Synovial Plica Syndrome: Symptoms & Treatment for Anterior Knee Pain

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By Tom Sutton, DPT Student

Introduction and Anatomy

In a study by Lee et al, synovial plica syndrome (SPS) of the knee is said to be a cluster of symptoms and not one specific presentation or cause. Some of these problems may consist of pain in the anterior region of the knee, clicking, clunking and popping sounds that can occur during functional activities such as squatting or negotiating stairs.  SPS can affect males and females alike, most commonly between the ages of 10-30. Plica is actually the name of a structure in most peoples’ knees, many are non-symptomatic,”inward folds of the synovial lining,”(1) that can be impinged between the quadriceps tendon and femoral trochlea when the knee flexes between 70-100 degrees.   The plica is attached to the articularis genus muscle and runs into the synovial lining of the knee, located on the medial side of the retropatellar fat pad.  Figure 1 Image-2presents an image of the plica in the knee. The study performed by Lee et al investigated what synovial plica syndrome is, how it can affect people and how to properly treat this type of knee pain.

Presentation

Given the fact that SPS may bring about a number of complaints and symptoms from patients, it is important to understand exactly what problems are present and how to diagnose SPS in order to demystify this type of knee pain. Lee et al reports is that SPS is most commonly without a mechanism of injury.(1) Plica-related problems in the knee can come about during knee flexion over time such as kneeling and sitting or repetitive exercises like running or biking.(4) The patient is going to complain mostly about pain and a “snapping” sound  on the medial side of the knee joint during flexion.(4) For a complete list by Lee et al, see Table 1 Image-1for signs and symptoms of knee SPS.(1) SPS can also mimic other pathologies such as meniscal problems, osteoarthritis of the knee and patellar tendinopathy.(1) According to Schindler, anterior knee pain is the “cardinal symptom” of plica syndrome (5). Since SPS can be caused by a traumatic mechanism of injury, overuse or associated with co-morbidities such as diabetes, (1) obtaining past medical history becomes more pertinent. Additionally, if the patient were to be younger and around the age of 13, it would be prudent to find out if they have been experiencing growth spurts, as symptoms of SPS can occur during this time.(1)

For more specific information on SPS, here is a printable booklet that is courtesy of Houston Methodist. (4)

Application & Closing Thoughts

Furthermore, if there is a stability or strength problem elsewhere in the body such as the back, hip or ankle, it is possible that this may cause problems in the knee that could explain the idiopathic nature of plica syndrome.(1) There are special tests that can be performed including Hughston’s Plica Test and the Stutter Test.(1) Although special tests do not hold diagnostic value, they can be helpful in ruling in and ruling out pathologies. Applying the knowledge from several SPS studies and sources, there are a number of ways to address a patient with SPS. Finding the cause of the problem should be the priority of the physical therapist as they begin to formulate a program for the patient. Treatment may consist of a wide variety of techniques such as soft tissue manipulation, stretching, functional exercise and postural education. Functional exercise and training will be very important because the patient can learn more efficient movements for everyday lifestyle as well as gain the strength needed in both lower extremities in a closed-kinetic chain (CKC) fashion. Below are a few examples of helpful CKC exercises. 

SPS has been shown to respond well to conservative treatment, (6) and most patients have demonstrated improvement and decreased pain.(1) An important takeaway from this is to understand why the patient is experiencing SPS and address the cause. Otherwise, it is possible the plica problem will linger and surgical methods may be weighed as an option. Although some studies have shown that most patients with failed conservative treatment have had success with surgery,(1) avoiding a resection procedure altogether would be a much better alternative.

img_7501Blog Post written by Tom Sutton, DPT Student at the University of St. Augustine. Tom is currently in his final Clinical Rotation with me at Catz Physical Therapy Institute.

