Effort thrombosis presenting as pulmonary embolism in a professional baseball pitcher

Paget-Schroetter Syndrome in a Patient With Posterior Shoulder Subluxation: A Case Report

ABSTRACT

Paget-Schroetter syndrome describes a primary thrombosis of the subclavian vein induced by effort. In most cases, the clinical presentation includes painful swelling, discoloration, and visible collateral circulation in the arm. Paget-Schroetter syndrome is treated with anticoagulation, rest, and physical therapy. In certain cases, invasive treatment such as thrombolysis and decompression surgery (first rib resection) may be necessary. We present the case of a 28-year-old healthy male patient with effort-induced deep vein thrombosis of the upper extremity after posterior shoulder subluxation. Anticoagulation, rest, and physical therapy were used to treat the patient, who became asymptomatic and was able to resume normal activities without restriction. To our knowledge, this is the first case of effort-induced upper extremity deep vein thrombosis after posterior shoulder subluxation. Paget-Schroetter syndrome is rare diagnosis that requires vigilance during musculoskeletal assessment for shoulder pain and swelling. The early detection, radiological confirmation, and prompt initiation of treatment are essential to successful management of Paget-Schroetter syndrome. The impact of associated posterior shoulder subluxation remains unclear.

Thoracic Outlet Syndrome in Sport: A Systematic Review

Thoracic outlet syndrome (TOS) is a rare and heterogeneous syndrome secondary to a compression of the neurovascular bundle in the thoracic outlet area. Muscle hypertrophy is recognized to induce vascular or neurogenic compression, especially in sports involving upper-arm solicitation. Athletes represent a distinctive population because of a specific management due to an ambitious objective, which is returning to high-level competition. We evaluated the scientific literature available for the management of TOS in athletes. Article research extended to March 2021 without other restriction concerning the date of articles publication. The search was performed independently by two assessors. A first preselection based on the article titles was produced, regarding their availability in English or French and a second preselection was produced after reading the abstracts. In case of doubt, a third assessor’s advice was asked. Case reports were selected only if the sport involved was documented, as well as the level of practice. Cohorts were included if data about the number and the sport level of athletes were detailed. Seventy-eight articles were selected including 40 case reports, 10 clinical studies and 28 reviews of literature. Baseball pitchers seem to be highly at risk of developing a TOS. The surgical management appears particularly frequent in this specific population. The prognosis of TOS in athletes seems to be better than in the general population, possibly due to their better physical condition and their younger age. Some studies showed interesting and encouraging results concerning return to previous sport level. Literature shows a strong link between TOS and certain sports. Unfortunately, this syndrome still lacks rigorous diagnostic criteria and management guidelines for athletes.

Atypical Presentation of Paget-Schroetter Syndrome: Case Report and Management

Upper extremity deep vein thrombosis (UEDVT) is a rare condition that makes early clinical evaluation and treatment important prior to the formation of deep vein thrombosis (DVT). Typical risk factors include male sex, young age, repetitive arm over abduction and hyperextension, indwelling catheters, cervical first rib, and thoracic outlet syndrome. One common cause of UEDVT is Paget-Schroetter syndrome (PSS). If untreated, pulmonary complications such as venous thromboembolic disease and pulmonary embolism (PE) may develop. We present a case of a 34-year-old Caucasian female who presented to the emergency department with sudden, acute right arm pain after blow-drying her hair, consistent with UEDVT. CT angiography (CTA) demonstrated moderate thromboembolic disease within segmental and subsegmental branches of the left upper, left lower, and right lower lobes. Ultrasonography (US) of the upper extremity showed non-compressibility of the right axillary and basilic vein, a finding consistent with acute DVT. Peripheral angiogram revealed imaging consistent with undiagnosed thoracic outlet syndrome secondary to effort thrombosis. The patient deferred surgical intervention and agreed to begin long-term anticoagulation therapy. PSS requires immediate recognition and treatment to prevent possible long-term neurologic and vascular compromise. Despite the patient lacking the typical population demographics, PSS should be considered given the patient's symptoms and presentation. Recognition of UEDVT despite classic signs and symptoms consistent with known risk factors is imperative upon clinical suspicion. Delay in clinical management may lead to fatal complications. We aim to highlight a case of PSS along with alternative pathways for treatment delivery.

