Skeletal Radiol (1991) 20 : 21-23
Skeletal Radiology
Caleific tendinitis of the vastus lateralis muscle A report o f three cases F.A. Ramon, M.D. 1, H.R. Degryse, M.D. t, A.M. De Schepper, M.D., Ph.D. 1, and E.A. Van Marck, M.D., Ph.D. 2 Departments of 1 Radiology and 2 Pathology, University Hospital, Antwerp, Belgium
Abstract. T h r e e cases o f calcific tendinitis o c c u r r i n g at a n u n u s u a l site (vastus lateralis t e n d o n ) are described. Findings on conventional radiography and computed t o m o g r a p h y t o g e t h e r w i t h the clinical h i s t o r y are c h a r a c teristic for this d i s o r d e r a n d reflect its n a t u r a l e v o l u t i o n . T h e a c t u a l role o f m a g n e t i c r e s o n a n c e i m a g i n g seems l i m i t e d to e x c l u d i n g n e o p l a s m a n d to d e m o n s t r a t i n g inf l a m m a t o r y c h a n g e s b e t t e r in the e a r l y stages o f disease.
Key words: Calcific tendinitis - Vastus lateralis m u s c l e - P a r o s t e a l soft tissue c a l c i f i c a t i o n - C o m p u t e d t o m o g raphy - Magnetic resonance imaging
Calcific tendinitis is r a r e e x c e p t in the s h o u l d e r r e g i o n [3, 4, 6, 15]. A l t h o u g h it c a n affect a l m o s t a n y t e n d o n i n s e r t i o n , o n l y a few o t h e r l o c a t i o n s h a v e b e e n m e n t i o n e d in the r e c e n t l i t e r a t u r e [2, 5, 7, 8, 11, 12]. T h r e e p a t i e n t s w i t h p a r o s t e a l soft tissue calcifications at the b a c k o f the t h i g h o n c o n v e n t i o n a l r a d i o g r a p h s were examined by computed tomography (CT) and magnetic r e s o n a n c e i m a g i n g ( M R I ) in o r d e r to rule o u t n e o p l a s m . T h e final d i a g n o s i s o f calcific tendinitis o f the v a s t u s lateralis m u s c l e was p r o v e d b y o p e r a t i o n a n d h i s t o l o g i c e x a m i n a t i o n . T h e clinical h i s t o r y a n d the r a d i o l o g i c a l findings w i t h special e m p h a s i s o n C T a n d M R I p r e s e n t a tion are reported.
Case reports Case 1 A 66-year-old man felt a sudden heavy pain at the back of the right thigh walking down the stairs. Physical examination on admission to the hospital revealed no abnormality. Conventional radiographs showed an egg-shell calcification at the lateral aspect Address reprint requests to: A.M.A. De Schepper, M.D., Ph.D., Department of Radiology, University Hospital Antwerp, Wilrijkstraat 10, B-2520 Edegem, Belgium
of the femur below the lesser trochanter. CT showed this calcification to be located in the vastus lateralis. Edema of the adjacent muscular tissue was noted (Fig. IA). On T1- and T2-weighted SE images in MRI the lesion had a low signal intensity while the surrounding edema was of high signal intensity on T2 weighting (Fig. 1B, C). Microscopic examination of a biopsy specimen showed a large calcified area surrounded by dense fibrous tissue and numerous giant cells. The diagnosis of calcifying tendinitis was made.
