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Rheumatoid arthritis baker's cyst and Вthrombophlebitis.

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Rheumatoid Arthritis, Baker’s Cyst,
and “Thrombophlebitis”
By ARMINE. GOOD
From a small series of patients hospitalized with rheumatoid arthritis, six
cases are presented in which Baker’s
cysts were associated with pain a n d
swelling of the calf, initially erroneously
diagnosed as thrombophlebitis. The
pathogenesis of these calf symptoms is
reviewed.
T
Ex u n pauco extense serie de casos d e
patientes hospitalisate con arthritis
rheumatoidee, sex es presentate in le
quales cystes d e Baker esseva associate
CQll dolores e tumescentia del sura, initialmente diagnosticate i n error como
thrombophlebitis. Le pathogenese d e iste
symptomas sural es revistate.
HE APPEARANCE of pain, swelling, and tenderness in the calf, uni-
lateral ankle edema, and a positive Homans’ sign calls for a presumptive
diagnosis of venous thrombosis. Although arthritis at the knee and ankle may
produce these signs and symptoms, there is usually no cause for confusion
when swelling and tenderness are predominant in and around the joints. In
patients with arthritis, however, swelling, erythema, tenderness and pain in
the calf may appear, clearly separable from articular involvement. Our recent
experience indicates that these symptoms are not uncommonly manifestations
of a Baker’s cyst rather than of phlebitis. In several instances, the cysts were
elicited only after calf swelling and erythema subsided, or patients were
properly positioned, standing with the knee in full extension.
MATERIAL
AND METHODS
As an outcome of our experience in Case 1 with the combination of rheumatoid arthritia, a Baker’s cyst, and suspected thrombophlebitis, 45 consecutive cases, beginning with
Case 1, of definite or classical rheumatoid arthritis hospitalized at Ann Arbor Veterans
Administration Hospital for various reasons during the period from November 1961
through December 1962 were screened for thrombophlebitis and Baker’s cysts (table 1.).
Twelve patients had popliteal cysts, either demonstrable or well documented in previous
records. Eight cases had had, at one time or another, a clinical diagnosis of thrombophlebitis in the lower leg; six of these were patients with Baker’s cysts, whose histories
are presented as follows:
CASE1
( AAVAH, A-8584) The patient, W. W. D., a 45-year-old male with definite rheumatoid
arthritis was admitted in November 1961, five months after the onset of polyarthritis. On
admission numerous joints were involved including the left knee, which was the site of
effusion, increased heat, and tenderness. There was no evidence of a Baker’s cyst. On the
14th hospital day, pain, increased heat, swelling, and non-pitting edema with a positive
Homans’ sign appeared in the left calf. A diagnosis of thrombophlebitis was made and
the patient was treated by elevation of the leg and hot soaks. After four days, pain, heat
From the Vaterans Admhktratwn Hospital, Ann Arbor, Mich., and the Depcrrtment of
Medicine, University of Michigan Medical School, Ann Arbm, Mich.
56
A R T H H I ~ IASN D
RIIEUhfATISM,
VOI.. 7 , NO. 1
(FEBRUARY),
1964
57
R.A., BAKER’S CYST AND THROMBOPHLEBITIS
12
History of systemic
corticosteroid therapy
8 (67%)
History of diagnosis
of thrombophlebitis
of leg veins
6 (50%)
24
9
16 ( 6 7 % )
4 (44%)
Total number of
episodes diagnosed
as thrombophlebitis
1
1
During corticosteroid
therapy
0
0
In absence of corticosteroid therapy
1
1
and edema subsided in the calf and a cystic, medial popliteal mass was delineated, measuring 4 cm. in width and extending downward 7 cm. from the transverse skin crease. This
was painless, persisted for three months, decreasing slowly in size, paralleling complete
disappearance of objective joint signs at the left knee. Follow-up to January 1963 has
disclosed no signs or sequellae attributable to venous disease.
CASE2
(AAVAH, A-663) The patient, C. E. D., a 54-year-old male with classical rheumatoid
arthritis symptomatic since 1954 was admitted in 1960 because of a suspected venous
thrombosis in the left calf. For five months, pain and swelling had been especially severe
at both knees. Two months previously he had noted sudden painful enlargement of the
left calf. The left calf was enlarged 2.5 cm. in circumference over the right and moderately tender. There was 2 f pitting edema in the left lower leg to, the mid tibia, I f similarly
on the right. The left Homans’ sign was positive; no erythema or heat were present.
