eMedicine Specialties > Orthopedic Surgery > Knee

Plica Syndrome: Workup

Author: Tracy Lee Bigelow, DO, Fellow, Department of Orthopedic Surgery, University of Florida
Coauthor(s): Charles T Mehlman, DO, MPH, Director, Musculoskeletal Outcomes Research, Associate Professor, Division of Pediatric Orthopedic Surgery, Cincinnati Children's Hospital Medical Center
Contributor Information and Disclosures

Updated: Aug 18, 2008

Workup

Imaging Studies

  • Plain radiographs of the knee are appropriate in the evaluation of a patient with plica syndrome. However, they are useful only in that they help eliminate other diagnoses.
  • Magnetic resonance imaging (MRI) is of limited value in detecting normal or pathologic plicae about the knee.17 It rarely demonstrates these structures conclusively (see Image 4). Jee et al published one of the only papers that touts the usefulness of MRI in diagnosing medial parapatellar plicae.18 They reported 95% sensitivity and 72% specificity with their MRI approach. It should also be noted that plica syndrome has been a major research interest at their center. To the best of the authors' knowledge, no other center has matched these numbers.

Diagnostic Procedures

  • Other adjunctive diagnostic studies include contrast pneumoarthrography and double-contrast arthrography, yet arthroscopy remains the standard for definitive diagnosis. Most plicae are found incidentally during knee arthroscopy.

Histologic Findings

The histology of a symptomatic plica is typically that of synovial tissue (type A macrophagelike cells and type B fibroblastlike cells) immersed in an inflammatory reaction.19 In other instances, the histology may show dense fibrotic tissue that only secondarily impinges upon articular surfaces to produce pain.

Kasim and Fulkerson found "fibrosis, vascular proliferation, and small nerves with deceased myelin (neuromata)" on histologic analysis of specimens from their plica patients.20

Staging

Jee et al stage medial parapatellar plicae according to how far the plica extends into the region of the patellofemoral joint.18 Their system is as follows:

  • 1+: Does not extend to the medial edge of the patella
  • 2+: Extends to the medial third of medial facet of the patella
  • 3+: Extends over one third to two thirds of the medial facet
  • 4+: Extends over more than two thirds of the medial facet

More on Plica Syndrome

Overview: Plica Syndrome
Workup: Plica Syndrome
Treatment: Plica Syndrome
Follow-up: Plica Syndrome
Multimedia: Plica Syndrome
References
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References

  1. Dupont JY. Synovial plicae of the knee. Controversies and review. Clin Sports Med. Jan 1997;16(1):87-122. [Medline].

  2. Pipkin G. Knee injuries: the role of the suprapatellar plica and suprapatellar bursa in simulating internal derangements. Clin Orthop. Jan 1971;74:161-76. [Medline].

  3. Jackson RW. History of arthroscopy. In: Diagnostic and Operative Arthroscopy. Philadelphia, Pa: WB Saunders Co; 1997:3-6.

  4. Rang M. The Story of Orthopaedics. Philadelphia, Pa: WB Saunders Co; 2000:493-497.

  5. Kurosaka M, Yoshiya S, Yamada M, Hirohata K. Lateral synovial plica syndrome. A case report. Am J Sports Med. Jan-Feb 1992;20(1):92-4. [Medline].

  6. Broom MJ, Fulkerson JP. The plica syndrome: a new perspective. Orthop Clin North Am. Apr 1986;17(2):279-81. [Medline].

  7. Bae DK, Nam GU, Sun SD, Kim YH. The clinical significance of the complete type of suprapatellar membrane. Arthroscopy. Nov-Dec 1998;14(8):830-5. [Medline].

  8. O'Dwyer KJ, Peace PK. The plica syndrome. Injury. Sep 1988;19(5):350-2. [Medline].

  9. Blok A, Weiss W, Dolata T, Szczepaniec M. Medial synovial plica. Ortop Traumatol Rehabil. Aug 30 2005;7(4):397-400. [Medline].

  10. Tindel NL, Nisonson B. The plica syndrome. Orthop Clin North Am. Oct 1992;23(4):613-8. [Medline].

  11. Lipton R, Roofeh J. The medial plica syndrome can mimic recurring acute haemarthroses. Haemophilia. Mar 19 2008;[Medline].

  12. Rovere GD, Nichols AW. Frequency, associated factors, and treatment of breaststroker''s knee in competitive swimmers. Am J Sports Med. Mar-Apr 1985;13(2):99-104. [Medline].

  13. Shetty VD, Vowler SL, Krishnamurthy S, Halliday AE. Clinical diagnosis of medial plica syndrome of the knee: a prospective study. J Knee Surg. Oct 2007;20(4):277-80. [Medline].

  14. Munzinger U, Ruckstuhl J, Scherrer H, Gschwend N. Internal derangement of the knee joint due to pathologic synovial folds: the mediopatellar plica syndrome. Clin Orthop. Mar-Apr 1981;(155):59-64. [Medline].

