Damage to the mediopatellar fold of the knee joint

In most patients, mediopatellar fold syndrome of the knee joint develops gradually and they get used to not paying attention to the characteristic unpleasant symptoms. However, this is wrong. Successful conservative treatment of this pathology is possible only at the initial stage. Therefore, if you have typical signs of the problem described in this article, we recommend that you consult an orthopedist as soon as possible. Only early treatment will allow you to avoid the need for surgery.

Mediopatellar fold syndrome usually develops at a fairly young age. During a standard examination, the doctor may not detect absolutely any pathological changes in the joint tissues. An x-ray shows the normal state of bone and cartilage tissue. But at the same time, a constant nagging pain appears, intensifying after physical activity.

The mediopatellar fold of the knee is an anatomical formation that is rudimentary. During the embryonic period of fetal development, this part separates the joint so that condyles, menisci, articular capsules, synovial cartilage tissue, etc. can fully develop. By the time pregnancy is completed, most people experience involution of this rudiment. But, if for some reason this does not happen, a person lives well with a mediopatellar fold inside the knee joint.

Problems arise when severe physical stress begins to be placed on the lower limbs. Clinical manifestations occur with hypertrophy (thickening) of the cartilage tissue of this fold.

The following risk factors may contribute to this:

• excess body weight (every extra kilogram has a huge impact on the condition of the joints);
• maintaining a sedentary, sedentary lifestyle, which causes degeneration of other tissues of the knee joint;
• heavy physical labor associated with the need to stay on your feet for a long time, lift and carry heavy objects;
• long walks and running;
• weightlifting;
• incorrect choice of shoes for everyday wear and physical education;
• diseases of the spinal column and large joints of the lower extremities;
• incorrect placement of the foot in the form of flat feet or club feet.

When diagnosing pain in the knee joint, the mediopatellar fold is found in approximately half of the patients who seek help. However, only 10% of them have this particular rudiment that causes discomfort. In all other cases, cartilaginous formation does not in any way affect the functionality of the bone articulation.

If you have unpleasant sensations in your knee joints or extraneous sounds when making movements in them, then we invite you to a free appointment with an orthopedist in our manual therapy clinic. Experienced doctors work here. They will be able to give you an accurate diagnosis. They will give recommendations for examinations and treatment.

Diagnostics

Pressing on the medial capsule of the knee joint is painful. Sometimes a dense chord-like structure is determined, the density of which changes at different angles of flexion in the knee joint. However, often the palpable structure does not correspond to the fold identified by arthroscopy .

Specific tests to detect the fold have not been described. Differential diagnosis should always be made with a medial meniscus tear . Although radiography and MRI do not provide additional information, they are useful in the differential diagnosis.

How is Plick syndrome diagnosed?

Diagnosing Plick syndrome can sometimes be a difficult process, even for your doctor. As previously discussed, various factors contribute to the occurrence of knee pain, especially internal knee pain, and diagnosis, which requires specialized approaches. For example, a torn meniscus or tendonitis can also cause knee pain, but diagnostic methods vary. So how is plica syndrome diagnosed?

Clinical Examination

The specialist will consider reviewing the patient's medical history and conducting a clinical examination. Each surgeon undergoes his own series of examinations, making a relative diagnosis of the disease. Clinical examinations are a series of tests that accurately indicate a doctor's diagnosis and treatment options, but they are not conclusive. Orthopedists perform these tests to evaluate three aspects: patellofemoral joint/extensor mechanism, joint damage, and knee instability. Each of these three categories has its own tests, which are:

• Patella and femoral tests include J-sign, Q-angel, patellar tracking, MPFL palpation test and patellar slide
• Tests for joint damage include the mcmurray test, the Apley's (shredding) test, the boler test, the squat test, and the duck test.
• Tests for knee instability include valgus (abduction) and varus (adduction) tests, Cabot maneuver, anterior, and posterior box tests, Lachman test, quadriceps active testing, axis shear (wrench) test, and Noyce sliding pivot test.

These measures help diagnose plick syndrome, although they are not always conclusive. And may be confused with other causes of knee pain. As a result, podiatrists often use advanced technology to obtain accurate results and diagnose plik syndrome.

Does Plica Syndrome Show Up on MRI?

Many people assume that using X-rays to diagnose plica syndrome is acceptable, but doctors have found that this procedure does not effectively show plica. This is where magnetic resonance imaging (MRI) of the foot comes to the rescue. This technique uses magnetic waves to indicate problems such as tears in the meniscus and knee ligaments. Therefore, an MRI can easily show any inflammation and damage to the plica.

