A 21-year-old male Korean soldier was referred to our hospital for an evaluation of painful multiple nodules that were on his lower legs. The nodules were seen by the patient six months before the evaluation, and the patient denied any history of local trauma. He complained of the presence and accentuation of the nodules whenever he flexed his legs or when he engaged in any form of physical exercise. The physical examination revealed multiple skin-colored, round, soft, subcutaneous nodules at the anterior-lateral margin of the mid-tibiae of both lower legs. Angiolipomatosis was suspected clinically. Incisional biopsy was performed, but it revealed no specific findings. The subsequent magnetic resonance imaging (MRI) failed to document any significant change.
Fig. 1. (A) The skin-colored nodules are obvious on the anterolateral aspect of the middle third leg when the patient is in a weight bearing position. (B) The normal appearance of the skin when the muscles of the leg are relaxed.
A “dynamic” physical examination was then performed. The nodules were more pronounced and firmer when the patient was standing with his hips, knees and ankle flexed (Fig. 1A). The lesions quickly disappeared at rest, i.e., with plantarflexion (Fig. 1B). Anterior tibialis muscle herniation was suspected, and the patient was evaluated by conducting an ultrasound examination with using a HDI-5000® Scanner (ATL Ultrasound, Bothell, WA, USA) and a 7- to 12-MHz linear array transducer in the longitudinal and transverse planes. Both static and dynamic sonographic imaging examinations were conducted. The dynamic examination included imaging during rest, isometric muscle contraction and compression of the herniation for reduction. The longitudinal sonogram at rest showed that the fascia was thinned and elevated by a small muscle bulge (Fig. 2A). With active dorsi- flexion of the feet, the anterior tibialis muscle was shown to slide under the thinned fascia, forming a greater degree of muscle protrusion (Fig. 2B). A reduction of the muscular herniation below the fascial defect was demonstrated with probe compression (Fig. 2C). The diagnosis of anterior tibialis muscle herniation was confirmed. The daily use of compression stockings and the avoidance of vigorous exercise were recommended. Follow-up was conducted after three months, and this revealed an increase in the size of the herniated muscles, which produced significant shin pain. The patient was then referred to the Orthopedic Surgery Department for surgical treatment.
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Fig. 2. (A) Longitudinal image of the right anterior tibialis muscle at rest, demonstrating focal fascial discontinuity (upward arrowhead) and slight muscular protrusion (downward arrowhead). (B) The ultrasono- graphic image of the anterior tibialis muscle during dorsiflexion. The fascial defect has enlarged over the resting defect (Fig. 2A), with improved definition of the fascial margins. The extent of muscular herniation is better defined. (C) Reduction of the muscular hernia with probe compression (F: fascia, M: muscle, S: skin).