Hi guys! This video is about myositis ossificans. Specifically, I'm going to discuss what it is,
how you get it, the process behind why they think it happens, other conditions you need to rule out,
how they diagnose it, as well as, of course, how you treat it.
So, my name is Maryke, for those of you who don't know me. I'm one of the physios from
sports-injury-physio.com, where you can get online physiotherapy assessment as well as treatment for
your injuries. Have a look at the description of this video if you want a link to our website.
Good! So, myositis stands for muscle or refers to muscle. Ossificans
refers to ossified or turning into bone. So, it's essentially bone that forms inside your muscle.
Now, there are four types: You can get it in reaction to trauma, so, sports injuries;
you can get a genetic variation which just happens because you've got a genetic fault in your DNA
or something; then, you can get it in association with paraplegia; and you can get it in association
with burns. But we're just going to look at the type that forms after you've had a sports injury.
So, they're not entirely sure about the process behind why this happens, but it's usually,
after you've had trauma, instead of the new cells that form are muscle fibres, or turn into muscle
fibres, it turns into bone. So, for some reason something goes wrong, and they think it's due
to an excessive inflammatory response; they're not really sure. It's usually after somebody's
had a bad contusion or a hematoma, so, where you bleed inside the muscle, and the blood is
contained in there. And I know from experience from the clinic that the few times I've seen it,
it's happened when somebody's taken an impact, or they've had a bad tear in the muscle. And it's the
most common place to get it - you can get it in absolutely any muscle - but the most common places
to get it in the legs is usually in the quadricep muscles or the adductor muscles. Especially,
it seems soccer players have an issue with getting it in the adductors. So, you get that a piece of
the muscle tears, or you get a contusion that it's an impact, and you get a lot of bleeding,
and that blood is contained within the fascia sheath, so it's trapped essentially. And that
seems to be one of the big risk factors; if it's in that situation, that that then turns into bone.
So, the management of those type of injuries becomes quite important.
Now, it goes through a process where, if it decides to go into that reaction that it's
starting to form bone, they talk about the acute phase for the first four weeks. Then,
it goes into an intermediate phase, and then – until eight weeks – and then, from eight weeks on,
it matures. And often, it then resolves on its own after eight weeks, but sometimes it doesn't.
Let me just see if I'm leaving anything out. Okay I'm going to talk about … Rehab is quite important
with regards to this, because if you have a patient who comes in with a bad hematoma, or
that you can feel that ... It feels like a hard sausage, usually, if the blood is stuck
in the fascia sheath … And really, really, really don't go and do hard massage on that,
or severe stretching of those muscles, because they think that is what predisposes people,
that it actually increases the trauma, increases the inflammatory reaction in that area, and then
you get the bone that forms. These patients usually present at the beginning phases just
with an injury like that. So, there's no … at that point you can't tell which way it’s going to go.
But then the pain lasts for longer than what you expect ... that type of injury. So,
the muscle should have healed by now, and they're still in pain, or you can start to
feel a real solid lump in there, that you kind of go, “That feels like a pebble moving around now,
or a very hard sausage.” So, it's not a pliable sausage anymore, like when it was just blood; it's
now turning into something that feels rock solid. Often, that muscle is extremely tight as well,
and people tend to try to stretch it, but it's not budging; and it's quite painful to try and
stretch, and it can even restrict, especially when it happens in the quadricep muscle,
the knee can often not want to bend because that quad is so tight. So, that's usually, if it's
starting to present like that, I'll definitely suspect that we're starting to see something like
myositis ossificans happening there. Yes, so other conditions that's worth ruling out are: There are
certain cancers that can present in a similar way, but it's all about the history of the injury. So,
if somebody came in and there was a history that they tore a muscle or they took a direct blow,
then you'd think that it's more likely just a traumatic myositis ossificans,
but if it's happened for no reason, and you can get these things happen without trauma as well,
but if it's not happened due to trauma and there are other things in the history
that they tell you, like weight loss and things like that, you do want to have it investigated,
because there are certain cancers that can present in similar ways. But like I said,
you only suspect it if the history doesn't fit with the type of injury you're suspecting it is.
You can diagnose it through X-ray or MRI scans; in the first couple of weeks you won't really
see something, but then about from week three, four, you start seeing the ossification, so,
the bone starting to form. And usually with this type of … with myositis ossificans,
it starts to form the bone from the outside in, whereas with cancerous type things, it forms the
bone from the inside out. So, that's one of the big ways that they can tell from imaging
which it is. There are blood tests and stuff that they can do as well, but I'm not … I don't
know what type of blood test and stuff that is, because it's not … by then I've referred you on.
Okay, so treatment wise, I would say the most important part of the treatment for
this condition is to identify that somebody is at risk of having it. So,
if somebody comes in with a bad muscle tear or a bad contusion, and that leg is really tight
because there's so much blood stuck in the fascia sheath, then do not force stretches, do not force
rehab; do everything you can to help that absorb. Do not do hard massage on that either, because
that can increase the bleeding in there, and it can also … You're not going to massage it away.
So then … And then just follow a very gentle rehab programme, trying to get the range back,
but you're not forcing anything. Now, I mean this condition can happen out of no fault of your own,
so it just decides to go into that phase as well. So, if that's started to happen, you pretty much
treat it according to symptoms. Modalities like ... gentle massage and things can sometimes help
with pain. Keep the rehab gentle; go according to levels of pain. But like I said earlier,
usually these things actually … most of them resolve all by themselves. Now, I actually have
a slide about the treatment, because there's one word that I cannot pronounce no matter how much
I try. So, most of these resolve on their own, but it can take up to six months to go away.
Shockwave, if it has properly calcified, can be a useful treatment modality for this for
some people. Then also, there are quite a few case studies that's now been written up about
the use of acetic acid iontophoresis – I can never say that word no matter how many times people make
me say that; that's why I wrote it down there for you. It's basically … What it means is,
you use ultrasound to get that acid to be absorbed through the skin and the tissue, and that seems,
according to case studies, to work pretty well. There haven’t been
any well-controlled randomised controlled trials for this, and I don't think we'll see any of those
easily, because this condition is not that common, that you can set it up as an easy trial to do.
But there's definitely some evidence that that can help. And I remember a case that we had in
clinic where, I think we actually managed to get patches that had a little thing inside them,
like – I can't remember what it was now – but I think it was with … it worked with a battery,
and the patient stuck that on for 12 hours a day or something with that acid in it,
and his did resolve by its own; he didn't need any further intervention. Now, often people can play
and do their sports, and that piece of bone is just happy in the muscle; it doesn't actually
bother them again. But in some cases, the piece of muscle causes trouble, and it causes ongoing pain,
and actually interferes with how well they can perform, or just day-to-day life. And also
depending on where that forms; if it's close to tendons or close to arteries or nerves,
it can cause a lot of pain. So then, surgery may be indicated, where they just go in
and they take the piece of bone out, and the research for that is quite solid that it does
resolve the issue quite quickly, and within six weeks people tend to be able to get back to their
sport. So, it's not one of those conditions where you want to avoid surgery at all cost.
But the research does suggest that, leave it for six months at least, because
most likely yours will resolve by itself in six months’ time. Excellent! So, let me know if you've
got any questions. And if you need more help with your injury, you're welcome to consult one of us
with via video call – link to the website is in the description of this video. Take care!