Journal of Orthopaedic Surgery 2011;19(3):354-8

Review article:
Plica syndrome of the knee
Nawfal Al-Hadithy,1 Panagiotis Gikas,2 Anant M Mahapatra,3 George Dowd3
1
Chase Farm Hospital, The Ridgeway, Enfield, Middlesex, EN2 8JL, United Kingdom
2
Barnet Hospital, Wellhouse Lane, Barts, Herts, EN5 3DJ, United Kingdom
3
Royal Free Hospital, 10 Pond Street, Belsize Park, London NW3 2PS, United Kingdom

formation of plicae. In the more popular theory, plicae

ABSTRACT
Plica syndrome is a pathological condition secondary
to inflammation. Plicae around the knee are common
and generally asymptomatic. They often are
misdiagnosed. The morphology of knee plicae varies;
mediopatellar plicae are the most common cause of
the plicae syndrome. An intermittent dull pain is
the most common symptom. Diagnosis is made by
exclusion. Ultrasonography is useful; arthroscopy is
the gold standard. Arthroscopic removal of the plica
may be necessary when conservative treatment for
up to 6 months fails.
Key words: disease management; patellofemoral pain
syndrome; ultrasonography
are the embryological remnants of the membranes
that separate the compartments. Synovial membranes
divide the knee into 3 separate compartments (medial,
lateral, and suprapatellar) during embryological
development. After the 16th week of gestation, these
synovial membranes resorb, forming a single cavity;
remnants of these membranes are believed to form
plicae.1,2 In the other theory, at approximately the
7th week of gestation, the space between the distal
femur and proximal tibial epiphysis is filled with
mesenchymal tissue. Cavitations develop in this tissue
as time proceeds. By week 10, the knee consists of a
single cavity lined by synovial tissue. It is proposed
that incomplete resorption of mesenchymal tissue
and failure of cavitation lead to plica formation.2,3
CLASSIFICATION

EPIDEMIOLOGY Synovial knee plicae have 4 types of morphology:

infrapatellar, mediopatellar, suprapatellar, and
There are 2 theories regarding the embryological lateral.4 The most common is the suprapatellar plica
development of the knee and the subsequent (also known as the plica synovialis suprapatellaris),

Address correspondence and reprint requests to: Mr Nawfal Al-Hadithy, Chase Farm Hospital, The Ridgeway, Enfield, Middlesex,
EN2 8JL, United Kingdom. E-mail: Nawfal@yahoo.com
Vol. 19 No. 3, December 2011 Plica syndrome of the knee 355

which is responsible for division of the suprapatellar PATHOLOGY

pouch from the knee. This plica has varying shapes,
either a complete tissue plane or as a porta. It Patients with plica syndrome differ from the
originates from either the posterior quadriceps asymptomatic population. In predisposed patients
tendon or the anterior femoral metaphysis, and with structurally abnormal plicae, symptoms were
passes to the medial side of the knee joint. In some
cases, it may be the cause of suprapatellar bursitis
and chondromalacia.5
The infrapatellar plica (also known as the
ligamentum mucosum) is usually a bell- shaped
synovial fold and originates from the intercondylar
notch in the region of the anterior cruciate ligament
and widens into the anterior joint space and attaches
onto the synovial lining of the infrapatellar fat pad.
According to its appearance, it is classified into 5
types: separate, split, vertical septum, fenestrated,
or none of the above.6 It is the most common plica
visualised during knee arthroscopy, where it
represents an impediment to gaining full views of the
joint interior.
The mediopatellar plica is the most common one
attributed to the development of the plica syndrome.
This plica is found in the coronal plane; it originates in
the suprapatellar region and passes inferiorly on the
medial aspect of the knee joint before inserting into the
infrapatellar (Hoffa) fat pad. Based on its appearance,
it is classified as type A (cord-like), type B (shelf-like,
but not covering the medial femoral condyle), type
C (covering the medial femoral condyle), and type D
(having a double insertion).7 Figure 1 Magnetic resonance image of the right knee
showing advanced patellofemoral arthropathy affecting
The lateral synovial plica is described as a the patellar articular surface with full thickness chondral
band running distally along the lateral parapatellar abnormalities.
synovium to the lateral patellar facet. Whether this
is a true septal remnant remains controversial, as it
seems more likely to be derived from the parapatellar
adipose synovial fringe.

