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Calcific tendonitis of the adductor brevis insertion
Clinical Radiology (2009) 64, 940e943
CASE REPORT
Calcific tendonitis of the adductor brevis insertion J. Tamangani, A.M. Davies, S.L.J. James, M. Christie-Large* Department of Radiology, The Royal Orthopaedic Hospital Foundation Trust, Northfield, Birmingham, UK Received 7 August 2008; received in revised form 12 January 2009; accepted 22 January 2009
Introduction Calcific tendonitis is a common, benign, self-limiting tendinopathy.1 There are characteristic imaging features that are readily recognized when calcific tendonitis occurs in typical locations such as the supraspinatus tendon. However, when it involves atypical locations, particularly if there is associated involvement of underlying bone, distinguishing it from neoplasm or infection can be challenging.2e4 We describe a case of calcific tendonitis involving the distal adductor brevis tendon with underlying bone involvement, initially thought to represent a traumatic lesion or surface malignancy.
Case report A 52-year-old white, female patient presented with a 6 month history of increasing pain in the proximal aspect of the right thigh requiring regular analgesia. The pain was exacerbated by walking and sometimes woke her up at night. She could not recall any trauma to the leg. Initial radiographs demonstrated a small focus of soft-tissue ossification posterior to the proximal right femoral shaft, just inferior to the lesser trochanter (Fig. 1). The combined radiological and orthopaedic differential diagnosis at this point included perostitis ossificans and a surface sarcoma (e.g., periosteal osteosarcoma). For further characterization and confirmation of the precise * Guarantor and correspondent: M. Christie-Large, Department of Radiology, The Royal Orthopaedic Hospital Foundation Trust, Bristol Road South, Northfield, Birmingham B31 2AP, UK. Tel.: þ44 121 685 4135; fax: þ44 121 685 4134. E-mail address: [email protected] (M. Christie-Large).
location of the lesion, a computed tomography (CT) examination was requested. The CT was performed about 15 weeks after the initial plain radiographs. This confirmed a focus of soft-tissue ossification measuring 1.7 1 cm posterior to the proximal right femoral shaft (Fig. 2). However, it also demonstrated an associated cortical abnormality with a localized area of irregular cortical thinning seen adjacent to the calcification. This raised concern that the lesion was malignant and hence the patient was referred to an orthopaedic oncology centre for assessment. A magnetic resonance imaging (MRI) examination was performed 5 weeks later. This showed abnormal high soft-tissue signal on the T2 fat suppressed sequences in the area of concern indicative of oedema (Fig. 3). At this point the diagnostic possibility of calcific tendonitis was raised. Bone scintigraphy demonstrated focal increased activity in the area of concern (Fig. 4). As calcific tendonitis was high on the list of differentials at this stage, a repeat CT examination was performed 6 weeks later (Fig. 5) to determine whether there had been a decrease in size, which would make this presumptive diagnosis more likely. However, the CT demonstrated no significant change in the nature or size of the lesion. Therefore, at this point, a biopsy and possible curative radiofrequency ablation to treat the lesion was considered. When the patient was admitted for elective CTguided biopsy 10 weeks later, the planning examination showed that the lesion had significantly reduced in size since the first CT (Fig. 6). The diagnosis of calcific tendonitis of the adductor brevis tendon was then confidently made based on the radiological course of the lesion and the fact that the patient was now symptom free. Biopsy was considered unnecessary.
0009-9260/$ - see front matter ª 2009 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2009.01.014
Calcific tendonitis of the adductor brevis insertion
941
Figure 1 Initial radiograph demonstrating a small focus of soft-tissue ossification just posterior to the proximal right femoral shaft (arrow).
Discussion Calcific tendonitis is a relatively common disorder the pathophysiology of which relates to deposition of calcium hydroxyapatite in a tendon. It occurs in up to 3% of adults, and is generally thought to be more common in females between the fourth and sixth decade of life.4e6 Patients may present with acute or chronic pain, but the diagnosis may also be made as an incidental finding on a radiograph that is acquired for other reasons.1,7 With involvement of the pelvis and lower limb, presentation may even mimic radicular pain from a herniated intervertebral disc.3,4 Figure 3 (a) T1-weighted MRI image of the soft-tissue mass positioned adjacent to the proximal femur. (b) T2weighted, fat-suppressed image of the same lesion shown in (a) demonstrating abnormal high signal within it.
Figure 2 Initial CT performed demonstrating a small focus of soft-tissue ossification just posterior to the proximal femoral shaft (arrow), with a subtle area of underlying cortical abnormality.
