Ask Dr. Geier – Plica Syndrome

I’m back!

Yes, after being away from the blog and social media almost completely for the last four weeks, I am excited to be back. I have always said that I really enjoy writing, communicating, and interacting about sports medicine, so my absence hasn’t been for lack of desire. I’ve been moving, which is never fun or easy. Plus, after writing 25 posts in 20 days in late March and early April, I honestly needed a break. But I have a huge number of topics and questions that have been building up, and I am eager to get them on the blog.

There are also, some exciting opportunities coming. As you might have seen, I am writing a regular column for the Charleston Battery site that will run in The Post and Courier as well. These posts will be similar to those written for the Family Circle Cup, which were widely read and shared. I have been writing for the STOP Sports Injuries blog, the Be Active Your Way blog, The Post and Courier, and Cover 2 Cover Magazine. If any readers out there are interested in sharing my posts with your local newspapers, magazines, or sports blogs, please touch base with me. I am asked frequently to write about specific topics, so I am sure that I can adapt content for almost any publication interested in sports injury topics.

Lastly, I want to thank a group you wouldn’t expect me to acknowledge – Philadelphia Phillies fans. In a two-day period my blog had over 500 unique visits from Philadelphia looking for information on flexor-pronator strains of the elbow. Why? Phillies pitcher Jose Contreras suffered that injury and was placed on the disabled list. Fans wanting more information on that uncommon injury searched for more information and found that the number one Google listing was my blog.

Why do I mention it? One of the reasons that I started the blog was to provide a forum to discuss injuries suffered by famous athletes. And it has worked all along, as the Famous Athletes category has provided a huge percentage of the incoming traffic to the blog. But I want to do more in this regard, so I want to encourage more sports fans to send questions or post more comments on famous athletes with injuries. I’m also thinking of using Twitter more in this regard. I encourage people who want to know more about an injured athlete to tweet the question and mention me (@drdavidgeier) or include a specific hashtag (#askdrgeier). There might even be more opportunities coming for these questions…

Now to this week’s Ask Dr. Geier column. It discusses a diagnosis that really had fallen out of favor in recent years but occasionally returns. As always, please refer to my disclaimer about me discussing specific medical information online or by email.

Thanks for sticking around!

David

Shawn in Plano, Texas asks:

What has been your experience with recovery after surgery to treat plica syndrome in terms of the patient getting back into playing shape? Especially in volleyball players?

There are two main points that I think are worth mentioning about plica syndrome to answer this question. First, surgery specifically to treat a painful plica is fairly unusual. It used to be done very frequently as a reason to perform arthroscopic surgery on the knees of athletic people, but sports medicine surgeons started to realize that these plicae were rarely the source of an athlete’s pain.

A plica is a band or fold of tissue within the knee. As embryos or fetuses, plicae of the knee are fairly common, and as humans age, they often go away. A significant percentage of people, however, do have plicae that remain within the knee. The problem is that the vast majority of people with plicae rarely have problems from them. Surgery to scope the knee and remove them would result in a huge number of unnecessary surgeries.

Often people with plicae that actually are symptomatic can still be treated without surgery. Rest, icing the knee, anti-inflammatory medications, and occasionally injection of small amounts of a steroid such as cortisone into the plica itself can relieve the symptoms. Occasionally athletes do not get better with these treatments. If the patient’s history, physical exam, and radiographic studies (such as an MRI) suggest the presence of a plica, particularly if it is swollen on the imaging, surgery can be attempted.

Fortunately, surgery to excise a painful or symptomatic plica, such as one that causes a clicking sensation on the inside of the knee, can be very successful. The surgery involves looking in the knee arthroscopically and using a shaver to remove this band of tissue. Usually it is a fairly quick recovery. The surgery takes 15 to 20 minutes, and the athlete is allowed to bear weight almost immediately. The first 10 to 14 days involve efforts to decrease swelling and regain range of motion and strength. Usually an athletic individual returns to exercise within days or one to two weeks. Usually return to full sports takes only three to six weeks, although full recovery often takes several months. The success rate for returning to sports at the same or higher level is usually very good, again assuming that the plica was the source of the pain.

