107: Knee Deep: Understanding Baker’s Cysts (with Whitney Lowe & Til Luchau)
Episode Transcript
Summary: Baker’s cysts, the most common cyst behind the knee, affect about 20% of all people. When painful, they can limit mobility and impact quality of life. In this episode, Til interviews Whitney about what Baker’s cysts are, what we as hands-on therapists can do about them, and how we can broaden the lens about the benefits of our work.
- Til Luchau’s Advanced-Trainings.com
- Whitney Lowe’s Academy of Clinical Massage
Resources:
- Nanduri A, Stead TS, Kupsaw GE, Deleon J, Ganti L. Baker ’ s Cyst Case Presentation. 2021;13(12). doi:10.7759/cureus.20403
- Burger C. Baker’s cyst. Chirurg. 1999;70(5):611-612. doi:10.1016/s2255-4971(15)30317-7
- Afandiyeva MA, Janbachishov QS. Baker’s cyst. Azerbaijan Med J. 2004;7(1):125-127. doi:10.1177/1941738113520130
Episode 107: Knee Deep: Understanding Baker’s Cysts (with Whitney Lowe & Til Luchau)
Whitney Lowe:
Welcome to The Thinking Practitioner Podcast.
Til Luchau:
A podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today.
Whitney Lowe:
I’m Whitney Lowe.
Til Luchau:
And I’m Til Luchau.
Whitney Lowe:
Welcome to The Thinking Practitioner.
Til Luchau:
Welcome to The Thinking Practitioner.
Whitney Lowe:
And welcome to The Thinking Practitioner, where Books of Discovery has been a part of the massage therapy and bodywork world for over twenty-five years. Nearly 3000 schools around the globe teach with their textbooks, e-textbooks and digital resources. Books of Discovery likes to say, “Learning adventures start here.” And they find that same spirit here on The Thinking Practitioner Podcast, and they’re proud to support our work knowing we share the mission to bring the massage and bodywork communities thought-provoking and enlivening content that advances our profession.
Til Luchau:
And here’s an interesting thing that I just learned. Instructors of manual therapy education programs can request complimentary copies of Books of Discovery’s textbooks for review, and use in your programs. Please reach out to BooksofDiscovery.com, and Thinking Practitioner listeners can explore their collection of learning resources for anatomy, physiology, pathology, ethics, and business mastery at BooksofDiscovery.com also, where you can save 15% by entering thinking at checkout.
Whitney Lowe:
And this episode is also sponsored by us at the Academy of Clinical Massage, where we welcome you to the next step in your path to clinical success. Our orthopedic and clinical massage programs are fully online, and are designed to elevate your skills in treating pain and injury conditions. You can learn at your own pace from anywhere. And as your instructor, I’ll be with you every step of the way, offering personalized guidance and support. Plus, our new payment plan makes this unique educational opportunity even more affordable than ever. So, join us and become part of a community dedicated to excellence in healing. Let’s enhance your practice together at academyofclinicalmassage.com.
Til Luchau:
That’s great, Whitney, you really are the instructor. You’re speaking to the first person there, and that really is you.
Whitney Lowe:
That is really me.
Til Luchau:
That’s so cool.
Whitney Lowe:
Yeah.
Til Luchau:
And I know you’ve been working hard on polishing, and putting a sparkle on what you’re doing now, so I think this is going to be great for people to go check that out.
Whitney Lowe:
Yeah.
Til Luchau:
See what you’re up to.
Whitney Lowe:
All right, well we’re just passing here in the United States, the Thanksgiving holiday period here, so we’ve all been kind of off for a little bit here, but great to be back on the air with you again, sir.
Til Luchau:
Some of us are off all the time. I’ve been a little off here and there, but I just live there. I live in this kind of off state and that works out I think.
Whitney Lowe:
I think so.
Til Luchau:
I’ve been more or less okay considering. How about yourself?
Whitney Lowe:
Yeah. And actually you just got back from Puerto Rico, right?
Til Luchau:
Yeah. Yeah, that was really run.
Whitney Lowe:
And you were doing a training program down there, is that correct?
Til Luchau:
Yep. We did an extended format training in the neck, jaw, and head, and that was so nice to have the time to really go deep, and a bunch of people that have taken the training before join us, and a bunch of new people. A pretty big group, and it was great to go through the material step-by-step, and have a bunch of time to do that.
Whitney Lowe:
Nice. Yeah. What’s the manual therapy community like in Puerto Rico? Is it training programs similar, or training level similar to here?
Til Luchau:
Pretty active. I would say… I don’t have a representative sample, but I know just from the people that come to our trainings, it’s a pretty high level of education and sophistication to what they’re doing. In fact, the assistants that came from the mainland were remarking in that too, how much experience and skill that practitioners there had.
Whitney Lowe:
Nice. Yeah.
