This article addresses a common cause of anterior knee pain. Appropriate diagnosis of this knee condition is commonly overlooked. The putative case report presents a male patient suffering with knee pain with an insidious onset.
When the condition is accurately diagnosed in a timely manner, the patient may anticipate resolution of the pain, but delayed diagnosis or misdiagnosis presents a less-than-desirable prognosis.
History / Subjective
Chief concern: "My knee hurts when I run or walk upstairs." For the past two months, this 32 year-old male doctoral student has been experiencing an aching sensation in his left knee when he walks upstairs, runs or does squats. He points to the area of the right joint line of the left knee as the site of his pain.
He denies any previous knee problems, but claims that his knees have clicked and popped for years with flexion and extension of the knees. For the past three weeks, he has noticed increased pain in the left knee after sitting for two hours in class.
The pain has been getting worse for the past month. He thinks that his new weightlifting program might be causing the problem. The ache becomes more severe with squats. He increased the weight on his shoulders to 250 pounds three months ago. Now, he is unable to perform deep squats without weights because of knee pain.
He rates the severity at 3-6/10. When walking up the stairs, his left knee hurts and "feels like it is going to give way." He takes NSAIDs for relief of the pain and sometimes applies ice, which also helps to reduce the pain.
Objective Findings
Posture: posterior inferior left iliac crest and anterior superior right iliac crest with a mild forward head posture, but without scoliosis.
Gait: normal without a limp.
Palpation: pain at the medial joint line of the left knee; ribbon-like tissue revealed and direct pressure and rolling of the tissue reproduces the anterior knee pain at the medial joint line.
Trigger points: active myofascial trigger points located in the left iliopsoas.
Gillet test: sacroiliac joint fixation left.
Long sit test: Functional leg-length inequalities with left leg appearing short supine and long seated.
Repetitive squats: produce pain at the medial joint line of the left knee and a mild limping gait.
Thessaly test: negative for knee pain
McMurray test: negative for knee pain
Hughston test: reproduces the pain in the left knee at the medial joint line.
Stutter test: reproduces the pain in the left knee at the medial joint line.
Clarke's patellar scrape test: produces crepitation and pain in the left knee.
Assessment / Diagnosis
- Synovial plica syndrome of left knee
- Patellofemoral pain syndrome
- Pelvic obliquity and functional leg-length inequality of the left lower extremity
Treatment Plan
- Recommend discontinuing the squat routine and running for two weeks or longer if the pain persists.
- Recommend progressive resistive exercise to strengthen the left vastus medialis muscle to improve tracking of the patella.
- Perform spinal manipulation and trigger-point releases to reduce pelvic obliquity, sacroiliac joint dysfunction, and functional leg-length inequalities.
Quiz Time
1. Pain along the medial or lateral joint line of the knee may indicate which of the following conditions?
a. Cruciate ligament sprain
b. Pes anserine bursitis
c. Patellofemoral pain syndrome
d. Meniscal injury
2. The Thessaly test is performed to reproduce pain with which of the following conditions?
a. Cruciate ligament sprain
b. Pes anserine bursitis
c. Patellofemoral pain syndrome
d. Meniscal injury
3. Which of the following tests are positive with synovial plica syndrome?
a. Stutter test
b. Hughston test
c. Squatting test
d. All of the above
4. What causes painful synovial plica syndrome?
a. Overuse
b. Poor conditioning of the quadriceps muscles
c. Bowlegs
d. All of the above
Notes / Clinical Pearls
Medial plica syndrome test: The medial plica test (or Hughston plica test) is done with the patient lying in the supine position. The examiner grasps around the knee with one hand from an anterolateral position and presses the patella medially with the heel of the hand while palpating the medial femoral condyle with the fingers of the same hand.
Stutter test: Patient positioning: sitting on the side of the table with knee flexed to 90 degrees. The examiner crouches down to knee level, placing the index and middle fingers on the center of the patella.
Action: The examiner asks the patient to extend the knee slowly while keeping the fingers on the patella and watches its movement. Positive finding: If the patella stutters or jumps during the course of movement, it is indicative of a plica. It is typically in the range of 45-70 degrees toward extension. Crepitus of the patella may also be felt.
Research resource: "Synovial plica syndrome (SPS) occurs in the knee, when an otherwise normal structure becomes a source of pain due to injury or overuse. Patients may present to general practitioners, physiotherapists, or surgeons with anterior knee pain with or without mechanical symptoms, and the diagnosis can sometimes be difficult. Several studies have examined the epidemiology, diagnosis, and treatment of SPS. We review these resources to provide an evidence-based guide to the diagnosis and treatment of SPS of the knee."1
Quiz Answers: The correct choice for all four of the multiple-choice questions is D.
Reference
- Lee PY, Nixion A, Chandratreya A, Murray JM. Synovial plica syndrome of the knee: a commonly overlooked cause of anterior knee pain. Surg J (N Y), 2017 Jan;3(1):e9-e16. Full-text access: www.ncbi.nlm.nih.gov/pmc/articles/PMC5553487/pdf/10-1055-s-0037-1598047.pdf.
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