Open Access Case

Report DOI: 10.7759/cureus.36127

Heterotopic Mineralization of the Medial

Collateral Ligament: Our Experience Treating
Review began 02/26/2023
Two Cases of Calcific Versus Ossific Lesions With
Review ended 03/05/2023
Published 03/14/2023 Ultrasonic Vacuum Debridement
© Copyright 2023 Kyungje Sung 1 , Altamash E. Raja 2 , Justin G. Tunis 3 , Brandon G. Tunis 4 , Kevin Zheng 1 , Walter I.
Sung et al. This is an open access article
Sussman 1, 5
distributed under the terms of the Creative
Commons Attribution License CC-BY 4.0.,
which permits unrestricted use, distribution, 1. Orthopaedics and Rehabilitation Medicine, Tufts Medical Center, Boston, USA 2. Rehabilitation Medicine, Rowan-
and reproduction in any medium, provided Virtua School of Osteopathic Medicine, Sewell, USA 3. Orthopedics and Sports Medicine, Geisinger Health System,
the original author and source are credited.
Scranton, USA 4. Physical Therapy, Geisinger Orthopedics and Sports Medicine, Scranton, USA 5. Sports Medicine,
Boston Sports & Biologics, Wellesley, USA

Corresponding author: Kevin Zheng, kzheng@tuftsmedicalcenter.org

Abstract
Chronic injury to the medial collateral ligament (MCL) is common following an acute knee injury. This case
report presents two patients that failed to respond to conservative treatment with clinical evidence of an
MCL injury and radiographic finding of a benign-appearing soft tissue lesion in the MCL. Calcified or
ossified lesions have been described with chronic MCL injuries. Ossification and calcification of the MCL
have been observed as potential causes of chronic MCL pain. Here, we detail the distinction between these
two distinct intra-ligamentous heterotopic deposits and describe a novel treatment approach using
ultrasonic percutaneous debridement, a technique that is typically reserved for tendinopathies. In both
cases, pain improved, and they were able to return to their prior level of function.

Categories: Physical Medicine & Rehabilitation, Orthopedics, Sports Medicine

Keywords: tenex, ultrasonic percutaneous debridement, hydroxyapatite calcification, pellegrini-steida lesion, chronic
mcl sprain

Introduction
The medial collateral ligament (MCL) is commonly injured in the knee, with ligamentous injuries accounting
for about 40% of knee injuries [1]. Specifically, a 10-year study found that MCL lesions make up 7.9% of all
sports-related knee injuries [2]. Most MCL injuries improve with conservative management [3], however,
chronic MCL pain has been described in up to 20% of patients following an acute injury [4]. In this report, we
present two patients with chronic medial knee pain after an MCL injury, both with intra-ligamentous
heterotopic mineralization of the MCL that did not respond to conservative management. Ossification and
calcification of the MCL have been described as potential causes of chronic MCL pain, but a clear distinction
between the two phenomena is usually not made. Here we compare the ultrasound appearances of these two
distinct intra-ligamentous deposits and describe a novel treatment approach.

Case Presentation
Patient 1
A 73-year-old male was referred by an orthopedist for focal, left medial knee pain 12 months after missing a
step while descending stairs. He reported a 3/10, intermittent, and sharp pain which worsened with bowling
as well as during the first few steps in the morning. Alleviating factors included rest and Ibuprofen. Prior
treatments included oral corticosteroids, prescription non-steroidal anti-inflammatory drugs (NSAIDs), and
a home exercise program which provided minimal relief. Intra-articular corticosteroid injection was
unhelpful. He denied associated swelling, locking, buckling, or instability.

Physical examination demonstrated a small joint effusion and medial joint line tenderness with normal
range of motion testing, strength testing, and an unremarkable neurovascular examination. Valgus stress
yielded no laxity but did reproduce medial knee pain. Patellar grind and passive knee flexion also caused
pain, however, the remainder of provocative testing was negative. Left knee radiograph showed a small
opacity adjacent to the medial femoral epicondyle but were otherwise unremarkable (Figure 1A). Figure 1
shows pre- and post treatment radiograph images.

How to cite this article

Sung K, Raja A E, Tunis J G, et al. (March 14, 2023) Heterotopic Mineralization of the Medial Collateral Ligament: Our Experience Treating Two
Cases of Calcific Versus Ossific Lesions With Ultrasonic Vacuum Debridement. Cureus 15(3): e36127. DOI 10.7759/cureus.36127
 FIGURE 1: Radiograph
Pre-procedure (A) and 6-month post-procedure (B) weight-bearing PA left knee radiograph

Diagnostic ultrasound revealed an intra-ligamentous calcification within the proximal MCL without
significant thickening of the ligament (Figure 2A). Figure 2 shows pre- and post treatment ultrasound
images.

