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Sonography of Muscle Hernias

¹ Department of Radiology, Royal Infirmary, Edinburgh EH3 9YW, United Kingdom.

Received May 6, 2002; accepted after revision June 18, 2002.

 
Address correspondence to I. Beggs.

Introduction

Top Introduction Examination Technique Sonographic Findings References

 
Most muscle hernias occur in the lower leg and affect the tibialis anterior muscle. Other muscles and sites, including the upper extremities, can be involved. Occupational and sporting activities, trauma [1, 2], chronic compartment syndrome [3], and weakness in the overlying fascia due to perforating vessels [4] have been implicated as causes. Muscle protrudes through a defect in the fascia into the subcutaneous fat and presents clinically as a soft-tissue mass.

Patients, usually adolescents or young adults, present with a swelling that usually appears or enlarges when the affected muscle is contracted or the patient is standing erect. The swelling is effaced or shrinks when the muscle is relaxed or the patient is supine but occasionally is effaced by muscle contraction. Increased conspicuity after exercise has been reported [5]. Patients and medical attendants are often concerned that the mass is a tumor. Most hernias are asymptomatic and require no treatment or have mild symptoms that may be relieved by support stockings. A few patients, often athletes, present with severe pain or cramps and require surgery [6]. Closing the fascial defect may result in acute compartment syndrome and is best avoided. Fasciotomy may produce an unsightly deformity and incomplete symptomatic relief, and fascial patch grafting using autologous fascia lata [7] or synthetic mesh has been recommended [8].

The sonographic features of muscle hernias are characteristic and exclude alternative clinical diagnoses such as tumors and muscle tears. Advantages of sonography include the ability to examine the patient dynamically or erect and to show the nature of the lesion to the patient during the examination. Because surgical repair is not usually needed, visualizing the hernia on sonography helps to reassure the patient.

Examination Technique

Top Introduction Examination Technique Sonographic Findings References

 
The initial clinical examination establishes the site of the swelling and the means to increase clinical conspicuity, such as standing or contracting the muscle. The skin should be marked because the mass may be difficult to feel during the sonographic examination. A standoff pad is unnecessary. Coupling gel should be applied liberally. A high frequency transducer (>7.5 MHz) should be used, and the gain and focus should be set to optimize the near field. The transducer should be applied lightly to avoid effacing the hernia. It may be necessary to get the patient to contract the muscle or to stand during the examination.

Sonographic Findings

Top Introduction Examination Technique Sonographic Findings References

 
Normal muscle is covered by thin echogenic fascia. Focal thinning and slight elevation of the fascia (Fig. 1A) are subtle evidence of muscle hernias that can easily be overlooked. In most cases the margins of the defect are clearly defined (Fig. 2A) and are easier to detect when the muscle is contracted. If the fascia is thinned but no defect is apparent, there may be a slight muscle bulge with elevation of the overlying fascia (Fig. 3A,3B).

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —48-year-old woman with hernia of tibialis anterior muscle that presented as painless mass at site of direct blow several years previously. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Longitudinal sonogram shows that fascia (arrow) is thinned and elevated by small muscle bulge. Note caliper marks at margins of defect in fascia.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —27-year-old man with tibialis anterior hernia that presented as painless swelling. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Transverse sonogram shows that margins of fascial defect are well-defined and marked by calipers. Note shallow bulge (arrows) of muscle through fascial defect.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —25-year-old man with small muscle hernia of forearm flexor muscles that presented after direct blow. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Longitudinal sonogram obtained with muscle relaxed shows small segment of thin, slightly elevated fascia with shallow bulge of hypoechoic muscle (arrows are at margins of fascial defect and herniated muscle).

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —25-year-old man with small muscle hernia of forearm flexor muscles that presented after direct blow. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Longitudinal sonogram shows that with muscle contracted, bulge (arrows) is larger. Fascia is thinned and elevated but remains in continuity.

Muscle herniation may be constant or intermittent. The herniated muscle and adjacent nonherniated muscle are less echogenic than normal muscle, possibly due to anisotropy [1] or atrophy [3] caused by the repetitive, low-grade trauma of the herniation (Figs. 2A,2B,2C). A mushroomlike appearance (Figs. 2B and 2C) results when the herniated muscle overlaps the fascial defect and has a convex superficial contour. The normal echogenic fibroadipose septa are pinched as they pass through the fascial defect, and this produces a spokelike appearance (Fig. 2B) of echogenic lines that radiate from approximately the center of the defect in the fascia. Prominent arterial pulsation identified in a minority of cases using color or power Doppler sonography provides support for the theory that muscle herniation occurs at sites of weakness [2, 3] in which vessels penetrate the fascia (Figs. 1B and 4A).

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —27-year-old man with tibialis anterior hernia that presented as painless swelling. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Transverse sonogram shows that contraction of tibialis anterior muscle results in more pronounced muscle bulge. Herniated muscle overlaps fascial margins producing mushroomlike appearance. Fibroadipose septa radiate in spokelike pattern from center of hernia. Herniated and adjacent muscle are strikingly hypoechoic.

