Muscle herniae: Conservative and surgical management. Systematic review.

BACKGROUND: Muscle herniae are often unrecognized. The primary objective of this systematic review is to evaluate the outcomes of conservative and surgical management for muscle herniae. The secondary objective is to define the most appropriate management for muscle herniae depending on aetiology and size of the fascial defect. METHODS: The PRISMA guidelines were used to organize this systematic review to assess the different management modalities and identify possible criteria useful to guide the management of muscle herniae. An electronic search of PubMed and Scopus databases was performed. RESULTS: A total of 132 patients were identified. Conservative management was carried out in 22 (16.7%) patients, and 110 (83.3%) patients underwent surgical procedures. Pain was reported in 3/22 (13.6%) patients managed conservatively. Post-surgical pain was reported in 0/5 (0%) patients treated with autologous graft repair, 1/15 (6.7%) patient with mesh repair, 2/13 (15.4%) patients with direct repair and 11/77 (14.3%) patients with fasciotomy. Return to normal activity was possible in 16/22 (72.7%) patients treated conservatively, 5/5 (100%) patients undergoing autologous graft repair, 13/15 (86.7%) with mesh repair, 62/77 (80.52%) with fasciotomy and 4/12 (33.3%) with direct repair. CONCLUSION: In congenital muscle herniae, fasciotomy should be considered the surgical choice to prevent complications. In post-traumatic muscle hernia, a small fascial defect can be treated with the direct suture repair, while mesh repair and autologous graft repair should be considered the most appropriate procedures to avoid severe complications such as compartment syndrome.

Minimally invasive fasciotomy for symptomatic tibialis anterior muscle hernia.

BACKGROUND: Symptomatic muscle herniae are an uncommon cause of chronic exercise induced leg pain. The most common site for muscle hernia is the tibialis anterior muscle. This study evaluates the outcome of a minimal incision fasciotomy in patients with a symptomatic muscle hernia of the tibialis anterior muscle, and their return to normal daily activities including sport. METHODS: The study reports mid-term results in a series of 22 consecutive patients (17 males and 5 females, median age: 22 years) with a unilateral tibialis anterior MH who had undergone minimally invasive fasciotomy between 2008 and 2019. Clinical outcomes were assessed with SF-36 and European Quality of Life-5 Dimensions scale (EQ-5D). The ability to participate in sport before and after surgery, and the time to return to training (RTT) and to sport (RTS) were recorded. RESULTS: At a median follow up after surgery of 23 months, both questionnaires showed a statistically significant improvement (P < 0.005). At the latest follow up, 16 of patients (73%) had returned to pre-injury or higher levels of sport/activity. The median time to return to training and to return to sport was 7 and 11 weeks respectively. No severe complications and no recurrence of symptoms were recorded. CONCLUSION: Minimally invasive fasciotomy is effective and safe for patients suffering from muscle hernia of the tibialis anterior muscle with good results in the mid-term. LEVEL OF EVIDENCE: IV.

Isolated partial tear of extensor digitorum longus tendon with overlying muscle herniation in acute ankle sports injury: role of high resolution musculoskeletal ultrasound.

Lateral Ankle sprain is a common sports-related trauma with the mechanism of injury ranging from inversion to plantar flexion. These injuries commonly affect the ligaments but can also affect the associated soft tissue structures like the eversion muscles and tendons. Prompt and accurate diagnosis of such injuries is warranted so as to ensure early return to play and prevent long-term complications. Lateral ankle sprain injuries in sports may not always be associated with ligament injuries. We report a never before reported case of lateral ankle sprain injury in a soccer player with the unusual finding of isolated partial tear of Extensor digitorum longus muscle and its fascia leading to myo-fascial herniation. The lateral ankle ligaments were intact. The diagnosis was clinched on a high-frequency ultrasound scan supported by dynamic maneuvers which in fact proved to be superior to MRI as the latter failed to demonstrate the myo-fascial herniation in our case. We therefore propose that real-time ultrasound scanning with dynamic maneuvers should be the first line of investigation to assess sports injuries in anatomically complex joints like the ankle.