Examination of the knees showed synovial effusion and increased heat bilaterally. With
bedrest and elastic bandage wraps for a week, the calf swelling and tenderness disappeared. Numerous recorded joint examinations previously and during this admission did
not disclose a popliteal cyst.
The patient was readmitted for evaluation on 10-19-61 at which time there was 1+
pitting edema of the ankles but no asymmetry of the calves or other signs suggestive of
venous disease. Baker’s cysts, 6 x 4 cm. on the left and 4% x 3 cm. on the right were
palpated. The patient stated that the cysts had been present since the time of his discharge from the hospital in 1960. These have persisted without associated symptoms to
the time of the most recent examination in November 1962 (see figs. 1 and 2). At bath
knees, chronic pain, effusion, and increased skin temperature have continued.
CASE3
(AAVAH A-184) The patient, F. J., a 52-year-old male with classical rheumatoid
arthritis symptomatic since 1945 was seen in December of 1962 because of a flare of
right knee pain and suspected recurrent phlebitis. In 1959, two months after the initial
appearance of arthritis in the right knee, he was hospitalized at the Ann Arbor Veterans
Administration Hospital with a diagnosis of acute thrombophlebitis, posterior compart-
5s
ARMIN E. GOOD
Fig. 1.-(C. E. D.), 1962-Posterior view of knees, with skin markings delineating t h e bilateral popliteal cystic masses.
ment, right leg. The right calf was swollen, warm, and tender; the Honians’ sign was
positive; pitting edema was present at the ankles bilaterally; and synovial effusion and
tenderness were evident a t the right knee. Oral anticoagulants were started. Calf swelling
cleared within several days and joint pain and swelling subsided somewhat. During admission a large, right popliteal cyst was discovered.
Because of involvement of the cervical spine, the patient was readmitted to the hospital
in 1980.There was no evidence of phlebitis, and a Baker’s cyst was not found. A Baker’s
cyst was not detected in the course of numerous examinations between 1980 and 1982.
In 1962 he experienced a recurrence of right knee pain and upper calf tenderness and
swelling, reminiscent to him of the symptoms preceeding the diagnosis of phlebitis in
1959. Examination two days after onset disclosed a soft, tender, 7 x 5 cm., cystic, right,
medial popliteal mass. Tenderness, increased heat, and effusion were present at the right
knee. The symptoms improved following a brief period of bed rest.
CASE4
(AAVAH A-23970) The patient, A. H., a 59-year-old male with classical rheumatoid
arthritis symptomatic since 1937 was admitted for the first time in January 1956 because
of swelling and increased heat in the left calf, where tenderness and a positive Homans’
sign were noted. The left calf appeared 30 per cent enlarged over the right. Synovial
effusion and increased heat were present at both knees. He gave a history of a mass in
the left popliteal space diagnosed by his doctor in 1954 as a Baker’s cyst, disappearing
after needle aspiration.
The patient was treated for snspected venous tliroinbosis by bedrest, elevation of the
leg and oral anticoagulants. The calf signs disappeared in two weeks except for a persistent, non-tender, firm mass in the upper medial calf. This was surgically explored and
found to be a thickly encapsulated .3 x 2 cm. inass high in the medial gastrocnemius containing a hematoma. Histologically this was found to be a fibrous capsule in which
R.A., BAKEICS CYST AND THROMBOPHLEBITIS
Fig. 2.-(C. E. D.), 1962-Left
protrusion of the popliteal cyst.
59
leg externally rotated 45", showing the medial
hemosiderin granules were plentifnl. A layer of fibrin was present on the inner surface
and the lumen was virtually filled with an organizing hematoma.
In January 1958 he was readmitted because of one week of tenderness, swelling, redness and heat in the left calf. A positive Homans' sign and 3 cm. increase in circumference
of the left calf over the right were noted. The calf signs disappeared in 10 days with
oral anticoagulation and bedrest.
He was admitted for re-evalution in February 1962 at which time an asymptomatic
left Baker's cyst, 2 x 3 cm. in size was elicited. On return visit since then the cyst has
fluctuated in size, paralleling more or less the degree of pain and effnsion of the left knee,
occasionally disappearing completely.
