My right calf swelled up so my primary doctor first thought it was a blood clot. But after I had a deep ultrasound they determined it was a popped Baker’s Cyst behind the Knee.
A Baker’s cyst can sometimes rupture (burst), resulting in fluid leaking down into your calf. This causes a sharp pain in your calf, which becomes swollen, tight, and red, but redness can be harder to see on brown and black skin. The fluid will gradually be reabsorbed into the body within a few weeks.
A Baker’s cyst (also known as a popliteal cyst) is a fluid-filled sac (cyst) behind the knee that causes tightness, pain, or knee stiffness that may worsen when you move your leg around or during physical activities. An accumulation of synovial fluid (which lubricates your knee joint) causes swelling and bulges to form a cyst at the back of the knee when under pressure. The important steps to treating a Baker’s cyst come in resting the affected leg and treating any potential underlying cause, such as arthritis.
If you think you have a Baker’s cyst, it is important you visit your doctor to rule out more serious afflictions, such as a blood clot or arterial obstruction. Sometimes, a Baker’s cyst can split open (rupture) and cause symptoms in the calf that can be similar to a deep vein thrombosis (DVT). A Baker’s cyst often gets better and disappears by itself over time. However, there are various treatments that may help if there are symptoms associated with it.
It is named after a doctor called William Baker who first described this condition in 1877. It is also sometimes called a popliteal cyst, as the medical term for the area behind the knee is the popliteal fossa. The cyst can vary in size from very small to large (it can be several centimeters across). Rarely, a Baker’s cyst can develop behind both knees at the same time.
The joint capsule is a thick structure that surrounds the whole knee and gives it some support. It is lined by a special membrane called the synovium. The synovium produces a fluid called synovial fluid. This fluid acts as a lubricant within the knee joint and helps to cushion it during movement.
There are also various tissue pouches called bursae next to the knee. A bursa is a small sac of synovial fluid with a thin lining. Bursae are normally found around joints and in places where ligaments and tendons pass over bones. They help to reduce friction and allow a maximal range of motion around joints. The bursa at the back of the knee is called the popliteal bursa.
Each knee joint also contains a medial and a lateral meniscus. These are thick rubber-like pads of cartilage tissue. The menisci cartilage sits on top of, and is in addition to, the usual thin layer of cartilage which covers the top of one of the bones of the lower leg, called the tibia. They act as shock absorbers to absorb the impact of the upper leg on the lower leg. They also help to improve smooth movement and stability of the knee.
A primary Baker’s cyst
A Baker’s cyst may develop just behind an otherwise healthy knee joint. This type of cyst is sometimes referred to as a primary or idiopathic Baker’s cyst and usually develops in younger people and in children.
It is thought that, in this type of Baker’s cyst, there is a connection between the knee joint and the popliteal bursa behind the knee. This means that synovial fluid from inside the joint can pass into the popliteal bursa and a Baker’s cyst can form.
A secondary Baker’s cyst
It is more common for a Baker’s cyst to develop if there is an underlying problem within the knee, such as arthritis or a tear in the meniscal cartilage that lines the inside of the knee joint. This is sometimes referred to as a secondary Baker’s cyst.
In a secondary Baker’s cyst, the underlying problem within the knee joint causes too much synovial fluid to be produced within the joint. As a result of this, the pressure inside the knee increases, and this has the effect of stretching the joint capsule. The joint capsule bulges out into the back of the knee, forming the Baker’s cyst that is filled with synovial fluid.
How common is a Baker’s cyst?
Baker’s cysts are most common between the ages of 35 and 70, particularly if there is an underlying knee condition. As above, primary Baker’s cysts can occur in children, typically between the ages of 4 and 7.
Arthritis is the most common condition associated with Baker’s cysts. This can include various types of arthritis, such as osteoarthritis (most common), rheumatoid arthritis, psoriatic arthritis, and gout.
