Right Knee

Objective

Diagnose and resolve recurrent right-knee mechanical locking, and slow the progression of early post-traumatic osteoarthritis. Working hypothesis is that a medial plica (not arthritis alone) is the primary cause of the locking — and may be driving the cartilage damage.

Context

• Prior surgery: Right-knee arthroscopy years ago to remove a loose body — which turned out to be a fragment of the patella (kneecap) itself.
• Chronic pattern: Intermittent mechanical locking for ~10 years post-surgery. Historically self-reduced by pulling the foot up into a seated/flexed position to “unpinch” it.
• April 2026 flare: First time the usual self-reduction stopped working. Couldn’t straighten without sharp medial pain, swelling on the inside of the knee, heavy limping, inability to bear weight properly.
• Distinctive symptom: A palpable, sometimes visible bump that clicks and locks/unlocks on the medial (inner) side. In the June visit also described marble-like bumps on both sides during locking, plus new giving-way / unsteadiness while standing and walking.

Provider

Dr. Jonathan C. Gordon, MD — Orthopedic Surgeon, Mount Sinai (PA-C: Chloe Goldfarb)

• Mount Sinai Doctors, 55 E 34th St, 3rd Floor, New York, NY 10016 · (212) 252-6131 (appt line 212-252-6182, fax 212-252-6080)
• Sports Medicine + Foot & Ankle; HSS fellowship; consultant for the Milwaukee Bucks, NYPD, FDNY
• (Same doctor seen for 2025 back issue — see Physio 2025-01-20)

Diagnosis & Imaging

MRI — April 28, 2026 (NJIN Jersey City, 3T, no contrast; read by Robert Forcella Jr, MD)

Impression:

1. 3 mm step-off along the weight-bearing lateral femoral condyle → healed fracture deformity, with subtotal cartilage loss lateral to the defect and mild osteophytosis → mild/early post-traumatic osteoarthritis.
2. Moderate cartilage thinning and fraying along the lower half of the medial patellar ridge and facet (chondromalacia — consistent with the old patellar loose-body history).

Key negatives: No meniscus tear (bucket-handle ruled out). No discrete loose body seen. No joint effusion or synovitis. All ligaments intact. No fracture/osteonecrosis. Extensor mechanism normal; normal patellar tracking. Plica was not commented on either way.

Self-review of the DICOM images (June)

Visually confirmed the lateral femoral condyle irregularity and the medial patellar cartilage thinning/fraying on axial slices. Consistent with the report. The locking source is not visible on static MRI — expected, since the catch is an intermittent dynamic event.

Working Hypothesis: Medial Plica Syndrome

The medial-side clicking bump + relief from patellar mobilization + decade-long intermittent locking + prior surgery (scar tissue thickens plica) all fit medial plica syndrome better than arthritis alone. Critically, plica may be the upstream cause of the medial patellar cartilage damage — a thickened plica acting as a shelf, abrading the medial patella/femoral condyle over years.

Grounded research (see logs below for citations)

• Symptom match: Medial plica syndrome classically presents with anteromedial pain, a palpable medial cord/click, and catching/pseudo-locking. ~50% of cases report clicking/giving-way/pseudo-locking.
• Why MRI missed it: MRI sensitivity for medial plica is only ~77% (specificity ~58%). Physical exam (MPP test) ~90%/89%; dynamic ultrasound ~90%/83%. Gold standard is arthroscopy. Diagnosis is primarily clinical, not imaging-based.
• Plica → cartilage damage: Documented that a plica can act as a shelf catching over the medial femoral condyle and eroding cartilage; mediopatellar plica is associated with medial patellar cartilage damage (“medial abrasion syndrome”).
• Treatment evidence: Conservative (VMO strengthening + hamstring stretching) resolves ~78% of cases. Intraplical steroid → ~73% full return. Arthroscopic resection → ~84% good/excellent (meta-analysis, 643 knees); the one RCT favored resection over physio at 2 years (Lysholm 89.7 vs 74.6).
• Caveat for me specifically: Plica-resection outcomes are worse when there are coexisting cartilage lesions (which I have). Resection alone may be insufficient; concurrent cartilage treatment + biomechanical correction may be needed.

Current Treatment Plan (Dr. Gordon)

Stepwise/conservative:

1. Viscosupplementation (HA “gel shots”) — series COMPLETE: #1 June 15, #2 June 22, #3 June 29, 2026.
2. Physiotherapy — now active (script issued Jun 29). PT 3×/week (TIW) × 4 weeks, ROM-focused. Doctor follow-up in 2–4 weeks.
3. Progression plan (my proposal, Gordon accepted): start PT for ~a week, then layer in rotational / knee-heavy movements; return to Gordon if issues arise. → Discuss with the physiotherapist how best to evaluate this progression.
4. Diagnostic arthroscopy — still reserved as last resort if conservative care fails.

