eswt - for myositis ossificans case

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d Original Contribution

SHOCK WAVES IN THE TREATMENT OF POST-TRAUMATIC MYOSITISOSSIFICANS

PAOLO BUSELLI ,* VALERIA COCO,y ANGELA NOTARNICOLA ,z SARA MESSINA ,* RAOUL SAGGINI ,x

SILVIO TAFURI ,xx LORENZO MORETTI ,z and BIAGIO MORETTI z*Shock Wave Therapy Division, Department of Specialist Rehabilitation, Hospital of Lodi (LO), Lodi, Italy; y Department of

Rehabilitation, Hospital of Acireale (CT), Acireale, Italy; z Department of Clinical Methodology and Surgical Techniques,Orthopedics Section, Faculty of Medicine and Surgery of University of Bari, General Hospital, Bari, Italy; x Department of Medicine and Science of Aging, G. DAnnunzio University of Chieti, Chieti, Italy; and xx Hygiene Section, Department of

Biomedical Sciences and Human Oncology, Faculty of Medicine and Surgery of University of Bari, General Hospital, Bari, Italy

( Received 3 July 2009; revised 6 November 2009; in nal form 21 November 2009)

AbstractMyositis ossicans (MO) is a fairly common evolution in sports activity and can be due to direct traumaor to repeated micro-injuries. The traditional therapeutic approach relies on a variety of treatments, such as phys-ical therapy but evidence of their proven clinical efcacy is lacking. The latest therapeutic option is surgicalremoval but this is a demolitive procedure andis frequently associated with a signicant loss of functional integrity.There are few articles in literature about the treatment of post-traumatic MO, and none on extracorporeal shockwave therapy (ESWT). We illustrate a case series of 24 sportsmen treated with three sessions of electro-hydraulicshockwave therapy and an associated rehabilitation program. Only a partial reduction of the ossication wasobserved in the X-ray images but all the patients showed signs of functional improvement immediately aftertherapy. Two months after the therapy, a normal range of motion and no signs of weakness were observed. Threemonths after treatment, 87.5% of patients resumed regular sports activities. (E-mail: [email protected] ) 2010 World Federation for Ultrasound in Medicine & Biology.

Key Words: Myositis ossicans, Shock wave therapy, Muscle injury, Stiffness.

INTRODUCTION

Muscle contusion injuries commonly occur in contact sports, potentially causing considerable morbidity inathletes. Contusions are the second most common causeof disability in athletes, the most common causes beingmuscular tears and strain. Myositis ossicans traumatica (MO) occurs after blunt trauma to muscle tissue.Although the mechanism of bone formation in themuscle is unclear, there are incidences ranging from

9% to 20% of this process in athletes who have sustaineda direct blow from a body part of an opponent, most often the knee ( Danchik et al. 1993 ). The most commonsite of occurrence is the anterior thigh and the processdevelops subsequent to the formation of an intramus-

cular hematoma ( Miller et al. 2006 ). Patients experiencetenderness and swelling at the site of injury and their symptoms are generally unresponsive to 1 week of rest. In the acute phase, treatment consists of immobili-zation of the muscle in tension, ice and elevation. Phar-macologic interventions such as indomethacin and other nonsteroidal anti-inammatory drugs (NSAIDs) mayalso be employed. Surgery is usually considered inpatients who suffer persistent continued pain, limitedmotion or a deterioration of function, after 4 to 6 monthsfrom the trauma ( Spencer and Missen 1989; Giombiniet al. 2003 ).

The aim of these clinical studies is to assess the ef-cacy of extracorporeal shock wave therapy (ESWT) in thetreatment of MO. Shockwave treatment was initially em-ployed for lithotripsy of kidney stones but has since beenextended to the treatment of calcied tendons and pseu-doarthrosis. The rationale for adoption of this treatment is the cavitation effect that has a mechanical actioninducing bleeding as well as a biologic action stimulatingtissue repair ( Tu et al. 2007 ).