References

  1. Nixion A, Chandratreya A, Murray J, Lee P. Synovial Plica syndrome of the knee: A commonly overlooked cause of anterior knee pain. The Surgery Journal. 2017;03(01):e9–e16. doi:10.1055/s-0037-1598047.
  1. Griffith CJ, LaPrade RF. Medial plica irritation: diagnosis and treatment. Curr Rev Musculoskelet Med 2008;1(01):53–60
  1. Dandy DJ. Anatomy of the medial suprapatellar plica and medial synovial shelf. Arthroscopy 1990;6(02):79–85
  1. Houston Methodist. http://www.houstonmethodist.org/orthopedics/where-does-it-hurt/knee/plica-syndrome/. Accessed March 12, 2017.
  1. Schindler OS. ‘The Sneaky Plica’ revisited: morphology, pathophy- siology and treatment of synovial plicae of the knee. Knee Surg Sports Traumatol Arthrosc 2014;22(02):247–262
  1. Bellary SS, Lynch G, Housman B, et al. Medial plica syndrome: a review of the literature. Clin Anat 2012;25(04):423–428

ACL Reconstruction: Ally

ally

I completely tore my ACL and partially tore my meniscus. I needed an ACL reconstruction and for part of my meniscus to be shaved off. CATZ was amazing in helping toward my recovery. The community of staff and athletes there is a constant source of support. Chris’s patience and encouragement was instrumental in getting to where I am, now. I was able to be fully medically cleared to attend the United States Naval Academynavy and I look forward to serving my country for years to come.

-Ally

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.

What Happens to the Patellar Tendon Gap After ACL Harvest?…and other common ACL questions.

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A common question regarding ACL reconstructions is,  “does the patellar tendon gap heal after the central third is harvested for an ACL graft? This is a great question because as you can see in the photos below one of the patellar tendons appears normal when the quad is on tension, while the other has an obvious gap. Continue reading “What Happens to the Patellar Tendon Gap After ACL Harvest?…and other common ACL questions.”

Youth Athlete Patellofemoral Pain: Home Exercise Routine

Patellofemoral pain syndrome (PFPS) is one of the most common knee disorders among the active population.  It is characterized by peripatellar pain during activity, descending stairs or with prolonged sitting.  All of these tasks sound like a typical day for an adolescent student-athlete.  The patellofemoral joint consists of the patella and its approximation within the distal femoral groove.IMG_1918 Continue reading “Youth Athlete Patellofemoral Pain: Home Exercise Routine”

Considerations for Adolescent ACL Reconstructions


Adolescent and young adult ACL reconstructions are a common diagnosis among my caseload.  I often get the opportunity to consult and or provide pre-operative physical therapy in many of these cases.  Nearly all of my ACL patients participate in athletics, so it’s imperative to return them to a high functional level.  Complete rehabilitation requires 9-12 months of focused therapy and dedicated hard work by the patient, but it’s also important to get off to a good start. Continue reading “Considerations for Adolescent ACL Reconstructions”

ACL Return to Sport Testing

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With all the research available  regarding ACL surgeries, evidence for return to sport guidelines remain undefined.  Many athletes are cleared for return to sport 6-9 months post-op regardless of physical objective performance data.  In fact I’ve had athletes who rehabbed elsewhere come in for a one time visit to have me evaluate them for return to sport.  Continue reading “ACL Return to Sport Testing”

ACL: What to do between diagnosis & surgery

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❗️Should I be doing anything before surgery⁉️ I get this question from patients & parents all the time…YES💯 ✴️✴️✴️ In Part 1 of this simple 🏡 program the focus is on maintaining ROM, decreasing swelling & keeping your muscles activated. ✴️✴️✴️ All of these exercises can be progressed and loaded heavier but you might as well get on your feet (Part 2) unless you have other damaged structures that prevent you from full WB. ✴️✴️✴️ In this video my athlete is 2 weeks post injury and a few days post MRI diagnosis. ✴️✴️✴️ For full explanation and longer videos check out the blog post💻 "ACL: What to do between diagnosis and surgery" chrisbutlersportspt.com 🔗link in bio for now ❤️ it? TAG someone who would be helped by this👍

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Tearing your ACL is typically a traumatic event, most of my ACL patients report knowing they did something serious to their knee.  This will usually land you in the office of an orthopedic specialist within a week of the incident.  Once there is confirmation and diagnosis of an ACL tear it can often take up to 2 months to schedule a surgical date, it may be due to personal schedules, surgeon schedule, or researching graft choicesContinue reading “ACL: What to do between diagnosis & surgery”