A 53-year-old male patient presented with painful right elbow snapping for one year without any improvement by conservative treatment. Clinical examination of the diseased elbow revealed visible snapping during flexion-extension of the pronated forearm.
Plain radiography of symptomatic right elbow demonstrated absence of loose bodies, progressed osteoarthritis and joint dislocation.
The patient underwent magnetic resonance imaging (MRI), which confirmed the presence of thickened posterolateral fold with increased cross-sectional area and heterogeneous signal intensity (Fig. 1, 2, 3 and 4). Areas of signal abnormality in the subcortical bone of the adjacent capitellum and in the radial head were also seen (Fig. 5).
BACKGROUND:
The symptomatic radiohumeral plica is an infrequent cause of lateral elbow pain. Synovial plicae are thought to be embryological remnants of the normal articular development, and are usually asymptomatic. Plicae can cause clinical symptoms when they become hypertrophied due to direct blow or repetitive microtrauma [1-5].
CLINICAL PERSPECTIVE:
Clinically, patients may present with pain and mechanical symptoms, including locking and snapping. These patients are usually diagnosed with lateral epicondylitis and the diagnosis of elbow synovial plica syndrome may be only established after failure of conservative treatment [1-5].
IMAGING PERSPECTIVE:
MRI is the preferred imaging technique for the investigation of elbow pathologic processes. MRI enables an accurate evaluation of hypertrophic synovial plicae, articular cartilage and associated injuries. T2-weighted and fat-sat MR images are especially helpful for the evaluation of plicae, which are characterized by thickening, greater than 3 mm, and irregular appearance. MRI is also used to evaluate synovitis and chondral lesions in the radial head and capitellum [1, 2].
MR arthrography assures the visualization of hypertrophic plicae and chondromalacia of the radial head and capitellum in patients without joint fluid [1].
OUTCOME:
Initially, nonsurgical treatment, including rest, physiotheraphy and nonsteroidal antiinflammatory agents. Failure of conservative therapy leaves arthroscopic debridement of the pathologic plica and physical therapy, leading to excellent outcomes [1, 2, 3].
TEACHING POINTS:
Hypertrophic synovial plica in the radiohumeral joint represents an embryological remnant of a synovial membrane. It is a rare cause of lateral elbow impingement, therefore it is usually misdiagnosed. Arthroscopic intervention should not be delayed by prolonged conservative treatment and leads to excellent outcomes.
Hypertrophic synovial plica in the radiohumeral joint.
Based on the provided elbow MRI images, the lesion is primarily located near the articular surfaces of the radial head and the capitellum (i.e., the radiohumeral joint). On T2-weighted and fat-suppressed sequences, a band-like or plica-like soft tissue structure can be seen within the joint space, with a thickness clearly exceeding 3 mm and showing irregular thickening. This structure is closely related to the surrounding articular cartilage or joint capsule, and mild joint effusion or synovial thickening is noted in some areas. No obvious fractures or extensive cartilage damage are detected, but localized cartilage wear or subtle joint surface irregularities should be considered.
Taking into consideration the clinical presentation (prolonged lateral elbow pain, clicking sensation, restricted movement, and inadequate response to conservative measures) and MRI findings indicating significant synovial plica thickening with mild synovial irritation, the most likely diagnosis is:
Radiohumeral Synovial Plica Hypertrophy/Proliferation.
Although this condition is not commonly encountered among causes of lateral elbow pain, under repetitive stress or chronic overuse, a hypertrophic synovial plica can form, leading to mechanical friction and causing pain and a clicking sensation.
1. Conservative Treatment:
• Rest and avoidance of excessive loading or repetitive actions, particularly activities involving excessive forearm pronation-supination or elbow flexion-extension.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) to help alleviate inflammation and pain.
• Appropriate physical therapy, including heat therapy, ultrasound treatment, strengthening exercises, and stretching to improve joint mobility and reinforce surrounding muscles.
If conservative therapy brings about significant improvement, it is advisable to continue for 2–3 months. If symptoms persist, show no marked improvement, or recur frequently, surgical intervention should be considered.
2. Surgical Treatment:
• Arthroscopic Debridement: For cases unresponsive to conservative treatment, arthroscopic resection of the synovial plica can be performed to eliminate mechanical impingement. This procedure frequently yields favorable outcomes.
3. Rehabilitation/Exercise Prescription (FITT-VP Principle):
• Frequency (F): Conduct rehabilitation exercises 3–4 times per week.
• Intensity (I): Begin with low-load and low-resistance exercises (e.g., using light resistance bands) and progressively increase intensity in line with pain relief and tolerance.
• Time (T): Each session lasts about 20–30 minutes, potentially divided into segments (e.g., 5 minutes for warm-up, 15–20 minutes for the main workout, 5 minutes for cooldown).
• Type (T): Emphasize isometric, isotonic, and light resistance exercises targeting the forearm extensors, flexors, and pronator/supinator muscles, in combination with both active and passive joint mobility exercises to maintain or improve elbow flexibility.
• Progression (P): As pain eases and functional capacity improves, gradually increase resistance levels, extend exercise duration, and introduce functional training (e.g., tennis, badminton) as tolerated, while avoiding overexertion or repetitive high-impact movements.
• Precautions: In patients with osteoporosis or reduced cardiopulmonary function, intensity should be ramped up slowly under professional supervision. If significant discomfort or other unusual symptoms occur during exercise, discontinue activity and seek medical advice.
This report is a reference-based analysis drawn from the current medical history and imaging data, and does not substitute for in-person evaluations or professional clinical advice. Patients should closely integrate these findings with their clinical status, adhere to regular follow-up visits, and follow specialized medical recommendations for treatment and rehabilitation.
Hypertrophic synovial plica in the radiohumeral joint.