Address correspondence to: Angela Notarnicola, Department of Clinical Methodology and Surgical Techniques, Orthopedics Section,Faculty of Medicine andSurgery of University of Bari,General Hospital,Piazza Giulio Cesare 11, 70124 Bari, Italy. E-mail: [email protected]

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Ultrasound in Med. & Biol., Vol. 36, No. 3, pp. 397409, 2010Copyright 2010 World Federation for Ultrasound in Medicine & Biology

Printed in the USA. All rights reserved0301-5629/09/$see front matter

doi:10.1016/j.ultrasmedbio.2009.11.007
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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MATHERIALS AND METHODS

This prospective clinical study was approved by theLocal Ethics Committee and observed the Declaration of Helsinki ethical principles for medical research involvinghuman subjects.

Twenty-four patients (all male, mean age 25.54years, range 1858 years), with post-traumatic MO, diag-nosed on the basis of the clinical history, physical exami-nation, X-rays and MRI, were treated. All patients freelysigned an informed consent statement to take part in thestudy. They were treated with ESWT and physiotherapy.A control group was absent.

The inclusion criteria were:

a diagnosis of MO, with ossication of more than 1 cmin length, as evaluated by X-ray;

age between 18 and 60 years; elite or sub-elite athletes;

painful symptoms and functional limitation lasting 1.5months or more; no heart pacemaker use; absence of systemic inammatory or neoplasticdisease;

no use of anticoagulants.

Before the injury all actively participated in varioussports: soccer ( n 5 12), skiing ( n 5 3), motorcycling(n 5 2), cycling ( n 5 1), mountain-bike ( n 5 1), basket-ball (n 5 1), swimming ( n 5 1), athletics ( n 5 1), karate(n 5 1) and skating ( n 5 1). MO were reported in specicmuscles of the lower extremities (quadriceps, n 5 10;vastus medialis, quadriceps and rectus femoris muscles,n 5 3; quadriceps and rectus femoris muscles, n 5 1;biceps femoris, n 5 1; adductors, n 5 2; quadricepts fem-oris, vastus lateralis and rectus femoris, n 5 3; vastus lat-eralis, n 5 1; sural triceps, n 5 1; adductors and bicepsfemoralis, n 5 1), or upper extremity (biceps brachialis,n 5 1). MO had been caused by sports trauma: musclecontusion (in 12 patients), bone fractures (in 4 patients),torn muscles (in 2 patients), wounds (in 2 patients) andsoft tissue cutting (in 4 patients) ( Table 1 ).

The traumawas associatedwith a largehaematoma. Inthefollowing weeks,pain anddifculties in mobilizing thelimb still persisted and the stiffness started to stabilize, re-sulting in a progressive range of motion (ROM) reduction.A few weeks after the trauma, radiographic analysis andMRI were performed and the diagnosis of MO was made.

In the immediate post-traumatic phase, the patientswere treated with rest, local application of ice and theadministration of aspirin or indomethacin. At the sametime, the subjects underwent local ultrasound therapyand physiotherapy every day, usually exercises of passivemanual mobilization and stretching but no particular improvements were observed. In the following weeks,

a marked muscle tenderness associated with reducedROM persisted. Subsequently, the subjects underwent further daily physiotherapy with manual and mechanicalpassive mobilization. Continuous passive motion (CPM)was associated with stretching exercises but yielded noappreciable results.

The surgical treatment option was excluded becauseof the mass involvement and diffusion inside the muscle:in fact, surgical removal would have signicantly jeopar-dized the muscle function of these young athletes.

In view of the poor results of physiotherapy and thelimits to surgical intervention, we administered shockwave treatment after an average of 4 6 2.09 months(range 1.514 months) from the trauma.

The ESWT was generated by two electro-hydraulicsystems, Evotron or Ossatron (Milano, Italy) OSA 140by HMT srl, in according with the guidelines of the Inter-national Society of Medical Shock Waves Therapy(ISMST) ( Thiele 2009 ). The skin region was put in direct contact with the shock waves generation tube, after applying ultrasound gel. Using an X-ray image in scale1:1, we outlined the area of ossication on the skin regionand administered 100 impulses per cm 2 of ossication,every 2 weeks for three sessions. The shock waves(SW) were performed without anaesthesia. We chose toapply medium power so the pain was well tolerated (rangefrom 0.13 to 0.23 mJ/mm2, mean 0.15 6 0.02 mJ/mm2),on the basis of the energy ux density (EFD) used in thetreatment of calcied tendons ( Moretti et al. 2005 ).

