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Case Report
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Ultrasound-guided treatment of medial
collateral ligament calcication of the knee
with TenJet™:acasereport
Michael Dakkak*,1
1Orthopaedic surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
*Author for correspondence: dakkakm@ccf.org
Calcication of the medial collateral ligament is a rare cause of medial knee pain along with
functional impairment. Most cases are asymptomatic but those that are symptomatic typically respond
to conservative management. However, in those instances with persistent symptoms that desire further
intervention but want to minimize the risks associated with surgery, we present a novel approach for
calcium removal with an ultrasound-guided percutaneous needle tenotomy with TenJet™as a reasonable
treatment modality.
First draft submitted: 31 August 2023; Accepted for publication: 18 December 2023; Published online:
8 January 2024
Keywords: hydroxapatite calcication •MCL •Ten Jet ™•ultrasonic percutaneous debridement
Calcific tendinopathy most commonly occurs within the rotator cuff of the shoulder but also presents in the hip,
thigh, knee, ankle and foot [1]. Although rare and often asymptomatic in the knee, those cases producing symptoms
can result in debilitating pain and function. Several instances have been described in the current literature affecting
the medial collateral ligament (MCL) of the knee often involving the ligament itself or Voshell’s bursa [2,3].
Treatments range from supportive with observation, physical therapy, corticosteroid injections, extracorporeal
shockwave therapy and arthroscopic or open surgical removal [3–6]. The current literature on calcification within
the MCL is scant and to date there are no universally agreed treatment guidelines.
Alternatively, minimally invasive techniques have been described to treat calcifications through an ultrasound-
guided percutaneous lavage [2,7]. This usually involves a double-needle approach while repeated fenestration of the
calcification leads to fragmentation of the calcific deposits [2]. However, over recent years percutaneous ultrasonic
tenotomy needle devices have been shown to successfully treat tendinopathy and fasciopathy [8,9].Todateonly
one prior case report has been recently published on using Tenex (Tenex Health, CA, USA) for removal of calcific
debris [10]. This report describes the first ever case of calcification within the MCL that was successfully treated
with a percutaneous ultrasound-guided resection using the TenJet™(HydroCision Inc., MA, USA).
Case report
An 81 year-old female with a past medical history of hypertension, hypothyroidism and chronic kidney disease
presented with chronic left medial knee pain for 3 years. The pain was rated as an 8/10 and described as dull localized
to the superior medial border of the knee and described to have a limited range of motion due to the stiffness
and pain. Prior to our initial evaluation, the patient attempted ice, heat, oral nonsteroidal anti-inflammatory drugs
(NSAIDs) and started physical therapy. She denied any fevers, weight loss or gain, history of trauma and history
of knee surgery. On examination, she could ambulate without assistance or antalgic. No erythema or effusion was
noted. She had a full range of motion passively but actively experienced tightness in the medial knee. There was
focal tenderness over the proximal MCL and crepitus with knee extension. The remainder of the examination was
normal. Plain films showed mild tricompartmental osteoarthritis, chonedrocalcinosis and a lobulated calcification
measuring 2.4 cm at the medial femoral condyle. (Figure 1). Diagnostic musculoskeletal ultrasound was performed
showing a multi-lobulated calcification in the superficial fibers of the proximal MCL measuring 2.4 ×0.8 ×
1.2 cm with posterior acoustic shadowing (Figure 1). There was no noted neovascularization with power doppler
Pain Manag. (Epub ahead of print) ISSN 1758-186910.2217/pmt-2023-0087 C
2024 Michael Dakkak
Case Report Dakkak
1
Figure 1. Standing weight bearing anterior to posterior (AP) radiographs of the knee. Initial evaluation where a 2.4
mm calcication is noted at the left femoral medial condyle (white arrow), also showed lateral compartment
chondrocalcinosis and mild osteoarthritis (upper panel). Initial diagnostic musculoskeletal ultrasound imaging of the
medial knee in a longitudinal view showing a lobulated calcium at the medial femoral condyle within the proximal
medial collateral ligament. White arrow indicated the calcication of the MCL (lower panel).
Subc: Subcutaneous tissue; MCL: Medial collateral ligament; MFC: Medial femoral condyle.
within the calcification. The MCL was intact without laxity upon valgus stress dynamic testing. A diagnostic 5 mL
0.5% Ropivacaine injection was performed intra-articular without any pain relief. A follow-up diagnostic injection
with 2 mL of 0.5% Ropivacaine was performed using a 25 gauge 1.5” needle under ultrasound guidance directly
into the calcification noted within the MCL to confirm the source of pain. Following this injection into the MCL
calcification, the patient’s knee was pain-free and had a full range of passive and active range of motion. Various
modalities including surgical removal or percutaneous ultrasound-guided vacuum resection were discussed in which
the patient proceeding with a percutaneous approach.
The procedure was performed in an ambulatory surgical center under sterile conditions. The patient was placed
supine and the calcification within the MCL was identified with ultrasound. A total volume of 3 mL of 0.5%
Ropivacaine was used on a 25g 1.5” needle to anesthetize the MCL and subcutaneous tissue. A skin wheal with
2 mL lidocaine and 1% epinephrine was performed in the superficial layer. Then, using a No. 11 blade a small
3 mm incision was made through which the TenJet device was placed and advanced into the area of calcification.
