601 - Intramuscular hemangioma presenting as an atypical cause of chronic gluteal pain: a case report

Case Diagnosis: A 59-year-old female with an intramuscular hemangioma

Case Description: The patient presented to sports medicine physiatry clinic with right posterior hip and buttock pain for at least ten years. There was no inciting event, and pain was persistent despite physical therapy. The pain was achy and radiated down the leg to her foot. Physical exam revealed 4/5 strength of right great toe extension, greater trochanter tenderness and weakness with lateral leg raise, and positive seated slump. Magnetic resonance imaging of the pelvis was reviewed, which showed a multilobulated cystic structure within the gluteal musculature. Electromyography and nerve conduction studies were obtained to rule out peripheral neuropathy or radiculopathy, which were normal. Bedside ultrasound of the gluteal musculature, including color doppler, revealed a multilobulated vascularized mass within the gluteus minimus.

Discussions: The patient was referred to orthopedic oncology for consideration of surgical resection due to worsening pain. The orthopedic team concluded that the vascular mass was an intramuscular hemangioma and that surgical removal may result in iatrogenic damage to the hip abductors, thus recommending interventional radiology consultation. The patient is now awaiting angiography with possible embolization and sclerotherapy with the interventional radiology team.

This case showcases a rare cause of chronic gluteal pain that could have been missed and attributed to gluteal tendinopathy versus myofascial pain if advanced imaging was not obtained. Point of care ultrasound can help with challenging diagnoses that do not fit classic presentations, and color doppler should be utilized to comprehensively assess atypical lesions.

Conclusions: Diagnostic point of care ultrasound is a key component of assessing atypical presentations of apparent musculoskeletal pain and ultimately may reveal non-musculoskeletal etiologies. Beyond assisting with diagnosis, ultrasound findings may guide management with directing referrals from physiatry clinics to appropriate specialists for atypical diagnoses.