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'''Original Editors ''' - [[User:Sofie Van Cutsem|Sofie Van Cutsem]] as part of the [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]  


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== Search Strategy ==
== Definition/Description ==
 
I consulted Pubmed to search for a good topic. I also consulted Pedro and Web of knowledge but I didn’t found much useful information. Finally I found my topic in a book of Romain Meeusen.
 
<br>
 
The keywords that I used: Pellegrini-Stieda syndrome, Pellegrini-Stieda disease, ossification medial collateral ligament, knee injuries, limited range of motion knee.


Most successful: Pellegrini-Stieda syndrome and Pellegrini-Stieda disease.<br>  
Is the presence of a radiological finding of calcification on the medial side of the knee as a consequence of trauma, plus clinical symptomatology of pain and diminished range of motion.<ref name=":1">Restrepo, J. P., & del Pilar Molina, M. [http://www.elsevier.es/en-revista-revista-colombiana-reumatologia-english-edition--474-articulo-pellegrinistieda-syndrome-more-than-radiological-S2444440516300498 Pellegrini–Stieda syndrome: More than a radiological sign].Revista Colombiana de Reumatología (English Edition).2016; ''23''(3)<sup>:</sup> 210-212.  </ref> This calcium deposit develops between the attachment of the medial collateral ligament and medial condyle.<ref name=":2">Brukner P. and Khan K. Clinical Sports Medicine. Sydney:  McGraw-Hill Australia. 2006</ref><ref name=":7">Kogon, P. L., Tchoryk, J., & Fleming, O. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2484441/pdf/jcca00068-0025.pdf Pellegrini-stieda disease]. The Journal of the Canadian Chiropractic Association.1987'';'' ''31''(4): 191. Level of evidence: 5</ref><ref name=":4">Shanker, V. S., Gadikoppula, S., & Loeffler, M. D. [https://bjsm.bmj.com/content/bjsports/32/1/73.full.pdf 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</ref>


<br><br>
The radiographic finding of the lesion is termed Pellegrini–Stieda phenomenon/lesion/sign, whereas the combination of the radiographic anomaly at the designated location with pain at that site is known as Pellegrini–Stieda syndrome.
 
[[File:Stieda Pellegrini Sign.jpg|center|thumb]]
== Definition/Description  ==


Pellegrini-stieda syndrome is a condition in which a calcification occurs on the medial side of the knee. This calcium deposit develops between the attachment of the medial collateral ligament and medial condyle.<br>[1, 6, 13]<br><br>
PS lesion might not entail one entity but represent a spectrum of traumatic lesions resulting in an ossification on the medial side of the distal femur.<ref name=":5">Somford, M. P., Janssen, R. P. A., Meijer, D., Roeling, T. A. P., Brown Jr, C., & Eygendaal, D. The Pellegrini–Stieda Lesion of the Knee: An Anatomical and Radiological Review. The journal of knee surgery. 2018</ref> The origin of calcification remains under debate but proposed origins are<ref name=":0">Somford, M. P., Lorusso, L., Porro, A., Van Loon, C., & Eygendaal, D. The Pellegrini–Stieda Lesion Dissected Historically. ''T''he journal of knee surgery.2018; 31(06): 562-567.</ref>:
* deep medial/tibial collateral ligament
* superficial medial/tibial collateral ligament
* medial patellofemoral ligament
* medial gastrocnemius
* adductor magnus
* vastus medialis.
Although the MCL was most often coined as the origin of the lesion (54% overall, 25% on MRI, and 57% during surgery), many cases remained undecided (50% on MRI) or no specific structure was found to be the origin (29% during surgery).<ref name=":0" />


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


The medial/tibial collateral ligament (MCL) is a broad, flat band that extends from the medial femoral epicondyle to the medial meniscus, tibial plateau, and adjacent shaft. It consists of superficial and deep components. The superficial component attaches distally to the medial aspect of the tibia and proximally to the medial femoral epicondyle. The deeper component originates from the medial joint capsule and attaches to the medial meniscus.


The superficial component is about 10 cm long and flat. The bursae separate the capsule and the medial meniscus of the superficial component. It may be one or more bursae. The superficial component of the medial collateral ligament crosses, in his way down to the medial site and posterior medial surface of the tibial, the tendons of the sartorius, gracilis and, semitendinosus, also separated by a bursa. Below the ligament runs the medial inferior geniculi vessels and nerve and the anterior section of the semimembranosus tendon. The deeper component is shorter than the superficial and descends posteriorly to the medial tibial plateau, proximal to the groove for the semimembranosus.


