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Table of Contents
IMAGING FOR RESIDENTS ANSWER
Year : 2020  |  Volume : 28  |  Issue : 3  |  Page : 197-199

A runner with right lateral knee pain


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 Submission15-Apr-2019
Date of Acceptance13-Jun-2019
Date of Web Publication07-Aug-2019

Correspondence Address:
Dr. Mathieu Boudier-Revéret
Department of Physical Medicine and Rehabilitation, University of Montreal Health Center, Montreal
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JMU.JMU_34_19

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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 2020 Dec 5];28:197-9. Available from: http://www.jmuonline.org/text.asp?2020/28/3/197/264068




  Section 2 – Answer Top


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).

Both ultrasound (US) [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] and magnetic resonance imaging (MRI) [Figure 6], [Figure 7], [Figure 8] of the right knee were performed.
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

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Figure 2: Right biceps femoris in long axis, with power Doppler activated over a cystic lesion deep to the biceps femoris

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Figure 3: Transverse view of the cystic lesion, measuring 9.0 mm × 5.9 mm in this axis

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Figure 4: Lobulated cystic lesion seen emanating from the proximal tibiofibular joint in transverse axis

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Figure 5: Longitudinal view of the multilobulated cystic lesion overlying the proximal anterior tibia

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Figure 6: Transverse cut of the right proximal leg on magnetic resonance imaging

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Figure 7: Coronal cut of the right knee on magnetic resonance imaging

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Figure 8: Sagittal cut of the right lateral knee on magnetic resonance imaging

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Interpretation

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

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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 Top


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 Top


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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
    
3.
Alsahhaf A, Renno W. Ganglion cyst at the proximal tibiofibular joint in a patient with painless foot drop. Pain Physician 2016;19:E1147-60.  Back to cited text no. 3
    
4.
Bianchi S, Abdelwahab IF, Kenan S, Zwass A, Ricci G, Palomba G, et al. Intramuscular ganglia arising from the superior tibiofibular joint: CT and MR evaluation. Skeletal Radiol 1995;24:253-6.  Back to cited text no. 4
    
5.
De Schrijver F, Simon JP, De Smet L, Fabry G. Ganglia of the superior tibiofibular joint: Report of three cases and review of the literature. Acta Orthop Belg 1998;64:233-41.  Back to cited text no. 5
    
6.
Dragoni S, Giombini A, Di Cesare A, Ripani M. A synovial ganglion of the knee: Two cases in athletes. Int J Sports Med 2008;29:692-5.  Back to cited text no. 6
    
7.
Gulati A, Lechler P, Steffen R, Cosker T, Athanasou N, Whitwell D, et al. Surgical treatment of recurrent proximal tibio-fibular joint ganglion cysts. Knee 2014;21:932-5.  Back to cited text no. 7
    
8.
Kaplan EB. Cyst (ganglion) connected with the proximal tibiofibular joint. Bull Hosp Joint Dis 1961;22:105-7.  Back to cited text no. 8
    
9.
Kelm J, Ames M, Weissenbach P, Engel C. A ganglion of the superior tibiofibular joint as a mucoid-cystic degeneration of unusual localization. A case report and review of the literature. Knee Surg Sports Traumatol Arthrosc 1998;6:62-6.  Back to cited text no. 9
    
10.
Lateur G, Pailhé R, Refaie R, Rubens-Duval B, Morin V, Boudissa M, et al. Ganglion cysts of the proximal tibiofibular articulation: The role of arthrodesis and combined partial fibula excision. Int Orthop 2018;42:1233-9.  Back to cited text no. 10
    
11.
Miskovsky S, Kaeding C, Weis L. Proximal tibiofibular joint ganglion cysts: Excision, recurrence, and joint arthrodesis. Am J Sports Med 2004;32:1022-8.  Back to cited text no. 11
    
12.
O'Rourke PJ, Byrne JJ. Giant ganglion of the proximal tibiofibular joint: A case report. Ir J Med Sci 1995;164:295-6.  Back to cited text no. 12
    
13.
Ward WG, Eckardt JJ. Ganglion cyst of the proximal tibiofibular joint causing anterior compartment syndrome. A case report and anatomical study. J Bone Joint Surg Am 1994;76:1561-4.  Back to cited text no. 13
    
14.
Mortazavi SM, Farzan M, Asadollahi S. Proximal tibiofibular joint synovial cyst – One pathology with three different presentations. Knee Surg Sports Traumatol Arthrosc 2006;14:875-9.  Back to cited text no. 14
    
15.
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.  Back to cited text no. 15
    
16.
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.  Back to cited text no. 16
    
17.
Giard MC, Pineda C. Ganglion cyst versus synovial cyst? Ultrasound characteristics through a review of the literature. Rheumatol Int 2015;35:597-605.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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