Muscle hernias of the leg: A case report and comprehensive review of the literature

Abstract

A case involving a retired, elderly male war veteran with a symptomatic peroneus brevis muscle hernia causing superficial peroneal nerve compression with chosen surgical management is presented. Symptomatic muscle hernias of the extremities occur most commonly in the leg and are a rare cause of chronic leg pain. Historically, treating military surgeons pioneered the early documentation of leg hernias observed in active military recruits. A focal fascial defect can cause a muscle to herniate, forming a variable palpable subcutaneous mass, and causing pain and potentially neuropathic symptoms with nerve involvement. While the true incidence is not known, the etiology has been classified as secondary to a congenital (or constitutional) fascial weakness, or acquired fascial defect, usually secondary to direct or indirect trauma. The highest occurrence is believed to be in young, physically active males. Involvement of the tibialis anterior is most common, although other muscles have been reported. Dynamic ultrasonography or magnetic resonance imaging is often used to confirm diagnosis and guide treatment. Most symptomatic cases respond successfully to conservative treatment, with surgery reserved for refractory cases. A variety of surgical techniques have been described, ranging from fasciotomy to anatomical repair of the fascial defect, with no consensus on optimal treatment. Clinicians must remember to consider muscle hernias in their repertoire of differential diagnoses for chronic leg pain or neuropathy. A comprehensive review of muscle hernias of the leg is presented to highlight their history, occurrence, presentation, diagnosis and treatment.

Ultrasound‐Guided Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg

“…in this region, along with numbness over the dorsum of the foot approximately 15 minutes after initiation of the precipitating physical activity due to irritation of the superficial peroneal nerve. 4,6 The diagnostic test of choice for chronic exertional compartment syndrome is measurement of intracompartmental pressure. 1,3,8 Chronic exertional compartment syndrome may be initially confused with "shin splints" or a tibial stress fracture.…”

Utility of the H‐reflex in diagnosing polyneuropathy

“…The rarity of this entrapment is perhaps related to the lateral compartment's large subcutaneous surface area with relatively increased compliance. 6 Nearly one third of individuals have a branch of the SFN in the anterior compartment, the most common site of muscle herniation. 5 This review excluded cases of muscle herniation with concurrent compartment syndrome.…”

“…The hypoechoic muscle herniating through the echogenic fascia often has a mushroom-like appearance, with the fibroadipose septa of the muscle pinched into a spoke-like arrangement. 2 6 There is no consensus on optimal surgical treatment, but it is important to keep in mind that increasing compartmental pressure with compression or closing the fascial defect can worsen neuropathic symptoms or cause acute compartment syndrome. 2,6 Patients in this series responded well to fasciotomy, which is a logical treatment when there is an associated nerve entrapment.…”

Tibialis Anterior Muscle Hernia: A Case of Chronic, Dull Pain and Swelling in Leg Diagnosed by Dynamic Ultrasonography

“…Due to chronic stress, the fenestrations enlarge and eventually muscle hernias bulge through these openings [3]. Traumatic or acquired hernias are seen secondary to penetrating trauma, direct trauma causing closed fracture with fascial tear and indirect trauma (force applied to contracted muscle causing fascial rupture) [4]. The anterolateral tibial compartment is the commonest site due to being a superficial and tight fascial compartment [5].…”

“…Although the clinical picture points towards the diagnosis, imaging, especially ultrasound, should be used to confirm it. The differential diagnosis of muscle hernias include varicosities, angiomas, arteriovenous malformation, lipomas, ruptured muscle (a pseudohernia) and soft tissue tumours [4]. However, these tumours do not show movement on changing the patient position.…”