Classification

The fold can be single, double or (rarely) triple, and its surface can be solid or perforated. Having visualized the fold, the patient's leg is bent and extended several times at the knee joint . The small fold (type 1) does not contact the medial femoral condyle during these manipulations. A large fold (type 3) may contact the femoral condyle and/or the patella.

There are three types of mediopatellar fold :

• Type 1 is a rudimentary ridge-like formation of the anteromedial capsule.
• Type 2 - a fold that does not impinge on the medial femoral condyle and/or the patellar facet during knee flexion.
• Type 3 is a fold that impinges on the medial femoral condyle and/or the patellar facet during knee flexion.

A very large fold can also be pinched during extension. A very large fold makes it difficult to move the arthroscope from the patellofemoral joint to the medial compartment. To avoid perforation of the fold, forceful movement of the optics should be avoided. To access the medial part of the joint, one of the following techniques is used:

Maximum knee extension. In some cases, this technique allows you to create a space between the fold and the femoral condyle, through which it is possible to advance the arthroscope in the distal direction.

Access to the medial compartment through the medial volvulus. The origin of the fold from the capsule is usually located at a short distance from the femoral condyle. At the same time, the space through which one can get distally into the medial inversion and further into the medial part of the joint remains free.

Access to the medial compartment through the lateral inversion. The arthroscope is retracted to the lateral femoral condyle, along the surface of which it is moved distally, and then passed over the intercondylar space, reaching the medial compartment. The advantage of this access is the ability to examine the lower surface of the fold. During the study, it is necessary to pay attention to the accompanying changes in the fold and surrounding articular surfaces:

Fibering of the free edge of the fold. Such changes indicate a permanent infringement of the fold between the patella and the femoral condyle.

Hyperplasia of synovial tissue on the crease or medial condyle of the femur. This indicates constant irritation of the fold due to pinching or contact with the medial femoral condyle during prolonged flexion.

Scar-altered and thickened edge of the fold. This is a sign of constant irritation caused by the “rolling” of the edge of the fold along the medial femoral condyle during flexion and extension.

Cartilage damage on the medial femoral condyle. Prolonged compression of the fold during flexion of the knee joint can damage the cartilage of the medial part of the femoral trochlea or the proximal part of the medial condyle.

Damage to the cartilage of the medial facet of the patella. When the fold between the femoral condyle and the patella is pinched, the cartilage of the medial facet of the latter can be damaged. Arthroscopic assessment of the mediopatellar fold is performed under “unnatural” conditions, as the joint cavity is distended by fluid or gas. As a result, the distance between the femoral condyle, the patella and the fold appears greater than without stretching.

How does Plick Syndrome Occur?

Any activity or injury that irritates the Plick will cause Plick syndrome. This syndrome develops over time in people who repeatedly bend or straighten their knees during activities such as cycling, running, and using stair lifts. However, doing strenuous and unusual exercises before the body is ready, as well as accidents, can irritate the plica and cause knee pain. If you have a structural problem that affects the joint between the kneecap and the femur, you are more likely to have plica syndrome. These structural problems may be related to the alignment of the knee joint or weakness of the muscles around the hips.

What are the symptoms of Plica syndrome?

The main and common symptom of Plica syndrome is knee pain, especially in the medial and anterior parts of the knees. And patients rarely feel pain behind the kneecap. It's interesting to know that the knee pain caused by this syndrome is painful rather than sharp and gets worse when you put more pressure on the knee, such as using a ladder, squatting, or bending. There are also various additional symptoms that differ from person to person, depending on the type and intensity of the injury. Some of these symptoms:

• Difficulty sitting for long periods of time
• Feeling of the knee being locked after sitting in a chair for a long time
• Feeling unsteady on stairs
• A clicking or cracking sound is heard when the knee bends. This sound is caused by the sliding of a thick plate along the condylar surface of the femur inside the knee joint.
• A pounding sensation in the knee that is often present in the early morning but gradually disappears after daily exercise.
• When you press on the kneecap, you will find a swollen plica
• I feel my knee going away

In addition to knee pain, which of the above symptoms do you have? Some patients say that we only have one or more of these symptoms, so this means that our knee pain is not caused by plica syndrome. However, this is a wrong attitude because all these symptoms are not manifested in humans, and their types and severity differ from patient to patient. If so, talk to your doctor if you want accurate information about this syndrome and its symptoms.

