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Patellar Whiskers and Acute Calcific Quadriceps Tendinitis in a General Hospital Population.

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1409
PATELLAR WHISKERS AND ACUTE
CALCIFIC QUADRICEPS TENDINITIS IN
A GENERAL HOSPITAL POPULATION
L. TRUJEQUE, P. SPOHN, A. BANKHURST, R. MESSNER,
and R. SEARLES
Described is a case of acute calcific quadriceps
tendinitis which presented as monoarticular arthritis. A
survey of general hospital patients revealed a 7%incidence
of calcification of the superior patellar tendon. The most
common concurrent abnormality was degenerative joint
disease (94%); concomitant chondrocalcinosis was not
seen. The “patellar whisker” is a relatively common xray finding that may be the clue to an uncommon cause of
acute arthritis.
Calcific tendinitis may present as an acute monoarticular arthritis (1). The attacks commonly involve
the shoulder, although occurrence at other sites is well
described (2-7). In addition to the usual monoarticular
presentation, Pinals and Short (8) described 4 patients
who suffered repeated attacks in multiple sites and
raised the possiblility that these patients suffered from
generalized disease clinically similar to chondrocalcinosis or gout. The present study was initiated by a
From the Department of Medicine, University of New Mexico, School of Medicine, Albuquerque, New Mexico 87131.
L. Trujeque: Resident, University of New Mexico, Associated Hospitals, Albuquerque, New Mexico; P. Spohn, Fourth-Year
Medical Student, University of Oregon, Portland, Oregon; A. Bankhurst, Associate Professor of Medicine and Senior Investigator of the
Arthritis Foundation, University of New Mexico; R. Messner, Professor of Medicine, University of New Mexico; R. Searles, Fellow in
Rheumatology, University of New Mexico.
Address reprint requests to Arthur D. Bankhurst, M.D.,
Associate Professor of Medicine, University of New Mexico School of
Medicine, Albuquerque, New Mexico 87131.
Submitted for publication February 28, 1977; accepted
March 22. 1977.
Arthritis and Rheumatism, Vol. 20,
No. 7 (September-October 1977)
patient with calcific quadriceps tendinitis w h o presented
with monoarticular arthritis involving the knee. It documents the relatively common occurrence of quadriceps
tendon calcification and emphasizes the diagnostic
problems related to the relatively rare symptomatic case
of calcific quadriceps tendinitis.
CASE REPORT
On August 25, 1976, CQ, a 59-year-old white male,
was admitted to the Albuquerque Veterans Administration
Hospital with what appeared to be an acute arthritis involving
the right knee. He was in good health until 3 days prior to
admission when he developed soreness and tenderness of the
right knee. He ascribed this to more vigorous physical activity
and remained home from work. The soreness subsided over
the next 2 days. On the day of admission, he awoke with a
painful erythematous swelling of the knee.
A similar episode in 1941 involved the left ankle and
right knee. A diagnosis of possible acute rheumatic fever was
made at that time. Those symptoms subsided with aspirin
treatment. Since then he denied all joint symptoms. During the
10 years prior to admission he was hospitalized several times
for hypertension and a carotid endarterectomy. His only medication during this time was a thiazide diuretic. Previous serum
uric acid, calcium, and phosphorus levels were normal. He
also had aspirin hypersensitivity with nasal polyposis and
asthma. He denied skin rash, fever, chills, sore throat, dysuria,
urethral discharge, diabetes, fatigue, myalgias, trauma, and
jaundice.
Physical examination revealed a white male in acute
distress. Oral temperature was 99°F; pulse and blood pressure
were normal. He was blind in the left eye due to old trauma.
Bilateral nasal polyps were noted. Examination of the lungs
revealed mild wheezes bilaterally. Cardiovascular exam was
TRUJEQUE ET AL
1410
normal except for a short systolic ejection murmur heard over
the aortic outflow tract. The joints were normal except for the
right knee. Although the entire knee was slightly erythematous, warm, and tender, the patellar tendon immediately
superior to the patella could be identified as being the point of
maximum erythema and pain. The patella itself was slightly
tender with mild erythema unassociated with edema. The most
superior portion of the right patellar tendon was only mildly
tender. There were no gouty tophi. Arthrocentesis yielded 20
ml of a viscous amber fluid with 19 white blood cells and n o
red blood cells per cu2. Polarized microscopy showed no crystals, and gram stain was negative. The right knee x-ray revealed calcification in the quadriceps tendon. The patellar
calcification was best seen under bright light exam. No
chondrocalcinosis was seen in either knee, but the left knee
had quadriceps calcification. Linear calcium deposits were also
seen adjacent to the left ankle. N o calcium deposits were seen
in either shoulder.