After therst session, thepatients started a rehabilita-tion program consisting of one daily session 6 daysa week. The rehabilitation program included passive andactive mobilization performed by a therapist, passivemobilization with CPM using a mechanical device(kinetic), bending being increased from 0 to a value set on the basis of the pain threshold. In addition, stretchingand proprioceptive exercises were proposed for a totalduration of about 80 min with a physiotherapy programquite similar to the one performed in the rst monthsfollowing the trauma. From the third week of treatment,isometric exercises for muscular reinforcement wereintroduced in the program; then, starting from the fthweek, exercises for muscular reinforcement with isotonicdevices in closed and open kinetic chain were performed,too. From the seventh week onwards, the physiotherapyfrequency was reduced to three sessions a week, whileeccentric exercise, at rst with natural load and thenwith overload, was introduced. From the third monthonwards, technical training on the pitch, even with ballexercises, was resumed ( Miller et al. 2006).

Evaluations were made before treatment and 1, 2, 3,6 and 12 months after treatment. These evaluationswere always performed by the same examiner andconsisted of:

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Table 1. This table shows the anamnesis, the side and the type of injury of the 24 cases affected by M

Patient (male) Age (years) Months after the trauma Trauma Sport Side of trauma

1 16 1,5 Contusion Soccer Right thigh Quadriceps femori2 49 2 Contusion Cycling Right thigh Quadriceps femori3 15 3 Contusion Basket Left thigh Quadriceps femori4 27 14 Contusion Soccer Right thigh Quadriceps femori5 18 9 Bone fracture Soccer Left thigh Vastus lateralis 6 26 2 Contusion Soccer Right thigh Quadriceps femori7 58 4 Wound Motorcycle Left thigh Quadriceps femori8 21 5 Wound Athletic Left thigh Biceps femoris 9 17 4 Bone fracture Soccer Left thigh Quadriceps femori

femoris10 25 1,5 Cutting Ski Right thigh Adductors 11 22 3 Contusion Karate Right thigh Quadriceps femori12 23 3 Contusion Soccer Left thigh Quadriceps femori

rectus femoris

13 27 2 Contusion Ski Left thigh Quadriceps femorirectus femoris14 17 8 Bone fracture Soccer Left thigh Quadriceps femori

rectus femoris15 35 4 Tear Swimming Right thigh Adductors 16 28 2 Cutting Skating Left thigh Sural triceps 17 27 3 Contusion Motorcycle Right thigh Quadriceps femoris

femoris18 31 2 Cutting Mountain bike Right thigh Adductors and bic19 35 4 Tear Ski Left arm Biceps brachialis20 29 3 Bone fracture Soccer Left thigh Quadriceps femori

femoris21 22 5 Contusion Soccer Right thigh Quadriceps femori22 18 3 Contusion Soccer Right thigh Quadriceps femori23 26 2 Contusion Soccer Right thigh Quadriceps femori24 25 7 Cutting Soccer Left thigh Quadriceps femoriMean 26.54 4.04 DS 10.1 2.9

MO 5 myositis ossicans.


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the visual analog scale (VAS) of pain on which patientsassigned a number between 0 (absence of pain) to 10(most severe);

Fischers algometer to quantify painful pressure on themuscle area affected by MO and expressed as Kg/cm 2

(Fisher 1987); assessment of the range of motion (ROM) articulationdecit of the functional insertion of the injured muscle;

X-rays of the ossication; the weeks taken to return to the sport-specic training,to the sport-specic activity and to competitive activity.

