Curr Rev Musculoskelet Med (2008) 1:53–60 57 Fig. 9 Palpation of semimembranosus bursae Fig. 10 Palpation of biceps femoris bursae thin plica band is very difﬁcult to perform and reliable placement of the needle during the injection is impossible [8]. It is generally not recommended to perform a diag- nostic arthroscopy to verify that a patient has an isolated medial plica irritation, because the most successful treat- ments for medial plica irritation are non-operative and an arthroscopy can cause further irritation and scarring of the medial synovial plica. It is recommended to obtain a standing AP, lateral, and 45 patellar sunrise (axial) radiographs of the knee to rule out other sources of pathology. While many patients who have an irritated medial synovial plica have normal radiographs, it is important to rule out that the patients do not have any underlying arthritis, areas of osteochondritis desiccans, osteophyte formation, fractures, or other bony pathology which could be contributing to the irritation of the medial synovial plica. In addition, diagnosis of medial plica irritation on MRI scans is non-speciﬁc [5]. The physical exam should be able Fig. 11 Intraarticular injection of 1% Lidocaine to demonstrate any signiﬁcant thickening and ﬁbrosis of a medial synovial plica. MRI’s are more useful in deter- mining if there are other pathologies contributing to medial synovial plica irritation rather than in directly diagnosing pathology in this portion of the knee. Treatment of medial plica irritation The main treatment regimen for medial plica irritation is non-operative. For patients who have medial plica irritation as their main diagnosis without any underlying knee pathology contributing to their plica irritation, there is a very good chance that their symptoms will improve with a guided rehabilitation program [1, 12]. The most successful rehabilitation programs focus on strengthening the quad- riceps muscles, which are directly attached to the medial plica, and avoiding activities which cause medial plica irritation [3]. These exercises can include quadriceps sets (Fig. 12), straight leg raises (Fig. 13), leg presses (Fig. 14), and mini-squats, as well as, a walking program, the use of a recumbent or stationary bicycle (Fig. 15), a swimming program, or possibly an elliptical machine. Patients should work on gradually increasing strength over time to over- come any strength deﬁcit in their quadriceps mechanism. Concurrent with this, patients should also work on a fre- quent hamstring stretching program throughout the day [5]. As mentioned previously, tight hamstrings can increase the force needed to extend the knee, which can be an important source of medial plica irritation. Thus, it is important to make sure that the hamstrings are stretched frequently to diminish this extra stress on the anterior part of the knee. Most patients can utilize either a self-directed or a physical therapy guided exercise program for the ﬁrst 6– 8 weeks after they have been examined. In the majority of