What is the management approach for a patient with a Pellegrini-Stieda lesion (calcification of the medial collateral ligament (MCL) of the knee)?

Management of Pellegrini-Stieda Lesion

Conservative management with physical therapy and NSAIDs should be the initial treatment for Pellegrini-Stieda lesions, as the medial collateral ligament (MCL) calcification typically responds well to non-operative treatment, with surgical excision reserved only for cases that fail 6+ months of conservative therapy. 1, 2

Initial Conservative Management (First-Line Treatment)

• Start with oral or topical NSAIDs for pain control, using the lowest effective dose for the shortest duration 3
• Implement supervised physical therapy focusing on quadriceps strengthening, range of motion exercises, and functional rehabilitation 2, 3
• Consider activity modification to reduce mechanical stress on the MCL during the acute symptomatic phase 4
• Continue conservative treatment for at least 6 months before considering interventional options, as most MCL injuries including calcifications respond to non-operative management 1, 2, 4

Second-Line Interventional Options (If Conservative Fails)

• Ultrasound-guided corticosteroid injection into the calcified MCL lesion can provide temporary relief and should be attempted before more invasive procedures 5

  • Limit to 2-3 injections spaced at least 3-4 months apart 3, 5
  • Monitor blood glucose in diabetic patients post-injection 6

• Ultrasound-guided percutaneous lavage (UGPL) is an emerging minimally invasive option for refractory cases 7, 5

  • This technique aspirates the calcium deposit similar to treatment of rotator cuff calcification 7
  • Can be combined with platelet-rich plasma (PRP) infiltration after lavage 5
  • Evidence shows significant pain reduction and functional improvement at 12 weeks and sustained benefit at 18 months 5
  • Radiographic resolution of calcification has been documented with this approach 5

• Radial extracorporeal shock wave therapy (rESWT) plus iontophoresis represents another non-surgical option for calcification management 8

Surgical Management (Last Resort)

• Surgical excision of the calcified lesion with MCL reconstruction should only be considered after failure of 6+ months of conservative treatment and interventional procedures 9
• Surgical technique involves excision of the bony Pellegrini-Stieda lesion with reconstruction of the MCL using the adductor magnus tendon 9
• Surgery is indicated when significant bone formation causes persistent pain and restricted knee motion despite exhaustive conservative measures 9

Critical Diagnostic Distinction

• Differentiate Pellegrini-Stieda syndrome from simple MCL calcification by confirming a traumatic history, as the syndrome specifically refers to post-traumatic calcification with pain and restricted range of motion 8
• Obtain AP and lateral knee radiographs to confirm calcification at the femoral attachment of the MCL 8, 7, 5
• Perform arthrocentesis if effusion is present to exclude pseudogout (calcium pyrophosphate deposition) or infection 3

Common Pitfalls to Avoid

• Do not rush to surgery - the vast majority of MCL injuries, including those with calcification, respond to conservative management even when complete tears are present 1, 2, 4
• Avoid prophylactic knee bracing as it provides no benefit and may increase medial knee forces 2
• Do not confuse this with acute MCL injury requiring different management - Pellegrini-Stieda represents chronic calcification, not acute ligamentous disruption 8