A Venous Malformation Presenting as Toe Walking

Abstract

A 13-year-old girl was referred for consideration of treatment with botulinum injection. She had been toe walking since the age of 3 years. This was first noticed on the right, but then became bilateral with persistent asymmetry. There was no significant birth, developmental, past medical or family histories. A diagnosis of idiopathic toe walking was reported. She underwent stretching exercises and serial casting. However, there was no obvious benefit. On examination, she had a fixed right equinus deformity with a prominent and slightly tender right calf. The rest of the clinical examination was unremarkable. Bedside ultrasound scanning demonstrated a diffuse echogenic lesion over the lateral aspect of the right calf. Magnetic resonance imaging demonstrated the presence of a vascular malformation within the muscles of the posterior compartment of the right calf (Figure 1, Figure 2). Doppler ultrasound confirmed slow blood flow in keeping with a venous malformation. Venous sclerotherapy was performed with reported improvement in her pain when walking. This was also hoped to improve her compliance with physiotherapy exercises.