BAKER CYST

DEFINITION

Baker’s cyst, or popliteal cyst, is a fluid-filled mass that is a distention of a preexisting

bursa in the popliteal fossa, most commonly the gastrocnemio-semimembranosus bursa. This
bursa is unique in that it communicates with the knee joint, unlike other periarticular bursa, it is
the opening in the joint capsule posterior to the medial femoral condyle. (14)

ETIOLOGY

Caused by a formation of fluid in the joints that trapped and bulge from the joint capsule
at the back of the knee like a follicle . The cause of the formation of the fluid in the joints is
because rheumatoid arthritis, osteoarthritis, and too much use of the knee. Baker's cyst caused
discomfort in the back of the knee. The cyst may be enlarged and elongated down into the calf
muscles. The liquid that released from the cysts can make the surrounding tissues become
inflamed, resulting symptoms such as thrombophlebitis. In addition, baker Cyst can be broken
because thrombophlebitis in popliteal vein (located in the back of the knee). (15)

EPIDEMIOLOGY

In studies, baker’s cyst is an asymptomatic knees in adults, baker’s cysts were identified
in 4.7% to 37% of the cases. This variant in prevalence could be caused by differences in
definitions; Johnson et al simply looked for the presence of a gastrocnemio-semimembranosus
bursa that communicated with the joint, not necessarily a pathologic presentation of the bursa.

In pediatric populations, the prevalence of popliteal cysts has been reported as 6.3%.
Although the prevalence of popliteal cysts varies, these cysts generally occur secondary to other
intra-articular pathology in adults. (14)

PATHOPHYSIOLOGY

A benign swelling of the semimembranosus bursa found behind the knee joint

Knee joint effusion communicates with posterior bursa through a valvular opening"

Valve allows movement in one direction only-out of knee

Fluid collects in the bursa causing enlargement and bursitis

Often reffered to as a popliteal/baker’s cyst

 A valvular opening of the posterior capsule, high up on the medial side and deep to the
medial head of the gastrocnemius, is present up to 40% to 54% of healthy adult knees, based on
studies. Radiopaque dye has been injected into popliteal cysts, confirming that fluid flow is from
the knee joint into the cyst, while reverse flow was not possible. It is thought that this 1-way
valvular opening allows fluid to pass into the gastrocnemius-semimembranosus bursa. As an
effusion is often present with intra-articular pathology, it is possible that the Baker’s cyst may
provide a protective effect on the knee by decreasing the hydraulic pressure within the knee
through the one way valve. This argument is strengthened by the finding that the volume of the
popliteal cysts is associated with the size of the knee effusions. This valvular opening allows
flow during knee flexion, but it is compressed closed during knee extension due to tension in the
semimembranosus and the medial head of gastrocnemius.

Histologically, the cyst walls resemble synovial tissue with fibrosis evident, and there
may be chronic nonspecific inflammation present. Osteocartilaginous loose bodies may also be
found within the cyst, even if they are not seen in the knee joint. The cyst fluid may be thickened
by the presence of fibrin. Histologic examination of symptomatic and nonsymptomatic cysts did
not reveal any difference microscopically.

Although popliteal cysts are most commonly found between the medial head of the
gastrocnemius and semimembranosus, they have been reported in other areas. Jensen and
Jorgensen reported on a lateral presentation of a popliteal cyst, which communicated with the
knee joint at the intercondylar fossa and herniated laterally through the iliotibial band. The
authors suggested that if a posterolateral cyst is discovered, further evaluation should be
performed to rule out a meniscal cyst or soft tissue tumor, as lateral presentation of popliteal
cysts are unusual.

Popliteal cysts may also be seen with a failed total knee arthroplasty due to osteolysis or
polyethylene debris. The cysts may be multilobulated or gigantic. Histologically, macrophage
phagocytosed polyethylene particles and particle-induced synovitis are seen.Popliteal cysts found
in knees with a previous arthroplasty may represent loosening of the components or polyethylene
wear. (16)

SYMPTOMS

Not all sufferers feel the symptoms before diagnosed with Baker cyst, especially small-
sized. If the size of the cyst is large enough, the symptoms that will probably be felt are:

a. Swollen behind the knee or the leg pain increase while stand
b. Pain in the knee
c. Stiff or difficult to stretch a knee
d. Bruising, especially at a time when the synovial fluid started leaking
e. Feel the thrill as a knock on the knee
These symptoms usually worsen when the sufferer is active or stand in quite a long time.
(17)

DIAGNOSIS
 At an early stage, the doctor will usually perform a physical test and ask about health
history, when the symptoms perceived, the severity of the symptoms, the pain that the patient
felt, and the trigger of the symptoms.

If the doctor suspect the tendency of Baker cysts, your doctor will probably suggest to do
a series of tests such as radiology, x-ray, MRI scans, and ultrasound to see the condition of the
knee and erase all of the possibility of another diagnosis. Currently, the main choice to diagnose
baker’s cyst is using the ultrasonography.(18)

TREATMENT

Generally, the Baker cyst disease can recover by itself. However, if the size of the cyst
and the condition is already severe enough, the doctor will probably recommend this treatment
below:

a. Drugs. The doctor will probably give you medicines to relieve symptoms, such as
injected corticosteroids for inflammation on the knee or nonsteroid anti inflammatory
drugs (NSAID) for the swelling. Pain relief medications such as ibuprofen, naproxen,
aspirin, acetaminophen (paracetamol)
b. Aspiration on synovial fluid. If fluid levels of sinoval disruptive enough, the doctor will
probably recommend to do aspiration for the discharge of the knee joint. This action
involves the use of needles combined with ultrasound.
c. Operation. In case of ruptur on the cartilage production caused by excess synovial fluid,
the doctor will probably suggest you to doing surgery to fix it. The suggestion to do
surgery usually given remove the cyst on the knee when other treatments are not
successful.
d. Physiotherapy. For sufferers who have difficulty walking, doctors will usually suggest
physiotherapy combined with another treatment methods in order to flex and strengthen
the knee joint.
In addition, the sufferer can relieve pain by doing physical therapy at home, such as
compress it with bags of ice for 10-30 minutes, raise a leg, or tie it with the elastic material.
Tools like the crutches can also be used to avoid pressure on the knee during walking. Rest
your feet during the treatment. (18)

COMPLICATIONS

Although rare, Baker cyst may cause complications if not treated appropriately. One
of the biggest complication is rupture of the cyst behind knee that experienced by patient
with percentation about 5-10 percent. This condition resulted in the synovial fluid leaked
onto calf and can trigger swelling. These symptoms are similar to deep venous thrombosis .
(19)

PREVENTION
Until today there is no particular way that can be done to prevent cyst Baker. Prevention can only
be done after the symptoms appear to avoid complications or to prevent the growth of new cysts
after recovery, such as:

1. Reduced physical activity. To relieve the pain and irritation in the knee joint, it is
recommended to reduce physical activity and looking for other alternatives in order not to
overload the knee. Ask the doctor about the proper fit of activity your condition.
2. Keep the weight ideal.Always keep your weight at a healthy boundaries so that the knee is
not getting the excess pressure.
3. In order that prevention can be performed optimally, follow the doctor's advice and consult it
to the doctor if something unusual happen. (20)