  15. Kim SJ, Min BH, Kim HK. Arthroscopic anatomy of the infrapatellar plica. Arthroscopy. Oct 1996;12(5):561-4. [Medline].

  16. Kim SJ, Choe WS. Arthroscopic findings of the synovial plicae of the knee. Arthroscopy. Feb 1997;13(1):33-41. [Medline].

  17. Monabang CZ, De Maeseneer M, Shahabpour M, Lenchik L, Pouliart N. MR imaging findings in patients with a surgically significant mediopatellar plica. JBR-BTR. Sep-Oct 2007;90(5):384-7. [Medline].

  18. Jee WH, Choe BY, Kim JM, et al. The plica syndrome: diagnostic value of MRI with arthroscopic correlation. J Comput Assist Tomogr. Sep-Oct 1998;22(5):814-8. [Medline].

  19. Pessler F, Dai L, Diaz-Torne C, Gomez-Vaquero C, Paessler ME, Zheng DH, et al. The synovitis of "non-inflammatory" orthopaedic arthropathies: a quantitative histological and immunohistochemical analysis. Ann Rheum Dis. Aug 2008;67(8):1184-7. [Medline].

  20. Kasim N, Fulkerson JP. Resection of clinically localized segments of painful retinaculum in the treatment of selected patients with anterior knee pain. Am J Sports Med. Nov-Dec 2000;28(6):811-4. [Medline].

  21. Strover AE, Rouholamin E, Guirguis N, Behdad H. An arthroscopic technique of demonstrating the pathomechanics of the suprapatellar plica. Arthroscopy. 1991;7(3):308-10. [Medline].

  22. Hardaker WT, Whipple TL, Bassett FH 3rd. Diagnosis and treatment of the plica syndrome of the knee. J Bone Joint Surg Am. Mar 1980;62(2):221-5. [Medline].

  23. Kinnard P, Levesque RY. The plica syndrome. A syndrome of controversy. Clin Orthop. Mar 1984;(183):141-3. [Medline].

  24. Vaughan-Lane T, Dandy DJ. The synovial shelf syndrome. J Bone Joint Surg Br. 1982;64(4):475-6. [Medline].

  25. Johnson DP, Eastwood DM, Witherow PJ. Symptomatic synovial plicae of the knee. J Bone Joint Surg Am. Oct 1993;75(10):1485-96. [Medline].

  26. Patel D. Plica as a cause of anterior knee pain. Orthop Clin North Am. Apr 1986;17(2):273-7. [Medline].

  27. Ewing JW. Plica: Pathologic or Not?. J Am Acad Orthop Surg. Nov 1993;1(2):117-121. [Medline].

  28. Rovere GD, Adair DM. Medial synovial shelf plica syndrome. Treatment by intraplical steroid injection. Am J Sports Med. Nov-Dec 1985;13(6):382-6. [Medline].

  29. Subotnick SI, Sisney P. The plica syndrome. A cause of knee pain in the athlete. J Am Podiatr Med Assoc. May 1986;76(5):292-3. [Medline].

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Further Reading

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Keywords

plica syndrome, medial synovial shelf, medial shelf, synovial chorda, medial pleat, Iino's band, Iino band, Aoki's ledge, Aoki ledge, medial intraarticular band, meniscus of the patella, mediopatellar pseudomeniscus, plica synovialis mediopatellaris, plica synovialis suprapatellaris, superomedial plica, medial suprapatellar plica, plica alaris elongata, ligamentum mucosum, plica synovialis patellaris, plica synovialis patellae, infrapatellar plica, infrapatellar fold, infrapatellar septum, knee pain

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Contributor Information and Disclosures

Author

Tracy Lee Bigelow, DO, Fellow, Department of Orthopedic Surgery, University of Florida
Tracy Lee Bigelow, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Osteopathic Association, and American Society for Surgery of the Hand
Disclosure: Nothing to disclose.

Coauthor(s)

Charles T Mehlman, DO, MPH, Director, Musculoskeletal Outcomes Research, Associate Professor, Division of Pediatric Orthopedic Surgery, Cincinnati Children's Hospital Medical Center
Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics, American Fracture Association, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society, Ohio State Medical Association, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society
Disclosure: Nothing to disclose.

Medical Editor

Miguel A Schmitz, MD, Consulting Surgeon, Department of Orthopedics, Klamath Orthopedic and Sports Medicine Clinic
Miguel A Schmitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas M DeBerardino, MD, Associate Professor of Orthopaedic Surgery, University of Connecticut Health Center
Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine
Disclosure: Arthrex, Inc. Grant/research funds Other; Arthrex, Inc. Honoraria Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None; Arthrex, Inc. Consulting fee Speaking and teaching

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS, Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital
Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society
Disclosure: Zimmer Stock Implant Designer

 
 
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