Osseous involvement with calcific tendonitis is unusual.2 Its presence can make the correct diagnosis more challenging as it raises the possibility of malignancy in the differential diagnosis. This is compounded by the fact that the peak age for calcific tendonitis corresponds to an age of increasing risk for metastatic disease.3 When bone is involved by calcific tendonitis, it is usually in the form of cortical erosions and subperiosteal bone formation. A periosteal reaction, if present, may have an aggressive appearance.2 There is a higher propensity for osseous involvement with lesions affecting the proximal linea aspera of the femur (as in this case) and proximal humerus.2,7e10 Current speculation is that this is as a result of an enthesitis due to the large mechanical forces generated
942
J. Tamangani et al.
Figure 4 Nuclear medicine bone scintigraph demonstrating an abnormal focus of increased activity corresponding to the lesion adjacent to the proximal femur.
by the muscles whose tendons insert at these sites.2,9,11 Deposition of calcium in the affected tendon insertion may also independently result in an inflammatory response resulting in a periosteal reaction.2 Classic findings on radiographs include a focus of soft-tissue calcification with a ‘‘comet tail’’ appearance. This sign confirms intratendinous location.2,8,12 Generally, the radiographs need to be of high quality and tangential views of the affected cortex are required. The latter helps to better characterize the calcifications and to assess any associated cortical erosions, periosteal reaction, or marrow involvement.2 CT is the technique of choice for evaluating the cortical involvement. It is also superior to radiography for the detection of soft-tissue calcification and medullary involvement.2,3 MRI is superior for evaluation of marrow involvement, but tendon calcification and subtle cortical involvement may not be appreciated. As a result of this, the soft-tissue and marrow abnormality may be more easily confused
for malignancy or infection on an isolated MRI examination. This is of particular concern as MRI is often used as the first imaging method to evaluate pain or suspected malignancy. Fortunately, marrow
Figure 5 CT examination performed 11 weeks after the initial CT examination showing very little change in appearance of the area of soft-tissue ossification (arrow).
Calcific tendonitis of the adductor brevis insertion
Figure 6 Planning CT examination for a biopsy performed 21 weeks after the initial CT demonstrates that the area of ossification is much smaller in size (arrow). Biopsy was not performed.
943
is often limited to non-steroidal anti-inflammatory agents (NSAIDs).1,13,14 Some authors advocate corticosteroid injections12; however, this has been associated with focal necrosis and reduced tendon strength.6 Other authorities advocate surgical excision of the calcific deposits if conservative treatment fails.16 However, both corticosteroid injections and surgical removal are rarely required. In conclusion, the present case illustrates the diagnostic dilemmas that arise when calcific tendonitis presents at an unusual site with associated cortical involvement. The presence of these two features can lead to difficulties differentiating calcific tendonitis from possible neoplasia or infection, radiologically. Knowledge of the unusual manifestations of this condition should enable diagnosis without the need for biopsy.
References involvement is not common in calcific tendonitis. However, this possibility emphasizes the importance of obtaining radiographic correlation in the setting of suspected neoplasm.2e4 In the retrospective review by Fleming and coworkers,2 all 13 patients with bone involvement demonstrated increased radiotracer uptake on bone scintigraphy. As in the present case, this tends to be focal and eccentric, indicating cortical involvement. Biopsy is not required when radiological findings are diagnostic of calcific tendonitis. Histology can be confused with a neoplastic process as chondroid metaplasia, which is a normal histology finding in calcific tendonitis, may be assumed to suggest a chondroid neoplasm, such as chondrosarcoma.2 It is thus important that the pathologist be informed if there is a history of injury or if calcific tendonitis is a possibility based on clinical and/or radiological grounds. In general, the symptoms of calcifying tendonitis tend to resolve spontaneously. There is no good data specifically investigating lesions involving the proximal femur. However, for supraspinatus calcific tendonitis, one series followed up 24 patients who had calcific deposits and also underwent arthroscopic subacromial decompression for a period of 2 years. In 19 (79%) of these patients the deposits became smaller despite no intervention.15 The postoperative results of these patients were indistinguishable from those of matched patients without calcific deposits who underwent the same procedures. The treatment of calcific tendonitis is controversial, as it is self-limiting and tends to resolve spontaneously. If treatment is considered at all, it
