eMedicine Specialties > Orthopedic Surgery > Knee

Plica Syndrome: Treatment

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

Treatment

Medical Therapy

Medical treatment of plica syndrome has been driven largely by empirical evidence. A structured program of stretching and strengthening exercises often leads to some improvement. This may include short-arc quadriceps extension exercises (terminal approximately 20° of extension). These exercises are aimed at optimizing patellofemoral biodynamic relationships in an effort to control symptoms. A patellar knee sleeve worn during sporting activities (usually a neoprene-type brace) may also be a useful adjunct for many athletes. In addition, nonsteroidal anti-inflammatory medications are a time-tested and confirmed aid for many athletes with plica syndrome.

Surgical Therapy

Surgical therapy for plica syndrome is virtually always arthroscopic. The arthroscopic surgeon needs to exclude other potential intra-articular causes of knee pain and then address any pathologic plicae. Plica resection may be performed with arthroscopic hand instruments, a motorized soft-tissue resector, or certain commercially available electrothermal devices.

Preoperative Details

The preoperative phase of treatment involves optimizing the patient's knee strength and flexibility in an effort to streamline postoperative rehabilitation. Preoperative preparation of the patient also involves education and appropriate goal setting. For instance, the patient should understand that therapeutic exercises typically begin shortly after surgery (hours to days) and that a full return to sports can be realized soon thereafter (days to weeks). Patients who know this in advance tend to achieve these goals quite readily.

Intraoperative Details

After arthroscopic evaluation establishes that no other intra-articular abnormalities need to be addressed, the plica can be resected. Using whatever tools work best in the surgeon's hands, the plica should be resected back to a point where it no longer impinges on articular structures. With beefy synovitic plicae that extend into the patellofemoral joint space (typically 50% or more) (see Image 5), this may require extensive debridement (see Image 6). With tough, fibrotic plicae that drape over the medial femoral condyle, this may involve little more than disruption of the tight band.

At times, even a suprapatellar plica may lead to symptoms. Strover et al reported on an arthroscopic technique demonstrating the pathomechanics of such suprapatellar plicae.21 They recommended that the arthroscope should be inserted through a lateral suprapatellar portal. Proximal visualization is then optimized. In those patients in whom the suprapatellar plica is symptomatic, progressive flexion of the knee results in the plical tissue becoming taut. It also makes contact with the medial femoral condyle and even becomes entrapped between the quadriceps tendon and medial femoral condyle.21

Postoperative Details

Postoperatively, the patient is started on a structured course of therapeutic exercise that initially emphasizes reestablishment of active quadriceps control and firing. This progresses to regaining full range of motion and then full strength. The patient concludes therapeutic recovery by gradually performing more and more sport-specific exercises until a controlled reentry to the sport is achieved.

Follow-up

Follow-up care focuses on confirmation that symptoms have abated. True recurrence of the original plical pathology is quite rare and is more likely to represent either an incomplete resection or entirely new knee pathology. Continued use of a patellar stabilizing-type brace is preferred by many patients.

Complications

Complications of surgical treatment of plica syndrome are really complications associated with arthroscopic surgery of the knee. These include septic arthritis, neurapraxias or neuromas, and synovial fistulae. Reflex sympathetic dystrophy may also occur following such surgery. The rate of each of these complications is extremely small (<1% in most cases). Only patients with particular risk factors (eg, diabetes, steroid dependence, history of RSD) may be at a significantly higher risk.

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

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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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