The medial collateral ligament (MCL)[attachment 3] is a broad, flat band that extends from the medial femoral epicondyle to the medial meniscus, tibial plateau, and adjacent shaft. It consists of superficial and deep components. The superficial component attaches distally to the medial aspect of the tibia and proximally to the medial femoral epicondyle. The deeper component originates from the medial joint capsule and attaches to the medial meniscus.
The medial collateral ligament is an important ligament, it has an important role in stabilizing the knee joint. The long fibers of the MCL primarily stabilize the medial side of the knee against valgus and external rotatory stress. The deeper part of this ligament also helps the anterior cruciate ligament in avoiding an anterior translation of the tibia on the femur.<ref>Agranoff A. Medial collateral and lateral collateral ligament injury. Abailable from:[http://emedicine.medscape.com/article/307959-overview <u><font color="#0066cc">http://emedicine.medscape.com/article/307959-overview</font></u>] (accessed 27/10/2011)</ref><ref>Knee guru. Anatomy of the collateral ligaments. Available from: [http://www.kneeguru.co.uk/KNEEnotes/node/881 <u><font color="#0066cc">http://www.kneeguru.co.uk/KNEEnotes/node/881</font></u>] (accessed 27/10/2011)</ref><ref>Schunke M. Schulte E. Schumacher U. Rude J. Voll M. Prometheus: Anatomische Atlas. Houten: Bohn Stafleu van Loghum, 2010</ref>


<br>The superficial component is about 10 cm long and flat. The bursae separate the capsule and the medial meniscus of the superficial component. It may be one or more bursae. The superficial component of the medial collateral ligament crosses, in his way down to the medial site and posterior medial surface of the tibial, the tendons of the sartorius, gracilis and, semitendinosus, also separated by a bursa. Below the ligament runs the medial inferior geniculi vessels and nerve and the anterior section of the semimembranosus tendon. The deeper component is shorter than the superficial and descends posteriorly to the medial tibial plateau, proximal to the groove for the semimembranosus.
== Epidemiology /Etiology  ==


<br>The medial collateral ligament is an important ligament, it has an important role in stabilizing the knee joint. The long fibers of the MCL primarily stabilize the medial side of the knee against valgus and external rotatory stress. The deeper part of this ligament also helps the anterior cruciate ligament in avoiding an anterior translation of the tibia on the femur.<br>[2, 3, 9]
The Pellegrini-Stieda syndrome is a relatively infrequent phenomenon and is commonly associated with sporting injuries.[5, 6] PSS Is more frequently in the male gender between 25 and 40 years of age.<ref name=":1" />  


<br><br>
Direct trauma or in a distant site (skull or spine), repetitive trauma, or after an overstretching injury to the medial collateral ligament and joint capsule can result in an avulsion of the medial femoral condyle or a tear of ligaments, tendons. This injury develop a hematoma or inflammatory edema of soft tissue as a result of tearing and shredding fibers at their femoral attachment <ref name=":2" /><ref name=":3">Turner, J. W., Syed, I. B., & Spencer, R. P. [http://www.ncbi.nlm.nih.gov/pubmed/932812 Two unusual causes of peripatellar nonmetastatic positive bone scans in patients with malignancies]. Journal of nuclear medicine: official publication, Society of Nuclear Medicine. ''1976;'' ''17''(8): 693-695. Level of evidence: 5</ref>. The soft tissues degenerate and become affected and subsequent deposition of hydroxyapatite or calcium pyrophosphate produces the calcification in the month following the trauma<ref name=":1" />
 
== Epidemiology /Etiology  ==


The Pellegrini-stieda syndrome is a relatively infrequent phenomenon. It is commonly associated with sporting injuries.<br>[5, 6]
Ossification could happen within 11 days to 6 weeks after post trauma. A network of the new bone formation around the periphery of the mass of the medial condyle is formed in 6 to 8 weeks. Duration of the condition is usually about 5 to 6 months.


