Which specialist should a patient with bilateral Baker's cysts be referred to?

Referral for Bilateral Baker's Cysts

For bilateral Baker's cysts without DVT or deep venous incompetence, the patient should be referred to an orthopedic specialist or rheumatologist for further evaluation and management. 1

Understanding Baker's Cysts

Baker's cysts (popliteal cysts) are fluid-filled masses in the popliteal fossa that typically represent distension of the gastrocnemio-semimembranosus bursa. These cysts often communicate with the knee joint through an opening in the joint capsule posterior to the medial femoral condyle 2.

Key clinical features:

• Located behind the knee, extending down the calf
• Present with swelling and tenderness
• Symptoms may worsen with exercise
• Also present at rest
• Do not typically present with intermittent symptoms 1

Rationale for Specialist Referral

1. Underlying Pathology: Baker's cysts in adults are rarely isolated findings and typically indicate underlying knee joint pathology that requires evaluation 2, 3:

   • Osteoarthritis
   • Meniscal tears
   • Rheumatoid arthritis
   • Other inflammatory conditions

2. Diagnostic Confirmation: While ultrasound has already identified the cysts, further assessment may be needed:

   • MRI may be indicated to evaluate associated intra-articular pathology 2
   • Assessment of the extent of the cysts and their communication with the joint 1

3. Treatment Planning: Management depends on addressing the underlying condition 4:

   • Conservative management of the primary knee disorder
   • Potential aspiration if symptomatic
   • Surgical intervention may be considered in select cases

Specialist Selection

Orthopedic Specialist

• Preferred if:
  • Patient has mechanical symptoms (catching, locking)
  • History of trauma
  • Suspected meniscal or ligamentous pathology
  • Consideration for surgical intervention

Rheumatologist

• Preferred if:
  • Signs of inflammatory arthritis
  • Multiple joint involvement
  • History of autoimmune disorders
  • Baker's cysts are common in rheumatoid arthritis (found in 47.5% of RA patients) 5

Management Considerations

The specialist will likely focus on:

1. Treating the underlying condition rather than the cyst itself 4, 6
2. Conservative management is typically first-line:
   • Anti-inflammatory medications
   • Physical therapy
   • Activity modification
   • Aspiration in select cases
3. Surgical intervention only when:
   • Conservative measures fail
   • Cysts are large and symptomatic
   • Underlying pathology requires surgical correction

Important Caveats

• Surgical excision alone has a high recurrence rate (63%) if the underlying knee pathology is not addressed 4
• Many Baker's cysts are asymptomatic and discovered incidentally 2
• Ruptured Baker's cysts can mimic deep vein thrombosis (pseudothrombophlebitis syndrome) 2
• Ultrasound is highly sensitive for detection but may not fully characterize associated intra-articular pathology 5

By referring to the appropriate specialist, the underlying cause of the Baker's cysts can be addressed, which is essential for effective management and prevention of recurrence.