A young male presented with painful soft tissue lumps on bilateral shoulders. There was no history of trauma.
Ultrasound revealed multiple bilateral intramuscular ill-defined heterogeneous solid-appearing masses, a few of which showed slight predominantly peripheral vascularity.
Following this, pre and postcontrast MR of bilateral shoulders showed multiple intramuscular masses in the infraspinatus and deltoid muscles. The largest mass measured 7.8 x 2.1 x 2 cm in the right teres minor and 1.2 x 0.9 x 0.8 cm in the left deltoid. These lesions essentially showed iso to be slightly brighter than the muscle signal on T1 and were heterogeneously bright on fluid-sensitive sequences (T2/STIR). On gradient recovery images, few susceptibility artefacts were seen within suggestive of haemorrhage. The predominant enhancement pattern was moderate to intense heterogeneous peripheral enhancement with central necrosis/cystic changes. Surrounding oedema, extending into the adjacent musculature and along intervening muscular planes with some enhancement and susceptibility, were also noted. Imaging findings were indeterminate, and various possibilities, including mesenchymal lesions, metastasis, myxomas, inflammatory/infective processes, nodular and proliferative fasciitis/myositis and multiple inflammatory myofibroblastic tumours, were given. The patient underwent a biopsy of the right teres minor lesion, which was consistent with haemangioma.
Intramuscular haemangiomas (IMH) are benign vascular tumours accounting for less than 0.8% of all soft tissue tumours but are the most common type of deep intramuscular tumours [1].
IMH are extremely rare and often hard to diagnose accurately due to lack of specific symptoms, deep location, absence of obvious cutaneous change, slow growth rate, and size and shape variability with relatively low diagnostic rates of about 8% to 19% [2].
An IMH is a benign vascular tumour that contains neoplastic proliferation of endothelial cells and often occurs in skeletal muscle, mostly accompanied by intramuscular angiolipomas [3].
Retrospectively, in our case, ultrasound revealed multiple intramuscular heterogeneous predominantly hypoechoic lesions, which are nonspecific and can be seen in haemangiomas [4]. We used MRI to further study the masses due to its excellent ability to delineate deep seated lesions and discern the relationship with adjacent structures. Typically, on MRI, haemangiomas reveal an intermediate signal on T1-weighted images and a high signal on T2-weighted images [5]. Both of these features were evident with the lesions in our case. However, due to atypical features like lack of flow voids, typical avid peripheral nodular contrast enhancement, presence of muscle, and perimuscular oedema, haemangiomas were not considered in the differential diagnosis. Orly et al. [6], in their systematic review of intramuscular haemangiomas, showed that all cases showed avid contrast enhancement and flow voids. Secondly, perimuscular oedema and haemorrhage are rare in benign haemangiomas and more common in infectious or aggressive lesions. In the same review article, Orly et al. found no cases of intramuscular haemangioma involving the deltoid or the rotator cuff musculature. Guedes et al. [7] reported only one case of intramuscular haemangioma in the deltoid, which showed the absence of typical imaging features of vascular lesions with the presence of non-vascular elements, similar to our case.
Though the imaging features were nonspecific, we wish to report this case due to the conglomerate of rare features in terms of atypical features, for example, pattern of enhancement, multiplicity and perimuscular oedema and haemorrhage. To the best of our knowledge, we are the first to report a case of multiple bilateral intramuscular haemangiomas affecting the deltoid and rotator cuff musculature. Emphasis is not on diagnosis but rather on including haemangiomas in a list of differential diagnoses of multiple soft tissue lesions around the shoulder girdle or within skeletal muscles, especially in young individuals.
Bilateral multiple intramuscular hemangiomas
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1. Ultrasound Examination: Multiple lesions with heterogeneous echogenicity are observed in the soft tissues of both shoulders, presenting predominantly hypoechoic areas mixed with irregular echo signals. Color Doppler shows blood flow signals within and around some of the lesions, suggesting a vascularized nature.
