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Arthroscopic management of calcific tendinitis of the popliteus tendon
Case Report
Arthroscopic Management of Calcific Tendinitis of the Popliteus Tendon T. Duncan Tennent, F.R.C.S. (Orth), and Vipool K. Goradia, M.D.
Abstract: Calcific tendinitis is seen most commonly affecting the rotator cuff but has not been previously reported affecting the popliteus tendon. Symptoms mimic a tear of the posterior horn of the lateral meniscus. Arthroscopic debridement of the calcific deposit results in resolution of symptoms. Key Words: Popliteus tendon—Calcific tendinitis—Lateral meniscus.
C
alcific tendinitis is part of a spectrum of calcium deposition diseases, causing pain and disability. The condition is seen most frequently in the rotator cuff, and a number of treatment modalities have been used, including ultrasound, corticosteroid injection, and arthroscopic debridement.1 Pain in the posterolateral joint line of the knee is commonly attributed to a meniscal tear. We report a case of calcific tendinitis of the popliteus tendon producing posterolateral knee pain that completely resolved with arthroscopic debridement. CASE REPORT A 47-year-old man presented with a history of pain in the posterolateral aspect of his left knee, which became worse on full flexion and with activity. There had been no clear history of trauma to the knee. There was no history of locking, catching, or instability. The patient had been given a diagnosis, by his family physician, of gout a year previously after an episode in
From Orthopaedic Research of Virginia, Richmond, Virginia, U.S.A. Address correspondence and reprint requests to Vipool K. Goradia, M.D., Orthopaedic Research of Virginia, Suite 207, 7660 Parham Rd, Richmond VA 23294, U.S.A. © 2003 by the Arthroscopy Association of North America 1526-3231/03/1904-3340$30.00/0 doi:10.1053/jars.2003.50124
which the knee had become swollen and painful. No further investigations had been undertaken, and the patient was not on any medication for gout. Physical examination revealed a ligamentously stable knee with palpable posterolateral joint-line tenderness and a positive McMurray’s test with pain being felt in the same region. Forty-five degree posteroanterior, lateral, and skyline radiographs of the knee revealed no abnormality. A clinical diagnosis of a tear of the posterior horn of the lateral meniscus was made and, as the symptoms had failed to resolve with antiinflammatories, the patient elected to proceed with arthroscopy. Arthroscopy of the left knee revealed extensive chondrocalcinosis affecting all compartments but no evidence of either a medial or lateral meniscal tear. All ligamentous structures were intact. There was no evidence of meniscal detachment or a loose body in the lateral gutter. A large deposit of calcific material, similar in appearance to that seen in calcific tendinitis of the shoulder, was seen within the popliteus tendon (Fig 1). The material was debrided using an arthroscopic shaver (Fig 2). The patient had complete resolution of his symptoms by 6 weeks postoperatively and returned to full duty at work. DISCUSSION Calcific tendinitis is most commonly encountered in the shoulder, but it has also been reported in the
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 4 (April), 2003: E35
1
2
T. D. TENNENT AND V. K. GORADIA
elbow, wrist (flexor carpi ulnaris), hand (intrinsics), neck, hip (gluteii, quadriceps, adductor magnus), knee (patellar tendon, biceps femoris), and the ankle and foot.2 It has not, to our knowledge, been reported in the tendon of popliteus. There are a number of treatment modalities including extracorporeal shock-wave therapy, corticosteriod injections, and arthroscopic debridement.1 The condition is part of a spectrum of disease in which there is both intra-articular and periarticular calcium hydroxyapatite and other related calcium phosphate crystal deposition. The condition may be primary, idiopathic, or secondary to a number of diseases, including end-stage renal failure, tumoral calcinosis, collagen vascular diseases, diabetes mellitus, and vitamin D intoxication. The underlying etiology and pathologic process for the idiopathic form is uncertain.3 Posterolateral knee pain with a positive McMurray’s test in a middle-aged man is most commonly due to a tear of the posterior horn of the lateral meniscus. For patients with persistent symptoms, arthroscopic resection or repair of the tear is the standard treatment. Chondrocalcinosis is a common incidental finding at surgery, and the incidence increases with age. In most cases the condition is asymptomatic. In this patient,
FIGURE 2. deposit.
Popliteus tendon following debridement of the calcific
despite the presence of calcific deposits in all compartments of the knee, the symptoms were localized to the posterolateral corner. A calcific deposit in the region of the popliteus tendon has been reported once in the German literature,4 but this was not confirmed arthroscopically. If the clinical diagnosis of a posterior horn lateral meniscal tear is not confirmed at arthroscopy, the popliteus tendon should be inspected for the presence of a calcific deposit. In this case, the tendon was debrided arthroscopically with a successful result. Care should be taken not to divide the tendon at surgery; there is a theoretical risk that the debrided tendon may rupture postoperatively. REFERENCES
FIGURE 1.
Calcific deposit within the popliteus tendon.
1. Holt PD, Keats TE. Calcific tendinitis: A review of the usual and unusual. Skeletal Radiol 1993;22:1-9. 2. Noel E. Treatment of calcific tendinitis and adhesive capsulitis of the shoulder. Rev Rhum Engl Ed 1997;64:619-628. 3. Hayes CW, Conway WF. Calcium hydroxyapatite deposition disease. Radiographics 1990;10:1031-1048. 4. Werlich T. Der interessante Fall—Tendinosis calcarea der Popliteussehne des Kniegelenkes. J Orthop Klinik Krankenhauses Seepark 1999;137:54-56.