Til Luchau:
Yeah.
Whitney Lowe:
Yeah.
Til Luchau:
Really enjoyed it.
Whitney Lowe:
Yeah. That’s great. Well, I’m sure it was a great, fortunate opportunity for them to get a chance to work with you as well. And I think it’s wonderful that you’re reaching out, and touching all those different points of the world nowadays too, because doing a lot of international stuff.
Til Luchau:
Kind of you to say. I’m looking forward to our conversation today. You named a topic that caught my ears. What are we talking about today?
Whitney Lowe:
Yeah, well I thought since this was the season of holidays and baking, then it would be appropriate for us to talk about baking today. But since I’m not really that good at baking, I thought maybe bakers would get us there. So we’re going to talk about Baker’s cysts today.
Til Luchau:
Baker’s cysts, all right. And this has to do with the knee, Baker’s cysts has to do with the knee. We need to think of a title for this episode that makes that clear, so we don’t have people complaining about the lack of muffin recipes or something like that.
Whitney Lowe:
Yeah. A half-baked approach to therapy on the knee, or something like that.
Til Luchau:
All right, there we go. Okay. So that’s interesting. Baker’s cysts… I’ve seen… I was trying to remember, it’s probably half a dozen, or fewer. I don’t think they’re that rare, but I think just in my personal experience, it’s not that extensive. I have a couple of anecdotes, but I’m really looking forward to learning from you, and hearing what you have to say about them, because I’m wanting to fill out my own Baker’s cyst knowledge.
Whitney Lowe:
Yeah. All right, let’s dive in.
Til Luchau:
Let’s dive in.
Whitney Lowe:
Yeah.
Til Luchau:
You want to start with what it is? What is a Baker’s cyst?
Whitney Lowe:
Yeah.
Til Luchau:
It’s not a muffin.
Whitney Lowe:
Baker’s cyst is an interesting… It’s a cyst, as you would imagine, which is a fluid-filled sort of sac, well you can call it, that appears on the backside of the knee. It gets its name from, again, it’s usually named after some older physician person. I can’t remember his first name, Mr. Baker, back in the 1870s, I think was when he first named this. But, there’s an interesting anatomical feature on the backside of the knee that leads to the development of a Baker’s cyst. So, essentially you have a bursa that is sitting between the medial head of the gastrocnemius, and the semimembranosus muscles. So this is again on the backside of the knee, toward the medial side, and there’s a bursa that’s back there. But this is not always a lot of other bursa. It has some unique anatomical features to it. In particular, there’s a communication between this bursa and the joint capsule of the knee on the posterior side. Yeah.
Til Luchau:
This is important
Whitney Lowe:
Yeah. And this communication is not present in everybody, but it is a pretty frequent anatomical variation, where there’s sort of an opening in the bursa that opens into the joint capsule. And so, what happens is, inside the knee from various different reasons, there may be swelling or a fusion develop inside the knee, and then that moves into this fluid-filled sac. And there’s sort of… Just because of the way it’s structured, it turns into kind of like a one-way valve that will let fluid go into it, but it won’t let the fluid come back out. So, it tends to accumulate in there, and that’s what creates the cyst, or the sort of bulbous fluid conglomeration on the back of the knee.
Til Luchau:
Okay. I’m getting the picture, and I think you’ve just named some important concepts here. One is the continuity between the bursa, the fluid-filled sac between these different muscles, and the synovial capsule, the fluid-filled capsule around the joint. So, they’re both about providing lubrication between moving structures, and so maybe it’s good that they’re connected, but you’re saying in some cases, especially when there’s something that causes some effusion, or swelling, or maybe fluid production within the joint capsule, that gets pushed out into this bursa through this one-way valve, and causes this lump, you said?
Whitney Lowe:
Yeah, sort of like a cyst feels like a lump of… A soft lump in the tissue, just like a cyst would feel on the back of your wrist, with a ganglion cyst that you often may get that develops around tendon sheaths, or something like that. So it feels nodular, but kind of larger, and lumpy. About golf ball, or ping pong ball size in many instances.
Til Luchau:
Okay. Is it important at this point for our audience to think about how they’re diagnosed? Are there differential considerations there?
Whitney Lowe:
Yeah, there are some important considerations about that. And a couple other things too, I’ve seen this in a few papers that we’re talking about, well why does this happen? Why does this occur? There may be some relationship between management of intra fluid pressure inside the knee joint, and this sort of sac and bursa can act like sort of a valve to get some of that pressure outside of the knee joint, and that’s been one theory, in terms of why that fluid accumulation is in there.
Til Luchau:
A little pressure chamber to relieve that pressure somehow.
Whitney Lowe:
Yeah.
Til Luchau:
Interesting. Okay.
