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Medial Plica Syndrome

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(Redirected from Plica Syndrome)

Other Names

  • Synovial Plica Syndrome (SPS)
  • Medial Plica Syndrome
  • Medial Plica Shelf Syndrome
  • Plica Syndrome
  • Knee Plica Syndrome
  • Medial Synovial Plica Syndrome
  • Pathologic Plica
  • Symptomatic Plica
  • Plica Irritation Syndrome

Background

History

  • First case published in 1979 by Mitel[1]

Epidemiology

  • Estimated prevalence among European studies is approximately 10%[2]
  • Up to 60% may be bilateral, although often not simultaneously[3]

Introduction

The four synovial plica of the knee[4]
Location of the synovial plica inside the knee joint.[5]
Superior view of the knee joint with pathologic mediopatellar plica. As the knee moves into flexion, a pathologic mediopatellar plica can impinge between the femur and patella. The impingement more commonly occurs when the knee is flexed 30 to 45 degrees[6]

General

  • Overuse condition characterized by irritation or inflammation of the synovial plica, most commonly the medial plica
  • Patient soften report clicking, snapping or catching sensation with knee flexion and extension
  • Symptoms are often worse with repetitive activities like running, squatting and climbing stairs
  • Treatment is non-surgical and ocassional surgical in refractory cases with good long term outcomes

Normal Plicae

  • Inward folds of the synovial lining and are present in most knees
  • Normally, thin and pliable and appear almost transparent

Pathologic Plicae

  • Inherent qualities change due to an inflammatory process that alters the pliability of synovial tissue
  • Can become inelastic, tight, thickened, fibrotic, and sometimes hyalinized

4 Major Plica

Medial Patellar Plica

  • General
    • Most important clinically
  • Pathology
    • May bowstring across the femoral trochlea, causing impingement between the patella and femur in knee flexion

Etiology

  • Majority of cases are idiopathic
  • Other proposed etiologies
    • Trauma (direct, blunt)
    • Twisting injuries
    • Overuse injuries, especially with inadequate healing
    • Repetitive flexion-extension
    • Hematoma
    • Diabetes Mellitus
    • Inflammatory Arthropathy
    • Any cause of synovitis
    • Increased activity levels

Anatomy of Synovial Plicae of the Knee

  • General
    • Inward folds of synovial lining present in most knees
    • Thin, pliable and almost transparent
    • Embryologically, they form during development and are generally resorbed
  • Medial Patellar Plica[7]
    • Proximally, it attaches to the Articularis Genus Muscle
    • Distally it inserts into the intra-articular synovial lining
    • Blends into the medial patellotibial ligament on the medial aspect of the retropatellar fat pad
  • Suprapatellar Plica
    • From suprapatellar space, extends from the medial wall of the knee toward the lateral wall
  • Infrapatellar Plica
    • Also called the Ligamentum Mucosum
    • Most common, resides in intercondylar notch

Risk Factors

Differential Diagnosis

Differential Diagnosis Knee Pain

Clinical Features

Demonstration of Hughstons Plica Test[8]
Illustration of the Plica Active Extension Test[9]

History

  • Patients report anterior or anteromedial knee pain
  • Other symptoms include clicking, clunking, buckling, and a popping sensation
  • Often worse with squatting, jumping, stairs, standing, etc
  • In pediatrics, may be associated with period of growth

Physical Exam: Physical Exam Knee

  • Mild effusion can be present
  • Can palpate by rolling finger over the plica fold which feels like a ribbonlike fold of tissue
  • Typically found underlying the medial femoral condyle
  • Medial femoral condyle may be tender

Special Tests

Evaluation

Sonogram of symptomatic right knee in 15-year-old female subject. Medial plica echo was defined as hyperechoic longitudinal zone (white arrowheads) sliding over anterior surface of medial femoral condyle (black arrowheads) toward hypoechoic patellar cartilage during dynamic examination. Thin hypoechoic border (arrow) of plica echo was seen[10]
Knee joint effusion. Diffuse synovial thickening and enhancement consistent with synovitis. Thickened medial patellar plica with a large focal near full thickness medial patella facet cartilage defect, which is a well recognized association[11]

Radiographs

Ultrasound

  • Dynamic Sonography[12]
    • Using arthroscopy to as gold standard
    • Paczesny found Sensitivity 90%, specificity 83%, diagnostic accuracy 88%

MRI

  • Findings[13]
    • Hypertrophied plica as a low-intensity signal
    • Often appears normal
    • Better seen if joint is effused

Arthroscopy

  • Remains gold standard for diagnoses
  • However, not recommended strictly for diagnostic purposes as subsequent scar tissue may worsen symptoms

Classification

Sakakibara classification of medial patellar plicae[14]

Ino Classification of Mediopatellar Plica

  • Type A: plicae exist as a thin, cord-like elevation of the synovial wall under the retinaculum.
    • Unlikely to cause symptoms
  • Type B: narrow synovium with a shelf-like appearance, does not cover the anterior surface of the medial femoral condyle
    • Unlikely to cause symptoms
  • Type C: larger, with a shelf-like appearance that partially covers the medial femoral condyle
  • Type D: similar to type C plicae, though this final type is fenestrated, splitting into two portions at its origin

