Bo Johnson

Dr Herzog
MSAT 6500
7-22-13
Medial Synovial Plica Syndrome
Medial synovial plicae are strips of elastic tissue connected to the tibiofemoral joint from
fetal development. Risk factors for developing and causes of medial synovial plica syndrome
include activities that involve prolonged periods of flexion and extension at the tibiofemoral or
any blunt force trauma. Symptoms of medial synovial plica syndrome include anteromedial
tibiofemoral pain, or joint stuttering with extension. Medial synovial plica syndrome can be
detected with sonography, arthroscopy, and infrequently with palpation and special tests.
Treatment for media synovial plica syndrome can either be surgical or non-operative
rehabilitation.
Synovial plicae of the knee are membranous tissues developed during the fetal stages of
life1. At the fetal stages, the synovial plicae served to separate the knee into different
compartments1. The medial synovial plica is a small, thin piece of highly-vascularized synovial
tissue located in between the articular surfaces of the tibia and femur1,2. The medial synovial
plica is also often described as a shelf of tissue located over the medial aspect of the tibofemoral
joint2. Proximally, the medial synovial plica attaches to the genu articularis muscle, which is
located on the distal anterior surface of the femur, just deep to the vastus intermedius muscle2.
The distal attachment site of the medial synovial plica is the distomedial intraarticular synovial

lining of the tibiofemoral joint2,3. At the distal attachment site, the medial synovial plica forms a
connection with the medial aspect of the retropatellar fat pad2,3. In between the attachment sites,
the medial synovial plica runs from the proximal attachment site to the far medial aspect of the
femur, down the medial femoral condyle, attaching distally at the intraarticular synovial lining2.
The medial synovial plica itself is made up elastic tissues which conform to the tibofemoral
joints articulations as it flexes and extends2,3. In medial synovial plica syndrome, the medial
synovial plica becomes very thick and fibrotic, losing some of its elasticity1,2. This causes
catching of the medial synovial plica over the medial aspect of the medial femoral condyle as it
articulates over the tibiofemoral joint during flexion and extension2.
Medial synovial plicae may become symptomatic through several mechanisms: direct
trauma/blows to the plica, blunt trauma, and twisting/torsion injuries1,2,3,4,5. Additional
mechanisms include activities involving repetitive flexion-extension actions of the knee (rowing,
running, cycling, etc), activities involving prolonged knee flexion, significantly increasing
activity levels, or any mechanism that would result in intraarticular bleeding, such as a torn
meniscus or subluxing patella1,2,4,5. Because of the proximal attachment of the medial synovial
plica at the genu articularis musle (therefore an indirect attachment to the vastus intermedius),
weak quadriceps muscular tone has been found to be a prevalent cause of medial synovial plica
syndrome2. Any other joint muscular balance instabilities of the tibiofemoral joint have been
known to be causal of medial synovial plica syndrome1,2. Scarred and thickened medial synovial
plica tissues have been shown to lead to increased symptoms later on in the individuals life as
well2. In one study, ninety four knees were examined that reported symptoms of medial synovial
plica syndrome. Of these knees, sixty four were caused by sport related injuries, five reported
symptoms after blunt force trauma via falling, the rest reported idiopathic causes6.

