[size=6]A 17-year-old presents to your clinic with a left lower extremity mass that has been present for the last year. The patient is a high-level dancer and travels nationally. He notes that the mass is more pronounced during activity and improves with rest. It does not cause him any pain or discomfort. On exam there is a 1 to 2cm mass palpable over the anterolateral calf. US shows a muscle herniation of the tibialis anterior through a fascial defect. What is the best next step in management of this patient?

 

a Primary fascial closure

 

b Repair with biologic mesh

 

c Compression stockings

 

d Fasciotomy

 

e Observation[/size]

E

[size=6]A 17-year-old presents to your clinic with a left lower extremity mass that has been present for the last year. The patient is a high-level dancer and travels nationally. He notes that the mass is more pronounced during activity and improves with rest. It does not cause him any pain or discomfort. On exam there is a 1 to 2cm mass palpable over the anterolateral calf. US shows a muscle herniation of the tibialis anterior through a fascial defect. What is the best next step in management of this patient?

 

a Primary fascial closure

 

b Repair with biologic mesh

 

c Compression stockings

 

d Fasciotomy

 

e Observation[/size]

E

E

correct answer

e Observation

 

Muscle herniations are rarely reported in the literature but common findings in active individuals. These can be divided into traumatic or constitutional origin with the tibialis anterior muscle the most involved muscle of the lower extremity. This is due to the repetitive trauma that can be seen in this muscle fascia, the superficial nature of the muscle and the tight fascial compartment. Individuals who do not present with an acute traumatic injury are felt to be at risk due to chronic stress that affects the underlying fenestrations of the muscle that allow for perforating vessels to traverse fascial planes. These fenestrations can enlarge leading to muscle herniation. Treatment depends upon symptomatology. Asymptomatic individuals are treated with observation. If symptoms develop, such as pain or discomfort, then compression stockings can be used. For those who continue to present with symptoms despite non-operative management, surgical treatment has been proposed. Primary repair of the fascial defect is no longer recommended due to the high recurrence rate and creation of higher intercompartmental pressures. Repairs with fasciotomy, mesh or grafts have all been proposed.