Whitney Lowe:
So, one of the reasons we wanted to talk about this is for manual therapists, is that you might find this on somebody, and not know what it is, and be really concerned. And that kind of gets back to your question of how do you recognize this? Frequently, they are evaluated simply by a physical examination first, because that’s where it might be most evident. A person comes in and says like, “There’s something behind my knee, I feel it back there, and I can put my fingers on it, and also, I feel it when I bend, or straighten out my knee.” So, those are things that will be identified with palpation. But then, for definitive identification, they’ll oftentimes nowadays use ultrasound to see if we can get distinctions between fluid-filled masses, and others that might be more solid, that could be a much more concerning tumor, or growth in that area. And then of course an MRI is kind of like the gold standard of being able to get the most information about what’s really happening back there.
Til Luchau:
All right. And is pain a consideration in terms of deciding what it is?
Whitney Lowe:
Pain can absolutely be a consideration, because there can oftentimes be pain associated with particular movements. And this is one that’s a little odd about the Baker’s cyst, which is, you would kind of think, at least I would think this way, that if you got a big glob of something behind your knee, it’s going to hurt most when you flex your knee and squeeze that glob of stuff that’s behind the knee. So, that certainly can happen. So, during motion you might feel pain during knee flexion, but actually with the Baker’s cyst it’s a little more consistently painful in knee extension, as opposed to knee flexion. And this has to do with the way in which the semimembranosus, and the gastrocnemius medial head sort of pull that bursa taut, and squeeze it against the deep fascia underneath, and cause it to be a bit more painful in the extension. So, it’s a little unusual finding, but that would help identify this as a likely cause there.
Til Luchau:
When I glanced just at the, “What is Baker’s cyst,” Google search real quick before our call, so I didn’t come in totally blind, it did say, “Pain upon flexion or extension.”
Whitney Lowe:
Yeah.
Til Luchau:
So it sounds like it’s both ways. I think the people that I’m thinking of, it was more painful, like you described, in extension.
Whitney Lowe:
Yeah.
Til Luchau:
Yeah.
Whitney Lowe:
And so that’s one of the methods that’s used to identify, and people might talk about this being more painful. And again, there’s some things that might be sometimes potentially confused with this, because of that, the pain sensations during the extension. There was a number of places in different papers about Baker’s cysts that I was looking at recently, saying that frequently this is misdiagnosed, and assumed to be a deep vein thrombosis, especially if the Baker’s cyst ruptures, and you have a conglomeration of fluid that maybe is outside the cyst, but it’s in around the knee area there, and it can have a lot of symptoms very similar to DVT.
Til Luchau:
To a deep vein thrombosis, which is a consideration for us
Whitney Lowe:
Absolutely. Yeah, because they’re both things that I think we can sort of assume from common sense, you don’t want to push on them further, when they’re already an inappropriate fluid accumulation in this area, in the posterior knee. And a lot of people are… I don’t know about you, but when I was in massage school training, there was a few places that they warned us about as in potential endangerment sites, and one of them was the backside of the knee, but the way that was often done is them saying, “Don’t touch anything on the back of the knee.”
Til Luchau:
“Don’t touch it.” That’s right. Yes.
Whitney Lowe:
So you do a nice long gliding stroke up the calf, and then you just lift up, and go over the knee, and then put your hand back down.
Til Luchau:
Or detour around the back of the knee. Yeah. In our knee class, that’s often one of the taboos people are up against. It’s like, “Wait a minute, we’re not supposed to touch back there.” And you’re articulating some of the rationales perhaps for that oversimplification, or that caution, saying there’s some delicate structures there, and it could be a DVT story, or it could be something that could be flared up or inflamed with too deep a work like a Baker’s cyst.
Whitney Lowe:
Right.
Til Luchau:
Well, are there particular risk factors, or populations that this will be more likely to appear in?
Whitney Lowe:
Yeah, absolutely. And this is kind of interesting, too. There seems to be a fair number of Baker’s cysts that occur in young people, for no parent reason, that they seem to just occur idiosyncratically, just no particular reason why they occur. But in older populations, they’re almost always associated with some type of knee pathology. Oftentimes it’s an internal knee joint injury, where there’s some other thing that might be causing excess inflammation like meniscal tears, ligament damage, or something like that, where there’s increasing degrees of inflammation within the joint capsule that will tend to lead to those happening. So, the meniscal tears, especially with the medial meniscus, tended to be statistically the most common rationale of a co-morbid thing that’s going along with them, and leading to the development of those Baker’s cysts.
Til Luchau:
Okay. So they seem to be correlated pretty strongly with those medial meniscus tears, or other damage, you said, or pathology of the knee joint, which goes along-
Whitney Lowe:
Yeah. And osteoarthritis is another one. Again, when you have inflammation, especially of wearing way of the protective articular cartilage on the ends of those bones, and you do have an inflammatory reaction in there, you’re going to have excess tissue fluid inside the capsule, and that’s when that’s likely to be squeezed out. And interestingly, when we were talking about that assessment characteristic a few minutes ago, about flexion and extension in the assessment process, this is something too, called… And again, I’m assuming this guy’s name is French, F-O-U-C-H-E-R, so it’s probably Foucher, I’m going to guess how it’s pronounced, Foucher’s sign.