What about the etiology of the condition?<br>The cause of the Pellegrini-Stieda syndrome is an injury to the attachment site of the medial collateral ligament to the medial condyle of the femur. This usually occurs after a direct trauma to the site, like for instance a hit on the inside of the knee with a ball at high speed or after an overstretching injury to the medial collateral ligament and joint capsule.<br>The mechanism can develop a hematoma or inflammatory edema as a result of tearing and shredding fibers at their femoral attachment7. The soft tissues degenerate and become affected, forming a place for deposition of calcium salts. After a while, the phenomena could occur: the inflammation subsides with partial or complete resorption of the calcium salts, or the mass becomes ossified and may be connected by a pedicle to the femoral condyle. The last is called Pellegrini-Stieda syndrome.<br>[5, 7]<br><br><br>
After a while, the phenomena could occur: the inflammation subsides with partial or complete resorption of the calcium salts, or the mass becomes ossified and may be connected by a pedicle to the femoral condyle. The last is called Pellegrini-Stieda syndrome. <ref name=":3" /><ref>Challans A. Pellegrini-Stieda disease. Available from: [http://www.wikiradiography.com/page/Pellegrini-Stieda+Disease <u><font color="#0066cc">http://www.wikiradiography.com/page/Pellegrini-Stieda+Disease</font></u>] (accessed 29/10/2011)</ref>


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


Pain and local swelling in the medial aspect of the knee are the two first symptoms following an injury like traumatic synovitis. The pain and disability will increase after a few weeks or months.<ref name=":1" />


The knee will be stiff with the limitation of flexion–extension movements of the joint. The stiffness in the knee will mainly hamper the stretching of the knee but also twisting of the knee will be rather difficult. In addition to the limitation of motion, it is possible that a tender lump can be seen on the inside of the knee.<ref name=":1" /><ref name=":6">Akinkunmi, S Vijayvargiya, C Prakash, M Kayode, G Awosanya. [https://print.ispub.com/api/0/ispub-article/4583 Pellegrini-Stieda Syndrome: Report Of Two Cases.] The Internet Journal of Radiology. 2009; 12(2). Level of evidence: 5</ref>


The term ‘Pellegrini-Stieda’ is only reserved for the few patients who are symptomatic; most of the patients with post traumatic calcification of the proximal aspect of the MCL are indeed asymptomatic. Pellegrini-Stieda disease is characterized by formation of a soft tissue edema followed by the formation of a dense, calcific infiltration of the swelling on the medial side of the knee. This happened within 11 days to 6 weeks after post trauma.6 (level of evidence 5) A network of new bone formation around the periphery of the mass of the medial condyle is formed in 6 to 8 weeks.6 Duration of the condition is usually about 5 to 6 months.6<br>Pain and local swelling are the two first symptoms following an injury like traumatic synovitis. There will be no full recovery from this injury, yet there will be symptomatic improvement. The pain and disability will increase after a few weeks or months. The knee will be stiff with limitation of movement and pain over the medial side of the knee. The stiffness in the knee will mainly hamper the stretching of the knee but also twisting of the knee will be rather difficult. In addition to the limitation of motion, it is possible that a tender lump can be seen on the inside of the knee.<br>[4, 6, 8, 11]
The majority of patients are asymptomatic.<ref name=":1" />
 
== Prognosis ==
 
 
<br>
 
== Differential Diagnosis ==
 
<br>
 
<br>


When a full range of motion in the knee is attained, and the athlete does not feel any form of pain, he can resume his activities. It is also important that the range of motion is symmetric on both sides. Also, the muscles, Quadriceps, and Hamstrings, have fully recovered. This means full power recovery.<ref name=":4" />
== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
[[File:Stieda Pellegrini X-ray.jpg|thumb]]


<br>
The combination of Pellegrini–Stieda phenomenon/lesion/sign, plus localized pain on medial side of the knee and diminished range of motion is enough to diagnose this Syndrome.<ref name=":1" />
 
<br>


== Outcome Measures  ==
Secondary to the mechanism of injury swelling or hematoma may displace the injured ligament or tendon and subsequently the calcification that can be viewed on conventional  X-ray.<ref name=":5" /> It can be observed a linear or curved calcification from the origin the medial collateral ligament and that may extend almost to the insertion. A new classification is proposed based on the location<ref name=":2" /><ref>Ridley, L. J., Han, J., Ridley, W. E., & Xiang, H. B[https://onlinelibrary.wiley.com/doi/epdf/10.1111/1754-9485.02_12786 eak‐type Pellegrini Stieda lesion]. Journal of medical imaging and radiation oncology.2018'';'' ''62<sup>:</sup>'' 120-120. </ref>:
* 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


