Download Deborah L Wieder 1992; 72:133-137. PHYS THER.

Treatment of Traumatic Myositis Ossificans with
Acetic Acid Iontophoresis
Deborah L Wieder
PHYS THER. 1992; 72:133-137.
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Case Report
Treatment of Traumatic Myositis Ossificans with Acetic
Acid Iontophoresis
Deborah L Wieder
The purpose of this case report i
s to document the treatment of a patient who had
traumatic myositis ossijicans with acetic acid iontophoresis. A 16-year-old boy developed quadricepsfemoris muscle myositis oss2Jicansas a result of a springboard
diving accident. A 2%acetic acid solution was administered via iontophoresis
into the myositis ossijicans,followed by 8 minutes of pulsed ultrasound at 1.5
wlcm2. The treatment was performed three times per week for 3 weeks. At the conclusion of the treatments, radiographic findings indicated a 98.9% decrease in the
size of the ossfied mas The patient regained full range of motion and was able
to return to pain-pee activity. This case repo7-r demonstrates the potential for a
therapeutic program of acetic acid iontophoresis and ultrasound in eliminating
myositis ossijicans. [Wieder DL. Treatment of traumatic myositis ossz~canswith
acetic acid iontophoresis. P@s Ther. 1992;72:133-13 7.1
Key Words: Acetic acids; Electrotherapy, iontophoresis;Myositis ossijicans,
Ultrasound.
Traumatic myositis ossificans is a reactive osseous lesion occurring in soft
tissues and at times close to bone and
periosteum.' It is a result of muscle
injury and often reinjury.' The hemorrhagic area is organized by granulation and fibrous tissue with fibroblastic cells from the endomysium, which
form broad sheets of immature fibroblasts.1 Primitive mesenchymal cells
proliferate within the injured connective tissue and give rise to osteoid and
chondroid formation at the periphery
progressing inward.' Eventually chondrogenesis occurs, and mature lamellar bone is formed. Calcification usually appears in 2 to 3 weeks. The
ossification of heterotopic bone occurs within 4 to 8 weeks.' Full matu-
rity is reached by 5 to 6 months, at
which time the mass may show some
decrease in size or resolution. The
most common sites of incidence are
the anterior thigh (quadriceps femoris
muscle) and the anterior arm (brachialis muscle).'
Little recent literature exists regarding
treatment for myositis ossificans. Traditionally, treatment for myositis ossificans has revolved primarily around
controlling hemorrhage. Rest, ice, elevation, compression dressings, and
immobilization are initiated with
moderate to severe contusions. In
addition, an anti-inflammatory agent
may be prescribed.3 Heat, continuous
ultrasound, massage, stretching, and
DL Wieder, MS, PT, ATC, is Clinical Director, Ohio Physical Therapy and Sports Medicine Inc,
25761 b r a i n Rd #302, Cleveland, OH 44070 (USA).
This research was presented at the Annual Conference of the American Physical Therapy Association; June 24-28, 1990; Anaheim. Calif.
exercise should be avoided initially so
as not to induce further bleeding in
the area.3
Immobilization is usually continued
until all pain has disappeared, at
which time range-of-motion maneuvers and strengthening exercises are
slowly initiated.3 Alternative treatments include surgery; aspiration of
the hematoma with subsequent injection of 1% lidocaine hydrochloride, anti-inflammatory steroids, and
lysosomal enzymes; cold laser therapy; radiation treatments; and acetic
acid iontophoresis.4'5
The literature has shown that traumatic myositis ossificans may take up
to 2 years to resolve. Surgical removal
of the ossified mass is often a debilitating option. Physical therapy protocols for this pathology have been argued in the literature.3-5 Because
traumatic myositis ossificans is an uncommon pathology, little research has
This article was submitted January 31, 1991, and was accepted August 28, 1991
52 / 133
Physical TherapyNolume 72, Number 2/February 1992
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been completed in this area of treatment. Treatment of this condition
with acetic acid iontophoresis may
result in a quicker, safer return to
activity and may eliminate the need
for surgical removal.
Iontophoresis is the introduction of
topically applied, physiologically active ions through the epidermis using
continuous direct current. Described
initially by Le Duc in 1908, iontophoresis is based on the principle
that an electrical charge will repel a
similarly charged ion." The clinical
use of acetic acid iontophoresis in the
treatment of patients with calcium
deposits was first described in 1955
by Psaki and Carroll7, and again in
1977 by Kahn8
The acetate ion found in acetic acid is
negative in polarity and has been cited
as effective in reducing the size of calcium deposits through the absorption
of calcium.7 Prior to complete ossification, myositis ossificans usually consists
of precipitates of calcium carbonate
that are not soluble in normal blood
pH levels? It has been postulated that
the aceta.te radical replaces the carbonate radical in the insoluble calcium
carbonate deposit, forming a more
soluble calcium acetate, as the following equation demonstratesg:
Iontophoresis would appear to be an
alternative treatment to injection for
introduction of the acetic acid. Because recurrent injury resulting in
additional bleeding often is a precursor to th~emyositis ossificans formation,1° additional damage to tissues
and resultant bleeding may occur
from invasive injection by a syringe
and needle.
