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Journal of Ultrasound

, Volume 22, Issue 4, pp 471–476 | Cite as

Treatment of a calcific bursitis of the medial collateral ligament: a rare cause of painful knee

  • Lisa GallettiEmail author
  • Vincenzo Ricci
  • Ernesto Andreoli
  • Stefano Galletti
Case Report

Abstract

Medial knee pain is common in clinical practice and can be caused by various conditions. In rare cases, it can even be by calcific bursitis of the medial collateral ligament (MCL). Treatment of calcific bursitis and/or calcification of the MCL classically includes observation, local injections, shockwave therapy and surgical resection. We report a case of nontraumatic medial knee pain poorly responsive to conservative treatments. Ultrasound (US) imaging revealed a massive lobed hyperechoic formation with partial acoustic shadow in the MCL context compatible with calcific bursitis, and magnetic resonance imaging (MRI) confirmed the presence of the bursa’s calcific deposit surrounded by hyperintense signal compatible with pericalcific edema. We performed a double-needle ultrasound-guided percutaneous lavage (UGPL), which is today a fairly common treatment for many musculoskeletal disorders, such as rotator cuff calcific tendinopathy and elbow extensor tendons pathology, but regarding the knee, it is not part of ordinary care. This report shows the clinical and imaging presentation of calcific bursitis of the MCL and describes in detail the technique to perform the UGPL with a system of two needles, two syringes and a double connection to ensure a correct lavage of the calcium deposit without significant intrabursal pressure increase and consequently without pain during the procedure.

Keywords

Medial collateral ligament Pain Voshell’s bursa Calcific bursitis Ultrasound Treatment 

Sommario

Il dolore localizzato alla regione mediale del ginocchio è di frequente riscontro nella pratica clinica e può essere causato da diverse condizioni patologiche, in rari casi anche da una borsite calcifica del legamento collaterale mediale (LCM). Il trattamento di una borsite calcifica e/o di una calcificazione del LCM prevede classicamente il monitoraggio clinico, le infiltrazioni locali, la terapia con onde d’urto ed infine la rimozione chirurgica. Riportiamo un caso di dolore localizzato alla regione mediale del ginocchio, non traumatico, scarsamente responsivo ai trattamenti conservativi. La valutazione ecografica ha rivelato la presenza di una voluminosa formazione iperecogena polilobata con parziale cono d’ombra posteriore nel contesto del LCM, compatibile con una borsite calcifica intra-ligamentosa; le scansioni di risonanza magnetica nucleare (RMN) hanno confermato la presenza del deposito endo-bursale circondato da segnale iperintenso compatibile con edema peri-calcifico. Abbiamo quindi eseguito una procedura di lavaggio percutaneo eco-guidato con due aghi, che ad oggi rappresenta un trattamento ampiamente utilizzato per diverse patologie del sistema muscolo scheletrico come la tendinopatia calcifica della cuffia dei rotatori della spalla e la patologia calcifica degli estensori di gomito, mentre per il ginocchio non rientra nei trattamenti eseguiti di routine. Questo articolo illustra le caratteristiche cliniche ed ecografiche della borsite calcifica del LCM ed ha l’obiettivo di descrivere in dettaglio la tecnica per eseguire un lavaggio percutaneo eco-guidato con un sistema di due aghi, due siringhe e un duplice tubo di raccordo per assicurare un completo lavaggio del deposito calcifico senza significativo aumento della pressione intra-bursale con l’obiettivo di minimizzare il dolore in corso di procedura.

