Causation Review Popliteal Cysts/Bakers Cyst of the

knee.

Prepared by Peter Larking

Senior Research Advisor
Research
Governance, Policy and Research
ACC
March 2011

Important Note
This review summarises information on popliteal cysts of the knee with a view to clarifying the
existing evidence on causation.
It is not intended to replace clinical judgement, or be used as a clinical protocol. A reasonable
attempt has been made to find and review papers relevant to the focus of this report but it is not
exhaustive. The content does not necessarily represent the official view of ACC or represent
ACC policy.

Contents
Causation Review Popliteal Cysts/Bakers Cyst of the knee ..................................................4
Summary ..................................................................................................................................4
Introduction.................................................................................................................................. 6
Methodology ................................................................................................................................. 6
Discussion..................................................................................................................................... 8
1. Prevalence.................................................................................................................................. 8
2. Prevalence of symptomatic cysts and significance of large popliteal cysts.............................. 12
3. Association with age................................................................................................................ 13
4. Gender..................................................................................................................................... 13
5. Association of popliteal cysts with meniscal pathology, effusion, osteoarthritis and ACL tears
................................................................................................................................................. 13
General studies .................................................................................................................. 13
Meniscal pathology............................................................................................................ 14
Effusion.............................................................................................................................. 15
Osteoarthritis ..................................................................................................................... 15
ACL tears ........................................................................................................................... 16
6. Association with trauma.......................................................................................................... 16
7. Association with knee pain and other symptoms.................................................................... 17
8. Association of popliteal cysts with other pathologies.............................................................. 18
Causation .................................................................................................................................... 18
Suggestions for reviewing claims to ACC where personal injury is said to be a substantial
causative factor............................................................................................................................ 19
Summaries of papers reviewed.20
Acknowledgements ..................................................................................................................... 26
References ................................................................................................................................... 27

Causation Review Popliteal Cysts/Bakers Cyst of the knee

Summary
At the suggestion of the Clinical Advisory Panel, Elective Services, ACC, a report has been
prepared on the etiology of popliteal cysts to assist with the determination of causation with
respect to compensability.
Popliteal cysts or Bakers cysts are found in the posteromedial aspect of the knee and are the
most frequently encountered cystic mass around the knee. The majority extend between the
deep fascia and the medial head of the gastrocnemius muscle and represent a fluid distension of
a bursa between the gastrocnemius and semimembranosus tendons through a communication
2
in the knee joint . It is claimed that the two requirements for cyst formation are the anatomical
communication and a chronic effusion3.
The main findings of the review follow. All the evidence statements rely largely on case series
studies or lower grade cohort studies. Evidence is therefore at best only moderate for most
statements.
1. The determination of prevalence of popliteal cysts is dependent on methodology; As
determined by MRI a prevalence of around 0 to 7% may be expected in middle aged
subjects with no internal knee derangements or disease, around 20% in the
asymptomatic knee of those with internal derangements in the contralateral knee, range
from 5 to 30% in those with suspected internal derangements of the knee and reach a
ratio of nearly one in two in older subjects with advanced osteoarthritis (OA).
2. There is some evidence that prevalence increases with age. In some case series studies,
over 50% of popliteal cysts found were in those over 50 years of age.
3. The effect of gender on prevalence does not seem to be an important consideration.
4. The presence of a popliteal cysts is strongly associated with internal derangements of the
knee:

Strong associations of popliteal cysts with medial meniscal tears are typically and
consistently reported. In many populations (case series studies), of those with
popliteal cysts, 70 to 90% had medial meniscal tears.

There is good evidence that prevalence of popliteal cysts is significantly associated

with the presence and size of effusion; typically around 70% of cases with popliteal
cysts had joint effusion.

There is good evidence that popliteal cysts have a high rate of occurrence in subjects
with OA and some evidence that prevalence is associated with severity of OA: in
older subjects with advanced OA prevalence of popliteal cysts may approach 50%.

5. There is good evidence that the great majority of popliteal cysts as detected by MRI or
ultrasonography are symptomless.
6. The mechanism of cyst formation as proposed by Lindgren1 supports the view that
degeneration of the knee joint capsule contributes to the formation of a popliteal cysts as
4

shown by the increased prevalence with age of a communication between the joint and
the bursa.
7. There is an absence of good data to show that prevalence of popliteal cysts are associated
directly with traumatic events but it seems highly likely that trauma resulting in internal
derangement, effusion or osteoarthritis will result in an increased incidence of popliteal
cysts as a consequence of the acquired pathology.
A number of criteria are given which may assist with the determination of compensability of
individual cases.

Causation Review Popliteal Cysts/Bakers Cyst of the knee

Introduction
At the suggestion of the Clinical Advisory Panel, Elective Services, ACC, a report has been
prepared on the etiology of popliteal cysts to assist with the determination of causation with
respect to compensability.
Popliteal cysts or Bakers cyst are found in the posteromedial aspect of the knee and are the
most frequently encountered cystic mass around the knee. As reported by Labropoulos4 the
majority extend between the deep fascia and the medial head of the gastrocnemius muscle.
Popliteal cysts are typically formed by an intercommunication between the posterior joint
5
capsule and the bursa which is lined with synovial cells . It is claimed that the two requirements
3
for cyst formation are the anatomical communication and a chronic effusion . Some authors
have emphasized the importance of the intercommunication as the means by which the
popliteal cysts can become symptomatic and responsive to intraarticular disease6.
Debris, hemorrhage, loose bodies and synovial proliferation can be present in the cyst7. Diseases
that cause chronic joint effusions such as inflammatory arthritis, crystal deposition diseases, OA
and internal derangements of the knee are associated with popliteal cysts7.
Popliteal cysts in children less than 16 of age are believed to have a different etiology to that in
adults and occur without intraarticular disorders and without communication between the
8
bursa and the joint cavity . In most cases they are treated successfully by conservative means.
Because of this their occurrence in children is not further considered here. Similarly popliteal
cysts in patients with rheumatoid arthritis has not been included although it should be noted
that prevalence of popliteal cysts with this condition may exceed 50%9.
Methodology
As the review is concerned with causation, the focus of the literature search was directed to
etiological factors that may be relevant, including pathophysiology and prevalence with age.
Because there is much literature, mostly case series in design, not all papers have been reviewed.
Case reports on less than 10 subjects were excluded. While this approach is less than ideal it is
practical. Key papers and topics that may have been missed can be added if drawn to our
attention. An emphasis has been placed on reviewing cohort and case/control studies when
they were available. Ovid Medline, EMBASE, TRIP, Cochrane and other evidenced based
healthcare databases were searched for papers relevant to the topic. Papers were graded
according to the Sign methodology (Appendix 1).

