Medial Plica Syndrome in Pregnant Female

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    • #3402
      Laura Thornton
      Moderator

      I’d love to get everyone’s feedback on this new patient of mine. Mike’s presentation on comparing signs and symptoms of plica vs. meniscus involvement was really helpful in this case.

      Referring Dx: Patellofemoral pain
      34 yo female, 1.5 yo boy and currently 30 weeks pregnant
      Works downtown as strategic planning director, usually desk work however does a good amount of walking around downtown to client’s offices
      Active female, in good health, previous runner however stopped when got pregnant

      *Subjective Asterisks*
      – L anterior/medial knee pain – occasional sharp pains at medial knee, “achiness” after increased activity (walking, over full flight of stairs) at 4-6 hours post and takes over 24 hours to cease, rare “catching”.

      MOI: initial injury in October 2015, was chasing around her kid and plant/twisted on her L knee – immediate sharp P! and localized swelling
      Initially was diagnosed with possible ACL and meniscal tear, but could not get imaging confirmation and would not operate due to pregnancy, was just told to rest and avoid uneven terrain.
      Over the next few weeks, her pain was not improving and was getting worse as her gait was changing due to her pregnancy “she was waddling more”. She went back to the Orthopedist, and they said it was not likely an ACL tear/meniscus but a patella dislocation. Gave her a number of exercises to perform and again, just to rest.

      She is really nervous about the exercises that were given because one, they were shown to her by a tech at the physician’s office and two, most of them were in supine. She really wants to get back to exercises because she feels like she wasted a lot of time just resting and feels weak in that knee now, and also wants to get back to running after the pregnancy.

      PMH: partial medial meniscus tear on L in high school, no treatment; runner’s knee in 2012 in same knee

      Primary hypothesis after subjective examination: L medial meniscus tear
      – I still had some concerns about a meniscus tear being the source of symptoms even though ruled out from physician. Previous medial meniscus tear, “catching”, MOI
      Differential List: Patellofemoral pain syndrome, L MCL sprain, plica syndrome

      *Objective Asterisks*
      – Stands with genu recurvatum and increased lumbar lordosis, mild pes planus B
      – Gait: Upright/slight posterior trunk lean, full knee extension upon heel strike, wide BOS and increased step length
      – Functional squat: WIDE stance, bilateral hip ER, hand on thigh to balance, painfree
      – Wore flats to session, reports that she usually wears flats most of the time
      – Full, painfree knee AROM and PROM
      – Denies tenderness to palpation at all structures around knee joint including joint lines except for around superior-medial patellar angle
      – Special testing: ACL, PCL, MCL, LCL, meniscus (McMurray’s, joint line tenderness, Thessaly’s, palpation with tibial IR/ER) all negative. Hughston’s plica test positive with “uncomfortable” feeling.
      – Lateral patella glide mild pain at medial patella
      – No isolated strength deficits, no observable quad atrophy

      Severity: Min –> Mod (when has pain, limits her walking distance, does not disturb sleep)
      Irritability: Min –> Mod (long duration before decrease back to baseline)
      Stage: Subacute
      Stability: Worsening

      Features Fit: Medial plica syndrome as the SOURCE of her symptoms. I used the comparison table that Mike provided in his presentation to assist with my diagnosis.

      For her initial treatment, I provided education on proper shoewear and pathomechanics of her knee condition with relationship to changes in her posture and gait. I also educated her on some exercise guidelines including not exceeding 5 minutes of supine positioning and motionless standing, with modifications that she can use to perform TKE’s and straight leg raises to make sure exercises were safe and effective.

      I could not find any articles helpful on treatment planning for knee pain and pregnancy, just general exercise guidelines and positions/exercises to avoid.

