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Author Topic: Right Knee Medial Plica Removal and Fat Pad Trim  (Read 288 times)

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Offline nw1942

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Right Knee Medial Plica Removal and Fat Pad Trim
« on: December 16, 2019, 06:48:04 AM »
Hi All,

23 y/o male


Following a 5 hour hike in July 2018 I developed persistent right knee pain and swelling over the medial anterior portion of the knee. Although, I probably didn't give it the best rest & recover regime. This has happened before, but it seemed to subside over the following days. I have dislocated this knee when I was 10.

I initially when through a round of PT with a dx of patellar tendonitis, this was over a course of 8 months. However, this didn't improve my symptoms. taping the patelly upwards to unload the anterior compartments seemed to give some releif prior to surgery. MRI showed small medial plica, normal medicus, tendons ligiments etc.
Following a steroid injection that didn't not improve my symptoms, I underwent an arthroscopy in July 2019 which found a small fibrotic medial plica, and some mild cartilage abrasion. I was told the plica was removed and cartilage cleaned up during surgery. The surgeon also said he did a small fat pad trim. Post-op I struggled to get the swelling down, but the pain had subsided significantly (I am guessing swelling stop whatever was rubbing from... rubbing!).

8 weeks after surgery I was pain-free and able to walk my dog for 30 minutes after work each day. I went on a 1.5-hour hike through the bush (moderate use of stairs), which followed with delayed swelling and pain 1-2 days after.

Since then I have never really been able to recover, the swelling appears to go down with extended extension and overnight during sleep, and will puff up and is very sore with flexion and repetitive flexion activities. Tender over on medial side of patella tendon.

Swelling is and always exclusive to the anterior medial compartment/over and below the medial femoral condyle.

I am currently unable to do any forms of exercise that involve and sort of knee flexion. I also have an office job (engineer), and to limit pain I sit with my legs straight and it is painful to get up and down from my chair and use stairs, car rides/ driving can become sore too if flexed.


Offline nw1942

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Re: Right Knee Medial Plica Removal and Fat Pad Trim
« Reply #1 on: December 16, 2019, 07:09:51 AM »
16/12/2019 Update:

Have since seen another 2 orthos.

4/11/2019 1st Orth, highly regarded in knee space in NZ. MC

Did a brief physical examination, which he did not believe showed anything significantly wrong with the knee. Order a high powered MRI of RK. No obvious problems on MRI, suggest I just live with it, and get RA markers checked.

22/11/2019 Second Ortho, first visit CL

Did physical examination, with pain when palpating just anterior and medial to the patella tendon (seems to be positive hoffas test). Was not able to access the MRI from 1st Ortho, so ordered a new MRI.

12/12/2019 CL MRI follow up

No obvious problems on MRI, low trochlear groove and hyperlaxity, also mild swelling within the joint. suggested try steroid injection into infrapatellar fat pad. took 3 days to notice, a significant reduction in swelling but the pain still present from prolonged standing, walking, and prolonged flexion, squatting is out of the question. Suggested hip X-ray to see if the pain is referred (I am thinking unlikely as swelling is also present).

Steriod injection has worked on swelling, but the pain seems to still be present if not slightly worse

Also suggested if things don't improve he might do another arthroscopy, with a fat pad trim. I will go an see him prior to this and ask to have infrapatellar plica removed, and fat pad investigated in anterior, medial and posterior surfaces for adhesions/inflammation.

Also should note I have re-started PT, with emphasis on increasing quad strength, and some glute exercises.

My thoughts are that the infrapatellar plica in causing the infrapatellar fat pad to course abnormally causing impingement/inflammation of some sort. I am suspecting the impingement may be between the femur and tibia as opposed to the common location of the patella-femur, based on where the pain is.


Offline kneegeek2020

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Re: Right Knee Medial Plica Removal and Fat Pad Trim
« Reply #2 on: July 28, 2020, 08:45:27 PM »
The medial plica of the knee has no function but surgeons can bill insurance companies 10k for removing it.  The fat pad is essentially the meniscus of the patella and removing it serves no purpose but again, the surgeon will be able to bill another 10k.  In my personal experience, the fat pad is the cushion for the patella and not having it greatly damages the knee.

Offline The KNEEguru

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Re: Right Knee Medial Plica Removal and Fat Pad Trim
« Reply #3 on: July 29, 2020, 08:21:55 AM »
Anterior knee pain is a problem both for the patient and for the surgeon, as it is generally difficult to identify the culprit/s, and the surgeon feels obligated to 'do something', which seems to often make things worse.

Plicae are normal, so should not be removed just because they are found on investigation. It is the traumatised, thickened plica that has a clearer role in causing medial symptoms, and can then often be felt with the examining fingers as a ropy structure along the side of the patella medially.

Tom Smallman, however, has done some interesting studies on patients with anterior knee pain, where he has showed that in many patients there is a relationship between the infrapatellar plica and the fat pad that can precipitate such pain - see https://www.kneeguru.co.uk/KNEEnotes/courses/alternative-viewpoint-anterior-knee-pain

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Offline The KNEEguru

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Re: Right Knee Medial Plica Removal and Fat Pad Trim
« Reply #4 on: July 29, 2020, 08:35:20 AM »
This is the bit of Tom Smallman's work that intrigued me most - https://youtu.be/QevOeWU7Y5Y
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