n

Case Report

Painful Intramuscular Lipoma of the

Infraspinatus: Unusual Location and
Presentation
Hee-won Park, MD, MA; Hannae Jo, MD; Sung Hoon Moon, MD, MS; Sora Baek, MD, PhD

abstract mass makes clinical diagnosis difficult

and further imaging should be considered.
Only a small number of cases of intramus-
Intramuscular lipomas are considered a rare type of benign lipomas. They are cular lipomas present with pain; these are
usually located deeper and are less palpable than subcutaneous lipomas. A located in the supraspinatus and deltoid
painful presentation with no palpable mass will make clinical diagnosis diffi- muscles.3-6
cult; in these cases, further imaging should be considered. Only a small num- To the authors knowledge, there have
ber of cases of intramuscular lipomas present with pain; these are located been no previous reports of painful intra-
in the supraspinatus and deltoid muscles. To the authors knowledge, there muscular lipomas involving the infraspi-
have been no previous reports of painful intramuscular lipomas involving the natus muscle. The authors report a case of
infraspinatus muscle. This article describes a case of intramuscular lipoma intramuscular lipoma with unique loca-
uniquely located in the infraspinatus muscle and presenting with shoulder tion in the infraspinatus muscle that pre-
pain. A 49-year-old woman presented with 2 months of left shoulder pain. sented with shoulder pain.
There was no history of preceding trauma. Pain was aggravated by lying on
the left shoulder and by the hand behind the back similar to Crass posi- Case Report
tion. On the physical examination, her shoulder joint range of motion was A 49-year-old woman presented with 2
slightly decreased. Simple radiography showed no significant abnormality, months of left shoulder pain and a visual
but ultrasonography revealed a hyperechogenic mass within the infraspinatus analog pain scale score of 50. There was
muscle. There was focal tenderness over the mass, but definite palpation of no preceding trauma. Pain was aggravated
the mass was not possible. Magnetic resonance imaging revealed a well-cir-
cumscribed, homogeneous lesion measuring 43 28 16 mm within the in- The authors are from the Department of Re-
fraspinatus muscle, leading to a diagnosis of intramuscular lipoma. Her pain habilitation Medicine (HP, HJ, SB) and the De-
partment of Orthopedic Surgery (SHM), Kangwon
was not improved with medication, suprascapular nerve block, and steroid
National University Hospital and School of Medi-
injections. Finally, surgical intervention was done and intramuscular lipoma cine, Kangwon National University, Chuncheon,
was confirmed by specimen. After excision, her shoulder pain was improved South Korea.
and resolved. [Orthopedics. 2016; 39(2):e370-e373.] The authors have no relevant financial rela-
tionships to disclose.
Correspondence should be addressed to: Sora

I
ntramuscular lipoma is a rare clinical
condition accounting for only 1.9%
of all benign lipomas.1 Intramuscu-
lar lipomas located in the shoulder girdle
are less frequent than those in the trunk
or lower limb.2 Unlike superficial lipo-
mas, intramuscular lipomas are located
within the muscle and sometimes are not
palpable on routine physical examination.
A presentation of pain without palpable
Baek, MD, PhD, Department of Rehabilitation
Medicine, Kangwon National University Hospi-
tal, Baengnyeong-ro 156, Chuncheon, Gangwon
24289, South Korea (sora.baek@kangwon.ac.kr).
Received: April 6, 2015; Accepted: June 22,
2015.
doi: 10.3928/01477447-20160307-03

e370 Copyright SLACK Incorporated

 n Case Report

by lying on the left shoulder and by the

hand behind the back similar to Crass po-
sition. On physical examination, glenohu-
meral joint range of motion was 105 in
forward flexion and 95 in abduction by
goniometer, and T2 spinous process touch
in external rotation and L5 spinous pro-
cess touch in internal rotation by Apley
scratch test. To minimize scapular mo-
tion during range of motion evaluation,
the patients scapula was stabilized. There
A B
was no definite palpable mass around the
Figure 1: Grey-scale ultrasound of the left infraspinatus muscle. Corresponding short axis view along
shoulder.
the infraspinatus muscle showing a relatively high echogenic mass (asterisk) compared with that of sur-
Radiography showed no significant rounding muscle (A). Long axis view showing longitudinal continuous internal echoes parallel to the long
abnormality. Ultrasonography revealed axis of the lesion (B).
a well-demarcated hyperechogenic mass
within the left infraspinatus muscle (Fig-
ure 1). There was focal tenderness over
the mass. Ultrasonography showed no
definite rotator cuff tendon pathology. A
mixture of 20 mg of triamcinolone and
5 mg of lidocaine was injected into the
subacromial-subdeltoid bursa under ul-
trasound guidance, reducing pain slightly
from visual analog pain scale score of 50
to 30. Aceclofenac was prescribed. The
next day, magnetic resonance imaging
A B
with gadolinium enhancement was per-
formed for further evaluation of the mass.
Magnetic resonance imaging showed a
well-defined fatty mass in the left infra-
spinatus muscle (Figure 2).
Pain was persistent at 1 week, and a
suprascapular nerve block was performed.
One week after the second injection, pain
had barely improved. The patient was re-
ferred for surgical excision of the lipoma.
The mass lesion was exposed through C D
a posterior approach by retraction of the
Figure 2: Intramuscular lipoma in the shoulder of a
posterior deltoid. The lesion was located 49-year-old woman. Corresponding axial T1-weighted
within the infraspinatus muscle and well (TR/TE; 563/10) (A) and T2-weighted (TR/TE; 4344/70)
marginated. There was no neurovascular (B) spin-echo magnetic resonance images showing a
involvement. The mass was easily ex- well-defined fatty mass (intramuscular lipoma measur-
ing 43 28 16 mm) in the left infraspinatus muscle
cised, with a lipomatous appearance mac- with a signal intensity similar to that of the subcutaneous
roscopically (Figure 3). adipose tissue. Corresponding T1-weighted fat-saturat-
Pain was reduced 1 day postopera- ed magnetic resonance image after administration of
tively. Pathology of the surgical specimen intravenous gadolinium showing no abnormal enhance-
ment (C). Oblique coronal (D) and sagittal (E) T1-weight-
confirmed intramuscular lipoma. Five ed magnetic resonance images showing intramuscular
weeks postoperatively, the patient was and longitudinal location within the infraspinatus muscle
pain free with full range of motion. E corresponding to the ultrasonographic findings.