Baker’s cysts may also develop if you have had a tear to the meniscus or to one of the ligaments within the knee, or if you have had an infection within your knee joint.
Baker’s cyst symptoms
Some people with a Baker’s cyst do not have any symptoms at all. Small cysts may not always be found during a knee examination and the cyst may be found incidentally during an investigation on the knee, such as a scan.
Usually, larger Baker’s cysts are more likely to cause symptoms. The swelling behind the knee might be able to be seen or felt;. . some people feel an ache around the knee area. It may be difficult to bend the knee if there is a large Baker’s cyst and the area behind the knee may feel tight, especially when standing up. Less commonly, there may be a sensation of clicking or locking of the knee.
If there is an underlying knee problem such as arthritis, there may also be symptoms related to that, such as knee pain or swelling of the knee joint itself.
The most common complication of a Baker’s cyst is for it to split open (rupture) – this is thought to happen in about 1 in 20 Baker’s cysts. If this happens, the fluid from inside the cyst can leak out into the calf muscle and cause swelling of the calf. Sometimes redness and itching of the skin of the calf can develop as a result of irritation caused by this fluid.
If a Baker’s cyst ruptures, it can sometimes be difficult to tell the difference between the ruptured cyst and a deep vein thrombosis (DVT). A DVT is a blood clot that forms in a leg vein. In these cases, it is important that investigations are carried out to exclude a DVT because it can be a serious condition that needs treatment. See the separate leaflet called Deep Vein Thrombosis for more detail.
Very rarely, a Baker’s cyst may become infected.
How is a Baker’s cyst diagnosed?
A Baker’s cyst is usually diagnosed by an examination of the knee. The swelling feels as though it is fluid-filled and it might be “transilluminate” (a light can be seen through it) which confirms the diagnosis of a cyst.
Usually no investigations are needed to confirm the diagnosis. If there is a doubt about the diagnosis then an ultrasound scan (or occasionally an MRI scan) might be used. If there is a concern about a DVT then specific tests (usually a Doppler ultrasound scan) will be arranged in the hospital.
Baker’s cyst treatment
A Baker’s cyst usually gets better and disappears by itself over time. However, the cyst may persist for months or even years before it goes. Most people have very few symptoms and no specific treatment is needed.
There are various treatment options that may help if there are symptoms associated with a Baker’s cyst. These include:
Treatment of any underlying knee problem
It is important that any underlying knee problem is treated. This may help to reduce the size of a Baker’s cyst and any swelling or pain that it causes. For example, if there is osteoarthritis of the knee joint, a steroid injection into the knee may help to relieve pain and inflammation. However, this does not always stop the cyst from coming back again.
If there is an injury to the knee such as a meniscal tear, treatment of this may help to treat the Baker’s cyst as well. See the separate leaflets called Knee Ligament Injuries and Meniscal Tears (Knee Cartilage Injuries) for more detail.
Treatment to help relieve symptoms
If the Baker’s cyst is causing pain or discomfort, one or more of the following may be helpful:
- Non-steroidal anti-inflammatory drugs (NSAIDs). These can help to relieve pain and may also limit inflammation and swelling. There are many types and brands. Some – such as ibuprofen or naproxen – can be bought over the counter from a pharmacy. Others require a prescription. NSAIDs can cause side effects – inflammation of the lining of the stomach which can cause pain and bleeding is the most serious. Regular or long-term use can cause damage to the kidneys and it is important to have regular blood tests if taking this medication regularly. Some people with asthma, high blood pressure, kidney failure, and heart failure may not be able to take NSAIDs so it is important to check with the pharmacist before buying these.
- Stronger pain relief. If the cyst ruptures, the fluid from inside the cyst may leak into the calf and cause worse pain. In this situation, stronger medication may be needed on prescription.
