plica syndrome - sports podiatry
Plica is a term used to describe a fold in the lining of the knee joint. Imagine the inner lining of the knee joint as nothing more than a sleeve of tissue. This sleeve of tissue is made up of synovial tissue, a thin, slippery material that lines all joints. The synovial sleeve of tissue has folds of material that allow movement of the bones of the joint without restriction.
Four plica synovial folds are found in the knee, but only one seems to cause trouble. This structure is called the medial plica. The medial plica attaches to the lower end of the knee cap and runs sideways to attach to the lower end of the thighbone at the side of the knee joint closest to the other knee.
Plica syndrome causes and symptoms
The plica only becomes a problem when the knee is irritated, causing an inflammation in the synovial sac. This is called plica syndrome. When the synovium is inflamed, the area of the medial plica becomes thicker. This thickened area then begins to catch on the femur as the knee moves. This in turn keeps the medial plica inflamed resulting in continued injury.
Over time the medial plica can be irritated by certain exercises, repetitive motions, or kneeling. Activities that repeatedly bend and straighten the knee, such as running, biking, or use of a stair-climbing machine, can irritate the medial plica and cause plica syndrome.
The primary symptom of plica syndrome is pain. There may also be a snapping sensation along the inside of the knee, as the knee is bent, due to the rubbing of the thickened medial plica over the edge of the thighbone. If the plica has become severely irritated, the knee may become swollen. Pain from plica syndrome usually occurs when the knee is straightened from a flexed or bent position to a straight position.
Plica Syndrome - treatment in the acute phase
If traumatic injury of the knee occurs immediate medical attention should be sought.
P - R - I - C - E
Protection - Your knee may be splinted, taped or braced to prevent medial plica injury. | |
Rest - You should rest from all activities that cause plica syndrome symptoms. Use crutches/cane until you can walk without pain or limping. | |
 | Ice - Place a plastic bag with ice on the knee for 15-20 minutes, 3-5 times a day for the first 24-72 hours. Leave the ice off at least 1 1/2 hours between applications. Concentrate the ice pack over the site of the medial plica. |
| Compression - Wrap an elastic bandage around the knee using even pressure. Wear this until swelling decreases. Loosen the wrap if your toes start to turn blue or feel cold. |
Elevate - Make sure to elevate the knee above heart level | |
plica syndrome restoring normal function
Exercises should not hurt, if they do stop!
Here are some exercises to help your plica syndrome recover Although plica usually only affects one knee it is beneficial to do exercises for both knees. After you do all the exercises as shown in the drawings, reverse your position, and do the exercises with your other leg, so both knees get the benefit of stretching.
plica syndrome stretches
Even though it is your knee that's is giving you problems muscles around the knee can be the cause of your plica syndrome symptoms. Muscle stretching greatly reduces medial plica stress.
Technique: | Hold each exercise 30seconds at a gentle stretch. Do not bounce! |
Frequency: | 6-10 repetitions/exercise, 5-7 days per week |
Iliotibial band and buttock stretch (right side shown)
Position yourself as shown above. Twist your trunk to the right and use your left arm to "push" your right leg. You should feel the stretch in your right buttock and the outer part of your right thigh. Hold the stretch for 30 seconds. Repeat on the other side. If plica syndrome symptoms worsen, stop!
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Technique: | Hold each exercise 20 seconds at a gentle stretch. Do not bounce! |
| Frequency: | 6-10 repetitions/exercise, 5-7 days per week |
Iliotibial band stretch (left side shown). Position yourself as shown above, with your right leg crossed in front of your left leg. Hold your hands together and move them toward the floor. You should feel a stretch in the outer part of your left thigh. Hold the stretch for 30 seconds. Relax then repeat on the other side. If these exercises irritate the medial plica stop!
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Technique: | Hold each exercise 20seconds at a gentle stretch. Do not bounce! |
Frequency: | 6-10 repetitions/exercise, 5-7 days per week |
Hamstring stretch Rest the leg to be stretched on a supporting surface while keeping the knee from bending. Lean forward toward your toes by bending at the waist and keeping your back straight. You should feel the stretch but it should not hurt. If plica syndrome symptoms worsen, stop! |
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Technique: | Hold each exercise 30 seconds at a gentle stretch. Do not bounce! |
Frequency: | 6-10 repetitions/exercise, 5-7 days per week |
Calf stretch
Foot alignment should be shoulder width apart, you can confirm this by standing either side of a straight line on the floor. When you take your rear foot back, it should not cross or move away from the midline, your foot should be pointing forward with your heel either flat on the floor, or raised if aiming to develop the stretch.
Your front leg should bend so that when you look down over your knee, you can see the tip of your toes. Lean forward aiming to keep a straight line with your heel, hip and head. If your medial plica is hurting when doing this exercise, stop! |
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plica syndrome strengthening
Technique: | Hold each exercise 30 seconds at a gentle stretch. |
Frequency: | 2-3 repetitions/exercise, 5-7 days per week |
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Quadriceps strengthening: straight leg
Position yourself as shown above. Hold your right leg straight for 30 seconds and then relax. If this makes your plica syndrome symptoms worse, stop!
