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Musculoskeletal clinical case of the month – Myositis Ossificans

Myositis Ossificans (MO)

Myositis Ossificans is a complication that can occur after muscle injury, and is particularly prevalent in the athletic population and young adults. It is characterised by abnormal calcification/bone growth in healing muscle after injury and usually occurs in the larger muscle groups. Sports whose participants are particularly susceptible to developing MO include;

  • contact sports where muscle contusion is common (e.g. rugby)
  • sports that involve high velocity running (e.g. sprinting) where muscle tears are common

Myositis Ossificans is the most common form of Heterophic Ossification, the umbrella diagnosis for a group of conditions where there is formation of extraskeletal bone in soft tissues.

Clinical Presentation

  • 46-year-old man
  • Avid marathon runner
  • Blunt trauma to left anterior thigh from fall on stairs 1 week ago
  • DH – Nil anticoagulants. Nil else.
  • PMH – Nil of note
  • FH – Nil of note
  • Examination left thigh
    • Difficulty walking
    • Large tense swelling
    • No bruising
    • Restricted range of knee flexion to 100 degrees
  • Ultrasound in clinic demonstrated;
    • Vastus Intermedius liquified haematoma
    • No other muscle injury
  • Patient had 60mls blood drained from haematoma on the same day and sent home with compression on thigh

Further injury and investigation

  • Patient unfortunately sustained re-injury to quadriceps whilst walking the dog which resulted in fresh re-bleed and new calcification formation
  • Range of knee flexion reduced further and now unable to flex beyond 80 degrees
  • Repeat ultrasound and MRI show development of myositis ossificans in Vastus Intermedius


  • Top left – Preliminary Ultrasound showing haematoma pre-drainage
  • Top right – Repeat Ultrasound after re-injury showing initial calcification deposits
  • Bottom left – MRI after re-injury confirming location of deposits in VI
  • Bottom right – X-ray thigh 2 months later showing mild resultant calcification
  • MO collage-1
mo Musculoskeletal clinical case of the month - Myositis Ossificans

Management post re-injury


  • Patient started on Indomethacin 200mg daily immediately, taken for 2 weeks total
  • New haematoma not amenable for repeat drainage as not liquified and increased risk of infection


  • First 48 hours post-re-injury
    • Tight compression throughout the length of the thigh
    • Offload on crutches
  • First 2 weeks
    • Partial weight-bearing
    • Quadricep length focused on in initial stages with passive prone knee bends
    • Quadricep muscle activation using isometric squeeze exercises
    • Muscle stimulation via compex
    • Pool based activity and stretches
    • Ongoing daily compression
  • Weeks 2-4
    • Return to normal walking unaided
    • Gym based rehab with concentric and eccentric quadriceps, gluteal and hamstring activation
    • Restoration of injured thigh muscle length (including hamstrings)
  • Weeks 4-6
    • Light jogging and continuation of strength and flexibility work
    • Week 8 return to running

Key learning points – Myositis Ossificans

  • Myositis Ossificans is a common condition in active people who exercise and are more susceptible to soft tissue injury
  • It occurs when soft tissue bruising and haematoma, results in calcific deposits
  • Recurrent muscle injury/bruising/haematoma increases the risk of MO
  • It is more common in larger muscle groups e.g. quadriceps, hamstrings
  • It is a radiology ‘DO NOT TOUCH’ lesion, i.e. should be diagnosed directly from x-ray or MRI
  • This is to avoid unnecessary surgical intervention. Biopsy at early stage may be indistinguishable from Sarcoma.
  • Investigation; X-ray is gold standard for detecting MO
  • Management;
    • No clear consensus on how to treat
    • Reducing soft tissue swelling, bruising, haematoma collection can help prevent formation e.g. compression, drainage of fluid
    • Indomethacin commonly used by sports medicine medical prescribers for a period of 2 weeks to prevent calcification
    • Once calcification is present, babotage and shockwave can help break down deposits and improve function
    • Novel therapies such as acetic acid solution administered via iontophoresis have mixed evidence
    • Surgical intervention may prompt further MO development
  • Rehabilitation;
    • Goal is to regain as much range of movement and strength ASAP.
    • Manual therapy and deep soft tissue around MO needs to be done with caution to prevent further spread
    • Normal functionality of muscle can be achieved despite large MO deposits
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    Administration and Social Media Manager
    Administration, LBSM

    Orla Mulligan is the administration and social media manager for LBSM. She has a strong background in sport having herself played netball at an elite standard for the U21s Northern Ireland team in the European Championships as well as the U21s competition for Saracen Mavericks.

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    Having graduated from University of Brighton with a MSc (hons) in Podiatry, Maddie focused her career in Podiatric Sports Injuries and Biomechanics. Previously she completed a BSc (hons) in Sport Science at Loughborough University.

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    Mr Prakash Saha is a Consultant Vascular Surgeon at LBSM. He takes pride in providing the best possible results for his patients by using the most appropriate non-surgical and surgical methods based on clinical evidence, patient results and satisfaction.

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    Mr Saha studied medicine at the United Medical & Dental Schools at Guy’s and St. Thomas’ Hospitals before completing his higher surgical training in London and the South East. During this time, he was awarded the prestigious NIHR Clinical Lectureship in Vascular Surgery at St. Thomas’ Hospital, giving him comprehensive training in open and endovascular techniques for treating arterial and venous disease. Prakash completed his aortic surgery training at the St. George’s Vascular Institute before carrying out a specialist fellowship at the Royal Prince Alfred Hospital, Sydney.

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    Medical Director, LBSM
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    Dr Ajai Seth is a Sport and Exercise Medicine Physician. He has dedicated his career to helping people with sport and exercise related injury and illness. He consults and treats everyone from the elite athlete to the weekend warrior.

    Dr Ajai Seth is part of the British Tennis Sports Physician team at the LTA and has also provided cover to elite athletes at Wimbledon Tennis, European Tour Golf, Premier League Football, British Athletics, and the Men’s England Football academies as part of the FA.

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    Dr Ajai Seth is dedicated to education, training and research and is a Senior Lecturer in Sports Medicine at King’s College London where he lectures in all aspects of Sports Medicine and Science.

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