      – Any suggestions for her to decrease pain in the short term as she is getting closer to her due date?
      – Would you guys try to give her any gait training to decrease the stress on her knees? We tried a few cues, but she wasn’t able to modify much because of her balance and anterior-displaced COM.
      – In terms of quad strengthening, I don’t want to stress her SIJ or knee joint so no quadruped or unilateral weight-bearing activities. Do you guys have any other suggestions for quad/LE strengthening?
      – Have you guys had similar patients who were pregnant and what modifications did you suggest to their exercise program?

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    • #3404
      Laura Thornton
      Moderator

      Here’s a recent review by Jenny McConnell on the treatment for infrapatellar fat pad and plica injuries. She describes a detailed anatomic and biomechanical view of the infrapatellar fat pad and synovium. She also talks about the IFP taping technique that unloads or “shortens” the tissue that Eric presented on. I’m not sold on the involvement of the infrapatellar fat pad in her case, do you guys think it would be worth trying on my patient anyway due to the close relationship between the two structures?

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    • #3407
      Nick Law
      Participant

      Halley,

      Thanks so much for posting. I certainly appreciate the difficulty with regards to the differentials for this patient. Just a few thoughts:

      – When you palpated her superior-medial patella (the area that was tender), did she identify this as HER pain, or distinct from her usual pain? Any sense of a taught band (e.g., thickened synovium)?

      – Did you/could you perform the medio-patellar plica test? Certainly not one I am very familiar with, believe it only has limited research, however if positive would certainly point you in a certain direction.

      – Hard to say if the fat pad itself is a pain generator for her (thanks for the updated article from McConnel also), however I certainly think that her landing/standing in full knee extension/hyperextension is not helping the cause. Eric has helped me to appreciate excessive knee hyperextension on a number of patients and the deleterious effects this has on the fat pad/other structures. I am sure that education and slight gait alteration will be nothing but helpful there.

      – Pregnant patients have been difficult for me to manage at times; definitely not sure I have the answer, however (as in all patients really), I think that education and an encouraging outlook/positive prognosis is always helpful. “Pregnancy certainly has its challenges and there are real changes occurring in your body right now, however there is absolutely no reason to fear that this will be a linger condition. You certainly should be able to get back to your pre-activity levels.” Something like that perhaps.

    • #3408
      Laura Thornton
      Moderator

      Great thoughts Nick.

      1. She described as “discomfort”, but was not HER pain. That’s a great question and cannot rely on this to tell me a whole lot, since we all have discomfort around structures especially around a joint that had experienced recent inflammation/injury. I should have specifically looked for a taut band, however cannot say that I palpated this.
      2. I didnt perform the medio-patellar plica test, just the Hughston test. I agree, it would have been useful to support with other findings and I am going to look into this at the next visit. This and more specific palpation to the area will hopefully give me some more insight.
      3. I completely agree on the effect of knee hyperextension and since the last weekend course, I am starting to address it much more frequently. I think that it’s going to be more problem solving with her to figure out how she can position and support her body without having to use hyperextension for stability.
      4. I really like how you have touched on the emotional side of her injury because she absolutely fits someone who needs more support and encouragement, especially since she has specific running goals post-partum. She is anxious about losing strength and the exercises she has been prescribed but is really determined to get back. I think even looking long term and setting a plan on exercise progression up to her due date, and then afterwards with an example of some running training plans once she is cleared by her physician.

    • #3409
      Nick Law
      Participant

      I heartily agree with the above, especially point four. I would not doubt that you can alleviate a substantial portion of this patients suffering just by positive feedback, healthy prognosis, long term goal setting where she can see how she can gradually return to activity even post labor. I really think that will help.

    • #3419
      Michael McMurray
      Keymaster

      Laura – I have concerns with this statement:

      “In terms of quad strengthening, I don’t want to stress her SIJ or knee joint so no quadruped or unilateral weight-bearing activities. Do you guys have any other suggestions for quad/LE strengthening?”

      I think the demand she puts on her system just walking, living in a world of gravity is less than what we consider “too much stress” on those tissues.

