Medial Synovial Plica Irritation Treatment & Management

Updated: Jul 22, 2022
  • Author: Robert F LaPrade, MD, PhD; Chief Editor: Craig C Young, MD  more...
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Acute Phase

Rehabilitation Program

Physical Therapy

The first mode of treatment for suprapatellar plical irritation of the knee is nonoperative. [6] 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. [6, 7] 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.

A study by Kan et al on 44 patients arthroscopically diagnosed with medial plica syndrome found that since the length of time from injury to surgery directly influenced the severity of cartilage damage, in order to reduce the potential for cartilage damage, surgical treatment should be an option when pain does not cease or when the medial synovial plica ruptures or covers part of the anterior aspect of the medial femoral condyle. [8]  In a study by Hufeland et al that included 35 young patients (mean age, 16 years), outcome, activity, and knee pain scores all improved significantly after arthroscopic resection of a symptomatic medial synovial plica. [9]

Some practitioners advocate resection of asymptomatic medial plicae in patients with a coexisting knee pathology that requires surgical intervention. [10] 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.


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. [11]

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.


Return to Play

Patients/athletes may return to participation in sports based upon their symptoms. Athletes are recommended to start out slowly and observe how their knee reacts overnight, before advancing their workout/exercise regimen. This gradual progression is important to follow because plical irritation appears to involve some tissue inflammation, which may take hours to develop after activities. Usually, it is safe to say that if a patient does not have pain or swelling with an activity, that it is safe to continue or attempt to advance in that activity.



The best way to prevent continued medial synovial plical irritation is to avoid those activities that cause irritation and to address the problem that caused the plical irritation in the first place. Such prevention strategies would include surgery to address meniscal tears or cartilage flaps or enrollment in a proper physical therapy program for those with patellofemoral dysfunction.