There’s… If you’re palpating that area behind the knee, it will tend to get softer as a person flexes their knee, and it will get firmer and more rigid as they extend the knee, which is the same correlation with why it’s more painful oftentimes in knee extension, because that cyst is being pulled taut against the related structures in there. So, this is one of the other things that you can be looking for when you’re finding something that looks like it might be symptomatic there, that is helpful and indicative of it being a Baker’s cyst, as opposed to some other type of mass that might not change, that might be a more concerning type of growth in that area.
Til Luchau:
So, did you get to cover the precautions? Did you say what you wanted to around that?
Whitney Lowe:
Yeah, I knew there was something else I wanted to go back to. So yeah, precautions around this, especially for us as manual therapists, we do want to be careful about doing anything that’s putting increased pressure on those areas, because that can possibly further aggravate the cyst back in that area. One of the things that I was curious about, because I had heard this question posed sometime, years ago, is like would something like manual lymphatic drainage maybe be helpful in that? And initially, when we think of anything where there’s excess inflammation, that does seem like a potential strategy that could be beneficial in addressing it, but in this instance, that fluid is all encapsulated within the cyst, so it’s pretty difficult for any of those particular techniques to be very helpful in doing anything with it. So, we do want to use caution, significant caution about any kind of pressure levels that are put on the backside of the knee if something like that does appear to be in there.
Til Luchau:
Oh, okay. So we’re back to don’t touch the back of the knee.
Whitney Lowe:
Carefully. Yeah.
Til Luchau:
Kidding. Pressure being the-
Whitney Lowe:
Superficial dermo-neural modulation type of techniques, myofascial things, or whatever.
Til Luchau:
Okay.
Whitney Lowe:
Yeah.
Til Luchau:
All right.
Whitney Lowe:
Yeah.
Til Luchau:
Right. And the watershed sign there being, is it painful? Is there a swollen mass? And especially is there flareups, or heat, or other signs that might be associated with a inflammatory.
Whitney Lowe:
And from the history-taking perspective, people often tend to complain more when they’re standing, or doing something where that knee is extended, as opposed to it being flexed, which is back to the same rationale that we had before.
Til Luchau:
When the bursa is doing its work, when the structures around it are pulled taut, and it’s trying to lubricate, or cushion relationship.
Whitney Lowe:
Yeah.
Til Luchau:
Okay. Effective techniques, or should be avoided with Baker’s cyst?
Whitney Lowe:
Yeah, so from a manual therapy perspective, this is another one of those things that I haven’t really found anything that I think is particularly helpful in really, let’s say, I’m using air quotes here, “treating this,” from a manual therapy perspective.
Til Luchau:
Yes.
Whitney Lowe:
I mean, we do want to try to encourage that fluid movement in there, but the very fact of the movement seems to be something that causes more fluid accumulation in some cases. And it doesn’t seem like any kind of manual therapy interventions are particularly helpful in reducing the amount of fluid in there. So, often that might be treated in traditional medical practices with aspiration, or attempts to draw fluid out of there with a needle-
Til Luchau:
Sticking a needle in there and sucking out the fluid. Yeah.
Whitney Lowe:
Yeah. Although I would say also that I had come upon one paper that was saying needle aspiration had limited effectiveness, because the fluid that accumulated in a Baker’s cyst was a lot thicker than it is in some other types of fluid masses, and it was hard to pull it back through the needle.
Til Luchau:
Hard to aspirate.
Whitney Lowe:
Yeah. So, some cases it seems like it might work well, and others not so well, and if something is going on for a long period without significant help, then they may go in and try to actually just cut it open, and excise it, and get the fluid out that way.
Til Luchau:
Yeah, I want some information about that, too, but I’m thinking this takes us into the area of symptoms that are bothersome to people, people come to us seeking help for, but it is hard for us to say that what we does has a direct benefit on the mechanism of that symptom.
Whitney Lowe:
Yeah.
Til Luchau:
This is in that class. And let’s say on the negative side of that, maybe we shouldn’t expect much. Maybe there’s not much we can do to help. Let’s say on the possibility side of that question, maybe there’s a lot we can do, even if it isn’t making the bump go away, or even draining it, or sometimes even changing the pain level. Sometimes there’s quite a bit of support we can provide. Reframing.
