Revista de Medicina Desportiva (English) November 2018 - Page 12

Figure 1 – Standing and slight muscle contraction of the left leg it can be seen a swelling on the anterolateral area of the left leg – first appointment. Figure 2 – Standing and only with a strong muscle contraction of the left leg is the MH visible on the anterolateral area of the left leg – 41 days after the 1 st appointment. MH it is important to check the type, the intensity and the frequency of the physical activities, and in the presence of a sportsman the clinical suspicion should be increased. The differential diagnosis for a MH is extensive and it includes hematomas, varicose veins, lipomas, arteriovenous malformations, angio- mas and soft tissue tumors. 1-3 A very relevant clue for the differential diagnosis is, as opposite to the MHs, the soft tissue tumors usually don’t change their shape when the body position is changed or after muscle contraction. 1 It is important to distinguish between muscle rupture and MH. Muscle ruptures result from the excessive stretching of the muscle fibers beyond their physical resist- ance, without necessarily any defect on the muscle sheath that would allow the muscle protrusion. 6 MH result precisely from a defect on the muscular sheath that allow the pro- trusion. 1-3 The muscle injuries can be classified on four grades depend- ing on the extension on the affected muscle and the imageology study. 6 The imageology study allows the confirmation of a suspected MH and the ultrasonography is a very accessible exam that can confirm the defect in the muscle sheath. 1-3,7.8 The magnetic resonance (MRI) is also another exam that can be per- formed. 1-3,7.8 However, MRI is more expensive and time consuming. 7,8 10 november 2018 www.revdesportiva.pt Figure 3 – The echography of the soft tissue with muscle contraction of the left leg shows the MH. Besides that, it might be needed a continuous muscle contraction dur- ing the realization of the MRI, that in case of pain may prevent the exam. Since the echography is a dynamic exam, it allows to see he dynamic nature of the associate symptoma- tology of the MH. 7 Due to these reasons, it must be preferable exam of choice for the diagnosis. 7,8 In the medical literature there is no consensus about the treatment. 1-3 Most of the MHs are asymptomatic and requires only surveillance. 1-3 The slight symptomatic hernias have conservative treatment with rest, restriction of physical exercise and the wear of compression socks. 1-3 The surgical technics for the symp- tomatic hernias include decompres- sion fasciectomy and primary fascia repair, including the direct closure of the defect with autologous or synthetic grafts. 1-3,9,10 The direct closure with a suture is not always possible and when performed it can result on a relapse of the MH or on a compartment syndrome. 2,3,9 These consequences may also result with autologous or synthetic grafts. 2,3,9 However, there are reports in the literature about the success- ful repair of the MH, with a good post-surgical outcome after surgical repair with synthetic mesh. 3,9,10 The decompressive fasciectomy has a lower probability to cause an acute compartment syndrome. 2,3,7 How- ever, the decompressive fasciectomy can weaken the muscle fascia and increase the possibility for a muscle hernia, especially on the young people involved on high intensity physi- cal activities. 2,9 In this clinical case the dimensions of the MH didn’t decrease during the follow-up, but to be best seen it was necessary a stronger muscle contraction. The clinical evolution must be seen with caution because of the relatively short time of follow- up. The patient was asymptomatic which justifies the conservative treatment. 1-3 In the case that later there would be associated symp- tomatology, being the pain the most frequent, or due to aesthet- ics reasons, it might be indicated the surgical treatment, where the decompressive fasciectomy or the reparation with synthetic mesh can be used. 1-3,7,10 In this case, it is admitted that the avoidance of weight lifting during the follow-up period contribute for the stabilization of the dimensions of the MH and prevented the symp- toms. The permission to perform other physical activities brought health benefits to the patient, since it is known the numerous benefits for health with physical exercise. 5 Conclusion The MHs are quite often underdiag- nosed and a high index of suspicion is needed for the diagnosis. They are frequent in adolescents and in the adulthood. 2,4 In face of a swell- ing that becomes more evident with muscle contraction, with previous trauma or high intensity physical involving the muscles on the area where the swelling exists, the diag- nosis of MH must be considered. The treatment of the MHs varies according the symptomatology. 1-3 Surgery may be indicated on those cases more symptomatic or for aesthetic reasons, and there several surgical techniques that must be considered on a case basis. 1-3,9,10