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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

Imaging

  • 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

Medical;

  • 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

Rehabilitation

  • 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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    Orla Mulligan
    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.

    She understands youth sport pathways having herself played and training in the netball Kent regional pathway. She has a keen interest in most sports and a good understanding of how injury and illness can impact on the mind and body, as well as rehabilitation pathways.

    She looks forward to speaking and assisting LBSM patients and gives her best support to them during their treatment pathway.

    A day in the life of Orla involves communicating with patients via phone and email, managing and organising clinics, operations and media management.

    Outside of work, Orla is a gym enthusiast, enjoys tennis and still finds the time for an occasional game of netball.

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    Associate, LBSM
    Musculoskeletal and Sports Podiatrist

    Maddie treats and manages complex foot and ankle injuries in London and Surrey.

    She is particularly interested in helping her patients improve their quality of life and achieve their personal goals, working closely with Foot and Ankle Consultants, Sports Medicine Doctors and Physiotherapists.

    Maddie has a sporting background herself having previously represented England in Hockey. She understands the demands of elite sport and the importance of physical and mental health. In her spare time, Maddie continues to enjoy an active lifestyle by running, cycling and attending a Pilates class.

    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.

    A day in the life of Maddie involves consulting patients in clinic, performing gait and biomechanical assessments, measuring and fitting orthotics and braces. She also regularly teaches and presents at sports medicine and podiatry conferences.

    Outside of work, Maddie still finds time to play hockey and enjoys running and skiing.

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    MBBS, PhD, FRCS
    Consultant Partner, LBSM
    Consultant in Vascular Surgery

    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.

    He treats fit and active people suffering with a range of cardiovascular issues, from painful leg swelling associated with exercise to venous insufficiency, post-thrombotic syndrome and leg ulcers. He also treats people with arterial system problems including poor circulation, compression syndromes and aneurysms. He carries out both endovascular and open aortic repair and has some of the best outcomes in the country.

    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.

    Mr Saha regularly lectures and runs workshops across the globe on the latest surgical techniques to treat vascular disease. He has also been awarded a number of research grants from the Royal College of Surgeons, the Circulation Foundation, the Wellcome Trust, the Academy of Medical Sciences, and the British Heart Foundation, which has led to over 80 publications and the development of innovative technologies to help treat patients. For this work, Prakash has received a number of prizes, including the Venous Forum prize from the Vascular Society of Great Britain and Ireland, an International Young Investigator Award, and an Early Career Investigator Award from the American Heart Association.

    A day in the life of Mr Saha involves seeing patients in clinic, operating in surgical theatre or lecturing at his university. He also regularly teaches and presents at vascular and sports medicine conferences.

    Mr Saha is an avid cyclist and tennis player (although yet to get a set of Dr Seth!). Outside of work, he spends time with his family who consists of 3 children and enjoys travelling.

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    MBBS, FRCR
    Consultant Partner, LBSM
    Consultant in Sports and Musculoskeletal Radiology

    Dr Gajan Rajeswaran is a Consultant Musculoskeletal Radiologist at LBSM, with an extensive background of working in elite sport. He is one of the most recognised radiologists in the sports medicine field. He provides top level imaging and medical diagnostic services for patients and athletes.

    Dr Gajan Rajeswaran completed his undergraduate medical training at Imperial College London and his radiology training at Chelsea & Westminster Hospital. He has obtained two post-CCT fellowships in musculoskeletal imaging. He was appointed as a consultant at Chelsea & Westminster Hospital in 2011.

    He has a passion for all sports having worked as a radiologist at the Glasgow Commonwealth Games and London World Athletic Championships and continues to support The Championships, Wimbledon. He also continues to work with a number of Premier League and Championship Football Clubs, Premier League Rugby Clubs, England Sevens Rugby, British Athletics and the Lawn Tennis Association.

    A day in the life of Dr Rajeswaran involves giving his expert opinion on investigations such as MRI and CT scans, x-rays and ultrasound. He also performs injection lists under ultrasound, CT and X-ray including spinal injections. He also regularly teaches and presents at sports medicine conferences.

    Dr Gajan Rajeswaran is an avid football fan and life-long fan of Tottenham Hotspur (for which he offers no apologies!). Outside of work, he spends time with his family and has a keen passion for photography.

    Dr Ajai Seth
    MBBS, BSc, MSc, MRCS, MRCGP, FFSEM
    Medical Director, LBSM
    Consultant in Sport and Exercise Medicine

    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.

    He also prides himself for working in disability sport and is currently the Chief Medical Officer for Team GB Wheelchair Tennis which has taken him to the Olympics and Paralympics.

    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.

    He also has a passion for travel and Expedition Medicine, which has seen him accompany medical, scientific and charity expeditions all around the world. He also has vast experience in treating musculoskeletal injuries from children and adolescents to veteran exercisers, both male and female.

    Dr Seth also has positions in leading Sport Medicine organisations, including the non-executive board for the UK’s largest Sports Medicine charity, BASEM and Past President for the Royal Society of Medicine. 

    A day in the working life of Dr Seth involves consulting his patients in clinic, performing diagnostics and ultrasound guided injections. He also regularly lectures and tutors students and presents at sports medicine conferences internationally. He also spends part of the working week at the National Tennis Centre, LTA, supporting British Tennis players.

    Outside of work, Dr Seth enjoys playing club tennis, triathlon, golf, running and skiing (but will give any sport a go!). He enjoys keeping fit and active and good quality family time with his wife and three children.