Case 2 A 45-year-old man was admitted to the hospital with a painful induration at the back of the right thigh. Over a period of 4 months the lesion became harder while the pain decreased. There was no history of trauma. Laboratory examinations gave normal results. CT revealed a rounded calcified nodule at the posterior aspect of the femur at the level of the lesser trochanter. A minimal erosion of the cortex was seen (Fig. 2). On MRI this lesion had a low signal intensity on both TIand T2-weighted SE images with an increased signal intensity of the surrounding soft tissues on T2-weighted images. The adjacent femoral cortex and marrow showed no abnormality. Microscopic examination showed normal cortical bone covered with fibrous tendon tissue. This connective tissue was interspersed by calcifications appearing as shiny amorphous coins and surrounded by numerous giant cells and histiocytes. Histological diagnosis of calcifying tendinitis was made. Case 3 A 45-year-old man presented with a 1-year history of pain in the right thigh, increasing on pressure. There was no prior trauma. Clinical examination revealed no further abnormalities. On conventional radiographs, an amorphous calcification was noted behind the femur, beneath the lesser trochanter (Fig. 3A, B). CT showed an inhomogeneous, rounded calcified spot in the vastus lateralis muscle with slight demineralization of the adjacent cortex (Fig. 3 C). On MRI the lesion was of low signal intensity on both Tland T2-weighted SE images without accompanying abnormalities in the adjacent bone and soft tissues. Microscopic examination showed hyaline connective tissue with histiocytes, giant cells, and calcified areas compatible with a diagnosis of calcifying tendinitis (Fig. 3 D). 9 1991 International Skeletal Society
22
F.A. Ramon et al. : Calcific tendinitis of the vastus lateralis muscle
Fig. 1. A C T demonstrates an ill-defined calcified area with edema of the surrounding muscle tissue. B On axial Tl-weighted MR image (SE 550/22; detail of the right thigh) the calcification has a low signal intensity. C This axial T2-weighted image (SE 2500/90) through the thigh demonstrates the low signal intensity calcified nodule with pronounced surrounding muscle edema (high signal intensity) Fig. 2. CT slice showing irregular calcium deposit in the tendon of insertion of the vastus lateralis muscle with associated cortical erosion
Fig. 3. A Frontal view of the right femur shows an amorphous calcification just below the lesser trochanter. B Frontal view, external rotation, shows the parosteal cloudlike calcifications below the lesser trochanter. C CT through the right thigh shows an inhomogeneous rounded calcification at the back of the femur. D Photomicrograph revealing a cell-rich fusocellular matrix with foreign-body giant cells (arrows) surrounding inhomogeneous calcifications. Hematoxylin-eosin, • 180
F.A. Ramon et al. : CaMfic tendinitis of the vastus lateralis muscle Discussion
Calcific tendinitis is a benign inflammatory disorder, occurring predominantly in the shoulder. Other locations sparsely mentioned in the literature are the tendon of the longus colli muscle [2], the insertion of the gluteus maximus [5, 10] and the flexor tendons of hands or feet [7, 11]. Association between calcific tendinitis and several diseases such as diabetes, thyroid disorders and tuberculosis has been reported [6, 15]. None of our patients, however, was suffering from any of these diseases. It should be noted that these etiological considerations relate to the shoulder region and not other locations. Bosworth et al. suggested the influence of repetitive motion or a chronic muscle insertion overload [3], but two o f our patients were sedentary workers and did not take part in any sporting activity. Several hypotheses on the pathogenesis have been proposed. Originally most authors assumed that calcifications appeared as a consequence of previous tendon necrosis. U h t h o f f et al. believe that hypoxia in the muscle insertion region leads to chondroid metaplasia and that this chondroid substance afterwards calcifies. The presence of histiocytes and giant cells at histologic examination is related to phagocytosis o f the calcium debris [13]. Calcific tendinitis usually causes no diagnostic problem. The clinical history is typical: complaints start with a sudden heavy painful sensation which gradually ameliorates while a hardening soft tissue mass arises. This evolution was seen in our three cases. On conventional radiographs, calcifications are thin and poorly defined in the early phase of the disorder. Progressively, they become more dense and rounded. With time the deposits may remain stable, enlarge or even disappear [2, 9]. However, some cases are persistent and may require aggressive treatment [4]. In our patients, however, the localization was atypical. All three presented with a calcified nodule at the back of the thigh. On CT the lesions were visualized in the tendon of insertion of the vastus lateralis muscle. Although based on single time point studies at varying periods after the onset of complaints, our CT findings seem to reflect