Plica Syndrome Treatment & Management

Medical Therapy

Medical treatment of plica syndrome has been driven largely by empirical evidence. A structured program of stretching and strengthening exercises often leads to some improvement. This may include short-arc quadriceps extension exercises (terminal approximately 20° of extension). These exercises are aimed at optimizing patellofemoral biodynamic relationships in an effort to control symptoms. A patellar knee sleeve worn during sporting activities (usually a neoprene-type brace) may also be a useful adjunct for many athletes. In addition, nonsteroidal anti-inflammatory medications are a time-tested and confirmed aid for many athletes with plica syndrome.

Surgical Therapy

Surgical therapy for plica syndrome is virtually always arthroscopic. The arthroscopic surgeon needs to exclude other potential intra-articular causes of knee pain and then address any pathologic plicae. Plica resection may be performed with arthroscopic hand instruments, a motorized soft-tissue resector, or certain commercially available electrothermal devices.

Preoperative Details

The preoperative phase of treatment involves optimizing the patient's knee strength and flexibility in an effort to streamline postoperative rehabilitation. Preoperative preparation of the patient also involves education and appropriate goal setting. For instance, the patient should understand that therapeutic exercises typically begin shortly after surgery (hours to days) and that a full return to sports can be realized soon thereafter (days to weeks). Patients who know this in advance tend to achieve these goals quite readily.

Intraoperative Details

After arthroscopic evaluation establishes that no other intra-articular abnormalities need to be addressed, the plica can be resected. Using whatever tools work best in the surgeon's hands, the plica should be resected back to a point where it no longer impinges on articular structures. With beefy synovitic plicae that extend into the patellofemoral joint space (typically 50% or more), as in the first image below, this may require extensive debridement, as in the second image below. With tough, fibrotic plicae that drape over the medial femoral condyle, this may involve little more than disruption of the tight band.

Plica syndrome. Preoperative appearance of medial

Plica syndrome. Preoperative appearance of medial parapatellar plica (a 4+ plica by the Jee classification, extending across more than two thirds of the medial facet of the patella).

Plica syndrome. Postoperative appearance of the sa

Plica syndrome. Postoperative appearance of the same patient as in Image 5 after plical resection.

At times, even a suprapatellar plica may lead to symptoms. Strover et al reported on an arthroscopic technique demonstrating the pathomechanics of such suprapatellar plicae.[31] They recommended that the arthroscope should be inserted through a lateral suprapatellar portal. Proximal visualization is then optimized. In those patients in whom the suprapatellar plica is symptomatic, progressive flexion of the knee results in the plical tissue becoming taut. It also makes contact with the medial femoral condyle and even becomes entrapped between the quadriceps tendon and medial femoral condyle.

Postoperative Details

Postoperatively, the patient is started on a structured course of therapeutic exercise that initially emphasizes reestablishment of active quadriceps control and firing. This progresses to regaining full range of motion and then full strength. The patient concludes therapeutic recovery by gradually performing more and more sport-specific exercises until a controlled reentry to the sport is achieved.

Follow-up

Follow-up care focuses on confirmation that symptoms have abated. True recurrence of the original plical pathology is quite rare and is more likely to represent either an incomplete resection or entirely new knee pathology. Continued use of a patellar stabilizing-type brace is preferred by many patients.

Complications

Complications of surgical treatment of plica syndrome are really complications associated with arthroscopic surgery of the knee. These include septic arthritis, neurapraxias or neuromas, and synovial fistulae. Reflex sympathetic dystrophy may also occur following such surgery. The rate of each of these complications is extremely small (< 1% in most cases). Only patients with particular risk factors (eg, diabetes, steroid dependence, history of RSD) may be at a significantly higher risk.

Outcome and Prognosis

The outcome of surgical treatment for well-selected patients with plica syndrome is very good.[32, 33, 34] A clinical trial conducted by Johnson et al in England demonstrated a success rate of more than 80%. In this same study, nearly 50% of patients in the control group experienced continued symptoms severe enough that they later returned for definitive arthroscopic resection of their plicae.

In a predominantly adult population (average age 25 y, age range 11-56 y), Kasim and Fulkerson reported 88% moderate-to-substantial improvement at an average of more than 4 years following resection of localized segments of painful retinacula (ie, plicae) about the knee.

Future and Controversies

Synovial plicae within the knee are clearly normal anatomic structures that can become potent pain generators.[36] Therefore, little debate exists as to whether they may become pathologically involved. Future treatment of plica syndrome may be supplemented further by improved brace designs and pharmacological treatments. Earlier recognition of patients with the syndrome might facilitate syndrome resolution by such means, in contrast to patients who experience years of symptoms.