Medial synovial plica syndrome has been shown to lead to further tibiofemoral
complications if left untreated due to the way in which it attaches. As mentioned earlier, during
knee flexion and extension, the medial synovial plica glides compactly over the medial femoral
condyle. In the event that the medial synovial plica becomes fibrotic and loses elasticity, this
frequent gliding can lead to irritation of the medial femoral condyle hyaline cartilage, resulting in
chondromalacia1,2,7,8,9.
If an individual has a medial synovial plica, as mentioned previously, individuals are at
risk for developing medial synovial plica syndrome if they participate in rigorous sports that
include repeated or prolonged periods of extension of flexion of the tibofemoral joint1,2.
Adolescents still in the growing process are at a risk of developing medial synovial plica
syndrome due to the attachment sites growing, putting stress on the medial synovial plica tissue5.
The incidence of an individual having a medial plica ranges from eighteen to sixty percent1,2. At
this time, correlations between a present medial plica and race or gender are inconclusive1,2.
The primary symptom of medial synovial plica syndrome is pain1,2,5. Individuals suffering
from medial synovial plica syndrome will report pain in the anteromedial surface of the
tibiofemoral joint, just medial to the medial facet of the patella, tenderness to palpation in this
area would represent medial synovial plica syndrome2,3,4,6,7,8. Further symptoms of medial
synovial plica syndrome could include an asymmetrical difference in the size of the tissue during
a bilateral palpation2. Individuals suffering from medial synovial plica syndrome may also report
clicking or crepitus during walking up and down stairs, or any activities associated with repeated
or prolonged knee flexion1,2,5. Visually, the tissues of the plica may appear to be white and
fibrous1.

Since the medial synovial plica is an elastic tissue, it cant be seen or detected on an xray1,10. For indviduals exhibiting symptoms of knee pain, palpation of the area medial to the
patella over the medial femoral condyle could detect medial synovial plica syndrome2. Positive
signs during palpation might reveal a thick, enflamed fibrous cord running the length of where
the medial synovial plica runs2. However one study looked at the diagnostic accuracy of
preoperative tibiofemoral evaluations and found that in nine knees positive for medial synovial
plica syndrome, preoperative evaluation registered no sign of medial synovial plica syndrome6.
Examiners can employ a special test called the plica stutter test to evaluate for medial
synovial plica syndrome11. With the patient sitting at the edge of an examination table with a
ninety degree angle at the tibiofemoral joint, the examiner will place a hand over the examinees
patella, with phalanges palpating over the medial femoral condyle11. The examinee will be
instructed to extend the tibofemoral joint through a full range of motion11. Positive signs for this
test would be if the patients tibiofemoral joint stutters between fourty-five and sixty degrees of
extension11. This is one of the only special tests for diagnosing medial synovial plica syndrome11.
It has not yet been evaluated for sensitivity or specificity, and it is only effective if there is no
swelling in the joint or joint capsule11.
If special tests and palpations fail to elicit any signs of medial synovial plica syndrome,
studies have shown that dynamic sonography detects abnormalities associated with medial
synovial plica syndrome, with good sensitivity and specificity10. In one particular study, eightyeight subjects with a palpable band of medial plica tissue and a history of activity-limiting pain,
aching, or clicking for longer than six months were examined10. The subjects ages ran from
seven years old to forty seven years old, with the mean age being twenty10. Sixty-one percent of
all subjects were female.10 Three different sonographic views were utilized during this study

using a twelve megahertz, thirty eight millimeter linear transducer10. The first view was a
constant echo sliding over the medial femoral condyle during medial and lateral translation of the
patella10. The second criterion was with the entry of the echo underneath the patella during
medial translation of the patella10. The last criterion used was if the patients felt any pain or
discomfort during any of the dynamic sonography tests10. After results were gathered using the
dynamic sonography, arthroscopy was utilized to verify medial synovial plica syndrome10.
Results were also compared to an asymptomatic, volunteer control group10. Upon completion of
the arthroscopic evaluation, sixty-eight plicae with pathological findings were found10. Sixty-one
of these findings tested positive during all three criterion of the dynamic sonograph10. Medial
plicae with pathologic findings were absent in twenty-three subjects10. The results from this study
show that dynamic sonography has eighty-eight percent accuracy in detecting medial synovial
plica syndrome10. Additionally, dynamic sonography achieved a ninety percent sensitivity with
an eighty-three percent specificity10.
Treatment options for medial synovial plica syndrome include either surgical or nonsurgical2,3. Surgically, studies have shown that excision or removal of the media synovial plica or
the retinacular bands that hold it in place are effective12,13,14. In one study, ninety-three patients
with one-hundred eighteen symptomatic medial plicae were given an arthroscopic excision of the
plica12. Patients were re-visited after an average of two years and interviewed on their progress
since the surgery12. One-hundred nine arthroscopies reported little to no pain, with an average
improvement score of forty-one points on a pain scale from one to one-hundred12. There were
five cases of post-operative hemarthrosis, but this was found to not affect the final outcome
results12. An additional study looked at ninety-five cases of adolescent (younger than fifteen
years old) anterior tibiofemoral pain that underwent arthroscopic surgery over a four year

