Pellegrini-Stieda syndrome

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

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Definition/Description

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 (1Mio). This calcium deposit develops between the attachment of the medial collateral ligament and medial condyle. [1, 6, 13]

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.

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 (3mio). The origin of calcification remains under debate but proposed origins are(4mio):

• 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 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).4mio

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 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. [2, 3, 9]

Epidemiology /Etiology

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.(1mio)

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 injure develop a hematoma or inflammatory edema of soft tissue as a result of tearing and shredding fibers at their femoral attachment(1,7) The soft tissues degenerate and become affected and subsequently deposition of hydroxyapatite or calcium pyrophosphate produces the calcification in the month following the trauma 1mio

Ossification could 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

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. [5, 7]

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. (1mio)

The knee will be stiff with 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.[1mio4, 6, 8, 11]

The majority of patients are asymptomatic. 1mio

Prognosis

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, 13]

Differential Diagnosis

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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
[1, 11]

Medical Management

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.
[6, 12]

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.
[14]

Physical Therapy Management

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
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
[10, 11, 12, 15]

References

1. Peter brukner and Karim Khan, Third edition (2006), Clinical sports medicine, p.549.
Opgezocht: 29/11/2011

2. Adam B. Agranoff MD, Medial collateral and lateral collateral ligament injury, (1994-2011).
Opgezocht: 27/10/2011, Link: http://emedicine.medscape.com/article/307959-overview

3. Dr. Sheila Strover, Knee guru information hub, anatomy of the collateral ligaments, (2011).
Opgezocht: 27/10/2011, Link: http://www.kneeguru.co.uk/KNEEnotes/node/881

4. Vinzendi, medisch advies bureau, (2006-2011)
Opgezocht: 27/10/2011, Link: http://www.sportkeuringen.com/index.php?option=com_content&view=article&id=136:knie-pellegrini-stieda-syndroom&catid=22:knie-klachten&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.
Opgezocht: 01/11/2011, Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2484441/pdf/jcca00068-0025.pdf
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.
Opgezocht: 01/11/2011, Link: http://www.ncbi.nlm.nih.gov/pubmed/932812
Level of evidence: 5

8. Pellegrini-stieda’s disease, post-traumatic para-articular osteoma
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).
Opgezocht: 19/11/2011

11. Akinpelu M., Vijayvargiya S., Prakash C., Kayode M., Awosanya G., Internet scientific publications (LLC, 1996-2011).
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
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).
Opgezocht: 01/11/2011, Link: http://www.nejm.org/doi/full/10.1056/NEJMicm040406
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.
Opgezocht: 01/11/2011, Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1756070/pdf/v032p00073.pdf
Level of evidence: 5

14. Kanthan Theivendran, Caroline J. Lever, William J. Hart, Good result after treatment of Pellegrini-Stieda syndrome.
Opgezocht: 02/12/2011, Link: http://www.springerlink.com/content/k8v74172p5912522/fulltext.pdf
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.
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.
Opgezocht: 25/12/2011, Link: http://www.ncbi.nlm.nih.gov/pubmed/7609967