myositis ossificans

hi all,

i've just seen a patient who looks like he is developing myositis ossificans but has some interesting other symptoms and i'd appreciate some opinions.

Hx: >4/52 traumatic impact to R gastoc playing soccer.
>sustained full force of opponent through 4 studs leaving 4 distinct breaks in skin and gross diffuse swelling in calf and localised swelling around stud marks.
>after 3 days bruising settled around foot
>rested for 4/52, local bruising resolved but general oedema remained in lower leg and ankle
>saw GP, told he had 'blood pockets' in gastroc & to take ibuprofen

Now: >difficulty walking so cycling everywhere
>wasted whole of L quadrant
>2 distinct lumps under stud marks which are exquisitely tender to palpate
>moderate oedema R ankle
>1.5cm increase in R mid calf girth
>grade 3 muscle strength only R calf

I know i have to get him X-ray'd to confirm myositis ossification but was wandering whether anyone could suggest why his ankle is still swollen. also what modalities can be used to treat either collagen laydown in the muscle or myositis ossification.

at the moment he has commenced on a eccentric strengthening programme for the R calf.

cheers,

tomc90

I would doppler scan him asap to rule out DVT!

hmm, he's seen his GP who was not concerned. I guess if i take his distil pulses when i next see him and test for this i can refer him back.

what if it isnt?

anyhother ideas?

I thought about suggesting testing for pedal pulses but would they not be present in anycase as any DVT would be on the way back to the heart, thus past the place you would feel for a pulse?

MO isn't usually acutely painful to touch at this early stage and it is much more common in the quads than in a calf muscle. It is more of a laying down of calcium in the bone and beomce more of a hard non-extensile lump rather than a painful cyst (which this could be).

The ankle swelling I assume is unilateral - on the injured side only?

You might also consider a ganglionic cyst that could have resulted from the direct trauma. Are there any distal neurological disturbances?

good point re:p ulses, i'll check again with the GP if i think its possibly a DVT

the swelling is unilateral, but neurological examination was normal.

the lumps feel consolidated in flattened pea sized masses and feel to be intramuscular, not subcutaneous. your thought about cystic lesions is a possibility

if it is this the case do they need draining, surgically removing, or would they respond to frictions/other therapy?

many thanks...

tomc90

You also have to consider that this simply needs more time. If he has had significant muscle damage, which it sounds like he has he may need anywhere up to another 4 weeks. Is the oedema firm (pitting) or loose, as any pitting oedema can take a long time to clear. As long as he is getting no worse there may be nothing to worry about. However, I am not saying forget about looking at pathology like DVT, simply that I have seen similar injuries that can appear severe at 4 weeks but just need more time and Rx.

The two distinct lumps can be little intramuscular or subcutaneous blood clots and difficulty walking due to resticted calf flexibility. Try heel raises etc...

If it is myositis, which it probably isnt if he's been resting and hasn't been getting rubbed, then NSAIDS like he's using, and especially Indocid, i think, which has been shown to inhibit calcification too, may be useful. And rest of course.

But I'm not suggesting you don't follow up other pathology if you suspect it. :rolleyes :rolleyes