Sport and Venous Thromboembolism

BACKGROUND

The occurrence of venous thromboembolisms (VTE) in association with sporting activity has been described but not yet systematically explored. The aim of this study was to determine the sites at which VTE occur in athletes, the accompanying features, and the special features of the symptoms and diagnosis, so that physicians can take the findings into consideration.

METHODS

A search of the literature in the databases PubMed, Web of Science, and Cochrane in accordance with the PRISMA criteria, together with a search of Google Scholar up to 29 February 2020.

RESULTS

No observational studies were identified. A total of 154 case descriptions were evaluated: 89 on upper-extremity deep vein thrombosis (DVT), 53 on lower-extremity DVT, and 12 on pulmonary embolisms with no evidence of thrombosis. Ninety-five percent of the upper-extremity DVT involved the region of the subclavian/axillary vein. Thoracic outlet syndrome (38%), hereditary thrombophilia/a family history of VTE (16%), intensive training (12%), and the use of oral contraceptives (7%) were identified as accompanying features. The upper-extremity DVT occurred mainly in male strength athletes and ball sports players. The lower-extremity DVT were located in the lower leg/knee (30%), the thigh (19 %), or occurred in combination in the lower leg-to-pelvis region (30 %). The features accompanying lower-extremity DVT were hereditary thrombophilia/a family history of VTE (30%), trauma (25%), immobilization (21%), and the use of oral contraceptives (11%). The lower-extremity DVT were found in endurance sports and ball sports. The symptoms may be obscured by sport-specific symptoms/trauma, and diagnosis is often delayed. Early D-dimer determination is useful and is complemented by diagnostic imaging.

CONCLUSION

VTE are found in association with sports. The background factors, the sites of VTE, the types of sports involved, and the accompanying features are all important to know. The symptoms may be obscured, and it may be difficult to reach the correct diagnosis. The possible presence of DVT must be borne in mind.

Paget-Schroetter syndrome in athletes: a comprehensive and systematic review

BACKGROUND

Paget-Schroetter syndrome (PSS) is a rare condition of axillosubclavian vein thrombosis often seen in athletes with a history of repetitive external rotation and abduction of the shoulder. The purpose of this review was to analyze the literature and characterize PSS in the athletic population, including risk of PSS by sport. We also provide a comprehensive review of PSS to inform clinicians on the pathophysiology, detection, and management of the condition.

METHODS

Four databases were reviewed to identify cases of PSS occurring in athletes. Data on patient demographics, reported sport, diagnosis, treatment, management, return to sport, and complications were extracted and analyzed by 2 independent reviewers.

RESULTS

Of the 123 cases of PSS identified, baseball and weight lifting had the highest incidence (26.8% and 19%, respectively), followed by swimming, football, and basketball. The average return to sport was 4.7 months, and 26.7% of subjects reported complications, most commonly pulmonary embolism.

CONCLUSION

In athletes presenting with upper extremity pain and swelling with a history of playing baseball or weight lifting, PSS should be higher on a clinicians differential diagnosis list. Swimmers, football, and basketball players are less likely to present with PSS but are still more likely than other types of athletes to develop the condition. Clinician awareness of PSS in athletes is critical to avoid delays in treatment and misdiagnosis, and to allow for a timely return to sport with minimal complications.

Effort Thrombosis in 2 Athletes Suspected of Musculoskeletal Injury

Objective

This case series describes the clinical presentation of effort thrombosis and the utility of sonography in its diagnosis.

Clinical Features

Two young male athletes presented to separate chiropractic clinics with suspected musculoskeletal shoulder injury. The first complained of dull shoulder pain after pitching in a baseball game and had no other signs or symptoms. The second presented after performing a weighted plank exercise and had prominent edema and discoloration of the affected extremity.

