having heterotopic ossification, please hep :(

Hi there,

6 months ago, I got hit by a car, by drunk driver and sustained a brain injury and my femur, tibia and fibula were broken. The doctors put some external construction on my leg, so that the bone wouldnt shrink. That has caused, that on quadriceps muscle, there was a bit of calcium that started growing into my muscle and as a result, I couldnt bend my knee very much. I started with 20 degrees or something but now I can bend my knee to 135 degrees. I cant squat but Im not far from that.

What helped me heaps was ultrasound on my quad. But now I came back to my country and was told that the ultrasound was breaking up hard tissue only, but not bone and they said that most likely, the ultrasound will probably not help me any more.

I know that there is a way how to solve the ossification, to basically cut off that tiny piece of bone that is stopping me from bending the knee to the maximum level.

However I have gone through so much after the accident that I would like to avoid operations if possible and would wanna treat that ossification with some medication, if something like that would work at all.

I was told that my range of knee bend is awesome and the reason is that I have been doing sports my whole life and Im still young, 28 years old. But I would like to continue with sport and do yoga which would involve squatting and I cant do it just yet.

Could you please help me?

Thank you so much,

Misha

Hi
Firstly I would interpret managing 135 degrees of knee flexion really good progress! Well done! 135 degrees allows you to do most things in life, particularly when living in a Western culture. However you may not be satisfied with this but given the complications you have been through and the risks as well as relative benefits of surgery I am not sure that surgery would be a great option anyway, at this stage. What do you need to do in your job, physically? As for sport, it depends what you want to do but just based on this range of motion this shouldn’t stop you doing a lot of things. For example. If this is your kicking leg football may be out. Contact sports may pt you at risk of of traumatising the area in eg in a tackle if the knee got bent badly or a direct blow to the muscle. But there are heaps of sports you could do. Basically anything in the water is cool! But there are lots of land-based activities that should be fine.

As yoga puts a lot of emphasis on stretching at the end of range you may find this is discouraging as you will constantly come up against limitations in many of the postures. On the other hand the slow, gentle but persistent stretching could be the a therapy! One alternative you might like to try is going to a Feldenkrais practitioner who teaches awareness-through-movement lessons. This approach might help you get around the limitation better, increasing your general flexibility, coordination and improving your ability to play sports.

One thing you didn’t mention: was your movement affected due to the brain injury? If so do you still have residual problems with your movement, other than the knee?

Continuing on improving the strength, endurance, and extensibility of the quadriceps might continue to help matters. We can almost always go on improving muscle function although at some point the improvements tend to tail off considering the amount of work we put into it. It might be worthwhile getting assessed the relative effect of the bone formation on the different parts of the muscle – the rectus femoris crosses both the hip and the knee – causing knee straightening with hip bending. This part of the quadriceps is stretched when you arch the hip back and bend the knee at the same time. The other three parts of the muscle all just cross the knee causing just knee straightening, regardless, and therefore when stretching the muscle the knee will only bend to the same amount regardless of the angle of the hip joint. Your exercise programme may want to separate these two components out to get maximal benefit.

As you may well know stretching the muscle is a bit controversial – I presume by now you are out of the inflammatory stage so stretching shouldn’t be a problem However your stretching should not be traumatising to the area – in which case you could cause more bleeding and set off more laying down of bone.

As a physiotherapist, I can’t really advise you about drug options. My limited understanding is that at this stage I am not sure if any drug is likely to help. Have you heard of the Biphsphonates? The one most studied in this class of drugs is Disodium Etidronate. This drug may slow down the formation of bone at the site. I understand that the evidence for this drug so far is not very strong. One negative about the drug is that it may delay the formation of bone rather than slow down the formation of bone. So when you stop taking the drug the bone formation just carries on. However that is just speculation. Here are a couple of sites you can read about it:
Pharmacological interventions for treating acute heterotopic ossification
Heterotopic Ossification: Treatment & Medication - eMedicine Physical Medicine and Rehabilitation

You could always discuss this option with your physician but I would go to a specialist to talk it through. One other thing to discuss with this type of drug is that you don’t what to be needing dental surgery in the mid to long term future. There is an uncommon but rather nasty complication with the jaw bone.

I would agree that ultrasound at this stage may not be of much benefit.

The final thing I would say isn’t very scientific but just as a physio who has worked in rehab for a long time. It sounds like you are doing really well. You are likely to get some further improvements with your muscle function if you continue to work on it but you will have to be patient. Changes will be slower than in earlier months