Notes

Funding

No funding was received.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Bellary SS, Lynch G et al (2012) Medial plica syndrome: a review of the literature. Clin Anat 25(4):423–428CrossRefGoogle Scholar
  2. 2.
    Morganti CM, McFarland EG, Cosgarea AJ (2002) Saphenous neuritis: a poorly understood cause of medial knee pain. J Am Acad Orthop Surg 10(2):130CrossRefGoogle Scholar
  3. 3.
    Siddiq MAB, Jahan I (2017) Medial collateral ligament calcification: a rare knee pain entity with literature review. Acta Radiol Open.  https://doi.org/10.1177/2058460117738549 CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Themistoklis V, Filon A et al (2016) Massive non-traumatic calcification of the medial collateral ligament of the knee. BMJ Case Rep.  https://doi.org/10.1136/bcr-2016-217743 CrossRefGoogle Scholar
  5. 5.
    Del Castillo-González F, Ramos-Álvarez JJ et al (2016) Ultrasound-guided percutaneous lavage of calcific bursitis of the medial collateral ligament of the knee: a case report and review of the literature. Skeletal Radiol 45:1419–1423CrossRefGoogle Scholar
  6. 6.
    Brantigan OC, Voshell AF (1943) The tibial collateral ligament: its function, its bursae, and its relation to the medial meniscus. J Bone Joint Surg Am 25:121–131Google Scholar
  7. 7.
    Stella SM, Ciampi B (2017) Ginocchio, richiami di anatomia e semeiotica ecografica. In: Galletti S (ed) Atlante di anatomia ecografica e biomeccanica muscoloscheletrica. Piccin, Padova, pp 402–459Google Scholar
  8. 8.
    Lanza E, Banfi G, Serafini G et al (2015) Ultrasound-guided percutaneous irrigation in rotator cuff calcific tendinopathy: what is the evidence? A systematic review with proposals for future reporting. Eur Radiol 25:2176–2183CrossRefGoogle Scholar
  9. 9.
    Galletti S, Magnani M, Rotini R et al (2004) The echo-guided treatment of calcific tendinitis of the shoulder. Chir Organi Mov 89(4):319–323PubMedGoogle Scholar
  10. 10.
    Galletti S, Serafini G, Minetti V, Galletti R, Mignani G (2018) Tendini, appendice: trattamento percutaneo ecoguidato della tendinopatia calcifica di spalla. In: Galletti S (ed) Ecografia patologica muscolo scheletrica, testo e atlante. Piccin, Padova, pp 376–386Google Scholar
  11. 11.
    Abate M, Salini V, Schiavone C (2016) Ultrasound-guided percutaneous lavage in the treatment of calcific tendinopathy of elbow extensor tendons: a case report. Malays Orthop J 10(2):53–55CrossRefGoogle Scholar
  12. 12.
    Serafini G, Sconfienza M, Lacelli F et al (2009) Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two needle US-guided percutaneous treatment—non randomized controlled trial. Radiology 252(1):157–164CrossRefGoogle Scholar
  13. 13.
    Bianchi S, Martinoli C (2007) Ultrasound of the musculoskeletal system. Springer, Berlin, pp 198–332CrossRefGoogle Scholar
  14. 14.
    Tagliafico A, Russo G, Boccalini S et al (2014) Ultrasound-guided interventional procedures around the shoulder. Radiol Med 119(5):318–326CrossRefGoogle Scholar
  15. 15.
    Clavert P, Sirveaux F, Sociètè française d’arthroscopie (2008) Shoulder calcifying tendinitis. Rev Chir Orthop Reparatrice Appar Mot 94:336–355CrossRefGoogle Scholar
  16. 16.
    Barile A, Bruno F, Mariani S et al (2017) Follow-up of surgical and minimally invasive treatment of Achilles tendon pathology: a brief diagnostic imaging review. Musculoskeletal Surg 101:51–61CrossRefGoogle Scholar
  17. 17.
    Uhthoff HK, Sarkar K (1989) Calcifying tendinitis. Baillieres Clin Rheumatol 3:567–581CrossRefGoogle Scholar
  18. 18.
    Barile A, La Marra A, Arrigoni F et al (2016) Anaesthetics, steroids and platelet-rich plasma (PRP) in ultrasound-guided musculoskeletal procedures. Br J Radiol 89(1065):20150355CrossRefGoogle Scholar