Synovial fold syndrome of the knee joint

The synovial fold (plica) is a protruding membrane between the synovium of the patella and the tibiofemoral joint. The fold is essentially composed of mesenchymal tissue that forms in the knee during the embryological phase of development [1]. This tissue forms membranes that divide the knee into 3 compartments: the medial and lateral tibiofemoral compartments and the suprapatellar bursa. This tissue usually begins to involute (fold inward) between 8 and 12 weeks of fetal growth and eventually resorbs, leaving a single empty area between the distal femoral epiphysis and the proximal tibial epiphysis: a single knee cavity. The movement of the fetus in the uterus contributes to this resorption. However, in many people the mesenchymal tissue is not completely resorbed and therefore the knee joint cavitation remains incomplete. As a result, in these people, folds can be observed, which are the internal folds of the synovium in the knee joint. Various degrees of separation of the cavities are visible in the human knee. It is estimated that plica is present in approximately 50% of the population [2].

The elastic nature of the synovial folds allows the bones of the tibiofemoral joint to move normally without restriction. However, if the same knee motion is repeated too often, such as bending and straightening the knee, or if there is a knee injury, these folds can become irritated and inflamed. This can lead to a disorder called plica syndrome. This refers to an internal disorder of the knee joint that interferes with the normal functioning of the knee joint.

This is an interesting problem, especially seen in children and adolescents, and occurs when the otherwise normal structure of the knee becomes a source of knee pain due to injury or overuse. The diagnosis is sometimes difficult to make because the main symptom of nonspecific anterior or anteromedial knee pain can indicate various diseases of the knee joint. But if, beyond any doubt, plica has been diagnosed as the source of knee pain, it can be properly treated [3].

Types of plik

In the knee, 4 types of folds can be distinguished, depending on the anatomical location in the cavities of the knee joint: suprapatellar, mediopatellar, infrapatellar and lateral folds. The latter are rarely seen, and therefore there is some controversy as to their existence or exact nature. The folds in the knee joint can vary in both structure and size; they can be fibrous or fatty, longitudinal or crescent-shaped [4].

Suprapatellar plica

The suprapatellar plica, also called the suprapatellar plica, superior plica, supramedial plica, medial suprapatellar plica, or septum, is a domed, crescent-shaped septum that typically lies between the suprapatellar bursa and the tibiofemoral joint of the knee. It runs down from the synovium on the anterior side of the femoral metaphysis to the posterior side of the quadriceps tendon, passing over the patella. Its free border under normal conditions appears sharp, thin, wavy or jagged. This type of plica may be present as an arcuate or peripheral membrane around an opening called a porta. It often merges with the medial fold. Because the patellar plate is attached anteriorly to the quadriceps tendon, it changes size and orientation as the knee moves [5].

Based on arthroscopic examination, suprapatellar folds can generally be classified according to location and shape into different types. Kim and Cho (1997) identified the following 7 types; [6]

1. There is no fold with sharp edges.
2. A vestigial fold with a protrusion less than 1 mm. Disappeared under external pressure
3. Medial fold lying on the medial side of the suprapatellar sac
4. Lateral fold lying on the lateral side of the suprapatellar sac
5. The arcuate fold is present medially, laterally and anteriorly, but not over the anterior thigh
6. A fold with an opening passing completely through the suprascapular sac, but with a central defect.
7. Complete fold dividing the suprapatellar sac into two separate compartments

Medial patella plica

The medial patellar plica is also known as the plica mediopatellaris, medial synovial protuberance, elongated patellar fold, medial parapatellar fold, patellar meniscus, or after its first two descriptions as Jonah's band or Aoki's protuberance. It is located along the medial wall of the joint [7]. It attaches to the underside of the patella and underside of the femur and crosses the patellar fold to attach to the synovium surrounding the infrapatellar fat pad. Its free border may have a different appearance. Because the medial plica is attached to the synovium covering the fat pad and patellar ligament, it also changes size and orientation as the knee moves. The medial fold is known to be the most commonly injured fold due to its anatomical location, and it is usually this fold that is used to describe plique syndrome.

Like the suprapatellar folds, the medial folds can also be classified based on their appearance. Kim and Cho identified the following 5 types: [8]

1. There is no synovial protrusion on the medial wall
2. Residual less than 1 mm of synovial elevation that disappears with external pressure
3. Shelf. Full fold with sharp free edge.
4. Repeated duplication of two or more shelves running in parallel. They can be of different sizes.
5. Fenestra. The shelf contains a central defect

Each type is subdivided depending on the size and relationship to the femoral condyle with flexion and extension of the knee into:

A—narrow, non-contiguous (never in contact with the femoral condyle).

B—Medium touch (touches the condyle as the knee moves).

C—wide covering (covers the femoral condyle).