Muscle Hernias in the Upper Limb: Treatment and Literature Review.

PURPOSE: A muscle hernia is defined as a protrusion of the muscle belly through an acquired or congenital fascial defect. A nontraumatic herniation may occur through congenital fascial defects or be acquired by means of exertion, blunt trauma, or a penetrating injury. In this study, our aim was to review our experience with this rare condition and report the results of surgical treatment of these cases. METHODS: During the period between January 1, 2014, and August 30, 2018, 12 cases of symptomatic muscle hernia in the upper limb were included in our study: 9 cases involving the forearm and 3 cases involving the arm. All patients underwent direct repair of their fascial defect with overlapping of the deep fascia using nonabsorbable sutures. RESULTS: There were improvements in postoperative pain, swelling, appearance, weakness, and paresthesia. There was significant improvement in the Disabilities of the Arm, Shoulder and Hand score from a mean of 51.8 before surgery to 6.9 after surgery. The mean period to return to activities of daily living was 18 days (range, 15-20 days). CONCLUSIONS: Muscle hernia in the upper limb is an uncommon condition that can be successfully treated. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Congenital Muscle Hernia of the Leg: A Rare Case in an Infant.

Muscle hernia is a dynamic protrusion of muscle fibers into subcutaneous tissues caused by a focal defect in the fascial sheath, rarely seen in an infant.

Bilateral non-traumatic lower leg fascial defects causing peroneal muscle herniation and novel use of a GraftJacket to repair the fascial defect.

Constitutional bilateral defects in the peroneal fascial compartment leading to muscle herniation are extremely rare. We present the case of a twenty-nine year old male carpenter with non-traumatic bilateral peroneal fascial defects, in which the symptomatic right side was successfully repaired using a GraftJacket®. This case report highlights the need for clinicians to remain aware of the diagnosis of muscle herniation as a cause of a painful mass in the lower limbs, especially when related to exercise. The judicious use of further imaging such as ultrasound in combination with MRI can be useful in differentiating a muscle hernia from other more sinister causes, such as malignancy.

Repair of Forearm Muscle Herniation Using Local Fascial Flap: A Case Report.

Forearm muscle herniation is a rare but known cause of symptomatic pain in the upper extremity caused by compression or strangulation of the muscle belly through a defect in the overlying fascia. Because of the rarity of this condition, optimal treatment is still widely unknown and debated. To date, there are various treatment methods published, including rest, physiotherapy, primary repair, fasciotomy, fascia lata inlay, onlay or wrap-around, mesh graft, and acellular porcine collagen matrix. In this study, a 61-year old man underwent an ulnar nerve transposition to correct cubital tunnel syndrome, resulting in subsequent symptoms of muscle herniation on the volar aspect of the forearm. Prominent muscle herniation was visible a few weeks after the onset of symptoms and surgical correction of the fascial defect was performed using a local fascial flap. Postoperatively, the patient's herniation symptoms resolved without signs of ulnar nerve entrapment. The rationale for this treatment option is discussed.

Superficial peroneal nerve compression due to peroneus brevis muscle herniation.

Muscle hernias of the extremities most commonly occur in the leg, between the knee and ankle. Symptomatic muscle hernias in the leg are rare cause of chronic leg pain and neuropathy, and not routinely encountered in surgical practice. Although this condition is especially an esthetic problem, with palpable subcutaneous soft tissue mass, it can lead to spontaneous pain, cramp, local tenderness or potentially neuropathic symptoms. Moreover, among leg muscles involved in this process, peroneus brevis is less frequent than tibialis anterior. Magnetic Resonance Imaging is the method of choice in establishing the diagnosis. Symptomatic cases can be treated surgically in different ways, the preferred one is nerve releasing with fasciotomy. The purpose of this case report is to present the Magnetic Resonance findings of a superficial nerve compression due to a peroneus brevis muscle herniation.

Determination of the predictive clinical parameters to diagnose chronic exertional compartment syndrome.

