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Medial Synovial Plica Irritation: Treatment & Medication
Updated: Oct 15, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
The first mode of treatment for suprapatellar plical irritation of the knee is nonoperative.1 All patients should have a program of physical therapy established for them, which includes closed-chain quadriceps kinetic exercises and a hamstring-stretching program. A closed-chain quadriceps exercise program should include the use of an exercise bike, leg presses, straight-leg raises (with and without leg weights), and the performance of mini-squats or use of a squat rack machine.
An important consideration to recognize is that patients who participate in open-chain quadriceps exercises, especially those who work on knee-extension exercises on a weight machine, often have an increase in their suprapatellar plical irritation.
In addition, patients should recognize that a hamstring-stretching program must be performed several times daily to maximize improvement. Approximately 50% of patients notice a significant improvement with an exercise program in the initial 6 weeks, with a larger percentage of the remaining patients improving with an additional 6 weeks of rehabilitation.
Recreational Therapy
Patients who have medial synovial plical irritation should avoid those activities that cause irritation of their knees until they note improvement with a physical therapy or home exercise program. Such precluding activities may include avoidance of stairs, squatting activities, or long-distance jogging or running.
Medical Issues/Complications
The most common complication associated with medial synovial plical irritation is continued pain or increased pain after surgery.1,2 For this reason, it is important to have exhausted all nonoperative forms of treatment for patients before any attempts at surgery.
Surgical Intervention
In patients who have exhausted all other means of therapy, an arthroscopic evaluation of the knee may be indicated. Because a debrided synovial plica results in alleviation of symptoms in only about 60-70% of cases, with some of the remaining patients actually having more pain after surgery, it is recommended that the synovial plica be debrided only if significant scar tissue is present in the plica or if shelf erosion is noted on the medial femoral condyle from a fibrotic plica.
Consultations
Any patient in whom conservative and/or surgical treatment protocol fails should have consultation with a subspecialist fellowship-trained orthopedic surgeon who deals with knee pathology.
Other Treatment
In patients who have persistent pain after a rehabilitation or home therapy program for synovial plical irritation, consideration should be given for a possible combined local anesthetic and corticosteroid injection to try and decrease some of the inflammation.3
Patients who undergo this injection need to recognize that their underlying quadriceps dysfunction and hamstring tightness still need to be addressed. After the injection, these individuals should either be enrolled in a physical therapy program or have a well-instituted home therapy program to maximize their chances for a good outcome.
Maintenance Phase
Rehabilitation Program
Physical Therapy
Once a patient has recovered from medial synovial plical irritation, the individual needs to recognize that there is very likely a risk for the recurrence of symptoms if he or she does not participate in a maintenance rehabilitation program. Always recommend to these patients that they try to work on a routine exercise program indefinitely to minimize their chances of recurrence of their knee pain.
Medication
Any of the nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to try to supplement the physical therapy program. Generally, it is recommended to start with over-the-counter (OTC) NSAIDs first. If these agents do not work, or if they work only in the maximum doses, prescription drugs may be utilized based upon the patient's previous success with these medications, drug allergies, or other medications.
Nonsteroidal anti-inflammatory agents
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but these agents may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Ibuprofen (Motrin, Ibuprin)
An OTC NSAID that is useful to decrease pain and inflammation. DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-800 mg PO tid
Pediatric
Not established
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or a high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
More on Medial Synovial Plica Irritation |
| Overview: Medial Synovial Plica Irritation |
| Differential Diagnoses & Workup: Medial Synovial Plica Irritation |
 Treatment & Medication: Medial Synovial Plica Irritation |
| Follow-up: Medial Synovial Plica Irritation |
| Multimedia: Medial Synovial Plica Irritation |
| References |
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References
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Broom MJ, Fulkerson JP. The plica syndrome: a new perspective. Orthop Clin North Am. Apr 1986;17(2):279-81. [Medline].
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].
Brushøj C, Albrecht-Beste E, Bachmann M, Hölmich P. Acute patellofemoral pain: aggravating activities, clinical examination, MRI and US findings. Br J Sports Med. Jun 11 2007;epub ahead of print. [Medline].
Dorchak JD, Barrack RL, Kneisl JS, Alexander AH. Arthroscopic treatment of symptomatic synovial plica of the knee. Long-term followup. Am J Sports Med. Sep-Oct 1991;19(5):503-7. [Medline].
Gurbuz H, Calpur OU, Ozcan M, Kutoglu T, Mesut R. The synovial plicae in the knee joint. Saudi Med J. Dec 2006;27(12):1839-42. [Medline].
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]. [Full Text].
Kim SJ, Choe WS. Arthroscopic findings of the synovial plicae of the knee. Arthroscopy. Feb 1997;13(1):33-41. [Medline].
Kim SJ, Shin SJ, Koo TY. Arch type pathologic suprapatellar plica. Arthroscopy. May 2001;17(5):536-8. [Medline].
Lyu SR. Relationship of medial plica and medial femoral condyle during flexion. Clin Biomech (Bristol, Avon). Nov 2007;22(9):1013-6. [Medline].
Patel D. Plica as a cause of anterior knee pain. Orthop Clin North Am. Apr 1986;17(2):273-7. [Medline].
Uysal M, Asik M, Akpinar S, et al. Arthroscopic treatment of symptomatic type D medial plica. Int Orthop. Aug 28 2007;epub ahead of print. [Medline].
Further Reading
Keywords
suprapatellar plica, medial retinaculum
