The Use of Dynamic Ultrasonography for the Confirmation of Lower Leg Muscle Herniation: DISCUSSION

Muscle herniation is defined as a protrusion of a portion of a muscle through a defect of the muscle fascia. The problem is mainly cosmetic, but the disorder may cause spontaneous pain, cramps or local tenderness. Muscle herniation is a relatively common complaint among athletes and it has been frequently reported in the orthopedic surgery litera­ture. Most dermatologists are unfamiliar with this condition, and they are likely to consider it as a peculiar kind of tumor. For the case presented herein, the provisional diagnosis was angiolipomatosis, and an unnecessary skin biopsy was performed.

Although the diagnosis of muscle herniation can be suspected upon careful physical examination (with performing the “fencer’s lunge” maneuver), ultrasonographic evaluation can be useful for making the definite diagnosis. Discontinuity at the site of the fascial defect with the associated muscle hernia- tion can be demonstrated on the static sonographic images. Examination during plantarflexion and dorsiflexion of the foot can demonstrate the varying size and shape of the herniation, which is post­ulated to reflect an increased pressure within the anterior fascial compartment of the leg. Transducer compression over the mass permits demonstrating the reduction of the herniated muscle, but this procedure could potentially result in a false negative examination if one does not recognize the persistent underlying fascia defect. Some authors have sug­gested that the addition of immediate post-exercise imaging could improve the conspicuity of the lesions and the confidence in making the proper diagnosis.

Other imaging techniques such as computer- assisted tomography (CT) and MRI have been used to identify the fascial defect. Muscles and the enclosing fascia have similar attenuation on CT and they are not easily separable. The CT diagnosis of a fascial defect is therefore presumptive, whereas with MRI, there is direct visualization of both the fascial rent and the muscle bulge. Yet the depiction of the fascial defect with MRI is not always straightforward. In the case presented herein, a fascial defect could not be identified with MRI, and this was possibly due to the close apposition of different structures in a reduced space. Moreover, it is not easy to perform a dynamic study with MRI as the patients are usually not able to cooperate properly.
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Ultrasound scanning has recently become an important diagnostic tool in dermatology because it is easy to use, completely safe and it provides im­portant diagnostic information. We believe that dermatologists should be familiar with anterior tibialis muscle herniation so that they can arrive at a proper diagnosis and make a surgical referral when they encounter positional subcutaneous nodules in the lower legs. We also suggest that dynamic ultrasonography is a non-invasive, highly accurate, readily available and cost-effective imaging techni­que for confirming muscle herniation.


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