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Synovial plica syndrome

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synovial plica syndrome diagnosis treatment review

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https://www.ncbi.nlm.nih.gov/books/NBK535362

Synovial plica syndrome

Synovial plica syndrome is a cause of anterior or anteromedial knee pain from irritation of a normal synovial fold inside the knee. These folds are remnants of embryologic partitions. Most cause no symptoms, but a plica, usually the medial patellar plica, can become inflamed, thickened, and fibrotic after repetitive activity, altered patellar tracking, or direct trauma. It may then rub on the medial femoral condyle during knee motion. Campbell's notes that chronic abrasion can eventually cause focal cartilage softening or damage. Campbell's Operative Orthopaedics, 15th ed., p. 3078.

Typical features

  • Aching pain at the front-inside of the knee
  • Pain with running, cycling, stairs, squatting, or prolonged sitting with the knee bent, sometimes called the cinema sign
  • Snapping, popping, clicking, catching, or a sensation of pseudolocking
  • Local tenderness near the medial border of the patella
  • Occasional swelling or stiffness after activity
A true fixed locked knee is less typical and should prompt assessment for a meniscal tear or loose body. The NCBI clinical review describes plica syndrome as activity-related pain with possible snapping, catching, stiffness, and pseudolocking.

Diagnosis

Diagnosis is mostly clinical, after excluding more common causes of anterior knee pain, such as patellofemoral pain syndrome, meniscal injury, patellar instability, tendinopathy, osteoarthritis, and osteochondral lesions.
  • Examination may reproduce tenderness or snapping as the knee flexes and extends.
  • Plain X-rays do not show a plica but can exclude bone or arthritic causes.
  • MRI may identify a thickened plica or cartilage injury, but a plica on MRI does not automatically prove it is the pain source.
  • Arthroscopy is the most reliable way to confirm a symptomatic plica, but is usually reserved for persistent, selected cases. Rosen's Emergency Medicine, p. 125? [Correction: textbook page metadata not supplied in extract.]

Treatment

First-line treatment is nonoperative for several weeks to months:
  1. Reduce aggravating activities temporarily, especially repeated deep knee flexion, running, cycling, and squats.
  2. Ice after activity and use an NSAID only if safe for you and advised by a clinician.
  3. Physiotherapy focused on:
    • Quadriceps strengthening, especially knee control
    • Hip abductor and external-rotator strengthening
    • Hamstring, quadriceps, and calf flexibility
    • Patellar tracking and gradual return to sport
  4. Address contributing factors such as training errors, weak hip musculature, poor biomechanics, or patellofemoral maltracking.
If properly delivered conservative treatment fails and the symptoms, examination, and imaging/arthroscopic findings all align, arthroscopic plica resection can be considered. It is most appropriate when a clearly thickened, impinging plica is present, particularly if it is associated with cartilage irritation. The clinical review of SPS cautions that plicae are common and should not be removed merely because one is seen if another cause better explains the pain.

Seek prompt in-person evaluation if

  • You cannot bear weight after an injury
  • The knee is hot, markedly swollen, red, or you have fever
  • There is a true locked knee that cannot fully straighten
  • Recurrent giving way, significant trauma, or persistent swelling occurs
  • Symptoms do not improve with rehabilitation
The prognosis is generally good when the mechanical and training contributors are addressed before prolonged cartilage damage develops.
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