Baker’s cyst treatments

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

The pain behind my knee

We get many people calling and emailing our staff about their problems with Baker’s Cysts. These people who contact us are usually not the “this cyst just developed,” people. They are the people who have had knee pain for quite some time and have been through all the conservative care options and are wondering why their doctor seems to be non-committal about recommending surgery for them to remove the problematic cyst. Does this sound like you? How about this story?

I had pain behind my knee slowly getting worse over time, about a year ago it got so that I had to visit the doctor. The doctor told me I have a Baker’s Cyst. If I rest it, if I ice it up, if I take anti-inflammatories it will go away. Well, it didn’t go away. I had to buy a knee brace to help me walk. Any amount of walking makes my knee hurt. I gave up going to the gym, the treadmill is something I can no longer do. I have been to a specialist, the recommendation there was for stronger anti-inflammatories and more resting. If that did not work then arthroscopic surgery, but even the surgery may not work and the cyst will come back. What can I do? 

What can you do? First, understand that the problem is not the Baker’s Cyst. The problem is what is causing the Baker’s Cyst

Most people with a Baker’s Cyst understand that they have a lot of things going on in their knee. If you have a Baker’s Cyst or worse, recurring Baker’s Cyst, you probably have an MRI that shows “degenerative changes in the knee”, “meniscus tears“, and “articular cartilage damage.” Your knee pain specialist has likely discussed with you that your Baker’s Cyst is a symptom of this degenerative damage, not the cause of it. Your doctor may tell you, “I can keep draining the cyst as it becomes a problem for you, but we should look to address the problem of what is causing it so we can see if we can provide a long-term answer.”

When you have knee instability, your knee is loose, wobbly, and painful. Your knee may give way or buckle or catch at any step. This is obviously not a normal condition and one your body tries to react to and correct. How does your body react? Swelling, lots of swelling. Your body’s natural response to knee looseness and instability is to swell up the knee with fluid. However, chronic knee swelling and synovial inflammation is not a normal situation either. Your knee cannot be in a constant state of inflammation.

The swelling or accumulation of fluid in the knee occurs, and is there, to act as a temporary brace, a sort of “water cast.” The “fluid brace,” is trying to keep everything in place as best it can. In the case of a Baker’s cyst, there is too much accumulation of fluid and a bulge, sac, or cyst forms behind the knee, causing discomfort, difficulty bending the knee, stiffness, and pain.

For many people, a visit to the orthopedist will result in an aspiration or draining of the cyst. This will usually provide immediate relief as the pressure of the swelling on the knee and calf is removed. For many people, a cortisone injection will be given immediately following the aspiration to shut down any inflammation that may cause the cyst to reappear. After the aspiration and possible cortisone shot, the patient will be told, “there is a great chance this will come back. If you start having knee pain, come back and we will do an MRI to see what is happening in your knee.”

Let’s point out again, a lot of people have a Baker’s Cyst drained, they get or do not get a cortisone injection, and that is the only time that the Baker’s Cyst will be a problem for them. These people may have had an isolated knee injury that promoted the formation of the Baker’s Cyst. When that knee injury healed, the Baker’s Cyst could be drained and this would be the end of it. These are not the people we see in our examination rooms.  The people we see have had multiple cysts, multiple aspirations to the point where aspiration is no longer possible. They have a recommendation for arthroscopic knee surgery or already had arthroscopic knee surgery. The people we see did not get the long-term or curative relief from these recommended treatments and their knee is much worse.

The Baker’s Cyst makes knee osteoarthritis worse

An August 2021 paper in the journal Medical principles and practice (1) made these observations in their comparison study of  97 patients with isolated knee osteoarthritis and 33 patients with knee osteoarthritis and Baker’s cyst).

  • Baker’s cysts associated with knee osteoarthritis contribute to the burden of knee symptoms. (In other words the cysts are causing symptoms on their own and these symptoms are combining with other pain and functional problems being caused by other aspects of the knee osteoarthritis. Therefore the Baker’s cyst should be dealt with because it is causing its own pain and disability problems.)
  • Conservative treatment (hyaluronic acid, corticosteroids, fluid withdrawal) of Baker’s cysts associated with knee osteoarthritis yields significant improvements, BUT, at six months the effectiveness of conservative treatment declines in patients with knee osteoarthritis associated with Baker’s cyst.
  • At 6 months, better outcomes were observed in patients with knee osteoarthritis without Baker’s cyst.

Treating the ruptured Baker’s Cyst – Cortisone and aspiration

A November 2020 paper published in the Clinical medicine insights. Arthritis and musculoskeletal disorders (2) sought to demonstrate the effectiveness and safety of ultrasonographic guided aspiration (fluid taken from cyst and the calf) performed with corticosteroid injection intra-lesional for ruptured Baker cysts. The study included 42 patients with knee joint disorder associated with ruptured Baker’s Cyst. The patients were treated by ultrasonographic guided aspiration then intra-lesional injection of corticosteroids once or twice, 1 week apart. Follow up were done weekly until complete resolution of symptoms.

