1

Myositis Ossificans
Also known as localized myositis ossificans, extra osseous
localized non neoplastic bone and cartilage formation, myositis
ossificans traumatica, myo-osteosis, myositis ossificans
circumscripta, traumatic ossifying myositis and ossifying
haematoma.
Reactive lesion occurring in soft tissues and at times near bone
and periosteum.
Myositis Ossificans
It is characterized by fibrous, osseous and cartilaginous
proliferation and by metaplasia. The term myo and itis is a
misnomer because skeletal muscle is often not involved and
inflammatory changes are rarely evident. Also in early phase of
evolution, formation of bone may not be observed, so term
ossificans is not always applicable.
Myositis Ossificans
Most if not all, have a history of trauma, simple severe blow or series of
repeated minor traumas. Condition may be classified according to its location
as extra osseous, periosteal or parosteal. Haematoma seems to be
necessary prerequisite. Muscles most often involved are brachialis,
quadriceps femoris and adductor muscles of thigh. It is significant that these
muscles gain attachment to bone over a wide surface area, suggesting that
periosteum participates to some extent in the process.
Myositis Ossificans
Young athletic men are predisposed. Region of elbow is a favorite
site, and when the process appears to restrict elbow motion
progressively, ill advised forcible manipulation will cause a
widespread involvement.
Pathogenesis
Muscle is commonly but not invariably involved, and fascia,
tendon and periosteum can also be the site.
Process is peculiar alteration within the ground substance of
connective tissue, associated with striking proliferation of
undifferentiated mesenchymal cells.
Pathogenesis
Initially
there is degeneration and necrosis, in case of muscle, disrupted
muscle fibers retract. In 3 to 4 days, fibroblasts from endomysium invade
 2

damaged area and rapidly form broad sheets of immature fibroblasts. At the
same time, primitive mesenchymal cells proliferate within injured connective
tissue. Intense cellular proliferation of fibroblasts and mesenchymal cells
produces a histological picture that may be erroneously diagnosed as
fibrosarcoma or myosarcoma.
Pathogenesis
Ground substance becomes homogeneous or glassy or waxy, suggesting
some type of edema. It increases in in amount and encloses some of
mesenchymal cells, which then assume the morphological characteristic of
osteoblasts. Mineralization follows and bone is formed. This events typically
takes place first within least damaged part i.e. periphery. As the process of
osteoid formation and mineralization changing in mature bone evolves, it
progressively extends towards the central, severely damaged area.
Pathogenesis
Any trauma that produces haematoma beneath the periosteum or damages
it sufficiently to elevate it, will produce highly cellular proliferation in space
between periosteum and bone; osteoid develops and is rapidly converted to
bone. When myositis is not removed and is allowed to mature, it becomes
oriented and covered by a cartilaginous cap, because of muscle action over
the lesion. This is called post traumatic osteochondroma and is common in
region of knee joint.
Clinical picture
Result of single or repeated trauma. Brachialis is a favorite site after
posterior dislocation of elbow. Elbow is quite swollen and tender and active as
well as passive motion is restricted. As pain and swelling decreases, a
circumscribed, indurated, later hard tumor mass is palpable. Active extension
of joint is limited due to inelasticity of muscle, and flexion is prevented by
obstruction by the mass.
Clinical picture
Ossification in deltoid is common in foot soldiers due to trauma caused by
carrying a rifle. The constant pressure of saddle against the adductors in
riders causes ossification in adductors. This syndrome is known as Prussian
disease.
Myositis ossificans is self limited, undergoes maturation and may persist as
a hard ossified mass, usually within a muscle or fixed to adjacent long bone.
In some cases it undergoes almost complete regression.
Diagnosis
Totally excised lesion or deep biopsy will demonstrate zoning
effect. Central area with numerous cells of various shapes and
sizes and occasional mitotic figures. Next zone shows osteoid
 3

formation with a fibrovascular background. This is more advanced

stage, cells are more uniform, indicating a benign lesion. In outer
zone, trabeculae of well formed bone and more mature fibrous
stroma are observed.
Treatment
Growth should not be removed in premature stage as it is
disastrous. The ossification becomes exuberant, infiltrates beyond
the original site, and compresses the soft tissues around beyond
hope of repair. When after serial x-rays the mass is dense, well
delineated, and at a stand still, it may be safely removed. It may be
possible to prevent myositis by aspirating the original haematoma.
Myositis ossificans progressiva
Congenital condition that starts without antecedent trauma before or shortly
after birth. Consists of frequently repeated episodes of sudden extension of
ossification in muscles, fascia, tendons and aponeuroses.
Raised eosinophil count.
Ossification usually starts with the upper back muscles, trapezius, latissimus
dorsi, and spreads distally involving soft tissue structures throughout the
body.
Myositis ossificans progressiva
IP joint of thumb, large toe and spine are liable to fuse. All joint
motion is finally lost and patient dies of inter current infection. This
condition is very rare.
There is no known effective treatment.
Corticotrophin seems to have some deterrent effect on
heterotrophic bone formation. Eosinophil count drops and joint
motion may even increase.
Tennis elbow
Chronic disabling pain in elbow, around radio humeral joint, is
called tennis elbow rather than epicondylitis or radio humeral
bursitis in view of lack of specificity regarding its origin.
Tennis elbow-Etiology
Common in people whose occupation require frequent rotary
motion of forearm e.g. tennis players, pipe fitters and carpenters.
Tennis elbow-Clinical picture
Onset is gradual.
 4

