlying cause is warranted for prevention of this and also to avoid any complications and further damage to the knee joint. For example, causes such as arthritis and infection must be treated.

Summary

A popliteal cyst (Baker cyst) is a large fluid-filled sac located in the popliteal fossa. While the cyst does not usually produce symptoms, some patients may experience stiffness, discomfort, unsteadiness, and/or limited range of motion of the affected knee. Popliteal cysts are observed in children and adults, although the etiologies vary between the two groups. 

The pathophysiology is attributed to processes involving the synovial fluid. Specifically, the bursa fills with fluid due to an increased gradient across the synovial cavity and the joint. Hence, this leads to sac enlargement and the subsequent development of the popliteal cyst. Once it forms, it either spontaneously regresses, or alternates between growing and shrinking. 

Diagnosis is established through a history, physical exam, and imaging such as ultrasonography (US), computed tomography (CT) and/or magnetic resonace imaging (MRI). Excluding deep venous thrombosis (DVT) or other pathology during the workup is paramount.

Most patients are treated conservatively. However, patient's refractory to treatment may need corticosteroid therapy or surgical intervention, though the latter is not routinely done. It is also pertinent to treat underlying diseases that may have contributed to the cyst development. 

Patient Information

A popliteal cyst, also called Baker's cyst, is a lump filled with fluid. This develops in the back of the knee. Most patients do not have symptoms. When this happens in adults, it is likely due to trauma, disease or infectionRheumatoid arthritis, osteoarthritis, gout, and inflammation are common causes. These conditions change the structure of the knee. Furthermore, extra fluid builds, causing a lump to form. This lump can grow or shrink, or it can disappear altogether. Patients usually feel a ball in the back of the knee.

Many patients will have no symptoms. Some will have mild pain and discomfort. Furthermore, patients feel like their knee is giving out due to its unsteadiness. Some will also feel stiffness

The cyst may resemble a blood clot which should be ruled out by your doctor.

Diagnosis is made through imaging. Your doctor will order one or more of these: x ray, ultrasound,  CT scan, and MRI.

For patients without symptoms, treatment is not necessary. In patients with mild cases, therapy consists of non-steroidal anti-inflammatory drugs (NSAIDs), other analgesics, and/or physical therapy. It is also recommended for the patient to elevate the knee, avoid strenuous activity, and apply ice. 

Patients who fail treatment could benefit from steroid injection directly into the affected knee. Surgery may be effective, but recurrence may occur. The need for surgery is decided on a case by case basis. 

Recommendations for prevention include wearing proper shoes, being cautious with physical activity, and exercising with warm ups and cool downs. If the patient experiences knee pain or injury, s/he should seek care for evaluation and possible treatment.

References

Article

  1. Andonopoulos AP, Yarmenitis S, Sfountouris H, et al. Baker's cyst in rheumatoid arthritis: an ultrasonographic study with a high resolution technique. Clinical and Experimental Rheumatology. 1995;13(5):633-636.
  2. Miller TT, Staron RB, Koenigsberg T, et al. MR imaging of Baker cysts: association with internal derangement, effusion, and degenerative arthropathy. Radiology. 1996;201(1):247-250.
  3. Volteas SK, Labropoulos N, Leon M, et al. Incidence of ruptured Baker's cyst among patients with symptoms of deep vein thrombosis. British Journal of Surgery. 1997;84(3):342.
  4. Handy JR. Popliteal cysts in adults: a review. Seminars in Arthritis and Rheumatism. 2001; 31(2):108-118.
  5. Simkin PA. Physiology of normal and abnormal synovium. Seminars in Arthritis Rheumatology. 1991; 21(3):179-183.
  6. Labropoulos N, Shifrin DA, Paxinos O. New insights into the development of popliteal cysts. British Journal of Surgery. 2004;91(10):1313-1318.
  7. Dinham JM. Popliteal cysts in children. The case against surgery. Journal of Bone and Joint Surgery. British Volume. 1975; 57(1):69-71.
  8. Fritschy D, Fasel J, Imbert JC, et al. The popliteal cyst. Knee Surgery, Sports Traumatology, Arthroscopy. 2006;14(7):623-8.
  9. Chatzopoulos D, Moralidis E, Markou P, Makris V, Arsos G. Baker's cysts in knees with chronic osteoarthritic pain: a clinical, ultrasonographic, radiographic and scintigraphic evaluation. Rheumatology International. 2008; 29(2):141-6.
  10. Taurino M, Rizzo L, Stella N, Mastroddi M, Conteduca F, Maggiore C, et al. Doppler ultrasonography and exercise testing in diagnosing a popliteal artery adventitial cyst. Cardiovascular Ultrasound. 2009; 7(1):23.
  11. Johnson LL, van Dyk GE, Johnson CA, et al. The popliteal bursa (Baker's cyst): an arthroscopic perspective and the epidemiology. Arthroscopy. 1997; 13(1):66-72.
  12. Ahn JH, Lee SH, Yoo JC, et al. Arthroscopic treatment of popliteal cysts: clinical and magnetic resonance imaging results. Arthroscopy. 2010; 26(10):1340-1347.
  13. Centeno CJ, Schultz J, Freeman M. Sclerotherapy of Baker's cyst with imaging confirmation of resolution. Pain Physician. 2008;11(2):257-261.

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Last updated: 2018-06-22 10:08