- Ice may also help to reduce swelling and pain. An ice pack can be made by wrapping ice cubes in a plastic bag or towel and applying it to the area for 10-30 minutes. (Ice should never be put directly next to the skin as it may cause ice burn.) A bag of frozen peas is an alternative.
- Crutches. Very occasionally, crutches may be needed to help take the weight off the affected leg whilst walking for a few days until the symptoms ease.
- Physiotherapy. Keeping the knee joint moving and using strengthening exercises to help the muscles around the knee is often very helpful.
There are some other treatment options that are sometimes used:
- Fluid drainage – sometimes a doctor may use a needle to drain excess fluid from the knee joint to help relieve the symptoms. However, it is common for the Baker’s cyst to re-form over time.
- Cortisone (steroid) injection – this is sometimes used following fluid drainage, to reduce the pain and inflammation caused by the cyst. It does not prevent it from coming back again.
- Surgery to remove the cyst – this is sometimes done, especially if a cyst is very large or painful and/or other treatments have not worked. Sometimes a keyhole method is used to close off the connection between the Baker’s cyst and the knee joint. The cyst is also sometimes removed using open surgery. Surgery may be carried out to treat an underlying problem at the same time – for example, repairing a meniscal tear.
Is Massage OK to relieve the swelling and pain from a Baker’s Cyst?
Unlike muscular injuries that respond well to massage, a Baker’s Cyst is not a muscular injury. In fact, massage should be avoided, as it will cause further irritation of the condition. A Baker’s Cyst contains inflammatory fluids.
A Baker’s cyst is a swelling that is not within muscle but contained within an enlarged synovial membrane at the back of the knee, in the popliteal fossa. The popliteal fossa is an area through which large blood vessels and nerves pass through en route to the lower leg, and is contraindicated to massage for this reason. Massage and pressure on a Baker’s cyst will be painful and unlikely to help the condition. In most cases, it will make the Baker’s cyst more painful, and if further irritated may make the cyst swell more.
Massage to the surrounding tissues such as the quadriceps, hamstrings, and calf muscle is safe provided the back of the knee is avoided.
Massage therapy can help individuals harboring a Baker’s cyst. By focusing on the probable underlying knee problem, the swelling and discomfort of a Baker’s cyst can typically be relieved. Seeking the cause of an imbalance in the knee can be aided by performing some manual resistive testing on your assessment skills. For more information on these tests, read the article, Eight Tests for Anterior Knee Pain.
Interestingly, popliteal cysts are located in an area contraindicated for most massage techniques. Although it is important for body workers to avoid deep, direct pressure on the cyst, it is still possible to have a significant therapeutic impact. Experts recommend treating the area above the cyst, primarily by addressing the hamstrings and adductors. Balancing the musculature supporting the knee joint compensates for pathological injury or torque contributing to knee dysfunction. Additionally, including lymphatic drainage massage techniques in a session will facilitate absorption of the excessive synovial fluid accumulation, leading to a quicker recovery.
The presence of a firm protrusion behind the knee should not be assumed by a massage therapist to be an innocuous Baker’s cyst. There is a possibility it could be a tumor or popliteal artery aneurysm, thus necessitating a thorough evaluation by a medical doctor.
It is very important for massage therapists to avoid firm pressure directly on the cyst. A Baker’s cyst could become large enough to locally impinge nerves or blood flow, which in the worst-case scenario could spawn an embolus. Familiarize yourself with the signs, symptoms, and risk factors for a deep vein thrombosis to avoid this potentially devastating scenario. Rarely, a Baker’s cyst bursts, and synovial fluid leaks into the calf region, causing sharp pain in the knee, swelling, and sometimes redness of the calf. These signs and symptoms closely resemble those of a blood clot in the leg. If a client demonstrates these symptoms, prompt medical evaluation must be sought.