Infrapatellar plica

The infrapatellar fold is also called the ligamentum mucosum, the inferior or anterior fold. It is a fold of synovium that originates from a narrow base in the intercondylar notch, passes distally in front of the anterior cruciate ligament (ACL), and is inserted into the inferior portion of the infrapatellar fat pad. It is often difficult to distinguish an infrapatellar plica from an ACL. It basically looks like a thin, cord-like fibrous ribbon. The infrapatellar fold is considered the most common fold in the human knee. It is currently debated whether this plica is structurally important for regular knee motion or not [9].

The classification of infrapatellar folds can be as follows: [10]

1. There is no synovial fold between the femoral condyles.
2. Separated. A complete synovial fold that has been separated from the anterior cruciate ligament (ACL).
3. Divided. A synovial fold that is separated from the ACL but is also divided into two or more cords.
4. Vertical partition. A complete synovial fold is attached to the ACL and divides the joint into medial and lateral compartments.
5. A fenestra is a pattern of vertical septum containing an opening or defect.

Lateral plica

The lateral fold is also known as the plica synovialis lateralis or lateral parapatellar fold. It is longitudinal, thin and located 1-2 cm to the side of the patella. It is formed as a synovial fold along the lateral wall above the popliteal foramen, extending inferiorly and inserted into the synovium of the infrapatellar fat pad. Some authors doubt whether this is a true remnant of the septum from the embryological phase of development or whether it originates from the parapatellar fatty synovial fringe [11].

This type of plica is observed only in rare cases; its frequency is well below 1%.

Epidemiology/etiology

Synovial folds are mostly asymptomatic and have little clinical consequence. However, they can become symptomatic when they are injured or irritated. It can result from a variety of conditions such as direct or plica trauma, blunt trauma, torsion injuries, repetitive knee flexion and extension, increased activity levels, medial muscle weakness, intra-articular bleeding, osteochondritis dissecans, meniscal avulsion, chronic or transient synovitis [ 12]. Once the initial injury has healed, patients may have no symptoms for a while, but then suddenly develop anterior knee pain a week or even months later.

The term plica syndrome is used to refer to an internal disorder of the knee joint caused by inflammation or trauma to the patella, medial patellar fold, or lateral fold, or a combination of these, and which interferes with the normal functioning of the knee joint [13]. It is known that the medial fold is the most commonly injured fold due to its anatomical location. The infrapatellar fold is not usually implicated when plica syndrome occurs. In summary, plica syndrome is often the result of overuse of the knee and is therefore common in people who engage in activities involving repetitive flexion-extension movements, such as cycling, running, team sports, gymnastics, swimming and rowing, and is particularly common. in teenage athletes.

The reported incidence of synovial folds shows wide variation, as does the incidence of ply syndrome. These differences are largely the result of individual investigators' interpretations and differences in nomenclature and scoring procedure.

Characteristics / Clinical picture

Under normal conditions, synovial folds are thin, pink and flexible. Under the microscope, they are visible as a lining of single or reduplicated synovial cells lying on a connective tissue stroma that contains numerous small blood vessels and collagen fibers, but no elastic fibers. This allows the folds to change size and shape as the knee moves [14].

When a fold becomes pathological, the normal characteristics of the tissue are changed due to the inflammatory process. They may become hypertrophied, exhibit increased vascularity, hyalinization and lose their typical characteristics of loose and elastic connective tissue. As a result, they can also become swollen, thickened and fibrous, and they will certainly interfere with the normal movement of the patella and femur.

In chronic cases, fibrocartilaginous metaplasia, increased collagenization and calcification will be observed. In particular, the medial lamina of the patella may be pulled across the acetabulum and medial femoral condyles or cut between the medial aspect of the patella and the medial condyle when the knee is flexed. Over time, this can lead to softening, degeneration (chondromalacia), or even erosion of the cartilage on the medial surface of the patella and trochanter. The fold will intrude into the patellofemoral joint (usually between 30° and 50° of flexion), then subluxate over the medial femoral condyle. The same mechanism can be observed with a pathological lateral fold, but in this case the lateral femoral condyle will be affected. A pathological suprapatellar fold will form between the quadriceps tendon and the trochanter of the femur.

Plica syndrome can cause a range of symptoms such as pain, clicking, popping, effusion, localized swelling, decreased range of motion, intermittent medial joint pain, instability, and patellofemoral joint locking. It is more common in teenagers and young adults, and even more common in women than men.