Case Report
A 16-~ear-01d
soccer player was
referred to my clinic by his physician
treatment of his
quadnceps
contusion." The patient history re-
vealed a diving accident 3 weeks
prior to referral in which he dove
from a diving board onto a swimmer
below. A small contusion developed
on his anterior superior iliac spine;
however, he continued to swim and
dive for the rest of the afternoon.
One week later, the patient noticed
increased swelling and pain in his
right lateral anterior thigh. This pain
became progressively worse until the
patient was unable to play soccer.
During the second week postinjury,
pain was increasingly present on descending stairs. The patient was able
to ambulate with full weight bearing
without pain, although running produced sharp pain in the lateral thigh.
He could remember no other traumatic incident since the diving accident. There was no history of prior
injury or illness. The patient did not
recall any joint pains or muscle aches
and had no complaints of sickness or
fatigue. He also could not recall having taken any prescribed medications,
including aspirin, since the diving
accident.
Examination by the physical therapist revealed that the patient had
pain that restricted passive knee
flexion greater than 80 degrees. The
patient was able to achieve full hip
ROM of 120 degrees. He had pain
with isometric knee extension, but
no pain with resisted hip flexion.
He was able to achieve full passive
knee extension, but was unable to
perform an isometric quadriceps
femoris muscle contraction in full
extension. The patient experienced
pain upon palpation of the vastus
lateralis musculature, and a wellcircumscribed firm mass approximately lox 6 cm was noted. The
mass was fixed, nonpulsatile, and
not warm. No signs of redness or
streaking around the mass were
found, and the patient had a normal
body temperature.
The patient was then referred back to
his physician with a suRgestion that
the physician investigate the possibil.
'IOMED Inc, 1290 W 2320 S, Salt I.akc City, UT 84119.
ity of myositis ossificans. The physician ordered anterior-posterior and
lateral radiographs of the right femur,
which revealed a maturing myositis
ossificans located in the region of the
vastus lateralis musculature (Fig. 1).
Radiographic measurements revealed
the mass to be 7.1 cm in length,
4.2 cm in width, and 2.1 cm in thickness. The physician hypothesized that
the small anterior superior iliac spine
contusion may have bled into the lateral thigh musculature, therefore contributing to the formation of the myositis ossificans.
The therapist discussed treatment options for myositis ossificans with the
physician. In an attempt to decrease
the size and possible progression of
the calcium formation, acetic acid iontophoresis was chosen to supplement
the physician's prescription of rest and
inactivity. The patient was treated with
acetic acid iontophoresis in accordance
with Sharp's protocol" for 3 weeks.
Both electrode sites were thoroughly
cleansed with an isopropyl alcohol
wipe, and the active (negative) drug
electrode was placed over the site of
ossification. Three milliliters of a 2%
acetic acid solution using a distilled
water dilution medium was introduced
into the active drug electrode. The
drug electrode (IOMED model
EL501*) consisted of a closed polyurethane reservoir with a semipermeable
membrane and an adhesive border for
fixation. The treatment area of the
electrode was approximately 2.5 cm in
diameter. A 4.2-cm2karaya pad was
used as the dispersive electrode and
was placed 8 cm distal to the active
electrode. Using an iontophoresis unit
(IOMED model PM6OO Phoresor Iontophoretic Drug Delivery System*),the
patient was treated with 4 mA of direct
current for 20 minutes, for a total of
80 a m i n , in accordance with Sharp's
protocol." This treatment was followed by 8 minutes of 1.5 w/cm2 of
pulsed ultrasound at a 50% duty cycle.
An ultrasonic coupling gel was used as
the transfer medium.
Ultrasound was administered directly
over the myositis ossificans site in an
attempt to decrease skin irritation and
to possibly further disperse the acetic
Physical Therapynolume 72, Number 2February 1992
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Flgure 1 . Pretreatment x-ray f i l m of right femur ofpatient with myositis ossificans: (A) anterior-posterior uiew; (B) lateral uiew.
acid throughout the injury site. Additional treatment consisted of mild
passive-range-of-motion (PROM) movements within pain-free limits for
5 minutes three times a week. The
patient was instructed to avoid any
painful activity including stair climbing.
He was instructed not to participate in
any sports during the 3-week treatment period. The iontophoresis, ultrasound, and passive stretching treatment was administered on alternate
days three times per week for 3
weeks. After the fifth treatment, the
mass became increasingly compressible, and the patient's pain-free ROM
improved to 110 degrees of knee
flexion.