PREVALENCE

The prevalence of plica syndrome varies, ranging

from 11 to 87% for suprapatellar plicae and 18 to
60% for mediopatellar plicae. The most commonly
reported range is 20 to 25% of the population.
Infrapatellar plicae may be present in around 65% of
patients.8 Lateral plicae and their rates are not well
known, with most of the studies from Japan9; its
range is around 1 to 2%. In an arthroscopic study of
400 knees,10 the rates are 87% for suprapatellar plica,
86% for infrapatellar plica, 72% for mediopatellar
plica, and 1.3% for lateral patellar plica. Symptomatic
plicae usually present in active patients undertaking
repetitive knee movements. Females appear to have a Figure 2 Arthroscopic excision of the plica through a
higher frequency of this condition.11 superomedial portal.
356 N Al-Hadithy et al. Journal of Orthopaedic Surgery

triggered by some stimulating events. The normal
appearance of plicae is of a thin, soft, flexible,
vascularised structure covered in synovium.
In pathological specimens, the plica appears
hypertrophied with elasticity loss, calcification,
hyalinisation, and fibrosis.12–14
Development of symptomatic plicae is associated
with an inflammatory process secondary to acute
trauma, repetitive stress injury, meniscal tears or loose
bodies, or osteochondritis dissecans. Inflammation
may be related to anatomic change within the knee
and the plica itself (as the plica becomes bowstringed
on the medial femoral condyle).15 This results
in abrasion on the condyle during knee flexion.
Inflammation can also result in oedema and damage
to tissue integrity and eventually lead to friable plicae
that damage nearby structures (femoral condyles)
and go on to cause condromalacia or secondary
synovitis.16,17 A less complicated cause may be natural
loss of elasticity in increasing age.
Occasionally the plica may be torn, ranging from
a partial tear to a bucket-handle or complete tear.
Torn plicae are usually secondary to direct trauma
or twisting. They can be found in the patellofemoral
joint during arthroscopy.18,19
SYMPTOMS AND DIAGNOSIS
Symptomatic plicae may cause considerable dull pain
in the anteromedial aspect of the knee; the pain may
be intermittent or aggravated by physical activity,

Plica syndrome of the knee:

Pain anteromedially
Pain worse on kneeling/crouching
Clicking/catching/intermittent locking

Normal radiographs/haematology/biochemistry

Yes No

Diagnosis confirmed Consider alternative diagnosis

Ultrasonography/magnetic resonance imaging

Normal
Normal

Consider arthroscopy

Diagnosis confirmed
Analgesia:
Non-steroidal anti-inflammatory drugs
Proton pump inhibitor

Trial of physiotherapy with/

without cryotherapy and anti- Torn plica
inflammatory drugs

Persisting
symptoms

Consider arthroscopic resection

Early arthroscopic debridement/resection of torn plica

Figure 3 Algorithm for diagnosis and management of plica syndrome

Vol. 19 No. 3, December 2011 Plica syndrome of the knee 357

and can be associated with locking, giving way, and
clicking within the joint.20 These symptoms are not
usually associated with knee effusions or swelling.21
In cases of torn plicae, locking and reduced knee
flexion are the common complaints.
There may be localised tenderness at the medial
and inferior patellar border, and on palpation rarely
a tender membrane may be discerned as a cord-like
structure. The patella itself is not unstable, but a false-
positive patellar apprehension test may be elicited,
owing to localised pain. A diagnostic test known
as ‘taut articular band reproduces pain’ entails
palpation of the medial peripatellar region to feel
the thickened plical band. The mediopaterllar plicae
test entails forced flexion of the knee to 90º while
maintaining a manual force to the inferomedial part
of the patellofemoral joint.22 The test is positive when
pain occurs in extension but is relieved at 90º flexion.
The test had 90% sensitivity and 89% specificity in
172 knees.22
Haematological and biochemical investigations
are invariably normal. Abnormal results should
lead to consideration of an alternative diagnosis.
Radiographs of the knee do not demonstrate plicae,
but are helpful in excluding other pathology.
Dynamic ultrasonography is highly effective
at detecting abnormalities of medial plicae in the
knee, and have good sensitivity (90%) and specificity
(83%).23 As a staging tool, magnetic resonance imaging
also has good sensitivity (95%) and specificity (72%),
depending on how far the plicae extending onto the
medial facet (Fig. 1).24 Contrast arthrography and
pneumoarthrography are of little use.25 Arthroscopy
of the joint for visualisation and treatment remains
the gold standard (Fig. 2).26
The diagnosis of the plica syndrome is made by
exclusion of clinical and radiological findings (Fig.
3). Its validity is often debated by those who do not
believe plicae to be of any relevance.
TREATMENT
Initial treatment for the plica syndrome involves pain
relief and anti-inflammatory drugs, combined with
limitation of the aggravating activities. Conservative
therapies include stretching of the quadriceps,
hamstrings, and gastrocnemius in combination with
cryotherapy and anti-inflammatory agents.27,28 Up to
60% of patients attain resolution of symptoms after
one year of conservative therapy, whereas 40% have
no benefit and eventually undergo surgery.28 Another
pharmacological intervention entails intraplical
steroid injection, after which 73% of 30 patients
achieved complete relief.29
Surgical intervention may be considered when
conservative therapy fails for at least 6 months.
Arthroscopic removal of the symptomatic plica
(usually the medial plica) through the superolateral
or direct medial portal is usually successful.25 Up to
34% of patients can expect to be pain-free following
this procedure, whereas 65% were able to resume
sporting activities.30
In cases of torn plicae, arthroscopic resection is
particularly effective. In 2 cases of a bucket-handle
tear following twisting injuries,31 symptoms resolved
completely after arthroscopic debridement. Resection
remains the only treatment for torn plicae.19,20

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