Chronic exertional compartment syndrome (CECS) is characterized by pain occurring during physical activity. As clinical examination is not sufficient to diagnose it, intracompartmental pressure (ICP) measure is used for CECS confirmation. Numerous clinical signs are reported but their diagnosis predictive ability has never been studied. We aimed to determine if the 12 classically reported clinical signs are predictive of CECS. We performed a single-centre retrospective cohort study on patients referred for CECS suspicion. Patients were asked to run on a treadmill. When pain occurred, post-exercise ICP was performed. We diagnosed CECS if the ICP was ≥30 mmHg and used a logistic regression to calculate the predictive value of clinical signs. One hundred twenty-five patients were evaluated. Ninety-six had CECS and 29 did not, according to the ICP 30 mmHg cut-off. Anterior and lateral compartments were the most frequently affected. After exercise, mean ICP was 58.6 mmHg ± 20.5 in the group with CECS versus 20.9 mmHg ± 4 in the group without (p < .001). Muscle hardness, muscle hernia after exercise, absence of pain at rest and pain recidivism for the same exercise were predictive of CECS. The predictive model associated muscle hardness (Odds Ratio (OR) = 2.18; p < .001) and muscle hernia after exercise (OR = 1.44; p < .001). This model identified 88.6% of CECS subjects. The ROC curve area was 0.808 [95% CI: 0.71-0.90]. This study confirmed the importance of clinical parameters to diagnose CECS. A better knowledge of the relevant parameters could help physicians to indicate invasive examinations.

The importance of dynamic ultrasound in the diagnosis of tibialis anterior muscle herniation.

Tibialis anterior muscle hernia is a challenging diagnosis. Ultrasound findings generally are negative because patients come to ultrasound study from home when they are at rest. When the operator of ultrasound suspects a muscle hernia, he has to scan the affected limb or the affected organ dynamically at rest and after stressing the limb. Here, we present a case of a 19-year-old dancer with anterior leg mass with negative ultrasonographic findings at rest but was diagnosed with tibialis anterior hernia after stress dynamic ultrasound.

Management of chronic exertional compartment syndrome and fascial hernias in the anterior lower leg with the forefoot rise test and limited fasciotomy.

BACKGROUND: Chronic exertional compartment syndrome can present either as anterolateral lower leg pain or as painful muscle herniation. If an athlete or a soldier wants to continue training, there is no proven effective nonoperative treatment, and fasciotomy of 1 or more of the lower leg muscle compartments is usually recommended. Our clinical protocol differs from most reported ones in the use of the forefoot rise test to increase pressure and provoke pain and our recommending minimal surgery of the anterior compartment only. We present results of surgery based on our clinical management flowchart. METHODS: Patients who had surgery during a 12-year period were reviewed by telephone interview or office examination. Pain was graded from 0 (none) to 4 (unbearable). Preoperative resting and exercise anterior compartment pressures were evaluated in most subjects before and immediately following a repeated weight-bearing forefoot rise test. Surgery was under local anesthesia, limited to the anterior compartment only and percutaneous (excepting muscle hernias). There were 36 patients, mean age 24 years. RESULTS: Of 16 patients who were originally operated unilaterally, 5 patients were later operated on the other side. Mean presurgery resting pressure was 56 mm Hg (40-80 mm Hg) rising to 87 mm Hg (55-150 mm Hg) with exercise. Mean exercise pain score dropped from 2.9 presurgery to 1.3 postsurgery (n = 35, P < .0001). Complications included superficial peroneal nerve injury (3 legs in 3 patients, 1 requiring reoperation). CONCLUSION: When we used our clinical management flowchart based on the forefoot rise test, percutaneous fasciotomy of the anterior compartment alone provided good clinical results. Care must be taken to prevent injury to the superficial peroneal nerve in the distal lower leg. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Repair of traumatic muscle herniation with acellular porcine collagen matrix.