the natural evolution of calcific tendinitis. Case 1 was diagnosed in the acute phase of the disease (2 weeks after onset of complaints). An ill-defined, cloudlike calcification associated with pronounced edema of the surrounding muscle tissue was seen. The complaints o f the second patient started 4 months before examination. After this delay CT demonstrated a more dense and sharply defined calcified nodule; edema of the muscle was mild. In case 3, the onset o f the pain dated from 1 year previously. On CT, the density of the deposit had become much less, probably because of partial resorption of the calcium by phagocytes. The nodule remained well delineated. Associated minimal changes (erosion, demineralization) of the femoral cortex were present in all three patients. As the atypical localization and the cortical changes raised suspicion of a parosteal malignancy, patients were referred for M R I examination. Both T1- and T2-
23 weighted SE sequences showed no evidence of a mass lesion. In the early stage, inflammation in surrounding tissue is demonstrated by ill-defined areas of high signal intensity on T2-weighted images. The calcifications are indirectly identified by their signal void on all sequences. Cortical changes, noted on CT, are not demonstrated on MRI. In summary, three cases of calcific tendinitis occurring at an unusual site (vastus lateralis muscle) are presented. On the basis of the findings using various imaging techniques, we believe that CT remains at present the first choice of procedure in the radiological investigation of calcific tendinitis. This is supported by the fact that CT allows better localization and a more precise definition of extent of the calcification than conventional radiography. CT is also more sensitive than M R I for disclosing calcific deposits and early cortical bone erosion [1, 14]. Furthermore, the typical morphology and small size of the calcifications, together with the absence of mass effect, are arguments provided by CT and not by M R I in favor of calcific tendinitis and against neoplasm. In addition to ruling out neoplasm more definitely, the current role of M R I seems limited to showing activity in the early stages of disease, by better demonstrating acute inflammatory changes. References
1. Aisen AM, Martel W, Braunstein EM, McMillin KI, Phillips WA, Kling TF (1986) MRI and CT evaluation of primary bone and soft tissue tumors. AJR 146:749 2. Artenian D J, Lipman JK, Scidmore GK, Brant-Zawadzki M (1989) Acute neck pain due to tendonitis of the longus colli: CT and MRI findings. Neuroradiology 31:166 3. Bosworth BM (1941) Calcium deposits in the shoulder and subacromial bursitis. JAMA 116:2477 4. Faure G, Daculsi G (1983) Calcified tendinitis: a review. Ann Rheum Dis 42, Suppl: 49 5. Hayes CW, Rosenthal DI, Plata MJ, Hudson TM (1987) Calcific tendinitis in unusual sites associated with cortical bone erosion. AJR 149:967 6. Mavrikakis ME, Drimis S, Kontoyannis DA, Rasidakis A, Moulopoulou ES, Kontoyannis S (1989) Calcific shoulder periarthritis (tendinitis) in adult onset diabetes mellitus: a controlled study. Ann Rheum Dis 48:211 7. Moyer RA, Bush DC, Harrington TM (1989) Acute calcific tendinitis of the hand and wrist: a report of 12 cases and a review of the literature. J Rheumatol 16:198 8. Nidecker A, Hartwig H (1983) SeRene Lokalisationen verkalkender Tendopathien. ROFO 139 : 658 9. Resnick D, Niwayama G (1981) Diagnosis of bone and joint disorders. Saunders, Philadelphia, p 1567 I0. Resnick D, Niwayama G (1983) Entheses and enthesopathy - anatomical, pathological and radiological correlation. Radiology 146:1 11. Rhodes RA, Stelling CB (1985) Calcific tendinitis of the forefoot. Ann Emerg Med (Sept) 24:751 12. Stark P, Hildebrandt-Stark HE (1983) Calcific tendinitis of the piriforrn muscle. ROFO 138 : 111 13. Uhthoff HK, Sartiar K, Maynard J (1976) Calcifying tendinitis: a new concept of its pathogenesis. Clin Orthop 18:164 14. Wetzel LH, Levine E, Murphey MD (1987) A comparison of MR imaging and CT in the evaluation of musculoskeletal masses. Radiographics 7 :751 15. Wright V, Haq AM (1976) Periarthritis of the shoulder: aetiological considerations with particular reference to personality factors. Ann Rheum Dis 35:213
Skeletal Radiology
Caleific tendinitis of the vastus lateralis muscle A report o f three cases F.A. Ramon, M.D. 1, H.R. Degryse, M.D. t, A.M. De Schepper, M.D., Ph.D. 1, and E.A. Van Marck, M.D., Ph.D. 2 Departments of 1 Radiology and 2 Pathology, University Hospital, Antwerp, Belgium
Abstract. T h r e e cases o f calcific tendinitis o c c u r r i n g at a n u n u s u a l site (vastus lateralis t e n d o n ) are described. Findings on conventional radiography and computed t o m o g r a p h y t o g e t h e r w i t h the clinical h i s t o r y are c h a r a c teristic for this d i s o r d e r a n d reflect its n a t u r a l e v o l u t i o n . T h e a c t u a l role o f m a g n e t i c r e s o n a n c e i m a g i n g seems l i m i t e d to e x c l u d i n g n e o p l a s m a n d to d e m o n s t r a t i n g inf l a m m a t o r y c h a n g e s b e t t e r in the e a r l y stages o f disease.
