Imagine this scenario. Your patient with upper limb burns complains of deep stabbing pain in the elbow every time he does exercises to improve joint range of motion. After a while, despite following your rehabilitation program to the letter and despite the fact that the scar is becoming softer, there is still no sign of improvement: range of motion is still limited and the patient still complains of pain. The patient starts to become frustrated and discouraged. His compliance decreases since he thinks rehabilitation is not working. You become frustrated too…
Maybe it’s worth considering the possibility that this may be caused by a post-burn complication called heterotopic ossification…
What is heterotopic ossification?
Heterotopic ossification (HO) refers to the abnormal growth of bone in non-skeletal tissues, such as around the joint, in joint capsules, ligaments, or by forming a bone bridge across the joints.
Basically, bone is growing where it should not.
HO can occur in temporomandibular joints, shoulder joints, elbow joints, joints of the hands, hip joints, knee joints, and ankle joints. But in our burn clinical practice, most cases occur in the elbows, shoulders and knees.
What causes heterotopic ossification?
Our current understanding of the specific causes and mechanism of HO is still limited, but it is understood that the inflammatory process and systemic responses to trauma play an important role. However, we do know that large burns, severe or deep burns and prolonged immobilization are risks factors that can contribute to the development of HO.
What are signs of possible post-burn heterotopic ossification?
In the above-mentioned scenario, there are clues that can point towards a potential HO problem. The therapist can be on the lookout for the following signs:
The patient complains of stinging or stabbing pain. It is different from the pain of stretching scars and seems to come from within the joint itself.
Joint range of motion is restricted in both flexion and extension, but scar contracture is not the cause of restriction.
During passive joint movements, the patient feels that the bones are locked, with a hard end feeling when trying to achieve maximum range.
Despite doing rehabilitation for a while, there is no visible improvement of range of motion.
What to do if we suspect heterotopic ossification?
If the therapist notices the above-mentioned signs and suspects HO:
Get a diagnosis: Make sure that the patient undergoes further examination with an orthopedist or plastic surgeon to confirm diagnosis and receive appropriate treatment.
Stop high-intensity passive stretching exercises: High intensity passive stretching exercises that exceed the pain-free threshold risk intensifying inflammation that caused HO in the first place, which will further accelerate ossification.
Why you need to be on the lookout for heterotopic ossification?
Although not every burn patient will develop HO, those who do will be severely affected by this post-burn complication. As the patient sees his progress stagnate while still bearing uncomfortable pain, he may lose his motivation to do rehabilitation. What’s more, limited range of motion will increase his dependence for activities of daily living. If the therapist ignores the patient’s exceptional pain and simply attributes it to a natural phenomenon during rehabilitation, or if the therapist attributes the lack of progress to a lack of patient effort, the patient may feel irritated and frustrated, which can further affect motivation and compliance to the overall rehabilitation program. That is why therapists should be able to understand and recognize the signs of HO, and help patients receive appropriate diagnosis and treatment.
If you want to learn more about…
How you can help prevent HO or at least ensure you’re your rehabilitation intervention does not contribute to the development of HO;
How you can play a role in the early detection of HO;
How you can adjust your rehabilitation plan before and after HO treatment to support the patient in his recovery.
…be sure to check out our online course “Heterotopic Ossification as a Post-Burn Complication.”