HAEl\1ATOMA AND MYOSITIS OSSIFICANS

HAEMA1'OlVIA AND MYOSITIS OSSIFICANS1

STUART D. GRAY, M.C.S.P., GRAD.DIP.REC., M.A.P.A.

Department 0/ Physical Education, Health and Recreation, 11"estern Australian SecondaryTeachers' College

147

Knocks and bruises are an accepted risk ofparticipation in contact or potentially contactsports. In fact exhibiting one's patches ofblack and blue seems to be a part of thegame.

Familiarity with bruises plus the singularterminology used to describe the more seriousones, for example, "charlie horse", "pointer"and "cork" has caused these common injuriesto be the most misunderstood and frequentlymistreated. The severity and the subsequenttreatment will in fact he determined mainlyby the site and the extent of bleeding.

It is not intended to discuss bleeding withinspecialized organs such as the eye, abdominalorgans or lung (where life or organ pre­serving first aid and transport to casualtyfacilities is imperative) but rather haematomabetween skin and fascia, between fascialplanes or muscle planes, within muscle bulkor beneath the periosteum of bone, wherephysiotherapy will playa major part in re­habilitation.

Dr. Alan Bass (1966) and physiotherapistBertie Mee (1965) both advisors in their re­spective field to the English Football Asso..

IDelivered at the XV Biennial Congress of the Aus..tralian Physiotherapy Association, Hobart, Februal'y,1977.

ciation have done much to encourage theexact diagnosis and specific treatment ofmuscle component injuries sustained in sport:Table 1 shows their basic treatment plan forthese soft tissue injuries.

Bass and Mee paid particular attention tohaematoma formation which they classifiedroughly into two groups - the intermuscularand the intramuscular.

In the intermuscular group the tear, or con..tusion, is situated more superficially in themnscle and extravasated blood is able to trackdown the intermuscular septa so that a rela..tively rapid resolution of symptoms is seen.

The intramuscular group, with bleedingdeep within the muscle and little or no extra..vasated blood outside of the sheath, remainsas a localized haematoma: swelling persistsalong with muscle weakness until healing byscar tissue is complete.

These injuries may occur in any musclemass but are most common on the anterioraspect of the upper arm and the anterolateralaspect of the thigh. Quadriceps contusion willbe used as an example although the principlesof treatment will be much the same for anymuscle group.

Site

TABLE 11

TREATMENT OF SOFT TISSUE INJURIES

Early Treatment Late Treatment

MusculoperiostealIntermuscularIntramuscularIvrusculotendinousTendonTendoperiosteal

Injections and partial restComplete rest (aspiration)Complete rest (aspiration)InjectionsRestInjections and partial rest

lAccording to Bass; 1966.

Injections and stretchingRapid build of power/stretchSlow build of power/stretchInjections and stretchingHeat, stretching, frictionsInjections and stretching

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At the time of injury it is almost impossibleto determine exactly at what level damage isgreatest and so a policy of "wait and see"should he adopted. First aid of cold, com­pression and elevation should be administeredusing icy cold towels, cotton wool or sponge,compressed by crepe bandage. The limbshould be rested in elevation on pillows withthe patient in bed.. Twenty..four hours laterthe intermuscular haematoma will appear tobe a great deal better whilst the intramuscularhaematoma will appear much the same, pos­sibly even worse-and especially if the correctfirst aid was not administered or physicalirritation, such as massage or further exercisewas suffered. The history of a player beingable to finish a game following a knock, but,after receiving a vigorous massage from atrainer, not being able to walk the next dayis all too common.

Between 12-24 hours after injury a precisediagnosis regarding the major site of con..tusion should be possible.. The lesion shouldalso be classified according to degree ofseverity-mild, moderate or severe, or, first,second and third degree.

A mild contusion is characterized by Ioea..lized tenderness in the quadriceps; kneemotion of 90 degrees or more; little or nolimp and only mild to moderate loss of musclepower.

A moderate contusion is characterized bya swollen tender muscle mass, less than 90degrees of knee flexion and a limp. The athleteis unable to climb stairs or arise from a chairwithout considerable pain.

A severe contusion is diagnosed when thethigh is markedly tender and swollen, kneeflexion is less than 45 degrees and the patientprefers not to weight-bear on the injured limb.The adjacent knee joint will have an effusionwhich is thought to be partly gravitationaloedema and partly a sympathetic reactionof the joint's synovial membrane. It is thesesevere contusions that are the most likely todevelop myositis ossificans (Jackson andFeagin, 1973). They will be discussed later.