<br>
MRI seems to be a noninvasive and more accurate imaging<ref name=":5" /> than conventional  X-ray<ref name=":5" /><ref name=":0" />


== Examination  ==
== Examination  ==


The patient complains about a severe, recurrent pain in the inner aspect of the knee.11 Most of the patients sustained an injury years, months or weeks earlier.1,11 The gait of the patient is normal with mild tenderness over de medial border of the knee.11 In most of the cases, on examination no swelling can be observed.1 The patient has some difficulty with full passive extension or twisting of the knee. There is no ligamentous laxity.11<br>[1, 11]<br><br>
The patient complains about a severe, recurrent pain in the inner aspect of the knee.<ref name=":6" /> Most of the patients sustained an injury years, months or weeks earlier.<ref name=":2" /><ref name=":6" />The gait of the patient is normal with mild tenderness over the medial border of the knee.<ref name=":6" />In most of the cases, on examination, no swelling can be observed.<ref name=":2" />The patient has some difficulty with full passive extension or twisting of the knee. There is no ligamentous laxity.<ref name=":2" /><ref name=":6" /><br>  


== Medical Management <br> ==
== Medical Management   ==
The treatment of the PSS is usually conservative.<ref name=":1" /><ref name=":2" />


The use of Aspirin or non-steroidal anti-inflammatory preparations could be prescribed in the treatment of this condition. And if pain persists is infiltration of a corticosteroid agent to the tender medial collateral ligament attachment useful. <ref name=":7" /><ref name=":8">Altschuler, E. L., & Bryce, T. N. [https://www.nejm.org/doi/pdf/10.1056/NEJMicm040406 Pellegrini–Stieda Syndrome]. New England Journal of Medicine.2006; ''354''(1), e1. Level of evidence: 5</ref>


If severe movement restriction because of damage of the medial collateral ligament, surgical excision of the calcification and ligament repair have been performed with good outcomes.<ref name=":1" /><ref>Theivendran, K., Lever, C. J., & Hart, W. J. Good result after surgical treatment of Pellegrini–Stieda syndrome. ''Knee Surgery, Sports Traumatology, Arthroscopy. 2009; 17''(10):1231-1233. Level of evidence: 3b</ref> The pain is gone and the knee again has his full range of motion. Their removal in the early stages of the disease is not recommended because of the high risk of relapse.<ref name=":1" />


The use of Aspirin or non-steroidal anti-inflammatory preparations could be prescribed in the treatment of this condition. And if pain persists is infiltration of a corticosteroid agent to the tender medial collateral ligament attachment useful. <br>[6, 12]
Measures such as rest, physical therapy, steroids, and lidocaine injections have been successfully used.<ref name=":1" />


== Physical Therapy Management    ==


First conservative work, with emphasis on avoiding overload and microtrauma, therefore forced rehabilitation or early sports resumption is to be avoided.


In some cases, the patients undergo surgery. There are good results after treatment of Pellegrini-Stieda syndrome. The pain is gone and the knee again has his full range of motion.<br>[14]<br>
Ice therapy is useful, as well as local and general antiinflammatory.<ref name=":9">Prof. Dr. R. Meeusen , Vrije universiteit brussel, cursus 488, (2011).</ref>(level of evidence 5) Even conservative rehabilitation and mobilization of the knee joint are necessary.  


The different steps of the functional rehabilitation can be completed, only in a more controlled and slow manner.<ref name=":9" />


 
<br>Some examples of knee bending exercises are:
<br>
* heel slides
 
* seated knee bending
== Physical Therapy Management <br>  ==
* seated chair slides
 