Whitney Lowe:
Absolutely. Yeah. Yeah. This gets back to a really important thing that I’ve had people say things to me over the years in terms of like, “Well, a lot of these, let’s say more serious kinds of orthopedic problems, there’s not something that massage can really do for that. So what’s really the point of kind of delving into these things?” But the point is, as manual therapy practitioners, we often spend more time with our clients than anybody else in the healthcare system, and a lot of times, some of these kinds of conditions are missed because people don’t take the time to do a thorough and comprehensive evaluation. And so, your role in the clinic and treatment room might end up being one of like, “Hey, I found this and nobody else did, because they weren’t really looking carefully and thoroughly enough for this area. This is something you need to go have checked out with somebody.” And that’s also really valuable treatment. That’s a really valuable input from the things you’re doing.
Til Luchau:
Well, this is a little nuanced, but there’s also the… This is some of the ones I’ve worked with more recently, the client who comes in having been told they have a Baker’s cyst, having worked with their Baker’s cyst in orthopedic work, and physical therapy, it’s still bothersome. They’re just seeking new options, trying to see what I can do for it.
Whitney Lowe:
Yeah.
Til Luchau:
There, my goal, and maybe I can think of two recent cases, and one I could say was clearly a success. The other I’m not so sure. My goal in that case is let’s define… Let’s change the definition of what helps, or what help means, because it’s usually from the client’s perspective and from mine too, when I hurt, let’s make it stop hurting. Let’s make that bump go away, or at least let’s make it stop hurting. Sometimes we can’t do that. Sometimes we can’t do that. And so, a lot of times we can, and we don’t have to deal with this problem, but the problem of not being able to make the pain go away, there’s a lot of creative ways to still be helpful even in that circumstance.
Whitney Lowe:
Yeah, I would certainly agree. And I think too, a lot of these are indicators that there’s also an underlying problem that needs to be addressed if you have a Baker’s cyst. It might be… Not be like, well, maybe I don’t know that I’ve got meniscal damage, or maybe I don’t know that I’ve got cartilage degeneration in there.
Til Luchau:
Yeah, absolutely. This is back to where some of the often, first people that can identify these things, and maybe in our screening function help them get a clearer diagnosis. But back to my client who’s done all that, and yes, does have a history of meniscal damage, lots of arthritis, he’s looking for help from his painful Baker’s cyst. What helped was somehow, I’m not even sure I can explain it. I think of it as again, refining proprioception, and de-threatening the experience. Maybe this is back to the D&M idea that you have. Let’s get the nervous system less alarmed about the fact that there’s some sensation there.
Whitney Lowe:
Yeah.
Til Luchau:
So there’s a lot I was able to do with him to make it feel a lot better. Now, did that make it go away for good? No, but part of my conversation with him was, “This is not our goal. This is not an appropriate thing for us to be trying to do, is to erase the cyst and erase the pain from your knee. That would be nice, but let’s do some experiments. Let’s see how it feels. Let’s see if that’s valuable to you, and beneficial.” And in his case it, he decided it was, even though, yeah, it would feel really good for a day or two, and we both felt a reduction in the size, and firmness of the cyst, not from me getting in there and mashing on it, but from gentler work with movement, and fluid, thinking about feeling for fluid, synovial fluid movement through there.
I was just playing with these ideas. I don’t know if I’m actually doing it or not, but we both felt the palpable change in the mass itself. Again, this is an N of one. This is one client, and it filled back up later. But part of the benefit I think he would say was again, just the greater understanding he had for it, and so at least he was less freaked out about it. He’d think, “Oh yeah, there’s that fluid sac filling up again,” rather than, “Oh yeah, there’s my messed up meniscus again.”
Whitney Lowe:
Yeah, and I think what you’re saying here too is so crucial, because that very fact of the reassurance of knowing a little bit more about what this might be. Anytime somebody feels a mass somewhere, immediately it becomes the freak out. Like, “Oh my gosh, what is this? Is this serious cancer? Am I going to be… Am I in really big trouble here?” And understanding more about what’s actually happening there, I think alleviates a lot of that anxiety. And that can play a big role in the pain reduction, and the improved function, like you said.
Til Luchau:
And of course our response is, “Well, if you’re concerned, please have that checked out.” Not like, “You’re probably okay.” Because there’s real reasons to have these things checked out, if someone has… In this case, he had quite a bit, so we were able to help him refine his both sensation, and his narrative about what was happening.
Whitney Lowe:
Yeah.
Til Luchau:
That’s the best I got for anything that we can’t directly press on, and make better.
Whitney Lowe:
Yeah.
Whitney Lowe:
And so again, I want to just call everybody’s attention to how valuable the combination of education, and manual therapy are together. When you are able to do that, give somebody reassurance about things, let them understand a little bit more about what might be potentially going on there, and then give comforting, caring, touch in that region to what you’re doing. That’s powerful work. It’s powerful work.
