What is the best management approach for a Pellegrini-Stieda lesion?

Management of Pellegrini-Stieda Lesion

Conservative management should be the first-line approach for Pellegrini-Stieda lesions, with surgical intervention reserved for cases that fail to respond to non-operative treatment. 1, 2

Understanding Pellegrini-Stieda Lesion

• Pellegrini-Stieda lesion refers to calcification at the femoral attachment of the medial collateral ligament (MCL) of the knee, typically following trauma to this area 3
• While many patients with the radiographic "sign" remain asymptomatic, some develop Pellegrini-Stieda syndrome characterized by pain, restricted knee motion, and functional limitations 3, 4
• The condition can occasionally present with severe symptoms mimicking other conditions such as acute septic arthritis 2

Treatment Algorithm

First-Line Treatment: Conservative Management (3-6 months)

1. Rest and Activity Modification

   • Temporary restriction of activities that exacerbate symptoms 1, 2
   • Gradual return to activities as symptoms improve 1

2. Anti-inflammatory Medications

   • Non-steroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation 1, 2

3. Physical Therapy

   • Structured rehabilitation program focusing on:
     • Range of motion exercises
     • Progressive strengthening of knee musculature
     • Proprioceptive training 1

4. Local Corticosteroid Injections

   • Can provide temporary relief for persistent symptoms 5
   • Consider limiting to 2-3 injections due to potential side effects

Second-Line Treatment: Minimally Invasive Procedures

For cases that fail to respond to 3-6 months of conservative management:

• Ultrasound-guided percutaneous lavage with platelet-rich plasma (PRP) infiltration
  • Emerging evidence shows this may be effective in reducing pain and improving function
  • Can lead to radiographic resolution of the calcification 5
  • Consider before proceeding to more invasive surgical options

Third-Line Treatment: Surgical Management

For persistent, functionally limiting symptoms despite conservative measures and minimally invasive procedures:

• Surgical excision of the calcified lesion with MCL reconstruction
  • Excision of the bony fragment with careful repair of the MCL 3, 4
  • In some cases, reconstruction using the adductor magnus tendon may be necessary 4
  • Provides good outcomes in properly selected patients with severe, persistent symptoms 4

Monitoring and Follow-up

• Clinical assessment at regular intervals (6-12 weeks initially)
• Radiographic evaluation to monitor changes in calcification
• Functional assessment using validated outcome measures (e.g., Lower Extremity Function Scale) 5
• Long-term follow-up (12-18 months) to ensure sustained improvement 5

Special Considerations

• The natural history of Pellegrini-Stieda lesions can be variable, with some cases resolving spontaneously and others requiring intervention 3, 1
• Surgical treatment should be reserved for cases with significant functional limitations that have failed conservative management 3, 4
• When surgical intervention is necessary, careful repair or reconstruction of the MCL is essential to maintain knee stability 4

Pitfalls and Caveats

• Avoid premature surgical intervention before an adequate trial of conservative management 1, 2
• Do not confuse Pellegrini-Stieda syndrome with other causes of medial knee pain such as medial meniscus tears or osteoarthritis 2
• Consider that some patients with radiographic Pellegrini-Stieda sign may remain asymptomatic and require no treatment 3
• Ensure proper rehabilitation following any intervention to prevent recurrence and optimize functional outcomes 4, 1