Plica Syndrome

Welcome to Vrije Universiteit Brussel's Evidence-based Practice project. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Search Strategy[edit | edit source]

I've been searching on pubmed and web of knowledge. Always with the words plica syndrome. On Pubmed thee were 102 results but interestings article only show the abstract. On Web of Knowledge I found 28 results. I found 4 articles who were really good and recent. My text is based ons these articles. I also used extra words such as anatomy, epdemiology to precious my searchtask.
The searching has been focused on pubmed, web of knowledge and google books. The words we used were plica syndrome, medial plica, lateral plica, ‘plica and literature’ and ‘therapy plica syndrome’. We easily found what we needed. We tried to search in recent articles and books.

[1]Definition/Description[edit | edit source]

Plica allows movement of the bones of the joint without restriction. It is overused when you make the same movement to often, such as bend and straighten the knee.
Plica syndrome is caused by the irritation and inflammatory reactions of the relic of the synovial plica.[7(Level 2B)]
It is an interesting problem that occurs when an otherwise normal structure in the knee becomes a source of knee pain due to injury or overuse. The diagnosis can sometimes be difficult (anterior knee pain), but if this is the source of your knee pain, it can be easily treated.

[2][3]Clinically Relevant Anatomy[edit | edit source]

The knee joint has 3 synovial cavities: medial, infrapatellar and suprapatellar. These cavities are so called plica. Lateral plica is seen infrequently because the joint space on the lateral side is faster formed. The suprapattelar bursae is found as a slit between femur and quadriceps. With the knee joint it forms a perforation. When the perforations of the suprapatellar bursae are incomplete with the knee joint, it leads to the development of the suprapatellar plicae.


- Suprapatellar plicae
The suprapatellar plicae lies between the true knee and the suprapatellar pouch, it is seen as a synovial membrane. Arthroscopic studies shows an incidence of the plica between 70% and 91%. It’s easy to report the suprapatellar plica as completely absent, by carefully attempting identifying the insertion of the articulus genu, this confusion can be avoid. Indicate a complete type of plica when the insertion of the muscle is not to be seen. When you aren’t sure what type of plica, use the classification table.


Table 1. Classification of suprapatellar plica [16(Level 3A)]
Type Description
Absent No sharp edged fold.
Vestigial Plica with less than 1 mm protrusion. Disappeared with external pressure
Medial Plica lying on the medial side of the suprapatellar pouch
Lateral Plica lying on the lateral side of the suprapatellar pouch
Arch Plica present medially, laterally and anteriorly but not over the anterior femur
Hole Plica extending completely across the suprapatellar pouch but with a central defect.
Complete Plica dividing the suprapatellar pouch into two separate compartments
[3(Level 2A)]


- Medial patella plica
Also known as the medial synovial shelf, plica synovialis mediopatellaris, and plica alaris elongata or after its first two descriptors as Iion's band or Aoki’s ledge. It attaches to the lower patella and the lower femur and can cross the suprapatellar plica to insert in the synovium surrounding the infrapatellar fat pad. Similar to suprapatellar plica, the medial plica has also a classification table by Kim and Choe.


Table 2. Classification of medial plicae [16(Level 3A)]
Type Description
Absent No synovial shelf on the medial wall
Vestigial Less than 1 mm of synovial elevation which disappears with external pressure
Shelf A complete fold with a sharp free margin.
Reduplicated Two or more sheves running parallel. They may be of differing sizes.
Fenestra The shelf contains a central defect
High-Riding A shelf like structure running anterior to the posterior aspect of the patella, in a position where I could not touch the femur.
Each type is subdivided according to size and relation to femoral condyle with flexion and extension of the knee into: A—Narrow non touch (never makes contact with the femoral condyle). B—Medium touch (touches condyle with knee movement). C—Wide covering (covers the femoral condyle).
[3(Level 2A)]


- Infrapatellar plica
Also called as ligamentum mocosum. Just like the medial plica the infrapattelar plica inserts in the synovium around the infrapatellar fat pad. The infrapatellar plica has a relation with the anterior cruciate ligament, it can be totally separated from the plica or attached to it. Here’s also a classification table.