Patients often report that symptoms are absent in the early stages of exercise, but may occur suddenly and gradually worsen. They are often accompanied by pain that can be described as intermittent, dull, and aching, and will be aggravated by exercises that place stress on the kneecap and hip, such as walking up or down stairs, squatting, kneeling, or holding the knee in a flexed position. for some time [15].

When symptoms occur, they are not easily distinguished from other intra-articular conditions and disorders of the knee. The pain can be localized in different places, such as the patella and the mid-patella area when the knee is extended. You may also hear a popping sound when you bend and straighten your knee. The combination of contraction of the quadriceps muscle and compression of the suprapatellar sac may also cause pain. What is common in patients with plica syndrome is that they often have a feeling of instability when walking on stairs or an incline.

It should only be considered as the underlying cause of a patient's symptoms when the patient does not respond to appropriate treatment for patellofemoral pain.

Differential diagnosis

• Patellofemoral syndrome
• Bilobed patella
• Patellar displacement
• Degenerative joint disease
• Hoffa syndrome
• Sinding-Larsen-Johansson disease
• Medial collateral ligament sprain
• Osteochondritis dissecans
• Bursitis "crow's foot"
• Meniscal tears

Diagnostic procedures

Because the symptoms observed in pathological pliques are not specific, the diagnostic tool must maintain a high level of suspicion and ideally work by exclusion to distinguish the condition from any other knee disorder [16].

• Physical examination: Unremarkable due to possible tenderness of the anteromedial capsule or area around the suprapatellar sac on direct palpation.
• Provocative test: A provocative test may be used that simulates the conditions that may lead to symptoms. These results will be considered positive if the symptoms obtained from the tests are similar to the symptoms the patient would normally experience. However, since similar symptoms may be associated with other diseases of the knee joint, this method will also not give a clear result.
• X-rays will not be of diagnostic value in determining whether patients have plica syndrome, as the X-ray will be negative. However, radiography may be useful in ruling out other syndromes that have symptoms similar to those of plica syndrome. If there are symptomatic folds, they will exhibit hypertrophy and inflammation. This will lead to thickening and eventually fibrosis. If fibrosis is significant, changes to the articular surface and subchondral bone may occur.
• Arthroscopy may be helpful because plica syndrome is often confused with chondromalacia or a medial meniscal tear. Lateral pneumoarthrography and double contrast arthrography have been used with variable success. When combined with CT scanning, it can not only visualize the plica, but also demonstrate whether impingement is present or not. However, it has now fallen out of use due to problems in obtaining reproducible and reliable results and exposure to radiation [17].
• Currently, the best results are obtained with MRI scanning. Most cases of plica syndrome do not require an MRI at all, but it can help rule out other pathologies that may be causing knee pain. An MRI can rule out bone contusions, meniscus tears, ligament injuries, cartilage defects... which may masquerade as plica syndrome. MRI is useful in assessing the thickness and extent of synovial folds and can also identify pathological folding, especially in the presence of intra-articular effusion [18].

Survey

One of the most important points in diagnosing medial synovial fold pathology is obtaining an appropriate medical history from the patient.

The pain is often described as a dull ache in the proximal medial aspect of the knee and along the border of the patella. Internal hydropsia and a palpable cord are often observed. The pain worsens with physical activity, overuse, and can also be bothersome at night. Most patients complain when climbing stairs, squatting, and getting up from a chair because these movements place stress on the patellofemoral joint. The patient may also complain of pain after sitting for a long time. About 50% of patients tell us that they have performed repetitive flexion and extension exercises. Trauma or overuse of another plica may cause the same complaints, but they are less common.

Specific physical tests to diagnose the medial plica include ply pinch tests. However, the pinch test will not work when the joint is swollen. Other examinations that may indicate the presence of a medial plica include the medial subluxation test, McMurray test, Eppley instability test, and Cabot test.

Medial fold testing is performed with the patient in the supine position and with the knee extended. Manual force is then applied with the thumb to the inferomedial aspect of the patellofemoral joint, checking for tenderness. If this tenderness clearly improves at 90° of flexion with the same manual force applied, the test is considered positive. Compared with arthroscopy, the sensitivity and specificity of this test were 89.5% and 88.7%, respectively, with a diagnostic accuracy of 89.0%.

Other provocative tests to diagnose medial plica syndrome may be the knee extension test or the knee flexion test. For the active extension test, the tibia is quickly extended as if you were moving your legs. The test is considered positive when it is painful due to sudden tension on the plate of the quadriceps femoris muscle. The flexion test is performed by rapidly rotating the tibia from full extension to flexion and interrupting the rotation between 30 and 60° of flexion. The test is also positive when there is tenderness as the plica is then stretched with eccentric contraction of the quadriceps muscle.