* knee bending on the stomach.  
First conservative work, with emphasis on avoiding overload and microtrauma. For example forced rehabilitation or early sports resumption is to be avoided. Ice therapy is useful, as well as local and general antiflogistica.10(level of evidence 5) Even conservative rehabilitation and mobilization of the knee joint are necessary. The different steps of the functional rehabilitation can be completed, only in a more controlled and slow manner.10<br>Some examples of knee bending exercises are heel slides, seated knee bending, seated chair slides and knee bending on stomach. To increase the stretch you can use a strap around your ankle and pull or use your other leg to pull. Knee straightening exercises are in lying or sitting position with a towel roll under your ankle so that your calf clears the table, you increase the stretch. You also can do knee straightening on stomach, you have to put the towel roll under the thigh and the feet off the edge of the table.15<br>[10, 11, 12, 15]<br><br>
To increase the stretch is useful to use a strap around the ankle and pull or pulling with contralateral leg. Knee straightening exercises could be performed in lying or sitting position with a towel roll under the ankle so that the calf clears the table and increase of the stretch can be done. Another option could be knee straightening on stomach, putting the towel roll under the thigh and the feet off the edge of the table<ref name=":9" /><ref name=":6" /><ref name=":8" /><ref>Kaiser Permanente. Tips and exercises for your knee stiffness and pain. Available from: [https://www.mydoctor.kaiserpermanente.org/ncal/Images/010526-035CL_tcm75-89999.pdf <u><font color="#0066cc">https://www.mydoctor.kaiserpermanente.org/ncal/Images/010526-035CL_tcm75-89999.pdf</font></u>] (accessed 06/12/2018)</ref><ref>Lephart, S. M., & Henry, T. J. Functional rehabilitation for the upper and lower extremity. The Orthopedic Clinics of North America.1995'';'' ''26''(3): 579-592.</ref> <br>
 
== Key Research  ==
 
Pellegrini-Stieda syndrome, Pellegrini-Stieda disease, ossification medial collateral ligament, knee injuries, limited range of motion knee.<br>
 
== Resources <br> ==
 
- Pubmed<br>- Web of knowledge<br>- Books<br><br>
 
== Clinical Bottom Line  ==
 
add text here <br>  
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
 
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== References  ==
== References  ==
 
[[Category:Vrije_Universiteit_Brussel_Project]]
1. Peter brukner and Karim Khan, Third edition (2006), Clinical sports medicine, p.549.<br>Opgezocht: 29/11/2011
[[Category:Conditions]]
 
[[Category:Knee]]
2. Adam B. Agranoff MD, Medial collateral and lateral collateral ligament injury, (1994-2011).<br>Opgezocht: 27/10/2011, Link: http://emedicine.medscape.com/article/307959-overview
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]
 
[[Category:Knee - Conditions]]
3. Dr. Sheila Strover, Knee guru information hub, anatomy of the collateral ligaments, (2011).<br>Opgezocht: 27/10/2011, Link: http://www.kneeguru.co.uk/KNEEnotes/node/881
<references />
 
4. Vinzendi, medisch advies bureau, (2006-2011)<br>Opgezocht: 27/10/2011, Link: http://www.sportkeuringen.com/index.php?option=com_content&amp;view=article&amp;id=136:knie-pellegrini-stieda-syndroom&amp;catid=22:knie-klachten&amp;Itemid=66
 
5. Andy C., Wiki Radiography, world’s largest radiography encyclopedia, Pellegrini-Stieda disease, (2010). Opgezocht: 29/10/2011, Link: http://www.wikiradiography.com/page/Pellegrini-Stieda+Disease
 
6. PL Kogon, Jerry Tchoryk, Owen Fleming, Pellegrini-stieda disease.<br>Opgezocht: 01/11/2011, Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2484441/pdf/jcca00068-0025.pdf<br>Level of evidence: 5
 
7. John W. Turner, Ibrahim B. Syed, and Richard P. Spencer,Two unusual causes of peripatellar nonmetastatic positive bone scans in patients with malignancies: case reports.<br>Opgezocht: 01/11/2011, Link: http://www.ncbi.nlm.nih.gov/pubmed/932812<br>Level of evidence: 5
 
8. Pellegrini-stieda’s disease, post-traumatic para-articular osteoma<br>Opgezocht: 01/11/2011, Link: http://www.patscotland.org.uk/medical_appendices/P/PELLEGRINI-STIEDA'S%20DISEASE.pdf
 
9. Schunke
 M., Schulte
 E.,
 Schumacher, tweede druk (2010). Anatomische atlas
 Prometheus:
 Algemene anatomie en bewegingsapparaat.
Nederland:
Bohn Stafleu Van Loghum.
 
