Intraarticular injection of 1% Lidocaine

Intraarticular injection of 1% Lidocaine
It is recommended to obtain a standing AP, lateral, and 45° patellar sunrise (axial) radiographs of the knee to rule out other sources of pathology. While many patients who have an irritated medial synovial plica have normal radiographs, it is important to rule out that the patients do not have any underlying arthritis, areas of osteochondritis desiccans, osteophyte formation, fractures, or other bony pathology which could be contributing to the irritation of the medial synovial plica.

In addition, diagnosis of medial plica irritation on MRI scans is non-specific . The physical exam should be able to demonstrate any significant thickening and fibrosis of a medial synovial plica. MRI’s are more useful in determining if there are other pathologies contributing to medial synovial plica irritation rather than in directly diagnosing pathology in this portion of the knee.

Treatment of medial plica irritation
The main treatment regimen for medial plica irritation is non-operative. For patients who have medial plica irritation as their main diagnosis without any underlying knee pathology contributing to their plica irritation, there is a very good chance that their symptoms will improve with a guided rehabilitation program . The most successful rehabilitation programs focus on strengthening the quadriceps muscles, which are directly attached to the medial plica, and avoiding activities which cause medial plica irritation . These exercises can include quadriceps sets , straight leg raises , leg presses , and mini-squats, as well as, a walking program, the use of a recumbent or stationary bicycle , a swimming program, or possibly an elliptical machine. Patients should work on gradually increasing strength over time to overcome any strength deficit in their quadriceps mechanism. Concurrent with this, patients should also work on a frequent hamstring stretching program throughout the day . As mentioned previously, tight hamstrings can increase the force needed to extend the knee, which can be an important source of medial plica irritation. Thus, it is important to make sure that the hamstrings are stretched frequently to diminish this extra stress on the anterior part of the knee.
Most patients can utilize either a self-directed or a physical therapy guided exercise program for the first 6–8 weeks after they have been examined. In the majority of circumstances, this program will alleviate the patient’s symptoms and the patient can often follow-up with their physician on an as needed basis if symptoms persist after this rehabilitation program. In this therapy regimen, patients participate in quadriceps strengthening exercises including a walking program, the use of a recumbent or stationary bicycle, a swimming program, or utilizing an elliptical machine. It is especially important to make sure that patients avoid knee extension exercises , because open chain exercises can cause plica irritation and limit patient’s improvements with an exercise regimen.


Concurrent with a good quadriceps strengthening program, it is also important to make sure that patients work on a frequent hamstring stretching program . They should work on stretching their hamstrings several times a day and not just once daily. As mentioned previously, tight hamstrings place extra stress on the anterior aspect of the knee when the patient tries to extend their knee and this is a frequent cause of medial plica irritation. Thus, it is important to make sure that patients do stretch their hamstrings concurrently with strengthening their quadriceps to maximize the benefit from an exercise program.


Hamstring stretching
In cases where patients are not getting better with a physical therapy program, or in those patients who have such an irritated plica that a therapy program may not be beneficial directly, consideration for an intraarticular corticosteroid injection is necessary. In candidates for an intraarticular steroid injection, we perform the injection to attempt to quiet down their knee symptoms such that they can participate in an exercise program to address their medial plica irritation. It is not sufficient solely to rely on the injection to quiet down ones knee because the underlying problem of a weak quadriceps mechanism and tight hamstring muscles may persist after the injection and result in a recurrence of the medial plica irritation after the beneficial effects of the injection wear off. Thus, it is very important to make sure that the patients do participate in an exercise program, even if they have complete relief of their symptoms, after an intraarticular steroid injection to treat medial plica irritation. It is usually necessary to have the patients refrain from exercising or placing any significant stress to their knee for the first 24–48 h after their steroid injection because the knee may have more post-injection soreness. In addition, it is important to document with the patients whether or not they had good pain relief while the local anesthetic portion of the injection was working to verify that they do have an intraarticular knee cause of their knee pain.

It is rare that patients need arthroscopic surgery to treat isolated medial plica pathology, because the medial plica is a part of the joint lining and resection of it will result in the joint lining growing back. Since the body heals back this type of resection with scar, the tissue may heal back with painful scar and the patient may have more symptoms. Since the treatment of a painful plica after an arthroscopic resection can often cause patients to have more pain than they did prior to the arthroscopic resection, it is important to make sure that a patient has pathology of this area which is not responsive to an exercise program, and possibly injections, prior to consideration of resection of this tissue . It is important to recognize that surgery for an irritated plica is uncommon, and historically it comprised only 2–5% of all arthroscopic surgery at a time when magnetic resonance imaging scans were not commonly used and more surgeries were performed for diagnostic reasons . We have found that arthroscopic resections of irritated plicas are rarely performed today. The usual instances where one may have some benefit from resection of a medial synovial plica may be where the plica is acting as a shelf which is catching over the medial femoral condyle and causing some erosion of the articular cartilage in this area. In these circumstances, patients may have good pain relief and decreased catching sensations in their knee after an arthroscopic resection of their medial plica. In this instance, it is usually not recommended to divide the pathologic plica and resect it totally because the pathologic plica may grow back and the patient may have recurrence of their symptoms . It has also been noted that the results of arthroscopic plica excision are more successful in adolescents than in older patients
Indirect treatment of the medial plica irritation may also be very beneficial to patients. In these instances, the pathology is deep within the knee. Treatment of localized areas of arthritis, meniscal tears, or other knee pathologies, may decrease the pain and swelling of the knee which resulted in secondary irritation of the medial plica. In these instances, it may be beneficial for the patient to undergo surgery to treat the secondary cause of plica irritation. In these circumstances, it is not recommended to resect the medial synovial plica, because there is a very good chance that it will get better with an exercise program after surgery and patients may not have pain relief of their plica irritation if it is resected arthroscopically.