Arthroscopic Management of Calcific Tendinitis of the Popliteus Tendon T. Duncan Tennent, F.R.C.S. (Orth), and Vipool K. Goradia, M.D.
Abstract: Calcific tendinitis is seen most commonly affecting the rotator cuff but has not been previously reported affecting the popliteus tendon. Symptoms mimic a tear of the posterior horn of the lateral meniscus. Arthroscopic debridement of the calcific deposit results in resolution of symptoms. Key Words: Popliteus tendon—Calcific tendinitis—Lateral meniscus.
C
alcific tendinitis is part of a spectrum of calcium deposition diseases, causing pain and disability. The condition is seen most frequently in the rotator cuff, and a number of treatment modalities have been used, including ultrasound, corticosteroid injection, and arthroscopic debridement.1 Pain in the posterolateral joint line of the knee is commonly attributed to a meniscal tear. We report a case of calcific tendinitis of the popliteus tendon producing posterolateral knee pain that completely resolved with arthroscopic debridement. CASE REPORT A 47-year-old man presented with a history of pain in the posterolateral aspect of his left knee, which became worse on full flexion and with activity. There had been no clear history of trauma to the knee. There was no history of locking, catching, or instability. The patient had been given a diagnosis, by his family physician, of gout a year previously after an episode in
From Orthopaedic Research of Virginia, Richmond, Virginia, U.S.A. Address correspondence and reprint requests to Vipool K. Goradia, M.D., Orthopaedic Research of Virginia, Suite 207, 7660 Parham Rd, Richmond VA 23294, U.S.A. © 2003 by the Arthroscopy Association of North America 1526-3231/03/1904-3340$30.00/0 doi:10.1053/jars.2003.50124
which the knee had become swollen and painful. No further investigations had been undertaken, and the patient was not on any medication for gout. Physical examination revealed a ligamentously stable knee with palpable posterolateral joint-line tenderness and a positive McMurray’s test with pain being felt in the same region. Forty-five degree posteroanterior, lateral, and skyline radiographs of the knee revealed no abnormality. A clinical diagnosis of a tear of the posterior horn of the lateral meniscus was made and, as the symptoms had failed to resolve with antiinflammatories, the patient elected to proceed with arthroscopy. Arthroscopy of the left knee revealed extensive chondrocalcinosis affecting all compartments but no evidence of either a medial or lateral meniscal tear. All ligamentous structures were intact. There was no evidence of meniscal detachment or a loose body in the lateral gutter. A large deposit of calcific material, similar in appearance to that seen in calcific tendinitis of the shoulder, was seen within the popliteus tendon (Fig 1). The material was debrided using an arthroscopic shaver (Fig 2). The patient had complete resolution of his symptoms by 6 weeks postoperatively and returned to full duty at work. DISCUSSION Calcific tendinitis is most commonly encountered in the shoulder, but it has also been reported in the
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 4 (April), 2003: E35
1
2
T. D. TENNENT AND V. K. GORADIA
elbow, wrist (flexor carpi ulnaris), hand (intrinsics), neck, hip (gluteii, quadriceps, adductor magnus), knee (patellar tendon, biceps femoris), and the ankle and foot.2 It has not, to our knowledge, been reported in the tendon of popliteus. There are a number of treatment modalities including extracorporeal shock-wave therapy, corticosteriod injections, and arthroscopic debridement.1 The condition is part of a spectrum of disease in which there is both intra-articular and periarticular calcium hydroxyapatite and other related calcium phosphate crystal deposition. The condition may be primary, idiopathic, or secondary to a number of diseases, including end-stage renal failure, tumoral calcinosis, collagen vascular diseases, diabetes mellitus, and vitamin D intoxication. The underlying etiology and pathologic process for the idiopathic form is uncertain.3 Posterolateral knee pain with a positive McMurray’s test in a middle-aged man is most commonly due to a tear of the posterior horn of the lateral meniscus. For patients with persistent symptoms, arthroscopic resection or repair of the tear is the standard treatment. Chondrocalcinosis is a common incidental finding at surgery, and the incidence increases with age. In most cases the condition is asymptomatic. In this patient,
FIGURE 2. deposit.
Popliteus tendon following debridement of the calcific
despite the presence of calcific deposits in all compartments of the knee, the symptoms were localized to the posterolateral corner. A calcific deposit in the region of the popliteus tendon has been reported once in the German literature,4 but this was not confirmed arthroscopically. If the clinical diagnosis of a posterior horn lateral meniscal tear is not confirmed at arthroscopy, the popliteus tendon should be inspected for the presence of a calcific deposit. In this case, the tendon was debrided arthroscopically with a successful result. Care should be taken not to divide the tendon at surgery; there is a theoretical risk that the debrided tendon may rupture postoperatively. REFERENCES
FIGURE 1.
Calcific deposit within the popliteus tendon.
1. Holt PD, Keats TE. Calcific tendinitis: A review of the usual and unusual. Skeletal Radiol 1993;22:1-9. 2. Noel E. Treatment of calcific tendinitis and adhesive capsulitis of the shoulder. Rev Rhum Engl Ed 1997;64:619-628. 3. Hayes CW, Conway WF. Calcium hydroxyapatite deposition disease. Radiographics 1990;10:1031-1048. 4. Werlich T. Der interessante Fall—Tendinosis calcarea der Popliteussehne des Kniegelenkes. J Orthop Klinik Krankenhauses Seepark 1999;137:54-56.