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Pellegrini Stieda Syndrome

Pellegrini Stieda Syndrome (PSS), sometimes termed Pellegrini Stieda disease or Köhler–Pellegrini–Stieda disease, is an uncommon clinical entity characterized by the presence of a pelliigrini-stieda sign on knee radiographs coupled with medial knee pain and restricted range of motion. Pelligrini was the first to describe the sign in 1905[1]Pellegrini, A. “Traumatic calcification of the collateral tibial ligament of the left knee joint.” Clin Mod 11 (1905): 433-439., Stieda would later publish a series of 5 cases.[2]Stieda, Alfred. “Uber eine typische verletzung am unteren femurende.” Archiv klin Chir 85 (1908): 815-826. The epidemiology of this disease is limited to cases and case reports and not well characterized in the literature. It is most commonly seen in young males age 25 to 40.[3]Scheib, J. S., and R. J. Quinet. “Pellegrini-Stieda syndrome mimicking acute septic arthritis.” Southern medical journal 82.1 (1989): 90-91.
There is a large osseous fragment along the medial femoral epicondyle at the expected attachment for the proximal medial collateral ligament, with multiple adjacent small comminuted fragments. This fragment is displaced from its parent site by approximately 5mm. [4]Case courtesy of Matt Skalski, Radiopaedia.org, rID: 32241
Calcific linear focus is present medial to the distal femur in the region of proximal attachment of the medial collateral ligament. [5]Case courtesy of The Radswiki, Radiopaedia.org, rID: 11752

The diagnostic criteria of PSS include (a) the classic findings of pelligrini stieda sign and a combination of symptomatology of pain and restricted range of motion. The Pelligrini-Stieda sign or lesion is a radiographic finding which describes calcification of the medial collateral ligament seen weeks to months after an inciting invite. For clarities sake, a Stieda fracture is a medial femoral condyle avulsion fracture caused by an injury to the MCL.

Thought to initially occur with an insult to the MCL, especially with valgus disruption of the MCL fibers which can be an (a) acute, direct trauma, (b) repetitive microtrauma and/or (c) overstretching. Subsequently, an acute inflammatory cascade initiates a delayed process of ossification which is typically thought to occur between two and six weeks following the event.[6]Theivendran K, Lever CJ, Hart WJ. Good result after surgical treatment of Pellegrini-Stieda syndrome. Knee Surg Sports Traumatol Arthrosc. 2009 Oct;17(10):1231-3. Origin of the calcification has historically been thought to be the MCL. However, cadaveric and MRI studies have also implicated the medial patellofemoral ligament, medial gastrocnemius, adductor magnus and vastus medialis.[7]Somford, M. P., Lorusso, L., Porro, A., Van Loon, C., & Eygendaal, D. The Pellegrini–Stieda Lesion Dissected Historically. The journal of knee surgery.2018; 31(06): 562-567. Associated conditions include an MCL injury, spinal coard and traumatic brain injuries, and vague associations with heterotopic ossification and myositis ossificans.
Anatomy of left knee joint and attachments of deep medial collateral ligament (MCL) above and below medial meniscus. (ACL, anterior cruciate ligament; LCL, lateral collateral ligament; PCL, posterior cruciate ligament.)[8]Jacob, George, et al. “Percutaneous arthroscopic assisted knee medial collateral ligament repair.” Arthroscopy Techniques 9.10 (2020): e1511-e1517.
Relationship of the MPFL (medial patellofemoral ligament), VMO (vastus medialis obliquus muscle), SM (semimembranosus), MGT (medial gastrocnemius tendon), POL (posterior oblique ligament) and sMCL (superficial medial collateral ligament)[9]Memarzadeh, Arman, and Joel TK Melton. “Medial collateral ligament of the knee: Anatomy, management and surgical techniques for reconstruction.” Orthopaedics and Trauma 33.2 (2019): 91-99.
When obtaining a history from the patient, they may or may not describe a known knee injury. Pain is typically localized to the medial knee with painful and restricted range of motion. Symptoms tend to get worse over time. On exam, the knee is stiff and restricted. Full extension is painful. There is tenderness to the medial femoral condyle and proximal MCL. A lump may or may not be tolerated. If a valgus stress test is performed it will be painful with or without laxity.
The diagnosis can be made with standard radiographs of the knee. The Pelligrini-Stieda sign involves a longitudinal linear opacity and calcification of the soft tissue located medial to the femoral condyle. It is important not to confuse this with a medial femoral condyle fracture or medial femoral condyle enthesophyte. MRI is not required but typical findings include an ossicle with bone marrow signle at the medial femoral condyle and a thickened MCL. The role of ultrasound us undefined.
T1 and T2 hypointense mass adjacent to the MCL origin from the medial femoral condyle typical of an ossified Pellegrini-Steida lesion.[10]Case courtesy of Chris O’Donnell, Radiopaedia.org, rID: 37592
Pelligrini-Stieda lesion seen on ultrasound. Note the hyperechoic calcification with posterior acoustic shadowing.[11]Image courtesy of sonotool.net, “Pellegrini-Stieda Lesions”
A classification system was proposed by Mendes.[12]Mendes, Luiz FA, et al. “Pellegrini–Stieda disease: a heterogeneous disorder not synonymous with ossification/calcification of the tibial collateral ligament—anatomic and imaging … Continue reading Type 1: a beak-shaped with inferior orientation and union to the femur: the ossification arises from the femur and extends inferiorly in the TCL. Type 2: drop-shaped with inferior orientation and parallel to the femur: located in the TCL, without attachment to the femur. Type 3: elongated with superior orientation: ossification lying in the distal adductor magnus tendon. Type 4: beak-like with superior orientation and inferior attached to the femur: ossification attached to the femur, extending into both the TCL and the adductor magnus tendon
Management is typically non-surgical and involves a combination of NSAIDS, corticosteroid injections and physical therapy with an emphasis on range of motion. Operative management is indicated and refractory cases and typically involves surgical excision of the calcifications. Rehabiliation includes an emphasis on avoiding overload, microtrauma with ice therapy and gentle mobilization. Return to play can be considered when full range of motion is restored, the athletic is pain free with symmetric range of motion and strength.[13]Shanker, V. S., Gadikoppula, S., & Loeffler, M. D. Post traumatic osteoma of tibial insertion of medial collateral ligament of knee joint. British journal of sports medicine.1998; 32(1): 73-74. … Continue reading
Most cases will resolve in 5 or 6 months with proper treatment. Surgical cases are more challenging. Surgical patients have varied clinical outcomes and a high recurrence rate. Reconstruction of the MCL is often required. Complications include restricted range of motion and subsequent joint contracture, gait abnormalities, decreased ADLs and chronic pain.

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