Pellegrini-Stieda syndrome

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Search Strategy

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.

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.

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.
[1, 6, 13]

Clinically Relevant Anatomy

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 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. It is commonly associated with sporting injuries.
[5, 6]

What about the etiology of the condition?
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.
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.
[5, 7]

Characteristics/Clinical Presentation

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
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.
[4, 6, 8, 11]

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

1. COCCYGEOPLASTY
By applying the novel techniques that are used in vertebroplasty and sacroplasty, coccygeoplasty is introduced as a new percutaneous treatment modality for fractures of the coccyx. This procedure can be helpful for patients with refractory pain resulting from a fracture of the coccyx and can be performed quickly and safely with high-resolution c-arm fluoroscopy. The coccygeal fracture treated with an injection of polymethylmethacrylate cement can provide early symptom relief. Although the promising results, an experience with a larger patient population is warranted. ( level of evidence C)

2. COCCYGECTOMY
Literature reports suggest that coccygectomy, partial or total removal of the coccyx, has been beneficial with success rates as high as 60-91%. However, coccygectomy is a more invasive procedure, with a common complication rate as high as 22%, and is usually associated with perineal contamination of the wound. Other complications could include persistent bleeding from the hemorrhoidal venous complex of the rectum. (level of evidence C)ix

Physical Therapy Management

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 451-452, level of evidence D
YU-TSAI T., LI-WEN T., CHENG-HSIU L., SHIH-WEI C., The influence of human coccyx in body weight shifting, medicine and science in sport and exercise, 2011, Volume 43, Number 5, pag. 494-496, level of evidence B
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 332, level of evidence D
HAARMAN H.J.Th.M., Klinische traumatologie, Elsevier gezondheidszorg, 2006, pag. 117, level of evidence D
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 461, level of evidence D
TEKIN L. et al., Coccyx fracture in patients with spinal cord injury, European journal of physical and rehabilitation medicine, March 2010, Volume 46, Number 1, pag. 43-46, level of evidence C
RAISSAKI M.T.,Fracture dislocation of the sacro-coccygeal joint: MRI evaluation, Pediatric radiology, March 1999, pag. 642-643, level of evidence D
LONSDALE E.F., A practical treatise on fractures, Walton and Mitchell printers, 1838, pag. 269-270, level of evidence D
MIYAMOTO K. et al., Exposure to pulsed low intensity ultrasound stimulates extracellular matrix metabolism of bovine intervertebral dosc cells cultured in alginate beads, Spine, November 2005, level of evidence B
EBNEZAR J., Essentials of orthopaedics for physiotherapist, Jaypee, 2003, pag. 174, level of evidence D
DEAN L.M. et al., Coccygeoplasty : treatment for fractures of the coccyx, J. Vasc. Interv. Radiol, 2006, pag. 909-912, level of evidence C
COOPER G., HERRERA J.E., Manual of musculoskeletal medicine, Wolters kluwer, Lippincott Williams & Wilkins, 2008, pag. 144, level of evidence D