      She has low irritability, so I sure would try to progress her tissue tolerance – improve strength/stability in a progressively loaded (pregnant), hypermobile system.

      Taping may be a way to unload some of the irritated tissues (Jenny’s article is helpful with some techniques) for short term pain relief, increased function.

    • #3420
      Michael McMurray
      Keymaster

      Laura-
      Have you followed up with her? Wondering how the second visit went. It sounds like there is a mechanical issue at her knee that needs addressed to return her to her PLOF, especially running, and while talking about how she’s feeling may help some i don’t think it is going to significantly reduce her symptoms.

      Taping to unload may help reduce the stress through the irritated tissue. Improving hamstring and quad length, improving quad and hip abductor strength and gradually loading the tissue are what i would think about as progressions for her. Unless she has a current SIJ or low back history i wouldn’t worry about SLS.

      Graduated therex and progressively loading her system will most likely help curb some of her fear and apprehension without ever having to talk about how she is feeling.

      Thanks for posting-

    • #3424
      Laura Thornton
      Moderator

      Thank you all for your thoughts. I think I needed some perspective on her case to get over my own fear of causing secondary problems.

      I have not seen her for her follow-up yet. I agree there is a mechanical issue at her knee and glad to hear that you all support taping as a possible intervention to decrease pain and irritability around the joint in the short-term.

      Yes, I agree that I was too cautious in terms of SL stance/unilateral weight-bearing with late term pregnancy and concerns of hypermobility. She doesn’t have a prior history of LBP or SIJ pain. It’s just a precaution that came across while doing researching on appropriate exercises for late term, so I guess I took that as an “avoid at all costs” warning.

      I will certainly let you all know about my first follow up visit! This is great reflection. Plan: gradual progression of quad and hip functional strengthening, hamstring and calf flexibility, stability within weight-bearing positions, and using taping to decrease pain and irritability

    • #3425
      ABengtsson
      Participant

      Laura – thanks for posting!

      You mentioned one of her S* was achiness after increased acitivity – walking/stairs; were you able to reproduce her syx with any fxn tests? What really helps me with ant knee pain pts is differentiating b/w contractile and non-contractile. For me it’s been usually enough to do a step up/down and either add manual patellar glides or manual pressure on the patellar tendon and then either mobilize or CFM. It sounds like she may have to do more repetitive testing if you can’t reproduce the syx with just one rep. Aaron showed me how to use pre-wrap to finagle a patellar tendon brace (really simple – just never thought of it) and I’ve used that quite a bit to figure out whether pressure on the tendon decreases syx with repetitive movement.

    • #3426
      Michael McMurray
      Keymaster

      Alex – how does that differentiate contractile versus non contractile?

      What is the contractile differential? Quad tendonopathy?

    • #3458
      ABengtsson
      Participant

      Eric – sorry for the late response.

      I use that as a functional test to guide the rest of my exam and possible treatment options. Generally yes to quad tendinopathy, but I’ve had some pts who presented similar to Laura’s (not pregnant though) in regards to testing and med plica appearing to be source of pain, who got relief from CFM to the pat tendon. Just using those tests to get a better idea of where I’m going with the rest.

    • #3461
      Laura Thornton
      Moderator

      Good questions Alex. I didn’t reproduce her pain in the knee during the examination. Since her pain came 4-6 hours after activity, I was not too concerned about reproducing it in the clinic and was satisfied with the plica testing at that time. However, she did complain of occasional sharp pains which maybe I should have gone after a bit more since Eric and Mike pointed out that she was not highly irritable at the initial evaluation.

      I may be reading too much into this but CFM or applying a patellar strap to the mid-portion of the tendon will change the moment arm of the patella as it’s tracks through the femoral groove. By decreasing the moment arm of the patellar tendon, the inferior pole of the patella will be less to impinge on infrapatellar structures into deep knee flexion movements. So regardless of presence of tendinopathy, I think that’s totally a fair treatment for irritation of the plica/infrapatellar fat pad anyway.

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