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Plica Syndrome

Plica Syndrome

Knee pain can have a lot of negative consequences on your daily activity. On your regular, healthy days, you may not notice how important knees are in sitting, standing, and running. However, it is during the disorders that you come to know of the importance of knee structures.

Most of you consider the knee joint a sturdy, hard structure donning a cap. Undoubtedly, the knee cap is a prominent feature of your leg anatomy, but there are numerous soft tissues as well that perform multiple functions. One such soft tissue present within the knee is plica.

What Is A Plica?

The knee joint (like all synovial joints) is surrounded by a synovial membrane. A synovial membrane is a fluid-filled capsule that helps minimize friction of the bones. Plica refers to the membranous fold inside the knee joint provided by mother nature to protect it. Plicae of the knee surround the joint.

The embryonic life of a human is characterized by these synovial folds. In some cases, the plicae are absorbed before birth. However, in a lot of cases, doctors have found remnants of the synovial plicae.

There are different types of plicae present in the knee. The list of membrane folds includes:

  • Suprapatellar plica
  • Medial patella plica (medial parapatellar plica)
  • Infrapatellar plica
  • Lateral plica (lateral para patellar plica)

Medial Plica Syndrome: Outcome Of Medial Plica Irritation

Irritation and inflammation of the synovial plicae of the knee lead to synovial plica syndrome. According to reports, synovial plica syndrome has a prevalence ranging from 3% to 30%, with anterior knee pain being the most common presentation. It is the most commonly overlooked cause of knee pain in adults.

Of all the plicae, the medical plica is most prone to getting affected by injury and irritation. Researchers call medial plica “the sneaky plica” because of its tendency to sneak into a painful disorder. Research shows that the high pressure between the medial femoral condyle and the medial plica increases its tendency to plica syndrome.

Due to the high prevalence of medial plica involvement, knee plica syndrome is generally referred to as medial plica syndrome in literature. The medial plica is present at the border of the patella (medial side) and the medial femoral condyle. Its anatomic position makes it prone to medial plica irritation and injury.

You may also get inflammation of the lateral plica and, therefore, lateral plica syndrome. This condition is also known as plica synovialis lateralis. The type of plica syndrome depends on the type of plica tissue involved. So. you may fall prey to plica synovialis infrapatellaris or plica synovialis mediopatellaris.

Signs And Symptoms Of Plica Syndrome

The most commonly observed symptoms of plica syndrome are:

Anterior Knee Pain

The pathological synovial plicae of the knee present with knee pain. Knee problems involving the soft tissues present as knee pain and restricted knee movement. Patients feel a great deal of knee pain which worsens on bending-straightening of the leg.

According to Plica syndrome patients, it is more of a dull ache rather than sharp or stabbing pain. The mediopatellar plicae only cause dull pain. Research shows that anterior knee pain is frequently associated with plica syndrome.

Per a study, suprapatellar plica presents as knee pain and is caused by irritation to the suprapatellar plica (is present within the suprapatellar pouch), the occurrence of which ranges between 65% and 78%.

One study advises doctors to investigate plica syndrome in cases of unclear anterior knee pain. Diseased infrapatellar plica of the affected knee may also be the potential cause of pain.

Clicking Sounds

Bending of the knee joint is at times associated with the production of cracking or clicking sounds. This can be attributed to the inflamed plica of the knee.

Grinding/Catching Sensations

A lot of times, knee plica syndrome patients visit the doctor for a grinding and catching sensation in the knee. The crack is most noticeable when standing up after sitting for long periods.

Swelling And Inflammation

As the disease progresses, the plica swells to cause knee problems. A swollen plica causes symptoms of knee plica syndrome. The grinding sensations and the clicking sounds are attributed to localised swelling of the medial plicae. According to a study, plica syndrome is a knee joint condition secondary to inflammation.

Instability Of The Knee Joint

Many patients with the syndrome often complain that their patellofemoral joint isn’t stable and gives away on movement. Arthroscopic findings revealed pathological synovial plicae to be a contributing factor to knee instability when climbing stairs or slant surfaces.

Differential Diagnosis

As mentioned, medial plica syndrome is a commonly overlooked cause of knee pain because of the merging symptoms with different knee joint conditions. The following conditions fall under the differential diagnosis of medial plica syndrome.

Torn Meniscus Vs. Plica Syndrome

A torn meniscus has symptoms similar to plica syndrome. It is the outcome of twisting injuries of the leg. Meniscus injuries fall under cartilage defects as the meniscus is a C-shaped, cartilaginous connective tissue between the thighbone and the shinbone.

Tendonitis Vs. Plica Syndrome

Patellar tendonitis (swelling of the patellar tendon) leads to patellofemoral pain, which is similar to the pain caused by plica syndrome. Oftentimes, doctors mistake tendonitis for plica syndrome. Tendonitis of the patella (knee cap) is mostly caused by overuse or abnormal forces (as in sports).

Bone Injury Vs. Plica Syndrome

Bone disruptions and fractures also fall under the DDs of plica syndrome. The attending doctors must do all the necessary tests to rule out differential diagnoses of the condition.

Causes Of Medial Plica Syndrome

The main cause of plica syndrome is overuse. By exposing the connective tissue of the knee to repeated stresses, you make it prone to disease. Irritation of the synovial plica contributes to the syndrome.

Overloading can also be negative for your synovial capsule and the synovial lining of the joint. Mostly, individuals who frequently bend and straighten their legs develop this disorder. Activities involving repeated bending/straightening include biking, climbing (stairs) and running, etc.