Evidence Statements
All the evidence statements below rely largely on patient case series studies or lower grade
cohort studies. Evidence is therefore at best only moderate for most statements.
1. The determination of prevalence of popliteal cysts is dependent on methodology; As
determined by MRI a prevalence of around 0 to 7% may be expected in middle aged
subjects with no internal knee derangements or disease, around 20% in the
asymptomatic knee of those with internal derangements in the contralateral knee,
range from 5 to 30% in those with suspected internal derangements of the knee and
reach a ratio of nearly one in two in older subjects with advanced OA.
2. There is some evidence that prevalence increases with age. In some case series
studies, over 50% of popliteal cysts found, were in those over 50 years of age.
3. The effect of gender on prevalence does not seem to be an important consideration.
4. The presence of a popliteal cyst is strongly associated with internal derangements of
the knee:

Strong associations of popliteal cysts with medial meniscal tears are typically and
consistently reported. In many populations (case series studies), of those with
popliteal cysts, 70 to 90% had medial meniscal tears

There is good evidence that prevalence of popliteal cysts is significantly

associated with the presence and size of effusion; typically around 70% of cases
with popliteal cysts had joint effusion

There is good evidence that popliteal cysts have a high rate of occurrence in
subjects with OA and some evidence that prevalence is associated with severity
of OA: in older subjects with advanced OA prevalence of popliteal cysts may
approach 50%.

5. There is good evidence that the great majority of popliteal cysts as detected by MRI
or ultrasonography are symptomless.
6. The mechanism of cyst formation as proposed by Lindgren1 supports the view that
degeneration of the knee joint capsule contributes to the formation of a popliteal
cysts as shown by the increased prevalence with age of a communication between
the joint and the bursa.
7. There is an absence of good data to show that prevalence of popliteal cysts are
associated directly with traumatic events but it seems highly likely that trauma
resulting in internal derangement, effusion or osteoarthritis will result in an
increased incidence of popliteal cysts as a consequence of the acquired pathology.

Discussion
The findings below are dependent on case series; no studies based on general populations were
found. The findings are 1. Prevalence
Many studies were based on patients attending clinics for investigation of suspected internal
derangements3 6 10-14, for osteoarthritis2 15-18 and for symptoms of DVT (along with controls and
4
those with internal derangements) . Sometimes a control group of patients was included and
these were classified as healthy volunteers4, not having knee pain13 or no or low grades of OA2 16.
Two cohort studies were reviewed19 20 but in each case subjects with predetermined
characteristics were randomly recruited so the true prevalence of popliteal cysts in the general
population cannot be determined from the data. The findings relating to prevalence are (Table
1):

4 21
13
2
16
In control groups (healthy volunteers , no knee pain , no OA or low grades of OA )
prevalence ranged from 0 7% (mean ages ranged from 45 - 61)

In patients referred for internal derangements of the knee prevalence in the

asymptomatic knee was 18.6% (mean age 43) 14

In subjects recruited from a Veterans population and of mean age 67 prevalence was 28%
in those with no knee pain but OA present, 33% in those with pain and OA and 9.1% in
those with without knee pain or OA20

Prevalence in patient populations with suspected internal derangements range from

4.7%22 (mean age 46) to 38%11 (mean age 39)

18
17
In patients with OA prevalence ranged from 22% to 47% this latter figure being seen
in subjects of median age 60 and with OA at multiple sites.

It would seem then that a prevalence of less than 7% may be expected in middle aged subjects1
with no internal knee derangements or disease, will be around 20% in asymptomatic knees of
those with internal derangements in the contralateral knee, range from 5 to 38% in those
presenting with internal derangement of the knee and reach a ratio of nearly one in two in older
subjects with advanced OA.
It is widely agreed that the prevalence of popliteal cysts is related to the diagnostic test
11
employed . High quality MRI is very sensitive and will find the cysts in as many as 38% of
patients referred with suspected nonacute knee internal derangements11. Many of these cysts are
small, asymptomatic and not usually of clinical relevance. MRI is protocol dependent as well
1

A study ( 23. Stehling C et al) investigating prevalence of knee lesions with past physical activity has reported
that in a random selection of 236, 45 55 year olds without knee pain and normal BMI, that by 3T MRI, popliteal
cysts were found in 31 images, a percentage prevalence of 13% (the present authors calculation) . This would
therefore suggest that by this technology presence of popliteal cysts in asymptomatic subjects is very common. The
data though has not been further used here as there are inconsistencies in relation to the popliteal cyst data which
inquires have not resolved.

though; it has been suggested that the low results of Fieldings study10 (5%) may be due to an
12
inappropriate imaging protocol although others using MRI have found low prevalence levels in
22
their populations . Ultrasonography appears to be also highly regarded for its diagnostic
utility16.

Conclusion
The quality of evidence on prevalence is largely dependent on case series data and there is a lack
of large community studies. It would seem however that popliteal cysts are very common in
populations with internal derangements of the knee or with osteoarthritis.
Most of the popliteal cysts found by the various diagnostic methods are asymptomatic and some
authors have speculated that if the structure is not giving rise to local symptoms that it should
24
not be called popliteal cyst at all .

Table 1. Prevalence of popliteal cysts. Summary of papers reviewed.

Author and study
design

Population

Number of
subjects and
mean age

% Prevalence
popliteal cysts

Selected from a random

117 women

34% overall

Notes

MRI methodology
Hayes

19

community cohort but

MRI

selected according to preset

Random selection

patient characteristics. Not

a true random selection of
community living subjects

A small popliteal cyst

was found in 29% of

Mean age, 46

knees; in another 5%
they were moderate to

Woman were in one

large.

of 4 categories
depending on the
presence of OA and
pain.

Tschirch

14

MRI

Patients with clinically

102 asymptomatic

suspected meniscal tears in

knees

18.6%

8% of popliteal cysts
were greater than

the contralateral knee.

30mm in diam
Mean age 43

Case series

Marti-Bonmati

Study investigated the

11

asymptomatic knee

39.6% female

Suspected internal

382 patients

38%

derangements of the knee

population had massive

MRI

Mean age 38.8

Case series

38% female

Hill

20

Subjects with and without

458 subjects

knee pain recruited from

MRI
Cross-sectional

Veterans Affairs and

Community sources

3.1% of total
cysts

In those with knee

In those without knee

pain and OA 33%

pain about one third

Mean age 67,

33% female, Subjects

of cysts were of
In those with OA but

moderate to large in

without knee pain

size but the clinical

Author and study

design

Population

Number of
subjects and
mean age

% Prevalence
popliteal cysts

Notes

were drafted into one

28%

relevance of these

of three groups.

larger cysts was not

In those without knee

investigated.

pain or OA 9.1%

Kornaat

17

Subjects with OA at

205 subjects with

multiple joint sites

multiple joint OA

47%

Popliteal cysts of grade

2 or 3 (moderate to

MRI

severe extension) were

80% female

not associated with

Cohort

pain.

