Myositis Ossificans of the Quadriceps

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Elout Witterzeel
Wouter Vervaet
Mathieu Van Durme

Pieter Van Den Bossche

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Definition/Description

Myositis Ossificans is a benign, meta-plasmatic, mostly self-limiting process in which bone or bone-like tissue formation takes place in skeletal muscle. It occurs mostly in large skeletal muscles such as quadriceps,brachialis & adductor of thigh.It may arise with or without trauma.But its common in young active athlete after a single traumatic injury.

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

• -Myositis Ossificans Traumatica (MOT) also called the non-hereditaryy myositis ossificans(associated with burns, haemophilia and neurological disorders)
• -Myositis Ossificans Progressiva (MOP), also called Fibroplasia Ossificans Progressiva (FOP).

Epidemiology /Etiology

MOP resulting from a direct blow or repeated injury is the most common representing 60-75% of total cases.

Post-traumatic MO occurs in about 20% of cases reported with large muscle hematoma associated with contusion or trauma. It lasts for an average of 1.1 years.It may also occur due to repetitive injury to the same area.

It's found in both contacts as well as non-contact sports. Its exact cause is unknown but mostly it's an error in the healing process where normal muscle cells known as fibroblast are replaced by immature bone cells.

Characteristics/Clinical Presentation

1. Pain;-Aching type of pain lasting for more time than in case of a simple muscle contusion.
2. Swelling;-Localised swelling on the anterior thigh or in some cases it may be in the whole limb.
3. Decrease ROM;-Gradual loss of ROM(Range of motion)

Along with the above symptoms,a careful history of injury gives an indication to diagnose MO

Differential Diagnosis

Malignant tumors of thigh such as lymphoma, osteosarcoma and rhabdomyosarcoma have similar symptoms.

Diagnostic Procedures

MRI is a gold standard investigation for any soft tissue mass,it helps to identify early developing cases.

Earlier Ultrasonography also helps to detect calcifying hematoma. Plain Radiograph shows calcified mass only in the advanced stage.CT scan or bone scans can also be performed to differentiate myositis ossificans from other conditions.

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].

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}