Tibialis Anterior muscle herniation mechanics, characteristics features and Physical therapy management before and after the surgical intervention and brief introduction about surgical process

1. TIBIALIS ANTERIOR
HERNIATION IN ATHLETES
PRESENTED BY
NITESH VERMA
MPT(SPORTS PHYSIOTHERAPY)

2. Tibialis Anterior Muscle
• Origin: Lateral condyle of tibia
- Upper two third of lateral surface of tibial shaft and adjoining
surface of interosseous membrane
• Insertion: Inferiomedial surface of median cuneiform and adjoining
part of base of first metatarsal bone
• Action: In non-weight bearing position
- Dorsiflexion of foot
- Inversion of foot

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In weight bearing position
- With Tibialis Anterior control eversion of foot and big
component of foot pronation
- Maintains medial longitudinal arch of foot
• Nerve supply: Deep Peroneal nerve
• Artery: Anterior Tibial artery

5. Tibialis Anterior Muscle Herniation
• Muscle hernia was first described by Hugo Ihde in 1929 and first
reported case in Kingdom of Bahrain
• There are about 200 cases of muscle hernias described in literature
• Hernia is defined as protrusion of tissue contained within a cavity
through the wall of cavity that contains it
• Muscle hernias are focal herniation of muscle tissue through a defect
in its fascial sheath
• Tibialis anterior muscle herniation is most common type of skeletal
muscle herniation in lower limb

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• Other muscles are- Peroneus longus muscle and Rectus Femoris
muscle
• Muscle protrude through a defect in fascia into subcutaneous fat and
present as a soft nodule
• Characteristic presentation of hernia is local visible mass at the site of
defect and more prominent in weight bearing position or resisted
dorsiflexion of ankle joint
• Presents in athletes, soldiers, mountain climbers and in professions
requiring excessive strain on legs

7. EHL= Extensor hallucis longus
EDL= Extensor digitorum longus
FDL= Flexor digitorum longus
FHL= Flexor hallucis longus
PB= Peroneus brevis
PL= Peroneus longus

8. Causes:
• Trauma
A. Penetrating trauma: Direct injury to the fascia
B. Direct trauma: Closed fracture that cause fascial tear
C. Indirect trauma: Force applied to the contracted muscle causing
acute fascial tear
• Constitutional hernia/Congenital hernia
1. Occur due to weakness in muscle fascia, after chronic stress

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2. May involve the fascial tissue as a whole or only a localized site
where blood vessels or nerves passes through the fascia
3. There are fenestrations in muscle compartments through which
perforating veins enter
4. Due to chronic stress, fenestrations enlarge and eventually muscle
hernias through these openings

10. Sign and Symptoms:
• Asymptomatic
• Localized swelling/Nodule
• Dull pain at the site of swelling
• Cramping
• Pain decreased with rest
• Numbness in the lateral portion
• Decreased swelling in supine positon
• Dorsiflexion weakness
• Increased localized pain and swelling in Fencer’s lunge position

11. Differential Diagnosis:
• Piezogenic pedal papules
• Lipoma
• Hematoma
• Fibroma
• Epidermoid cyst
• Tumour
• Varicose vein
• Arteriovenous aneurysm

12. Confirmatory Diagnosis:
Diagnostic Ultrasound Magnetic Resonance Imaging (MRI)
Tibialis anterior muscle hernia : Diagnostic Ultrasound by Dr Maulik S Patel
Tibialis anterior muscle hernia: a rare differential of a soft tissue tumour Arun et al 2015

13. Conservative Management:
• Stage 1: Rest and avoid weight bearing
Compression stockings/crepe bandage
Isometric exercise for Tibialis anterior muscle
• Stage 2: Concentric contraction of Tibialis anterior in weight bearing
position
• Stage 3: Eccentric exercises for Tibialis anterior muscle
• Stage 4: Sports-specific Plyometric exercises

14. Surgical Management:
• When conservative management fails then need to go for surgical
treatment
• Most commonly used surgical technique is direct closure of fascia
defect by tightening the area (high chance of re-herniation)
• This technique increases the intracompartmental pressure and later
patient may develop anterior compartment syndrome
• More successful and current surgical approach is longitudinal
fasciotomy with or without a graft/synthetic mesh

15. Post operative Physiotherapy management
• In small muscular hernia no specific post operative physiotherapy
treatment required
• But in large hernia post operative physiotherapy is important for
patient to go back in particular sports

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S.No. INTERVENTION POSITIONING PROCEDURE FREQUENCY
1. Short leg splint TP*: Standing
PP** Supine/long sitting
Ankle in moderate (5-10◦)
plantarflexion
2 hours on and 1 hour
off
Remove during
exercise and sleeping
2. Isometric exercise TP: Standing
PP: Supine/long sitting
Patient is asked to pull the foot
towards self
Hold for 5 seconds
and repeat the
exercise for 10 times x
2 sets, 3 times a day
3. Non weight-bearing
walking with walker
TP: Standing next to patient
PP: Walker standing
Patient is advised to walk
without touching affected limb
on the ground
6 minutes x 2 times a
day

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4. Concentric exercise TP: Standing towards foot end
of patient
PP: Supine with foot out of the
couch
This exercise is performed with
help of a loop band. The
therapist holds one side of the
band and other end on
patient’s forefoot.
Patient is asked to pull the foot
towards self
Repeat the exercise 10
times x 3 sets, 3 times
a day
5. Partial weight-bearing
walking
TP: Standing with patient
PP: Standing with walker
Patient is advised to place
forefoot of affected limb on
the ground during walking
6 minutes x 3 times a
day
6. Full weight-bearing
walking with walker
TP: Standing with patient
PP: Standing with walker
Patient is asked to place both
the feet on ground to initiate
and progress walking
6 minutes x 3 times a
day
7. Heel walking TP: Standing with patient
PP: Standing
Patient is instructed to walk on
both heel
2 minutes x 3 times a
day

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8. Half squats
(Bilateral)
TP: Standing beside patient
PP: Standing
The patient is asked to perform
half squat
Hold for 30 seconds x
10 times x 3 sets, 2
times a day
9. Eccentric exercise TP: Standing towards foot end
of patient
PP: Supine/high sitting with
foot out of the couch
A loop band/theraband is
overlapped over the forefoot of
patient. One side is held by the
patient and simultaneously is
asked to push the forefoot
towards the ground
Repeat the exercise 10
times x 3 sets, 3 times
a day
TP*: Therapist Position
PP**: Patient Position

19. THANK YOU