Median age 60
Sansone

22

MRI

Patients referred for

1001 patients, 33%

internal derangement of the

female, mean age 36.

4.7%

knee.

Case series
Fielding

10

Case series

Patients mostly referred for

1103 patients, mean

internal derangement of the

age 36.3,

knee

approximately equal

5%

nos. of male and

MRI

female.
21

Tarhan

Patients with OA and

58 patients with

controls

symptomatic knee

Case series

OA (mean age 57.4,

Cases 35% by MRI

Controls 6.9%

83% female) and 16

MRI and US

volunteer control
subjects (mean age
59, 75% female).

12

Miller

Case series

Patients referred to

384 patients, mean

Orthopaedic Clinic mainly

age 47, gender split

for internal derangement of

not described

19%

the knee

MRI
Ultrasonography
Labropoulos

Healthy volunteers

50 subjects, 50%

4%

female, mean age 45

Ultrasonography

(prevalence based on
legs not cases)

Cases/controls

Painful knees (Suspected

internal derangement of the

100 subjects, 46%

knee, inflammatory

female, mean age 54

19.8%

conditions or previous
trauma)
Suspected DVT

162 subjects, 52%

9.5%

10

Author and study

design

Population

Number of
subjects and
mean age

% Prevalence
popliteal cysts

Notes

female, mean age 51

15

de Miguel Mendieta

Attendees at a

81 patients with knee

Rheumatology Clinic

pain associated with

Ultrasonography

OA, 20 without knee

pain;

Cases/controls from Case

series

Knee pain group =

mean age 66, 93%
female.

In those with knee

pain 37%

No knee pain group =

mean age 62, 70%

In those without 15%

female.
18

Naredo

Patients attending clinic

50 consecutive

In those with knee

with primary OA

patients, 90 knees

pain 22%,

Ultrasonography

symptomatic, 10
knees asymptomatic

Case series

Without knee pain

0%.

Mean age 64.3, 88%

female
13

Rupp

100 cases scheduled for

100 cases with knee

arthroscopy;

pain, mean age 41,

Ultrasonography

In cases - 20%

mm

35% female,
100 hospital patients with

Case control (unmatched)

5% were small < 30

50% medium 30 50
Controls 0%

no knee complaints
100 without, mean

mm
45% large >50mm

age 50, 45% female

Chatzopoulos

Patients with chronic OA

196 patients with

Chronic OA 37%

chronic OA, 75%

Ultrasonography

Controls with no OA

female, mean age 69

Controls 2%

otherwise not described

Case series

54 controls, gender
and age not given

16

Fam

Patients , Primary OA >= 2

50 patients, mean age

Patients, 42%

64.6, 84% female

Prospective case control

Controls, inpatients with

series

OA <=1

Controls 0%
25 controls, mean age
61.3, 48% female

Ultrasonograpy
25

Liao

Case control
Ultrasonography

All referred for

1,120 patients of

ultrasonography of the

whom 145 had

knee

popliteal cyst.

12.9%

8% were ruptured

Mean age of those

with cysts was 59.6,
age range 21 94;

11

Author and study

design

Population

Number of
subjects and
mean age

% Prevalence
popliteal cysts

Notes

55% female
Other methods
Johnson

Case series

Patients referred for

187 patients, 195

37% of knees had a

internal derangement of the

knees

popliteal bursa

knee.
Mean age 40, 32%

Arthroscopy
3

Wolfe

Case series

female
Patients referred for

Group 1, 247 knees,

Group 1, 23% (of

internal derangement of the

mean age 27, 15%

knees)

knee (mainly).

female
Group 2, 32%

Arthrography

Group 2, 202 knees,

mean age 40, 52%
female

Pulich

26

Patients whose chief

940 subjects

complaint did not relate to

Case series
Arthrography

24.9%

23.5% were
symptomatic

the popliteal space, usually

meniscal tears

2. Prevalence and significance of large cysts

The prevalence of clinically relevant, popliteal cysts including large cysts is not well described
in the case series data reviewed. Tschirch14 found that of the popliteal cysts found in
asymptomatic knees (of those with suspected internal derangements in the contralateral knee),
8% were greater than 30mm; Other studies reporting on prevalence of larger cysts in their
studies included Marti-Bonmati11 who found 3.1% (cf. to a total of 38%) and Hill20 6.5% (cf.
13
20.8%)in older asymptomatic veterans. Rupp who reported a prevalence of 20% of cysts in
those being investigated for knee pain found that 95% had medium or large sized cysts.
Vasilevska27 concluded that size of the popliteal cyst was strongly correlated with degenerative
changes of the cartilage and the degree of medial meniscus degeneration whereas Hayes19 found
no significant statistical association of size with OA.
In one series of 940 arthrograms, 76% of cysts were asymptomatic and of these 21% had a
26
palpable mass .
Liao25 reported that 8% of his series had ruptured cysts.
Conclusion
It is concluded that often case series will find that of those with popliteal cysts a variable
proportion, often much less than one third, will have larger cysts but even these are not always
symptomatic14. Some case series do have a much higher prevalence of large cysts13.

12

3. Association with age

It is widely believed that the prevalence of popliteal cysts increases with age and that it is
significantly higher in those over 50 years of age by which time they are relatively common.
There is some evidence for this belief. Statistically significant effects of age on prevalence were
observed in the case series studies of Labropoulos 4 and Johnson6. Labropoulos4 found that
incidence was significantly higher in those with DVT or knee symptoms over 50 years of age
(p<0.001). Some authors noted that the mean age of those with cysts was higher than those
without3 10 11; Sansone22 for example found that those with cysts were of mean age 46 years
compared to 36 in those without and Fielding10 reported that the mean age of their total case
series was 35.4; the mean age of those with popliteal cysts was 51.6 and more than 50% of cysts
2
were found in those over 50 years of age. Age trends are not always observed though .
Lindgren(1978) found that the frequency of communication of the gastrocnemiosemimembranosus bursa and the joint increased with age; over half of those over 50 had such a
communication1
Prevalence of meniscal lesions and OA is strongly related to age28 and it would seem reasonable
to assume that the increase with age is at least in part due to the increase in intra-articular
pathology with age4.
Conclusion
It is concluded that there is reasonable evidence for an increase in prevalence of popliteal cysts
with age but the evidence is not strong and results are dependent on the case series populations
studied.
4. Gender
There is a tendency in many of the studies reviewed (Table 1), for females to have a lower
prevalence of cysts compared to males. Sansone for example found in his series 63% were in
men22. This gender difference is only thought by some to reflect the lower incidence of intraarticular lesions in woman3. The higher prevalence in men is not always observed though 2 12 25
and the prevalence of an intercommunication between the joint space and bursa has been
29
reported as being independent of gender .
Conclusion
It is difficult to draw any conclusions on gender given the absence of studies in the general
population, the preponderance of men with internal derangements of the knee and the
preponderance of women presenting with OA in many of the populations studied. Gender does
not appear to be an important factor though.