Pain appears over outer aspect of elbow and is referred to

forearm. It is persistent and intensified by grasping or twisting
motions. In short, all muscles required for grasping and supination
which originate from lateral epicondyle, epicondylar ridge and a few
fibers from anterior capsule of elbow joint.
Tennis elbow-Clinical picture
Well localized point of tenderness at either epicondylar ridge,
lateral epicondyle, lower edge of capitellum anteriorly, laterally over
radio humeral space or one area in the circumference of radial
head during rotation of forearm.
Range of motion is normal. There is weak grasp and dropping of
objects particularly with forearm pronated.
Tennis elbow-Clinical picture
Pain can be reproduced by completely extending the elbow, pronating
forearm and forcibly flexing wrist. Active attempts of dorsiflexion of the wrist
and supinate the forearm against resistance will likewise intensify the pain.
The condition infrequently involves the medial epicondyle where pain is
intensified by strong grasping, active flexion of wrist and pronation of forearm
against resistance. This is called Golfer’s elbow or medial epicondylitis.
Tennis elbow-X-Ray
X-rays are usually negative. Occasionally a small flake of bone
anterior to the epicondyle suggests an avulsion or surface of
epicondyle may be roughened as an indication of Peri Osteitis.
Tennis elbow-Pathology
Actual pathology is unknown.
May be caused by tearing of tendon fibers from their attachment to
epicondyle . The constant muscle contractions prevent healing,
creating a traumatic Peri Osteitis.
Annular ligament undergoes hyaline degeneration and may be the
source of pain.
Tennis elbow-Treatment
Conservative treatment is effective in most cases but recurrence is
common.
Rest : Complete rest with posterior moulded cast or splint,
maintaining relaxation of extensors by flexion at elbow, supination
and extension at wrist. This should be removed daily for gentle
exercises to avoid elbow stiffness.
 5

Tennis elbow-Treatment
Heat : Moist compresses or SWD is used.
LAHC : Multiple punctures are made in tender area and either steroid alone
or a combination of steroid and local anesthetic is injected and repeated at
intervals of 1 to 2 weeks for 3 to 4 doses.
Radiation therapy : 3 sittings of 200 rads in air to each of three fields-
anterior, posterior and lateral. One field is treated every other day.
Tennis elbow-Treatment
Manipulation : Principle is to convert the partial tear of conjoined tendon into
a complete tear, thereby detaching the tendon from chronically inflamed
periosteum.
Technique : Elbow flexed and forearm supinated, epicondyle is massaged
for 10 minutes. Then elbow is fully extended and forearm forcibly adducted to
create varus position. This is repeated every 2 or 3 days; about 4 treatments
are sufficient to provide relief.
Tennis elbow-Treatment
Technique : While the fingers and wrist are held fully flexed and
forearm pronated, the elbow is forced into full extension while firm
pressure is applied with thumb over the tender epicondyle.
Miscellaneous : Ultrasonic therapy gives equivocal results.
Phenylbutazone produces excellent results but it is not
recommended due to its potential toxicity.
Tennis elbow-Treatment
Surgical treatment usually gives immediate and lasting relief. It is indicated
when conservative treatment fails.
Technique : Under tourniquet, curved linear longitudinal incision made just
posterior to lateral epicondyle. Deep Fascial covering over conjoined tendon
is divided transversely. IM septum is also divided. Conjoined tendon is
severed at the epicondyle, epicondylar ridge and remaining fibers detached
by subperiosteal elevation.
Tennis elbow-Treatment
Conjoined tendon and extensor muscles are allowed to displace
distally. Lateral incision into joint anterior to collateral ligament
exposes the capitellum and radial head. A portion of annular
ligament is cut. Only skin and SC tissue are closed and elastic
compression bandage is applied and immediate joint motion
permitted. Removal of annular ligament is optional and does not
affect stability.
 6

Tennis elbow-Treatment
Denervation : Under cover of brachioradialis muscle, radial N gives off a
branch that can be traced to periosteum of lateral epicondyle. After exposure
of radial N, it is lifted gently and articular branches are identified and excised
from anterior and lateral surface of epicondyle. Postoperatively injection of
periosteal and articular branches are blocked with local anesthetic to test the
effectiveness of denervation.