Key words: Calcific tendinitis - Vastus lateralis m u s c l e - P a r o s t e a l soft tissue c a l c i f i c a t i o n - C o m p u t e d t o m o g raphy - Magnetic resonance imaging
Calcific tendinitis is r a r e e x c e p t in the s h o u l d e r r e g i o n [3, 4, 6, 15]. A l t h o u g h it c a n affect a l m o s t a n y t e n d o n i n s e r t i o n , o n l y a few o t h e r l o c a t i o n s h a v e b e e n m e n t i o n e d in the r e c e n t l i t e r a t u r e [2, 5, 7, 8, 11, 12]. T h r e e p a t i e n t s w i t h p a r o s t e a l soft tissue calcifications at the b a c k o f the t h i g h o n c o n v e n t i o n a l r a d i o g r a p h s were examined by computed tomography (CT) and magnetic r e s o n a n c e i m a g i n g ( M R I ) in o r d e r to rule o u t n e o p l a s m . T h e final d i a g n o s i s o f calcific tendinitis o f the v a s t u s lateralis m u s c l e was p r o v e d b y o p e r a t i o n a n d h i s t o l o g i c e x a m i n a t i o n . T h e clinical h i s t o r y a n d the r a d i o l o g i c a l findings w i t h special e m p h a s i s o n C T a n d M R I p r e s e n t a tion are reported.
Case reports Case 1 A 66-year-old man felt a sudden heavy pain at the back of the right thigh walking down the stairs. Physical examination on admission to the hospital revealed no abnormality. Conventional radiographs showed an egg-shell calcification at the lateral aspect Address reprint requests to: A.M.A. De Schepper, M.D., Ph.D., Department of Radiology, University Hospital Antwerp, Wilrijkstraat 10, B-2520 Edegem, Belgium
of the femur below the lesser trochanter. CT showed this calcification to be located in the vastus lateralis. Edema of the adjacent muscular tissue was noted (Fig. IA). On T1- and T2-weighted SE images in MRI the lesion had a low signal intensity while the surrounding edema was of high signal intensity on T2 weighting (Fig. 1B, C). Microscopic examination of a biopsy specimen showed a large calcified area surrounded by dense fibrous tissue and numerous giant cells. The diagnosis of calcifying tendinitis was made.
