Working Diagnosis:
1. Atypical, recurrent dissecting Baker's cyst's
2. Bilateral knee OA with grade 4 chondromalacia
3. Degenerative lateral meniscus tear
4. Inflamed medial peripatellar plica
5.Partial ACL tear.

Treatment:
Patient's posterior swelling improved with compression stockings. No surgical intervention was recommended for Baker's cyst or intra-articular pathology by Orthopedics. Rehabilitation focused on lower extremity strengthening, ice massage, joint protection, edema control, and low-impact exercises. Further imaging was not pursued given interval improvement in symptoms.

Outcome:
Ambulation duration and low-impact fitness gradually improved without significant calf swelling or knee pain. Lower extremity edema and ecchymoses resolved with compression stockings. Pain was controlled with ice and acetaminophen.

We transitioned her fitness routine to low-impact swimming, stationary biking, and pool-based Zumba classes. Follow-up was scheduled at one month intervals.

Author's Comments:
-MSK Ultrasound is an accurate, high-yield modality for evaluating location, extent, complexity of Baker's cysts and associated pathology.

-MSK Ultrasound guided intra-articular aspiration and corticosteroid injections are viable treatment options for symptomatic Baker's cysts.

-Treatment of Baker's cysts should target co-existing knee pathology including chondral, meniscal, and cruciate lesions.

-Evaluation for thrombophlebitis/DVT is crucial to proper management of Baker's Cyst's given similar clinical presentations.

-No consensus exists on treatment of complex Baker's cysts (dissection/rupture). Conservative, symptom-based therapy is reasonable.

Editor's Comments:
This case displays the value of MSK Ultrasound for the diagnosis and treatment of a Baker's Cyst. For this patient, US allow for serial imaging of the cyst in the outpatient primary care sports medicine clinic.

References:
1. Chen, C.K., H.L. Lew, and R.I.H. Liao, Ultrasound-Guided Diagnosis and Aspiration of Baker's Cyst. American Journal of Physical Medicine & Rehabilitation, 2012. 91(11): p. 1002-1004.
2. De Mesa, C. and M.A. Dajoyag-Mejia, Infected ruptured Baker's cyst in a spinal cord injury patient. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists, 2012. 91(11): p. 1005-6.
3. Di Sante, L., et al., Ultrasound-guided aspiration and corticosteroid injection of Baker's cysts in knee osteoarthritis: a prospective observational study. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists, 2010. 89(12): p. 970-5.
4. Fang, C.S., C.L. McCarthy, and E.G. McNally, Intramuscular dissection of Baker's cysts: report on three cases. Skeletal Radiology, 2004. 33(6): p. 367-71.
5. Fritschy, D., et al., The popliteal cyst. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 2006. 14(7): p. 623-8.
6. Handy, J.R., Popliteal cysts in adults: A review. Seminars in Arthritis and Rheumatism, 2001. 31(2): p. 108-118.
7. Handy, J.R., Popliteal cysts in adults: a review. Seminars in Arthritis and Rheumatism, 2001. 31(2): p. 108-18.
8. Isenberg, D. and A. Socci, Images in emergency medicine. Woman with leg swelling. Dissecting Baker's cyst. Ann Emerg Med., 2010. 56(5): p. 582, 590.
9. Marra, M.D., et al., MRI features of cystic lesions around the knee. Knee, 2008. 15(6): p. 423-438.
10. Miller, T.T., et al., MR imaging of baker cysts: Association with internal derangement, effusion, and degenerative arthropathy. Radiology, 1996. 201(1): p. 247-250.
11. Wisniewski, S.J., N. Murthy, and J. Smith, Ultrasound Evaluation of Baker Cysts: Diagnosis and Management. Pm&R, 2012. 4(7): p. 533-537.
12. Wolfe, R.D. and B. Colloff, Popliteal cysts. An arthrographic study and review of the literature. The Journal of bone and joint surgery. American volume, 1972. 54(5): p. 1057-63.
13. Tsang, J.P.K. and Yuen, M.K. Sonography of Baker's Cyst (Popliteal Cyst): the Typical and Atypical Features. Hong Kong J Radiol, 2011(14) p. 200-6.

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