Collected data were loaded into a database and ana-lysed with the statistical software Epi-Info 3.3 (publicdomainsoftware-CDC Atlanta, GA, USA; WHO Ginevra,Swaziland). The nonparametric Mann-Whitney test wasapplied to compare the subsequent variables (VAS,

0

2

4

6

8

10

Before SW After 1month

After 2months

After 6months

After 12months

mean value of VAS

**

Mann-Whitney test: Kruskal-Wallis H=82.7, p=0.0000

**** **

Fig. 1. Values of visual analog scale (VAS)(0-10) before shock waves (SW) and during the follow-up of the study. At 1, 2,3, 6 and 12 months after the SW the decrease of VAS is signicant statistically (ANOVA F 5 118.3; p 5 0.000).

0

1

2

3

4

5

6

Bef ore SW After 1 month After 2 mont hs After 6 months After 12 months

mean value of Fisher Algoritm (kg/cm2)

**

Mann-Whitney test: Kruskal-

**** **

Wallis H=823.88, p=0.0000

Fig. 2. Values of Fisher algorithm (Kg/cm2) before SW and during the follow-up of the study. At 1, 2, 3, 6 and 12 monthsafter the shock waves (SW), the decrease of Fisher algorithm is statistically signicant (ANOVA F 5 78.9; p 5 0.000).



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Fischers algometer and ROM);besides, the Students t -test was used to compare the dimension of ossicationarea on radiography (RX) images. All data were expressedas mean 6 SD and median. A p value less than 0.05 wasregarded as signicant.

RESULTS

All 24 patients completed the study protocol. Weadministered a cumulative average of 3833 6 1362impulses in everyone during three sessions to each patient.The EFD ranged from 0.13 to 0.23 mJ/mm2 (mean0.15 6 0.02 mJ/mm2) and we applied a frequency of 4.0 Hz. We registered a signicant progressive decreasein the intensity of pain measured using the VAS scaleand Fischers algometer and an improvement of theROM in all the patients ( Figs. 1, 2 and 3 ). We obtaineda complete clinical and functional resolution in 21 of the24 patients, with a return to sport-specic training after 7.17 6 3.05 weeks, to sport-specic activity after 11.32 6 4.06 weeks and to competitive activity after 13.05 6 4.17 weeks. Except for three patients, all hadmade a complete return to the previous sport activitywithin the 12 months of the follow-up ( Table 2 ). However,the X-ray images showed only a partial reduction of theossication area in all the patients. Before the SW, theossication area was 38.33 6 13.63 cm 2 (median40 cm 2 ) (range1580 cm 2 ), vs. 35.54 cm 2 6 12.09 (range1570 cm 2 ) at 12 months (t -test, T-statistic 5 0.75, p 5 0.05) (Figs. 4, 5, 6, 7, 8 and 9 ).

Before the ESWT, the ROM decit was -37.1 622.5 (median 30 ), the VAS was 5.4 6 1.2 (median 5)

and the Fischer algometer score was 2.6 6 1 Kg/cm 2

(median 2.5 Kg/cm 2 ).After the end of SW therapy, the ROM (Mann-Whit-

ney test: Kruskal-Wallis H 5 68.53, p 5 0.0000), the

-60

-50

-40

-30

-20

-10

0

Before SW After 1month

After 2months

After 6months

After 12months

mean deficit of range of moviment ()

**

Mann-Whitney test: Kruskal-Wallis H=68.53, p=0.0000

** ** **

Fig. 3. Values of range of motion (ROM) (degrees of motion) before shock waves (SW) and during the follow-up of thestudy. At 1, 2, 3, 6 and 12 months after the SW the improvement of ROM is signicant statistically (ANOVA F 5 38.58;

p 5 0.000).

Table 2. The table presents the time for the return to sport activity after the SW treatment in each of the 24 patients

Patient

Return to sport (weeks)

Return tosport-specic

training

Return tosport-specic

activity

Complete returnto previous

agonistic activity

1 12 No return No return2 6 10 123 6 10 124 6 14 165 10 10 126 6 10 128 7 11 149 12 14 16

10 4 16 1811 6 8 1912 6 10 1213 6 10 1214 No return 10 12

15 6 No return No return16 6 10 1217 6 8 1018 4 8 1019 4 8 1020 16 8 1021 6 24 2822 6 10 1223 6 10 1224 12 20 No returnMean* 7.17 11.32 13.5SD* 3.05 4.06 4.17

SW 5 shock wave.*excluding the patients who had not improved.