Table 3. Classification of Infrapatellar plicae [16(Level 3A)].
Type Description
Absent No synovial fold between the condyles of the femur.
Separated A complete synovial fold that was separate from the anterior cruciate ligament (ACL).
Split Synovial fold that is separate from the ACL but is also divided into two or more cords.
Vertical septum A complete synovial fold tht is attached to the ACL and divided the joint into medial and lateral compartments.
Fenestra A vertical septum pattern that contains a hole or defect.
[3(Level 2A)]
 

[4][5][1]Epidemiology /Etiology[edit | edit source]

Pain starts most of the time after exercising for a long time. A plica causes pain when it’s irritated. It can be irritated by overuse, due to exercises where you bend and straight the knee all the time. For example cycling and running. Pain on the medial side of the knee, along the border of the patella, is usually due to overuse of the plica synovialis medialis. Most of the time there’s a intern hydrops and a string palpable. For the other plica’s the complaints are the same but less frequent. It’s more common in adolescent athletes.

The prevalence of suprapatellar plica syndrome is ranging from 11% to 87% and for mediapatellar plica syndrome, it varies from 18% to 60%. Infrapatellar plica syndrome has a mean of prevalence of 65% of patients.
Plica syndrome is most common in patients who undergo repetitive knee movements. It also occurse more in females than in males.[8(Level 2A)]

Characteristics/Clinical Presentation[edit | edit source]

The pain can be located at different places like the supra- patellar and the mid-patellar region when extending the knee. You can also hear cracking noises when flexing of extending the knee.
The combination of contracting the quadriceps and the compression of the supra-patellar pouch can also be the cause of pain.
What occurs frequently in patients with plica syndrome is that they often have a sense of instability when walking upstairs, downstairs or slopes[7(Level 2B)]

Differential Diagnosis[edit | edit source]

- patellar femoral syndrome
- patella bipartite
- patellar maltracking
- degenerative joint disease
- hoffa syndrome
- sinding-Larsen-Johansson disease
- medial collateral ligament sprain
- osteochondritis dissecans
- pes anserinus bursitis
- meniscal tears
- patellar maltracking
[8(Level 2A)] [9][10][11(level 2A)][13(level 2A)][14(level 2A)]

Diagnostic Procedures[edit | edit source]

Radiography isn’t helpful to see if there is a plica syndrome, the radiograph will be negative. Radiography can be helpful to rule out other syndromes where the symptoms are common with a plica syndrome (see differential diagnosis). If there is symptomatic plicae, it will demonstrate hypertrophy and inflammation. This will lead to thickening and eventually fibrosis. If the fibrosis is significant, changes in the articular surface and the subchondral bone may occur.
Arthroscopy can be used because plica syndrome is often confused with chondromalacia or a medial meniscal tear.[12][10]
Most cases of plica syndrome do not require MRI but it can help to rule out other pathologies that can cause knee pain. MRI can detect a pathologic plica, but only if an effusion is present. An MRI also shows excludes bone bruises, meniscus tears, ligament injuries, cartilage defects, OCD lesions,… that may masquerade as plica syndrome.[9]

Outcome Measures[edit | edit source]

add links to outcome measures here (also see Outcome Measures Database)

Examination[edit | edit source]

One of the most important points in diagnosing medial synovial plica pathology is obtaining an appropriate history from the patient. The pain is often described as a dull pain in the proximomedial aspect of the knee which increases with activity and is practically bothersome at night. Most patients have complains when doing stairs, squads and standing up from a chair because these movements create a stress on the patellofemorale joint. The patient may also complain of pain following prolonged periods of sitting. About 50% of the patients let us know that they have been doing exercises with repetitive flexion and extension.[15(Level 2A)]

Medical Management
[edit | edit source]