Til Luchau:
Nice. And then part of their overall self-care strategy, or team, or whatever, just to help them attend to something that’s bothersome can be really valuable too. And then there we got to watch the tendency to think, “Oh yeah, I can really help all the way. I can do it myself.” Because there’s a lot of other things that someone like him could do, and did do that helped him quite a bit.
Whitney Lowe:
Yeah.
Til Luchau:
Should we go back to the impact? Is that something that we covered adequately? We talk about what happens to people when they’re dealing with this?
Whitney Lowe:
Yeah, I’m not sure that we did go over that much. So yeah, we can touch base on that, and let’s do.
Til Luchau:
Yeah. So what’s the typical impact of someone dealing with a Baker’s cyst like this?
Whitney Lowe:
Well, I think a lot of it is going to be… It’s kind of what we were just talking about too though, apprehension, concern, fear about what’s going on in there, what really is happening there. And of course, the natural one is pain that people feel from various types of activities can certainly limit their capability for doing a lot of those activities significantly because of it.
Til Luchau:
And that’s huge. I mean, as someone who dealt with a knee injury earlier this year, the effect on my mood, and the effect on my daily rhythm, and the effect on my aspirations for even my to-do list, everything was affected by the fact that I couldn’t move very easily. And extension, anything that limits or makes extension painful has a big impact, more arguably than flexion, because we extend on every step, we extend all the time. So, if it’s painful to do that, you just don’t want to take as many steps.
Whitney Lowe:
Yep. Yeah. And then you’ve got all kinds of other complications that are then potentially happening from the immobility, and like you said, just the sort of psycho-emotional capability of, “I can’t move. I want to move. I know I need to move, because it hurts when I do these kinds of things.” That has some serious limitations, as well.
Til Luchau:
You mentioned, I think you mentioned conventional treatments, aspiration, surgery.
Whitney Lowe:
Yeah. So sometimes, if the baker’s cyst does not respond to other types of conservative treatment, because sometimes corticosteroid injections are used as an anti-inflammatory strategy, and if those are unsuccessful, all those other methods are unsuccessful, they will oftentimes go to an excision, or basically going in and cutting open the cyst, to be able to try and attempt to drain it, and suture the bursa back up. But again, if you don’t deal with the underlying pathologies that are leading to the fluid development, which is oftentimes something like meniscal damage, or arthritis or something like that, this may be a recurring problem. And there’s a lot of reports of treatments that were short-term successful, but then the fluid accumulation returned again, because the underlying problem hadn’t really been dealt with.
Til Luchau:
Or inflammatory load, and all kinds of things that could just keep that coming back.
Whitney Lowe:
Yeah. Yeah. I’m curious to hear your perspective on this from your specialized study, and work with inflammation a lot.
Til Luchau:
Inflammation, yeah.
Whitney Lowe:
Do you think is there maybe a… And I don’t know statistically if this is true, maybe a greater percentage, or preponderance of people having something like this when there is systemic inflammation as opposed to just localized knee joint problems?
Til Luchau:
I know no statistics, but I’m absolutely sure that’s the case.
Whitney Lowe:
Yeah.
Til Luchau:
Because one thing, inflammatory… I mean, inflammation is at the root of 99% of everything we deal with, say, musculoskeletally. And when it’s local, it’s influenced by what’s going on in our whole body. So, if there are difficulties that my immune system is facing on a day-to-day basis, it’ll show up in local ways constantly. And it’s not as simple as like, “Let’s just take some turmeric and turn down inflammation and we’re good.” It’s a complex, interlocking, multi-causal system that involves both your attitude, and behavior, and rest, and certainly things like diet, but a lot of it comes down to the things we know, activity levels, rest, sugar consumption, those are the big three, big four.
Whitney Lowe:
Yeah.
Til Luchau:
So yeah, I’m sure that if someone really… Let’s just put it back to me. If I was really dealing with a Baker’s cyst that was persistently painful and flaring up again, I would be looking at my overall inflammatory profile, and not just that spot in my body. A lot of times when the body can cope, and resolve inflammation easier, not just turn it off, but actually resolve it, which means rest and exercise basically, then all these local things get a lot better.
Whitney Lowe:
Yeah. And I think that points to the crucial value of taking a comprehensive, and thorough history when you’re talking to people. Because if you don’t ask about some of those kinds of things, you might not see the connection, or they may not see the connection at all between the fact that I had this other bowel, or inflammatory problem, and something else that’s going on here in my knee, or somewhere else in the body, as well.
Til Luchau:
And a lot of this goes beyond our most immediate scope for sure, but it’s just useful for us to keep in mind that it’s not always just the knee.
Whitney Lowe:
Yeah.
Til Luchau:
If someone is dealing with serious medical issues, or smoking two packs of cigarettes a day, or something like that, then there’s going to be body symptoms related to that, for sure.
