Myositis Ossificans Traumatica of the Deltoid Ligament in a 34 Year Old
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0008-3194/2010/229–242/$2.00/©JCCA 2010 Myositis ossifi cans traumatica of the deltoid ligament in a 34 year old recreational ice hockey player with a 15 year post-trauma follow-up: a case report and review of the literature Dr. Brad Muir, HBSc(Kin), DC, FCCSS(C)* Myositis ossifi cans traumatica is a relatively common La myosite ossifi ante traumatique est une blessure injury associated with sports especially those involving relativement courante liée à la pratique des sports, contact. It continues to frustrate both athlete and health particulièrement les sports de contact. Elle continue practitioner alike due to its continued lack of treatment de frustrer les athlètes et les professionnels de la santé options and a lengthy natural history. This case study en raison de l’absence d’options de traitement et du chronicles the observation of a 34 year old recreational fait qu’elle existe depuis longtemps. Cette étude de cas ice hockey player who presented 7 years post-trauma, raconte l’observation d’un joueur de hockey sur glace was diagnosed with myositis ossifi cans traumatica de ligue récréative de 34 ans qui reçut un diagnostic and was followed up on 8 years later (15 years post- de myosite ossifi ante traumatique après 7 ans, et trauma). This case report is suspected to be the fi rst qu’on examina ensuite 8 ans plus tard (15 ans après le published case study of its kind. The literature review traumatisme), Cette étude de cas est probablement la outlines the various types of myositis ossifi cans, its première en son genre. Une analyse de la documentation incidence, pathogenesis, differential diagnoses including à ce sujet souligne les divers types de myosite ossifi ante, osteosarcoma, and the various methods/modalities sa fréquence, sa pathogénie, les différents diagnostics, reported in its treatment. notamment l’ostéosarcome, et les diverses méthodes/ (JCCA 2010; 54(4):229–242) modalités signalées dans son traitement. (JCCA 2010; 54(4):229–242) key words: myositis ossifi cans traumatica, mots clés : myosite ossifi ante traumatique, heterotopic ossifi cation, post-traumatic myositis ossifi cation hétéropique, myosite ossifi ante post- ossifi cans, ice hockey, deltoid ligament traumatique, hockey sur glace, ligament deltoïde Introduction sidered rare in children under 10 years of age1 and males Myositis ossifi cans traumatica (MOT) is often defi ned as are more often affected than females.3 heterotopic, non-neoplastic proliferation of bone in an The incidence of MOT following quadriceps contu- area previously exposed to trauma and hematoma.1,2 sions is reported at varying percentages depending on the The most common areas that are affected by MOT severity of the injury. Mild contusions have shown an in- are the quadriceps femoris, brachialis anticus, and the cidence of MOT of 0–9%, moderate to severe 17–72% adductor muscles of the thigh3 although it may occur and recurrent contusion 100%.4,5 Contusions of the thigh anywhere. It can happen at any age, but occurs most fre- are generally graded according to the subsequent loss of quently in adolescents and young athletes, with over half range of motion at the knee joint. Contusions are graded of the cases occurring in the third decade.1,3 MOT is con- as mild (active ROM greater than 90º), moderate (45–90º) * Assistant Professor, Canadian Memorial Chiropractic College, 177 Carnwith Drive East, Brooklin, ON L1M 2J5. Tel: (416) 482-2546 ext. 123 (CMCC), (905) 428-9370 (practice) © JCCA 2010 J Can Chiropr Assoc 2010; 54(4) 229 Myositis ossifi cans traumatica Figure 1 Photograph of patient’s bilateral ankles. Figure 2 Photograph of the patient’s left medial ankle. The arrow indicates the area of myositis ossifi cans The arrow indicates the area of myositis ossifi cans traumatica of the left medial ankle. traumatica. and severe (less than 45º).5 Arrington6 grades thigh con- years after the injury, he had returned to play competi- tusions as: mild – near normal ROM, local tenderness, tive hockey and didn’t recall any limitation although the no gait abnormality; moderate – swollen tender muscle, lump had not resolved. Four years post injury, he began 75% ROM, antalgic gait; and severe – marked tenderness/ to notice the lump was larger and was becoming increas- swelling, 50% ROM with a severe limp. Muscle contu- ingly irritated from the direct pressure of tightening his sion injuries are second only to strain injuries as a major skate laces. He was also getting sharp pain in his foot cause of morbidity in the modern athlete.2 with pivoting while skating and noticed decreased range This paper presents a case study of a 34 year old recrea- of motion especially in dorsifl exion. Seven years