Our case series looks at four unusual presentations of HAD affecting the origin of the peroneus longus at the fibular head,
the longus colli muscle,
common extensor origin in the elbow and the gluteus medius tendon in the hip.
Almost any tendon in the body is susceptible to HAD.
The supraspinatus tendon in the shoulder is the most commonly affected.
The hip joint is one of the more reported sites.
Calcific deposits may be seen in any of the peri-articular tendons and more commonly the gluteal tendons [5].
Case 1:
A 50 year old lady presented with exquisite right lateral hip pain and limited range of movement on abduction.
On examination there was marked tenderness over the right greater trochanter.
A plain radiograph demonstrated dense calcification lateral to the greater trochanter (Figure 1).
Fig. 1: Plain X-ray of the right hip demonstrates amorphous dense calcification in the projection of the right gluteal tendon insertion at the right greater trochanter (red arrows)
Fat suppressed MRI imaging confirmed the presence of calcification in the gluteus medius tendon with marked peri-calcific oedema (Figure 2).
Fig. 2: Coronal STIR image of the pelvis confirms the calcific depositis in the right gluteus medius tendon with surrounding oedema extending into the surrounding soft tissues and musculotendinous junction (red arrows)
Follow up MRI demonstrated complete resolution of the calcific deposits and oedema.
Case 2:
A 47 year old lady presents with pain on the lateral aspect of her knee.
Initial radiograph is normal.
The pain persisted and was tender to touch particularly at the proximal fibular head.
A focussed ultrasound demonstrated a calcific deposit at the myotendinous junction of the peroneus longus with a peri-calcifc hypoechoic halo (Figure 3).
Findings were confirmed on MR which showed marked peri-calcifc oedema predominantly in the muscle belly of peroneus longus (Figure 4).
Fig. 4: Sagittal PD fat saturated images of the knee demonstrate a calcific deposit in the myotendinous junction of the proximal peroneus longus (red arrow) with marked reactive myositis
Case 3:
A 48 year old man complained of acute shooting pain on the lateral aspect of his right elbow.
There was marked tenderness on palpation of the lateral epicondyle.
A plain radiograph confirmed the presence of a calcification in the lateral epicondyle (Figure 5).
Fig. 5: Plain radiograph of the right elbow shows a large dense calcification lateral to the lateral epicondyle (red arrows)
An ultrasound confirmed the calcification in the common extensor origin with marked surrounding neovascularity on Doppler studies (Figure 6).
This is seen as marked surrounding oedema on subsequent MRI with reactive myositis in the extensor carpi radialis brevis (ECRB) muscle belly (Figure 7).
Fig. 7: Coronal MR image demonstrates intra-tendinous calcification in the common extensor origin (red arrow) with striking myositis in the muscle belly of ERCB
Case 4:
A 35 year old man presented with 48 hours of neck stiffness.
A plain radiograph demonstrates straightening of the cervical spine with subtle calcification anterior to the dens.
This was initially overlooked (Figure 8).
Fig. 8: Subtle calcifications in the anterior soft tissues of the neck (red arrows) with straightening of the cervical spine
A MRI was performed which showed marked pre-vertebral soft tissue oedema.
Post contrast studies did not reveal any collections.
A CT confirmed the presence of punctate calcifications in the pre-vertebral soft tissues at the C1-2 vertebral levels (Figure 9,
10).
Fig. 9: Fat saturated T2 weighted axial MR image (left) demonstrates marked pre-vertebral oedema (red arrows) and corresponding axial non contrast CT (right) shows the co-existing pre-vertebral soft tissue calcifications (red arrows).
Fig. 10: Sagittal STIR image of the cervical spine. Red arrows delineate the marked pre-vertebral oedema in the longus colli musculature.