MARCH/APRIL 2016 | Volume 39 Number 2 e371

n Case Report
A B
Figure 3: Surgery was performed via the posterior approach. The lesion was embedded within the infraspinatus and well marginated. Marginal excision was done
(A). The excised mass lesion was 4 3 2 cm, oval, and yellowish similar to lipoma (B). Microscopically, the tumor showed mature adipocytes (hematoxylin-
eosin, original magnification x200) (C).
Discussion
Benign lipomatous lesions are the
most common benign soft tissue tumor
and represent the largest single group of
mesenchymal tumors.7 Most of them are
located in the superficial subcutaneous
plane and composed of mature fatty tis-
sue.8 Intramuscular lipoma is a form of
benign lipomatous lesion intimately asso-
ciated with muscular tissue.2
Intramuscular lipomas are rare com-
pared with superficial lipomas.1 Intramus-
cular lipoma is more common in the lower
limbs and trunk, with the shoulder girdle
less often involved.2 Intramuscular lipo-
mas of the shoulder region are especially
uncommon. There are only isolated case
reports of intramuscular lipoma involv-
ing the shoulder muscles, including the
deltoid,5,6 supraspinatus,3,4 and subscapu-
laris.9 Intramuscular lipoma of the infra-
spinatus muscle has not been reported in
the literature.
Most intramuscular lipomas are not
painful. Among 40 cases with intramus-
cular lipoma involving the lower limb,
upper limb, and trunk, including 6 of
the deltoid muscle, an asymptomatic
mass was the most common symptom
in 24 (60%) of the cases. Swelling with
no palpable mass was the second most
common symptom (13 cases, 32.5%).
Three patients (7.5%) reported pain.10
The presenting symptom of an intramus-
cular lipoma was also usually a painless
mass when located in the upper extrem-
e372
ity.11 Although there are few cases in the
literature documenting intramuscular li-
poma in the shoulder, some of them had
shoulder pain as the initial presenting
symptom. Intramuscular lipomas located
in the supraspinatus had a painful pre-
sentation with impingement syndrome.3,4
Many of the intramuscular lipomas locat-
ed in the trapezius and deltoid were not
painful,10,11 but in a few reports, lipomas
in the deltoid were painful.5,6
Unlike superficial lipomas, intra-
muscular lipomas are located within the
muscle and sometimes are not palpable on
physical examination.3,4 Painful intramus-
cular lipoma without palpable mass could
possibly delay the final diagnosis or be
misdiagnosed as a common shoulder pain
syndrome, such as rotator cuff syndrome
or adhesive capsulitis. In cases of pain-
ful shoulder unresponsive to conventional
treatment, further imaging workup should
be considered despite there being no pal-
pable mass.
Ultrasonographic evaluation is widely
being used in the diagnosis of musculo-
skeletal disorders. In the current case,
the ultrasonographic image showed a
hyper-echoic lesion within the involved
muscle. However, ultrasonographic fea-
tures of deep-seated lipoma tend to be
variable. Paunipagar et al12 reported 64
deep-seated lipomas in which 36 (56%)
were intramuscular type. Echogenicity of
lipoma was hyperechoic to muscle in 37
cases (57%), isoechoic to muscle in 13
C
(21%), and hypoechoic to muscle in 14
(22%).12
Surgical outcomes have been satisfac-
tory in case reports.3-5 Su et al13 reported 8
patients with intramuscular lipoma treated
by marginal excision. The surgical results
were good, and no local recurrence was
noted in an average follow-up period of
40 months.
Conclusion
Pain due to intramuscular lipoma can
be cured by surgical excision of the tumor.
Intramuscular lipoma in the infraspinatus
is rare and is not considered a common
cause of shoulder pain. Definite palpa-
tion of the mass is not always possible and
further diagnostic efforts are required to
avoid misdiagnosis.
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