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Pellegrini Stieda Syndrome

From WikiSM

Other Names

  • Pellegrini Stieda Syndrome
  • Pellegrini-Stieda Syndrome (PSS)
  • Pellegrini-Stieda Disease
  • Pellegrini-Stieda's Disease
  • Köhler–Pellegrini–Stieda disease

Background

  • This page refers to so-called Pellegrini Stieda syndrome (PSS)

History

  • Pellegrini in 1905 was the first to describe the sign of Pellegrini–Stieda[1]
  • Stieda later published a series of 5 cases[2]

Epidemiology

  • Not well described in the literature
  • Incidence is unknown

Introduction

Anatomy of left knee joint and attachments of deep medial collateral ligament (MCL) above and below medial meniscus. (ACL, anterior cruciate ligament; LCL, lateral collateral ligament; PCL, posterior cruciate ligament.)[3]
Relationship of the MPFL (medial patellofemoral ligament), VMO (vastus medialis obliquus muscle), SM (semimembranosus), MGT (medial gastrocnemius tendon), POL (posterior oblique ligament) and sMCL (superficial medial collateral ligament).[4]

General

  • Diagnostic criteria
    • Classic radiographic findings of pellegrini-stieda sign
    • Combination of clinical symptomatology of pain and restriction in the range of motion

Pellegrini–Stieda Sign

  • Also called Pellegrini-Stieda lesion,
  • Calcification of the medial collateral ligament of the knee
  • This is seen months/ years after trauma, either direct or indirect

Pathophysiology

  • Thought to initially occur with an insult to the medial collateral ligament
    • Involves some form of valgus stress with disruption of MCL fibers
    • Acute, direct trauma
    • Repetitive trauma
    • Overstretching injury
  • Causing acute inflammation that initiates a process of delayed ossification
    • Hematoma, ecchymosis, swelling may or may not be noted
    • Can occur as early as 2 weeks or as late as 6[5]
  • Other implicated causes include
    • Micro-repetitive trauma from therapeutic manipulation of a restricted knee joint
    • Post-surgical rehabilitation
  • Origin of the calcification has been debated[6]
  • Stieda Fracture
    • Avulsion fracture of medial femoral condyle from the MCL

Associated Conditions

Risk Factors

  • Male[7]
  • Age 25-40

Differential Diagnosis

Differential Diagnosis Medial Knee Pain

Differential Diagnosis Knee Pain

Clinical Features

History

  • History of knee injury, sometimes vague
    • May involve specific knee-knee collision during sport
    • Can be as proximal as a 3 weeks or years later
  • Pain typically localizes to medial knee
  • Range of motion is often decreased/ painful
  • Can get worse over time

Physical Exam: Physical Exam Knee

  • Knee is stiff, restricted range of motion
  • Full knee extension is often painful
  • Tenderness to the medial femoral condyle area/ proximal MCL
  • Lump may or may not be palpated

Special Tests

Evaluation

Large calcification (pelligrini-stieda lesion) of the medial knee[8]
T1 and T2 hypointense mass adjacent to the MCL origin from the medial femoral condyle typical of an ossified Pellegrini-Steida lesion.[9]
Pelligrini-Stieda lesion seen on ultrasound. Note the hyperechoic calcification with posterior acoustic shadowing[10]

Radiographs

  • Standard Radiographs Knee
    • Sufficient to make diagnosis when combined with clinical exam
  • Pellegrini Stieda Sign
    • Longitudinally linear opacity
    • Calcification in the soft tissue located medial to the medial femoral condyle
  • Note
    • Do not confuse with medial femoral condyle avulsion fracture
    • Do not Medial femoral condyle enthesophyte

MRI

  • Findings
    • Ossicle or enthesophyte showing bone marrow signal at the medial femoral condyle
    • Medial collateral ligament is usually thickened

Ultrasound

  • Findings
    • Hyperechoic calcification with posterior acoustic shadowing
    • The MCL may be thickened

Classification

Proposed Classification Based on Location[11]