The ply snap test can be used to check for medial fold irritation. To palpate the medial synovial fold, the patient lies supine on an examination table with relaxed legs. For the medial synovial fold, the examiner palpates the ligament by running the fingers along the fold, which is located between the medial border of the patella and the area of ​​the adductor tubercle of the medial femoral condyle. Under the finger, which is pressed directly against the underlying medial femoral condyle, the ligament will appear as a ribbon fold of tissue. The test is positive when it produces a sensation of mild pain. But you should also compare the score to a normal knee to see if there is a difference in the amount of pain. It has been shown that this can be quite painful in some patients because the medial joint and synovium are well innervated.

Treatment

Treatment for plica syndrome should initially be conservative in providing symptom relief through rest, use of NSAIDs, and physical therapy. If this treatment does not improve or if symptoms worsen, your doctor may use intra-articular corticosteroid injections. However, this approach appears to produce better results in younger people and in patients with only short-term symptoms.

If nonoperative measures do not help, surgery should be considered. This is often the only option if the disease has become chronic and/or the plica has undergone irreversible morphological changes. The surgery will involve arthroscopy, in which the fold will be removed. It is important to remove the entire fold to avoid fibrosis or structural changes with subsequent recurrence of pain and symptoms. However, the integrity of the capsule and supporting structure must be maintained during resection of the plica, as trauma may lead to patellar subluxation. Another possible complication often seen with plica surgery is excessive intra-articular bleeding. Therefore, intraoperative hemostasis using electrocoagulation is recommended to avoid postoperative hemarthrosis. Before resection of the synovial fold, it is also important to first consider possible other intra-articular pathologies that exist in the patient. Complete removal of the retinacular stripes may also be necessary to ensure success.

Postoperative rehabilitation after plica resection is usually quick. Physical therapy is recommended to begin 48-72 hours after surgery to prevent intra-articular scarring and stiffness. NSAIDs may be prescribed to reduce the risk of intra-articular fibrosis and protect against recurrence. Most patients can resume exercise within 3 to 6 weeks. However, there may be some variation in recovery time, and patients should ensure that they are fully recovered before resuming physical activity or sports.

The overall success rate of plica resection is generally good and will largely depend on whether the plica is the only pathology or not. Concomitant pathologies such as chondromalacia of the patella and femur will reduce the likelihood of success [19].

Physiotherapy

Conservative treatment initially consists of pain relief with NSAIDs and repeated cryotherapy throughout the day using ice packs or ice massage to reduce initial inflammation. Other measures would include limiting aggravating activities by modifying daily physical movements to reduce repetitive flexion and extension movements and by correcting biomechanical abnormalities (tight hamstrings, weak quadriceps). Additionally, microwave diathermy, phonophoresis, ultrasound, and/or friction massage could be considered. Friction massage is also used in this therapy to break up scar tissue. Immobilizing the knee in an extended position for a few days can sometimes be helpful, as can avoiding maintaining the knee in a flexed position for longer periods [10].

Once acute inflammation has subsided, physical therapy can be initiated to reduce compressive forces through stretching exercises and increase quadriceps strength and hamstring flexibility [9].

This treatment is usually recommended for the first 6-8 weeks after the initial examination [1].

It consists of strengthening and improving the flexibility of the muscles adjacent to the knee, such as the quadriceps, hamstrings, adductors, abductors, gastrocnemius and soleus [8][9].

Key components of the rehabilitation program will include flexibility, cardiovascular training, strengthening, and return to daily activities.

• The extension flexibility exercise is a passive knee extension exercise in a supine position with a foam roller placed under the ankle. Gravity will help stretch your knee as much as possible. If possible, you can make the exercise more challenging by placing dumbbells on the front of your knee [15].
• Sets for quadriceps [15]
• Exercise for passive knee extension while lying on your stomach, knees on a bench (leg without support) [17].
• Straight leg raise [15]
• Leg presses [15]
• Also, mini-squats, a walking program, use of an exercise bike, a swimming program, or perhaps an elliptical machine are the most successful rehabilitation programs [15].

Rehabilitation programs will have the greatest success by focusing on strengthening the quadriceps muscles, which are directly attached to the medial fold, and avoiding activities that irritate the medial fold [15].