Under ultrasound guidance, the TenJet device was utilized to deliver high-velocity sterile saline with a Venturi
10.2217/pmt-2023-0087 Pain Manag. (Epub ahead of print) future science group
Ultrasound-guided treatment of medial collateral ligament calcication of the knee with TenJet™Case Report
Figure 2. Standing weight bearing anterior to posterior (AP) radiographs of the knee 2 week-post procedure. Plain
radiographs AP from the 2 week-post procedure appointment showing resolution of the calcication at the medial
femoral condyle with persisting lateral compartment chondrocalcinosis and mild osteoarthritis (upper panel).
Ultrasound examination in long-axis to the medial collateral ligament during the TenJet™procedure showing the
needle tip (white arrow) penetrating the calcium within the MCL with decreased lucency of the calcium and
reduction in size of the calcium (lower panel).
MCL: Medial collateral ligament; Subc: Subcutaneous tissue.
suction effect at the 12-gauge needle tip creating a cutting window to remove the calcific debris (Figure 2). The
total treatment time was for approximately 3 min until there was a sonographic resolution of the calcification. The
incision was closed with Steri-Strips (3M; MN, USA) and then covered with a Tegaderm (3M) dressing. Patients
were then placed in a hinged knee brace for 2 weeks post-procedure.
At 2 weeks post-procedure there was complete resolution of the calcification on radiographs (Figure 2). The
patient reported complete relief of her symptoms with a visual analogue scale (VAS) score of 0/10 and subsequently
weaned out of the knee brace. Given her resolution of symptoms a shared decision was made not to initiate a
physical therapy program. The patient remained without clinical or radiographic evidence of recurrence at her
6 week, 3 month and 1 year follow-up appointments.
Discussion
Calcification of the MCL is a rare cause of medial knee pain and most commonly occurs following a traumatic
ligamentous injury to the MCL [11]. However, in our case, there was no known or reported history of trauma.
Through the authors’ literature review, there are very few cases ever reported to date describing calcium within
the MCL [2–7,10,12–15]. Typically most cases are not symptomatic, but for those that become symptomatic, it is
reasonable to initially treat with a conservative approach [15]. However, for those cases in which symptoms persist
future science group 10.2217/pmt-2023-0087
Case Report Dakkak
options remain limited and no current standard of care exists for removal of these lesions. Recalcitrant cases often
have been historically treated with surgery as the mainstay of treatment [3].
There are only three other reports of removal through a percutaneous ultrasound-guided approach utilizing
previously described techniques [2,10]. Two cases involved the utilization of Tenex which has several differences from
TenJet. Tenex uses ultrasonic energy and simultaneously irrigates the tendon with sterile saline while TenJet utilizes
high-pressurized saline jet through a cutting window to resect tissue and waste fluid through a Venturi effect at the
needle tip [9,16]. Aside from these devices as treatment options, the other modality described in previous literature
involves multiple operators with a double needle approach with repeated fenestration [2]. Both scenarios have shown
to be an effective and reasonable option. In our case our patient reported to have a faster recovery period compared
with prior approaches as the two other patients were noted to have 60 and 80% relief at the first follow-up visit
between 10 to 14 days post procedure. To our knowledge, this is the first description of MCL calcification of the
knee that was treated with a percutaneous ultrasound-guided resection device utilizing TenJet.
Conclusion
The occurrence of calcification within the MCL is a rare phenomenon that can result in medial knee pain. Clinicians
should be aware that this condition may arise without any history of trauma and can lead to considerable pain
with functional limitations. Early diagnosis through plain radiographs and advanced imaging is important to
further evaluate adjacent structures and other causes of medial knee pain. Although a majority of cases are often
asymptomatic, this case report highlights the importance of identifying an unusual presentation in the management
of MCL calcification that had not responded to conservative management. Ultrasound-guided percutaneous
tenotomy with TenJet is a low-risk procedure and a reasonable treatment option for symptomatic recalcitrant cases.
Executive summary
•Calcication of the medial collateral ligament (MCL) is a rare but signicant cause of medial knee pain, often
treated conservatively, with few cases requiring more invasive interventions.
•The report presents a novel, minimally invasive technique using ultrasound-guided percutaneous approach with
Ten Jet ™, effectively treating MCL calcication in a patient unresponsive to conservative treatments.
•This case highlights the importance of considering MCL calcication in the differential diagnosis of medial knee
pain and introduces an effective, low-risk alternative to surgical intervention for symptomatic cases.
Acknowledgments
Thanks to the Cleveland Clinic Orthopaedic and Rheumatologic Institute, specically Cleveland Clinic Sports Medicine research
team, staff, and research personnel whose efforts related to this project made this consortium successful.
Financial disclosure
The author has no nancial involvement with any organization or entity with a nancial interest in or nancial conict with the
subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or
options, expert testimony, grants or patents received or pending, or royalties.
Competing interests disclosure
M Dakkak does consult work with Hydrocision. The author, their immediate family, and any research foundation with which they
are afliated did not receive any nancial payments or other benets from any commercial entity related to the subject of this
article. The author has no other competing interests or relevant afliations with any organization or entity with the subject matter
or materials discussed in the manuscript apart from those disclosed.
Writing disclosure
No writing assistance was utilized in the production of this manuscript.
Ethical conduct of research
The authors state that they have obtained verbal and written informed consent from the patient for the inclusion of their medical
and treatment history within this case report.
10.2217/pmt-2023-0087 Pain Manag. (Epub ahead of print) future science group
Ultrasound-guided treatment of medial collateral ligament calcication of the knee with TenJet™Case Report
Open access
This work is licensed under the Creative CommonsAttribution 4.0 License. To view a copy of this license, visit http://creativecomm
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