Intramuscular Vascular Malformations

Abstract

Intramuscular vascular malformations are a rare subset of vascular lesions and present a considerable diagnostic challenge. The majority of vascular lesions are initially misdiagnosed 17,20,31 and are often attributed to more common musculoskeletal disorders. 14,30,38 Sports medicine practitioners need to be familiar with intramuscular vascular malformations because up to 20% of cases have symptoms of exertional leg pain. 20 Exertional leg pain, a common symptom seen by sports medicine practitioners, is defined as exercise-related leg pain distal to the knee and proximal to the talocrural joint. Depending on the study methodology, exertional leg pain has an incidence of 12.8% to 82.4% in athletes. 29 Although a comprehensive review of exertional leg pain is beyond the scope of this report, the differential diagnosis is broad and includes musculoskeletal, vascular, and neurologic etiologies (Table 1).Here we present a case of intramuscular venous malformation in the flexor digitorum longus muscle in a 15-yearold female runner with exertional leg pain. Treatment options for intramuscular venous malformations include observation, sclerotherapy, or surgical resection. Although a variety of different sclerosing agents have been described in the literature, to our knowledge, this is the first report of doxycycline sclerotherapy for intramuscular venous malformations. CASE REPORTA 15-year-old female runner presented with a 1-year history of exertional leg pain that gradually began while training for cross-country running. There was no associated trauma. Since initially developing symptoms, the patient had proceeded to participate in cross-country running, basketball, and lacrosse at her high school.Initially the pain was present only during running, but it progressed so that the patient started experiencing pain when walking and then eventually at rest. The pain localized to the left anteromedial lower leg. The patient reported associated left lower extremity swelling, occasional numbness and tingling in all 5 toes, and intermittent nondisabling low back pain. Her medical history was not significant.When symptoms first occurred 1 year prior, the patient initially saw an orthopaedic surgeon. At the time, a radiograph of the left lower extremity was obtained, with normal results. The patient was treated for a presumptive tibial stress fracture with a walking boot, but after 6 weeks of nonoperative management, the patient remained symptomatic. She was started on diclofenac, with minimal relief, and was prescribed physical therapy. Attempts at stretching, strengthening, and soft tissue manipulation worsened the patient's symptoms, and therapy was discontinued after only a few sessions.Further workup, including magnetic resonance imaging (MRI) of the lumbar spine and MRI of the left lower extremity without contrast, demonstrated normal results. Compartment pressure testing was performed with a handheld compartment pressure-testing device (Stryker Corporation) and was normal (before exercise: anterior = 11 mm Hg, lateral = 13...

Ultrasound-Guided Doxycycline Injection for Aseptic Olecranon Bursitis: Case Report

“…These 3 cases highlighted resolution of posterior elbow swelling at 2 to 3 weeks post injection follow-up appointments; and the bursitis had not recurred at the second follow-up visits, which were 5 or 6 months after the doxycycline injection. Doxycycline is a preferred sclerosant as it is readily available at a low cost and has a low risk profile (2). Other sclerosants are more expensive, like bleomycin, or painful on administration, such as talcum powder (8).…”

“…Other sclerosants are more expensive, like bleomycin, or painful on administration, such as talcum powder (8). Use of doxycycline as a sclerosant has been documented for treatment of vascular malformations, lymphatic malformations, Morel-Lavallée lesions, seromas, hepatic cysts, and malignant pleural effusions (2)(3)(4)8,11,12).…”

“…No matter the cause, the result is an inflammatory pathway leading to swelling caused by protein and synovial-type fluid leaking into the bursa (1). Sclerotherapy with doxycycline is documented in the current literature to treat malignant pleural effusions, vascular and lymphatic malformations, Morel-Lavallée lesions, seromas, and hepatic cysts, as well as in a single case series on landmark-guided injections for olecranon bursitis (2)(3)(4). Sclerotherapeutic agents such as doxycycline, bleomycin, ethanol, tetracycline, and talcum powder have been used to treat many other tissue separations leading to potential space for fluid to collect (5-7).…”

Recurrent subcutaneous and muscular angiomatosis with spontaneous regression in a foal

“…In human medicine there have been case reports of muscular vascular hyperplasia associated with pain and swelling, but sometimes similar cases have been reported in the literature as 'intramuscular haemangiomas' or 'skeletal haemangiomas'. 14 Clinical signs of angiomatosis can be very similar to other vascular malformations/proliferations, such as arteriovenous fistulas, hamartomas, haemangiomas and haemangiosarcomas, so histological examination plays a major role in the diagnosis of this disease. 1 Histologically, angiomatosis presents as ill-defined vascular proliferations lined by a single layer of endothelial cells with no cellular atypia.…”

A Case of Focal Myopathy With Neuropathy Caused by Intramuscular Vascular Malformation

“… 2 These symptoms are generally aggravated upon exertion or when the affect parts are in a specific position. 3 4 5 Moreover, some cases of intramuscular VM manifest as motor weakness and muscle atrophy. 6 However, these symptoms are also present in other diseases, such as musculoskeletal disease.…”