The most important part of the quadriceps muscle to train is the m.vastus mediale. Full range of quadriceps training is not recommended as it places excessive compression on the patella at a 90° angle. Instead of straight leg raises and short-arch quadriceps exercises at an angle of 5°-10°, you should also strengthen the hip adductors [10]. Other important components of this treatment are a stretching program for these muscles (quadriceps, hamstrings and gastrocnemius) and knee extension exercises. The purpose of these knee extension exercises is to strengthen the tensor muscles of the joint capsule. But if the patient has too much pain when reaching terminal extension, then this should be avoided [12]. This conservative treatment is effective in most cases, but surgery is necessary in some patients. In this case, postoperative therapy is necessary. Postoperative treatment is identical to conservative treatment and usually begins 15 days after surgery. The main goals of physical therapy for plica syndrome are to reduce pain, maximize exercise, and increase muscle strength.

The type of plica, the patient's age, and the duration of symptoms will greatly influence the success of conservative, non-operative treatment of plica syndrome. It is generally believed that infrapatellar and lateral fold syndrome is not very responsive to physical therapy and usually requires surgical intervention. Success of conservative therapy is also more likely in younger patients with a short duration of symptoms, since the fold has not yet undergone morphological changes. Overall, the overall success rate of nonsurgical treatment is relatively low, and complete symptom relief is achieved only in rare cases.

Sources

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3. https://internationalskeletalsociety.com/getattachment/8906efba-8607-46de-b4a7-91245c98eabe/CR02.aspx
4. Kenta, & Khanduja. (2009). Synovial plicae around the knee. The Knee, 97-102.
5. (nd) Retrieved 12 21, 2010, from Physiotherapy in banff for the knee: https://www/activemotionphysio.ca/article.php?aid=347
6. Ihra, & Vrdoljak. (2003). Medial synovial plica syndrome of the knee: a diagnostic pitfall in adolescent athletes. Journal of pediatric orthopedics-Part B, 44-48.
7. Schindler OS. 'The Sneaky Plica' revisited: morphology, pathophysiology and treatment of synovial plicae of the knee. Knee Surg Sports Traumatol Arthrosc. 2014 Feb. 22 (2):247-62. [Medline].
8. Dupont JY. Synovial plicae of the knee. Controversies and review. Clin Sports Med. 1997 Jan. 16(1):87-122. [Medline].
9. Curr Rev Musculoskelet Med. Mar 2008; 1(1): 53–60.fckLRPublished online 2007 Nov 27. doi: 10.1007/s12178-007-9006-z
10. Yilmaz, Golpinar, Vurucu, Ozturk, & Eskandari. (2005, October). Retinacular band excision improves outcome in treatment of plica syndrome. International Orthopedics, 291-295.

to sum up

After reading this article, you will learn everything you need to know about Plick syndrome. But in short, plica is present in most people's knees and usually does not cause problems. According to research, the plica is located in 87% of knees at the top of the patella, 72% of knees at the inside of the knee, and 86% at the bottom of the knee. The upper and lower knee plicas rarely cause pain, but what causes internal knee pain is the medial plica. To learn more about medial knee pain, click here to read the related article. However, it is controversial whether Plick syndrome is hereditary or not. What is your opinion? Please write us your valuable comments below.

Could Plica Syndrome Come Back?

The answer to this question is both yes and no. If you have used non-surgical treatments for Plick syndrome, this problem may return. But how? Let's say you rely solely on corticosteroid injections and don't do any strengthening exercises. In this case, symptoms will appear again after a short period of time. Or, if you skip your exercise program, you may not be able to get rid of your knee pain.

On the other hand, after arthroscopy the plica may grow back, but will no longer be asymptomatic. Under these circumstances, plica syndrome will not return, and you can safely do your favorite activities. But overall, to avoid any knee injury, you need to be very careful and lead a healthy lifestyle. A balanced diet, a healthy weight, exercise and knowing how to sit correctly have a significant impact on knee health .

Treatment of Plick syndrome

Fortunately, plick syndrome is more treatable than other causes of knee pain. When it comes to treatment, you may think that it means knee surgery, while Plick surgery is the last and rarest choice in treating this problem. Self-care and exercise are the main treatment options for plik syndrome, and patients often experience good results.

Self-help methods

Try to reduce or stop activities that put stress on your knee, such as running, jumping, or climbing stairs, before attempting any activity. Other alternative activities such as swimming will help you maintain your fitness. Use anti-inflammatory drugs such as ibuprofen to relieve pain. Doctors also recommend placing an ice pack on your knee for 20 minutes every two to three hours to reduce inflammation. These are self-help tasks that are best completed before beginning practical exercises to treat an inflamed plica.