Post-traumatic myositis ossicans d P. B USELLI et al . 401


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VAS (Mann-Whitney test: Kruskal-Wallis H 5 82.7, p 5 0.0000) and theFischer algometer score (Mann-Whit-ney test: Kruskal-Wallis H 5 823.88, p 5 0.0000)showed statistical signicant improvements. In fact, at the rst month the ROM decit decreased to 6.7 68.5 (median 5 ), the VAS decreased to 1.6 6 1.2(median 1) and the Fischer algometer score improved to4.4 6 0.9 Kg/cm 2 (median 4 Kg/cm 2 ).

Two months after ESWT the improvement hadcontinued: the ROM decit was 2.5 6 6.6 (median0 ), the VAS was 0.6 6 0.9 (median 0 ) and the Fischer algometer score 5.5 6 0.8 Kg/cm 2 (median 6 Kg/cm 2 ).

Six months after ESWT the ROM decit was 2.75 6 7.2 (median 0 ), the VAS was 0.2 6 0.6(median 0 ) and the Fischer algometer score was5.8 6 0.5 (median 6 Kg/cm 2 ).

Finally, 12 months after ESWT the ROM decit was 2.75 6 7.2 (median 0 ), the VAS was 0.23 6 0.7(median 0) and the Fischer algometer score was5.9 6 0.4 (median 6 Kg/cm 2 ).

DISCUSSIONMyositis ossicans traumatica is dened as a non-

neoplastic proliferation of cartilage and bone in an area of muscle that has been exposed to trauma. The pathogen-esis of MO formation is largely unknown. It has beenhypothesized that rapidly proliferating mesenchymal cellsultimately differentiate into bone-forming cells and osteo-blasts in thepresence of localized tissueanoxia, producingectopic bone and cartilage. In addition, muscle damageleads to prostaglandin synthesis, which attracts inamma-tory cells to the site of injury, fostering the formation of

heterotopic bone ( Aro et al. 1991 ). Ackerman described(1958) three zones in the lesion:

central zone: extremely varied cells and atypical mitoticgures;

middle zone: orientated osteoid tissue; outer zone: well-formed bone.

The symptoms include persistent pain in the trauma-tized zone and increased by exion, local tenderness andstiffness, in association with a ROM reduction, affectingthe corresponding joint. This functional reduction signi-cantly impedes sports activity, especially in high levelathletes (Booth and Westers 1989 ). Evidence of post-trau-matic stiffness appears at a very early stage, after a fewweeks, with abnormal bone formation in the soft tissue(Sodl et al. 2008 ). The initial damage is followed by soft tissue swelling, which grows within 1 to 2 months intoa solid, painful mass. The MO radiographic frame showsoccular calcied density in the soft tissues 2 to 6 weeksfrom the disease onset; within 6 to 8 weeks the calcica-tion becomes sharply circumscribed and ossicationstend to adhere to the periosteum ( Wang et al. 1999 ).Magnetic resonance imaging (MRI) can be used in theacute stage to dene the localization of the muscular lesion; however, interpretation of the tissue frame evolu-tion in the subsequent phase proves more difcult ( Shir-khoda et al. 1995 ).

Rehabilitation of patients with MO should includerestoration of exibility, strength and proprioception.The traditional therapeutic approach relies on a varietyof treatments such as physical therapies, ranging fromtherapeutic ultrasound to local hyperthermia ( Giombiniet al. 2007) or roentgen therapy ( Ciambellotti and Ripa-monti 1984 ), medication, ranging from systemic NSAIDs

0

5

10

15

20

25

30

35

40

before SW after 12 months

ossification area (cm2)

t-test, T-statistic=0.75, p=0,05

Fig. 4. Values of area of ossication before shock waves (SW) and during the follow-up of the study. At 1, 2, 3, 6 and 12

months after the SW the decrease of the ossication is not statistically signicant.