The CBC was remarkable in that the white blood
count was 12,600 with no shift to the left. Urinalysis and serum
chemistries were normal with calcium of 10.2 mg/100 ml and
phosphorus of 3.7 mg/100 ml. Uric acid, alkaline phosphatase. BUN, and creatine were normal. Tests for rheumatoid
factor, antinuclear antibody, and VDRL were negative. The
patient responded to phenylbutazone and rest. Within 3 days
the episode had completely subsided. Followup x-rays of the
knee 3 weeks later were unchanged except for lack of soft
tissue swelling. The patient had no further acute symptoms
during a 3-month followup period.
METHODS
The incidence of quadriceps calcification was determined by a review of all knee x-rays taken at the Albuquerque
Veterans Administration Hospital (AVAH) and Bernalillo
County Medical Center (BCMC) during the period August 1,
1976, to September 15, 1976. Approximately 8% of the x-rays
taken during this period were never retrieved. The male7tofemale ratio was 2.1: 11 with an average age of 41 (range: 2
days-85 years). X-rays of 234 patients were screened for calcification located in the region of the quadriceps tendon. The x-
Table 1. Pertinent Clinical Data of Patients with Quadriceps Tendon Calcification
Type of
Quadriceps Calcification
Associated Radiological
Diagnoses
Degenerative
Joint
Disease
Patellar
Whisker
Age
Sex
R
L
R
L
Other
ES
80
F
t
+
+
+
Fx'
sz
F
F
F
F
M
M
F
+
+
$
+
+
+
NAt
+
NA
Fx
FF
MR
67
62
83
63
78
60
70
35
16
62
66
57
M
+
t
+
+
JM
VK
52
66
M
M
+
RM
34
56
67
M
M
F
+
+
Patient
AP
TN
EM
MM
CQ
LB
OA
EB
KC
wo
TB
M
M
M
M
+
+
+
$
+
NA
+
+
t
t
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
NA
+
+
+
Fx
Fx
+
+
+
+
Tripartate
R Patella
+
t
* Fracture.
t Not available.
$ Distinct dense deposits not associated with the patella and chondrocalcinosis.
Symptoms
Increasing knee pain 15 years after bilateral total knee
arthroplasties
Trauma, swollen knee
Chronic bilateral knee pain
Chronic bilateral knee pain, hyperparathyroidism
Painful R knee X 6 weeks
Swollen hot R knee
Swollen hot R knee, hyperuricemia, no crystals
Chronic bilateral knee pain
Trauma, unable to bear weight
Trauma, R hip pain, schizophrenia, aphasia
Multiple episodes swelling, chronic bilateral knee pain
Pain in legs when resting, venous insufficiency
History of inflamed knee, chronic bilateral knee pain.
hyperuricemia
Hx of locking and pain R knee, meniscus tear R knee
L knee intermittent pain
R knee chronic pain
Pain L knee X 10 months
Trauma R knee
Pain R knee X 2 months, ankylosing spondylitis
PATELLAR WHISKERS
141 1
rays were also scrutinized for signs of chondrocalcinosis and
degenerative joint disease. X-ray files of all patients with tendon calcification were examined for periarticular calcification
involving other joints. Medical records of these patients were
then examined for pertinent points of history, physical, and
laboratory data.
either their degenerative joint disease or the patellar
whisker. Second, 2 patients had a history of an acutely
inflamed joint. Third, 6 of the patients had a history of
chronic knee pain without evidence of inflammatory
disease.
RESULTS
DISCUSSION
Radiological and clinical diagnoses of knee pathology obtained from x-ray files of the patients were
tabulated. The most common radiologic diagnoses were
as follows: trauma with no radiologic abnormality
(33%), degenerative joint disease (20%), no diagnosis
(20%), previous or new fracture (13%), and quadriceps
tendon calcification (7%). Fourteen other diagnoses occurred with an incidence between 1 and 4%. It was
noteworthy that calcification of the quadriceps tendon
was the fifth most common diagnosis. Table 1 provides a
breakdown of 18 patients with the pertinent positive
finding. One patient (TN) is exceptional. This patient
had severe chondrocalcinosis with calcification of cartilage and multiple tendons around the knee. Calcification in the quadriceps tendon was a distinct deposit not
associated with the patella. This patient also had hypercalcemia and an elevation of parathyroid hormone level
consistent with a diagnosis of hyperparathyroidism.