Whitney Lowe:
Yeah. Yeah. Yes. I think you were getting ready to ask me something. I interrupted you a moment ago, so I don’t know if that derailed your train-
Til Luchau:
I don’t remember what it was. I don’t remember what it was, but I got a lot of questions here still. What should a session be modified for someone? How should a session be modified? How would I change my session if I suspect someone has a Baker’s cyst, or I know they do? Have we covered that? Is it just like, don’t use the pressure on the knee, or is there more too than that?
Whitney Lowe:
Yeah, we talked about that a little bit, and I think that’s just kind of the big precaution is don’t do something that is going to further aggravate this. Now, if this is the first time you see it with somebody, then that’s going to be different, because we’re going to probably suggest that they go have this evaluated by somebody who’s got the capability to look into detail, to find out what’s really going on in there. And if it’s a recurrent one-
Til Luchau:
And I’m probably not going to say, “That could be a blood clot or a tumor.” I’m probably not going to say that.
Whitney Lowe:
Right. Let’s hope not. Yeah.
Til Luchau:
Yeah, I’m going to encourage them to have it checked out. Say, “This is something you probably want to have checked out.” Or you do more.
Whitney Lowe:
Yeah. Yeah. If it’s that person that is… The recurring person like you were talking about too, working with them more frequently, then I think you’ve got a little bit more leeway, the things that you’re doing, as long as you’re exercising caution, but you can look at some more significant strategies about, what can we do with processes of increasing awareness in this area, of decreasing pain sensations, or through more superficial types of applications? All those can be valuable and beneficial, even if they’re not specifically draining the cyst, like you mentioned. I think there’s still a great deal of benefit there.
Til Luchau:
I know what I was going to mention, compression is something that I’ve heard people use, and some of my clients have used for relief, just applying a compression brace, or fitting while they’re doing activity to keep the swelling from happening, to try to prevent it, head it off.
Whitney Lowe:
Yeah. Have they found that successful, do you know?
Til Luchau:
Yeah, to some extent. I think with the tools we can get.
Whitney Lowe:
Yeah. Yeah.
Til Luchau:
Okay. Well, we’ve covered a lot. What else do you think people would need to know about this?
Whitney Lowe:
Well, one of the things that is a question that comes up for me around this is, if you’ve got this pathoanatomical structure process, where you have a one-way valve that lets fluid go into this bursa sac essentially, and then accumulate in there. I mean, I don’t know the answer to this. It’s just something I ponder. It seems like if that keeps happening, how does it ever get out of there naturally, anyway? Does it just gradually get reabsorbed? And I don’t know the answer to these questions, but it seems like you might develop a situation where this just continues to try to push more in there, and then there’s a certain point at which you can’t get more fluid in that sac, unless some of it goes out of there. So, that’s an interesting idea to ponder. Or maybe just enough of it doesn’t accumulate fast enough, and there is some degree of resorption or something.
Til Luchau:
I’m guessing, based on just my thinking, and my biases, but also from, again, this very limited population of people that I’ve worked with on a more ongoing basis, that it comes down to frequency of irritating activities, that there is some return. This valve is not like a hydraulic valve. It’s made out of connective tissue, and things like that, and as such, it probably leaks some. So, over time things do drain, or maybe perfuse to some extent.
Whitney Lowe:
Yeah.
Til Luchau:
So then it becomes like, how frequently can I do my hike up the mountain that makes my Baker’s cyst flare up? And again, from this one client, again, thank you for this one client, it was pretty clearly activity related. If he did something too strenuous, he would be really swollen and sore the next day.
Whitney Lowe:
Yeah.
Til Luchau:
And so then for him it was like, “How much can I do it, and how frequently can I do it, so that my body essentially recovers from that?”
Whitney Lowe:
Yeah. You said something here that just caught my attention for a moment. This might be worthy of a study to look into this, which is that it’s probably not a perfect valve, like you said, anatomically, and there’s probably a little bit of leakage, in which case, if you’ve got a balloon, and you’re trying to get all the water out of it, and there’s just a little bit of leakage at the opening of that balloon, what if you squeezed it more within certain parameters? What if we just did a lot of knee extension movements that pulled that taut, and sort of squeezed it? Might that actually be therapeutic somewhere down the road there?
Til Luchau:
Yeah. It’s that Goldilocks thing between not wanting to flare it up, but wanting to “massage it” enough to encourage perfusion.
Whitney Lowe:
Yeah.
Til Luchau:
It’s finding the dosing, frequency, pacing, all the kind of things, because it does, you can definitely flare those things up, just getting in there and trying to erase them. Like I said, that’s not what to do.
Whitney Lowe:
Right. So that would be an interesting study for somebody who’s looking for an interesting research project to engage in there,
Til Luchau:
Yeah. Or an experiment to try with your good rapport client who’s been screened medically, like I happen to have had.
Whitney Lowe:
Yeah.
Til Luchau:
Good experiments there.
Whitney Lowe:
Yeah.
