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Heterotopic Ossification Workup

  • Author: John Speed, MBBS; Chief Editor: Consuelo T Lorenzo, MD  more...
Updated: Apr 02, 2015

Laboratory Studies

See the list below:

  • Creatine kinase
    • This test is not specific for HO but is of value in determining the severity of muscle involvement and may be helpful in planning treatment of HO. Rossier and colleagues showed in 1973 that patients with an acute form of HO after SCI have elevated CK levels that correlate with histologic involvement of muscle.[7] Two subsequent studies found CK to be useful in the diagnosis and management of HO. Singh and coauthors reported significantly higher CK levels in patients with HO.[16] Data published by Sherman and colleagues indicated that a higher level of CK ultimately correlates with a more severe form of HO, suggesting more widespread involvement of surrounding muscle.[17]
    • These results are promising, because they indicate that CK may reliably predict a higher risk of HO development, can help to predict the severity of a patient's HO, and can be used to follow treatment success.
  • C-reactive protein
    • The initial stage of HO is manifested by a prominent inflammatory response. This acute reaction is accompanied by changes in levels of cytokines that stimulate the production of acute-phase proteins, one of these being C-reactive protein (CRP).
    • A study by Estrores and colleagues indicated that the serum concentration of CRP correlates better than does the erythrocyte sedimentation rate with the inflammatory activity of HO after SCI.[18] In their study, the normalization of CRP in serum was accompanied by a resolution of the inflammation of soft tissue. It seems that administering nonsteroidal anti-inflammatory drugs (NSAIDs) in the early phase of HO, as well as monitoring the serum CRP level, may provide added benefit in reducing the inflammatory reaction that is proposed to be an important factor in HO's genesis.
  • Alkaline phosphatase
    • The AlkP level, once a commonly used test, is not often employed today.
    • In many patients, serum AlkP levels are not elevated in acute HO.
    • The elevation can be nonspecific because of associated skeletal injuries or the surgical treatment of fractures.
    • The serum AlkP level is of little value in determining the maturity of HO prior to surgical removal.

Imaging Studies

Bone scintigraphy [19]

Ideally, the use of diagnostic imaging should focus on the detection of nonmineralized HO, because the presently available medication, etidronate, can inhibit early mineralization.[19] In this respect, bone scintigraphy and ultrasonography are recommended imaging studies for the early diagnosis of HO.

Bone scintigraphy is highly sensitive in the early diagnosis of HO. This is the most commonly used diagnostic study for HO.

Freed and colleagues evaluated the 3-phase bone scan in the detection of HO and found that a marked vascular blush and increased blood pool about the hips preceded the development of clinical HO by 2-4 weeks.[20] The 3-phase bone scan using technetium-99m (99m Tc) diphosphonate is used in diagnosing and monitoring HO.


This is also used in the early diagnosis of HO about the hips. However, no data are available on the diagnostic value of ultrasonography in the diagnosis of HO in other joints (eg, knee, shoulder, elbow).


While plain radiography is highly specific in the diagnosis of HO, this method lacks sensitivity in early diagnosis. Because soft-tissue calcification must occur for radiographic evidence of HO to be present, radiographs are not helpful in the early stages. Radiologic examinations do not show evidence of HO until a flocculent, patchy appearance develops, as calcium is deposited about 7-10 days after the onset of clinical symptoms.

This patchy appearance coalesces and enlarges on subsequent examinations, and by 2-3 months, the boundaries of the HO demarcate with the appearance of mature bone. Radiography, however, is not reliable at assessing the maturity of HO, because more mature areas may hide immature areas.

CT scanning and MRI

Computed tomography (CT) scanning and magnetic resonance imaging (MRI) may be useful in delineating local anatomy prior to resection.

The role of CT scanning and MRI in the evaluation of other aspects of HO has not been well established.

A retrospective study by Bachman et al indicated that CT scanning can be used prior to the excision of HO from the elbow to distinguish the paths of the radial and median nerves and to precisely determine the distance of these nerves from the ossification. In a study of 22 patients who had undergone removal of HO from the elbow, CT scan distinguished the radial nerve from the HO in 21 patients and the median nerve from the HO in 17 cases. The distance of HO from these nerves (3 mm and 9 mm from the radial and median nerves, respectively) was also determined.[21]

Three-dimensional (3D) stereolithography

This can be beneficial in the perioperative management of symptomatic HO. High-resolution CT scanning is used to create models that can assist during HO excision by allowing frequent intraoperative reference that contributes to the avoidance of iatrogenic neurovascular injuries.[22]


Other Tests

See the list below:

  • Biopsy
    • Biopsy has no role in the diagnosis of HO, but it has been considered as a means of helping to determine maturity.
    • There is a possible risk of inadequate sampling, because mature and immature HO may be intermixed.
Contributor Information and Disclosures

John Speed, MBBS Professor (Clinical), Division of Physical Medicine & Rehabilitation, Adjunct Associate Professor, Department of Physical Therapy, Adjunct Professor, NursingDirector, Traumatic Brain Injury Rehabilitation, Medical Director, Inpatient Rehabilitation Unit, University of Utah School of Medicine

John Speed, MBBS is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Pain Society, Association of Academic Physiatrists, International Association for the Study of Pain, International Society of Physical and Rehabilitation Medicine, Utah Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Additional Contributors

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons

Disclosure: Received research grant from: Shriners Hospitals for Children; Physical Sciences Inc<br/>Received income in an amount equal to or greater than $250 from: SimQuest Inc -- consultant on burn mapping softwear ($1,500).


Kresimir Banovac, MD, PhD Professor, Departments of Rehabilitation Medicine and Medicine, Associate Vice Chairman, Department of Rehabilitation Science, University of Miami Miller School of Medicine; Medical Director, Spinal Cord Injury Rehabilitation Unit, Jackson Memorial Medical Center

Kresimir Banovac, MD, PhD is a member of the following medical societies: American Spinal Injury Association

Disclosure: Nothing to disclose.

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