This interesting case demonstrates the benefit of linking musculoskeletal ultrasound with a clinical examination...with great images!. This 18 year old football club academy player had been referred to the ultrasound department with a three year history of a lump which appeared intermittently over the medial aspect of her leg.
She had been seen by an Orthopaedic physician and had an ultrasound scan without conclusive findings or diagnosis. She was also referred to an Orthopaedic surgeon who requested an MRI scan which came back with no lump.
The MRI Images can be seen here...
When I saw her in the clinic she came along with her mother quite upset and depressed that nobody seemed to know what was wrong and more importantly she could not play football. On further questing, I asked her what provokes the lump in her leg, she said being on her feet and exercising for 5-10 mins. I initially examined over the concerned area with the use of ultrasound, and did not reveal any mass, lump or cyst. I then asked her to do whatever she needed to do to aggravate the lump...after 5 min of squatting, hopping and jumping around, I could see a small lump appear over the medial aspect of the distal leg. I then used the ultrasound to examine her leg over the lump and there was a small muscle hernia piercing the facial plane of the Tibialis Anterior muscle.
Both patient and her mother were very pleased and grateful that someone had found the problem. We sent the report back to the Orthopaedic team with evidence of exertional Tibialis Anterior muscle hernia. The patient is now on a waiting list for surgical management.A useful free text journal article reviewing muscle is by Beggs (2003) and is available here. A further case study can be found here.
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