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Medial plica irritation: diagnosis and treatment

Griffith CJ, LaPrade RF - Curr Rev Musculoskelet Med (2008)

Bottom Line: The majority of the patients will respond well to a non-operative treatment program consisting of quadriceps strengthening along with concurrent hamstring stretching.In cases which do not respond initially to an exercise program, an intraarticular steroid injection may be indicated.In those few patients who do not respond to a non-operative treatment program, an arthroscopic resection of their medial plica may be indicated, especially in those cases where a shelf-like plica has been found to be causing damage to the articular cartilage of the medial femoral condyle.

Affiliation: Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue, R200, Minneapolis, MN 55454, USA.

ABSTRACT

Medial plica irritation of the knee is a very common source of anterior knee pain. Patients can complain of pain over the anteromedial aspect of their knees and describe episodes of crepitation, catching, and pseudo-locking events with activities. Patients commonly have pain on physical examination upon rolling the plica fold of tissue over the anteromedial aspect of their knees and often have tight hamstrings. The majority of the patients will respond well to a non-operative treatment program consisting of quadriceps strengthening along with concurrent hamstring stretching. In cases which do not respond initially to an exercise program, an intraarticular steroid injection may be indicated. In those few patients who do not respond to a non-operative treatment program, an arthroscopic resection of their medial plica may be indicated, especially in those cases where a shelf-like plica has been found to be causing damage to the articular cartilage of the medial femoral condyle.

Proximal and distal translation of superior and inferior poles of patella within trochlear groove. (a) Proximal translation (b) Distal translation
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Fig5: Proximal and distal translation of superior and inferior poles of patella within trochlear groove. (a) Proximal translation (b) Distal translation

Mentions: As with any other physical diagnosis, it is important to concurrently ascertain if there are other areas of pathology for structures that are located close to the medial synovial plica to confirm one’s diagnosis. In acute injuries, one should make sure that there is no injury to the meniscofemoral portion of the superficial medial collateral ligament. In this instance, one would apply a valgus stress to the knee and palpate at the joint line for both any potential joint line opening to application of the valgus stress and also to see if there is any well localized pain or edema in the region of the meniscofemoral portion of the superficial medial collateral ligament (Fig. 3). In addition, in acute injuries, one should make sure that there has not been a lateral patellar subluxation episode with injury to the medial patellofemoral ligament. The lateral patellar apprehension test, performed with the knee flexed to approximately 45° of knee flexion, can help to determine if there has been injury to the medial patellofemoral ligament by applying a lateral translation force to the patella when it is flexed to approximately 45° of knee flexion and assessing if this translation causes pain or an apprehensive feeling like the patella will dislocate (Fig. 4). This pain should be different from pain produced when the plica is rolled under ones fingers. Further, one should make sure that the pain over the medial aspect of the knee is not directly due to localized or diffuse areas of chondromalacia of the patellofemoral joint. In this instance, one would roll the superior and inferior poles of the patella both proximally and distally, as well as medially and laterally, in the trochlear groove, to determine if there is any true retropatellar crepitation with translation of the patella in the trochlear groove (Fig. 5a, b). This evaluation is different from assessing for crepitation of the patellofemoral joint with active flexion and extension of the knee (Fig. 6a, b) as many of these patients may have catching of their medial plica causing the crepitation with active flexion and extension of the knee rather than true patellofemoral chondromalacia causing this auditory occurrence. In addition, one should assess for hamstring tightness, which can cause stress to the anterior aspect of the knee, by assessing the hamstring-popliteal angle (Fig. 7) and by palpation of the main hamstring attachment sites of the knee (pes anserine bursa (Fig. 8), semimembranosus bursa (Fig. 9), and biceps bursa (Fig. 10)).Fig. 3

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Medial plica irritation: diagnosis and treatment

Griffith CJ, LaPrade RF - Curr Rev Musculoskelet Med (2008)

Proximal and distal translation of superior and inferior poles of patella within trochlear groove. (a) Proximal translation (b) Distal translation
© Copyright Policy
Fig5: Proximal and distal translation of superior and inferior poles of patella within trochlear groove. (a) Proximal translation (b) Distal translation
Mentions: As with any other physical diagnosis, it is important to concurrently ascertain if there are other areas of pathology for structures that are located close to the medial synovial plica to confirm one’s diagnosis. In acute injuries, one should make sure that there is no injury to the meniscofemoral portion of the superficial medial collateral ligament. In this instance, one would apply a valgus stress to the knee and palpate at the joint line for both any potential joint line opening to application of the valgus stress and also to see if there is any well localized pain or edema in the region of the meniscofemoral portion of the superficial medial collateral ligament (Fig. 3). In addition, in acute injuries, one should make sure that there has not been a lateral patellar subluxation episode with injury to the medial patellofemoral ligament. The lateral patellar apprehension test, performed with the knee flexed to approximately 45° of knee flexion, can help to determine if there has been injury to the medial patellofemoral ligament by applying a lateral translation force to the patella when it is flexed to approximately 45° of knee flexion and assessing if this translation causes pain or an apprehensive feeling like the patella will dislocate (Fig. 4). This pain should be different from pain produced when the plica is rolled under ones fingers. Further, one should make sure that the pain over the medial aspect of the knee is not directly due to localized or diffuse areas of chondromalacia of the patellofemoral joint. In this instance, one would roll the superior and inferior poles of the patella both proximally and distally, as well as medially and laterally, in the trochlear groove, to determine if there is any true retropatellar crepitation with translation of the patella in the trochlear groove (Fig. 5a, b). This evaluation is different from assessing for crepitation of the patellofemoral joint with active flexion and extension of the knee (Fig. 6a, b) as many of these patients may have catching of their medial plica causing the crepitation with active flexion and extension of the knee rather than true patellofemoral chondromalacia causing this auditory occurrence. In addition, one should assess for hamstring tightness, which can cause stress to the anterior aspect of the knee, by assessing the hamstring-popliteal angle (Fig. 7) and by palpation of the main hamstring attachment sites of the knee (pes anserine bursa (Fig. 8), semimembranosus bursa (Fig. 9), and biceps bursa (Fig. 10)).Fig. 3

Bottom Line: The majority of the patients will respond well to a non-operative treatment program consisting of quadriceps strengthening along with concurrent hamstring stretching.In cases which do not respond initially to an exercise program, an intraarticular steroid injection may be indicated.In those few patients who do not respond to a non-operative treatment program, an arthroscopic resection of their medial plica may be indicated, especially in those cases where a shelf-like plica has been found to be causing damage to the articular cartilage of the medial femoral condyle.

Affiliation: Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue, R200, Minneapolis, MN 55454, USA.

ABSTRACT

Background: Medial plica irritation of the knee is a very common source of anterior knee pain. Patients can complain of pain over the anteromedial aspect of their knees and describe episodes of crepitation, catching, and pseudo-locking events with activities. Patients commonly have pain on physical examination upon rolling the plica fold of tissue over the anteromedial aspect of their knees and often have tight hamstrings. The majority of the patients will respond well to a non-operative treatment program consisting of quadriceps strengthening along with concurrent hamstring stretching. In cases which do not respond initially to an exercise program, an intraarticular steroid injection may be indicated. In those few patients who do not respond to a non-operative treatment program, an arthroscopic resection of their medial plica may be indicated, especially in those cases where a shelf-like plica has been found to be causing damage to the articular cartilage of the medial femoral condyle.

View Similar Images In: Results  - Collection
View Article: Pubmed Central -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=2684145&rFormat=json&query=null&req=5