Abstract
Distal biceps femoris tendon is an unusual site of calcific tendinitis and a rare cause of knee pain. We present a case of 72-year-old lady who presented with a six-month history of pain over the lateral aspect of knee. Subsequent imaging demonstrated calcific deposits within the biceps femoris tendon substance. She was then successfully treated with ultrasound-guided barbotage of the calcium deposits and peri-tendinous corticosteroid injection. Clinical awareness of the unusual sites of calcific tendinitis with imaging evidence is important for early diagnosis and appropriate management.
Keywords: Calcific tendinitis, Biceps femoris, Ultrasound guided barbotage
1. Introduction
Calcific tendinitis is a common cause of periarticular pain, most commonly involving the rotator cuff tendons. Less commonly it can involve sites such as Achilles tendon, longus colli and gluteus maximus. Distal tendon of biceps femoris is an extremely rare site of involvement, causing lateral knee pain. Extensive search of medical literature revealed only one previous reported case.1
2. Case report
A 72-year-old lady presented to Orthopaedic clinic with six months history of pain over the lateral aspect of her left knee. She had no history of trauma to the knee. The pain radiated towards her ankle and was rated as being 8 out of 10 on a visual analogue scale. She denied any aggravating or relieving factors. She reported disturbance of sleep along with uncomfortable sensation on functional activities. She had past medical history of ischaemic heart disease and was taking lansoprazole.
On examination, she was walking independently. Extensor mechanism was intact. She was tender around the fibular head and varus stress testing was uncomfortable.
Blood tests showed normal inflammatory markers (C-Reactive Protein <4 mg/L, Erythrocyte Sedimentation Rate 7 mm/h, White Cell Count 8.2 × 109/L). Frontal and lateral knee x rays (Fig. 1) demonstrated multifocal calcium deposits at the proximal fibula and MR images (Fig. 2) confirmed the presence calcific deposits within the distal biceps femoris tendon, just proximal to its fibular insertion. These findings were in keeping with calcific tendinitis.
Fig. 1.
A, Frontal and B, Lateral knee x rays demonstrate multifocal calcium deposits at the proximal fibula as indicated by the arrows.
Fig. 2.
A, Coronal Proton density fat saturation MR. B, Sagittal gradient echo MR. C, Sagittal proton density non fat saturation MR. Images confirm the presence of multifocal calcium deposits (white arrows) within the distal biceps femoris tendon (black arrow).
The patient did not respond well to conservative treatment and physiotherapy. She went on to have ultrasound-guided barbotage of the calcium deposits and peri-tendinous corticosteroid injection, which achieved complete symptomatic relief.
3. Discussion
Osteoarthritis is the most common cause of lateral knee pain in the elderly population. Traumatic meniscal tears and ligaments injuries and chronic overuse conditions like iliotibial band friction syndrome are amongst the more commonly seen pathology in the younger age group. Calcific tendinitis within the distal biceps femoris tendon is rare. Current understanding of calcific tendinitis is limited though it is thought to be caused by a cell-mediated deposition of hydroxyapatite crystals within the periarticular soft tissues.2,3 This leads to inflammation and pain around the joint.
It is most commonly known to affect the rotator cuff, specifically supraspinatus tendon, however, can be seen within other joints including the hip, elbow and wrist joints.1 Apart from tendons, the ligaments and bursae are the other periarticular structures which may show calcific deposits. It has been reported in association with chronic kidney disease, diabetes, trauma, metabolic causes such as hyperparathyroidism and other hypercalcaemic states.4,5 It is important to exclude above-mentioned causes for recurrent and recalcitrant calcific tendinitis, as the condition is unlikely to improve without treating the underlying factors.
Imaging is an important tool for confirmation of the diagnosis. X rays show periarticular calcium deposits within the soft tissue (Fig. 1). In the present case, given the unusual location of the calcium deposit, an MRI scan was performed, which confirmed the presence of calcium within the substance of distal biceps femoris tendon (Fig. 2). A calcific focus in and around the knee is usually an intracapsular loose body, as a result of osteoarthritis or old trauma. However, an obvious extracapsular location, adjacent to the fibular styloid process should raise concerns for calcific tendinitis and in the context of symptoms, warrants further investigation of this potentially treatable condition.
The management is similar to the calcific tendinitis of rotator cuff. In majority of the patients, calcific tendinitis is self-limiting with resorption of calcium resulting in pain relief.6 A vast majority of patients are managed conservatively with pain relief followed by maintenance of activity by exercises and muscle strengthening.
The other treatment methods include ultrasound guided barbotage (needling and lavage) of calcium deposits, extracorporeal shock wave therapy and arthroscopic excision. Ultrasound guided barbotage is a widely accepted and safe treatment for calcific tendinitis.7 A study of chronic calcific tendonitis in 420 patients found that, with non-operative treatment only, symptoms persisted in 27% patients.8 These patients went on to have arthroscopic removal of the calcific deposit. Radial shockwave therapy has also been found to be safe and effective, resulting in significant reduction in pain and improvement in shoulder function after 4 weeks.9
In conclusion, distal biceps femoris is an unusual site for a rather common pathology of calcific tendinitis, which can present with lateral knee pain. Diagnosis is made on knee radiograph, which shows soft tissue calcium deposits. MRI is useful to confirm the presence of calcium deposits within the tendon substance. We believe that knowledge of the unusual sites of calcific tendinitis, as in this case, can help early diagnosis and facilitate appropriate management.
Acknowledgements
We would like to thank Dr Joanne Edwards, Speciality Registrar Radiology, Mr Nicholas Shaw, Consultant Orthopaedics and Trauma and Dr Imroz Singh Sachdev, Consultant Radiologist for their valuable contributions towards this case report.
References
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