CASE5
( AAVAH A-2343) The patient, 0. P., a 61-year-old white male with classical rheumatoid arthritis symptomatic since 1938 was admitted in December 1961 with a diagnosis of
thrombophlebitis of the left calf. Three weeks previously severe pain and swelling had
appeared at the left knee and calf, followed in several days by a tender, bluish discoloration and swelling of the medial left calf. On admission the left knee was irritable and
difficult to move because of pain. An edematons, warm, tender swelling was noted in the
left calf exhibiting yellow-green discoloration, 8 x 16 cm. in size, extending downward
from the left popliteal space. A well healed, linear surgical scar was noted in the medial
le't calf. Synovial effnsion was marked at the left knee and minimal on the right. The
calf pain and induration cleared slowly within one month, coincidentally with improvem m t in the signs at the left knee joint.
Records were then obtained from an outside hospital where a diagnosis of thrombophlebitis was made in December 1957 became of left calf tenderness and a positive
Homans' sign. Active arthritis was present in both knees at the time. Within two weeks
the calf signs disappeared except for a sausage shaped mass approximately X! cm. in
ARMIN E. GOOD
60
length extending from the popliteal space into the calf. This was explored and found to
be a mesothelially lined cyst with a densely collagenous wall. Injection of dye into the
knee joint demonstrated communication with the cyst. A diagnosis of Baker’s cyst was
made.
Follow-up to 1962 has disclosed no reappearance of a discrete, fluctuant mass in the
left calf or popliteal area. However, in the light of the well documented history of a popliteal cyst simulating thromhophlehitis, the abrupt calf swelling and pain followed by
hemorrhagic discoloration in 1961 suggested a recurrent popliteal cystic protrusion, perhaps rupturing spontaneously. The admitting diagnosis of thromhophlebitis was abandoned.
CASE6
(AAVAH A-8397) The patient, J. P. P., a 74-year-old white male was admitted in
November 1961 with classical rheumatoid arthritis symptomatic since 1953. Objective
changes were present in numerous joints, especially the knees, where warmth, tenderness
and synovial effusion were noted. Erythema and ill defined swelling was present over
the medial aspect of the left calf, where dilated superficial varicosities were seen distally.
The Homans’ sign was negative. There was bilateral pitting ankle edema, most marked
in the left leg. A diagnosis of probable phlebothronibosis of the left calf was made. Four
days later a cystic mass was delineated in the medial gastrocnemius extending down 7
cm. from the transverse skin crease (fig. 3 ) . This was reaclily reducible by manual compression, producing a bruit audible on auscultation with a stethoscope over the patella.
It was felt that the previous diagnosis of phlehothromhosis was an error. Over the subsequent year, the cyst decreased somewhat in size and produced no significant symptoms.
DISCUSSION
Cystic tumors of the popliteal space have been variously called popliteal
cysts, synovial cysts, posterior hernias of the knee joints, Baker’s cysts, semimembranous bursae or gastrocnemius semimembranous bursae. Characteristically these present as cystic swellings distal to the transverse skin crease,
closely associated with the medial insertion of the gastrocnemius (See Fig.’s
1-4). Tenderness is usually minimal and symptoms may be entirely absent.
At times the mass may be palpable only with the patient erect and the knee
in full extension. The cysts are occasionally lax1 and difficult to elicit proximally because of the overlying popliteal fat pad and deep fascia. They may
present as a mass in the lower calf as distal as the Achilles tend or^.^-^ In the
calf, the cystic nature may be obscured by overlying r n ~ s c l e . ~
Wilson, Eyre-Brook, and Francis demonstrated a patent communication
between the knee joint and the gastrocnemius-semimembranous
bursae in
17 of 30 cadaver dissecti0ns.l In the presence of arthritis of the knee, the escape of joint fluid into the bursa via this communication is generally regarded
as the pathogenesis of popliteal ~ y s t s . Adams
~ - ~ in 18407 a d Baker in 188S5
emphasized the etiologic importance of rheumatoid arthritis and other causes
of joint effusion in the production of popliteal cysts.