Exercises

The most effective treatment program for Plick syndrome is to perform exercises that strengthen the muscles around the knee, such as the quadriceps and hamstring muscles. Consult a physical therapist about how to perform these exercises correctly, as doing them incorrectly can lead to other serious knee injuries. And the good news is that patients experience improvement within 6-8 weeks of starting exercise and physical therapy. These practice exercises:

Strengthening the quadriceps muscle

Having strong quadriceps muscles is beneficial because it reduces the risk of plica inflammation. According to statistics, people with weak quadriceps muscles were more likely to develop inflammation in the quadriceps. This is because the plica is indirectly attached to the quadriceps muscles. Now you know that you need to strengthen your quadriceps muscles to treat an irritated plica. Exercises to strengthen these muscles include:

• Quadriceps strengthening exercise
• Ab exercise for legs
• Exercise bike exercise
• straight leg raises
• mini squats
• Swimming
• Walking
• A ride on the bicycle
• Using an Elliptical Machine

Hamstring strain

In addition to strengthening your quadriceps muscles, you should also strengthen your hamstring muscles. The muscles behind your hips or hamstrings allow you to stretch your legs back and bend your knees. These large muscles do not play a significant role in everyday activities such as walking, and most of them are used in strength exercises such as running, jumping and climbing. Therefore, hamstring injury is a significant source of plica inflammation. To strengthen your hamstring muscles, it is best to do the following exercises regularly:

• Bend your knee while standing: To maintain balance, stand up straight and grab the back of a chair or table with both hands. Stand on one leg, bend the knee of the other leg and hold for three seconds.
• Bend your knee with a resistance band: Tie a resistance band to the sole of your foot on one side and the other to your ankle. Lie on your stomach, bring your knees to your hips and hold for three to five seconds.

• Air squat
• Partner Hamstring Curls
• Deadlift with dumbbells on stiff legs

In most cases, these treatments relieve the symptoms of Plick syndrome and make patients feel better. But what if symptoms don't go away after two to three months?

Intra-articular injection of corticosteroids

This injection aims to reduce the pain and symptoms associated with this syndrome so that patients can participate in exercise therapy programs. Unfortunately, some patients rely solely on intra-articular corticosteroid injections and skip physical therapy. Even if symptoms improve after the injection, you should exercise because if you don't have strong quadriceps and hamstrings, your plica may become inflamed again. But physical therapists should tell you not to do anything that puts stress on your knee 24 to 48 hours after the injection. Otherwise, you may experience pain in your knee joints after the injection.

Additional Suggested Treatments

In addition to exercise therapy programs, your physical therapist may recommend additional effective treatments for Plick syndrome. For example:

• Massage or manipulation of the knee joint
• Tap your knee or wear a support brace
• Wearing orthoses
• Use herbal extracts to reduce inflammation
• Wear appropriate medical shoes

Surgery

Will I need surgery? Undoubtedly, this question is on the minds of many patients. As mentioned earlier, medial plate surgery is the latest option for improving this condition. Surgeons recommend surgery if none of the treatments or exercise programs resolve the plica inflammation and the patient's symptoms and pain do not worsen over time. You may be one of those people who are afraid of surgery, but you should know that Plica surgery, which is called arthroscopy, is a painless and simple operation. So what is arthroscopy? “During this operation, the surgeon inserts a fiber optic camera inside the knee joint to directly view the internal structure of the knee joint. This way, the doctor can see the inside of the knee and diagnose inflammation in the plica and treat it at the same time. This is an outpatient procedure, and your doctor will usually use sedation to keep you comfortable during the procedure. This means you can go home on the day of surgery. Arthroscopy is an innovative technology to identify the causes of knee pain, which has paved the way for treatment of knee problems.

Recovery after surgery

The recovery period after arthroscopic surgery varies from patient to patient depending on various factors. For example, the patient's anatomy and physiology, as well as the type of procedure performed during arthroscopy, are important factors. two to six weeks to fully recover During this time, you should rest and avoid activities such as exercise, shopping, or lifting heavy things. Your doctor will refer you to a physical therapist after surgery to help you strengthen your knee again. You start with gentle exercises that reduce pain and swelling, and gradually strengthen your quadriceps and hamstrings by doing more strenuous exercises. If you continue with this program, you can be sure that your knee pain will completely improve within 3-4 months.

Does Plica Syndrome Go Away?

This question may be a question for many patients. Do you know, why? People believe that knee problems will never heal and that treatments will not work. The opposite is true for plick syndrome, so even at home you can correct this knee problem. Research shows that about 60% of patients with plik syndrome recover successfully within 6-8 weeks with non-surgical treatment. These are promising statistics, so if your doctor diagnoses you with Plica syndrome, don't worry because it will be treated. In the continuation of this article, you are given all the necessary and basic methods of treating this syndrome.