5. Association of popliteal cysts with meniscal pathology, effusion, osteoarthritis and

ACL tears

General studies

It is commonly stated that popliteal cysts are almost always associated with other pathologies of
the knee such as internal derangements and OA and the evidence found in the studies reviewed

13

here would support this view. Miller in his case series12 determined by MRI the prevalence of
popliteal cysts in a general orthopaedic population of 384 subjects (mean age 47), and their
association with effusion, internal derangement, and degenerative arthropathy. Overall
prevalence of popliteal cysts was 19%; 99% were associated with other pathology and 80.5 %
with meniscal tears. There were significant associations (P < .01) for effusion, meniscal tears,
and degenerative arthropathy, independent of one another. The probability of having a popliteal
cyst for the whole series given the presence of any one variable was 0.08-0.10; any two
variables, 0.19-0.21; and all three variables, 0.38. They found only one case in the series which
occurred in the complete absence of internal derangement, effusion or degenerative joint
disease.
22
Sansone in his case series found that popliteal cysts were associated in 94% of cases with one,
or more disorders detected by MRI; the commonest lesions were meniscal (83%), frequently
involving the posterior horn of the medial meniscus, chondral (43%), and anterior cruciate
ligament tears (32%).

Conclusion
Case series data therefore suggest strong associations of intra-articular pathology with prevlance
of popliteal cysts.

Meniscal pathology

Strong associations with medial meniscal tears are typically and consistently reported. For
example Rupp in a controlled study of hospital patients13 found that of those with popliteal
cysts, 70% had medial meniscal tears compared to a prevalence of 19% in those without tears, a
3
difference that was highly significant. Wolfe found in patients at an airforce medical centre
(mean age 27), that of those with popliteal cysts, 86% had damage to one or both menisci; in
their general hospital population (mean age 40) of those with popliteal cysts 94% had damage
to one or both menisci.

Fielding10 reported that 71% of those with popliteal cysts had medial meniscal tears; and
lateral tears were seen in 38%

Sansone found that 90% of his cases with poplitieal cysts had medial meniscal tears and
16.6% lateral

Ahn31 found 68% of those with larger popliteal cysts had medial meniscus tears and 29%
lateral tears.

30

Studies that related prevalence of popliteal cysts to type of meniscal tear were not found apart
from the case series study by Marti-Bonmati who found prevalence to be statistically related to
the presence of meniscal degeneration and to meniscal tearing11. Further analysis of tear type
was not made. In subjects with primary OA the presence of popliteal cysts was significantly
18
associated with medial meniscus protrusion .
Though cysts have a high association with tears at the posterior horn of the medial meniscus
they are also associated with lateral tears and some consider that the incidence of association is
simply a reflection of the ratio of medial to lateral tears reported in the literature3.

14

Conclusion
It is concluded that meniscal tears and degeneration occur with high frequency in those who
have popliteal cysts.

Effusion

Wolfe3 believed that while there was a strong association between prevalence of popliteal cyst
and medial meniscal tears of the posterior horn this association is commonly observed because
it is one of the commonest joint derangments seen; they considered that it was the presence of
an effusion producing abnormality that was important.
There is good evidence that prevalence of popliteal cysts is significantly associated with the
presence and size of effusion11 12 20. 77% of cases with popliteal cysts had joint effusion in Millars
12
25
11
20
series , 91.7% in Liaos and 70% of Marti-Bonmatis . Hill found that in those with
moderate to larger effusion, 43.2% had cysts compared to 22.7% in those with an effusion
which was small or absent. There was also a weak but statistically significant relationship
between size of effusion and size of cyst. A case series study of those with primary OA of grade
2 or more found that effusion was present in 86% of knees with cysts compared to 36% without
cysts (p<0.02)16.
While Miller showed that effusion was strongly associated with the presence of popliteal cysts
he also concluded from his data that cysts could occur where there were normal physiological
amounts of fluid in the presence of a meniscal tear and/or degenerative arthropathy.
Vasilevska27 in their series in patients with medial compartment OA found no relationship
between the size of popliteal cysts and effusion.
Suggestions to account for the development of popliteal cysts in the absence of increased joint
effusion have been that fluid accumulation occurred within the cyst from previous resolved
joint effusions11 and that altered biomechanics due to presence of internal derangements are
sufficient to squeeze even normal amounts of fluid into the bursa. This last suggestion is
supported by studies which have shown that intra-articular pressure is higher in patients with
meniscal abnormalities compared to that in healthy individuals12.
Some authors suggest that the development of popliteal cysts cannot be explained by the
accumulation of intraarticular fluid accumulation alone; other factors are important as well such
as the patency status of the interconnection between the bursa and the joint, and the intrinsic
features of the joint capsule2.
Conclusion
It is concluded that effusion is an important feature associated with the development of
popliteal cysts but it is probably not the sole factor.