Bodyworkers are regularly presented with all types of pain and physical abnormalities. Some clients will announce they have a Baker’s cyst while others will just ask if you can help reduce the swelling behind their knee. Regardless of the presentation, massage therapists are best prepared to handle these situations when they are properly informed of the condition being presented, understand any danger lurking, and are comfortable knowing what they can do to aid in the client’s recovery.
Massage for Popliteal Fossa
- Self-massage of the Popliteus Grasp your lower leg with both hands and put your thumbs together. Now press into the lower lateral side of the hollow of the knee and into the lateral side of the calf. Slide your thumbs over the muscle and seek for painful tensions. It is important to move the skin over the muscle but to not slide over the skin.
What is friction massage of the popliteal fossa?
[Purpose] Friction massage (friction) of the popliteal fossa is provided for the purpose of relieving pain related to circulatory disorders by improving venous flow in the lower legs.
Where is the popliteal fossa located?
The popliteal fossa is a diamond-shaped area located on the posterior aspect of the knee. It is the main path by which vessels and nerves pass between the thigh and the leg. In this article, we shall look at the anatomy of the popliteal fossa – its borders, contents, and clinical correlations.
The popliteal fossa is diamond-shaped with four borders. These borders are formed by the muscles in the posterior compartment of the leg and thigh:
- Superomedial – semimembranosus.
- Superolateral – biceps femoris.
- Inferomedial – medial head of the gastrocnemius.
- Inferolateral – lateral head of the gastrocnemius and plantaris.
- The floor of the popliteal fossa is formed by the posterior surface of the knee joint capsule, popliteus muscle, and posterior femur. The roof is made of up two layers: popliteal fascia and skin. The popliteal fascia is continuous with the fascia lata of the leg.
The popliteal fossa is the main conduit for neurovascular structures entering and leaving the leg. Its contents are (medial to lateral):
- Popliteal artery
- Popliteal vein
- Tibial nerve
- Common fibular nerve (common peroneal nerve)
The tibial and common fibular nerves are the most superficial of the contents of the popliteal fossa. They are both branches of the sciatic nerve. The common fibular nerve follows the biceps femoris tendon, traveling along the lateral margin of the popliteal fossa.
The small saphenous vein pierces the popliteal fascia and passes between the two heads of the gastrocnemius to empty into the popliteal vein.
In the popliteal fossa, the deepest structure is the popliteal artery. It is a continuation of the femoral artery and travels into the leg to supply it with blood.
Clinical Relevance: Swelling in the Popliteal Fossa
The appearance of a mass in the popliteal fossa has many differential diagnoses. The two main causes are a baker’s cyst and an aneurysm of the popliteal artery.
A Baker’s cyst (popliteal cyst) refers to the inflammation and swelling of the semimembranosus bursa – a sac-like structure containing a small amount of synovial fluid. It usually arises in conjunction with osteoarthritis of the knee.
Whilst it usually self-resolves, the cyst can rupture and produce symptoms similar to deep vein thrombosis.
An aneurysm is a dilation of an artery, which is greater than 50% of the normal diameter. The popliteal fascia (the roof of the popliteal fossa) is tough and non-extensible, and so an aneurysm of the popliteal artery has consequences for the other contents of the popliteal fossa.
The tibial nerve is particularly susceptible to compression from the popliteal artery. The major features of tibial nerve compression are:
- Weakened or absent plantar flexion
- Paraesthesia of the foot and posterolateral leg
An aneurysm of the popliteal artery can be detected by an obvious palpable pulsation in the popliteal fossa. An arterial bruit may be heard on auscultation.
Rarer causes of a popliteal mass include deep vein thrombosis, adventitial cyst of the popliteal artery, and various neoplasms (such as rhabdomyosarcoma).
How to treat popliteus?
For the popliteus, eccentric strengthening (closed kinetic chain) of the quadriceps is effective in reducing strain on the popliteus. Patients should not run until the knee is free of pain, then they should limit their workouts and downhill running for at least 6 weeks. During the treatment, cycling provides a good alternative exercise.
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