FIGURE 2: Ultrasound images

Patient 1 initial (A), and 6-month post-procedure (B) ultrasound images, long-axis to the medial collateral ligament
(MCL) and the calcification (circle)

After a lengthy discussion regarding treatment options, the patient decided to proceed with an ultrasound-
guided ultrasonic percutaneous debridement. At 10 days post procedure, the patient reported 60 %
improvement. At the six-week follow up, the patient stated 90% improvement with only mild discomfort on
awakening that subsided after a few steps. He denied any instability, swelling, or limitations with daily
activities. By the 6th week, the patient had resumed bowling. After 6 months, the patient reported 99%
improvement with occasional discomfort when sleeping in the lateral recumbent position. Repeat

2023 Sung et al. Cureus 15(3): e36127. DOI 10.7759/cureus.36127 2 of 9

 radiograph (Figure 1B) and ultrasound imaging (Figure 2B) at this time demonstrated near-complete
resolution of the calcification. He endorsed complete satisfaction with the procedure, as it allowed him to
return to his previous level of function and perform optimally in his weekly bowling league.

Patient 2
A 46-year-old male was injured as he was getting out of water and was hit by a rogue wave causing valgus
stress on the right knee. He was initially seen in an urgent care facility and placed in a knee immobilizer.
Ten days later, he presented to the sports medicine clinic with medial knee pain and tenderness over the
medial femoral condyle, but no associated extra-articular swelling. There was no joint effusion. Range of
motion, strength, and neurovascular examination were unremarkable. There was no laxity with valgus
stress, and provocative testing was negative. Initial X-rays of the knee were unremarkable.

Despite a period of rest and non-steroidal anti-inflammatory drugs (NSAIDs) the patient continued to have
intermittent sharp pain over the medial knee, especially when rising from a chair. Magnetic resonance
imaging (MRI) performed one month from the date of injury showed patellofemoral chondromalacia and a
grade 2 sprain of the MCL with most of the fibers intact. Physical therapy was prescribed, but at five months,
the patient continued to have pain. An intra-articular cortisone injection provided no relief and repeat knee
radiographs demonstrated a Pellegrini-Stieda (PS) lesion (Figure 3A).

FIGURE 3: Radiograph
Pre-procedure (A) and post-procedure (B) weight bearing PA radiograph with the knee in 45 degrees of flexion.
Based on Mendes et al. classification, likely a type I PS lesion

Diagnostic ultrasound showed thickening of the proximal MCL and confirmed an intra-ligamentous
ossification within the proximal MCL (Figure 4).

2023 Sung et al. Cureus 15(3): e36127. DOI 10.7759/cureus.36127 3 of 9

 FIGURE 4: Ultrasound images
Long-axis to the medial collateral ligament (MCL) showing the Pellegrini-Stieda (PS) lesion within the ligament

Treatment options were discussed, including continued conservative management, ultrasonic percutaneous
debridement, or open surgical debridement. The patient decided to proceed with the ultrasound-guided
ultrasonic percutaneous debridement approximately six months from the initial injury.

Two weeks post-procedure, the incision healed completely, and the patient reported 80% improvement in
pain. At the 8-week follow-up, the patient reported 90% improvement and X-rays showed an increase in the
size and density of the PS lesion compared to pre-procedure X-rays (Figure 3B). At 6- and 12-month follow-
ups, the patient reported complete pain relief.

Description of the procedure

The procedure was completed under sterile conditions in an outpatient office for patient 1 and in an
ambulatory surgical center for patient 2. Both patients were positioned in the lateral decubitus position, and
the intra-ligamentous calcification/ossification was localized with ultrasound (Sonosite Edge II, HFL50x
Linear Array Transducer, 6-15 MHz for patient 1 and GE Logiq E, 12L-RS Linear Array Transducer, 5-13 MHz
for patient 2). For patient 1, ropivacaine 0.5% (6 mL) was used and for patient 2, a solution of lidocaine 1%
without epinephrine (2 mL) and ropivacaine 0.5% (2 mL) was injected around the PS lesion using a 25-gauge
1.5” needle for anesthesia. A stab incision was made with an 11-blade scalpel for the TENEX probe (Tenex
Health, Lake Forest, California). In both cases, the probe was introduced through the incision and guided to
the pathologic tissue.

The TENEX probe was activated by depressing the foot pedal, and the diseased tendon was fragmented and
removed with a total energy time of 2:05 minutes and 1:38 minutes for patients 1 (Figure 5) and 2 (Figure 6),
respectively. The stab incision was closed with a Steri-Strip (3M, St. Paul, Minnesota) followed by gauze and
Tegaderm for both patients. The patients were allowed to return to normal activity as tolerated without
restrictions. No bracing or formal physical therapy was prescribed. The patients were instructed to
discontinue NSAIDs one week prior and six weeks post-procedure. Post-procedure pain was managed with
cryotherapy, acetaminophen, and tramadol.

