Question
QUESTION: hello,
i have been having on and off knee pain in my right knee for years. i
have never hurt it in any way. i am a 23 year old healthy male and have
been examined by my doc and the er when the pain gets real bad. i get
xrayed and told that nothing looks abnormal. pain killers and muscle
relaxers dont help. for the last three days the pain has been so bad i can
barly walk and when i do my knee gives out and i almost fall, and the
pain is radiating from my knee now down to my ankle and is very
painful, it  doesnt feal like a muscle ache or strain or anything and i havent
hurt it in any way i just woke up with it. my question is what could
it be and what kind of tests can i ask for since regular exams and xrays
arent showing anything. thank you for any help.could it be arthritis?



ANSWER: Good question Eric,

First I would demand an MRI, if that is negative you'll need to check compartment pressures to rule out compartment syndrome. Blood work should include a C-reactive protein to rule out an inflammatory cause. A uric acid may be wise along with an ANA to be thorough. Tough call here, if I can personally examine you I would be more apt to get to the bottom of it. I would certainly begin with these tests first.

Thank you for this rare and challenging question, (I like these types):), they make me really dig deep! Good Luck and let me know for sure what the final Dx is, this will kill me if I'm left in the dark. Odd stuff like this is what I live for.

Take care Eric and Good Luck!

Dr. Timothy Durnin
drs.chiroweb.com

---------- FOLLOW-UP ----------

QUESTION: thank you, i got the mri and they told me that i have plikia? i think i spelled that right, they said its a water type substance behind my knee and they want me to see a specialist. could you tell me more about what that means and how its treated? thanks for your help.

Answer
Hi Eric,



A plica is a thin wall of fibrous tissue that are extensions of the synovial capsule of the knee. During fetal development, the knee is divided into three (3) separate compartments. As the fetus develops these compartments develop into one large protective cavity (synovial membrane). The majority of people have remnants of these three cavities referred to as a plica. Most often the plica is on the medial (inside) of the knee at the level of the medial femoral condyle. Most individuals are not adversely affected by the presence of plicas.

The plica only becomes a problem when the knee is irritated, causing an inflammation in the synovial sack. When the synovium is inflamed, the area of the plica becomes thicker. This thickened area then begins to catch on the femur as the knee moves. This in turn keeps the plica inflamed resulting in a viscous cycle.

The plica can be located anywhere in the knee. The exact symptoms will be determined by the plica抯 location. The most common location is along the medial (inside) side of the knee. The plica can tether the patella to the femur, be located between the femur and patella, or located along the femoral condyle. Regardless of location the pain is due to the plica catching or being pinched between the patella and femur. If the plica connects the patella to the femoral condyle, symptoms will mimic patello-femoral syndrome.

With out a complete clinical examination, the plica may be missed, resulting in an inappropriate rehabilitation plan. For example, if the patella is tethered by the plica, the clinician may design a rehab plan to address a patello-femoral disorder. This may only exacerbate the condition. If the plica is truly tethering the patella, the rehab should focus on decreasing the inflammation, and increasing the overall strength of the quad muscles.

Treatment of Plica Syndrome

A DC that has therapy in his office should do the following.......
Theraputic exericses and modalities may also be used to treat the plica. To attack the inflammation, modalities such as iontophoresis (utilizing low intensity electric current to transport medications through skin), phonophoresis (using ultrasound to transport medications through skin), and ice are most commonly utilized.

Rehabilitative exercises should be instituted when the inflammation has been controlled and pain levels are falling. These exercises should focus on increasing overall quadriceps, hamstring, and calf strength., as well as increasing overall muscular flexibility. Examples of appropriate exercises are: pain-free squats that progress to one-leg squats, side step-ups, closed chain terminal knee extension, and applicable sport-specific exercises. Care should be taken to avoid deep squats as this can increase pain and inflammation.

The exercises should be performed utilizing PRE (progressive resistance exercises) principles, gradually increasing load and intensity as pain and inflammation allows.

I ask only that you take a few seconds to rate my response. Your feedback helps me refine my expertise and helps to guide future questioners.


Thank you for your question Eric and good Luck!

Dr. Timothy Durnin
drs.chiroweb.com