Disclosures: Mohamed Nour Abdullah, MD: No financial relationships or conflicts of interest

Case Diagnosis: A case of a patient diagnosed with HO on the shoulder after prolonged immobilization due to COVID-19.

Case Description or Program Description: The patient is a 48-year-old female who contracted COVID-19, complicated by acute hypoxic respiratory failure requiring mechanical ventilation and prone positioning for 6 weeks, dysphagia, tracheostomy, proximal weakness, and functional decline. She was transferred to an LTAC for ongoing care, and once weaned off mechanical ventilation and stabilized, was admitted to inpatient rehabilitation. Her therapies were limited by proximal weakness in all limbs, left foot drop, neuropathic pain, bilateral shoulder pain, with pronounced range of motion restrictions in the left shoulder. Shoulder X-ray series revealed prominent heterotopic ossification inferior to the left glenohumeral joint.

Setting: Inpatient rehabilitation hospital

Assessment/Results: She received indomethacin for 6 weeks and intravenous pamidronate. Therapies included range of motion and stretching exercises, alongside traditional therapy for proximal weakness. After treatment, she had notable improvements in pain, range of motion, performing overhead activities, transfers, and activities of daily living. Critical illness polyneuropathy was confirmed on electrodiagnostic testing.

Discussion (relevance): Heterotopic ossification is a debilitating condition usually seen after traumatic brain injury, spinal cord injury, stroke, or burns. It is characterized by bone formation in soft tissues around joints and typically presents with debilitating pain and loss of range of motion with a bony end feel. Plain radiographs fail to visualize HO in the early stage ( < 6 weeks) as bone is not yet ossified, requiring triple phase nuclear bone scan to detect. In some cases, surgical excision to prevent or treat contracture is unavoidable, but prone to bleeding and recurrence.

Conclusions: This case, and a few recent publications, demonstrate this unusual sequela of COVID-19. Early identification and treatment can reduce severity and improve functional outcomes.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-case-of-shoulder-heterotopic-ossification-post-covid-19-early-rehabilitation-considerations/