Plica Syndrome of the Elbow: Causes, Symptoms, Diagnosis, and Treatment

What is Plica Syndrome of the Elbow?

Plica syndrome of the elbow is a condition characterized by pain and dysfunction resulting from the inflammation or impingement of a synovial fold (plica) within the elbow joint, most commonly affecting the posterior olecranon plica.

Understanding Elbow Anatomy and Plica

The elbow is a complex hinge joint formed by the articulation of three bones: the humerus (upper arm bone) and the ulna and radius (forearm bones). This joint allows for flexion and extension, as well as pronation and supination of the forearm. The joint is encased by a fibrous capsule lined with a synovial membrane, which produces synovial fluid to lubricate the joint.

Within the synovial membrane, certain areas can form folds or "plica" (plural: plicae). These are normal anatomical structures, often remnants of fetal development, which serve no known functional purpose in the adult joint. While plicae can be found in various joints, including the knee (where they are more commonly symptomatic), they are also present in the elbow. In the elbow, plicae are typically found in the anterior (front) and posterior (back) compartments. The posterior olecranon plica is the most frequently implicated in plica syndrome of the elbow.

What is Plica Syndrome?

Plica syndrome of the elbow occurs when one of these synovial folds becomes irritated, inflamed, or mechanically impinged within the joint. While the plica itself is a normal structure, it can become symptomatic under certain conditions. When the elbow moves, the plica can be pinched or compressed between the bones, particularly during specific movements like full extension. Over time, repeated impingement can lead to:

• Inflammation: The plica becomes swollen and tender.
• Fibrosis: The plica thickens and stiffens, losing its normal elasticity.
• Chondromalacia: Damage to the articular cartilage in the area due to chronic impingement.

This chronic irritation leads to pain, clicking, and potentially limited range of motion.

Causes and Risk Factors

Plica syndrome of the elbow is often multifactorial, stemming from a combination of factors that cause the plica to become symptomatic:

• Acute Trauma: A direct blow to the elbow or a fall on an outstretched arm can cause the plica to become pinched and inflamed.
• Repetitive Motion and Overuse: Activities involving repetitive elbow flexion and extension, such as throwing sports (baseball, javelin), racquet sports (tennis, badminton), or certain occupational tasks, can lead to chronic irritation and impingement of the plica.
• Anatomical Variations: Individuals may have a naturally larger or more prominent plica, making it more susceptible to impingement.
• Joint Swelling/Effusion: Accumulation of fluid within the joint can compress the plica against articular surfaces.
• Muscle Imbalances: Weakness or tightness in the muscles surrounding the elbow and shoulder can alter joint mechanics, predisposing the plica to impingement.

Common Symptoms

The symptoms of elbow plica syndrome can vary in intensity and presentation but often include:

• Pain: Typically localized to the back of the elbow, often worse with activities that involve full elbow extension or repetitive movements. The pain can be sharp, aching, or a dull throb.
• Clicking, Popping, or Snapping Sensation: A distinct mechanical sound or feeling may be experienced, particularly during elbow extension. This is often due to the plica catching or snapping over a bony prominence.
• Limited Range of Motion: Difficulty achieving full elbow extension is a common finding, as this movement can cause the plica to be pinched.
• Tenderness to Palpation: The area over the posterior aspect of the elbow may be tender when pressed.
• Swelling: While not always present, localized swelling around the elbow joint can occur, especially after activity.
• Weakness: Secondary to pain and disuse, some individuals may experience a perceived weakness in the affected arm.

