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Plica Syndrome

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Introduction

A plica is a congenital extension of the synovial membrane that is formed in the knee during the embryological phase of development, dividing the knee up into three distinct sections. Normally, the tissue starts to fold inwards and is eventually reabsorbed to leave a joint cavity between the tibia (shin bone) and femur (thigh bone). However, sometimes this does not happen meaning that the cavity remains incomplete. As a result, plica can be observed which represents partial completion of inward folds of the membrane. There are four types of plica that can become problematic in the knee depending on the location of your pain. The most common is the medial patellar plica (Bellary et al., 2012).

Signs & Symptoms

Often you may experience locking that resolves almost instantaneously, clicking or popping and a feeling that your knee feels slightly unstable. You may experience discomfort if you have been sitting for a long period of time accompanied with a catching or locking sensation when you get up. Often the discomfort experienced can be described a dull aching pain that will aggravate when walking up or down stairs or holding the knee in a fixed position (Schindler, 2014). You may also experience nocturnal discomfort.

Causes

Often people with plica do not have any symptoms. However, sometimes they can become inflamed due to excessive movement or trauma which prevents normal functioning of the knee. Typically, a plica can become irritated from overuse. Often this is caused by excessive bending and straightening of the knee outside of the norm of what you may be used to doing. Otherwise, the plica can become irritated from trauma such as a direct impact to the knee (Al-Hadithy, Gikas, Mahapatra, & Dowd, 2011).

Assessment & Diagnosis

At Pure, your Physio will take a detailed history of your symptoms followed by a thorough clinical examination to establish an informed hypothesis of the structures contributing to your pain and provide a working diagnosis. A fast and accurate diagnosis will mean that the most effective treatment and management plan can be implemented straight away, helping to achieve optimal outcomes. Your Physiotherapist will want to know how your condition is effecting you day to day so that your treatment can be tailored to your needs and will mean personalised goals can be established. Regular re-assessment will ascertain if your are making progress towards your goals and will allow adjustments to your treatment to be made.

Self-Management

Initial conservative management should include the RICE protocol: rest, ice compression and elevation, which should be maintained over the first 72 hours to treat an inflamed plica. Within this regime, it is worth noting that a brief period of rest (2-4 days) is recommended to allow symptoms and irritation to settle.

 

This period of rest is usually employed in conjunction with nonsteroidal anti-inflammatory drugs (NSAID) can be taken to alleviate the pain which can be prescribed by your GP or a topical NSAID gel can be applied to the irritated plica to reduce inflammation. Ice can also be applied for 15-20 minutes every 4-7 hours during the inflammatory phase. Compression and elevation will assist with swelling reduction. This should be guided by your Physiotherapist.

Physiotherapy

Once the acute inflammation is reduced, your specialist Physiotherapist will create a specific self-management and exercise protocol in order to help resolve the issue which will be modified as your make progress. Gentle massage around the plica or area of discomfort can help break up scar tissue to improve symptoms. We provide ongoing support and advice so that you can effectively manage your symptoms and reduce the likelihood of further complications in the future.

Escalation of Treatment

Conservative management is effective in most cases. However, if conservative management does not improve your symptoms it may be that surgery may be the only option particularly if the plica has undergone irreversible chronic changes that won’t respond to conservative management. Physiotherapy is recommended starting 48 to 72 hours post-op, to prevent scarring and stiffness. NSAIDs can be prescribed to reduce the risk of intra-articular fibrosis and to protect against plica recurrence (Griffith & LaPrade, 2008).

References

Al-Hadithy, N., Gikas, P., Mahapatra, A. M., & Dowd, G. (2011). Plica syndrome of the knee. Journal of Orthopaedic Surgery19(3), 354-358.

 

Bellary, S. S., Lynch, G., Housman, B., Esmaeili, E., Gielecki, J., Tubbs, R. S., & Loukas, M. (2012). Medial plica syndrome: a review of the literature. Clinical Anatomy25(4), 423-428.

 

Griffith, C. J., & LaPrade, R. F. (2008). Medial plica irritation: diagnosis and treatment. Current reviews in musculoskeletal medicine1(1), 53-60.

 

Schindler, O. S. (2014). ‘The Sneaky Plica’revisited: morphology, pathophysiology and treatment of synovial plicae of the knee. Knee Surgery, Sports Traumatology, Arthroscopy22(2), 247-262.

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