Til Luchau:
Well, this is great. Anything else you want to say as we wrap it up?
Whitney Lowe:
Yeah, it’s not… Again, first of all, I just want to comment. This is not a terribly common thing, so it’s not something you’re going to see probably really frequently, but it’s not terribly uncommon, as well, it may occur in a moderate number of people. So, these are just some things that I think are really helpful for us to be aware of as manual therapy practitioners to watch for. And also, like we said, a lot of times what we’re doing is helping to educate our clients to be more attuned, and aware about some of these kinds of things. So, our goal here is to really just touch base on these things. Like, “Here’s something else to think about that you might not have heard much about or might not be aware of,” but you don’t need to freak out about it necessarily. But just know there’s some things that will be really helpful if you’ve got a good understanding of what this might be, and therefore you can relay some of that onto your clients as well.
Til Luchau:
There you go. I just Googled prevalence of Baker’s cyst, 19% of asymptomatic adults in one study, and more prevalent-
Whitney Lowe:
Wow, that’s pretty high.
Til Luchau:
Yeah.
Whitney Lowe:
Yeah.
Til Luchau:
Well, that just goes to the thing. They’re normal part of anatomy too. That’s the asymptomatic ones. It’s only some of them that become symptomatic and more prevalent, two age peaks, four to seven years, you mentioned the youngsters that sometimes have them. And 35 to 70 years old, those populations with Baker’s cysts.
Whitney Lowe:
Yeah.
Til Luchau:
And this is… Maybe it’s super common. Maybe them getting flared up isn’t so common, but it brings to the fore these important questions about how does our work support our clients’ symptoms, especially when they come to us wanting us to be the mercenary to get rid of their symptom, and it may not be a obvious or clear mechanism for us to do that, we can still be helpful in so many ways.
Whitney Lowe:
Yeah, yeah.
Til Luchau:
This is a great poster child for that concept as well. So, I want to thank you for bringing it forward.
Whitney Lowe:
This is the heartening back to our… I’d have to look up the number of the episode that we did. I believe it was with Mark Bishop. We were talking about client expectations, how valuable, and important it is in making significant headway therapeutically with people by the confidence that they build in you and your knowledge. So again, this is why I think it’s so helpful to know about a lot of these types of things, and be able to talk intelligently with our clients about some of the possibilities of things to think about, because that enhances their confidence in you as a practitioner, and that has positive therapeutic outcomes.
Til Luchau:
Well, thanks for helping fill in some gaps in my knowledge base.
Whitney Lowe:
All right, well, thank you too for… Yeah, it was great client stories, too, that you were illustrating that with, and give us another perspective about ways to address this.
Til Luchau:
Yeah.
Whitney Lowe:
Yeah.
Til Luchau:
Well, thanks to our sponsors. We are supported also by ABMP, Associated Bodywork and Massage Professionals. ABMP membership gives professional practitioners like you a package including individual liability insurance, free continuing education, and quick reference apps, online scheduling, and payments with PocketSuite, and much more.
Whitney Lowe:
And do remember ABMP CE courses, podcasts, and Massage and Bodywork Magazine always feature expert voices, and new perspectives in the profession, including from you, Til, and from myself. Thinking Practitioner listeners can save on joining ABMP at abmp.com/thinking. Thanks again, ABMP. And thanks to all of our listeners, and to our sponsors. As we said too, you can stop by our sites for show notes, video transcripts, and any extras. You can find that over on my site at academyofclinicalmassage.com, and Til, where can they find that with you?
Til Luchau:
advanced-trainings.com.
Whitney Lowe:
Great. And if you have comments, questions, or things you’d like to hear us talk about, just record a short voice memo on your phone, and email it to us at [email protected]. You can also write there, if you’re a person who likes to type. We’ll take all those messages in, and you can look for us on social media. I’m there, of course, under my name, Whitney Lowe. And Til, where can people find you there on social?
Til Luchau:
My name, yes, my name Til Luchau. Yeah, I want to hear some of your Baker cyst stories. I’d love to hear some more.
Whitney Lowe:
Yeah, that’d be curious. Yeah.
Til Luchau:
I’m hoping to get some of those, like your successes, your failures, your quandaries, your whatever. Just send us some of those. If you could also rate us on Apple Podcasts, that would be very appreciated. It does help other people find the show, and you can hear us on Spotify, Stitcher, Podbean, or wherever else you listen. Please do share the word, and tell a friend. Thanks for today, Whitney.
Whitney Lowe:
Thank you, sir. It’s great to talk with you again, and we have got some other interesting episodes. We’re going to round out the end of this year with a couple of really exciting interview episodes that we have on our plate coming up soon. And then looking forward to some more stuff coming in the new year as well.
Til Luchau:
I can’t wait. See you later.
Whitney Lowe:
All right, sounds good.