Osteoarthritis (OA)
2

Chatzopoulos has determined the prevalence by ultrasonography of popliteal cysts in knees

with chronic osteoarthritic pain, reporting a case series study on 196 patients (mean age 69,
75% female) and 54 non-osteoarthritic controls, (age and gender mix not given). Popliteal
cysts were detected in 37% of OA patients compared to 2% in non OA patients. Abnormal and
intense tracer accumulation in early-phase bone scintigraphy (detects the severity of
inflammation in soft-tissue) was significantly more frequent in osteoarthritic knees with

15

popliteal cysts than in those without. Similarly Fam16 has determined the prevalence and
significance of popliteal cysts in primary OA of the knee in a prospective case-control series.
They found that cysts were present in 42% of patients with OA; 38% had bilateral cysts. In the
controls no cysts were detected. The majority of cysts were small and symptomless. The
occurrence of popliteal cysts correlated with the radiological grade of OA and were detected in
47% of knees with grade 3 or 4 OA compared to 18% with grade 2 p<0.03). They concluded
that OA may be a more common cause of popliteal cysts than generally recognized.
The results of some other studies were;
Ahn31 found in his case series on of those with a popliteal cysts, knee pain and an
associated intra-articular lesion, that 39% also had degenerative cartilage damage
25
Liao reported that 50.6% of those with popliteal cysts had OA
In a cohort study of patients with OA at multiple joint sites, 47% of patients had a
popliteal cyst17
Rupp also found a statistically significant association between prevalence of popliteal
13
cysts and presence of OA ; in patients with popliteal cysts grade 3 and 4 cartilage lesions
were predominant (70%) whereas in those without cysts only 6% had grade 3 or 4
lesions
In a case control study based on case series patients 35% of those with OA had popliteal
cysts compared to 6.9% of controls21

Qualitative associations with OA have also been reported15 19 20.

Conclusion
It is concluded that there is good evidence that popliteal cysts have a high rate of occurrence in
subjects with OA and some evidence that prevalence is associated with severity of OA.

ACL tears

Some authors found no statistical association between tears to the ACL and prevalence of
11 12
10
popliteal cysts . Feilding though found a 13% association with complete tear of the ACL and
22
Sansone in their study of 1001 adults referred for MRI for intra-articular disorders (mean age
36, 33% women) found an association in 32% of cases.
Conclusion
It is concluded that an association of popliteal cysts with ACL tears is found but it does not
reach the magnitude of the associations with meniscal tears, effusion, and OA. Moreover given
the close association of chronic ACL tears to other pathologies of the knee it is possible that the
ACL tear association with popliteal cyst prevalence is a reflection of the onset or development of
that pathology.
6. Association with trauma
Many studies did not address a history of trauma as a contributing factor 3 4 12 14 17 20 22 27 30. Cysts
certainly occur in the absence of a history of acute trauma, as in a number of studies patients
presenting after acute trauma were excluded. And excluding trauma cases does not seem to

16

exclude the finding of high rates of prevalence in populations with various pathologies such as
13
11
15
18
19
21
2
internal knee derangements or OA, eg 20% , 38% , 37% , 22% , 34% , 35% and 37% .
Pulich26 reported that 61% of those with popliteal cysts had a history of trauma. Johnson6 found
that 64% of his case series of patients presenting for suspected internal derangements of the
knee who had a bursal communication had a history of trauma compared to 66% of those
without a bursal communication. They concluded that there was no significance to the
presence of a history of trauma and prevalence of cysts.
Only one study investigated the prevalence of popliteal cysts in younger subjects (247 knees,
mean age 26, 85% male) most of whom presented with suspected internal derangement of the
knee3. This study is of some relevance since at this age significant degenerative pathology
would not be expected to be at an advanced state: cysts were found in 23% of knees.
A study that investigated the relationship of severe focal knee lesions to past physical activity
has reported that whereas prevalence of cartilage, meniscus and ligament lesions, bone marrow
edema and joint effusion were significantly related to past activity level, popliteal cysts were
23
not .
Conclusion
It is concluded that there is no good evidence to show that popliteal cysts form as a result of
trauma itself, however it seems reasonable, in the absence of good evidence to assume that
trauma resulting in internal derangements of the knee will then result in formation of popliteal
cysts in an unknown proportion of the population.
7. Association with knee pain and other symptoms
Popliteal cysts are often asymptomatic5. The presence of popliteal cysts as detected by MRI in
asymptomatic knees in subjects of mean age 42 was 18.6%14. Pulich found in his case series that
of the popliteal cysts observed in 24% of patients, 75% were asymptomatic.
Patients with symptoms typically present with internal or mechanical derangements, swelling, a
palpable mass, pain, tenderness or signs and symptoms of thrombophlebitis. Large popliteal
cysts may cause compression of adjacent structures, lead to mechanical problems in knee
5
flexion and limited mobility and may cause ischaemia and deep vein thrombosis .
There is conflicting evidence that prevalence is related to knee pain. In a cohort study of
patients with OA at multiple joint sites 47% of patients had a popliteal cyst; the presence of a
popliteal cyst was not however related to clinical symptoms and severe (Grade 2 or 3) cysts
were not significantly related to pain or stiffness17.
Labrapoulos4 though, found a much higher incidence of popliteal cysts in those with knee
symptoms compared to those without pain (19.8% v. 4%) as did de Miguel Mendieta(37% v.
15%) 15, Naredo18 (22% v. 0%) and Hill20 (33% v.20.8%). Not all of these differences were
statistically significant.
Conclusion
It is concluded that popliteal cysts may occur frequently in populations with asymptomatic
knees but there is a tendency for cyst prevalence to be higher in knees that are symptomatic.
The evidence for this statement is of low quality and findings probably depend on the
population studied.

17

8. Association of popliteal cysts with other pathologies

Because small studies and case reports were not included in this review the relation of
pathologies other than that reported above has not been researched. According to Labropoulos4
who summarised the literature on this topic, other pathologies associated with popliteal cysts
include total knee replacement, rheumatoid arthritis, and infections including tuberculosis
coccidiomycosis, sarcoidosis candidiasis and brucellosis. Labropoulos reviewing others work
concluded like Wolfe3 that any pathology that can cause a knee effusion can cause popliteal
cysts.
Causation
Theories regarding formation of popliteal cysts centre on the relative weakness of he posterior
joint capsule5 and increased intra-articular pressure due to joint effusion or altered
biomechanics (meniscal tears or degenerative joint disease) which causes the extravasation of
32
joint fluid into the gastrocnemius-semimembranosus bursa . The increased pressure leads to
32
the gradual formation of an enlarging popliteal cyst . The flow of fluid may be valvular or free.
24
Lindgren found in subjects with symptomatic and palpable popliteal cysts that a valve
mechanism was present in 61% of cases.
Lindgren1 concluded from his studies on cadavers that degeneration of the knee joint capsule
increased with age and its elasticity diminished; these conditions then facilitated the tearing of
1
the posterior part of the capsule on extension of the joint . He considered that with increasing
age, less and less strain was required for such a tear to occur. Fluid in the joint associated with
other pathologies, which also increase with age, played a role in causing a rise in pressure in the
dorsal part of the joint on flexion. A communication between the joint and the bursa then
resulted from either a tear in a degenerated joint capsule or through a rupture of the thin
membranes in a previously formed slit.
Wolfe3 considered that there was overwhelming evidence that popliteal cysts were usually
secondary to intra-articular pathological processes and Rupp13 concluded that the popliteal cyst
was a secondary phenomenon and treatment should address the underlying intra-articular
lesions.
Conclusions
The mechanism of cyst formation as proposed by Lindgren supports the view that degeneration
of the knee joint is largely causative in the formation of a popliteal cyst as shown by the
increased prevalence of a communication between the joint and the bursa with age. There is
little evidence to suggest that trauma to the knee is it itself a risk factor but it seems highly
likely that trauma resulting in internal derangement or osteoarthritis of traumatic origin will
result in an increased incidence of popliteal cysts.
From an evidential point of view the above statements may be said to be reasonable in the light
of the available evidence but they are by no means definitive. From ACCs perspective such
mechanisms suggest that both degeneration and trauma can be the cause the formation of a
popliteal cyst. Trauma is likely to be causative in many younger subjects.