BACKGROUND: Muscle hernias are uncommon clinical conditions with no uniform solution of repair. Biocompatible mesh allows for repair of hernias without the donor site morbidity and complications from direct repair under tension. METHODS: Over a 6-month period at a Level 1 Trauma centre, four consecutive symptomatic muscle hernias were identified, two in the forearm and two in the lower limb. Three resulted from high-speed motorbike accidents, one from a mining accident. All patients had hernia repair at a minimum of 4 months post accident. A 10 × 15 cm × 1.0 mm sheet of acellular collagen matrix was fashioned to fit as an underlay of the fascia defect. Patients were clinically followed at the 2-, 6-, 12- and 26-week mark. Final phone contact was made 18 months post-operatively. RESULTS: All patients were pleased with their cosmetic and functional outcomes. All patients returned to work and sport 3 months after reconstruction. CONCLUSION: Symptomatic hernias as a result of trauma can be safely reconstructed with a biological mesh implant. This approach can prevent complications from previously described methods and return to active lifestyles with good results.

Diagnosis and management of symptomatic muscle herniation of the extremities: a retrospective review.

BACKGROUND: There is a paucity of published literature on diagnosis and surgical management of muscle herniation of the extremities, with most reported cases involving military personnel and men aged 18 to 40 years. Hypothesis/ PURPOSE: The purpose of this study is to describe the presentation, diagnosis, and results of fasciotomy for symptomatic muscle herniation in young athletes. We hypothesize that fasciotomy can be a safe and effective treatment option that allows the majority of athletes to return to sports. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From 2001 to 2011, 26 athletes (19 women; 11 runners) with a mean age 19.0 ± 4.0 years (range, 14.2-28.4 years) underwent fasciotomy for symptomatic muscle herniation at the authors' institution. Retrospective chart review recorded pertinent patient data and clinical course. Questionnaires were sent to all patients to assess satisfaction with surgery, ability to return to sports, and residual symptoms. RESULTS: Muscle hernias were classified as primary (n = 8, 31%), postsurgical (n = 8, 31%), and associated with underlying untreated chronic exertional compartment syndrome (n = 10, 38%). The tibialis anterior muscle (n = 12, 46%) was most commonly involved. The mean time from onset of symptoms to surgery was 15.1 ± 8.6 months (range, 3-38 months). Dynamic ultrasound (5/6 patients, 83%) was more accurate than magnetic resonance imaging (3/18, 17%) at identifying the hernia. At median follow-up of 28 months (range, 12-127 months), 17 patients (65%) had returned to sports. Seventeen patients (65%) completed the postoperative questionnaire; 14 reported being satisfied with their results (82%). Mild residual symptoms were common (9 of 17 respondents, 53%), especially in runners (5 of 7, 71%), all of whom were satisfied with surgery. Patients with a postsurgical muscle herniation took the longest to return to sports and were the least likely to return to sports, had the highest rate of dissatisfaction with surgery, and were most likely to have persistent symptoms not improved by surgery. CONCLUSION: Fasciotomy is a safe surgical option for symptomatic muscle herniation in young athletes. Many patients are able to return to sports and most are satisfied with surgery. Residual symptoms are common, especially in runners. Patients with postsurgical muscle herniations may have the worst clinical outcome.

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

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.

Les auteurs présentent le cas d'un vétéran âgé retraité ayant une hernie symptomatique du muscle court péronier responsable d'une compression du nerf péronier superficiel associée à une intervention chirurgicale précise. Les hernies symptomatiques des muscles des membres se produisent surtout dans la jambe et constituent de rares causes de douleurs chroniques de la jambe. Par le passé, les chirurgiens militaires traitants ont consigné les premiers cas de hernies de la jambe observés chez les recrues militaires actives. Une anomalie aponévrotique focale peut provoquer la herniation d'un muscle, une masse sous-cutanée palpable entraînant de la douleur et des symptômes au potentiel neuropathique associés à une atteinte nerveuse. On n'en connaît pas la véritable incidence, mais l'étiologie est classée comme secondaire à une faiblesse aponévrotique congénitale (ou constitutionnelle) ou à une anomalie aponévrotique acquise, qui découle habituellement d'un traumatisme direct ou indirect. On pense que l'occurrence la plus élevée s'observe chez les jeunes hommes physiquement actifs. L'atteinte du muscle tibial antérieur est la plus courante, mais d'autres muscles peuvent être touchés. L'échographie dynamique ou l'imagerie par résonance magnétique permet souvent de confirmer le diagnostic et d'orienter le traitement. La plupart des cas symptomatiques répondent bien à un traitement prudent, la chirurgie étant réservée aux cas réfractaires. Il existe diverses techniques chirurgicales, de la fasciotomie à la réparation anatomique de l'anomalie aponévrotique, mais aucun consensus ne se dégage quant au traitement optimal. Les cliniciens doivent se souvenir d'envisager les hernies musculaires dans le diagnostic différentiel des douleurs chroniques ou des neuropathies de la jambe. Une analyse approfondie des hernies musculaires de la jambe est présentée afin d'en faire ressortir les antécédents, l'occurrence, la présentation, le diagnostic et le traitement.

