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Dr Isstelle Joubert 2 nd yr M Sports and Exercise Medicine September 2012.

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Presentation on theme: "Dr Isstelle Joubert 2 nd yr M Sports and Exercise Medicine September 2012."— Presentation transcript:

1 Dr Isstelle Joubert 2 nd yr M Sports and Exercise Medicine September 2012

2 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

3 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 PAIN

4 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

5 PREVIOUS HISTORY:  partial tear in ACL of L knee – 2 seasons before Rx: conservative, limited ROM brace no meniscal injuries  No other medical history

6 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

7 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

8 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

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

10 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

11 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

12 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

13 CLINICAL EVALUATION: Reverse Lachman: negative - normal PCL Patellar Apprehension testing: negative Medial and Lateral Translations: not reproduce pain McMurray’s test discomfort medial Appley’s Posterior Grind test aspect of knee Tell Sally test: marked discomfort on medial rotation ?? medial meniscus pathology

14 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

15 CLINICAL EVALUATION:  Biomechanical Assessment failed to show any signs of biomechanical problems predisposing to pain in L knee

16 DIFFERENTIAL DIAGNOSIS

17 Baker’s Cyst Pes Anserinus Bursitis Torn Popliteus Muscle / Popliteus Tendinopathy Hamstring Insertional Tendinopathy Medial Meniscus Tear Posterior Cruciate Sprain Gastrocnemius Tendinopathy Synovial Plica Baker’s Cyst Pes Anserinus Bursitis Torn Popliteus Muscle / Popliteus Tendinopathy Hamstring Insertional Tendinopathy Medial Meniscus Tear Posterior Cruciate Sprain Gastrocnemius Tendinopathy Synovial Plica

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19  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

20  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

21 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

22 3 STAGE SUMMARY

23  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

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25  Active Baker’s cyst with Pes Anserinus Bursa pressure surgical repair indicated  Passive None at this stage

26 PLAN & PROGRESSION

27 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

28 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 ROS (day 8 post-op) scar fully healed replaces the multi- layered system used with the traditional 'Robert Jones Dressing'

29 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

30 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

31 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

32 Baker’s Cyst Discussion

33 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

34 DEFINITION 1 st 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

35 INCIDENCE

36 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)

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38  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  intra-articular pressure changes direct flow of synovial fluid from supra-patellar bursa knee popliteal cyst Lindgren & Rauschning, 1980 pressure -6 mmHg knee flexion pressur e 16 mmHg knee extension

39  repeated micro-trauma of gastroc-semimem bursa: enlargement  joint capsule herniation into popliteal fossa (Handy, 2001)  trauma causative in 1/3 of cases (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

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41  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

42 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) occlusion of popliteal artery: ischemia of lower limb (Wachter et al, 2005) compression of popliteal vein: venous obstruction, pseudo-thrombophlebitis, thrombophlebitis (Drescher & Smally, 1997)

43 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

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45  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

46  Plain radiography  is not modality of choice  other intra-articular pathologies, i.e. calcification / loose bodies in joint space (Brukner & Khan, 2012)

47  Ultrasonography  great value (size1-2 cm)  easy, quick, inexpensive, non-invasive  not Dx of other intra-articular pathology (B & K, 2012)  1 st U/S-dx: 1972 (McDonald & Leopold, 1972) Baker Cyst

48  Ultrasonography  sonographic diagnosis of Baker’s cyst presence of cystic soft tissue mass post of knee visualising of communicating anechoic or hypo- echoic fluid between semimembranosus and medial gastrocnemius muscles (Ward and Jacobson, 2001)  distinguish Baker’s cyst from ganglion cysts popliteal aneurysm other popliteal masses

49  Magnetic Resonance Imaging (MRI)  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) gold standard: MRI Baker Cyst

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51 intra-articular body in cyst

52 Baker Cyst ruptured cyst

53 MANAGEMENT

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

55  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)  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

56  review diagnosis  ?persistent underlying knee pathology  repeat of glucocorticoid injection  arthroscopic knee surgery  non-communicating cysts: non-responsive to intra-articular injections direct aspiration and glucocorticoid injection  no joint pathology: surgical excision  review diagnosis  ?persistent underlying knee pathology  repeat of glucocorticoid injection  arthroscopic knee surgery  non-communicating cysts: non-responsive to intra-articular injections direct aspiration and glucocorticoid injection  no joint pathology: surgical excision MANAGEMENT Ultrasound-guided direct cyst corticoid injection  indicated intra-articular injection of gluco-corticoids failed to relief symptoms non-communicating Baker’s cysts

57  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)  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

58  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 Risks:  wound sepsis  synovial fistulae  recurrence: 2y post-op f/u on MRI-study (Calvisi et al, 2007) disappeared: 64% reduced: 27% persisted: 9% MANAGEMENT

59 POST-OP REHABILITATION

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

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

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64 differential diagnosis !!  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 anti- coagulation therapy (if mistaken for DVT) could be dangerous!

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66 1.Acebes JC, Sanchez-Pernaute O, Diaz-Oca A, et al. Ultrasonographic assessment of Baker’s cysts after inatr- articular 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 Baker’s 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

67 5.Calvisi V, Lupparelli S, Giuliani P. Arthroscopic all-inside suture of symptomatic Baker’s 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.4 th 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

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69 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 Baker’s 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

70 20.McDonald DG, Leopold GR. Ultrasound B-scanning in the differentiation of Baker’s 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 22.Ward EE, Jacobson JA. Sonographic detection of Baker’s cysts: Comparison with MR imaging. Am J Roëntgenol. 2001;176(2);373-80


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