Medial Synovial Plica Irritation Treatment & Management
- Author: Robert F LaPrade, MD, PhD; Chief Editor: Craig C Young, MD more...
The first mode of treatment for suprapatellar plical irritation of the knee is nonoperative. 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.
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.
The most common complication associated with medial synovial plical irritation is continued pain or increased pain after surgery.[5, 6] For this reason, it is important to have exhausted all nonoperative forms of treatment for patients before any attempts at surgery.
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.
Some practitioners advocate resection of asymptomatic medial plicae in patients with a coexisting knee pathology that requires surgical intervention. This is based on the idea that removing a medial plica helps to prevent future complications; however, this has been a source of debate in the orthopedic field.[#TreatmentAcutePhaseConsultations]
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.
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.
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.
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.
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