Do you have any injury questions that I can discuss? Go to the Contact section and send me your questions!

40 Responses to Ask Dr. Geier – Plica Syndrome

  1. Doctor Geier,
    I have recently been diagnosed w/ a plica band injury after playing volleyball. I’m a marathon runner as well. My orthopedic dr. said that I can continue to run during rehab. I have read mixed things about this. Just curious what your thoughts would be.
    Thank you for your time.

    • I think there isn’t an absolutely correct answer. If a patient starts running early, he or she might get back to 100% running condition faster, but the risk is that the knee could swell, delaying full recovery. Running will not cause harm to the knee, per se, so I think it depends on the patient and symptoms.

  2. Dr. Geier,

    My son is a baseball player that had surgery in June 2012 to remove plica and two small bone spurs in his elbow, he started throwing in august as a freshman on his college baseball team, he has has had pain on and off throughout the season it tend to bother him as the throwing routine increases, we’ve been told he has some tendinitis and it seems to continue to flare up. what can we do to fully recover, he is now red shirting but i’m concerned that this is becoming chronic

    • I can’y say in his case without seeing him. But generally when young pitchers rehab from injury, we emphasize strengthening of not just the elbow, but also the shoulder, upper and lower back, core, and legs as well as work to correct mechanics flaws. Often problems in these areas lead to increased stress on the elbow.

  3. Dr. Geier,

    In 2007 I had surgery to remove a plica. I had multiple intense traumas to the knee in quick succession, and that night my knee had swelled tremendously and I couldn’t bend it past 90 degrees. The next few months consisted of physical therapy, steroid injections, and eventually surgery, which fixed the problem. However, when doing the surgery, the doctor found that the plica had actually gotten wedged in my knee joint, and eroded away some of the cartilage.

    It’s almost six years later, and I’m starting to get pain and popping in the same place, the front inner part of my right knee. I haven’t increased my exercise regimen any…it begins to hurt just from being on my feet for a few hours.

    Do you know if plica syndrome has a tendency to re-surface, or do you think it’s more likely that the new pain and popping sensations are related to the fact that my knee is missing some cartilage?

    • Lisa, I can’t say specifically in your case. I have not had issues with recurrence of plicae, but i rarely have found many patients to need surgical removal. The ones that were truly symptomatic did get relief with removal, and the plica did not return. Articular cartilage damage in the medial (inside) of the knee can present similar symptoms as well, so it can always be difficult to know exactly what the cause of pain, clicking, popping, etc. is for a patient.

  4. Hello Dr. Geier,

    I have had bilateral knee pain for 1.5 year which started with tightness around my knees with no apparent swelling or pain when i touch any part of my knee. The tightness started at a point where I was very inactive since i was stuyding for boards, i had no direct injury or anything. Now the tightness is still present, worse when im sitting. When i bend my knee to about 25 degrees or squat I get a sharp pain on the superior border of my patella. And there is a tender point in the femur on the patellar surface that i can only touch in bending my knee all the way. Thats the tender point or what i believe the cause of my pain. My knee also clicks/pops when I extend it only. The MRI is normal.

    I’ve been told that it might be suprapatellar plica, but i have read many unsuccesful plica surgery stories, not sure if i should have the surgery! do you think my symptoms are from plica?

    • I really cannot give you a specific answer to your question, as I haven’t seen you as a patient or examined you or seen any radiographic studies. Generally a plica can cause pain and a snapping sensation just medial (inside) the patella. Unfortunately there are many causes of medial and anterior knee pain.

  5. Dr. Geier,

    I was diagnosed with a patella tracking injury from a thickened plica on my left knee. I experience pain in the medial section of the knee (this has been a source of pain for over 1 year now, and I became more serious looking into it over time because it was really becoming uncomfortable).

    Initially my orthapedic thought nothing of the MRI. The MRI showed a contusion on the medial side. I went to a physical medicine doctor and he told me it’s likely the thickened plica is causing a traction injury, and the constant traction issue is causing that contusion.

    To take care of it he had me on an anti-inflammatory for 6 weeks to reduce the swelling in the knee. He also had me go to PT 2-3 times a week where I received electric ice/stim and ultrasound treatment and worked on a variety of exercises to strengthen my vastus medialis. The physical medicine doctor told me that strengthening the vastus medialis will help pull the patella back into a more appropriate anatomical position.