period6. Of the cases, only nine were shown to have had medial synovial plica syndrome, but the
findings from the study suggest that tibiofemoral arthroscopy is a useful tool in defining
diagnoses for tibiofemoral pathologies6. No preoperative evaluations successfully screened for
medial synovial plica syndrome6.
One research study outlined an effective surgical technique used in removing the medial
synovial plica14. Sixty-eight subjects with symptomatic medial synovial plica were the subjects in
this study14. With general anesthesia, a large incision is made in the superolateral border of the
patella14. An arthroscope is introduced into this incision and navigated underneath the patella14.
With the tibiofemoral joint in full extension, and the tibia in internal rotation, the media synovial
plica is readily seen14. From this position, the medial synovial plica is excised at the attachment
at the infrapatellar fat pad, and excised back to its synovial reflection14. Postoperative follow ups
revealed that fifty-six percent of patients remained asymptomatic one to three months after the
surgery14. An additional twenty-four percent of patients reported improvement of symptoms, but
chronic mild discomfort with activities of daily living14.
Another surgical procedure for treating medial synovial plica syndrome is excision of the
retinaculum which lies deep to the medial synovial plica13. In one study, a comparison of the
effectiveness between medial synovial plica excision and retinacular band coupled with medial
synovial plica excision was examined13. Twenty-four symptomatic medial synovial plicae were
separated into two groups; the control group, which received only an arthroscopic excision of the
medial synovial plica, and the test group, which received arthroscopic excision of the medial
synovial plica and the retinacular band13. All subjects reported pain with flexion past ninety
degrees, with eighteen cases of a catching or stuttering sensation in extension-13. Patients were
interviewed in a follow up meeting to assess pain, range of motion, patellar stability and

quadriceps atrophy after the operation and compared to preoperative scores13. Patients were also
evaluated using Lysholm scores13. In the control group, the mean Lysholm score before the
operation was thirty-three, with postoperative scores averaging seventy-one13. The test group
began with a mean preoperative score of forty-four and improved to an average of ninety-three
on the Lysholm score after the surgery13. This study suggests that treatment of medial synovial
plica syndrome may be improved with arthroscopic excision of the deep retinacular band of the
medial synovial plica.
Most cases of medial synovial plica syndrome remain non operative2,3. Patients with
symptomatic medial synovial plica syndrome can implement rehabilitation programs to alleviate
symptoms and reduce irritation2. Successful rehabilitation programs target quadricep
strengthening due to the attachment sites of the medial synovial plica, while avoiding medial
synovial plica irritation at the same time2. Common exercises for medial synovial plica
rehabilitation are isometric quadriceps contractions, leg presses, and partial squats2. Successful
rehabilitation programs implement functional cardiovascular endurance exercises, such as
walking, swimming, and/or cycling1,2. Strengthening the quadriceps muscles alleviates pressure
on and facilitates tibiofemoral joint extension2. Concurrent with gradual quadriceps strength
increase, patients also need to improve flexibility in the hamstring muscles2. Hamstring muscles,
which act as primary tibiofemoral joint flexors, can cause anterior tibiofemoral pain when tight
by increasing the force necessary to extend the tibofemoral joint, leading to symptomatic medial
synovial plica2,11. Most rehabilitation programs last anywhere from six to eight weeks until full
alleviation of symptoms are reported2.
In cases where little to no signs of improvement are reported with a rehabilitation
program, patients may receive an intraarticular corticosteroid injection. Since this method of

