Shaw-Gang Shyu1, Mathieu Boudier-Revéret2 1 Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan 2 Department of Physical Medicine and Rehabilitation, University of Montreal Health Center, Montreal, Canada
Date of Submission
15-Apr-2019
Date of Acceptance
13-Jun-2019
Date of Web Publication
07-Aug-2019
Correspondence Address: Dr. Mathieu Boudier-Revéret Department of Physical Medicine and Rehabilitation, University of Montreal Health Center, Montreal Canada
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JMU.JMU_34_19
How to cite this article: Shyu SG, Boudier-Revéret M. A runner with right lateral knee pain. J Med Ultrasound 2020;28:197-9
How to cite this URL: Shyu SG, Boudier-Revéret M. A runner with right lateral knee pain. J Med Ultrasound [serial online] 2020 [cited 2023 Mar 30];28:197-9. Available from: http://www.jmuonline.org/text.asp?2020/28/3/197/264068
Section 2 – Answer
Case
A 45-year-old male in good health participating in marathons and triathlons presented with dull discomfort over his right lateral knee in the past 4 months, without any traumatic event reported. The pain was mechanical, without any neurological symptoms. Musculoskeletal and neurological examinations were normal, except for pain over the right proximal tibiofibular joint (PTFJ).
Figure 1: Right biceps femoris in long axis, with a multilobulated cystic lesion deep to the biceps femoris, measuring 6.7 mm × 5.7 mm with anechoic content
The imaging results matched the clinical picture, demonstrating a lobulated ganglion cyst of the PTFJ. There was no focal entrapment of the right common peroneal nerve by the cyst. Even though on US, the cystic lesion was in proximity with the PTFJ, it was only on MRI that a nonequivocal connection with the joint could be demonstrated, thus confirming the suspected diagnosis of PTFJ ganglion cyst. Other findings that were considered nonclinically significant on MRI were intrasubstance injury of the posterior cruciate ligament, medial meniscus tear, and patellar chondromalacia.
Given the patient was still symptomatic after a trial of oral nonsteroidal anti-inflammatory medication, US-guided cyst aspiration followed by injection (20 mg triamcinolone acetate and 2 ml 1% xylocaine) was performed as a less invasive option compared to surgical excision [Video 1]. A small amount (<2 ml) of serosanguinous mucinous gel-like fluid was aspirated [Figure 9]. The analysis of the fluid showed regular synovial fluid profile without detectable crystals.
Figure 9: Aspirate from the right proximal tibiofibular joint ganglion cyst
After the aspiration and injection, his physiatrist suggested casual activity and physiotherapy. His symptoms improved gradually, with no resting pain and no limitation during walking. He even participated and completed the half marathon 2 weeks after the intervention. He was still doing well and symptom free at the 1-month follow-up.
Discussion
The first report of a PTFJ ganglion cyst in the literature dates back to 1891.[1] However, it remains an uncommon entity: a retrospective study of 654 patients who had knee MRI for any reason found that the prevalence of ganglion cysts originating from the PTFJ was 0.76%.[2] Most data published to date on this pathology are made of case reports and case series.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13]
The presentation can include a painless or painful lateral knee mass, with or without common peroneal nerve involvement with varying degrees of neurological involvement.[14] A case of secondary anterior compartment syndrome has even been described,[13] as the cyst can extend and grow intramuscularly.[4],[15]
US appearance of a ganglion cyst typically fulfills these criteria: well-demarcated avascular and anechoic mass with posterior enhancement that is most often connected to a joint or tendon sheath.[16] It is lined by dense connective tissue and contains gel-like fluid rich in hyaluronic acid and other mucopolysaccharides.[17]
Regarding treatment, cyst needle aspiration and steroid injection have been described with anatomic landmarks in the literature, but no clear recurrence rate has been established.[11] A more reliable long-term option remains surgical excision of the cyst with complete resection of the ganglion stem and closure of the capsule.[9] However, in refractory cases presenting with common peroneal nerve involvement, joint excision by proximal fibulectomy has been advocated.[7]
Conclusion
One must keep in mind to include PTFJ in a comprehensive knee examination. US is a good screening tool to confirm the cystic nature of a lateral knee lesion and can also help identify nerve involvement potentially associated with PTFJ ganglion cyst.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Barrie HJ, Barrington TW, Colwill JC, Simmons EH. Ganglion migrans of the proximal tibiofibular joint causing lesions in the subcutaneous tissue, muscle, bone, or peroneal nerve: report of three cases and review of the literature. Clin Orthop Relat Res 1980;149:211-5.
Ilahi OA, Younas SA, Labbe MR, Edson SB. Prevalence of ganglion cysts originating from the proximal tibiofibular joint: A magnetic resonance imaging study. Arthroscopy 2003;19:150-3.
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Muckart RD. Compression of the common peroneal nerve by intramuscular ganglion from the superior tibio-fibular joint. J Bone Joint Surg Br 1976;58:241-4.
Lin CS, Wang TG, Shieh JY, Chen WS, et al. Accuracy of sonography in the diagnosis of superficial ganglion cyst and lipoma. J Med Ultrasound 2009;17:107-13.
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