10. Prof. Dr. R. Meeusen , Vrije universiteit brussel, cursus 488, (2011).<br>Opgezocht: 19/11/2011
 
11. Akinpelu M., Vijayvargiya S., Prakash C., Kayode M., Awosanya G., Internet scientific publications (LLC, 1996-2011).<br>Opgezocht: 26/11/2011, Link: http://www.ispub.com/journal/the-internet-journal-of-radiology/volume-12-number-2/pellegrini-stieda-syndrome-report-of-two-cases.html<br>Level of evidence: 5
 
12. Eric L. Altschulder, M.D., Ph.D. and Thomas N. Bryse M.D., MT., Sinai school of medicine, New York, The new england journal of medicine, Pellegrini-stieda syndrome, (2011).<br>Opgezocht: 01/11/2011, Link: http://www.nejm.org/doi/full/10.1056/NEJMicm040406<br>Level of evidence: 5
 
13. V Shiv Shanker, S. Gadikoppula, M D Loeffler, Post traumatic osteoma of tibial insertion of medial collateral ligament of the knee joint.<br>Opgezocht: 01/11/2011, Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1756070/pdf/v032p00073.pdf<br>Level of evidence: 5
 
14. Kanthan Theivendran, Caroline J. Lever, William J. Hart, Good result after treatment of Pellegrini-Stieda syndrome.<br>Opgezocht: 02/12/2011, Link: http://www.springerlink.com/content/k8v74172p5912522/fulltext.pdf<br>Level of evidence: 3b
 
15. The permanente Mediacal Group, regional health education and physical therapy, tips and exercises for your knee stiffness and pain, 2009.<br>Opgezocht: 22/12/2011, Link: http://www.permanente.net/homepage/kaiser/pdf/64676.pdf
 
16. Lephart SM, Henry TJ, functional rehabilitation for the upper and lower extremity, department of Orthopaedic surgery of Pitgtsburg, Pennsylvania, USA.<br>Opgezocht: 25/12/2011, Link: http://www.ncbi.nlm.nih.gov/pubmed/7609967<br>
 
[[Category:Vrije_Universiteit_Brussel_Project|Vrije_Universiteit_Brussel_Project]]

Latest revision as of 01:28, 29 August 2019

Original Editors - Sofie Van Cutsem as part of the Vrije Universiteit Brussel's Evidence-based Practice project

Top Contributors - Sofie Van Cutsem, Claudia Karina, Admin, Kim Jackson, Daphne Jackson and WikiSysop  

Definition/Description[edit | edit source]

Is the presence of a radiological finding of calcification on the medial side of the knee as a consequence of trauma, plus clinical symptomatology of pain and diminished range of motion.[1] This calcium deposit develops between the attachment of the medial collateral ligament and medial condyle.[2][3][4]

The radiographic finding of the lesion is termed Pellegrini–Stieda phenomenon/lesion/sign, whereas the combination of the radiographic anomaly at the designated location with pain at that site is known as Pellegrini–Stieda syndrome.

Stieda Pellegrini Sign.jpg

PS lesion might not entail one entity but represent a spectrum of traumatic lesions resulting in an ossification on the medial side of the distal femur.[5] The origin of calcification remains under debate but proposed origins are[6]:

  • deep medial/tibial collateral ligament
  • superficial medial/tibial collateral ligament
  • medial patellofemoral ligament
  • medial gastrocnemius
  • adductor magnus
  • vastus medialis.

Although the MCL was most often coined as the origin of the lesion (54% overall, 25% on MRI, and 57% during surgery), many cases remained undecided (50% on MRI) or no specific structure was found to be the origin (29% during surgery).[6]

Clinically Relevant Anatomy[edit | edit source]

The medial/tibial collateral ligament (MCL) is a broad, flat band that extends from the medial femoral epicondyle to the medial meniscus, tibial plateau, and adjacent shaft. It consists of superficial and deep components. The superficial component attaches distally to the medial aspect of the tibia and proximally to the medial femoral epicondyle. The deeper component originates from the medial joint capsule and attaches to the medial meniscus.

The superficial component is about 10 cm long and flat. The bursae separate the capsule and the medial meniscus of the superficial component. It may be one or more bursae. The superficial component of the medial collateral ligament crosses, in his way down to the medial site and posterior medial surface of the tibial, the tendons of the sartorius, gracilis and, semitendinosus, also separated by a bursa. Below the ligament runs the medial inferior geniculi vessels and nerve and the anterior section of the semimembranosus tendon. The deeper component is shorter than the superficial and descends posteriorly to the medial tibial plateau, proximal to the groove for the semimembranosus.

