Ryan M. Kelly, MD
Resident Physician
Northwestern McGaw/Shirley Ryan AbilityLab
Chicago, Illinois, United States
Joel Kopcow, BS
Medical Student
UCSF School of Medicine
San Francisco, California, United States
Leslie Rydberg, MD
Associate Professor, Clerkship Director, Associate Residency Program Director
Shirley Ryan AbilityLab and Northwestern University Feinberg School of Medicine
Chicago, Illinois, United States
A previously independent 65-year-old male with a history of COVID-19 pneumonia complicated by prolonged respiratory failure presents to the rehabilitation clinic over two years since his initial infection with impairments including difficulty with ambulation and exertional dyspnea requiring oxygen supplementation. His physical examination was notable for severe limitations in hip range of motion (ROM) in all planes. Hip X-rays revealed marked heterotopic ossification (HO) with near fusion across the iliac bones and femur bilaterally. Multidisciplinary outpatient rehabilitation with physical and occupational therapy was initiated, focusing on targeted stretching and flexibility to improve functional status, with interim improvement demonstrated in balance, gait speed, and ROM.
Discussions:
HO is a rare complication of COVID-19 infection and there is limited literature guiding the identification and treatment of these patients in the rehabilitation setting. The pathophysiology of HO formation following COVID-19 infection remains unclear, but it has been hypothesized that immobility and systemic inflammation may lead to disruption of bone formation pathways and myositis. As was the case with this patient, mechanical ventilation and prolonged hospital stays may increase the risk of developing HO and severe functional impairments via a mechanism not yet well described. In the case of this patient, HO as a contributor to his severe impairments remained undiscovered and untreated for nearly three years prior to his presentation for functional evaluation.
Conclusions:
This case highlights the need for greater surveillance of functional impairments in the long COVID population. As we continue to uncover the long-term sequelae of COVID-19, physiatrists must be on guard to rapidly identify and treat complications early to maximize function. While prevention of immobility is ideal, when infeasible, the early identification of complications like HO can facilitate earlier interventions with targeted therapies for functional optimization and consideration of surgical intervention prior to development of severe debility.