• His rationale: studies show injections outperform arthroscopy. (Valid for OA/degenerative meniscus — Moseley NEJM 2002, Sihvonen NEJM 2013, BMJ 2017 — but not directly applicable to a mechanically catching plica / flap / loose body.)
• Considered and declined: BPC-157 peptide trial (experimental; <30 human subjects published; FDA Category 2 since 2023).

The Tripwire

Viscosupplementation lubricates an arthritic joint; it does nothing for a catching plica, cartilage flap, or loose body. If the mechanical symptoms — true locking, the marble bumps, buckling while walking — persist or worsen despite the shots + PT, that’s the signal this isn’t (just) arthritis, and the arthroscopy / plica conversation should reopen. Improvement in ache alone ≠ the mechanics being fixed. The rotational-movement phase of PT is the real test — that’s when a catching plica/flap would reveal itself.

Self-Reduction Technique (confirmed working)

When it catches: press directly on the medial bump + tilt the patella up/away from the inner knee + gently extend. Confirmed effective. Do this at the first sign of catching — far easier than undoing a full lock. Do not force extension.

PT Script (issued 2026-06-29, Gordon / Goldfarb PA-C)

• Dx: ® knee · Frequency: TIW (3×/week) · Duration: 4 weeks · Follow-up: 2–4 weeks · Remarks: ROM
• Checked orders: Massage · Exercise · ROM · Home Program · Stretching · Ultrasound · Modalities of Choice

Questions to bring to the physiotherapist (first eval)

• How will we evaluate readiness to progress from ROM-only into rotational / knee-heavy loading (the ~1-week gate)?
• Can you do a clinical plica assessment (MPP test, Hughston Fold, Stutter test) and watch the medial clicking bump during ROM/rotation?
• The instability while standing resolves when I lift the patella — is that telling us something about tracking/VMO timing vs. a mechanical catch?
• What objective markers will we track (ROM degrees, pain, episodes of catching/giving-way) so we know if rotation provokes the mechanics?
• Structural vs. arthrogenic giving-way — can we assess quad activation/VMO timing?

Exercise Program (evidence-based, equipment-free — bridge/home program)

Daily:

• VMO: terminal knee extensions (towel under knee, last 30°, squeeze) — 3×15
• Straight-leg raises with foot externally rotated ~30° — 3×15/leg
• Isometric quad sets, 10s holds — ×20 (do anywhere)
• Hamstring stretch, 30s ×2-3/leg (tight hamstrings worsen PF compression)
• Patellar mobilization — glide kneecap up/down/side-to-side, 10 reps each (keeps plica/soft tissue supple)

Every other day:

• Clamshells, side-lying leg raises, glute bridges — 3×15 each (hip/glute control offloads the knee)
• Shallow wall sits (~30°, never deep) — 30-60s ×3

Avoid (until cleared in PT): deep squats, lunges below 90°, running/jumping, sudden loaded full extension. Good: swimming, cycling (high seat), elliptical, flat walking. Rotational/knee-heavy movements to be introduced under PT guidance after ~1 week.

Next Actions

• Book the first PT eval (TIW × 4 weeks, ROM-focused) and bring the script
• At PT eval, raise the progression-evaluation + plica-assessment questions above
• Run the rotational-movement test after ~1 week of PT — this is the tripwire; watch for locking/catching/giving-way
• Schedule doctor follow-up with Gordon in 2–4 weeks (per script)
• Track relief-duration trend now that all 3 shots are done; note any breakthrough instability
• If mechanics persist through PT → reopen arthroscopy / plica conversation with Gordon
• Consider a second opinion at HSS Institute for Cartilage Repair while still in the age window where cartilage restoration has best outcomes — Dr. Andreas Gomoll, Dr. Benedict Nwachukwu, or Dr. Answorth Allen (535 E 70th St; (212) 606-1855)

Appointment Index

Medical appointments live on the “Urgent” Google Calendar (not “Personal”). Injections #1 and #3 arrived as SMS/Apple reminders and aren’t on Google Calendar; #2 is on the Urgent calendar.