Lyu and Hsu Classification of Mediopatellar Plica

  • Type A plica has no direct contact with the medial femoral condyle
  • Type B plica rides onto, but not beyond half of the condyle
  • Type C plica covers more than half of the medial femoral condyle.
  • Further subclassified into grades I-V based on thickness, degree of fibrosis

Management

Nonoperative

  • General
    • First line treatment in vast majority of cases
    • Often directed at underlying etiology (i.e. systemic illness or other structural knee disease)
    • Majority of treatment recommendations based on Patellofemoral Pain Syndrome, not necessarily specific to plica syndrome
  • Activity Modification
    • Modify their activities that are known to exacerbate plica syndrome
    • Examples include high-impact loading such as jumping, squatting, or lunging
  • Physical Therapy
    • Emphasis on Quadriceps strengthening, hamstring stretching
    • Decrease compressive forces in the knee
  • Kinesiology Taping
  • Corticosteroid Injection

Operative

  • Indications
    • Failure of conservative management
  • Technique
    • Arthroscopic resection

Rehab and Return to Play

Rehabilitation

  • Phase I: Control pain/inflammation, restore ROM, gait training[15]
  • Phase II: Achieve full ROM, advanced strengthening, proprioception, and cardiovascular conditioning
  • Phase III: Sport-specific functional progression, tailored to the athlete’s demands

Rehab Protocol PDFs

Return to Play

  • General RTP Criteria
    • Symptom resolution
    • Full ROM
    • Restoration of strength
    • Successful functional testing
    • Psychological readiness

Prognosis and Complications

Prognosis

  • General
    • Generally favorable with a timely diagnosis and appropriate management
    • Younger patients with a shorter course of illness are more likely to respond to conservative measures[16]
  • Following surgical intervention
    • Long-term follow-up studies show sustained improvement in knee function and pain scores[17]

Complications

See Also

Internal

External

References

  1. ↑ Mital, Mohinder A., and John Hayden. "Pain in the knee in children: the medial plica shelf syndrome." The Orthopedic Clinics of North America 10.3 (1979): 713-722.
  2. ↑ Lee, Paul Yuh Feng, et al. "Synovial plica syndrome of the knee: a commonly overlooked cause of anterior knee pain." The Surgery Journal 3.1 (2017): e9.
  3. ↑ Dupont J Y. Synovial plicae of the knee. Controversies and review. Clin Sports Med. 1997;16(01):87–122
  4. ↑ Image courtesy of radsource.us
  5. ↑ Lee, Paul Yuh Feng, et al. "Synovial plica syndrome of the knee: a commonly overlooked cause of anterior knee pain." The Surgery Journal 3.01 (2017): e9-e16.
  6. ↑ Hoehmann, Christopher L. "Plica syndrome and its embryological origins." Edorium J Orthop 3 (2017): 1-12.
  7. ↑ Dandy D J. Anatomy of the medial suprapatellar plica and medial synovial shelf. Arthroscopy. 1990;6(02):79–85.
  8. ↑ Lee, Paul Yuh Feng, et al. "Synovial plica syndrome of the knee: a commonly overlooked cause of anterior knee pain." The Surgery Journal 3.01 (2017): e9-e16.
  9. ↑ Image courtesy of uptodate.com, "Medial patellar plica test"
  10. ↑ Paczesny, Łukasz, and Jacek Kruczynski. "Medial plica syndrome of the knee: diagnosis with dynamic sonography." Radiology 251.2 (2009): 439-446.
  11. ↑ Case courtesy of Andrew Dixon, Radiopaedia.org, rID: 18022
  12. ↑ Paczesny L, Kruczynski J. 2009. Medial plica syndrome of the knee: Diagnosis with dynamic sonography. Radiology 251:439–446.
  13. ↑ Garcia-Valtuille R, Abascal F, Cerezal I, Garcia-Valtuille A, Pereda T, Canga A, Cruz A. 2002. Anatomy and MR imaging appearances of synovial plicae of the knee. Radiographics 22:775–784.
  14. ↑ Image courtesy of radsource.us
  15. ↑ De Carlo, Mark, and Brain Armstrong. "Rehabilitation of the knee following sports injury." Clinics in sports medicine 29.1 (2010): 81-106.
  16. ↑ Sznajderman T, Smorgick Y, Lindner D, Beer Y, Agar G. 2009. Medial plica syndrome. Isr Med Assoc J 11:54–57.
  17. ↑ Prejbeanu, Radu, et al. "Long term results after arthroscopic resection of medial plicae of the knee—a prospective study." International orthopaedics 41.1 (2017): 121-125.
  18. ↑ Lyu SR. 2008. Arthroscopic medial release for medial compartment osteoarthritis of the knee: The result of a single surgeon series with minimum follow-up of four years. J Bone Joint Surg Br 90:1186–1192.
Created by:
John Kiel on 7 July 2019 05:31:24
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Last edited:
5 January 2026 00:25:43
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