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to local iontophoresis, as well as local injection of different drugs (mesotherapy) ( Wieder 1992 ; Jarvinenet al. 2005, 2007 ). According to a review by Haran for the Cochrane Systematic Review, there is insufcient evidence to recommend the use of disodium etidronateor other pharmacologic treatments for MO ( Haran et al.2004 ). A technique of manual rupture, diacutaneous -brolysis, of the muscular calcications has also beenproposed by Colombo and Ekman (1978) . The latest ther-apeutic option is surgical removal of the anatomical part affected by MO ( Benetos et al. 2006 ). The decision to op-erate is often due to a serious functional deteriorationreducing the sports performance, related to a considerableROM limitation and to the presence of severe pain. Thesubsequent return to sports activities will depend onthe athlete demonstrating nearly full limb strength andcoordination.

Shock waves are dened as a sequence of singlesonic pulses characterized by high peak pressure(100 MPa), a fast pressure rise ( , 10 ns) and short dura-tion (10 ms). Since 1996, scientic research has startedto focus on the use of extracorporeal shock wave therapy(ESWT) in the treatment of muscle-tendon pathologies(Rompe et al. 1996 ). In 2000 and then in 2001, theFood and Drug Administration granted approval for theuse of this method in the treatment of heel spur ( Wanget al. 2006 ) and calcic shoulder tendonitis ( Sems et al.2006 ). Many authors have reported that the effect of stim-ulation with ESWT leads, at the tissue level, to the devel-opment of mending phenomena in association withneovascular angiogenesis, which is associated to anincrease of RNA-synthetase and to a rebalancing of intra-cellular homeostasis, coupled with an increase of nitricoxide (Wang et al. 2003; Thiel 2001 ).

Fig. 5. Patient 1: before shock waves (SW), the radiograph of the femur reveals a bone formation anteriorly.



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We performed an extensive literature review,including an Internet search with Google.com and MED-LINE searches from 1970 to 2009. We used the terms:ossication and myositis ossicans. Articles in English,German, French and Italian were selected. There were4277 articles of a general kind referring to the different ossication types and to the different therapies proposedand 301 articles related to MO; only 46 of these speci-cally refer to MO in sports. Finally, we found no articlesrelated to ESWT applied to MO.

On the strength of our positive experience of theapplication of ESWT to treat calcied tendonitis, wewere encouraged to use this therapy in the treatment of MO. Further support to this therapeutic hypothesis wasoffered by the good results described by some authors inthe use of ESWT for heterotopic ossication treatment

(Vannini et al. 2000 ). We were principally supported bythe rationale that SW are able to break up calcicationsin tendon disease ( Jakobeit et al. 2002 ). Therefore, we ex-pected to obtain similar results in the administration for MO, whereas in fact we observed only a partial reductionof the ossication area. However, we elicited a substantialimprovement of the pain and of the functional ROM in thetreated segment. This discoveryled us to consider whySWcould disaggregate the calcication in tendinopathy but not the ossication in MO. Codman suggested that thecalcied tendonis the result of a sequence of degeneration,necrosis and calcication ( Uhthoff 1975 ). Followinginvestigatorsdescribedcalcifyingtendinopathyas calciumdeposits in necrotic collagen tissue ( Tashjian et al. 2009 ).Therefore, the application of shockwave therapy in calci-ed tendon induces an increased pressure within the

Fig. 6. Patient 1: before shock waves (SW), the magnetic resonance (MR) scan shows the myositis ossicans in thequadriceps muscle.

http://google.com/http://google.com/


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therapeutic focus, causing fragmentation and cavitationinside the amorphic calcications, leading to disorganisa-tion anddisintegrationof these deposits ( Loewetal. 1999 ).This effect does not occur when there is lamellar boneorganized in osteons in the target zone because there istoo little space to generate cavitation ( Russo et al. 2000 ).