18

Suggestions for reviewing claims to ACC where personal injury is said to be a substantial
causative factor
33

It is suggested that trauma may be accepted as a causative factor of a popliteal cysts when

There is a clear history of a trauma event likely to be causative

There was no history of knee pathology prior to the injury

The traumatic event resulted in the development of internal pathology to the knee
consistent with the injury and which is consonant with the formation of a popliteal cyst.
Such pathology would include effusion and medial meniscal tears likely to be of
traumatic origin.

The patient has not been symptom free from the date of injury (evidence of
derangement)

The symptoms are unilateral only, in the injured knee

The popliteal cyst developed within a reasonable period from the date of injury

When the subject is older the presence of significant pre-existing meniscal degeneration,
OA and rheumatoid arthritis should be excluded. There should be no signs of advanced
joint disease in the contralateral knee. A weight bearing x-ray may be desirable.

19

Summaries of papers reviewed

General papers
14
1. Tschirch has shown by MRI in a case series of 102 asymptomatic knees (mean age 43,
40% female) that the prevalence of popliteal cyst was 18.6% (26 cysts in 19 knees).
Sign level 3.

2. Labropoulos 4 has investigated the aetiology of popliteal cysts by prospectively studying

426 legs in 312 individuals with ultrasonography. Participants included healthy
volunteers (n=50, 50% female, mean age 54), patients with a painful knee (n= 100, 46%
female, mean age 45), and a group of patients with signs and symptoms of deep vein
thrombosis (DVT) (n=164, 52% female, mean age 51). They found that the prevalence of
popliteal cyst increased with age and was significantly higher in those aged over 50 years
and with knee or DVT symptoms (P < 0.001). Compared with controls (incidence 4.0
per cent), cysts were more common in patients with DVT symptoms (9.5 per cent; P =
0.141) and those with painful knees (19.8 per cent; P < 0.001). All cysts were located in
the posteromedial aspect of the popliteal fossa. They concluded that popliteal cysts are
relatively common in patients over 50 years old with a painful knee or with signs and
symptoms of DVT. A cross-sectional study but largely based on case series. Sign level 3.
3. Marti-Bonmati11 has evaluated the prevalence of popliteal cysts in a prospective case
series of 382 consecutive patients by MRI (38% female, mean age 39) . No patient had
rheumatoid arthritis, infection or trauma. Of the 382 patients, 145 had Popliteal cysts
(38.0%). Cyst content was minimum in 99, moderate in 34 and massive in 12. Joint
effusion was observed in 269 patients (70.4%), being minimal in 140 patients, moderate
in 119 and massive in ten. Meniscal lesions were observed in 195 patients (51%), while
58 patients (15%) had a cruciate ligament lesion. Popliteal cyst had a statistically
significant direct relationship with the presence and quantity of synovial fluid (P=0.002)
and with the presence and type of meniscal lesion (degeneration or tear) (P=0.01) but
not with cruciate ligaments or cartilage lesions. Patients with popliteal cysts were older
than those without which was of statistical significance (mean age 41.8 v. 36.9; Chi Sq =
0.003).
It was concluded that the presence and volume of popliteal cysts in MR studies of the
knee are related to the quantity of synovial fluid, and to the presence and severity of
meniscal lesions. Prospective case series. Sign level 3.
30

4. Sansone described 30 cases of popliteal cyst (37% female, mean age 56) as seen at
arthropscopy and by sonography. In all cases there was an associated intra-articular
pathology. 90% of cases were related to a medial meniscal tear on the posterior horn and
the tear had horizontal components. In 10% (3) of cases the medial meniscus was
normal; 2 of the 3 cases had chondral lesions, the third serious rheumatoid synovitis.
66% had chondral lesions. In all cases a connection between the joint space and the cyst
was found. A case series Sign level = 3.
22
5. Sansone has studied the epidemiological features of popliteal cysts in 1001 adults
referred for MRI of intra-articular disorders (mean age 36, 33% women). Popliteal cysts
were seen in 4.7% of this group of whom 37% were women. The mean age of those with

20

cysts was higher than the whole group, 46 v. 36 (P<.001). The cysts had the highest
prevalence in those 50 60 and increased gradually with age. A communication with
the joint was invariably found. The cysts were associated with one, or more, disorders
detected by MRI in 94% of cases. The commonest lesions were meniscal (83%),
frequently involving the posterior horn of the medial meniscus, chondral (43%), and
anterior cruciate ligament tears (32%). 42% had chondral injury graded 3 or 4. Case
series, Sign level = 3.
6. Johnson6 has sought to establish by arthroscopy the incidence of popliteal cysts in 187
consecutive knee surgery patients (199 knees, mean age 40, 32% female). A cyst was
defined as such only if it had a communication with the knee joint via the posterior
medial compartment. 37% of knees had a popliteal bursa so identified (mean age 43.4,
33% female, age range 13.0 75 years) There was a significant correlation with age
(p<.05) for right knees only. A history of trauma was identified in 66% of the those
without bursal communication and in 64% of those with cysts and respectively, posterior
pain, 15% v. 21%; joint effusion in 37% v. 32%; meniscal tear in 66% v. 71% and OA
80% v. 82%. None of these differences were significant. Case series, Sign level = 3.
7. Wolfe3 has analysed by arthrography two case series: Group 1; 247 knees, Mean age 27,
15% female; and Group 2; 202 knees, mean age 40, 52% female. They found that in
Group 1 the prevalence of cysts was 23%; 24% in males and 19% in females. 86% of
those with cysts had damage to one or both menisci. The lateral meniscus was damaged
in 12.5% of patients. In group 2, prevalence was 32%; 36% in males and 27.6% in
females. 94% had damaged menisci. The lateral meniscus was involved in 14% of
patients. The average age of those with cysts was always greater than those without, 32
v. 26 in group one and 46 v. 37 in group 2. Incidence of cysts increased with age from
25.7% in those 21 30 to 53.5% in those 51 90. They considered that there was
overwhelming evidence that popliteal cysts were usually secondary to intra-articular
pathological processes. Case series Sign level = 3.
10