1. Faure G, Daculsi G. Calcified tendonitis: a review. Ann Rheum Dis 1983;42(Suppl.):49e53. 2. Fleming DJ, Murphey MD, Shekitka KM, et al. Osseous involvement in calcific tendinitis: a retrospective review of 50 cases. AJR Am J Roentgenol 2003;181:965e72. 3. Kraemer E, El-Khoury GY. Atypical calcific tendinitis with cortical erosions. Skeletal Radiol 2000;29:690e6. 4. Hodge JC, Schneider R, Freiberger RH, et al. Calcific tendinitis in the proximal thigh. Arthritis Rheum 1993;36: 1476e82. 5. Bosworth BM. Calcium deposits in the shoulder and subacromial bursitis: a survey of 12,122 shoulders. JAMA 1941;116: 2477e82. 6. Uhthoff HK. Calcifying tendonitis. Ann Chir Gynaecol 1996; 85:111e5. 7. Mizutani H, Ohba S, Mizutani M, et al. Calcific tendonitis of the gluteus maximus tendon with cortical bone erosion: CT findings. J Comput Assist Tomogr 1994;18:310e2. 8. Hayes CW, Rosenthal DJ, Plata MJ, et al. Calcific tendonitis in unusual sites associated with cortical bone erosion. AJR Am J Roentgenol 1987;147:967e70. 9. Thornton MJ, Harries SR, Hughes PM, et al. Calcific tendonitis of the gluteus maximus tendon with abnormalities of cortical bone. Clin Radiol 1998;53:296e301. 10. Holt PD, Keats TE. Calcific tendonitis: a review of the usual and unusual. Skeletal Radiol 1993;22:1e9. 11. Uhthoff HK, Sarkar K. Calcifiying tendonitis. Clin Rheumatol 1989;3:567e81. 12. Hendrix RW, Rogers LF, Davis Jr TM. Cortical bone metastases. Radiology 1991;181:409e13. 13. Chow HY, Recht MP, Schils J, et al. Acute calcific tendonitis of the hip. Arthritis Rheum 1997;40:974e7. 14. Friz P, Bardin T, Laredo JD, et al. Paradiaphyseal calcific tendonitis with cortical bone erosion. Arthritis Rheum 1994;5:718e23. 15. Tillander BM, Norlin RO. Change of calcifications after arthroscopic subacromial decompression. J Shoulder Elbow Surg 1998;7:213e7. 16. Rotini R, Bungaro P, Antonioli D, et al. Algorithm for the treatment of calcific tendinitis in the rotator cuff: indications for arthroscopy and results in our experience. Chir Organi Mov 2005;90:105e12.
CASE REPORT
Calcific tendonitis of the adductor brevis insertion J. Tamangani, A.M. Davies, S.L.J. James, M. Christie-Large* Department of Radiology, The Royal Orthopaedic Hospital Foundation Trust, Northfield, Birmingham, UK Received 7 August 2008; received in revised form 12 January 2009; accepted 22 January 2009
Introduction Calcific tendonitis is a common, benign, self-limiting tendinopathy.1 There are characteristic imaging features that are readily recognized when calcific tendonitis occurs in typical locations such as the supraspinatus tendon. However, when it involves atypical locations, particularly if there is associated involvement of underlying bone, distinguishing it from neoplasm or infection can be challenging.2e4 We describe a case of calcific tendonitis involving the distal adductor brevis tendon with underlying bone involvement, initially thought to represent a traumatic lesion or surface malignancy.
Case report A 52-year-old white, female patient presented with a 6 month history of increasing pain in the proximal aspect of the right thigh requiring regular analgesia. The pain was exacerbated by walking and sometimes woke her up at night. She could not recall any trauma to the leg. Initial radiographs demonstrated a small focus of soft-tissue ossification posterior to the proximal right femoral shaft, just inferior to the lesser trochanter (Fig. 1). The combined radiological and orthopaedic differential diagnosis at this point included perostitis ossificans and a surface sarcoma (e.g., periosteal osteosarcoma). For further characterization and confirmation of the precise * Guarantor and correspondent: M. Christie-Large, Department of Radiology, The Royal Orthopaedic Hospital Foundation Trust, Bristol Road South, Northfield, Birmingham B31 2AP, UK. Tel.: þ44 121 685 4135; fax: þ44 121 685 4134. E-mail address: [email protected] (M. Christie-Large).