Indeed, SW do not induce fractures in cortical bone ( Pau-wels et al. 2004 ). Therefore, we hypothesized that thismight be the reason why SW could not produce a completedisaggregation of ossications in muscle tissue.

Nevertheless, during our study we appreciated theclinical recovery of the patients. This could be explained

Fig. 7. Patient1:3 monthsafter shockwaves (SW), theradiography (RX)shows theminimal reduction of theossication area.



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on the basis of some previous studies that have investi-gated the effects of SW on muscle. They argued that SW induce softening of the myogelosis and a signicant alleviation of pain in hypertonic diseases ( Kirkali et al.1995; Kraus et al. 1999; Manganotti and Amelio 2005 );a direct effect of shock waves on muscles is consideredin accordance with the documented therapeutic effectsseen on tendon and bone: neo-angiogenesis that inducesa washing-out of catabolic products, the synthesised NOthat produces anti-inammatory effects and the releaseof growth factors that activates cellular repair processes(Wang et al. 2008 ). Moreover, it has been demonstratedthat muscle spasm is reduced in the muscle tissue andthe contractile capacity is increased thanks to metabolicmodulations at the mitochondrial level. These modula-tions are useful in MO, where the weakness and swelling

are caused by the considerable oedema and the catabolicloss of muscle protein locally and around the injury site(Ackerman 1958 ).

Similar results are shown in the application of SW inthe treatment of avascular necrosis of the bone (AVN).Some clinical studies have investigated the effects princi-pally on AVN of the hip and they found a signicant improvement in pain and in functionality without substan-tial changes of lesion on radiograph and MRI ( Wang et al.2005, 2008 ). Therefore, these articles suggest that extra-corporeal shock wave treatment may reorganize patho-logic memory traces, thus, giving cause to real andpermanent pain relief ( Wess 2008 ).

In our experience, already after 1 month from the endof the ESWT, patients had less pain and a statisticallysignicant functional recovery. These results persisted

Fig. 8. Patient 1: at RX image the ossication has partially disintegrated 12 months after extracorporeal shock wavetherapy (ESWT).



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and further improved over the 1-year follow-up term.After an average of 13 weeks, 87.5% of the patientswere able to resume competitive sports activities. Weobserved, as other authors had previously reported usingother physiotherapy schedules, that ESWT does not induce a signicant reduction of the ossication ( Bernardet al. 2002; Parikh et al. 2002 ). Nevertheless, our clinicalndings support the application of ESWT in MO, demon-strating that even in absence of the total disgregationof theossication, the treatment improved the trophism of thedamaged muscle tissue.

The results of the current clinical experience revealthat at rst the administration of physiotherapy alone hasbeen unsuccessful and only when the shock waves wereassociated, the management of MO became efcacy: theinjury tissue beneted from the SW for the biologicstimulus and from the physiotherapy for the physicalone.

However, our experience is a preliminary casestudy. As mentioned before, it has the limitation of theabsence of a control group. At present, we propose tocontinue this study with the adoption of a randomization

Fig. 9. Patient 1: the magnetic resonance (MR) scan shows the reduction of MO 12 months after extracorporeal shockwave therapy (ESWT).



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into two groups to compare the effects of the cooperationof ESWT and physiotherapy vs. only physiotherapy. It seems to be necessary for classication of ESWT asevidence-based medicine. The administration of fewsessions of middle energy SW promises to improve theresults of existing standards management of MO.

Besides, it should be interesting to value the efcacy of ESWT in the earlier stage of MO, when the fully ossiedis not jet made up.

In conclusion, the current literature indicates that shock waves offer an interesting therapeutic opportunityfor restoring the physiologic conditions of muscle-tendonextensibility. MO is not an uncommon sequela of sportsinjuries. It is most likely to occur after contusions or strains and is often of major clinical consequence if not treated appropriately. In the treatment of MO, we suggest associating ESWT to traditional rehabilitation methods.ESWT is noninvasive, inexpensive and without side-effects andcould be a viable alternative to surgery. Further experimental studies are needed to verify the effects of SW treatment on the tissues in this disease.

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eswt - for myositis ossificans case

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