Diagnosis

Diagnosing plica syndrome of the elbow requires a thorough clinical evaluation by a healthcare professional, often involving:

• Medical History: Detailed questions about the onset of pain, aggravating and alleviating factors, and activity levels.
• Physical Examination:
  • Palpation: The examiner will feel for tenderness over specific areas of the elbow.
  • Range of Motion Assessment: Checking for limitations in elbow flexion and extension.
  • Specific Provocative Tests: Maneuvers that attempt to reproduce the symptoms by compressing or irritating the plica, such as passively extending the elbow while applying pressure.
• Imaging Studies:
  • X-rays: Primarily used to rule out other bony pathologies like fractures, arthritis, or loose bodies, which can mimic plica syndrome symptoms. Plica itself is not visible on X-ray.
  • Magnetic Resonance Imaging (MRI): While plicae are soft tissue structures and can be seen on MRI, their presence alone does not confirm plica syndrome. MRI can help identify inflammation, thickening of the plica, and rule out other soft tissue injuries (e.g., ligament tears, tendinopathy).
  • Ultrasound: Can sometimes visualize a thickened or inflamed plica and guide diagnostic injections.
• Diagnostic Injection: A corticosteroid injection into the posterior compartment of the elbow can be both diagnostic and therapeutic. If the injection provides significant pain relief, it strongly suggests the plica is the source of the symptoms.

Treatment and Management

Treatment for elbow plica syndrome typically begins with conservative measures. Surgical intervention is considered if conservative approaches fail to provide adequate relief.

Conservative Management

• Rest and Activity Modification: Avoiding activities that aggravate the symptoms is crucial. This may involve temporarily reducing or modifying sports or occupational tasks.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Over-the-counter or prescription NSAIDs can help reduce pain and inflammation.
• Physical Therapy: A structured rehabilitation program is often highly effective. This may include:
  • Pain and Swelling Management: Modalities like ice, heat, or therapeutic ultrasound.
  • Range of Motion Exercises: Gentle exercises to restore full, pain-free elbow extension.
  • Strengthening Exercises: Targeting the muscles around the elbow, shoulder, and core to improve overall stability and biomechanics.
  • Proprioceptive Training: Exercises to improve joint awareness and control.
  • Activity-Specific Modification: Guidance on proper technique for sports or work tasks.
• Corticosteroid Injections: An injection of corticosteroid directly into the inflamed area of the plica can provide significant, albeit often temporary, pain relief by reducing inflammation. These are usually limited in number due to potential side effects.

Surgical Intervention

If conservative treatments fail to alleviate symptoms after a reasonable period (typically 3-6 months), surgical removal of the symptomatic plica may be recommended.

• Arthroscopic Plica Excision: This minimally invasive procedure is the preferred surgical approach. Small incisions are made, and an arthroscope (a small camera) is inserted into the joint to visualize the plica. Specialized instruments are then used to carefully resect (remove) the inflamed or impinged portion of the plica.
• Post-Operative Rehabilitation: Following surgery, a structured physical therapy program is essential to restore range of motion, strength, and function. Recovery typically involves a period of immobilization followed by progressive exercises.

Prognosis and Recovery

The prognosis for plica syndrome of the elbow is generally good with appropriate management. Most individuals respond well to conservative treatment. For those requiring surgery, arthroscopic excision of the plica has a high success rate in alleviating symptoms and restoring function. Adherence to a prescribed rehabilitation program, whether conservative or post-surgical, is critical for optimal recovery and preventing recurrence.

Prevention

While not all cases of plica syndrome can be prevented, certain measures can help reduce the risk, particularly for those involved in repetitive arm activities:

• Proper Warm-up: Always perform a thorough warm-up before engaging in sports or activities that stress the elbow.
• Gradual Progression: Increase the intensity, duration, or resistance of activities gradually to allow the tissues to adapt.
• Correct Technique: Ensure proper technique in sports and occupational tasks to minimize undue stress on the elbow joint. Consider working with a coach or trainer.
• Strength and Flexibility Training: Maintain balanced strength and flexibility in the muscles surrounding the elbow, shoulder, and core.
• Listen to Your Body: Do not push through pain. If you experience elbow discomfort, rest and address the symptoms early to prevent them from escalating into a chronic condition.