Moreover, in the first case described in his original report, Baker was concerned with the differential diagnosis between a popliteal cyst and a venous
thrombosis, when he encountered a patient presenting with unilateral ankle
edema, calf swelling, and dilatation and tortuousity of the superficial veins
distal to the knee. Others have associated a popliteal cyst with edema of the
lower leg and foot.”.” The popliteal vein, medial distally, crosses over the
RA., BAKER’S CYST AND THROMBOPHLEH~TJS
61
Fig. &-(J. P. P.), 1961-Medial aspect of left lower leg showing Baker’s cyst
presenting as sausage shaped swelling arising from popliteal space. At the lower
pole, saphenous varicosities are visible.
artery in the popliteal space, subject to compression between a popliteal
cyst and the artery. Thus, venous compression by inapparent popliteal cysts
may account for certain instances of unexplained dependent leg edema, a
problem encountered in a proportion of patients with rheumatoid arthritis.1°
In general Baker’s cysts found in association with rheumatoid arthritis have
been remarkably asymptomatic, tending to wax and wane in concert with
the synovial effusion of the knee. The pathogenesis of the exceptional attacks
of calf pain and diffuse swelling associated with popliteal cysts remains somewhat conjectural. Firstly, is the possibility that these attacks are due to venous
thrombosis, facilitated by Baker’s cysts. This has not, however, been our experience in cases 4 and 5, where operative exploration disclosed no thrombosis,
nor that of Harvey and C o r c o ~who
, ~ described four patients operated upon
because of large popliteal cysts extending to the mid calf and below. They
noted that these cysts were readily confused with thrombophlebitis of the
leg veins, the initial diagnosis in each instance. At surgical exploration, they
69
ARhlIN E. GOOD
Fig. 4.-Posterior view of knees, from patient with rheumatoid arthritis, showing,
on the right leg, the typical medial location of a popliteal cyst, distal to the
transverse skin crease. The cystic m a s s produced 110 symptoms and the patient
was unaware of its presence.
did not feel that venous disease contributed significantly to the symptoms,
although in one patient a single small thrombosed vein was discovered.
Apart from venous compression, other possible explanations for calf symptoms include rupture of the cyst, hemorrhage into the cyst, inflammation or
synovitis of the cyst wall, and even associated rheumatoid granulomata.
Others have commented upon the rapid appearance and enlargement of
cysts, suggesting rupture and escape of free fluid.4 Haggart found the walls
of popliteal cysts to be densc near the knee but generally friable and easily
ruptured distally.s Rupture is also suggested by the fact that a large proportion of specimens show no definite lining of synovial cells, but merely an
intermingling of lymphocytes, plasma cells and h i~ tio c y te s "and
~ ~ polymorphonuclear cells.3 Histiologically, there is often evidence of hemorrhage,
such as clumps of intracellular hemosiderinl and fibrin deposition." Within
the cyst wall, an irregular palisade-like fibroblastic formation resembling that
seen in a rheumatoid nodule has been o b s e r ~ e d . ~ , ~
In our material, episodes of calf pain followed periods of increased symptoms of arthritis at the knees. Synovial effusion was a prominent finding in
each instance. In case 1 in which the knee was observed closely before and
after the appearance of the mass, the pain and inflammatory signs may have
been due to acute enlargement or dissection of the cyst. In cases 4 and 5,
there is evidence for hemorrhage, although in the latter case this may have
been induced by anticoagulants.
In retrospect a t least, it appears that the diagnosis of thrombophlebitis was
R.A., BAKER’S CYST AND THHOMBOPHLEBITIS
63
erroneous in each of our six cases. Follow-up has been notable for the absence
of sequelae of thrombophlebitis such as palpable thrombosed veins, pulmonary embolism, and signs of venous insufficiency. Fever and tachycardia
were absent in each case. It is noteworthy that none of our six patients manifested any of the follcwing, more or less definitive, signs of thrombophlebitis:
tenderness along the course of a deep vein; visible, tender, erythematous, or
palpable cords; cyanosis of the calf; dilatation of collateral veins; edema above
the knee; and arterial spasm.
The diagnoses of thrombophlebitis, in each of our cases, were made on the
basis of several of the following presumptive signs or symptoms: pain in the
calf, diffuse calf tenderness, Homans’ sign, increase of skin temperature,
erythema, and edema distal to the knee. These signs have demonstrated merit
in the early diagnosis of venous thrombosis, especially in certain high-risk
situations, such as in the postoperative hypercoagulable state. However, in
dealing with a patient with synovial effusion or recent flare of synovitis in
the knee, these presumptive signs of thrombophlebitis should be interpreted
with due skepticism. In order to prevent prolonged hospitalization due to
needless anticoagulant therapy, the wise course in such a setting may be to
treat the synovitis aggressively and the possible phlebitis conservatively. Thus
intra-articular injection of compound F can be combined with bed rest,
elevation of the leg, elastic wrappings and close observation. When the calf
signs subside completely in 24 to 48 hours, it may be inferred that the diagnosis of deep venous thrombosis is in error. As edema subsides, the delineation of a Baker’s cyst may provide an alternative explanation for calf
symptoms.