Injuries can also trigger swelling and inflammation in the soft tissues. A knee injury sustained during games/sports can also lay the foundation for an achy knee.

How To Diagnose Plica Syndrome?

Patients with a history of knee aches undergo a thorough physical examination. The physical exam helps rule out any similar knee conditions. If suspected, your doctor may perform a physical test called the plica stutter test (Mital-Hayden test).

In this test, the patient lies supine, and the examiner stands on the side of the affected knee. The patient’s flexed knee (at 30 degrees) is held/supported by the examiner. In this position, the examiner applies pressure on the lateral patella and then glides the hands medially. Inflamed synovial plicae produce pain indicating plica syndrome.

To better visualise the knee structures, the doctor might also order an X-ray or MRI scan (Magnetic resonance imaging scan).

Treatment

The main of the plica syndrome treatment is to ease pain and improve knee movement. Various conservative treatment modalities have been effective in the management of the disorder.

Medications

Painkiller medicines are advised to lower pain. Acetaminophen, ibuprofen and naproxen can offer some help by lowering the inflammation.

Physical Therapy

One of the most efficacious and potent strategies for alleviating soft tissue pain is physical therapy. A study shows that plica syndrome can be treated well with a combination of physical therapy and corticosteroid injections. Many patients have reported improvement in symptoms by lowering inflammation of the knee plica. The modality is great for all types of knee plicae i.e., infrapatellar plica, suprapatellar plica, and mediopatellar plica. Surgical options are availed when these conservative strategies fail to respond.

Steroid Injections

Injecting steroids into the affected knee can minimize the localized swelling. It provides instant relief, and superior results are seen if the corticosteroid injections are paired with physical therapy of the joint.

Physical therapy and corticosteroid injections are the gold standards in plica syndrome management.

Stretching And Exercises

The best way to relieve pain and prevent plica syndrome is by doing stretches and exercises. Increasing your knee strength by doing knee extension exercises and stretches has been shown to work for many patients. Simple exercises like swimming, biking and running can help strengthen the leg muscles.

A physical therapist can guide you about the stretches. The most useful training exercises for plica syndrome patients include:

Quadriceps Strengthening

The quadriceps are one of the major muscles of the thigh. You can do different exercises to strengthen the quadriceps tendon and the muscle. The most power-inducing stretches include leg presses, straight leg raises, mini squats and quadriceps sets.

Hamstring Stretches

Making the hamstrings robust is also crucial because tight hamstrings contribute to plica syndrome. The hamstrings are a strong group of muscles present at the back of your thighs that extend to the pelvis and shin bone. A well-directed physical therapy aids in relaxing the tight hamstrings, which can be beneficial for plica syndrome patients.

An arthroscopic investigation is a process to diagnose Plica syndrome. The doctor inserts a small camera into the knee joint via a small incision. The camera is accompanied by surgical tools when needed.

Medial Synovial Plica Resection (Knee Surgery)

Medial synovial plica resection is a type of arthroscopic surgery used to manage plica syndrome. Arthroscopic resection is only indicated when conservative treatment fails.

According to a randomized controlled trial, arthroscopic resection of the synovial plica improves symptoms. Arthroscopic plica resection significantly improves clinical symptoms after 2 years of follow-up.

Reports suggest that arthroscopic removal of the plica is indicated when conservative strategies fail for up to 6 months. Similarly, infrapatellar plica excision (arthroscopic resection) has also been shown to be effective in treatment.

How Can I Recover Quickly From Plica Syndrome Surgery?

There are multiple factors that govern your recovery from the surgery. The patient’s overall health is a major factor that controls the recovery. Patients with underlying comorbidities, such as diabetes, cardiovascular disease, etc., have delayed healing. Keeping a good diet filled with vegetables and anti-inflammatory foods (ginger, turmeric, etc.) speeds up the process of healing.

Wait for a couple of weeks before starting to drive. Your dominant knee (right knee in most cases) takes more time to heal, i.e., around a couple of weeks. On the other hand, the left knee may recover within four to five days.

Take good rest before resuming normal physical activities.

FAQs

  1. What does plica syndrome feel like?In most cases, the knee plica is asymptomatic. However, plica syndrome presents as knee pain on the anterior side. The pain is most pronounced when you have bent or your knee extended. Climbing the stairs and sitting for long periods is difficult. Patients also complain of cracking sounds accompanied by grinding/crunching sensations. What makes a lot of patients concerned is the giving away of the knee when moving.
  2. How do you treat plica syndrome in the knee?In most cases, plica syndrome is treated well with conservative strategies. Physical therapy and localized corticosteroid injections are the gold standards of treatment. Symptomatic management can be done with medicines. Arthroscopic resection of the plicae is indicated when patients do not respond to non-surgical strategies.
  3. Does plica syndrome go away?Plica syndrome does not go away on its own but can be successfully treated with simple strategies such as medicines and physical therapy.
  4. How do you get rid of plica?The best way to get rid of plica inflammation is to strengthen the muscles. Pain management is done using medicines and physiotherapy. Local steroid injections into the knee can lower inflammation. You can add quadriceps and hamstring strengthening exercises to your routine to prevent recurrence.
  5. How do you test for Plica syndrome?Plica syndrome is tested with the plica stutter test, which is a part of the physical examination. Doctors also order radiographic imaging such as X-rays and MRI scans to rule out similar conditions like tendonitis and a torn meniscus.
  6. Does Plica show up on MRI?Yes, MRI scans can help appreciate an abnormally swollen plica. MRI scans are great at visualizing soft tissue changes in the joints. Magnetic resonance imaging scans also aid in diagnosing other intra-articular pathologies.

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