Results and observations:

  • The highest frequency of ruptured Baker’s Cysts was noticed in rheumatoid arthritis patients (42.8%),
  • Pain and function scores improved significantly in all patients at both post injection evaluation visits (1 week and 12 weeks).
  • Ultrasonographic features improved significantly with complete disappearance of free fluid in the calf in 35 (83.3%) cases 1 week after the injection, and in 41 (97.6%) after 12 weeks.
  • In regard to the fluid in the Baker’s Cyst, only four (9.5%) cases showed complete disappearance after 1 week and there was recurrent Baker’s Cyst in 38 (90.5%) cases which required reaspiration. While after 12 weeks, Baker’s Cyst were completely disappeared in 23 (54.8%) cases, most of the relapsed BCs were complex Baker’s Cysts.

Moreover, in this study we found the relapse frequency of BCs was (45.2%) at the end of follow up among the studied patients and additionally, we found that most of the relapsed cysts were complex BCs after one week follow up.

Simple Baker’s Cyst becomes a complicated Baker’s Cyst

One morning you may have gotten up and your calf and ankles were filled with fluid. This caused you a great concern as you may not be aware that your Baker’s Cyst could rupture and you are thinking the worst. You were probably relieved when you went to your doctor and you were told “your Baker’s Cyst ruptured, all this fluid will eventually be reabsorbed into the body, keep your leg elevated, take anti-inflammatories, and if need be, pain-killers until this goes away.”

Of course, this doesn’t just happen when you go to sleep, people report that they “popped,” their cyst walking upstairs or simply walking at a brisk pace. Some reported that they had so much fluid behind their knee that when it popped their calf and shin “weeped,” water for days. For some people, even this may simply go away. For many others, the simple Baker’s Cyst (the one and done type)  has turned into the complicated Baker’s Cyst, (the Baker’s Cyst that is here to stay type) and can rupture frequently.

In a July 2019 study, published in the American Journal of Physical Medicine & Rehabilitation (3),  specialists examined 47 knees with Baker’s Cyst in 45 patients (2 patients had the Baker’s Cyst in both knees.)

What makes for a Complicated Baker’s Cyst?

  • Ultrasound findings which show the spread of a thicker (gel-like) fluid into the front of the knee (the suprapatellar recess or bursa area).
    • Note: As Baker’s Cysts continue to form, the fluid within them becomes thicker and thicker. The body is producing a “heavier grade oil.” This heavier grade makes future aspirations difficult and at some point impossible.
  • Synovial inflammation and chronic swelling
  • Greater knee pain
  • Clear indication of advanced osteoarthritis, including the greater prevalence of bone spurs
  • Evidence of Meniscus tears

Of the 47 knees:

  • There were 22 knees with a simple cyst and
  • 25 knees with a complicated cyst.

As we mentioned above, in our clinics it is usually the complicated cyst people we see.

The surgical treatment of Complicated Baker’s or Popliteal synovial cysts remains controversial

There are not many treatment options for a complicated Baker’s Cyst because the complicated Baker’s Cyst is secondary to other knee problems. So we have people who come into our clinics, we ask them what type of treatments have you received? They tell us they received non-steroidal anti-inflammatory drugs, and when the initial doses did not provide relief, they received larger doses at a greater frequency. They were also instructed to ice and rest. These are the typical “conservative care” options that are explored before surgery. Once these treatments failed, then the surgical discussion started.

Again, the problem with cyst draining and surgical removal of the cyst is that neither of these approaches addresses the damage that is causing the cyst to form in the first place, whether it is the damage to the meniscus, damage to ligaments, damage to the cartilage. Further, surgery involving any joint, and especially the knee, is very invasive and prone to post-surgical problems.

Doctors reporting in the medical journal Sports Health (4) wrote: “Surgical excision (removal) of the Baker’s cyst without treatment of any intra-articular lesions (tears and other damage) has been reported; however, the results have been disappointing because of the high rate of recurrence. . . The high rate of recurrence is believed to be a result of the continued presence of intra-articular pathology and associated recurrent effusions.”

  • In simple terms, the damage in the knee that is causing the swelling needs to be fixed in order to get rid of a Baker’s Cyst. If nothing gets fixed, the problem persists.
In his illustration a MRI reveals a large Baker's Cyst. The Baker's Cyst is usually the end result of other types of knee damage that is causing knee instability. In this MRI image that damage is coming from a complex degenerative Meniscus tear.
In this illustration, an MRI reveals a large Baker’s Cyst. The Baker’s Cyst is usually the end result of other types of knee damage that is causing knee instability. In this MRI image that damage is coming from a complex degenerative Meniscus tear.

Even after Total Knee Replacement Baker’s Cysts Remain

Doctors in Germany tested the widely held belief that recurring Baker’s cyst will be cured after total knee replacement. Here are the surprising results they published in the Bone and Joint Journal (5).