At the conclusion of nine treatments,
radiographs revealed the mass to be
2.8 cm in length, 0.3 cm in width, and
0.8 cm in thickness (Fig. 2). These
results represent a 98.9% decrease in
the size of the mass. The patient regained full knee ROM of 149 degrees
and was able to resume playing soccer pain-free. He had no pain with
any activities of daily living including
running and descending stairs. A protective Orthoplastt "donut" thigh pad
was then placed over the area of previous injury in an attempt to protect
against future injury to the thigh musculature during athletic activity.
What caused the reabsorption of the
calcifying myositis ossificans in this
patient is unknown. Ultrasound may
have enhanced the resorption of the
soluble calcium acetate. It is also
questionable whether the ultrasound
treatment itself played a role in the
resolution of the mass. It has been
inconclusively argued in the literature
as to whether bone reabsorption or
formation is enhanced by ultra~ound.12~13
Properly controlled studies
are necessary to determine the efficacy of the individual entities of the
treatment program chosen.
Myositis ossificans seems to be a selflimiting disease. There is a spontaneous resolution after maturation in
many cases,14but reports have shown
that traumatic myositis ossificans may
take u p to 2 years to resolve. Only a
small percentage seem to need surgical excision; however, this is often a
'~ohnson&Johnson Products, 501 George, New Bmnswick, NJ 08903
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Physical TherapyNolume 72, Number 2/February 1992
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Flgure 2. Posttreatment x-rayjilms of right femur of patient with myositis ossijicans: (A) anterior-posterior view; (B)Lateral view.
debilitating option. Possible clinical
implications for acetic acid iontophoresis may include myositis ossificans, caIcific joint deposits, frozen
shoulder, and heel spur formation.
Summary and Conclusions
As traumatic myositis ossificans is an
uncommon pathology, little research
has been completed in this area of
treatment. This case report describes
the treatment of a 16-year-oldboy
with a diagnosis of posttraumatic myositis ossificans. The patient's 3-week
physical therapy program consisted of
a 2% acetic acid iontophoresis treatment followed by pulsed ultrasound
and mild PROM movements. Following completion of the program, a
98.9% reduction in the size of the
calcifying mass was demonstrated by
radiographic evidence. Further studies
are needed to support the use of acetic acid iontophoresis for both treatment and possible use as prevention
once initial trauma has occurred. Controlled studies with acetic acid iontophoresis and myositis ossificans are
necessary to establish a cause-effect
relationship. Additional research, including single-subject designs, should
be implemented to document the
efficacy of this procedure.
Acknowledgment
I gratefully acknowledge Dr Wdliam
Schmidt and Dr Sherill Hayes for their
collaboration and encouragement.
References
1 Tyler JL, Derbekyan V, Lisbona R. Early diagnosis of myositis ossificans with T099m
diphosphonate imaging. Clin Nucl Med.
1984;9:460462.
2 Huss CD. Myositis ossificans of the upper
arm. Am J Sports Med. 1980;8:419424.
3 Nalley J, Susan Jay M, Durant RH. Myositis
ossificans in an adolescent following a spow
injury.J Adolesc Health Care. 1985;6:46&462.
4 Ellis M, Frank HG. Myositis ossificans traurnatica: with special reference to the quadriceps fernoris muscle. J Trauma. 1966;6:
724738.
5 Jackson DW, Feagn JA. Quadriceps contusions in young athletes./ Bone Joint Surg
[Am]. 1973;55:95-104.
6 Cummings J, Iontophoresis. In: Nelson RM,
Currier DP, eds. Clinical Electrotherapy. East
Norwalk, Conn: Appleton & Iange; 1987:231.
7 Psaki CG, Carroll J. Acetic acid ionization: a
study to determine the absorptive effects upon
calcified tendinitis of the shoulder. Phys Ther
Rev. 1955;35:8447.
8 Kahn J. Acetic acid iontophoresis for calcium deposits: suggestion from the field. Phys
Ther. 1977;57:65&659.
Physical Therapy/ZTolume 72, Number 2February 1992
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136/55
9 Kahn J. Principles and Practice oJElectrotherapy. New York, .W:Churchill Livingstone
Inc; 1987;165.
10 Antao NA. Myositis of the hip in a professional soccer player. Am J Sports 'Wed.
1988;16:82-83.
11 Sharp N . Acetic acid: a solution for some
frozen shoulders. Phoresor Forum. 1988;7(5):1.
12 Cline PD. Radiographic follow.up of ultrasound therapy in calcific bursitis: case report.
Phys Ther. 1963;43:659-660.
13 Ziskin MC, Michlovitz SL. Therapeutic ultrasound. In: Michlovitz SL, ed. Thermal &en& in
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1986:160.
14 Thorndike A. Myositis ossificans traurnatica.
JBone Joint Surg [Am/. 1940;22:315-323.
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Treatment of Traumatic Myositis Ossificans with
Acetic Acid Iontophoresis
Deborah L Wieder
PHYS THER. 1992; 72:133-137.
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