2. MRI Examination: Multiple lesions with relatively clear boundaries and varying shapes are seen in the deltoid and parts of the rotator cuff musculature of both shoulders. On T1WI, they display isointense or slightly hypointense signals; on T2WI, they show hyperintense signals. After contrast enhancement, some lesions demonstrate irregular enhancement. Mild edema signals may occasionally be observed in surrounding muscles and fascia. Scattered hemorrhage or more complex signal components are noted in some lesions, but no typical “flow void” sign of high-flow vascular lesions is present. Overall morphology and distribution are uncommon, involving both deltoid muscles and a portion of the rotator cuff.
Based on imaging findings, patient’s age, and symptoms, the following differential diagnoses are primarily considered:
1. Intramuscular Haemangioma (IMH): Usually presents with high signal intensity on T2WI, visible vascular networks, and enhancement. However, if the lesion has mixed components or hemorrhage, it may show atypical imaging features.
2. Soft Tissue Sarcoma: Such as malignant fibrous histiocytoma or synovial sarcoma. These often demonstrate more aggressive features, including invasive growth, bone destruction, or extensive soft tissue involvement.
3. Hematoma or Inflammatory Lesion: In the absence of a clear history of trauma, repeated small vessel ruptures or localized inflammation could present with relatively heterogeneous features. However, these are typically accompanied by an acute pain history or abnormal inflammatory markers.
4. Other Benign Soft Tissue Tumors: For instance, lipomas or schwannomas, but these commonly lack significant vascularization or hemorrhage signals. On MRI, they usually exhibit characteristic fatty components or involvement of nerve pathways.
Considering the patient’s young age, bilateral shoulder involvement with vascularized soft tissue masses, and postoperative histopathological confirmation, the most likely diagnosis is: Multiple Bilateral Intramuscular Haemangiomas in the Shoulder Region.
1. Treatment Strategy:
- Conservative Management: For smaller lesions with mild symptoms, observation may be considered, along with oral analgesics or local pain relief. Regular imaging follow-ups may be necessary to assess lesion progression.
- Active Intervention: If lesions are large, cause significant symptoms affecting daily activities, or raise concerns of malignant transformation, interventional procedures (e.g., sclerotherapy) or surgical resection may be considered.
- Surgical Indications: Recurrent, uncontrollable pain or significant enlargement of the lesion accompanied by functional impairment warrants surgical excision and pathological diagnosis. Intraoperative management should aim for complete resection of the lesion, followed by appropriate physical therapy.
2. Rehabilitation / Exercise Prescription: Adhere to a gradual and individualized approach.
- Initial Phase (Inflammatory Relief):
· Perform passive and gentle active shoulder joint movements, avoiding overly large ranges of motion or heavy loads;
· Frequency: 3–4 times per week, 10–15 minutes each session;
· Intensity: Low, not triggering pain or significant discomfort.
- Intermediate Phase (Functional Training):
· Increase light resistance exercises without significant pain, such as using resistance bands or small dumbbells to train the deltoid and rotator cuff muscles;
· Frequency: 2–3 times per week, resting on alternate days;
· Intensity: Moderate, around 40%–50% of maximum strength, 20–30 minutes each session, progressively increasing resistance.
- Advanced Phase (Strengthening and Return to Activity):
· Further enhance shoulder stability and muscle strength, incorporating core training and overall coordination exercises;
· Frequency: 3–5 times per week;
· Intensity: Can increase to moderate-to-high levels based on recovery status, ensuring avoidance of excessive shoulder use;
· Combine flexibility and dynamic balance training for better preparedness in daily activities or sports events.
Throughout the rehabilitation process, regular imaging (or ultrasound) evaluations are recommended to ensure no significant lesion enlargement or worsening. If the patient has special conditions (e.g., fragile bones, compromised cardiopulmonary function), corresponding adjustments in exercise methods or monitoring are required to ensure safety.
This report is generated by an intelligent medical assistance system based on available information and is for clinical reference only. It does not replace an in-person consultation or professional medical advice. Patients should make diagnosis and treatment decisions after thorough discussion with qualified healthcare professionals, considering their individual circumstances.
Bilateral multiple intramuscular hemangiomas