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Technique: | Hold each exercise 5-10 seconds at a gentle stretch. |
Frequency: | 6-10 repetitions/exercise, 5-7 days per week |
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Quadriceps strengthening: straight leg lift. Position yourself as shown above. Raise your right leg several inches, and hold it up for 5 to 10 seconds. Then lower your leg to the floor slowly over a few seconds. Then repeat the exercise. Causing medial plica pain to become worse? Stop!
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Technique: | Hold each exercise 5-10 seconds. |
Frequency: | 5-10 repetitions/exercise, 5-7 days per week |
Hip adductor strengthening
While sitting, squeeze a rubber ball between your knees. Hold the squeeze for 5 to 10 seconds. (If you don't have a ball, put your hands or fists between your knees and then squeeze.) If your plica syndrome symptoms become worse, stop! |
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Technique: | Hold each exercise for 5-10 seconds |
Frequency: | 10 repetitions/exercise, 5-7 days per week |
Hip abductor strengthening(left side shown, front and side views)
Position yourself as shown above, standing on your left leg with the knee slightly bent. Slowly raise your right foot about 30 degrees, hold for a few seconds, and then slowly lower the foot and straighten both legs. Don't let your pelvis tilt (be crooked), and don't let your knees turn inward during bending. Plica syndrome symptoms made worse? Stop! |
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Repeat the exercises below several times with each leg on a daily basis. Over several weeks, increase the resistance by adding ankle weights or by looping purse straps or the handle of a weighted pail over your ankle. Start with one or two pounds, adding one-half pound at a time as you build strength.
WARNING. Only do these strengthening exercises when the medial plica has settled down completely. These should not be carried out if the symptoms of plica syndrome are still evident.
Bent-Leg Raises
This strengthens the inner thigh muscle to balance the pull on the knee joint from the outer thigh, which is often stronger.
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Straight-Leg Raises
This strengthens the thigh muscles to help support the knee joint.
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Preventing plica syndrome
Remember that most plica syndrome problems happen at the contact phase of gait (when the foot hits the ground) due to increased biomechanical stress at this point.
Golden rule- Don't ignore the problem, it won't go away!
The way we function biomechanically is predominantly controlled by genetics, its hereditary (runs in the family). The way you function is set and cannot be cured. What you can do however is control lower limb biomechanics by altering foot position during the contact phase of gait. This can be achieved by wearing a good shoe (see our shoe guide) with orthotics (foot beds), knee strengthening and knee support.
1. Check your footwear
Are your running shoes worn and in need of replacing? If so change them. The chances of medial plica injury is greatly increased with higher impact forces so a good shock absorbing shoe is a must. For more advice on running trainers our running shoe advice page is worth reading. Read more->
Below are a selection of trainers that are ideal for athletes.
Trainers for a neutral or under pronating foot type
Trainers for over pronators
rectify Poor biomechanics with orthotics
The way your foot strikes the ground and the forces that are placed on it can have a direct effect on causing plica syndrome and can also delaying healing times. Check our biomechanics page for detailed information. Read more->
Knee strengthening
The single best exercise to improve the strength of the muscles around the knee is eccentric loading. This is usually done none weight bearing, however the use of a wobbleboard is an excellent way to strengthen muscles around the knee, foot and ankle in a controlled gentle manner. Whilst our clinicians have found it a brilliant way to strengthen muscles around the knee, traditionally a wobbleboard was used to help balance (proprioception). Proprioception is the nerve connection from the brain to the foot. This is often damaged/ disrupted after injury and can increase the chances of injury from recurring. It can also significantly delay recovery.
Use of a wobbleboard therefore has a dual benefit in the treatment of plica syndrome.
Knee support
Consider purchasing a knee brace . This device provides extra stability to the knee when playing sports. The material also causes localised vasodilation (opening of the blood vessels) increasing circulation to the area. This is vital as all ligaments have a notoriously poor blood supply. Increasing circulation to the ligaments can reduce the chance of injury. Stabilising the knee also reduces the mechanical stresses that can irritate the medial plica.
Plica syndrome prevention checklist summary
plica syndrome returning to sporting activity
The goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen your plica syndrome injury, which could lead to permanent damage. Everyone recovers from plica syndrome at a different rate. Return to your activity is determined by how soon your medial plica recovers, not by how many days or weeks it has been since your injury occurred.
You may safely return to your sport or activity when, starting from the top of the list and progressing to the end, each of the following is true:
You have full range of motion in the injured leg compared to the uninjured leg.
You have full strength of the injured leg compared to the uninjured leg.
You can jog straight ahead without medial plica pain.
You can sprint straight ahead without plica syndrome symptoms.
You can do 45-degree cuts, first at half-speed, then at full-speed.
You can do 20-yard figures-of-eight, first at half-speed, then at full-speed.
You can do 90-degree cuts, first at half-speed, then at full-speed.
You can do 10-yard figures-of-eight, first at half-speed, then at full-speed.
You can jump on both legs without medial plica pain and you can jump on the injured leg without pain.
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