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Plica Syndrome
From WikiSM
Other Names
- Synovial Plica Syndrome (SPS)
- Medial Plica Syndrome
Background
- This page refers to plica syndrome, a disease of thickened synovial lining of the Knee Joint
- Symptoms often overlap greatly with Patellofemoral Pain Syndrome
History
Epidemiology
- Estimated prevalence among European studies is approximately 10%[1]
- Up to 60% may be bilateral, although often not simultaneously[2]
Pathophysiology
- 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
- Can be described by location
- Suprapatellar
- Mediopatellar
- Infrapatellar
- Lateral (rare, more controversial)
Mediopatellar
- 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
Pathoanatomy
- Plicae
- Inward folds of synovial lining present in most knees
- Thin, pliable and almost transparent
- Embryologically, they form during development and are generally resorbed
- Mediopatellar Plica[3]
- 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
- From suprapatellar space, extends from the medial wall of the knee toward the lateral wall
- Ligamentum Mucosum
- Most common, resides in intercondylar notch
Risk Factors
- Systemic illness
- Diabetes Mellitus
- Inflammatory Arthropathy
Differential Diagnosis
- Fractures
- Dislocations & Subluxations
- Patellar Dislocation (and subluxation)
- Knee Dislocation
- Proximal Tibiofibular Joint Dislocation
- Muscle and Tendon Injuries
- Ligament Pathology
- Arthropathies
- Bursopathies
- Patellofemoral Pain Syndrome (PFPS)/ Anterior Knee Pain)
- Neuropathies
- Other
- Bakers Cyst (Popliteal Cyst)
- Patellar Contusion
- Pediatric Considerations
- Patellar Apophysitis (Sinding-Larsen-Johnansson Disease)
- Patellar Pole Avulsion Fracture
- Tibial Tubercle Avulsion Fracture
- Tibial Tuberosity Apophysitis (Osgood Schalatters Disease)
- Proximal Tibial Metaphyseal Fracture
- Proximal Tibial Physeal Injury
Clinical Features
- 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
- Hughstons Plica Test: Knee flexed and extending while palpating medial femoral condyle
- Stutter Test: Knee extended while observing for 'stuttering' of the patella
- Plica Active Extension Test: Patient quickly, actively extends knee as in kicking a ball
- Plica Flexion Test: Patient quickly flexes knee from full extension
- Medial Patellar Plica Test: Apply inferomedial for to patella, flex and extend the knee
Evaluation
Radiographs
- Standard Radiographs Knee
- Typically normal
Ultrasound
- Dynamic Sonography[4]
- Using arthroscopy to as gold standard
- Paczesny found Sensitivity 90%, specificity 83%, diagnostic accuracy 88%
MRI
- Findings[5]
- 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
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
Prognosis
- Younger patients with a shorter course of illness are more likely to respond to conservative measures[6]
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
- Needs to be updated
Return to Play
- Needs to be updated
Complications
- Patellofemoral Pain Syndrome
- Knee Osteoarthritis
- Especially of the medial compartment[7]
- Inability to return to sport
- Chronic pain
See Also
- Internal
- External
- Sports Medicine Review Knee Pain: https://www.sportsmedreview.com/by-joint/knee/
References
- ↑ 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.
- ↑ Dupont J Y. Synovial plicae of the knee. Controversies and review. Clin Sports Med. 1997;16(01):87–122
- ↑ Dandy D J. Anatomy of the medial suprapatellar plica and medial synovial shelf. Arthroscopy. 1990;6(02):79–85.
- ↑ Paczesny L, Kruczynski J. 2009. Medial plica syndrome of the knee: Diagnosis with dynamic sonography. Radiology 251:439–446.
- ↑ 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.
- ↑ Sznajderman T, Smorgick Y, Lindner D, Beer Y, Agar G. 2009. Medial plica syndrome. Isr Med Assoc J 11:54–57.
- ↑ 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:
4 October 2022 15:55:01
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