Case 2 A 45-year-old man was admitted to the hospital with a painful induration at the back of the right thigh. Over a period of 4 months the lesion became harder while the pain decreased. There was no history of trauma. Laboratory examinations gave normal results. CT revealed a rounded calcified nodule at the posterior aspect of the femur at the level of the lesser trochanter. A minimal erosion of the cortex was seen (Fig. 2). On MRI this lesion had a low signal intensity on both TIand T2-weighted SE images with an increased signal intensity of the surrounding soft tissues on T2-weighted images. The adjacent femoral cortex and marrow showed no abnormality. Microscopic examination showed normal cortical bone covered with fibrous tendon tissue. This connective tissue was interspersed by calcifications appearing as shiny amorphous coins and surrounded by numerous giant cells and histiocytes. Histological diagnosis of calcifying tendinitis was made. Case 3 A 45-year-old man presented with a 1-year history of pain in the right thigh, increasing on pressure. There was no prior trauma. Clinical examination revealed no further abnormalities. On conventional radiographs, an amorphous calcification was noted behind the femur, beneath the lesser trochanter (Fig. 3A, B). CT showed an inhomogeneous, rounded calcified spot in the vastus lateralis muscle with slight demineralization of the adjacent cortex (Fig. 3 C). On MRI the lesion was of low signal intensity on both Tland T2-weighted SE images without accompanying abnormalities in the adjacent bone and soft tissues. Microscopic examination showed hyaline connective tissue with histiocytes, giant cells, and calcified areas compatible with a diagnosis of calcifying tendinitis (Fig. 3 D). 9 1991 International Skeletal Society
22
F.A. Ramon et al. : Calcific tendinitis of the vastus lateralis muscle
Fig. 1. A C T demonstrates an ill-defined calcified area with edema of the surrounding muscle tissue. B On axial Tl-weighted MR image (SE 550/22; detail of the right thigh) the calcification has a low signal intensity. C This axial T2-weighted image (SE 2500/90) through the thigh demonstrates the low signal intensity calcified nodule with pronounced surrounding muscle edema (high signal intensity) Fig. 2. CT slice showing irregular calcium deposit in the tendon of insertion of the vastus lateralis muscle with associated cortical erosion
Fig. 3. A Frontal view of the right femur shows an amorphous calcification just below the lesser trochanter. B Frontal view, external rotation, shows the parosteal cloudlike calcifications below the lesser trochanter. C CT through the right thigh shows an inhomogeneous rounded calcification at the back of the femur. D Photomicrograph revealing a cell-rich fusocellular matrix with foreign-body giant cells (arrows) surrounding inhomogeneous calcifications. Hematoxylin-eosin, • 180
F.A. Ramon et al. : CaMfic tendinitis of the vastus lateralis muscle Discussion
Calcific tendinitis is a benign inflammatory disorder, occurring predominantly in the shoulder. Other locations sparsely mentioned in the literature are the tendon of the longus colli muscle [2], the insertion of the gluteus maximus [5, 10] and the flexor tendons of hands or feet [7, 11]. Association between calcific tendinitis and several diseases such as diabetes, thyroid disorders and tuberculosis has been reported [6, 15]. None of our patients, however, was suffering from any of these diseases. It should be noted that these etiological considerations relate to the shoulder region and not other locations. Bosworth et al. suggested the influence of repetitive motion or a chronic muscle insertion overload [3], but two o f our patients were sedentary workers and did not take part in any sporting activity. Several hypotheses on the pathogenesis have been proposed. Originally most authors assumed that calcifications appeared as a consequence of previous tendon necrosis. U h t h o f f et al. believe that hypoxia in the muscle insertion region leads to chondroid metaplasia and that this chondroid substance afterwards calcifies. The presence of histiocytes and giant cells at histologic examination is related to phagocytosis o f the calcium debris [13]. Calcific tendinitis usually causes no diagnostic problem. The clinical history is typical: complaints start with a sudden heavy painful sensation which gradually ameliorates while a hardening soft tissue mass arises. This evolution was seen in our three cases. On conventional radiographs, calcifications are thin and poorly defined in the early phase of the disorder. Progressively, they become more dense and rounded. With time the deposits may remain stable, enlarge