post- tional ice hockey player who was diagnosed with MOT of injury, he began to notice increased pain when turning the deltoid ligament of the ankle 7 years post-trauma and around pylons while demonstrating drills as a hockey followed up on 8 years later (15 years post-trauma). coach. Stopping, and backward skating had also become painful and pivoting was still diffi cult due to pain. He Case Report also noted increasing diffi culty going up stairs and felt he had to lift his leg higher to get his foot fl at on the next History stair. At this point, he presented to the clinic for examina- A 34 year old recreational hockey player presented with tion and possible imaging. an unusual bony lump just anterior and inferior to his There was no history of recent infection, sudden un- left medial malleolus (see Figure 1 and 2). He reported explained weight loss or night pain. Systems review re- that the lump had started following blocking a shot in a vealed a history of seasonal bronchitis but was otherwise hockey game 7 years previously. He was able to fi nish unremarkable. Previous medical history revealed a pre- the game and had partial weightbearing following the vious right shoulder surgery for recurrent subluxation but game. The foot became increasingly swollen and was no other major traumas or motor vehicle accidents. He treated with rest and ice. No radiographs were taken at did not report any previous injury to the left foot or ankle. the time of the initial injury. He reported that the lump Family history did not reveal anything relevant. He is an had increased in size slowly over the next few years. Two otherwise healthy individual who exercises regularly and 230 J Can Chiropr Assoc 2010; 54(4) B Muir Figure 3 Medial sagittal CT image of the left ankle 7 years post injury showing an irregular ossifi c density anteroinferior to the medial malleolus indicating myositis ossifi cans traumatica of the deltoid ligament. Figure 4 Axial CT image of the left ankle 7 years post The white arrow indicates the area of ossifi cation. injury showing an irregular ossifi c density medial to the medial malleolus. The white arrow indicates the area of ossifi cation. does not smoke. This patient is a factory worker and a part-time hockey coach. Plan of management He did not report any numbness or tingling in his foot The initial plan of management for this patient was to rule or ankle. out any insidious diagnosis, including osteosarcoma, with the imaging. The diagnosis of osteosarcoma was unlikely Physical examination due to the slow, progressive nature of the injury and its Upon examination, the patient was able to ambulate nor- lack of pain but it was felt imaging was prudent in this mally. A visible prominence was noted anterior and in- case. Following the diagnosis, the patient was informed ferior to the medial malleolus of his left foot. Active and of the natural history of MOT and that there were few passive range of motion revealed a decrease of 40% in proven treatment options available at that time. Due to dorsifl exion, inversion and eversion due to restriction not the relatively minor irritation experienced during hockey pain. Plantar fl exion was decreased 10–20% due to soft and activities of daily living the patient was not interested tissue restrictions. (The patient felt he could go further in surgery and decided to treat the area symptomatically but was tight and no bony end feel was noted.) Joint play with ice and rest as needed. A “wait and see” approach of the midtarsal joints was within normal limits. Other was taken with instructions that if the lump was increas- ranges of motion were full and pain free. Strength was ing in size and/or pain that the patient was to return for slightly decreased compared to the right side in all ranges further examination. but there was no pain. Palpation of the bony mass re- vealed some point tenderness but the foot and ankle were 15 Year Follow-up otherwise pain free. Radiographs and a CT were ordered The patient, now 42 years old, was contacted to follow-up for this patient at this point in the examination (see Figure on his status. The patient reported that he felt there was 3–6) . little change in the size of the lesion on his left ankle. He still had similar restrictions with regard to his on-ice ac- Diagnosis tivities including quick pivoting and demonstrating drills The patient was subsequently diagnosed with myositis os- and his activities of daily living including going up stairs. sifi cans traumatica of the left deltoid ligament of the ankle. He felt these activities were diffi cult due to his decreased J Can Chiropr Assoc 2010; 54(4) 231 Myositis ossifi cans traumatica Figure 5 Coronal CT image of the left ankle 7 years post injury showing an irregular ossifi c density anteroinferior to the medial malleolus.