What is the best course of treatment for a patient presenting with a painful mass in the left gluteus, suspected to be either a muscle knot or a lipoma, with a palpable deep small mass in the area?

Management of Painful Deep Gluteal Mass

Begin with plain radiographs followed by ultrasound imaging to differentiate between a muscle knot and lipoma, with MRI reserved for deep-seated masses or atypical features. 1

Initial Diagnostic Approach

Plain radiographs should be obtained first as the fundamental initial step for any suspected soft-tissue mass, even though they may be unrewarding for small, deep-seated, or non-mineralized masses. 1 Radiographs can identify intrinsic fat in approximately 11% of soft-tissue masses and may detect calcification or bone involvement that could alter management. 1

Ultrasound as Primary Imaging

Ultrasound is the most appropriate next step for this clinical scenario, though its diagnostic accuracy is considerably less for deep masses compared to superficial lesions. 1 For deep lipomas specifically, ultrasound accuracy drops precipitously. 1

Characteristic Ultrasound Features to Assess:

For lipoma: 2, 3, 4

• Hyperechoic or isoechoic appearance compared to surrounding fat
• Well-circumscribed margins with thin, curved echogenic lines
• Minimal to no internal vascularity on Doppler examination
• No acoustic shadowing

Red flags requiring advanced imaging: 2, 4

• Heterogeneous echotexture or irregular margins
• Unexpected vascularity patterns
• Size >5 cm in diameter
• Rapid growth or pain (as in this case)

When to Proceed to MRI

Given the deep location in the gluteal region and presence of pain, MRI should be strongly considered even if ultrasound suggests a benign lipoma. 1 The gluteal region represents a deep anatomic location where ultrasound has significant limitations. 1

MRI is specifically indicated for: 1, 2

• Deep-seated masses (as in this case)
• Masses larger than 5 cm
• Painful masses
• Lower limb/gluteal location (higher concern for atypical lipomatous tumor)
• Diagnostic uncertainty on ultrasound

Critical Pitfall to Avoid

Deep-seated lipomas in the gluteal/lower limb region have heightened concern for atypical lipomatous tumor (well-differentiated liposarcoma), which requires different surgical management with en bloc resection rather than simple excision. 1, 2 These tumors tend to be larger, deep-seated, and located in the lower limb. 1

If MRI shows concerning features (nodularity, thick septations, stranding), obtain core needle biopsy with MDM-2 amplification analysis to definitively differentiate benign lipoma from atypical lipomatous tumor. 2 This distinction is crucial as it fundamentally alters the surgical approach. 2

Management Algorithm

For this specific case of a painful, deep gluteal mass: 1, 2

1. Obtain plain radiographs of the pelvis/hip to exclude bone involvement or calcification
2. Proceed to ultrasound with Doppler examination
3. Given the deep location and pain, strongly consider MRI regardless of ultrasound findings
4. If MRI shows typical benign lipoma features and size <5 cm, observation with clinical follow-up may be appropriate
5. If symptomatic (pain), rapidly growing, or showing atypical features, complete en bloc surgical excision is standard treatment
6. If MRI shows concerning features, obtain core needle biopsy with MDM-2 analysis before definitive surgery

Muscle Knot Consideration

A true "muscle knot" (myofascial trigger point) would not present as a discrete palpable mass on physical examination and would not be visible on imaging studies. 1 The presence of a palpable deep mass makes a structural lesion (lipoma or other soft-tissue tumor) far more likely than a functional muscle abnormality.