The treatment of a plica syndrome consists of physiotherapy and rest. If this doesn’t have a big influence, you can start with corticosteroid injections and anti-inflammatory medicines. This way of handling has a success rate of less than 20% and appears to have more influence on young people with short-term symptoms. If this therapy fails, you can always perform surgery. This surgery involves an arthroscopy where preferably the whole plica should be removed.[14(Level 2A)]

[1][6]Physical Therapy Management
[edit | edit source]

Conservative treatment consists of limiting aggravating activities, correcting biomechanical abnormalities (tight hamstrings, weak quads), pain relief with NSAIDS/ cryotherapy and physical therapy aimed at decreasing compressive forces (increasing quadriceps strength and increasing hamstring flexibility).[9]
First you need to reduce the inflammation. You can do this with ice and by resting. If this doesn’t work you can try ice massage, ultrasound and/or friction massage. Friction massage is also used in this therapy to break down scar tissue.[10] Once the inflammation is reduced you can start with the conservative treatment.This treatment is usually recommended for the first 6-8 weeks after initial examination.[11(level 2A)]
It consists of strengthening and flexibility of muscles around the knee, such as the Quadriceps, Hamstrings, adductors, abductors, M Gastrocnemius and M Soleus. [8(level 2A)][9][11(level 2A)][12][13(level 2A)]


The most important part of the quadriceps to train is the m. vastus mediale. Full range of quadriceps is not recommended because these create excessive patellar compression at 90°. Instead straight leg raises and short-arc quadriceps exercises at 5°-10°, also hip adductor strengthening should be performed. Other exercises to be performed are squad, go up and down the stairs and lunging forward. [10] Other important components of this treatment are a stretching program for these muscles (quadriceps, hamstrings and gastrocnemius) and knee extension exercises.[8(level 2A)][11(level 2A)] The goal of this knee extension exercises is the strengthening of the tensor musculature of the joint capsule. But if the patient has too much pain when reaching terminal extension, then this should be avoided.[12] This conservative treatment is effective in most cases, but in some patients a surgery is necessary. The surgical therapy includes arthroscopic removal of the synovial plica. In this case a post-operative therapy is necessary. The post-operative treatment is identical to the conservative treatment and is usually started 15 days after the surgery. The main goal of physiotherapy in plica syndrome is to reduce pain, maximize the ROM and increase the strength of the muscles. (1)

Key Research[edit | edit source]

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources
[edit | edit source]

1. Gilberto Luis Camanho. (20 october 2009). Treatment of Pathological Synovial Plicae of the Knee  http://www.ncbi.nlm.nih.gov/pubmed/20360913 (A)

(n.d.). Retrieved 12 21, 2010, from Physiothearpy in banff for the knee: http://www.activemotionphysio.ca/article.php?aid=347

Irha, & Vrdoljak. (2003). Medial synovial plica syndrome of the knee: a diagnostic pitfall in adolescent athletes. JOURNAL OF PEDIATRIC ORTHOPAEDICS-PART B , 44-48.


Kenta, & Khanduja. (2009). Synovial plicae around the knee. The Knee , 97-102.


Lipton, & Roofeh. (2008, Juli). The medical plica syndrome can mimic recurring acute haemarthroses. HAEMOPHILIA , pp. 862-862.


Tindel, & Nisonson. (1992). The plica syndrome. ORTHOPEDIC CLINICS OF NORTH AMERICA , 613-618.


Yilmaz, Golpinar, Vurucu, Ozturk, & Eskandari. (2005, Oktober). Retinacular band excision improves outcome in treatment of plica syndrome. INTERNATIONAL ORTHOPAEDICS , pp. 291-295.

