Revista de Medicina Desportiva (English) November 2018 - Page 11

Rev. Medicina Desportiva informa, 2018; 9(6):9-11. Hard Work, Soft Swelling – Muscular Hernia Dr. Luís Duarte 1 , Dra. Marisa Bizarro 1 , Dra. Dora Alves 2 1 Resident of Medical General Practitioner, USF Grão Vasco; 2 Medical General Practitioner Specialist USF Grão Vasco – Viseu, Portugal RESUMO / ABSTRACT The muscular hernia is defined as a protrusion of muscle tissue through a defect in the muscular fascial sheath. Muscular hernias are often underdiagnosed or misdiagnosed. They are divided into traumatic and constitutional, being the anterior tibial muscle the most frequently affected. A mass that is visible only during contraction of the musculature favors the diagnosis, and this should be confirmed by imaging. Most are asymptomatic, requiring no treatment. When they are slightly symptomatic, resting, restriction of physical exercise and the use of compression stockings is indi- cated. Surgery may be indicated in the highly symptomatic cases. PALAVRAS-CHAVE / KEYWORDS Muscular hernia, physical activity Inroduction A muscle hernia (MH) is defined as protrusion of muscle tissue through a defect of the muscle fascia sheath. 1-2 The MHs (muscle hernias) can afflict any area in the body, but they are more frequent in the lower limbs, where the tibial anterior muscle is most often affected. 1-3 Usually they are underdiagnosed or incorrectly diagnosed as an hematoma or a varicose vein. The true incidence of MH in the lower limb is unknown. The MH are traumatic or constitu- tional, where the constitutionals can have a starting point from the holes located on the muscle compartments through which the perforating veins penetrate. Due to the chronic stress, the dimensions of those holes increase allowing the protrusion of the muscle tissue. 1 The traumatic MHs result from direct and indirect trauma. 1 Usually MHs appear on young sporstman. 4 They can be seen as a protuberance that is only visible when standing or after muscle contraction. 4 On rest, this protuber- ance usually is not seen. 4 MHs can be symptomatic or asymptomatic. When they are symptomatic, pain is usually the main symptom. 3 The diagnosis is clinical based and later supported by image exams, where echography is the more accessible. 1-3 There is no ideal treatment for the muscle hernias. 1-3 Treatment varies according the symptomatology and it can include rest, physical exercise restriction, use of compression stockings, surgery or just surveil- lance. 1-3 Clinical case This is the case about a young male, 17 years old, gym practitioner, twice a week, one hour / day for 18 months. The gym activities fre- quently included the elevation of 40kgs weights, with both lower limbs at the same time. He had 3 hours of physical education at the school and a walking of 30 minutes daily. He denied the regular practice of other physical and sports activities. He had no personal or family relevant pathological background. He had an appointment because of a swelling of about 1,5 x 1,5 cm located on the anterolateral area of the lower third of his left leg for 8 days. He denied pain, functional limitation and there wasn’t any change of the color on the leg. He denied any fall or other trauma, just referring the already described physical activity. On physi- cal examination there was a swell- ing with soft consistence, mobile, without pulsation, measuring about 1,5 com on its longer axis on the anterolateral area of the lower third of his left leg. There wasn’t nor pain on palpation, nor any change of the skin coloration or of the local tem- perature. The swelling was visible with sight contraction of the left leg muscle. At rest and without contrac- tion the swelling was not visible. An ultrasonography directed to the soft tissue was ordered to clarify the situation and a conservative treatment was started, with surveil- lance and eviction of weight training for the legs. The ultrasonography revealed a muscle hernia, with 15mm of extension and without criteria of rupture. He had another medical appointment 41 days after the first visit for reevaluation. He stated the perception of a decrease on the size of the MH on the left leg and denied any other symptomology. He indicated that only once went to the gym during that period, but without lifting weights with the left leg. He had participated at school on the physical education classes without restrictions. On physical examination it was seen he same dimensions of the MH, measuring about 1,5cm on its longer axis. There wasn’t any change on the skin color and also with no pain on palpa- tion. However, the MH was now only seen after vigorous muscle contrac- tion of the leg. Once again, he was advised for surveillance and eviction of weight training for the legs, but without any restriction for other physical activities. A reevaluation was scheduled after 3 months. Discussion It seems that the study of MHs, especially those of the lower limbs, started on 1929 by Hugo Idhe. 1 His- torically, the military surgeons, when they studied the MHS on military recruits, gave a great contribution for the knowledge of this pathology. 2 The true incidence of MHs on the lower limbs is unknown, because some of the them are asymptomatic that do not promote the medical aid. 2,3 This clinical case shows that, although physical exercise has several health benefits, when exag- gerated or deregulated can bring disastrous consequences. 5 In the presence of a clinical suspicion of a Revista de Medicina Desportiva informa setembro 2018 · 9