TREATMENT

It is common practice in Western Australiato give the patient a home treatment in..struction sheet which explains his condition.

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This practice helps to reduce the incidence ofmistreatment, particularly if provided at thetime of first aid.

Intermuscular HaematomaTreatment of the intermuscular haematoma

will he relatively dynamic. The day afterinjury, contrast applications of hot packs al­ternated with ice packs in 15..20 minute doses,viII be administered hefore pulsed ultrasound.

Exercise in the form of static contractions,straight leg raising and knee flexion withinlimits of pain may also commence the dayafter injury. With the milder injuries it mayeven be possible to jog.

Exercise should he "a little but often" forthe first 48 hours and followed by prophy­lactic applications of ice.

Slow, passive stretching exercises canusually he performed within 48..72 hours andvigorous stretching can usually he adminis..tered by the physiotherapist within a week.

Return to light training is usually within3-10 days following the occurrence of inter..muscular haematoma.

Intramuscular HaematomaTo reduce the risk of calcification (myo­

sitis ossificans) the treatment of the intra..muscular haematoma is always cautious.

Cold applications to the elevated limb maybe persisted with for as long as a week insome cases, whilst compression bandaging isoften discontinued after the first 24 hours asthe surface irritation is sometimes sufficient toretard progress.

The use of anti-inflammatory agents suchas indomethacin (Indocid) and oxyphenbuta­zone (Tanderil) is favoured by many, par­ticularly in the early stages, although there isnot a great deal of evidence from suitablyconducted clinical trials to justify their rou­tine use (Fitch and Gray, 1974).

A daily assessment of the inflammatorysigns and symptoms should provide the cri­teria for the progression of treatment and thesystem used in some single blind and doubleblind trials has proved a satisfactory method:a score is given 0..4 (Table 2), for pain atrest, pain on movement, local tenderness, localswelling, and range of movement (Table 3).

HAEMATOMA AND MYOSITIS OSSIFICANS 149

TABLE 21

ASSESSMENT OF DISABILITY

Score Degree Severity

0 Absent1 Mild Present but not incon-

veniencing2 Moderate Constantly aware of symp..

toms3 Severe Handicapped by symptoms4 Very severe Incapacitated by symptoms

lFitch and Gray, 1974.

In an uncomplicated recovery relief of painand loss of swelling will he evident after 3..5days of a regime of frequent applications ofcold packs, with the limb in elevation, andisometric contractions performed gently butoften. At this stage the patient is usually ableto walk without crutches. Hot and cold packs,alternating every 15·20 minutes are now intro­duced and pulsed sound may be used if localtenderness will allow. Unresisted knee move­ments are encouraged within the pain..freerange.

It should he noted that there has beenmounting evidence in recent years to indicatethe value of pulsed electromagnetic energy(Wilson, 1974), particularly in the acutestages of inflammation; however, it is sus..pected that a progressive exercise programmeis more important once knee flexion improvesbeyond 90 degrees.

The aims of exercise are now twofold:firstly, to rednee pain and swelling, and torecover muscle strength and extensibility;secondly, to maintain cardiorespiratory andgeneral muscular fitness. Swimming will serveboth these aims. Swimming style should beobserved to ensure that it does not involve anexaggerated knee flexion that might aggravatethe condition. If the athlete cannot swim thenthe hydrotherapy pool may be used for localexercise, and general fitness can be maintainedwith a balanced, progressive circuit in thegymnasium.

Exercises for the injured part are onlyadded at the rate of one every 1-2 days tosafeguard against regression, which wouldnecessitate a return to the stage of coldapplications and rest.

TABLE 31

DAILY ASSESSMENT

Signs and Symptoms Day 1 Day 2 Day 3

Pain at rest 0 I 2 (3) 4 0 1 2 (3) 4

Pain on movement 0 I 2 3 (4) 0 1 2 (3) 4Local tenderness 0 1 2 3 (4) 0 I 2 3 (4) etc.Local swelling 0 1 2 (3) 4 0 1 2 (3) 4Range of movement 0 I 2 (3) 4 0 1 2 (3) 4

Score 17 16 14

lAdapted from Fitch and Gray, 1974.

After 10-14 days a marked improvement inknee range of movement to 90 degrees ormore may be expected: straight leg raisingexercises lying prone, supine and on the sideare introduced, and more intensive forms ofheat may be administered. I prefer to use ashort-wave inductothermy cable coiled aroundthe thigh; but the results obtained by micro­wave and direct ultrasound seem to be muchthe same.

Where possible patients are given four ormore treatment sessions in a day, their exer..cise programme followed by electrotherapyand ice, followed by exercise, and so on.