8. Fielding has reviewed MRIs from a case series to find the incidence of popliteal cyst and
its associated injuries in 1103 patients referred for evaluation of internal derangement;
(approximately even numbers of male and female, mean age 36.3). The incidence of
popliteal cyst was 5%. Mean age of those with cysts was 51.6 and those without 35.4.
50% of cysts occurred in those greater than 50. 71% of those with cysts had a meniscal
tear at the posterior horn of the medial meniscus. Lateral tears were found in 38%; 27%
had tears in both menisci. 13% had a tear to the ACL, 71% had supratellar joint
effusions and 21% signs of OA. They concluded that the reported higher incidence
found with arthrography is thought to be due to arthrographic distension of normal,
collapsed bursae. Case series, Sign level 3.
12

9. Miller has determined by MRI the prevalence of popliteal cyst in a general orthopaedic
population and its association with effusion, internal derangement, and degenerative
arthropathy in 384 subjects, mean age 47, age range 14 88.
Prevalence was 19%. 62.3% of those with cysts were female. Mean age of those with
cysts was 53 compared to those without cysts of 46 years. The epicentre of 44% cysts
were located at the level of the knee joint and 52% slightly superior to it. 99% of cysts

21

were associated with other pathology, 80.5% being with meniscal tears. No association
was found between popliteal cyst and anterior cruciate ligament tear or medial collateral
ligament injury. There were significant associations (P < .01) for effusion, meniscal tear,
and degenerative arthropathy, independent of one another. Probability of having
popliteal cyst given the presence of any one variable was 0.08-0.10; any two variables,
0.19-0.21; and all three variables, 0.38. Case series Sign level = 3.
10. Rupp13 has studied by ultrasonography the prevalence of popliteal cysts and the
associated intraarticular lesions via a prospective case-control study based on case series
subjects. They studied 100 patients scheduled for arthroscopic surgery of the knee, all
with knee pain (mean age 41, 35% women) and 100 patients without any knee
complaints as a control group (mean age 50, 45% women) from subjects hospitalised for
other spine, joint or foot surgery. The prevalence of popliteal cysts was 20% in the study
group and 0% in the control group. Patients with a popliteal cyst had a significantly
higher prevalence of medial meniscal tears (70% versus 19%) (P<.001) and of chondral
lesions (85% versus 28%) (P<.001). Tears of the lateral meniscus were more evenly
distributed (20% versus 36%) (p = ns). They concluded that the popliteal cyst is a
secondary phenomenon and that treatment should address the underlying intraarticular
lesions. Case-control Sign level 3.
1 29

11. Lindgren has described the anatomy and histology of the gastrocnemiosemimembranosus bursa after reviewing 544 patients attending for clinical arthrography
and 248 knee joints from 154 autopsy cases (Age range 10 100). A communication
between the joint and the bursa was found with greater frequency in the older subjects,
frequency increasing from age group 10 - 19 to 40 50 from where it appears to plateau
at around 50 to 60% of subjects: a communication was present in over half of those over
50 years, none in those under 10. There was no gender difference in the frequency of a
communicating bursa; the frequency did not differ between those with and without
other knee abnormalities as established by radiography; the duration of symptoms had
no influence on the frequency of joints with and without communication. The wall of
the bursa and the wall of the joint capsule had a similar histological appearance. They
concluded that the results supported the hypothesis that the popliteal cyst is formed via
rupture of the joint capsule giving a communication with the normal gastrocnemiosemimembranosus bursa. Case series sign level 3.
26

12. Pulich has investigated asymptomatic popliteal cysts in 940 patients of whom 234 had
popliteal cysts; 179 were asymptomatic. No age or gender data was given. Prevalence
was 24.9%; 76.5% were asymptomatic. Of those with asymptomatic cysts; 68.2% had a
history of a related traumatic event and 59.8% had meniscal tears; 70.4% had no joint
effusion. The author suggests that the term popliteal cyst refer only to a clinically
evident entity. Case series, Sign level 3.

Association with OA, effusion and knee pain

1. Hayes19 studied 117 randomly selected women (mean age, 46 years; range, 32-56 years)
selected from a community-based arthritis study (n = 1053) with 30 women in each of

22

four categories: (a) no pain and no OA of the knee, (b) no pain and OA of the knee, (c)
pain and no OA of the knee, and (d) pain and OA of the knee; a small popliteal cyst was
found in 29% of knees; in 5% they were moderate to large. The prevalence of popliteal
cyst did not significantly correlate with radiographically determined incidence of OA
though a qualitative trend was observed. Sign level 2-.
2. Hill 20 has evaluated the association of effusions, popliteal cysts, and synovial thickening
with knee symptoms in older persons in a cross-sectional analysis of subjects selected
from a veterans cohort. The knee pain/XROA group had knee symptoms and
radiographic OA (259 male, 122 female (33%)); No knee pain/XROA (radiographic OA)
group (17 male, 8 female) had no knee symptoms and radiographic OA; and No knee
pain/no XROA group (29 male, 23 female) had no knee symptoms and a normal
radiograph. Mean age 67. Popliteal cysts were seen in 20.8% of those without knee pain
and 33% of those with knee pain. The cysts were more common in those with OA than
in those without. Prevalence was also related to size of effusion (p<.001). After
adjusting for the severity of radiographic OA, there was no difference in the prevalence
of popliteal cysts between those with and without knee pain. It was concluded that knee
pain is not related to the presence of popliteal cysts. A cross-sectional analysis of a
selection from a cohort. Sign level 2-.
3. de Miguel Mendieta15 investigated the prevalence of clinical and sonographic factors
associated with painful episodes in patients with knee OA. Patients were selected from
attendees at a Rheumatoid Clinic; Group A: 81 patients with knee pain during physical
activity >or=30 mm in visual analogue scale (VAS) for pain for at least 48 h prior to
inclusion (96.3% female, mean age 66.8); Group B: 20 patients without knee pain from
at least 1 month prior to inclusion (70% female, mean age 62.1). The prevalence of
popliteal cyst was 37% v 15% (P=0.06). Sign level 3.
4. Naredo18 has compared ultrasonographic findings with clinical and radiographic
assessment of knee OA. Fifty consecutive patients with primary knee OA attending
rheumatology clinic, mean age 64.3, 88% female, 10 unilateral OA, 40 bilateral were
examined clinically and with ultrasonography. 22.2% of knees with symptoms (90
knees) had a popliteal cyst, none without symptoms had cysts (p = NS). The presence of
popliteal cyst was significantly associated with medial meniscus protrusion (p<.005),
and effusion (P,.005) but not with pain. Sign level 3.