Clinical Bottom Line[edit | edit source]

add text here

Recent Related Research (from Pubmed)[edit | edit source]

see tutorial on Adding PubMed Feed

Extension:RSS -- Error: Not a valid URL: Feed goes here!!|charset=UTF-8|short|max=10

References[edit | edit source]

1. ↑ 1.0 1.1 1.2 Lipton, & Roofeh. (2008, Juli). The medical plica syndrome can mimic recurring acute haemarthroses. HAEMOPHILIA , pp. 862-862.
2. ↑ Tindel, & Nisonson. (1992). The plica syndrome. ORTHOPEDIC CLINICS OF NORTH AMERICA , 613-618.
3. ↑ M. Kent et al.; Synovial plicae around the knee; The Knee; Volume 17, Issue 2, Pages 97-102,2010; (Level 2A)
4. ↑ (n.d.) Retrieved 12 21, 2010, from Physiotherapy in banff for the knee: http://www/activemotionphysio.ca/article.php?aid=347.
5. ↑ Ihra, &Vrdoljak. (2003). Medial synovial plica syndrome of the knee: a diagnostic pitfall in adolescent athletes. Journal of pediatric ortopaedics-Part B, 44-48.
6. ↑ Yilmaz, Golpinar, Vurucu, Ozturk,& Eskandari. (2005, October). Retinacular band excision improves outcome in treatment of plica syndrome. International Orthopaedics, 291-295.
7. Camanho GL ; Treatment of pathological synovial plicae of the knee. Clinics. 2010;65(3):247-50; (Level 2B)
8. Nawfal Al-Hadithy et al.; Review article - Plica syndrome of the knee, Journal of Orthopaedic Surgery 2011;19(3):354-8; (Level 2A)
9. V.Morelli et al.; Sports medicine – an issue of primary care clinics in office practice; Elsevier Health Sciences; 28 June 2013; chapter 7 plica syndrome
10. W.I.Hammer; Functional soft-tissue examination and treatment by manuel methods; Jones and Bartlett publishers; 2007; p.375-376
11. Tal Sznajderman MSc et al.; review – medial plica syndrome; Dept. of Orthopedic Surgery; Assaf Harofeh Medical Center Zerifin 70300, Israel; 2008;11:54–57 (level 2A)
12. R.T.Morrissy et al.; Lovell and Winter’s Pediatric Orthopaedics; Lippincott Williams & Wilkins; 2006; p.1413
13. Sharath S.Bellary et al.; Medial plica syndrome – a review of the literature, department of anatomical sciences; st. George’s university, school of medicine; Grenada; West indies; Clinical Anatomy 25:423–428 (2012)(level 2A)
14. Tal Sznajderman et al. ;Medial Plica Syndrome ; januari 2009; Israel Medical Association Journal Vol 11; (Level 2A)
15. Chad J. Griffith et al. ; Medial plica irritation: diagnosis and treatment; 2008; Curr Rev Musculoskelet Med; (Level 2A)
16. Arthroscopic Classification of Suprapatellar Plica and Medial Synovial Plica; Mitsuru Hanada et. al.; Scientific research; Surgical Science, 2012, 3, 425-429 (Level 3A)

  1. 1.0 1.1 1.2 Lipton, & Roofeh. (2008, Juli). The medical plica syndrome can mimic recurring acute haemarthroses. HAEMOPHILIA , pp. 862-862.
  2. Tindel, & Nisonson. (1992). The plica syndrome. ORTHOPEDIC CLINICS OF NORTH AMERICA , 613-618.
  3. Kenta, & Khanduja. (2009). Synovial plicae around the knee. The Knee, 97-102.
  4. (n.d.) Retrieved 12 21, 2010, from Physiotherapy in banff for the knee: http://www/activemotionphysio.ca/article.php?aid=347.
  5. Ihra, &Vrdoljak. (2003). Medial synovial plica syndrome of the knee: a diagnostic pitfall in adolescent athletes. Journal of pediatric ortopaedics-Part B, 44-48.
  6. Yilmaz, Golpinar, Vurucu, Ozturk,& Eskandari. (2005, October). Retinacular band excision improves outcome in treatment of plica syndrome. International Orthopaedics, 291-295.