The medial collateral ligament is an important ligament, it has an important role in stabilizing the knee joint. The long fibers of the MCL primarily stabilize the medial side of the knee against valgus and external rotatory stress. The deeper part of this ligament also helps the anterior cruciate ligament in avoiding an anterior translation of the tibia on the femur.[7][8][9]

Epidemiology /Etiology[edit | edit source]

The Pellegrini-Stieda syndrome is a relatively infrequent phenomenon and is commonly associated with sporting injuries.[5, 6] PSS Is more frequently in the male gender between 25 and 40 years of age.[1]

Direct trauma or in a distant site (skull or spine), repetitive trauma, or after an overstretching injury to the medial collateral ligament and joint capsule can result in an avulsion of the medial femoral condyle or a tear of ligaments, tendons. This injury develop a hematoma or inflammatory edema of soft tissue as a result of tearing and shredding fibers at their femoral attachment [2][10]. The soft tissues degenerate and become affected and subsequent deposition of hydroxyapatite or calcium pyrophosphate produces the calcification in the month following the trauma[1]

Ossification could happen within 11 days to 6 weeks after post trauma. A network of the new bone formation around the periphery of the mass of the medial condyle is formed in 6 to 8 weeks. Duration of the condition is usually about 5 to 6 months.

After a while, the phenomena could occur: the inflammation subsides with partial or complete resorption of the calcium salts, or the mass becomes ossified and may be connected by a pedicle to the femoral condyle. The last is called Pellegrini-Stieda syndrome. [10][11]

Characteristics/Clinical Presentation[edit | edit source]

Pain and local swelling in the medial aspect of the knee are the two first symptoms following an injury like traumatic synovitis. The pain and disability will increase after a few weeks or months.[1]

The knee will be stiff with the limitation of flexion–extension movements of the joint. The stiffness in the knee will mainly hamper the stretching of the knee but also twisting of the knee will be rather difficult. In addition to the limitation of motion, it is possible that a tender lump can be seen on the inside of the knee.[1][12]

The majority of patients are asymptomatic.[1]

Prognosis[edit | edit source]

When a full range of motion in the knee is attained, and the athlete does not feel any form of pain, he can resume his activities. It is also important that the range of motion is symmetric on both sides. Also, the muscles, Quadriceps, and Hamstrings, have fully recovered. This means full power recovery.[4]

Diagnostic Procedures[edit | edit source]

Stieda Pellegrini X-ray.jpg

The combination of Pellegrini–Stieda phenomenon/lesion/sign, plus localized pain on medial side of the knee and diminished range of motion is enough to diagnose this Syndrome.[1]

Secondary to the mechanism of injury swelling or hematoma may displace the injured ligament or tendon and subsequently the calcification that can be viewed on conventional  X-ray.[5] It can be observed a linear or curved calcification from the origin the medial collateral ligament and that may extend almost to the insertion. A new classification is proposed based on the location[2][13]:

  • 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

MRI seems to be a noninvasive and more accurate imaging[5] than conventional  X-ray[5][6]

Examination[edit | edit source]

The patient complains about a severe, recurrent pain in the inner aspect of the knee.[12] Most of the patients sustained an injury years, months or weeks earlier.[2][12]The gait of the patient is normal with mild tenderness over the medial border of the knee.[12]In most of the cases, on examination, no swelling can be observed.[2]The patient has some difficulty with full passive extension or twisting of the knee. There is no ligamentous laxity.[2][12]

Medical Management[edit | edit source]

The treatment of the PSS is usually conservative.[1][2]

The use of Aspirin or non-steroidal anti-inflammatory preparations could be prescribed in the treatment of this condition. And if pain persists is infiltration of a corticosteroid agent to the tender medial collateral ligament attachment useful. [3][14]

If severe movement restriction because of damage of the medial collateral ligament, surgical excision of the calcification and ligament repair have been performed with good outcomes.[1][15] The pain is gone and the knee again has his full range of motion. Their removal in the early stages of the disease is not recommended because of the high risk of relapse.[1]

Measures such as rest, physical therapy, steroids, and lidocaine injections have been successfully used.[1]

Physical Therapy Management[edit | edit source]

First conservative work, with emphasis on avoiding overload and microtrauma, therefore forced rehabilitation or early sports resumption is to be avoided.