17
5. Kornaat has prospectively evaluated the association between clinical features and
structural abnormalities found at magnetic resonance (MR) imaging in patients with
osteoarthritis (OA) of the knee in a cross-sectional analysis of a cohort. The study
examined by MRI 205 subjects (80% female) of median age 60 years; all patients in had
symptomatic OA at multiple joint sites. 35% had radiographically diagnosed OA in the
knee. 47% of patients had a popliteal cyst. The presence of a popliteal cyst was not
related to clinical symptoms; Grade 2 or 3 cysts were not significantly related to pain
(p=.16) or to stiffness p = .14. Cross-sectional analysis of cohort. Sign level 2-.

23

6. Vasilevska27 has evaluated the relationship between size of popliteal cyst and medial
compartment knee osteoarthritis in a retrospective review of a case series. 66 patients
with popliteal cyst and medial compartment knee osteoarthritis were investigated. 31
had a large popliteal cyst (65% female, mean age 54) and 35 had a small popliteal cyst
(only detectable by MRI) (66% female, mean age 59). In the group with the large
popliteal cysts, 84% had medial compartment cartilage loss and 58% of these had
associated 3rd degree meniscal degeneration; 16% cases had only medial meniscus
involvement. There was a statistically significant relationship between meniscal
degeneration and distension of the cyst (p<.01) in this group. In the second group, 48%
of cases had cartilage loss, and of these 82% had 3rd degree meniscal degeneration. In
52% of cases meniscus degeneration was only present. They concluded that the size of
the popliteal cyst was strongly correlated with degenerative changes of the cartilage and
with the degree of meniscus degeneration in the medial compartment of the knee joint.
Sign level 3.
7. Chatzopoulos2 has determined the ultrasonographic prevalence of popliteal cysts in
knees with chronic osteoarthritic pain in a case series study on 196 patients with chronic
OA, (mean age 69, 75% female) and 54 non-osteoarthritic controls, (age and gender mix
not given). Popliteal cysts were detected in 37% of OA patient compared to 2% in non
OA patients. 9% of patients had bilateral cysts. There was no significant difference in
prevalence between men and woman nor was an age affect observed although this may
have been due to the population studied. Abnormal and intense tracer accumulation in
early-phase bone scintigraphy (detects the severity of inflammation in soft-tissue) were
significantly more frequent in osteoarthritic knees with popliteal cysts (97 and 56%,
respectively), than in those without (89 and 40%, respectively, P<0.05 for both). A case
series; Sign level 3.
8. Fam16 has determined the prevalence and significance of popliteal cysts in primary
osteoarthritis (OA) of the knee in a prospective case-control series by ultrasonography in
50 patients with primary OA (grade 2 or more) , mean age 64.6, 84% female; and 25
controls, mean age 61.3, 48% female with radiographic OA = 0 or1. They found that
cysts were found in 42% of patients; (38%) had bilateral cysts, and in 0% of controls.
The majority of cysts were small and symptomless. The occurrence of cysts correlated
with the presence of knee effusion (effusion was present in 86% of knees with cysts
compared to 36% without cysts (P<.02)) and the radiological grade of OA (P<.002).
Cysts were detected in 47% of knees with grade 3 or 4 OA compared to 18% with grade
2 (p<.03). They concluded that OA may be a more common cause of popliteal cysts
than generally recognized. Prospective case series, Sign level = 3.
31

9. Ahn has examined the functional and magnetic resonance imaging (MRI) outcomes of
popliteal cysts with combined intra-articular pathologies that were treated
arthroscopically. There were 31 subjects with popliteal cysts combined with pain and an
intra-articular lesion or with larger popliteal cysts unresponsive to aspirations; 55%
female, mean age 47.7.
The connecting valvular mechanism was found in all cases. 68% were associated with
medial meniscal tears, 29% lateral meniscal tears, 39% degenerative cartilage damage and
6% synovitis. Case series, Sign level 3.

24

25

10. Liao has investigated the pathology associated with popliteal cyst (BC) in patients
attending a rheumatology clinic using a case series design. Of 1,120 patients who
underwent ultrasound studies, 145 had popliteal cyst; mean age 59.6, 54% female.
Prevalence 12.9%. The associated diseases were as follows: 50.6% osteoarthritis of the
knee, 20.6% rheumatoid arthritis, 13.9% gout, 7.8% seronegative spondyloarthropathy
and 7.2% pyrophosphate arthropathy. Effusion was present in 91.7% of knees with
popliteal cysts and synovitis present in 69.9%. Case series, Sign level 3.
11. Tarhan21 has reported the prevalence of the abnormalities detected by magnetic
resonance imaging (MRI) and ultrasonography in a group of 58 patients with
symptomatic knee OA (mean age 57.4, 83% female) and 16 volunteer control subjects
(mean age 59, 75% female). All knees with OA had cartilage abnormalities on US
examinations and normal cartilage was detected in less than 3% of these knees by MRI.
Joint effusion was present in 24.1% of the controls; 6.9% had synovial thickening and
6.9% popliteal cysts as shown by MRI. In the cases, synovial thickening was present in
50%, effusion in 85% and popliteal cysts in 35% as determined by MRI. This study
confirmed that there was a significant correlation between the MRI and US techniques
for evaluating the cartilage and soft tissue changes in the patients with knee OA.
Case series, Sign level 3.

25

Appendix One, Level of evidence in the SIGN system

SIGN criteria for classifying studies.
Score
Design
1++
High quality meta-analyses, systematic review of RCTs, or RCTs with a very low risk of bias
1+
Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1Meta-analyses, systematic reviews of RCTs or RCTs with a high risk of bias
2++
High quality systematic reviews of case-control or cohort studies. High quality case-control or
cohort studies with a very low risk of confounding, bias or chance and a high probability that
the relationship is causal
2+

Well conducted case control or cohort studies with a low risk of confounding, bias or chance
and a moderate probability that the relationship is causal

2-

Case control or cohort studies with a high risk of confounding, bias or chance and a significant
risk that the relationship is not causal.

Non-analytic studies

Expert opinion

Acknowledgements
The timely and helpful assistance of the ACC librarians, Helen Brodie and Beth Tillier is
gratefully acknowledged.

26

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