Anterior Tibial Muscle Hernia Treated with Local Periosteal Rotational Flap: A Case Report

Tibialis anterior muscle hernia is the most common hernia among lower extremity muscles. This condition can be diagnosed by physical examination and radiologic findings, especially by dynamic ultrasonography. There are surgical methods of treatment for muscle hernia, including direct repair, fasciotomy, fascial patch grafting using autologous fascia lata or synthetic mesh. We report a case of tibialis anterior muscle hernia treated with local periosteal rotational flap. Because there are several advantages to the local periosteal rotational flap, such as lack of donor site morbidity, lack of skin irritation, low cost, simplicity, and an easy approach, this technique could be an option for tibialis anterior muscle hernia.

Treatment of a symptomatic forearm muscle herniation with a mesh graft.

Symptomatic muscle herniations are an unusual cause of upper extremity pain in the athlete that is rarely reported in the literature. Out of 18 reported cases of upper extremity herniations, only 3 were caused by strenuous exertion. This article describes a successful repair of a 21-year-old rock climber's ventral forearm herniation with polypropylene mesh.

Treatment of a symptomatic forearm muscle herniation with a wrap-around fascia lata graft.

Muscle herniation in the extremity is a well-recognized cause of symptomatic pain on exertion. Only 17 cases involving the upper limb has been previously described, 11 of them involving the anterior compartment of the forearm and only 2 were caused by strenuous exertion. Treatment for this condition ranged from nonsurgical, primary closure with palmaris longus interweave, formal fasciotomy, to closure with a tensor fascia lata graft.This is a study of a 28-year-old man who had a symptomatic swelling on the volar aspect of his left forearm while working on a car-door assembly line that resulted in a significant decreased of his grip strength, work capacity and median nerve symptoms. It did not improve after 6 months of conservative management including hand therapy and splintage. The patient subsequently underwent a tensor fascia lata graft wrap-around. Postoperatively his symptoms resolved with improvement in his grip strength and hand function. The rationale for the treatment option chosen is discussed.

A Case of Forearm Muscle Herniation after Radial Forearm Sensory Tendocutaneous Free Flap

PURPOSE: Although muscle hernia has been well described in the lower-extremity, muscle hernias in the upper extremity are extremely rare. As with lower extremity muscle hernias, the forearm muscle hernia may result from forced exertion of strenuous activity or following blunt trauma. The objective of this paper is to report an extraordinary case of forearm muscle hernia after radial forearm sensory tendocutaneous free flap with references. METHODS: A 58-year-old male patient received wide excision and radical neck dissection and lower lip reconstruction with radial forearm sensory tendocutaneous free flap for squamous cell cancer on the lower lip. 16 weeks after the operation, he complained of protruding mass on the forearm and the size was increasing. In postoperative 18 weeks, MRI showed herniation of flexor digitorum superficialis. For unaesthetic cause and preventing progress, the authors performed direct fascial closure and Mesh graft. RESULTS: In 12 months after the surgery there was no recurrence and the patient remained symptom-free. CONCLUSION: Pain on extremity exertion and unaesthetic buldge of forearm due to forearm muscle hernia were the primary indications for surgery which consist of direct closure, fasciotomy, fascia lata onlay graft, fascia lata inlay graft, etc. The authors experienced uncommon forearm muscle hernia after radial forearm free flap and satisfying result of treatment.