  19. 19.
    Oliva F, Giai Via A, Maffulli N (2012) Physiopathology of intratendinous calcific deposit. BMC Med 10:95CrossRefGoogle Scholar
  20. 20.
    Uhthoff HK, Loehr JW (1997) Calcific tendinopathy of the rotator cuff: pathogenesis, diagnosis and management. J Am Acad Orthop Surg 5:183–191CrossRefGoogle Scholar
  21. 21.
    Nakase T, Takeuchi E, Sugamoto K et al (2000) Involvement of multinucleated giant cells synthesizing cathepsin K in calcified tendinitis of the rotator cuff tendons. Rheumatology 39:1074–1077CrossRefGoogle Scholar
  22. 22.
    Kim YS, Lee HJ, Kim YV, Kong CG (2014) Which method is more effective in treatment of calcific tendinitis in the shoulder? Prospective randomized comparison between ultrasound-guided needling and extracorporeal shock wave therapy. J Shoulder Elbow Surg 23:1640–1646CrossRefGoogle Scholar
  23. 23.
    Robotti G, Canepa MG, Bortolotto C, Draghi F (2013) Interventional musculoskeletal US: an update on materials and methods. J Ultrasound 16(2):45–55CrossRefGoogle Scholar
  24. 24.
    Cura JL et al (2007) Sonographically guided percutaneous needle lavage in calcific tendinitis of the shoulder: short- and long-term results. AJR Am J Roentgenol 189(3):W128–W134CrossRefGoogle Scholar
  25. 25.
    De Zordo T, Ahmad N, Ødegaard F et al (2011) US-guided therapy of calcific tendinopathy: clinical and radiological outcome assessment in shoulder and non-shoulder tendons. Ultraschall Med 32(Suppl 1):S117–S123PubMedGoogle Scholar
  26. 26.
    Witte PB, Selten JW, Navas A et al (2013) Calcific tendinitis of the rotator cuff: a randomized controlled trial of ultrasound-guided needling and lavage versus subacromial corticosteroids. Am J Sports Med 41(7):1665–1673CrossRefGoogle Scholar
  27. 27.
    Sconfienza LM, Albano D, Messina C et al (2018) How, When, Why in Magnetic Resonance Arthrography: an International Survey by the European Society of Musculoskeletal Radiology (ESSR). Eur Radiol 28(6):2356–2368CrossRefGoogle Scholar
  28. 28.
    Orlandi D, Mauri G, Lacelli F et al (2017) Rotator cuff calcific tendinopathy: randomized comparison of us-guided percutaneous treatments by using one or two needles. Radiology 285:518–527CrossRefGoogle Scholar
  29. 29.
    Draghi F, Robotti G, Jacob D et al (2010) Interventional musculoskeletal ultrasonography: precautions and contraindications. J Ultrasound 13(3):126–133CrossRefGoogle Scholar
  30. 30.
    Cocco G, Draghi F, Schiavone C (2018) Ultrasonographic diagnosis and percutaneous treatment of insertional calcific tendinopathy of iliotibial band case report. Euro Rad.  https://doi.org/10.1594/eurorad/case.15881 CrossRefGoogle Scholar
  31. 31.
    Rebuzzi E, Coletti N, Schiavetti S, Giusto F (2008) Arthroscopy surgery versus shock wave therapy for chronic calcifying tendinitis of the shoulder. J Orthop Traumatol 9:179–185CrossRefGoogle Scholar
  32. 32.
    Fields LK, Muxlow CJ, Caldwell PE (2014) Arthroscopic treatment of subscapularis cacific tendonitis. Arthrosc Tech 3:e571-3CrossRefGoogle Scholar

Copyright information

© Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB) 2019

Authors and Affiliations

  1. 1.Physical Medicine and Rehabilitation UnitSan Giovanni in PersicetoBolognaItaly
  2. 2.Department of Biomedical and Neuromotor Science, Physical Medicine and Rehabilitation UnitIRCCS Rizzoli Orthopaedic InstituteBolognaItaly
  3. 3.Physical Medicine and Rehabilitation UnitUniversity Hospital Policlinico Sant’Orsola-MalpighiBolognaItaly
  4. 4.Musculoskeletal Ultrasound SchoolItalian Society for Ultrasound in Medicine and Biology (SIUMB)BolognaItaly

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