  • I: beak-shaped with inferior orientation and union to the femur: the ossification arises from the femur and extends inferiorly in the TCL
  • II: drop-shaped with inferior orientation and parallel to the femur: located in the TCL, without attachment to the femur.
  • III: elongated with superior orientation: ossification lying in the distal adductor magnus tendon
  • IV: beak-like with superior orientation and inferior attached to the femur: ossification attached to the femur, extending into both the TCL and the adductor magnus tendon

Management

Nonoperative

Operative

  • Indications
    • Severe, refractory cases
  • Technique
    • Surgical excision of calcifications

Rehab and Return to Play

Rehabilitation

  • General approach
    • Stretching and range of motion exercises
  • Initial
    • Emphasis on avoiding overload, microtrauma
    • Ice therapy
    • Mobilization
  • Knee bending exercises/ stretching
    • Examples include heel slide, seated knee bending, chair slides

Return to Play/ Work

  • Return to play can be considered when the following criteria is met[12]
    • Full range of motion is restored
    • Athlete is relatively pain free
  • Range of motion should be symmetric
  • Quadriceps and hamstring strength should be normal and symmetric

Prognosis and Complications

Prognosis

  • Most cases resolve in 5-6 months
  • Surgical outcomes
    • High variance in patient outcomes overall
    • High recurrence rate
  • Surgical excision may require reconstruction of the MCL

Complications

  • Restricted range of motion
    • Subsequently, patients can develop joint contracture
  • Gait abnormalities
  • Decreased activities of daily living
  • Chronic Pain

See Also

Internal

External

References

  1. ↑ Pellegrini, A. "Traumatic calcification of the collateral tibial ligament of the left knee joint." Clin Mod 11 (1905): 433-439.
  2. ↑ Stieda, Alfred. "Uber eine typische verletzung am unteren femurende." Archiv klin Chir 85 (1908): 815-826.
  3. ↑ Jacob, George, et al. "Percutaneous arthroscopic assisted knee medial collateral ligament repair." Arthroscopy Techniques 9.10 (2020): e1511-e1517.
  4. ↑ Memarzadeh, Arman, and Joel TK Melton. "Medial collateral ligament of the knee: Anatomy, management and surgical techniques for reconstruction." Orthopaedics and Trauma 33.2 (2019): 91-99.
  5. ↑ Theivendran K, Lever CJ, Hart WJ. Good result after surgical treatment of Pellegrini-Stieda syndrome. Knee Surg Sports Traumatol Arthrosc. 2009 Oct;17(10):1231-3.
  6. ↑ Somford, M. P., Lorusso, L., Porro, A., Van Loon, C., & Eygendaal, D. The Pellegrini–Stieda Lesion Dissected Historically. The journal of knee surgery.2018; 31(06): 562-567.
  7. ↑ Scheib, J. S., and R. J. Quinet. "Pellegrini-Stieda syndrome mimicking acute septic arthritis." Southern medical journal 82.1 (1989): 90-91.
  8. ↑ Altschuler, Eric L., and Thomas N. Bryce. "Pellegrini–stieda syndrome." New England Journal of Medicine 354.1 (2006): e1.
  9. ↑ Case courtesy of Chris O'Donnell, Radiopaedia.org, rID: 37592
  10. ↑ Image courtesy of sonotool.net, “Pellegrini-Stieda Lesions”
  11. ↑ Mendes, Luiz FA, et al. "Pellegrini–Stieda disease: a heterogeneous disorder not synonymous with ossification/calcification of the tibial collateral ligament—anatomic and imaging investigation." Skeletal radiology 35 (2006): 916-922.
  12. ↑ Shanker, V. S., Gadikoppula, S., & Loeffler, M. D. Post traumatic osteoma of tibial insertion of medial collateral ligament of knee joint. British journal of sports medicine.1998; 32(1): 73-74. Level of evidence: 5
Created by:
John Kiel on 24 April 2024 14:00:07
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Last edited:
1 May 2025 20:53:23
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