2023 Sung et al. Cureus 15(3): e36127. DOI 10.7759/cureus.36127 4 of 9

 FIGURE 5: Ultrasound image
Demonstrating ultrasonic percutaneous debridement for patient 1. Needle (yellow arrows) directed to the
calcification (circle).

FIGURE 6: Ultrasound images

Demonstrating ultrasonic percutaneous debridement for patient 2. The needle (arrows) was directed to the
Pellegrini-Stieda (PS) lesion (A) and the hypoechoic thickened degenerative medial collateral ligament (MCL) (B).

Discussion
MCL sprains are classified based on instability (Table 1), and chronic MCL pain that lacks instability presents
a therapeutic dilemma. Incomplete tears (grades I and II) and isolated tears (grade III) without instability are
typically treated non-operatively [5,6], and surgical management is typically reserved for patients with
instability [5,7]. In both cases presented here, the patients had an orthopedic surgery consultation for
chronic medial knee pain and were not surgical candidates due to the lack of instability. Both patients were
found to have heterotopic mineralization of the MCL.

2023 Sung et al. Cureus 15(3): e36127. DOI 10.7759/cureus.36127 5 of 9

 Fetto and Marshall: MCL sprains are classified based on laxity with valgus stress and the knee in 0° and 30° of flexion

Grade
No valgus laxity in 0° and 30° of knee flexion
I

Grade
Valgus laxity in 30° of knee flexion, but stable in 0°
II

Grade
Valgus laxity at in 0° and 30° of knee flexion
III

Hughston: MCL sprains are classified based on severity (Grade I, II, and III) and laxity (Grade 1+, 2+, and 3+)

Grade
I First-degree tear, involving a few fibers with localized tenderness, but stable

Grade
Second-degree tear, involving more fibers with generalized tenderness, but stable
II

Grade 1+: 3-5 mm of

absolute medial
separation

Grade Grade 2+: 6-10 mm of

Third-degree tear, complete ligament rupture with instability Grade III injuries are further subdivided
III absolute medial
by laxity with the amount of joint separation from valgus stress in 30° of knee flexion
separation

Grade 3+: >10 mm of

absolute medial
separation

TABLE 1: MCL Classification Systems

Two different classifications of medial collateral ligament (MCL) sprains have been described [8,9]

Heterotopic mineralization of the MCL can be due to either calcification (patient 1) or ossification (patient 2)
of the ligament, and pose a diagnostic challenge [10,11]. Calcified or ossified lesions in the MCL are not
frequently reported in the literature and can be radiographically indistinguishable. These deposits can have
varied appearances and locations, but pathologically, calcifications involve the deposition of calcium salts
and ossification suggest osseous bone formation [12].

Historically, mineralization of the MCL on radiographs has been described as Pellegrini-Stieda lesions,
named after early twentieth century Italian and German surgeons that described ‘ossifications’ of the MCL
at or near its proximal insertion of the medial femoral condyle [13], and are characterized based on location
and shape (Table 2) [14]. PS lesions have also been described in the tendon of the adductor magnus muscle,
medial gastrocnemius muscle or medial patellofemoral ligament [15], and are often associated with trauma
[16]. Refractory cases of PS lesions may require surgical debridement of the lesion. However, the surgical
literature on the management of PS lesions is limited, with most cases reported before 1965 [15]. Challenges
to surgical approaches include high rates of recurrence [17,18], and larger lesions may require surgical
reconstruction of the MCL [17]. Delaying surgery and allowing the lesion to mature (~ 12 months) before
removing the ectopic bone may decrease the risk of recurrence [19].

2023 Sung et al. Cureus 15(3): e36127. DOI 10.7759/cureus.36127 6 of 9

 PS Lesion: Appearance: Location:

Type 1 “beak-like” Extends into the MCL

Type 2 “tear-drop” Localizes within the MCL, but detached from the femoral condyle

Type 3 “elongated” Above femur within the adductor magnus tendon

Type 4 “beak-like” Extends into the MCL and adductor magnus tendon

TABLE 2: Radiographic descricription of Pellegrini-Steida Lesions

MCL: Medial collateral ligament

Hydroxyapatite calcifications of the MCL are uncommon, and to the authors' knowledge, only 11 case
reports have described calcification of the MCL [16,20-29]. Calcifications are thought to be caused by soft
tissue hypoxia leading to fibrocartilaginous metaplasia, cellular necrosis, and deposition of hydroxyapatite
crystals [20]. Corticosteroid injections and shockwave therapy have been described as treatment modalities
[21]. Radiographically, hydroxyapatite calcifications can be indistinguishable from detached PS lesions (type
II, III or IV lesions), but hydroxyapatite calcifications are a distinct clinical entity and should be
differentiated from PS lesions as their pathophysiology likely differs [22,23]. Soft tissue calcifications and
ossifications are usually detected with plane films but have a similar radiopaque appearance. MRIs can help
rule out associated pathology but can overlook small lesions.