When it is not possible for the patient tospend so much tinle at therapy, he is askedto follow the exercise programme, which isclearly explained on the home treatment in-

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struction sheet, 3..4 times a day and to reportfor treatment and assessment at the clinic justonce a day.

Exercises are gradually added until thepatient is performing all the twelve basic exer­cises that are listed on his programme (Table4) plus his general fitness programme. Thepatient is then able to return to specific lighttraining in an average of 4·6 weeks afterinjury.

TABLE 4THIGH CONTUSION: EXERCISE SCHEDULE

1. Static contractions of thigh muscles and gluteii.2. Knee flexion and extension within limit of pain~ without resistance.

3. Straight leg raising -lying prone, supine, onside.

4. Swimming using gentle freestyle or backstrokekick..

5. Knee flexion against resistance.6. Cycle and/or walking.7.. Extension of knee against resistance, within

painfree range.S. Step ups.9. Full squats without weight.

10. Passive stretching.11. Half squats with weight.12. Jogging - increasing distance before speed.

Each exercise is performed with a light load"vhen first introduced so that an individualexercise might start with 3 sets of 10 re­petitions with no weight, progressing gradu­ally to 3 sets of 20, and then back to 3 setsof 10 when a light resistance is introduced.The swhnming load will vary greatly depend..in~ upon the skill of the individual but willprogress usually at the rate of one pool width,or 20 metres a day.

Afyosids OssificansIf the intramuscular haematoma has not

shown marked improvement in 10-14 daysthen it is highly likely that calcification istaking place. Calcification can usually bedetected on X-ray film in the third week afterinjury, rarely before, but it can take a littlelonger before becoming evident.

The added complication of calcificationdoes not alter the content of the treatmentprogramme that has j list been outlined, butit will make a drastic difference to timing.

Aust.l..Physiather., XXIII, 4, December, 1977

Recovery will now be scheduled in monthsrather than weeks.

Treatment progression is still governed bya daily assessment of signs and symptoms butwith additional information from serial X-rayexaminations.

The typical general stages seen radio­logically are: firstly the early formation ofcalcification seen as a diffuse cloud (Fig.. 1)vvhich then starts to consolidate and will ap­pear as a denser, more defined mass (Fig. 2).The density of the lesion gradually matures,developing a '\Tell-organized trabecular patternand often a fairly well-defined thin cortex(Fig .. 3) which is not seen in more sinisterlesions. Once maturation of the mass is com..plete a very gradual resorption process willcommence (Thorndike, 1940; Ellis and Frank,1966; Hait et al., 1970; Jackson and Feagin,Ope cit.).

Histologically the "zone phenomenon" oftraumatic myositis ossificans can be demon­strated where according to Staple et ale (1973),"The inner zone is undifferentiated fibroustissue impossible to distinguish from fibro­sarcoma. Directly adjacent is a middle zonecontaining osteoid elements. The peripheralzone contains well-organized bone which mayhave a fibrous capsule."

Recovery time will depend largely upon thesize of the mass, and its position but generallyspeaking a marked relief of pain can be ex­pected in 1..2 weeks.

A marked improvement in knee flexionshould be seen in 4i..6 weeks and a return tolight training in 12..14 weeks. It should bepointed out that this is an average progressionand that although a return to activity hasbeen seen in less time it is very often muchlonger-even up to 12 months after injury.

There are many theories of mechanism ofdevelopment of myositis ossif1.cans that havebeen reviewed by Adams (1975) but as yetthese theories have not been substantiated.Ryan (1969) states that apparently, whenthere is damage to the muscle sheath, thesarcolemnla cells proliferate and may dif·ferentiate into fibroblasts and osteohlasts.. Ifsufficient osteoblasts are formed, they beginto lay down new bone. Carey (1924) sum­marized numerous theories:

HAEMATOMA AND MYOSITIS OSSIFICANS 151

1. Organization of haematoma, which pro­gresses from fibrous tissue to cartilageand, finally, to bone.

2. Bone formation within a muscle as a re­sult of detached periosteal flaps.

3. Rupture of periosteum which allows bonecells to escape into the muscle and pro..liferate.

4. Metaplasia of intramuscular connectivetissue into bone.

5. Underlying constitutional make-up predis..posing to myositis ossificans (diasthesia).

6. Calcification of a haematoma.

shearing strains, can produce the separationof skin and subcutaneous tissues from thedeeper tissues.

