Curr Rev Musculoskelet Med (2008) 1:53–60 59 Fig. 17 Hamstring stretching In cases where patients are not getting better with a physical therapy program, or in those patients who have such an irritated plica that a therapy program may not be beneﬁcial directly, consideration for an intraarticular cor- ticosteroid injection is necessary. In candidates for an intraarticular steroid injection, we perform the injection to attempt to quiet down their knee symptoms such that they can participate in an exercise program to address their medial plica irritation. It is not sufﬁcient solely to rely on the injection to quiet down ones knee because the under- lying problem of a weak quadriceps mechanism and tight hamstring muscles may persist after the injection and result in a recurrence of the medial plica irritation after the beneﬁcial effects of the injection wear off. Thus, it is very important to make sure that the patients do participate in an exercise program, even if they have complete relief of their symptoms, after an intraarticular steroid injection to treat medial plica irritation. It is usually necessary to have the patients refrain from exercising or placing any signiﬁcant stress to their knee for the ﬁrst 24–48 h after their steroid injection because the knee may have more post-injection soreness. In addition, it is important to document with the patients whether or not they had good pain relief while the local anesthetic portion of the injection was working to verify that they do have an intraarticular knee cause of their knee pain. It is rare that patients need arthroscopic surgery to treat isolated medial plica pathology, because the medial plica is a part of the joint lining and resection of it will result in the joint lining growing back. Since the body heals back this type of resection with scar, the tissue may heal back with painful scar and the patient may have more symptoms. Since the treatment of a painful plica after an arthroscopic resection can often cause patients to have more pain than they did prior to the arthroscopic resection, it is important to make sure that a patient has pathology of this area which is not responsive to an exercise program, and possibly injections, prior to consideration of resection of this tissue [2]. It is important to recognize that surgery for an irritated plica is uncommon, and historically it comprised only 2– 5% of all arthroscopic surgery at a time when magnetic resonance imaging scans were not commonly used and more surgeries were performed for diagnostic reasons [5]. We have found that arthroscopic resections of irritated plicas are rarely performed today. The usual instances where one may have some beneﬁt from resection of a medial synovial plica may be where the plica is acting as a shelf which is catching over the medial femoral condyle and causing some erosion of the articular cartilage in this area [3, 13, 14]. In these circumstances, patients may have good pain relief and decreased catching sensations in their knee after an arthroscopic resection of their medial plica. In this instance, it is usually not recommended to divide the pathologic plica and resect it totally because the pathologic plica may grow back and the patient may have recurrence of their symptoms [5]. It has also been noted that the results of arthroscopic plica excision are more successful in ado- lescents than in older patients [8]. Indirect treatment of the medial plica irritation may also be very beneﬁcial to patients. In these instances, the pathology is deep within the knee. Treatment of localized areas of arthritis, meniscal tears, or other knee pathologies, may decrease the pain and swelling of the knee which resulted in secondary irritation of the medial plica. In these instances, it may be beneﬁcial for the patient to undergo surgery to treat the secondary cause of plica irritation. In these circumstances, it is not recommended to resect the medial synovial plica, because there is a very good chance that it will get better with an exercise program after surgery and patients may not have pain relief of their plica irritation if it is resected arthroscopically. References 1. Amatuzzi MM, Fazzi A, Varella MH. Pathologic synovial plica of the knee. Results of conservative treatment. Am J Sports Med 1990;18(5):466–9. 2. Broom MJ, Fulkerson JP. The plica syndrome: a new perspective. Orthop Clin North Am 1986;17(2):279–81. 3. Dorchak JD, Barrack RL, Kneisl JS, Alexander AH. Arthroscopic treatment of symptomatic synovial plica of the knee: long-term followup. Am J Sports Med 1991;19(5):503–7. 4. Dye SF, Vaupel GL, Dye CC. Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. Am J Sports Med 1998;26:773–7. 5. Ewing JW. Plica: pathologic or not? J Am Acad Orthop Surg 1993;1:117–21.