The other 17 patients had calcification of the
quadriceps tendon with the appearance of a patellar
whisker. The calcification had its origin from the anterior superior edge of the patella and fanned out into the
quadriceps tendon (Figure 1 ). This calcific whisker was
radiologically distinct from osteophytic spurs that occur at the posterior margin of the patella. Patellar whiskers were bilateral in 9 of the 16 patients in whom x-rays
of both knees were available. In no case was an inferior
patellar whisker noted. In the 2 patients with serial knee
films, the patellar whisker was noted on the initial film
and progressively enlarged.
Concurrent changes of degenerative joint disease
were noted in 94% of patients with patellar whiskers. In
a complimentary fashion, 36% of the patients with
changes of degenerative joint disease had a patellar
whisker. None of the patients with a patellar whisker
had chondrocalcinosis. The average age of patients with
the patellar whisker was 61 (range: 34-80 years).
The symptoms of the 17 patients with patellar
whiskers are of particular interest. The patients fall into
three groups. First, 7 patients were seen because of knee
trauma and had no history of chronic arthritic complaints. Therefore, 41% of the patients with patellar
whiskers had no symptoms tha; could be related to
Acute calcific tendinitis involving the quadriceps
tendon is a rarely appreciated diagnosis. This report
emphasizes that it may be missed without careful physical examination of the knee and equally careful study of
the knee x-ray. In our patient tenderness was maximum
over the superior patellar border and was less marked
over the synovium of the suprapatellar pouch. Synovianalysis was consistent with a sympathetic effusion, a
finding not previously emphasized in the literature describing acute calcific tendinitis. Calcium in the tendon
was best seen when the x-ray was viewed with a bright
light. Essentially no information in the literature deals
with the incidence of calcification of the quadriceps
Fig 1. Lateral x-ray ofthe right knee of patient CQ showing the anterior
superior patellar whisker (arrow).
1412
tendon. Our survey has shown a surprising incidence of
7% in a general hospital population. The most common
form appears to be the superior patellar whisker. Of
particular interest was the paucity of chondrocalcinosis
of the knees in these patients. The most common concurrent abnormality was degenerative joint disease.
The incidence of acute quadriceps tendinitis is
noteworthy. It may have occurred in one other of the 18
patients with radiographic evidence of calcification in
this area. Although this other patient (EM) had a history consistent with acute tendinitis, it was not proved.
The incidence of more chronic symptoms directly attributable to this entity is difficult to define, since most of our
patients with chronic symptoms had concurrent degenerative joint disease.
It is interesting to speculate that the symptoms
and effusion we observed were related to the deposition
of microcrystals, although such a relationship is unproved in our case report. It has been shown that calcium hydroxyapatite crystals deposited in various animal species can be associated with acute or subacute
synovitis (9). Codmap noted small spherical globules in
joint fluids of patients with calcific peritendinitis (10).
These globules have been defined by x-ray diffraction as
calcium hydroxyapatite crystals. Dieppe el al. have developed a method for identifying calcium hydroxyapatite crystals using scanning electron microscopy and
an energy dispersive microanalytical system (9). Although the sophistication of modern laboratory examination has enabled us to include calcific peritendinitis
TRUJEQUE ET AL
as a crystal induced arthropathy, these methods may not
be available to the generalist. Therefore, a careful physical examination of the knee and a systematic evaluation
of the knee x-ray are of prime clinical importance.
REFERENCES
I . Thompson G R , et al: Calcific tendinitis and soft tissue
calcification resembling gout. J Am Med Assoc
203:464-470, I968
2. Condos B: Observations of periarthritis calcarea. Am J
Roentgen 77:93-108, 1957
3. Cannon RB, Scdmid FR: Calcific periarthritis involving
multiple sites in identical twins. Arthritis Rheum
16:393-396, 1973
4. Key JA: Calcium deposits in the vicinity of the shoulder
and other joints. Ann Surg 129:737-755, 1949
5. Jones GB: Acute episodes with calcification around the
hip joint. J Bone Joint Surg 37B:448-452, 1955
6. King JC, Mahaffey CK: Bursitis and peritendinitis: The
diagnosis and treatment. Southern Med J 46:469-474,
1953
7. Lamb DW: Deposition of calcium salts in the medial
ligament of the knee. J Bone Joint Surg 34B:233-235, 1955
8 . Pinals RS, Short CL: Calcific periarthritis involving multiple sites. Arthritis Rheum 9566-574, 1966
9. Dieppe PA et al: Apatite deposition disease: a new arthropathy. Lancet 7954:266-268, 1976
10. Codman EA: The Shoulder. Boston, Thomas Todd Co.,
I934
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