treatment does not address underlying causes of medial synovial plica syndrome2,8, it is often
coupled with further rehabilitation programs after one to two days post injection2. One study
looked at the effectiveness of coupled steroidal and long lasting anesthetic injection over just
long lasting anesthetic injection8. This study chose forty subjects who all reported signs of
medial synovial plica syndrome8. A further criterion was established that subjects were to have
full range of motion with no ligamentous instability in order to rule out other possible
tibiofemoral pathologies8. The ten person control group, which received only the long lasting
anesthetic, only reported relieved symptoms for the duration of the anesthesia8. The experimental
group of thirty patients received follow up appointments one to two years post injection8. Each
subject was prescribed a muscular rehabilitation program, and twenty-seven patients saw
significant improvements with fewer and less severe symptoms8. The findings from this study
suggest that therapeutic steroidal injections, coupled with anesthesia and rehabilitation
programming, can be an effective non-surgical treatment for medial synovial plica syndrome.
Medial synovial plica syndrome is an infrequently encountered disorder of the medial
synovial plica. Individuals whom participate in activities with a high risk of blunt force trauma to
the tibiofemoral joint or with repetitive flexion and extension of the tibiofemoral joint are at risk
for developing medial synovial plica syndrome. After diagnosis, treatment options vary from
muscular rehabilitation to excision of the medial synovial plica and the deep retinaculum.

Works Cited
1. Sznajderman, T. Medial Plica Syndrome. Israel Medical Association Journal.
http://www.ima.org.il/FilesUpload/IMAJ/0/40/20498.pdf 2009; 11(1): 54-57.
Accessed July 21, 2013
2. Griffith C, LaPrade R. Medial Plica Irritation: Diagnosis and Treatment. National
Center for Biotechnological Information.
www.ncbi.nlm.nih.gov/pmc/articles/PMC2684145/#!po=53.5714. Published March
2008. Accessed July 20, 2013.
3. Cluett J. Plica Syndrome. About Orthopedics.
Orthopedics.about.com/cs/otherinformation1/a/plica.htm. Last Updated July 21, 2008.
Accessed July 20th
4. Orthogate. Plica Syndrome. Orthogate for Patients. www.orthogate.org/patienteducation/knee/plica-syndrome.html. Published July 20, 2006. Accessed July 20, 2013.
5. Anderson S. Overuse Knee Injuries in Young Athletes. The Physician and Sports
Medicine. 1991; 19:12 75-78
6. Hagino T. Knee Pain in Pediatric Patients: Comparison with Preoperative Clinical
Diagnosis. Archives of Orthopedic and Trauma Surgery. 2012. Doi: 10.1007/s00402013-1725-6
7. Lyu SR. Medial Plicae and Degeneration of the Medial Femoral Condyle. Journal of
Arthroscopic and Related Surgeries. 2006; 22(1): 17-26. Doi:
10.1016/j.arthro.2005.08.039
8. Nottage W, Sprague N, Auerbach B, Shahriaree H. The Medial Patellar Plica
Syndrome. The American Journal of Sports Medicine. 1983; 11:4 211-214
9. Zeren, B. Symptomatic Bucket Handle Tear of the Medial Patellar Plicae in Three
Patients. American Journal of Sports Medicine. 2004; 32(7): 1748-1750. Doi:
10.1177/036354650326178
10. Paczesny L. Medial Plica Syndrome of the Knee: Diagnosis with Dynamic Sonography.
Radiology. 2009; 251: 439-446. Doi: 10.1148/radiol.2512081652
11. Starkey, C. Examination of Orthopedic and Athletic Injuries. Philadelphia, PA. E.A.
Davis Company; 2010
12. Flanagan J, Trakru S, Meyer M, Mullaji A, Krappel F. Arthroscopic Excision of
Symptomatic Medial Plica. Acta Orthop Scand. 1994; 65(4): 408-411. Published
December 5, 1993. Accessed July 20, 2013.
13. Yilmaz C. Retinacular Band Excision Improves Outcome in Treatment of Plica
Syndrome. International Orthopedics. 2005; 29: 291-295. Doi:10.1007/s00264-0050676-0
14. Rovere G, Adair D. Medial Synovial Shelf Plica Syndrome. The American Journal of
Sports Medicine. 1985; 13:6 382-386