Finally, our experience with this consecutive, unselected series of patients
with rheumatoid arthritis does not support the suggestion4 that corticosteroid
therapy increases the incidence of Baker’s cysts. Of 24 patients with a history of knee involvem,ent but without popliteal cysts, 16 (67 per cent) had
received systemic corticosteroids. Of the 12 patients with Baker’s cysts, all
of whom had had objective evidence for arthritis of the corresponding knee,
eight ( 67 per cent) had received corticosteroids. Likewise the acute episodes
of calf symptoms, originally diagnosed as thrombophlebitis, in the overall
group of 45 patients did not appear related to the use of corticosteroids.
Of 10 such episodes among eight patients, only four occurred during corticosteroid therapy (table 1).
SUMMARYAND CONCLUSIONS
1. A survey of 45 consecutively hospitalized patients with rheumatoid arthritis disclosed a history of a diagnosis of thrombophlebitis of the leg veins
in 12 and of Baker’s cysts in eight.
2. Six of the patients who had both “thrombophlebitis” and Baker’s cysts
are presented, illustrating the thesis that the presumptive signs of thrombophlebitis may be mimicked by the sudden enlargement of, hemorrhage into,
or perhaps rupture of the cyst.
3. In each case, synovial effusion of the corresponding knee was obvious;
64
ARMIN E. GOOD
an exacerbation of arthritis in the knee usually preceded the episodic calf
symptoms.
4. Although retrospectively the diagnosis of thrombophlebitis per se was
probably erroneous in each of these cases, Baker’s cysts may occasionally interfere with the venous return in the leg.
5. Our data do not suggest that popliteal cysts are precipitated or make
worse by prolonged corticosteroid therapy.
REFERENCES
1. Wilson, P. D., Eyre-Brook, A. L., and
Francis, J. D.: A clinical and anatomical study of the semimembranosus
bursa in relation to popliteal cyst.
J. Bone & Joint Surg. 20:963, 1938.
2. Kersley, G. D., Barber, H. S., Cregan,
J. C . F., and Gibson, H. J.: Degenerative rheumatoid changes. J. Bone &
Joint Surg. 36B:238, 1954.
3. Burleson, R. J., Bickel, W. H., and
Dahlin, D. C.: Popliteal cyst: A
clinicopathological survey. J. Bone &
Joint Surg. 38A: 1265, 1956.
4. Harvey, J. P., Jr., and Corcos, J.: Large
cysts in lower leg originating in the
knee occurring in patients with rheumatoid arthritis. Arth. & Rheumat.
3:218, 1960.
5. Baker, W. M.: The formation of abnormal synovial cysts in connection
with the joints. St. Bartholomew’s
Hosp. Rep. 21:177, 1885.
6. Meyerding, H. W., and VanDemark,
R. E.: Posterior hernia of the knee
(Baker’s cyst, popliteal cyst, semimembranosus bursitis, medial gastrocnemius bursitis and popliteal
bursitis ) . J.A.M.A. 122:858, 1943.
7. Adams: Chronic rheumatic arthritis of
the knee joint. Dublin J . M. Sc. 17:
520, 1840.
8. Haggart, G. F.: Posterior hernia of the
knee joint: a cause of internal derangement of the knee. J. Bone &
Joint Surg. 20:363, 1938.
9. Lewin, P.: The knee and related structures. Philadelphia, Lea & Febiger,
1952, p. 271.
10. Short, C. L., Bauer, W., and Reynolds,
W. E.: Rheumatoid Arthritis. Cambridge, Mass., Harvard University
Press, 1957, pp. 323-5.
Armin E. Good, M.D., Chief, Rheumtology Section, Veterans
Administration Hospital, Ann Arbor, Michigan; Assistant Professor of Internal Medicine, University of Michigan Medical
Center, Ann Arbor, Michigan.
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