Myositis Ossificans of the Quadriceps

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Original Editors

Elout Witterzeel
Wouter Vervaet
Mathieu Van Durme

Pieter Van Den Bossche

Top Contributors - Hardik Bhatt, Annelies Noppe, Kim Jackson, Karen Wilson, Wanda van Niekerk, WikiSysop and Lucinda hampton  

Search Strategy

Databases searched: Pubmed, Web Of Knowledge.
Keyword Searches: ‘Myositis ossificans’, Myositis Ossificans Quadriceps’, ‘Fibroplasia Ossificans’, ‘myositis Ossificans treatment and quadriceps’, ‘Contusion Quadriceps’, ‘Muscle Strain Quadriceps’, ‘stages of myositis ossificans’.
Search Timeline: October 7th 2012 - december 1st 2012.

Definition/Description

Myositis Ossificans is a metaplasmatic process in which normal bone replaces normal soft tissue. It is regarded as an adaptive or metaplastic process, it is not regarded as a neoplasm. It is often seen with inflammans. The soft tissue won’t only calcify but also ossify.
Myositis ossificans is a severely disabling disorder of muscle tissue, which transforms in hardened tissue with bonelike characteristics. These symptoms can be caused by contusions, strains or other traumatic injuries, but also as a genetic mutation of the muscle.

These different causes of myositis ossificans divide the disorder into two subgroups:

• -Myositis Ossificans Traumatica (MOT) also called the non heriditary myositis ossificans
• -Myositis Ossificans Progressiva (MOP), also called Fibroplasia Ossificans Progressiva (FOP).

Clinically Relevant Anatomy

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Epidemiology /Etiology

Children who have FOP experience during their first decade of life sporadic episodes of painful soft tissue swellings which are often precipitated by soft tissue injury, viral infections, muscular stretching intramuscular injections, falls or even fatigue. These swellings transform the soft tissue such as the skeletal muscles, tendons, ligament, fascia and aponeuroses into heterotopic bone. This means that bone is formed outside the skeleton, which makes movement impossible. [3]
FOP is caused by a recurrent activating mutation (617G>A; R206H) in the gene ACVR1/ALK2 encoding activin A receptor type I/ Activin-like kinase 2, a bone morphogenetic protein (BMP) type I receptor. Another mutation which also has FOP as a result is the heterozygous ACVR1 missense mutations in conserved amino acids.
As explained before, another cause of myositis ossificans is injury. When there is no genetic mutation present, we call this form of MO Myositis Ossificans traumatica. MOT is an inflammatory process of muscle in its early stages, before the ossificans is visual with a roentgen ray. We can see that tumor calor and dolor are all present in this stage.

Characteristics/Clinical Presentation

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Differential Diagnosis

There are three types of myositis ossificans: [9]
-Type1: There is a thin stalk of bone formed between the ossified muscle and bone.
-Type2: A broad are of ossified muscle in located between muscle and bone.
-Type3: The ossified muscle is not connected to the bone, and even appears to derive completely from muscle.

Diagnostic Procedures

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Outcome Measures

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Examination

As MO can only be accurately diagnosed after about two weeks and generally requires further investigations rather than a standard clinical examination, the intial treatment follows that of a quadriceps contusion. When a new patient arrives at a physiotherapist for a consult, the physiotherapist will take his history. If there are thigh strain or contusion like following symptoms [6] [1]:
- anterior thigh pain
- sharp pain during activity
- mostly initiated during sports
- stiffness
- Night and developing morning pain
- improving of the range of motion, later a slight decrease
Myositis ossificans could be one of the possible disabilities. these symptoms often go with swelling and a reduced range of motion.
After a meticulous history we can continue with examination, next step is the observation. An obvious deformation can be seen such as a bulge or defect in the muscle belly. Sometimes there is a presentation of a hematoma [5].
The palpation can give us some more information about the area of the maximal tenderness and feeling for any defect in the muscle.
Muscle force can be concluded out of the strength test of the knee extension and hip flexion. Adequate strength testing of the rectus femoris must include: resisted knee extension with the hip, first flexed and in the second testing, with the hip in extension. these test are best evaluated when the patient is sitting and prone-lying because of the optimum assessment of the quadriceps motion and flexibility. During passive stretching, resisted muscle activation and direct palpation the patient can have a feeling of pain over the muscle strain.
The grading of the injury, the direction for further diagnostic testing and treatment will be determined by the tenderness, palpable defect and strength at the onset of muscle injury.

Medical Management

Operative removal of the ossification is only indicated when the ossification occurs near a joint in the origin or in the insertion of a muscle, where joint functions are permanently impaired. (and then only from twelve to twenty-four months after the injury.) At present, there is no definitive treatment. A brief 4-day treatment of high- dose corticosteroids may help to reduce the intense inflammation and tissue edema, seen in early stages. It starts within the first 24 hours of a flare-up. [3]

Physical Therapy Management

Proper treatment of the contusion injury causing MO can help reduce the incidence of MO by reducing the size and presence of hematoma formation. (8)
Unfortunately, once MO has been diagnosed there is very little physical treatment that can be utilized to increase the speed that the bone is reabsorbed naturally by the body. Electrotherapy, including opined TENS (high frequency), can be used over the quadriceps group to help reduce pain and muscle spasm [11]. Pain free, gentle ROM exercises can also help in the management of MO. If the treatment has no effect, then the only other alternative is surgical removal [12].
Treatment of a contusion should be handled quite cautious. Immediate treatment of a contusion: – rest
– cold therapy application – elevation
– compression
After the bleeding has stopped, treatments which may induce heat into the muscle can be applied. Other treatments can be electrotherapy, ultrasound and soft tissue therapy for example sports massage. If necessary stretching can be used to retake lost range of motion degrees [5].

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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[1] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2941577/ {3A}
[2] http://ghr.nlm.nih.gov/condition/fibrodysplasia-ossificans-progressiva {3B}
[3] http://www.ojrd.com/content/pdf/1750-1172-6-80.pdf
[4] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2941577/?tool=pubmed {3B}
[5] http://www.physio-pedia.com/Quadricpes_Muscle_Contusion
[6] http://myositisossificansofthequadriceps.wikispaces.com/Presenting+Signs+%26+Symptoms
[7] Joel M. Kary, Diagnosis and management of quadriceps strains and contusions, 2010 {3B}
[8] Järvinen, T. L., Sievänen, H., Jokihaara, J. and Einhorn, T. A. (2005), Revival of Bone Strength: The Bottom Line. J Bone Miner Res, 20: 717–720. doi: 10.1359/JBMR.050211 {4}
[9] Beiner, J. M., & Jokl, P. (2001). Muscle Contusion Injuries: Current Treatment Options. Journal of the American Academy of Orthopaedic Surgeons, 9, 227-237. {3B}
[10] Lipscomb, A. B., Thomas, E. D., & Johnston, R. K. (1976). Treatment of myositis ossificans traumatica in athletes. The American Journal of Sports Medicine, 4(3), 111. {2B}
[11] Brukner, P., & Khan, K. (2009). Clinical sports medicine. North Ryde, N.S.W: McGraw-Hill. {5}
[12] Buselli, P., Coco, V., Notarnicola, A., Messina, S., Saggini, R., Tafuri, S., Moretti, L., & Morretti, B. (2010) Shock Waves in the Treatment of Post-Traumatic Myositis Ossificans. Ultrasound in Medicine, 36(3), 397-409. {3A}