    The problem is, I’m off the anti-inflammatory medication now, I’ve advanced quite a bit in my strengthening of my vastus medialis, but it doesn’t seem to get much better. Initially, in the opening few weeks, it felt better, but at the 2-3 month mark of treatment, it’s plateaued.

    Normally I wouldn’t be too concerned, but I’m a 25 year old male in pretty good shape. I’m a physical education teacher and lead an active lifestyle. I also coach track in the Spring where I run with my students. I’ll have plenty of time off until then, but what should my next course of action be?

    My physical medicine doctor seemed hesitant to use a cortisone shot, but said it would be an option. Will a cortisone shot alleviate the pain? Because I’m still not comfortable in a lot of different exercises. And, when would I seek out advice on seeking an operation?

    The problem I come across with that, at least, is that my physical medicine/rehab doctor told me that most orthopedics don’t look at the plica as a source of pain. They often glance over it in the MRI and think nothing of it (which is what my orthopedic did). Would orthopedics even be willing to consider such an operation and would it be worth it for someone physically active like myself?

    • Adam, thanks for the question. I cannot answer it specifically in your case, as I explain in the post. Generally I haven’t found many patients to have plicae that are actually the cause of their symptoms. If one is, then trying a cortisone shot directly into the plica or arthroscopic excision of the plica might be reasonable options. I probably have performed only two or three arthroscopies and plica excisions in my career, as nonoperative treatment of the patient’s pain or other symptoms usually alleviates it (and shows that the plica wasn’t the problem). The ones I have had to debride were usually very swollen and thickened and actually were causing a very painful snapping with knee motion. Other sports medicine surgeons might disagree, but I don’t know many that perform isolated plica excisions often.

  6. I had a partial medial Meniscectomy in Dec 2012 and the medial plica was removed as it was inflamed and interfering with the knee. We are over 4 months post op the meniscus part is fine, but the plica still gives me pain when swim, bike, or walk. Had another MRI and there is a small amount of scar tissue that grew in place of the plica. Anyway my doctor tome me no exercise for 2 months and no PT (never completed PT anyway he told me to stop) He said it hasnt benn given time to heal because I bike, walk, and do elliptical. I am at my whits end here. Maybe I should go to another doctor.

    • Paul, I really cannot give you a specific answer to your question, as I am not involved in your care. Usually removal of a plica isn’t a problem from a pain standpoint, but I have seen people swell more after surgery. The amount of meniscus removed and status of the articular cartilage often play a role in time to return to full activities as well. It is important for patients to get rid of all swelling and get full motion and strength back as quickly as they can, but that can take time and work with a physical therapist.

  7. Hello, I just had a plica excision due to medial & anterior knee pain x yrs. worsening on flexion & extension. I didn’t have an injury before surgery.I’m three weeks out of arthroscopy and since surgery I have had bruising in the lateral & lateral posterior knee with a snapping sensation when bending knee. It is very painfull. What could this be.Thanks!

    • I can’t say specifically in your case, since I didn’t perform the surgery. Generally a patient’s knee is swollen for weeks after surgery. That extra fluid can cause the patella to track differently and cause a popping or snapping sensation. Plus the quad weakness can add to that issue. Generally as patients get more motion and strength, their complaints resolve.

  8. Can an inflamed plica cause pain on the outside of the knee? The inside of my knee has never hurt but during my exam the Dr. pushed on it and it was tender. He said that it was plica syndrome and when inflamed it was causing the pain on the outside of my knee. I have tried researching more about Plica Syndrome and have never seen anything about lateral knee pain, so it made me curious. He said my MRI looked amazing. Even after resting for 2 months and doing several stretches/strengthening exercises, my lateral knee pain still returns after I walk about a mile and a half or run about a half mile. If I stop immediately it doesn’t bother me, but will return every time I walk or run.

    • I can’t say in your case specifically, but I don’t think I’ve seen a plica cause lateral pain personally.