location of the lesion, a computed tomography (CT) examination was requested. The CT was performed about 15 weeks after the initial plain radiographs. This confirmed a focus of soft-tissue ossification measuring 1.7 1 cm posterior to the proximal right femoral shaft (Fig. 2). However, it also demonstrated an associated cortical abnormality with a localized area of irregular cortical thinning seen adjacent to the calcification. This raised concern that the lesion was malignant and hence the patient was referred to an orthopaedic oncology centre for assessment. A magnetic resonance imaging (MRI) examination was performed 5 weeks later. This showed abnormal high soft-tissue signal on the T2 fat suppressed sequences in the area of concern indicative of oedema (Fig. 3). At this point the diagnostic possibility of calcific tendonitis was raised. Bone scintigraphy demonstrated focal increased activity in the area of concern (Fig. 4). As calcific tendonitis was high on the list of differentials at this stage, a repeat CT examination was performed 6 weeks later (Fig. 5) to determine whether there had been a decrease in size, which would make this presumptive diagnosis more likely. However, the CT demonstrated no significant change in the nature or size of the lesion. Therefore, at this point, a biopsy and possible curative radiofrequency ablation to treat the lesion was considered. When the patient was admitted for elective CTguided biopsy 10 weeks later, the planning examination showed that the lesion had significantly reduced in size since the first CT (Fig. 6). The diagnosis of calcific tendonitis of the adductor brevis tendon was then confidently made based on the radiological course of the lesion and the fact that the patient was now symptom free. Biopsy was considered unnecessary.
0009-9260/$ - see front matter ª 2009 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2009.01.014
Calcific tendonitis of the adductor brevis insertion
941
Figure 1 Initial radiograph demonstrating a small focus of soft-tissue ossification just posterior to the proximal right femoral shaft (arrow).
Discussion Calcific tendonitis is a relatively common disorder the pathophysiology of which relates to deposition of calcium hydroxyapatite in a tendon. It occurs in up to 3% of adults, and is generally thought to be more common in females between the fourth and sixth decade of life.4e6 Patients may present with acute or chronic pain, but the diagnosis may also be made as an incidental finding on a radiograph that is acquired for other reasons.1,7 With involvement of the pelvis and lower limb, presentation may even mimic radicular pain from a herniated intervertebral disc.3,4 Figure 3 (a) T1-weighted MRI image of the soft-tissue mass positioned adjacent to the proximal femur. (b) T2weighted, fat-suppressed image of the same lesion shown in (a) demonstrating abnormal high signal within it.
Figure 2 Initial CT performed demonstrating a small focus of soft-tissue ossification just posterior to the proximal femoral shaft (arrow), with a subtle area of underlying cortical abnormality.
Osseous involvement with calcific tendonitis is unusual.2 Its presence can make the correct diagnosis more challenging as it raises the possibility of malignancy in the differential diagnosis. This is compounded by the fact that the peak age for calcific tendonitis corresponds to an age of increasing risk for metastatic disease.3 When bone is involved by calcific tendonitis, it is usually in the form of cortical erosions and subperiosteal bone formation. A periosteal reaction, if present, may have an aggressive appearance.2 There is a higher propensity for osseous involvement with lesions affecting the proximal linea aspera of the femur (as in this case) and proximal humerus.2,7e10 Current speculation is that this is as a result of an enthesitis due to the large mechanical forces generated
942
J. Tamangani et al.
Figure 4 Nuclear medicine bone scintigraph demonstrating an abnormal focus of increased activity corresponding to the lesion adjacent to the proximal femur.
by the muscles whose tendons insert at these sites.2,9,11 Deposition of calcium in the affected tendon insertion may also independently result in an inflammatory response resulting in a periosteal reaction.2 Classic findings on radiographs include a focus of soft-tissue calcification with a ‘‘comet tail’’ appearance. This sign confirms intratendinous location.2,8,12 Generally, the radiographs need to be of high quality and tangential views of the affected cortex are required. The latter helps to better characterize the calcifications and to assess any associated cortical erosions, periosteal reaction, or marrow involvement.2 CT is the technique of choice for evaluating the cortical involvement. It is also superior to radiography for the detection of soft-tissue calcification and medullary involvement.2,3 MRI is superior for evaluation of marrow involvement, but tendon calcification and subtle cortical involvement may not be appreciated. As a result of this, the soft-tissue and marrow abnormality may be more easily confused
for malignancy or infection on an isolated MRI examination. This is of particular concern as MRI is often used as the first imaging method to evaluate pain or suspected malignancy. Fortunately, marrow
Figure 5 CT examination performed 11 weeks after the initial CT examination showing very little change in appearance of the area of soft-tissue ossification (arrow).
Calcific tendonitis of the adductor brevis insertion
Figure 6 Planning CT examination for a biopsy performed 21 weeks after the initial CT demonstrates that the area of ossification is much smaller in size (arrow). Biopsy was not performed.