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C. —27-year-old man with tibialis anterior hernia that presented as painless swelling. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Longitudinal sonogram (with findings similar to those in B) with muscle contracted shows that hypoechoic herniated muscle overlaps margin of fascial defect (arrow).

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —48-year-old woman with hernia of tibialis anterior muscle that presented as painless mass at site of direct blow several years previously. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Color Doppler sonogram (shown here in black-and-white) shows prominent vessel traversing fascia at site of hernia.

View larger version (156K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A. —30-year-old woman with hernia of tibialis anterior muscle presenting as painless mass that was effaced by foot dorsiflexion. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Transverse color Doppler sonogram (shown in black-and-white) shows both muscle and vessels protruding through fascial defect.

The sonographic appearances of muscle herniation can be subtle. Care must be taken to ensure that gain settings optimize the near field. It is important not to press too hard. Even relatively light transducer pressure may reduce and efface the hernia (Figs. 5A and 5B). The skin mark helps to locate the hernia if detection is difficult. Asking the patient to contract the muscle (Figs. 2B and 2C) or to stand (Figs. 6A,6B,6C) also helps to identify the site and the nature of the hernia, although occasionally contraction effaces the hernia (Fig. 4B). Exercise may increase hernia conspicuity (Fig. 7A,7B).

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A. —15-year-old girl with tibialis anterior muscle hernia that presented as intermittent nontender swelling. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Longitudinal sonogram shows small hernia (arrow).

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B. —15-year-old girl with tibialis anterior muscle hernia that presented as intermittent nontender swelling. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Longitudinal sonogram shows effacement of hernia by moderate pressure, although fascia (arrow) is thinned.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A. —39-year-old man with hernia of tibialis anterior muscle causing minimal discomfort. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Transverse sonogram of tibialis anterior hernia obtained with muscle relaxed and supine shows small, hypoechoic bulge with elevation of fascia (arrow).

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B. —39-year-old man with hernia of tibialis anterior muscle causing minimal discomfort. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Transverse sonogram shows hernia (arrow) is partly effaced by pressure.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C. —39-year-old man with hernia of tibialis anterior muscle causing minimal discomfort. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Transverse sonogram shows enlargment of hernia when patient stands. Herniated muscle overlaps defect in fascia. Note caliper marks on margins of fascia and herniated muscle.

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B. —30-year-old woman with hernia of tibialis anterior muscle presenting as painless mass that was effaced by foot dorsiflexion. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Transverse sonogram shows that with muscle contracted, hernia and vessels are effaced, and fascia (arrow) is in continuity.

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A. —31-year-old male soldier presented with exercise-induced pain and swelling due to tibialis anterior muscle hernia. He is currently awaiting surgical repair. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Transverse sonogram obtained before exercise shows small muscle hernia (arrows).

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B. —31-year-old male soldier presented with exercise-induced pain and swelling due to tibialis anterior muscle hernia. He is currently awaiting surgical repair. All images were obtained on HDI 5000 scanner (ATL Ultrasound, Bothell, WA) using 7- to 12-MHz linear array transducer. Transverse sonogram obtained after exercise shows that hernia (arrows) is more conspicuous. Note calipers on margins of fascial defect.

Most muscle hernias are treated by reassurance because they produce no or few symptoms and do not affect function. A few painful hernias need surgery. Patients are frequently concerned that the palpable lump is a tumor. The hernia can be shown to the patient using sonography. Alternative diagnoses such as muscle tears and tumors are excluded.

References

Top Introduction Examination Technique Sonographic Findings References

 

1. Bianchi S, Abdelwahab IF, Mazzola CG, Ricci G, Damiani S. Sonographic examination of muscle herniation. J Ultrasound Med 1995;14:357 -360[Abstract]
2. Mellado JM, Pérez del Palomar L. Muscle hernias of the lower leg: MRI findings. Skeletal Radiol 1999;28:465 -469[Medline]
3. van Holsbeeck MT, Introcaso JH. Musculoskeletal Ultrasound, 2nd ed. St. Louis: Mosby. 2001:64 -66
4. Braunstein JT, Crues JV. Magnetic resonance imaging of hereditary hernias of the peroneus longus muscle. Skeletal Radiol 1995;24:601 -604[Medline]
5. Bates DG. Dynamic ultrasound findings of bilateral anterior tibialis muscle herniation in a pediatric patient. Pediatr Radiol 2001;31:753 -755[Medline]
6. Miniaci A, Rorabeck CH. Tibialis anterior muscle hernia: a rationale for treatment. Can J Surg 1987;30:79 -80[Medline]
7. Golshani SD, Lee C, Sydorak R. Symptomatic forearm muscle hernia: repair by autologous fascia lata inlay. Ann Plast Surg 1999;43:204 -206[Medline]
8. Marconi F. Repair of anterior tibial muscle hernia. (letter) Plast Reconstr Surg 1993;92:768

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