Bradshaw et al. (1972) reported on fourcases of such traumatic "cysts" that may be..come evident weeks or months after an initialinjury. These authors state that "the initialhaematolna may be replaced by serosanginousfluid sometimes with residual clot and thespace can acquire a fibrous lining which pre..vents fusion of the separated layers". These"cysts" tend to recur after aspiration and inlater stages the fibrous lining may becomecalcified.

FIGURE I FIGURE 2 FIGURE 3

Subcutaneous Haematoma

One other type of haematoma formationshould be mentioned.. It is not seen so oftenhut it can be as troublesome as the intra..muscular lesion. I am referring to the sub­cutaneous haematoma which occurs ,\Thensevere trauma to the soft tissue, particularly

Treatment of this lesion in early stagesshould he repeated aspirations, frequent coldapplications, persistent compression and rest.Once swelling has been controlled pulsedultrasound may be used but preferablythrough a mediulTI of "debubbled" water.Shortwave diatherlny or direct ultrasoundmay he used during the stage of resolution..

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If conservative treatment is not successfulwithin a few "reeks then large spaces maybecome lined by a shiny silver-white layer offibrous tissue that seems to prevent the fusionof the separated layers and the obliteration ofthe space" In these cases Bradshaw advisessurgical excision.

SUMMARY

The immediate first aid of cold, compression andrest in elevation is most important where haematomaformation is suspected following trauma. On the dayfollowing injury an accurate diagnosis should bemade relating to the part injured, the tissue involved,the site of bleeding and the severity of the condition.Confusing slang terminology should he avoided.

Treatment of intermuscular lesions should bedynamic and resolution should be rapid. Treatmentof intramuscular and subcutaneous lesions, wherecalcification is a possibility, should be cautious, par­ticuJarly when introducing exercises..

Exercise aims should always be twofold when treat­ing an injured athlete, that is, rehabilitation of theaffected limb and maintenance of general fitness.Specific training should not be resumed until reso­lution of the lesion is complete.

REFERENCES

ADAMS, R. D. (1975): Diseases 0/ Muscle, a Studyin Pathology. 3rd Edition, pp. 401..405, Harper andRow, Hagerstown.

BASS, A. L. (1966): "Rehabilitation after Soft TissueTrauma". In Proceedings 0/ the Royal Society ofMedicine, 59 : 653.

BRADSHAW, J. R., DAVIES, G. T., EDWARDS, P. W. andRICHARDS, H. J. (1972) : "The Radiological Demon-

Aust.l.Physiother., XXIII, 4, December, 1977

stration of Traumatic Cysts Due to Severe SoftTissue Trauma".. British Journal oj Radiology,45 : 905-910.

CAREY, E. J. (1924): "Multiple Bilateral TraumaticPeriosteal Bone and Callus Formations of theFemurs and Left Innominate Bone". Archives ojSurgery, 8 : 592-603.

ELLLS, M. and FRANK, H. G. (1966): "Myositis Os­sificans Traumatica, with Special Reference to theQuadriceps Femoris Muscle". The Journal ofTrauma, 6, 6 : 724-738.

FITCH, K. D. and GRAY, S. D.. (1974): "Indo..methacin in Soft Tissue Sports Injuries". MedicalJournal 0/ Australia, 1 : 260-263.

HAlT, G., BOSWICK, J. A. and STONE, N. H. (1970):"Heterotopic Bone Formation Secondary to Trauma(Mvositis Ossificans Traumatica)". The Journalof Trauma, 10, 5 : 4,05-411.

JACKSON, D. E. and FEAGIN, J. A. (1973): "Quad·riceps Contusions in Young Athletes, Relation ofSeverity of Injury to Treatment and Prognosis".The Journal oj Bone and Joint Surgery, 55-A,1 : 95-105.

MEE, B. (1965): "Physiotherapy in ProfessionalFootball". Physiotherapy, 51 : 117-120.

RYAN, A. J. (1969): "Quadriceps Strain, Ruptureand Charlie Horse" ~ AI.edicine and Science inSports, 1, 2 : I06~111.

STAPLE, T. W., MELSON, G. L. and EVENS, R. G.(1973) : "Miscellaneous Soft Tissue Lesions of theExtremities". Seminars in Roentgenology, VIII,I : 117-127.

THORNDIKE, T. (194{)): "Myositis Ossificans Trau­matica". The Journal of Bone and Joint Surgery,XXII, 2 : 315-323.

WILSON, D. H. (1974): "Comparison of Short WaveDiathermy and Pulsed Electromagnetic Energy inthe Treatment of Soft Tissue Injuries". Physio­therapy, 60, 10 : 309..310.