943
is often limited to non-steroidal anti-inflammatory agents (NSAIDs).1,13,14 Some authors advocate corticosteroid injections12; however, this has been associated with focal necrosis and reduced tendon strength.6 Other authorities advocate surgical excision of the calcific deposits if conservative treatment fails.16 However, both corticosteroid injections and surgical removal are rarely required. In conclusion, the present case illustrates the diagnostic dilemmas that arise when calcific tendonitis presents at an unusual site with associated cortical involvement. The presence of these two features can lead to difficulties differentiating calcific tendonitis from possible neoplasia or infection, radiologically. Knowledge of the unusual manifestations of this condition should enable diagnosis without the need for biopsy.
References involvement is not common in calcific tendonitis. However, this possibility emphasizes the importance of obtaining radiographic correlation in the setting of suspected neoplasm.2e4 In the retrospective review by Fleming and coworkers,2 all 13 patients with bone involvement demonstrated increased radiotracer uptake on bone scintigraphy. As in the present case, this tends to be focal and eccentric, indicating cortical involvement. Biopsy is not required when radiological findings are diagnostic of calcific tendonitis. Histology can be confused with a neoplastic process as chondroid metaplasia, which is a normal histology finding in calcific tendonitis, may be assumed to suggest a chondroid neoplasm, such as chondrosarcoma.2 It is thus important that the pathologist be informed if there is a history of injury or if calcific tendonitis is a possibility based on clinical and/or radiological grounds. In general, the symptoms of calcifying tendonitis tend to resolve spontaneously. There is no good data specifically investigating lesions involving the proximal femur. However, for supraspinatus calcific tendonitis, one series followed up 24 patients who had calcific deposits and also underwent arthroscopic subacromial decompression for a period of 2 years. In 19 (79%) of these patients the deposits became smaller despite no intervention.15 The postoperative results of these patients were indistinguishable from those of matched patients without calcific deposits who underwent the same procedures. The treatment of calcific tendonitis is controversial, as it is self-limiting and tends to resolve spontaneously. If treatment is considered at all, it
1. Faure G, Daculsi G. Calcified tendonitis: a review. Ann Rheum Dis 1983;42(Suppl.):49e53. 2. Fleming DJ, Murphey MD, Shekitka KM, et al. Osseous involvement in calcific tendinitis: a retrospective review of 50 cases. AJR Am J Roentgenol 2003;181:965e72. 3. Kraemer E, El-Khoury GY. Atypical calcific tendinitis with cortical erosions. Skeletal Radiol 2000;29:690e6. 4. Hodge JC, Schneider R, Freiberger RH, et al. Calcific tendinitis in the proximal thigh. Arthritis Rheum 1993;36: 1476e82. 5. Bosworth BM. Calcium deposits in the shoulder and subacromial bursitis: a survey of 12,122 shoulders. JAMA 1941;116: 2477e82. 6. Uhthoff HK. Calcifying tendonitis. Ann Chir Gynaecol 1996; 85:111e5. 7. Mizutani H, Ohba S, Mizutani M, et al. Calcific tendonitis of the gluteus maximus tendon with cortical bone erosion: CT findings. J Comput Assist Tomogr 1994;18:310e2. 8. Hayes CW, Rosenthal DJ, Plata MJ, et al. Calcific tendonitis in unusual sites associated with cortical bone erosion. AJR Am J Roentgenol 1987;147:967e70. 9. Thornton MJ, Harries SR, Hughes PM, et al. Calcific tendonitis of the gluteus maximus tendon with abnormalities of cortical bone. Clin Radiol 1998;53:296e301. 10. Holt PD, Keats TE. Calcific tendonitis: a review of the usual and unusual. Skeletal Radiol 1993;22:1e9. 11. Uhthoff HK, Sarkar K. Calcifiying tendonitis. Clin Rheumatol 1989;3:567e81. 12. Hendrix RW, Rogers LF, Davis Jr TM. Cortical bone metastases. Radiology 1991;181:409e13. 13. Chow HY, Recht MP, Schils J, et al. Acute calcific tendonitis of the hip. Arthritis Rheum 1997;40:974e7. 14. Friz P, Bardin T, Laredo JD, et al. Paradiaphyseal calcific tendonitis with cortical bone erosion. Arthritis Rheum 1994;5:718e23. 15. Tillander BM, Norlin RO. Change of calcifications after arthroscopic subacromial decompression. J Shoulder Elbow Surg 1998;7:213e7. 16. Rotini R, Bungaro P, Antonioli D, et al. Algorithm for the treatment of calcific tendinitis in the rotator cuff: indications for arthroscopy and results in our experience. Chir Organi Mov 2005;90:105e12.