Medial knee fold syndrome is a specific type of synovitis of the knee joint. Plica mediopatellaris is the Latin term for the fold of the synovium in the medial compartment of the knee. This structure is not a disease in itself, but it can cause persistent pain in the knee joint. The synovial fold consists of the mesenchymal tissue that forms in the knee during the embryological phase of development. During fetal life, this tissue forms connective tissue septum that divide the knee joint into three compartments, which disappear with development, and their remnant may be folds of the synovial membrane on the joint wall, commonly known as files (from the Latin word plica - fold). The synovial fold is located on the medial side of the patella and begins in the suprapatellar region, continuing diagonally to Hoffa's fat body.
It is not known exactly what percentage of people has this structure, but for sure the vast majority. In a few of these people, however, the fold is large enough to cause conflict and pain.
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Causes, symptoms and diagnosis of synovial fold syndrome
Pain in the presence of a synovial fold occurs only when the structure is irritated. Then, fold hypertrophy, fibrosis or its inflammation may occur, which in turn causes "rubbing" of the fold against the medial condyle of the femur or even wedging between the condyle and the kneecap. This tissue conflict in the joint gives pain, sometimes exudation, the feeling of jumping in the joint.
Among the causes of pain and discomfort in patients with synovial fold syndrome, there are primary and secondary irritations. The primary causes of irritation are caused by a fall on a knee, a direct impact on the medial part of the kneecap or as a result of prolonged overload associated with working in a bent knee position and frequent climbing stairs. In addition, practicing sports such as running or cycling, where continuous knee extension and flexion work is dominant, may lead to irritation of the fold. In this case, the cause of the dysfunction is a disturbance in muscle function consisting in weakening of the muscles of the front side of the thigh (especially the medial part) and contracture of the flexor muscles. Secondary irritations include meniscal damage, tissue inflammation, and other knee conditions.
The most common symptoms of synovial fold irritation include:
- pain and discomfort in the anterior or anteromedial knee compartment;
- pain located under the kneecap, felt on the inside of the knee, worsening after prolonged sitting with bent knees or physical activities such as: walking up stairs, running, cycling, and exercises that involve squatting, kneeling and squatting;
- intermittent and episodic discomfort - occurs shortly after physical activity;
- the occurrence of painful jumps and episodes of blocking the knee (not always);
- a feeling of fullness and stretching of the knee;
- swelling at the site of the injury and a palpable lump under the skin;
- limb function limitation.
Accurate diagnosis of the synovial fold syndrome is difficult because it is often confused with meniscus damage, patellar chondromalacia, pain syndrome of the patellofemoral joint, or osteitis and cartilage.
Diagnostics in the first place is based on collecting a detailed interview from the patient and conducting an appropriate clinical examination. Sometimes the symptoms are so unequivocal that the clinical examination and history alone are sufficient for a correct diagnosis.
If the symptoms are not clear, the second step is to perform an X-ray examination of both knee joints in three projections: anterior-posterior, lateral and in Marchant's projection (axial projection in the knee flexion up to 45 degrees), which will allow for the detection or elimination of any changes. degenerative processes within the knees or pathologies within the patellofemoral joint, ultrasound of the knee and magnetic resonance imaging of the knee (MRI).
The above studies may turn out to be crucial from the point of view of the diagnosis of concomitant pathologies within the knee joint and may significantly bring the orthopedic surgeon closer to making a correct diagnosis indirectly, on the basis of excluding other knee dysfunctions. In some cases, despite the X-ray, ultrasound of the knee and MRI of the knee, there is no clear answer and in these cases the doctor decides to undergo arthroscopy of the knee joint, which leaves no doubts in making the correct diagnosis.
Risk factors influencing the development of the synovial fold syndrome
The most important factors leading to an increased incidence of synovial fold syndrome are:
- a thicker, larger fold in the knee,
- weakness of the quadriceps muscle and contracture of the flexor muscles,
- knee valgus and flat feet,
- practicing sports in which there is a risk of direct injury to the knee joint,
- practicing disciplines that require strength work of extension and flexion of the knee joint (e.g. running, cycling),
- common training mistakes: lack of warm-up and stretching, too intense training, incorrect exercise technique or overtraining and lack of proper recovery after exercise.
Treatment of synovial fold syndrome
First of all, in the treatment of the synovial fold syndrome, it is always suggested physiotherapy aimed at reducing the conflict and an attempt to reduce the predisposition to its formation. In the second one, you can try to inject the fold with a steroid under ultrasound guidance. If all this does not help, the doctor decides to have the fold removed arthroscopically. The procedure of arthroscopic cutting or removal of a fold is one of the simpler and shorter-lasting arthroscopic operations and allows for a quick return to full activity within 2-4 weeks.