Ice therapy is useful, as well as local and general antiinflammatory.[16](level of evidence 5) Even conservative rehabilitation and mobilization of the knee joint are necessary.

The different steps of the functional rehabilitation can be completed, only in a more controlled and slow manner.[16]


Some examples of knee bending exercises are:

  • heel slides
  • seated knee bending
  • seated chair slides
  • knee bending on the stomach.

To increase the stretch is useful to use a strap around the ankle and pull or pulling with contralateral leg. Knee straightening exercises could be performed in lying or sitting position with a towel roll under the ankle so that the calf clears the table and increase of the stretch can be done. Another option could be knee straightening on stomach, putting the towel roll under the thigh and the feet off the edge of the table[16][12][14][17][18]

References[edit | edit source]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Restrepo, J. P., & del Pilar Molina, M. Pellegrini–Stieda syndrome: More than a radiological sign.Revista Colombiana de Reumatología (English Edition).2016; 23(3): 210-212. 
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Brukner P. and Khan K. Clinical Sports Medicine. Sydney:  McGraw-Hill Australia. 2006
  3. ↑ 3.0 3.1 Kogon, P. L., Tchoryk, J., & Fleming, O. Pellegrini-stieda disease. The Journal of the Canadian Chiropractic Association.1987; 31(4): 191. Level of evidence: 5
  4. ↑ 4.0 4.1 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
  5. ↑ 5.0 5.1 5.2 5.3 Somford, M. P., Janssen, R. P. A., Meijer, D., Roeling, T. A. P., Brown Jr, C., & Eygendaal, D. The Pellegrini–Stieda Lesion of the Knee: An Anatomical and Radiological Review. The journal of knee surgery. 2018
  6. ↑ 6.0 6.1 6.2 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. ↑ Agranoff A. Medial collateral and lateral collateral ligament injury. Abailable from:http://emedicine.medscape.com/article/307959-overview (accessed 27/10/2011)
  8. ↑ Knee guru. Anatomy of the collateral ligaments. Available from: http://www.kneeguru.co.uk/KNEEnotes/node/881 (accessed 27/10/2011)
  9. ↑ Schunke M. Schulte E. Schumacher U. Rude J. Voll M. Prometheus: Anatomische Atlas. Houten: Bohn Stafleu van Loghum, 2010
  10. ↑ 10.0 10.1 Turner, J. W., Syed, I. B., & Spencer, R. P. Two unusual causes of peripatellar nonmetastatic positive bone scans in patients with malignancies. Journal of nuclear medicine: official publication, Society of Nuclear Medicine. 1976; 17(8): 693-695. Level of evidence: 5
  11. ↑ Challans A. Pellegrini-Stieda disease. Available from: http://www.wikiradiography.com/page/Pellegrini-Stieda+Disease (accessed 29/10/2011)
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 Akinkunmi, S Vijayvargiya, C Prakash, M Kayode, G Awosanya. Pellegrini-Stieda Syndrome: Report Of Two Cases. The Internet Journal of Radiology. 2009; 12(2). Level of evidence: 5
  13. ↑ Ridley, L. J., Han, J., Ridley, W. E., & Xiang, H. Beak‐type Pellegrini Stieda lesion. Journal of medical imaging and radiation oncology.2018; 62: 120-120.
  14. ↑ 14.0 14.1 Altschuler, E. L., & Bryce, T. N. Pellegrini–Stieda Syndrome. New England Journal of Medicine.2006; 354(1), e1. Level of evidence: 5
  15. ↑ Theivendran, K., Lever, C. J., & Hart, W. J. Good result after surgical treatment of Pellegrini–Stieda syndrome. Knee Surgery, Sports Traumatology, Arthroscopy. 2009; 17(10):1231-1233. Level of evidence: 3b
  16. ↑ 16.0 16.1 16.2 Prof. Dr. R. Meeusen , Vrije universiteit brussel, cursus 488, (2011).
  17. ↑ Kaiser Permanente. Tips and exercises for your knee stiffness and pain. Available from: https://www.mydoctor.kaiserpermanente.org/ncal/Images/010526-035CL_tcm75-89999.pdf (accessed 06/12/2018)
  18. ↑ Lephart, S. M., & Henry, T. J. Functional rehabilitation for the upper and lower extremity. The Orthopedic Clinics of North America.1995; 26(3): 579-592.
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