  9. I have had discomfort in my right elbow for about a year and a half now. It started pretty much as soon as I graduated college and started working full time. I am fairly certain that the discomfort and pain has to do with the long hours I spend at the computer. I have tried countless remedies including oral steroids, cortizone injections, over the counter pain meds, physical therapy, tens unit, massage, etc. and nothing works.
    Among my most prevelant symptoms is that I feel the urge to “pop” my elbow many many times a day. When I straighten out my elbow I feel a small popping sensation almost like some tissue is gliding in and out of the joint. Popping my elbow only provides temporary relief and then it goes back to bothering me almost instantaneously.
    I have been diagnosed by my orthapedist as having a plica in my elbow and am scheduled to get the plica removed via a synovectamy of the elbow in december.
    Have you encountered any patients with similar symptoms before? Is this characteristic of an elbow plica? Any thoughts on the surgery, recovery time, likelihood that my discomfort will be cured?

    • As a side note I’ve tried taking a week off from work to rest the elbow and I’ve also tried splinting the elbow to keep it straight while I sleep. Neither worked.

    • I’ve had patients with painful popping of the elbow. Most of them did well with nonoperative measures, like short-term activity modification and physical therapy.

  10. Hi just wondering if I would be able to play football again I had plica surgery around 7 weeks ago and I was hoping to get back in to soccer please advise how long I should wait before playing again

    • I can’t say specifically in your case. Generally the goal is to get athletes back to sports. Plica removal surgery usually requires 4-12 weeks for return, in my experience.

  11. Ive done knee plica removal on 22/8/13, about two months ago. Ive suffered pain, swelling and clicking sound for the past 1.5 years. Is it normal for it to click now even after surgery? I still have minor pain but alot of clickings I would say.

    On the other note, during my arthroscopy, my surgeons found whitish tissue in my synovium which diagnosed as early stage synovial chondromatosis. I was told to be on constant glucosamine & omega 3 supplements as prevention of it flaring up. No other cure or treatment to it. As I understand, there should not be pain from this unless my knee gets inflammed again, which can be years yo come.

    My concern is, if clicking is normal during the recovery time of my arthoscope…if it is, will it still persist?

    • I can’t say specifically in your case. If a knee is still swollen, the patella might track slightly abnormally and cause some clicking that eventually goes away. That is probably a question better directed to you orthopaedic surgeon.

  12. I’m having surgery to remove a plica in my knee, but i also have a partially torn lateral meniscus that my doctor said he isn’t going to do anything about. I’m a basketball player and I just want to do what’s best to get back on the court. What should I do?

    • Garrett, I can’t really say without being involved in your care. You might consider asking him about the meniscus tear and the risks and benefits of leaving a tear alone.

  13. Dr,
    I went to four doctors and was diagnosed with osteoarthritis of the patella. A fifth doctor said he thinks the source of the pain is my plica. My understanding you can only determine this by athroscopy. I also had an MRI. Is it possible the plica is the problem or is it the arthritis causing the pain? I am researching this extensively before going through surgery. I am not meeting with the doctor for one month since he is so booked up. The pain only prevents running otherwise I can run, ski, bike, swim etc. day after day pain free.

    • Unfortunately only the surgeon examining you or looking at your studies can give you an idea of the source of the pain in your case.

  14. I appreciate this site! Thank you, it is a great resource. I recently had plica surgery on both knees. I am confident I needed it on at least my left, but had similar problems starting with the right and didn’t want the same thing to occur. I had both medial plicae excised arthroscopically within a month, the surgeon said they looked identical during surgery. The first one was worse and still hurts a lot at certain times (similar localized sharp pain.) I find that a day or two following exercise (3 hours downhill skiing or just 15 min. on elliptical) I have sometimes excruciating pain (but little swelling), so have been resisting more frequent exercise. I also have a lot of pain with 90 degree wall-sits but can do 45 degrees for as long as I want. Squats are very painful. I do PT 3x/week. I was very fit prior to plica problems about a year ago. My Dr. feels the pain is normal as it’s only been 4 months and recovery can take 6(?) Does this seem correct? I realize it’s hard to recommend without seeing me, but I remove all of your responsibility for any advice – would you tend to favor an aggressive rebound strategy despite the pain or do you feel like that could potentially make things worse? Many thanks!

