Knee and Thigh Swelling- Recreational Athlete

Abstract

HISTORY: 30-year-old male recreational athlete with right knee arthritis presents with complaints of intermittent left knee effusion and severe posterior thigh fullness for three years. Pain can be burning or sharp in nature. Symptoms improve with rest and are worse with standing and walking. He notes difficulty with exercise, but is able to continue treadmill and stationary bicycle despite the above symptoms. Symptoms briefly improved with intra-articular steroids, moderately improved with oral Methotrexate, and dramatically improved with oral steroids. Patient had one episode of iritis that resolved. Past medical history for similar symptoms in the right knee for six years associated with intermittent oral ulcers. Family history positive for mother with arthritis and brother with Behcet's Disease. PHYSICAL EXAMINATION: Visible effusion of right knee. No left knee effusion at the time of exam. Positive fullness approximately 4 cm proximal to the left popliteal fossa. Full range of motion at the knees bilaterally. No tenderness to palpation of left knee area. All ligaments stable. DIFFERENTIAL DIAGNOSIS: Spondyloarthropathy Behcet's Disease Systemic lupus erythematosus Popliteal cyst Bursitis of gastrocnemius, pes anserine, biceps, semimembranosus Meniscal injury Hematoma Tendinopathy TESTS AND RESULTS: MRI Left thigh and knee- outside read:Possible semimembranosus tearing with suggestive large hematoma. Effusion, pes anserine bursitis, meniscal tear.MRI Left thigh and knee – inside read:Possible large popliteal cyst versus hematoma.Left knee arthrogram:Irregularity and lobulation of the joint capsule consistent with synovitis, multilobulated popliteal cyst extending proximally (anteriorly and within the semimembranosus muscle) and distally. Findings consistent with an inflammatory arthritis. FINAL WORKING DIAGNOSIS: Very large popliteal cyst with continuity into intra-articular space. Spondyloarthropathy- presumably Behcet's variant Meniscal Tear- not responsible for patient's symptoms TREATMENT AND OUTCOMES: Patient has been followed in conjunction with rheumatology. Patient has been on Methotrexate 12.5 mg weekly for several months with moderate improvement. Patient has had several steroid injections, which provided only one to two weeks' benefit. Patient continues his exercise program of cycling and treadmill running with no worsening of symptoms. Patient has been referred to an orthopedic joint specialist for consideration of left knee synovectomy for symptomatic control. Patient had been offered physical therapy training for joint protection, but was not interested.