What is the treatment for medial plica irritation?

Treatment for Medial Plica Irritation

The treatment for medial plica irritation should begin with conservative management including quadriceps strengthening exercises, hamstring stretching, and activity modification, with surgical intervention reserved only for cases that fail to respond to non-operative measures. 1, 2

Understanding Medial Plica Syndrome

Medial plica syndrome occurs when the medial synovial fold of the knee becomes irritated, thickened, or inflamed. This condition is characterized by:

• Intermittent, dull, aching pain medial to the patella above the joint line
• Pain that increases with activity, especially knee flexion and extension
• Episodes of crepitation, catching, and pseudo-locking events
• Tenderness when rolling the plica fold over the anteromedial aspect of the knee
• Often associated with tight hamstrings

Diagnostic Approach

Diagnosis is primarily clinical, with these key elements:

• Physical examination revealing pain upon rolling the plica fold over the anteromedial knee
• Magnetic Resonance Imaging (MRI) is the most useful imaging modality to confirm the presence, size, and location of the plica 3
• Arthroscopy remains the gold standard for definitive diagnosis 4

Treatment Algorithm

First-Line Treatment (Conservative Management)

1. Activity modification and rest

   • Reduce activities that exacerbate symptoms
   • Avoid repetitive knee flexion and extension when painful

2. Physical therapy

   • Quadriceps strengthening exercises
   • Concurrent hamstring stretching
   • This combination addresses both muscle imbalance and mechanical factors 2

3. Pain management

   • Non-steroidal anti-inflammatory medications (NSAIDs)
   • Ice application to reduce inflammation

Second-Line Treatment

If symptoms persist after 4-6 weeks of first-line treatment:

1. Intra-articular corticosteroid injection

   • Particularly effective for cases with significant inflammation 2, 4

2. Advanced physical therapy

   • Consider adding kinesiology taping which has been shown to improve pain relief and functionality more effectively than exercise alone 5

Third-Line Treatment (Surgical Intervention)

If conservative measures fail after 3-6 months:

1. Arthroscopic resection
   • Complete excision of the symptomatic plica
   • Particularly indicated when:
     • Conservative treatment has failed
     • A shelf-like plica is causing damage to the articular cartilage of the medial femoral condyle 2
     • Functional limitations persist despite adequate conservative management

Considerations for Treatment Selection

• Age and duration of symptoms: Conservative treatment tends to be more effective in younger patients with shorter symptom duration 1
• Severity of symptoms: More severe cases with mechanical symptoms may require earlier surgical intervention
• Evidence of cartilage damage: Presence of damage to the medial femoral condyle may necessitate surgical intervention

Common Pitfalls to Avoid

1. Misdiagnosis: Medial plica syndrome is frequently confused with medial meniscus tears or patellofemoral pain syndrome
2. Premature surgery: Failing to give conservative management adequate time (at least 3-6 months)
3. Incomplete plica excision: During arthroscopy, the entire symptomatic plica should be removed to prevent recurrence
4. Overlooking tight hamstrings: Addressing only quadriceps weakness without concurrent hamstring stretching may lead to suboptimal outcomes
5. Ignoring other potential sources of anterior knee pain: Ensure proper differential diagnosis before focusing solely on plica syndrome

Conservative management should be exhausted before considering surgical intervention, as most patients will respond well to a properly structured non-operative treatment program focusing on quadriceps strengthening and hamstring flexibility.