In our two cases, diagnostic ultrasound provided additional clinical information. PS lesions generally have
posterior acoustic shadowing, whereas calcifications may have a faint, partial, or absent acoustic posterior
shadowing [21,30], and findings can vary depending on whether the calcification is in the inactive (i.e.
precalcific or calcific) phase or the resorptive phase [16]. In the inactive phase, calcifications are dense and
have more acoustic shadowing, which can limit the clinician’s ability to differentiate between an ossification
and calcification. In these cases where the distinction is unclear, the term “heterotopic mineralization”
should be used to encompass both ossified lesions and calcifications of the MCL.

There are limited treatment options described for the management of chronic MCL pain, and refractory pain
may require surgical management. Open excision of PS ossific lesions can be challenging [17], and there is
limited data for managing refractory MCL calcifications with arthroscopic resection or ultrasound-guided
percutaneous lavage [20,23,25-27]. Percutaneous treatment of calcific tendinopathy is not a new concept
with the procedure being performed with fluoroscopic guidance since the 1970s [31] and with ultrasound
guidance since the 1990s [32]. In rotator cuff calcifications, ultrasound-guided percutaneous fenestration
[33], lavage or needle barbotage [34], and ultrasonic barbotage have been described [35,36]. Ultrasonic
percutaneous debridement is not a novel technology, and in one study, the ultrasonic approach required
fewer repeat procedures or subsequent surgery compared to the traditional barbotage group for rotator cuff
calcific tendinopathy [36]. In this retrospective study, the authors used the TENEX microtip to emulsify the
pathologic tissue and to both irrigate and aspirate the pathologic tissue. The authors also found that the
percutaneous ultrasonic barbotage procedure was a quicker and more efficacious in removing the
calcifications with the ultrasonic microtip than traditional barbotage [36].

To the authors' knowledge, percutaneous ultrasonic barbotage has not been described for MCL
calcification. In this case report, patient 1 had resolution of the calcification within the MCL after the
percutaneous ultrasonic debridement, but patient 2 had persistence of the heterotopic mineralization
despite the ultrasonic debridement. The lesion in patient 2 was hard, and the physician could not advance
the microtip into the lesions, which was consistent with a heterotopic ossification or a PS lesion. The size
and density of the heterotopic mineralization did not significantly change after the procedure (Figure 3).
Previous studies of PS lesions have reported that in addition to ossification at the enthesis, there are
degenerative changes to the ligament [19]. In addition to treating chronic tendinopathy [37-39],
percutaneous ultrasonic debridement has been described for the management of chronic MCL sprains [40].
The authors suspect that the clinical improvement in these cases was also due to healing of the pathologic
chronic MCL pain after the ultrasonic debridement. The use of needling to treat tendinosis has been well
documented. The theory behind the procedure is that repetitively passing the needle through the area of
pathology disrupts the chronic degenerative process, causes bleeding and inflammation, and increases
growth factors; thus, converting the chronic degenerative process into an acute condition, making it more
likely to heal [41]. Fenestration and needling have not been well studied on ligaments, but in one study, a
combination of corticosteroid injection and fenestration of incomplete MCL injuries has been shown to
result in 96% of patients having an immediate and sustained return to sports [42]. The authors suspect that
the clinical improvement in this case was also due to healing of the pathologic chronic MCL pain after the
ultrasonic debridement.

2023 Sung et al. Cureus 15(3): e36127. DOI 10.7759/cureus.36127 7 of 9

 Conclusions
Chronic MCL pain has limited treatment options. The authors believe these cases highlight important
potential imaging features and the main consideration of ossified or calcified lesions in chronic MCL pain.
In both cases, the patients had a significant and sustained improvement in pain after the ultrasonic
debridement procedure. The results of these cases suggest that we should approach these distinct pathologic
processes with different treatment goals. In cases of MCL ossification, the outcome may not require the
removal of bony pathology and should focus on the debridement of the pathologic tissue within ligament. In
contrast, with MCL calcification, the objective should be to remove the calcification. Further studies are
needed to validate these treatment modalities for chronic MCL pain, calcifications and ossifications.

Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: Walter I Sussman declare(s) personal fees from Trice Medical. Dr.
Sussman is an education consultant for Trice Medical. . Other relationships: All authors have declared that
there are no other relationships or activities that could appear to have influenced the submitted work.

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