Date	Event (calendar source)	Calendar link
2026-04-21, 10:15 AM	FOLLOW UP, Dr. Gordon — Visit 1 (Personal)	cal
2026-04-28	MRI — NJIN Jersey City	(not on calendar)
2026-05-04, 3:15 PM	FOLLOW UP, Dr. Gordon — Visit 2, MRI review (Personal)	cal
2026-06-15, 10:30 AM	Injection #1 (SMS/Apple reminder)	(not on Google Calendar)
2026-06-16, 9:25 AM	Internal Medicine video visit — Sherlette Smith, NP (Urgent)	cal
2026-06-22, 10:30 AM	INJECTION with Jonathan Gordon, MD — #2 (Urgent)	cal
2026-06-29, 10:30 AM	Injection #3 + PT referral issued (SMS/Apple reminder)	(not on Google Calendar)
~mid-July	Doctor follow-up with Gordon (2–4 wks per script) — to book	(not yet booked)

Logs

2026-04-21 — Acute flare + Visit 1, Dr. Gordon (cal)

Knee locked that morning, couldn’t straighten without sharp medial pain, swelling on the inside; usual flexion self-reduction failed for the first time. Worked through unlocking techniques (dangling rotation, towel fulcrum, muscle-energy quad contract/relax). Appointment same morning at 10:15 AM: PA suspected possible bucket-handle meniscus tear; nothing done pending MRI. Brace provided (not a full immobilizer). Dr. Gordon ordered MRI stat.

2026-04-28 — MRI

NJIN Jersey City. Results: early post-traumatic OA (lateral femoral condyle step-off) + medial patellar chondromalacia. No meniscus tear, no loose body, no effusion. (See Diagnosis section.)

2026-05-04 — Visit 2, MRI review (cal)

3:15 PM. Dr. Gordon: essentially early arthritis, “unfortunate” given age. No clean surgical fix on imaging. Proposed: anti-inflammatories + PT + low-impact + gel shots; floated BPC-157 trial. No cartilage-restoration discussion.

2026-05 — Research + self-directed analysis

Verified each recommendation against literature. Gel shots: supported for symptom relief, but PT/strengthening outperforms injections in some trials. BPC-157: experimental, declined. Identified the gap: no explanation for the locking, and no plica exam. Built the medial-plica hypothesis after noting the medial clicking bump and that patellar tilt unlocks it. Grounded it in peer-reviewed sources (MRI insensitivity for plica; plica→chondromalacia causal chain; resection outcomes). Sources incl. NIH/PMC (LaPrade & Wentorf medial plica irritation), Physiopedia, ScienceDirect 2025 narrative review, Radsource, BMC Musculoskeletal Disorders 2026, PMC meta-analysis (643 knees), the plica-vs-physio RCT, and Paczesny 10-yr follow-up (cartilage-lesion caveat).

~late May–early June — Thailand (3 weeks)

Traveled with brace. Maintained equipment-free exercise program + ocean swimming. See Thailand Trip.

2026-06-15 — Injection #1 (SMS/Apple reminder, ~10:30 AM)

First HA gel shot, Dr. Gordon, Mount Sinai. Plan: PT after the shot series. In the appointment, raised the mechanical symptoms (locking, medial catch, marble bumps both sides, new buckling while walking) and asked about diagnostic arthroscopy — Dr. Gordon prefers to reserve it until conservative care fails. Tripwire set (see above). (Separate Internal Medicine video visit with Sherlette Smith, NP on Jun 16 — unrelated to the knee.)

2026-06-22 — Injection #2 (10:30 AM, Urgent calendar) (cal)

Second HA gel shot, Dr. Gordon, Mount Sinai (55 E 34th St, 3rd Fl).

Gordon said: no physio until the injection series is finished; expect to feel even better this week (cumulative effect).

Interval since shot #1:

• Felt good most of the week. Saturday: instability on the lateral side while just standing; lifting the patella resolved it.
• Read: real but likely temporary relief; a mechanical/instability symptom still broke through → tripwire behavior. Not a singular mechanical lock — there’s a giving-way component even while standing. Patella-up resolving it keeps pointing at the patellofemoral / plica mechanism, not the lateral femoral condyle OA.

2026-06-29 — Injection #3 (final) + PT referral issued

Third and final HA gel shot, Dr. Gordon, Mount Sinai. Series complete.

Plan set today (my suggestion, Gordon accepted):

• Start PT now → ~1 week of ROM/foundational work, then progress into rotational / knee-heavy movements.
• Return to Gordon if issues arise during/after the rotational phase.
• → Need to discuss with the physiotherapist how best to evaluate that progression (what to watch for, how to know it’s safe to load rotation).

PT script (Gordon / Goldfarb PA-C): ® knee · TIW × 4 weeks · ROM-focused · follow-up 2–4 weeks. Orders: Massage, Exercise, ROM, Home Program, Stretching, Ultrasound, Modalities of Choice. (Full detail in PT Script section above.)

Significance: This is the inflection point. The injection series did its job on the OA/ache side; now the rotational-loading phase is the real test of the mechanical hypothesis. If locking/catching/giving-way shows up when rotation is introduced, that’s the evidence to push for the plica/arthroscopy workup. Frame the first PT eval around evaluating the mechanics, not just strengthening.

Related

• Thailand Trip — overlapping period; brace + medical contingency planning
• Physio 2025-01-20 — same provider (Dr. Gordon), prior back issue (spondylolisthesis)
• Brain Dump — original scattered action items now consolidated here