Knee Plica Syndrome

The plica syndrome has been associated with anterior pain as well as clicking, catching, locking, or pseudo-locking of the knee, and it may even mimic acute internal derangement of the knee.

Synovial Plica Syndrome of the knee was first described in the beginning of the last century.

Postmortem studies have shown plica to be present in 20–50% of knees, with the highest prevalence in individuals of Japanese descent. There is some controversy regarding the prevalence of the plica syndrome, with some reports suggesting that it does not exist:

Jackson et al., Dandy, and others have stated that although plicae may indeed cause symptoms, the syndrome is overdiagnosed and many normal synovial plicae are removed. Conversely, other authors consider the plica syndrome to be a common cause of anterior pain in the knee that is often misdiagnosed, and believe that a suprapatellar membrane is virtually never asymptomatic.

See Also: Patellofemoral Pain Syndrome

Knee Plica Anatomy

During fetal development, the knee is separated into three compartments by synovial membranes. At 4 to 5 months of development, the partitions resolve to form a single cavity. Incomplete or partial resorption results in incomplete synovial shelves or plica.

The three joints involved in the developing knee from which the remnants evolve are:

1. the joint between the fibular and the femur;
2. the joint between the tibia and the femur;
3. the joint between the patella and the femur.

The most common plica in the knee is called the anterior or inferior plica, or mucous ligament. This plica is represented by tape-like fold running from the fat pad to the intercondylar notch of the femur and overlying the ACL.

The plicae to the medial and lateral sides of the patella, which run in a horizontal plane from the fat pad to the side of the patellar retinaculum, are referred to as the superomedial or superolateral plicae or the suprapatellar membrane, or the medial or lateral synovial shelf.

It has been suggested that symptomatic synovial plicae are one of the causes of anterior pain in the knee in children and adolescents.

See Also: Knee Muscles Anatomy

Plica Syndrome Symptoms:

The plica syndrome has been associated with anterior pain as well as clicking, catching, locking, or pseudo-locking of the knee, and it may even mimic acute internal derangement of the knee.

Any condition that produces chronic irritation, trauma, or scarring may result in thickening of the plicae and the production of signs and symptoms internal derangement of the knee.

Sherman and Jackson have proposed a set of criteria for the Plica Syndrome diagnosis:

1. History of the appropriate clinical symptoms.
2. Failure of nonoperative intervention.
3. Arthroscopic finding of a plica with an avascular fibrotic edge that impinges on the medial femoral condyle during flexion of the knee. This is often a diagnosis of exclusion and can only be confirmed at arthroscopy.
4. No other abnormality in the knee that would explain the symptoms. It has also been suggested that a localized area of
   chondromalacia at the site of impingement by a plica on the femoral condyle is evidence that a plica is the cause of the symptoms.

Plica Syndrome Test has been used to help in diagnosis of plica syndrome of the knee.

See Also: Plica Syndrome Test

The mediopatellar plica (also termed Lino’s shelf ), although the least common, this variety is often the cause of problems if it becomes thickened, resulting in pain with palpation over the medial parapatellar area (medial plica irritation). The severity of symptoms is not proportional to the size or breadth of the synovial plica.

There also appears to be no correlation between the duration of symptoms and the presence of pathologic changes in the plica.

A palpable band or snapping, especially over the medial femoral condyle, should be sought.

Several authors have noted an association between the presence of plica and the development of chondral lesions of the femoral condyle. These degenerative changes have been suggested to be caused by a pathological medial plica that snaps or impinges against the underlying femoral condyle during knee motion.

Radiology

Plicae are not visualized well on plain radiographs, but a double-contrast arthrogram may demonstrate a suprapatellar
plica or an anterior plica.

A skyline radiograph may demonstrate a synovial shelf.

Dynamic ultrasonography has been reported to have a diagnostic accuracy of 88%, sensitivity of 90%, and specificity of 83% in the evaluation of medial plica syndrome; however, this technique is highly operator dependent.

Plica Syndrome Treatment

The conservative Plica Syndrome Treatment involves:

1. stretching of the quadriceps, hamstrings, and gastrocnemius as well as isometric strengthening,
2. cryotherapy,
3. ultrasound,
4. patellar bracing,
5. anti-inflammatory medication,
6. an altered sports-training schedule for plica syndrome exercises.

In an uncontrolled study, this type of Plica Syndrome Treatment resulted in an improvement in 40% of patients over a 1-year period.

Injection of the synovial plica with corticosteroids and a local anesthetic in another uncontrolled study was reported to have an excellent result in 73% of patients.

Plica Knee Surgery:

When patients are truly symptomatic, or when conservative measures have failed, a plica knee surgery is done with surgical excision and it is usually curative.

Excision usually is done by arthroscopic techniques, although a limited excision can be performed through a medial parapatellar incision.

Simply incising or sectioning the plica is not recommended because of the possibility that the continuity of the plica will be restored by scar tissue.

References

1. Griffith CJ, LaPrade RF. Medial plica irritation: diagnosis and treatment. Curr Rev Musculoskelet Med. 2008 Mar;1(1):53-60. doi: 10.1007/s12178-007-9006-z. PMID: 19468899; PMCID: PMC2684145.
2. Hardaker WT, Whipple TL, Bassett FH 3rd. Diagnosis and treatment of the plica syndrome of the knee. J Bone Joint Surg Am. 1980 Mar;62(2):221-5. PMID: 7358753.
3. Zanoli S, Piazzai E. The synovial plica syndrome of the knee. Pathology, differential diagnosis and treatment. Ital J Orthop Traumatol. 1983 Jun;9(2):241-50. PMID: 6654660.
4. Johnson DP, Eastwood DM, Witherow PJ. Symptomatic synovial plicae of the knee. J Bone Joint Surg Am. 1993 Oct;75(10):1485-96. doi: 10.2106/00004623-199310000-00009. PMID: 8408137.
5. GRAY DJ, GARDNER E. Prenatal development of the human knee and superior tibiofibular joints. Am J Anat. 1950 Mar;86(2):235-87. doi: 10.1002/aja.1000860204. PMID: 15410671.
6. Ogata S, Uhthoff HK: The development of synovial plica in human knee joints: An embryologic study. Arthroscopy 6:315–321, 1990.
7. Johnson LL: Diagnostic and Surgical Arthroscopy: The Knee and Other Joints. St. Louis, MI: C.V. Mosby, 1981.
8. Ogata S, Uhthoff HK. The development of synovial plicae in human knee joints: an embryologic study. Arthroscopy. 1990;6(4):315-21. doi: 10.1016/0749-8063(90)90063-j. PMID: 2264900.
9. Dugdale TW, Barnett PR: Historical background: Patello-femoral pain in young people. Orthop Clin North Am 17:211–219, 1986.
10. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
11. Campbel’s Operative Orthopaedics 12th edition Book.
12. Millers Review of Orthopaedics -7th Edition Book.