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Online Exclusives

A Closer Look At Glomangioma In The Plantar Fascia

While glomus tumors are rare, benign and painful neoplasms that typically present in the hand, these authors discuss a case involving an abnormal presentation of a glomangioma present in the plantar fascia band in a 60-year-old male.

Glomus tumors are rare vascular tumors with a reported incidence of 1.6 percent of all soft tissue tumors in the body.1 Glomus tumors are tumors of the glomus body, an anatomical and functional unit composed of specialized smooth muscle cells. This unit functions as an arteriovenous shunt linking arterioles and venules.2 A thermoregulatory functional unit results when the glomus cells surround and narrow the lumen of the Sucquet-Hoyer canal, which branches from the arteriole and leads to the collecting venule segment. 

One mostly sees glomus tumors in the extremities with approximately 75 percent of reported cases being in the hands.3 Symptoms typically present as painful paroxysmal attacks when the extremity is exposed to cold.4 Symptomatic glomus tumors are characterized by a classic triad of symptoms, including pain, cold intolerance and point tenderness over the mass.5 However, atypical presentations may necessitate further evaluation, including magnetic resonance imaging (MRI) and histology. 

The use of MRI may be beneficial in identifying certain features of glomus tumors before surgical excision. Lesions will usually have low T1-weighted signal intensity with a high T2-weighted signal intensity. A specific MRI finding common to all glomus tumors is the diffuse and intense signal, which results from the use of gadolinium.6-8 While glomus tumors demonstrate classic features with T1- and T2-weighting as well as contrast enhancement, researchers have reported atypical presentations in which MRI alone did not help diagnose a glomus tumor.9 Furthermore, while MRI may identify many characteristics of soft tissue tumors, the differentiation of benign from malignant lesions is not absolute.8 Clinicians may combine imaging findings with clinical findings, specifically the size, location, borders and adjacent tissue involvement, to help form a differential diagnosis and create a surgical plan.7 

The treatment of choice for glomangioma is surgical excision. Other treatments include sclerotherapy with sodium tetradecyl sulfate and hypertonic saline. In this case report, we present an abnormal presentation of a glomangioma in the plantar fascia band. Currently, we are unaware of any reported cases of glomus tumors involving the plantar fascial band. Such tumors are extremely uncommon and could lead to misdiagnosis.

When A Patient Presents With A Few Years Of Heel Pain

A 60-year-old male with no significant past medical history presented to the clinic with a chief concern of pain in the center of his left heel and a palpable mass for the past few years. He stated that he only has the pain when it gets cold outside. The patient notes the pain is intermittent in presentation but is localized to the area of the mass. The patient notes that a previous physician diagnosed plantar fasciitis and recommended conservative treatment options including injection, orthotics and other offloading modalities with no relief. Physical examination revealed a small, non-mobile, deep mass without pain on direct palpation. X-rays did not show any abnormal findings and we did not perform advanced imaging.

We scheduled the patient for surgical excision due to the obvious palpable mass and abnormal clinical presentation. We created a four cm incision midline on the plantar aspect of the heel along the palpable mass. Careful sharp and blunt dissection revealed an irregularly-shaped, pink-tan rubbery mass, which extended from the subcutaneous tissue into the plantar fascia band (see first photo above). Fully excised from the plantar fascial band, the specimen measured 1.2 x 1.0 x 0.7 cm. We preserved the specimen in formalin and sent it for pathologic diagnosis (see second photo above).

Pathology results described the lesion as an unoriented, irregularly-shaped pink-tan and yellow-tan soft tissue fragment, which was lobulated and rubbery in texture. The final pathology diagnosis was a benign glomangioma. The patient healed uneventfully after surgical excision and his symptoms resolved without any pain or reoccurrence after his 18-month follow-up.

Concluding Thoughts

Due to the rarity of glomangioma of the foot and especially of the plantar fascia, any presentation of a lesion and accompanying acute pain with cold exposure should raise a clinical suspicion for glomangioma. This type of mass is especially challenging to diagnose as the typical presentation is mostly in the hands, specifically underneath the fingernails. Although MRI was not part of the workup in our case, we recommend the use of MRI to help ensure the correct diagnosis is obtained. A thorough workup should be the driving force for surgical planning and treatment. In addition, a histopathological diagnosis is imperative postoperatively to confirm the diagnosis. Earlier diagnosis results in sooner definitive surgical treatment of glomangiomas, resulting in less morbidity to the patient and overall better quality of life.

Dr. Pajouh is a third-year Foot and Ankle Surgery Resident at Hunt Regional Medical Center in Greenville, Tx.

Dr. Bhakta is a third-year Foot and Ankle Surgery Resident at Hunt Regional Medical Center in Greenville, Tx.

Dr. Brancheau is the Director of the Department of Foot and Ankle Surgery at Hunt Regional Medical Center in Greenville, Tx.

Dr. Smith is affiliated with the Department of Foot and Ankle Surgery at Baylor Garland Hospital in Garland, Tx.

Online Exclusives
By Jonathan Pajouh, DPM, Parth Bhakta, DPM, Steven Brancheau, DPM, FACFAS and Scott Smith, DPM, FACFAS
References
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  2. Shin D-K, Kim M-S, Kim S-W, Kim S-H. A painful glomus tumor on the pulp of the distal phalanx. J Korean Neurosurg Soc. 2010;48(2):185–187.
  3. Carroll RE, Berman AT. Glomus tumors of the hand: review of the literature and report on twenty-eight cases. J Bone Joint Surg Am. 1972;54(4):691–703.
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  5. Walsh JJ 4th, Eady JL. Vascular tumors. Hand Clin. 2004;20(3):261-268.
  6. Glazebrook KN, Laundre BJ, Schiefer TK, Inwards CY. Imaging features of glomus tumors. Skeletal Radiol. 2011;40(7):855–862. 
  7. Walker EA, Song AJ, Murphey MD. Magnetic resonance imaging of soft-tissue masses. Semin Roentgenol. 2010;45(4):277–297.
  8. Walker EA, Fenton ME, Salesky JS, Murphey MD. Magnetic resonance imaging of benign soft tissue neoplasms in adults. Radiol Clin North Am. 2011;49(6):1197-1217.
  9. Dahlin LB, Besjakov J, Veress B. A glomus tumour: classic signs without magnetic resonance imaging findings. Scand Plast Reconstr Surg Hand Surg. 2005;39(2):123-125.

 

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