  • After one year, a Baker’s cyst was still present in 85% of patients tested.
  • Despite a reduction in associated Baker’s cyst related symptoms from before surgery  (71%) to after surgery (31%). Of the patients who had reported Baker’s cyst associated symptoms pre-operatively, (44%) still complained of such symptoms one year after surgery.

CONCLUSION: Baker’s cysts had resolved in only a small number of patients (15%) one year after total knee replacement and symptoms from the cysts persisted in 31%.

People still getting Baker’s Cysts after knee replacement.

Knee instability is a tricky thing. You can have a knee replacement and your knee can still be wobbly and unstable and painful. See our article: Finding help for post knee replacement pain.

The above study where 44% of patients still complained of Baker’s Cysts symptoms one year after surgery. was from 2016. The same researchers then published a follow up study in 2020. Let’s see if anything changed. Here are the summary highlights published in January 2020 in The Bone & Joint Journal.(6)

  • In this prospective case series, 105 total knee arthroplasty (replacement) patients were included. All patients who received surgery had a diagnosis of primary osteoarthritis and had preoperatively presented with a Baker’s cyst.
  • At the short- and mid-term follow-up, a Baker’s cyst was still present in 85.3% of the patient in the short-term and 33.0% in the mid-term follow up patients, respectively.
  • Of those patients who retained a Baker’s cyst at the short-term follow-up, 35.6% had popliteal symptoms.
  • Of those patients who continued to have a Baker’s cyst at the mid-term follow-up, 56.7% were still symptomatic.

At an average follow-up of 4.9 years after total knee replacement, the majority (67.0%)  of the Baker’s cysts that were present preoperatively had disappeared. The probability of cyst resolution was dependent on the size of the Baker’s cyst at baseline, with an 83.7% probability of resolution for smaller cysts and 52.1% probability for larger cysts.

Basically, even after knee replacement Baker’s Cysts can be problematic and the problem will be worse depending on how big your cyst was before surgery. How does this happen? Continued knee instability and damage to the replacement surgery’s surviving soft tissue. So if this can happen after knee replacement, what about before knee replacement?

Non-Surgical Prolotherapy for Baker’s Cysts
In this brief video a demonstration of aspiration of the Baker’s Cyst and knee instability treatment

  • At 0:50 seconds, demonstration of draining the Baker’s cyst under ultrasound guidance prior to Prolotherapy treatment. Prolotherapy is a simple series of dextrose injections that are explained below.
  • At 1:05 Treating the knee instability with Prolotherapy and combining Platelet Rich Plasma injections. Platelet Rich Plasma is using your own blood platelets to accelerate healing. The treatment is explained in fuller detail below.
  • At 1:13 demonstration of the treatments on a patient’s knee

  • Prolotherapy is a simple regenerative medicine injection treatment.
  • Injections of dextrose, a simple sugar, is given into the knee to stimulate the immune response to repair damaged, loose weakened ligaments.
  • The concept is that the injections will help bring about stability to the knee by tightening the knee capsule.
  • The Baker’s cyst forms and reoccurs in response to the body’s need to stabilize the knee and prevent hypermobility and degenerative damage by creating swelling.
  • Tighten the loose knee, correct the problems that generate the swelling, Baker’s Cysts go away and the fluid is reabsorbed into the body.

One more thing, for the Baker’s Cyst to fill up, there has to be a “port,” that allows the fluid to move into the cyst. This port can be created by the fluid’s pressure in the knee. If you remove the fluid pressure, the port closes.

Doctors in Turkey presented a case history in which they suggested Prolotherapy, specifically dextrose Prolotherapy injections diminished the size of the baker’s cyst knee by changing the “water pressure on the knee.” This is what they wrote in the Journal of Clinical and Diagnostic Research (7).

Why the dextrose? Because the dextrose had an impact on the amount of glucose in the knee. Glucose in correct amounts is necessary for wound healing. Too much glucose as seen in diabetes results in healing problems. The dextrose had a regulatory effect and created a “hypertonic” situation, that is it added to the water pressure levels of the cyst innards. Because of the added pressure, the liquid began seeping out of the cyst and back into the knee joint where regular immune system functions could remove the fluid. The Prolotherapy injections squeezed out the baker’s cyst.

Prolotherapy, stimulated the injured tissue, whether it’s the ligaments or the meniscus, to repair itself. 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.

If you have questions about Baker’s Cyst treatment options, get help and information from our Caring Medical staff

1 Abate M, Di Carlo L, Di Iorio A, Salini V. Baker’s Cyst with Knee Osteoarthritis: Clinical and Therapeutic Implications. Medical Principles and Practice. 2021 Dec;30(5):401-7. [Google Scholar]
2 Mortada M, Amer YA, Zaghlol RS. Efficacy and Safety of Musculoskeletal Ultrasound Guided Aspiration and Intra-Lesional Corticosteroids Injection of Ruptured Baker’s Cyst: A Retrospective Observational Study. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2020 Nov;13:1179544120967383. [Google Scholar]
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