Working Diagnosis:
Fibroadipose vascular anomaly (FAVA)

Treatment:
Patient's mother was initially undecided, but the patient and family decided to move forward with cryoablation 3 months after diagnosis. Repeated cryoablation was recommended by the performing Interventional Radiologist as needed, but surgical excision was encouraged if no pain relief was achieved with the initial cryoablation procedure.

Outcome:
After cryoablation, patient reported minimal change in pain level with activity. She was still unable to play lacrosse or other sports due to significant, activity limiting pain. She occasionally experienced episodic pain at rest as well. The patient and family remained undecided on moving forward with surgical excision.

Author's Comments:
When dealing with vascular lesions, it is important to involve Interventional radiology early on as they are familiar with many of the treatments and characterization of these type of lesions under ultrasound. Ultrasound characterization of these lesions remains an area of opportunity for sports medicine physicians.
Previous studies highlight that pain limits mobility and could be a cause for worsening contractures with delayed treatment. When cryoablation and other treatments fail, surgical excision should be considered. Surgical excision is more invasive, but the literature shows eliminating ongoing pain may compensate for the loss of muscle bulk.
Although most sports medicine physicians will not be directly involved in the treatment of FAVA, some may encounter patients presenting with musculoskeletal complaints of pain, joint contractures, limp, or toe walking.
These common complaints can be misdiagnosed as muscular strains, growing pains, idiopathic toe walking, apophysitis, or venous malformations.
Awareness of this unique vascular entity is important in establishing accurate diagnosis when a patient presents with significant activity limiting muscular extremity pain with normal radiographs.

Editor's Comments:
The lesion described in this case is a rare vascular abnormality called a "Fibro-adipose Vascular Anomaly" or FAVA. Description of these lesions was first published in 2014 by A. Alomari et. al. These lesions are found within muscle bodies and seem to replace normal muscle tissue with fibrofatty overgrowth and dilated venous structures. Although cases are limited, these lesions appear to affect the limbs, the female sex, and there may be a common genetic mutation involved as well. Treatment with cryoablation, embolization, surgical resection, or a combination of these interventions have yielded reassuring results in patients' pain reduction and return to function.

References:
Alomari AI, Spencer SA, Arnold RW, Chaudry G, Kasser JR, Burrows PE, Govender P, Padua HM, Dillon B, Upton J, Taghinia AH, Fishman SJ, Mulliken JB, Fevurly RD, Greene AK, Landrigan-Ossar M, Paltiel HJ, Trenor CC 3rd, Kozakewich HP. Fibro-adipose vascular anomaly: clinical-radiologic-pathologic features of a newly delineated disorder of the extremity. J Pediatr Orthop. 2014 Jan;34(1):109-17. doi: 10.1097/BPO.0b013e3182a1f0b8. PMID: 24322574.

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