or even disappear [2, 9]. However, some cases are persistent and may require aggressive treatment [4]. In our patients, however, the localization was atypical. All three presented with a calcified nodule at the back of the thigh. On CT the lesions were visualized in the tendon of insertion of the vastus lateralis muscle. Although based on single time point studies at varying periods after the onset of complaints, our CT findings seem to reflect the natural evolution of calcific tendinitis. Case 1 was diagnosed in the acute phase of the disease (2 weeks after onset of complaints). An ill-defined, cloudlike calcification associated with pronounced edema of the surrounding muscle tissue was seen. The complaints o f the second patient started 4 months before examination. After this delay CT demonstrated a more dense and sharply defined calcified nodule; edema of the muscle was mild. In case 3, the onset o f the pain dated from 1 year previously. On CT, the density of the deposit had become much less, probably because of partial resorption of the calcium by phagocytes. The nodule remained well delineated. Associated minimal changes (erosion, demineralization) of the femoral cortex were present in all three patients. As the atypical localization and the cortical changes raised suspicion of a parosteal malignancy, patients were referred for M R I examination. Both T1- and T2-
23 weighted SE sequences showed no evidence of a mass lesion. In the early stage, inflammation in surrounding tissue is demonstrated by ill-defined areas of high signal intensity on T2-weighted images. The calcifications are indirectly identified by their signal void on all sequences. Cortical changes, noted on CT, are not demonstrated on MRI. In summary, three cases of calcific tendinitis occurring at an unusual site (vastus lateralis muscle) are presented. On the basis of the findings using various imaging techniques, we believe that CT remains at present the first choice of procedure in the radiological investigation of calcific tendinitis. This is supported by the fact that CT allows better localization and a more precise definition of extent of the calcification than conventional radiography. CT is also more sensitive than M R I for disclosing calcific deposits and early cortical bone erosion [1, 14]. Furthermore, the typical morphology and small size of the calcifications, together with the absence of mass effect, are arguments provided by CT and not by M R I in favor of calcific tendinitis and against neoplasm. In addition to ruling out neoplasm more definitely, the current role of M R I seems limited to showing activity in the early stages of disease, by better demonstrating acute inflammatory changes. References
1. Aisen AM, Martel W, Braunstein EM, McMillin KI, Phillips WA, Kling TF (1986) MRI and CT evaluation of primary bone and soft tissue tumors. AJR 146:749 2. Artenian D J, Lipman JK, Scidmore GK, Brant-Zawadzki M (1989) Acute neck pain due to tendonitis of the longus colli: CT and MRI findings. Neuroradiology 31:166 3. Bosworth BM (1941) Calcium deposits in the shoulder and subacromial bursitis. JAMA 116:2477 4. Faure G, Daculsi G (1983) Calcified tendinitis: a review. Ann Rheum Dis 42, Suppl: 49 5. Hayes CW, Rosenthal DI, Plata MJ, Hudson TM (1987) Calcific tendinitis in unusual sites associated with cortical bone erosion. AJR 149:967 6. Mavrikakis ME, Drimis S, Kontoyannis DA, Rasidakis A, Moulopoulou ES, Kontoyannis S (1989) Calcific shoulder periarthritis (tendinitis) in adult onset diabetes mellitus: a controlled study. Ann Rheum Dis 48:211 7. Moyer RA, Bush DC, Harrington TM (1989) Acute calcific tendinitis of the hand and wrist: a report of 12 cases and a review of the literature. J Rheumatol 16:198 8. Nidecker A, Hartwig H (1983) SeRene Lokalisationen verkalkender Tendopathien. ROFO 139 : 658 9. Resnick D, Niwayama G (1981) Diagnosis of bone and joint disorders. Saunders, Philadelphia, p 1567 I0. Resnick D, Niwayama G (1983) Entheses and enthesopathy - anatomical, pathological and radiological correlation. Radiology 146:1 11. Rhodes RA, Stelling CB (1985) Calcific tendinitis of the forefoot. Ann Emerg Med (Sept) 24:751 12. Stark P, Hildebrandt-Stark HE (1983) Calcific tendinitis of the piriforrn muscle. ROFO 138 : 111 13. Uhthoff HK, Sartiar K, Maynard J (1976) Calcifying tendinitis: a new concept of its pathogenesis. Clin Orthop 18:164 14. Wetzel LH, Levine E, Murphey MD (1987) A comparison of MR imaging and CT in the evaluation of musculoskeletal masses. Radiographics 7 :751 15. Wright V, Haq AM (1976) Periarthritis of the shoulder: aetiological considerations with particular reference to personality factors. Ann Rheum Dis 35:213