    • Plica surgeries can be more difficult in terms of recovery than patients think. Generally working aggressively to regain motion, strength, and function with a physical therapist can get patients back to prior levels. Since I am not involved with you, it is hard to say if aggressive rehab is what you need. Hope it gets better!

  15. I just had a medial plica removed from my righz knee this morning. I have had a meniscal tear in my left knee about 2 years ago. I was able to bear full weight on it just hours after surgery. Now today with my plica removal I am in a lot more pain anf unable to put full weight on my leg. Is this any cause for concern?

    • I can’t say specifically in your case, but plica surgeries can be painful and have swelling, even more than people expect.

  16. I had plica removal surgery just over a year ago and still have pain. My range of motion is good, but the knee feels very tight and I have pain above a below the knee that just won’t go away. The post op MRI showed inflammation and scar tissue that don’t seem to be going away. I haven’t been able to run and cut back and forth because of the pain and the knee doesn’t feel stable.
    Any advice would be greatly appreciated.

    • You probably would be better off asking you orthopaedic surgeon. Often, though, a surgeon can arthroscopically clean out scar tissue to help with pain and range of motion. Your surgeon can direct you to treatments appropriate in your specific case.

  17. I had a synovectomy and plica removal of my left knee this past January for medial pain. Cortisone injections only gave very temporary relief. Post surgery rehab has been difficult. An MRI reveals inflammation. Keeping the knee flexed for 5 plus minutes results in pain upon extension of the knee and takes about 1 to 2 minutes before the knee is fully functioning. A big problem is a “clunking” sound and noticeable movement between the upper and lower leg when I flex the knee – walking, exercising, or on my back simply flexing the knee. I can hear the clunk and see the clunk of the lower leg slightly moving either out or in alignment of the upper leg – not sure what direction. Walking is not a problem after a couple of minutes. Any activity that requires impact and/or movement makes my knee feel slightly unstable.

  18. Hi Doc
    I had my medial plica surgery, done 3 weeks ago.
    My leg is stll very stiff and painful, I cannot bend down, going up and down stairs is very painful.
    I don’t have full range of motion. I have been doing the exercises at home and pysio 2x a week.
    I am limping with slight pain, tightness and swelling.
    Is all this normal in the healing process?

    I’m very stressed about this, when I speak to my OS about this, his answer is that he does not know.
    Please help with any advise on healing.

    Kind Regards
    Lee

    • Plica surgery can be harder than most patients think to overcome. Often there is quite a bit of stiffness and swelling. You are correct that you’re orthopaedic surgeon can give you more specific advice than I can, unfortunately.

  19. Hi doctor

    I have a bit of a medical mystery. I get intermittent swelling in my left knee and have been since the age of 10. There is not that much pain mostly swelling. I have had the whole rheum work up and have seen many rheumatologist and it is always negative. Once the swelling starts nothing can get it under control unless I get a synovectomy. I have had three thus far. Pathology on synovial tissue is always non specific. The rest of the knee is completely healthy.

    I know from my own experience that it is something bio mechanical that is causing irritation and causing the synovitis. As every time it’s swelled something has changed I.e getting new pair of orthotics. My orthopaedic surgeon does not know what to think and has never seen anything like this. This past time however he removed a large plica. He also realized that the past surgery he missed it has we saw it on an old MRI. Is it possible that the plica could be causing the synovitis?

    • I have seen a plica cause localized pain, irritation, swelling and snapping, although I have never seen one cause generalized swelling or synovitis. Having said that, I can’t really tell what could be going on in your case without examining you and looking at your studies. I hope it goes well!

  20. Dr. Geier,

    I have been diagnosed with likely Plica syndrome bilaterally. My symptoms seem to fit clinically. I was playing sports with my nephews (I am 43 and not in shape for what I did- soccer, basketball, batting cages). I have begun physical therapy for my symptoms this week. You have said most people get good results with conservative treatment without surgery. How long (on average) does it take to typically see a response from PT.

    Thanks so much for your time.

    Brian

    • Every patient is different, and it is often difficult to tell if the place is a patient’s clear source for pain. Having said that, I usually see pain resolve over 4-6 weeks, although it can take longer,

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