Calc and Cysts

[Diane]

Hi Steve,

I was scanning a middle aged female the other day. I saw an echogenic area in the inferior portion of the glenohumeral capsule when I was measuring it. I think I’ve seen it once before and was thinking it could be a crystal deposit? Patient wasn’t overly tender there though…

Also sometimes when I’m scanning the rot cuff I see these tiny cysts that sit just superior to the tendon. Are these ganglion cysts? Do they come from the tendon? Are they a sign of tears or are they just happen to occur because of a degenerative process?

Thanks!

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[Stephen Bird]

Hi Diane,

Interesting images.

I think the small cystic area represents a ganglion cyst arising from the joint capsule. It likely results from a small injury to the joint capsule and a little synovial fluid leaks from the capsule creating a ganglion cyst. You see similar appearances adjacent to the plantar plates in the foot and the flexor sheaths in fingers etc.
I doubt this is going to be symptomatic.

The echogenic deposit is interesting. It like like it is within the joint capsule. Did you think it was within the hyaline cartilage? My impression was that is is within the joint capsule but not in the cartilage.
It certainly looks like crystal deposition, but a very small deposit.

Options:

CPPD
Gout
Hydroxyapatite

Could it also just be a little fat within the joint capsule or some other debris within the joint capsule synovial fluid?

I am uncertain about this one.

Again I wonder if it is significant for the patients presenting symptoms.

Steve.

[Stephen Bird]

Was there any hydroxyapatite within the rotator cuff tendons?

When you have hydroxyapatite within the cuff it often spills into the bursa and creates pain.

It could spill into the joint capsule and create this appearance.

You can also get hydroxyapatite within any joint capsule called calcific peri- arthritis.

Steve

[Jonathan Wride]

Hi Steven,

Really liked the tips on scanning the SSP in low-tension and high-tension positions and finding it so useful for opening out tears in full crass position.

I was scanning a patient yesterday (37 YO male) with classic calcific tendinitis symptoms. Sonographically had calcification throughout his r/cuff. However on scanning his SSP there was an odd anechoic cystic change within the mid-substance of the tendon. Did not appear to be a tear or acoustic shadow and I have not seen anything like that before. I have attached a long and short axis of SSP in full crass position. Just wondered if you have seen anything similar?

Appreciate any thoughts.

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[Stephen Bird]

Hi Jonathan,

Absolutely I have seen this before.

This is an appearance that you get sometimes when you have an acute hydroxyapatite deposition within a tendon.

I have seen this exact appearance in the supraspinatus and the subscapularis before.

It is one of the appearances you can get as the hydroxyapatite matures.
It is a type of liquificateon of the hydroxyapatite deposit.
If you scanned it a week ago it would have just looked like a regular calcific tendinosis, but now the deposit has liquified and you can see the central cavity.
If you stick a needle into it you usually get an aspiration that is somewhat orange in colour with fluid / blood and hydroxyapatite crystals making up the contents.

You can see a similar appearance when we perform a barbotage / lavage procedure on a hydroxyapatite deposit. As we irrigate and aspirate the deposit it reveals this central cavity which looks just like your image.

Steve

[Stephen Bird]

I have attached a slide from my teaching material.

You can see the classic appearance of hydroxyapatite in the tendon on the initial scan.
On the follow up scan you can see how it has mattered and liquified.

You can then see what we aspirated from it.
It is one of there pathways of evolution for a hydroxyapatite deposit.

Steve

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[Jonathan Wride]

Superb knowledge as always. Greatly appreciated. Thanks.

[Jonathan Wride]

Hi Steve,

Another slightly odd case. 58 year old female – treating her for right frozen shoulder. She describes very early impingement type symptoms on the left shoulder and was worried about developing bilateral frozen shoulder. I had a scan and although I am suspicious of early capsulitis there was an odd focal anechoic cystic region within the subacromial bursa likely causing impingement. Have you seen burial cysts before? it did not have any internal vascularity and was not easily compressible. I have attached images below.

Best wishes,

Jon

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[Jonathan Wride]

*bursal not burial!

[Stephen Bird]

Hi Jon,

You have to love predictive text when it does that to you,

Yes, I have seen exactly the same appearance on several occasions and have always wondered what they represent. Essentially it is exactly as you describe, a cyst within the bursa.
But I am not sure of the ethology. Is it a “ganglion” arising from the synovial lining of the bursa?
Whatever the ethology, I have seen these and depending on the location they may get caught under the CA ligament and cause some impingement.

I wonder if you popped a 22G needle into one and aspirated if it would disappear or if the contents is thick?

next time I see one I will suggest it to my radiologist !

Steve

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