# Ultrasound-Guided Manual Therapy for Limitation of Knee Flexion Due to Quadriceps Contusion With Heterotopic Ossification: A Case Report

## TL;DR

A soccer player with knee flexion limitation due to quadriceps contusion and heterotopic ossification recovered quickly using ultrasound-guided manual therapy.

## Contribution

Ultrasound-guided manual therapy is presented as a novel, non-surgical approach for treating heterotopic ossification.

## Key findings

- Ultrasound-guided manual therapy improved knee flexion and pain in a patient with heterotopic ossification.
- Dynamic ultrasonography confirmed improved tissue gliding after treatment.
- The patient returned to sport in two months, much faster than typical conservative recovery times.

## Abstract

Heterotopic ossification (HO) is a known complication of quadriceps contusions that can lead to pain and limitation of knee flexion. Although conservative treatment is generally recommended, the therapeutic role of manual therapy in HO remains unclear.

We describe a 20-year-old collegiate soccer player who developed HO in the vastus intermedius after a quadriceps contusion, presenting with knee flexion limited to 120° (both active and passive) and severe pain (Numeric Rating Scale: NRS, 8/10). Dynamic ultrasonography revealed impaired tissue gliding. Ultrasound-guided manual therapy, including lifting and transverse gliding maneuvers, was performed. After the first session, knee flexion improved to 130° with pain relief (NRS, 3/10), and dynamic ultrasonography confirmed improved tissue gliding. With weekly rehabilitation and a structured home program, the patient achieved full pain-free flexion and running within one month, and returned to team training at two months.

Previous reports suggest that return to sport after conservative management of quadriceps HO may take up to 24 weeks. In contrast, this case demonstrated recovery within eight weeks, likely due to restoration of soft tissue mobility rather than reduction of the ossified lesion.

This case highlights the clinical novelty of ultrasound-guided manual therapy for HO, which has rarely been reported in the literature. Dynamic ultrasonography enables precise visualization of adhesions, directly enhancing the accuracy and effectiveness of manual therapy. This approach may be considered before surgical excision, particularly in athletes who require an early return to sport.