Working Diagnosis:
Final Diagnosis:
Low Flow Venous Malformation of the Left Femur with both an intraosseous and extraosseous component.

Treatment:
Full restrictions from all impact activities.
Compression stockings.
Aspirin therapy for intermittent intralesional thrombosis (1).
Interventional Radiology consultation for sclerotherapy.

Outcome:
Conservative medical measures failed. The patient continued to have intermittent periods when he was in such intense pain that it restricted his ability to perform his activities of daily living. Therefore, the decision was made to proceed with sclerotherapy (1).

Author's Comments:
Due to the risk of pathologic fracture, impact activities such as karate were restricted until the final diagnosis was made and sclerotherapy performed. At one month follow up status-post sclerotherapy, the patient has been pain-free. He’s slowly returning to impact activites. He can perform all activites of daily living as well as jog without pain. Over the next one month he will continue to advance his activity as tolerated and eventually return to sport. Follow up at 3-6 month intervals is needed to determine the need for repeat sclerotherapy.

Editor's Comments:
This is an interesting case, because a vascular malformation likely is not the first idea that comes to mind for a Sports Medicine physician treating a painful thigh mass. Of note, muscular venous malformations often grow in parallel to the growth of the patient, although they tend to grow more rapidly during puberty or pregnancy (3)-- given the patient's age, this could explain why he had only recently experienced symptoms. Ultrasound is an excellent way to evaluate any such thigh mass, because it can give you a number of clues to the diagnosis. A venous malformation is generally hypoechoic and heterogeneous in appearance, will be compressible and shows non-pulsatile blood flow. If the ultrasound identifies a non-compressible mass, one must start to think of a solid soft tissue neoplasm such as a rhabdomyosarcoma or neuroblastoma metastasis. Pulsatile blood flow seen on doppler imaging suggests a strong arterial component to the lesion, which rules out a venous malformation and makes an arteriovenous malformation or hemangioma more likely (4). Further imaging studies, such as MRI or CT, are useful for better characterizing the venous malformation in order to plan treatment.

References:
1) Breugem C, Maas M, Breugem M, et al. Vascular Malformations of the lower limb with osseous involvement. J Bone Joint Surg [Br] 2003; 85-B(3):399-405.

Legiehn G, Heran M. A Step-by-Step Practical Approach to Imaging Diagnosis and Interventional Radiologic Therapy in Vascular Malformations. Semin Intervent Radiol 2010; 27(2):209-231.

3) Dubois J, et al. Soft-Tissue Venous Malformations in Adult Patients: Imaging and Therapeutic Issues. Radiographics 2001; 21:1519-1531.

4) Trop I, et al. Soft-Tissue Venous Malformations in Pediatric and Young Adult Patients: Diagnosis with Doppler US. Radiology 1999; 212:841-845.

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