Intervention and Outcome

In the first patient, who had no physical signs to suggest thrombosis, a normal sonographic musculoskeletal shoulder exam prompted imaging in the abduction-external rotation position. This provided visualization of a thrombus in the axillosubclavian vein. Emergent referral followed, and treatment was initiated with thrombolysis and surgery, which resolved his condition. The second patient had physical signs consistent with effort thrombosis and was also referred to the emergency department, where sonography was performed and revealed thrombosis of the axillary and basilic veins. He responded to anticoagulants and thrombolysis and avoided surgery.

Conclusion

Effort thrombosis has a variable presentation that can mimic common musculoskeletal disorders and has a poorly defined diagnostic pathway. Acute shoulder pain in an athlete, especially with extremity edema after repetitive exertion, warrants urgent imaging such as sonography and emergent referral. Clinicians should understand the importance of a timely evaluation and diagnosis of effort thrombosis and that imaging may include sonography as a first-line imaging tool.

Effort Thrombosis Provoked by Saxophone Performance

BACKGROUND

Internal jugular venous thrombosis (IJVT) is an uncommon condition rarely diagnosed in the outpatient setting. IJVT carries significant morbidity and mortality and must be considered in the differential diagnosis for new-onset neck pain and swelling, especially in the emergency setting. Paget-Schroetter syndrome (PSS), or primary thrombosis secondary to effort, is an uncommon, likely under-recognized etiology of thrombosis. We report a case of PSS extending from the right subclavian vein into the right internal jugular vein, suspected based upon patient history and physical examination and confirmed by point-of-care ultrasound (POCUS). We then review the presentation, causes, and diagnostic standards for PSS.

CASE REPORT

We present a case of a 79-year-old man who presented to the Emergency Department with acute right-sided neck pain 1 day after playing the saxophone for 4 h the prior evening. POCUS confirmed Paget-Schroetter syndrome, or primary effort thrombosis of the internal jugular vein. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first documented case of PSS resulting from venous stasis with prolonged Valsalva maneuver and vascular trauma with activity of playing the saxophone. The significance of this case is the unusual etiology of a rare presentation and the ability to diagnose this condition quickly and accurately with POCUS.

Paget-Schroetter syndrome: treatment of venous thrombosis and outcomes

Thoracic outlet syndrome (TOS) is a rare clinical entity with many etiologies. Venous thoracic outlet syndrome (VTOS), also called Paget-Schroetter syndrome (PSS), is a primary "effort" thrombosis. Here we will focus on the pathophysiology, anatomy, clinical presentation, treatments, and outcomes of VTOS. Treatment involves anticoagulation, catheter-directed thrombolysis, and surgical decompression. Early diagnosis and treatment can improve symptoms and quality of life.

Performance of wells score to predict deep vein thrombosis and pulmonary embolism in endurance athletes

INTRODUCTION

There are an increasing number of reports describing deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in otherwise healthy endurance athletes. The Wells score is the most commonly used clinical prediction rule to diagnose DVT/PE in clinical populations. However, the Wells score may have limited utility for recognition of DVT/PE in athletes, contributing to missed or delayed diagnosis.

OBJECTIVE

We performed an analysis of the ability of the Wells score to identify DVT/PE events in athletes through a review of published case reports.

METHODS

A systematic search of the literature yielded 11 case reports.

RESULTS

The Wells score had a 100% failure rate in identifying athletes with DVT (0/6) and PE (0/5), resulting in a delayed diagnosis for DVT of 20 ± 14 days. Retrospectively removing 'differential diagnosis' from the clinical prediction rule for DVT changed the Wells score median from 0 (range: -1 to 0) to 2 (range: 1 to 2); the threshold for predicting DVT as 'likely'. There were limited clinical characteristics captured in the Wells score for PE that were applicable to athletes, highlighting the need for reappraisal. Although the Wells score failed to accurately triage athletes with known DVT and/or PE, the addition of a D-dimer value (mean: 1566 ± 758ng/dL) to the Wells score correctly identified 9/9 athletes.

CONCLUSIONS

The Wells score had a 100% failure rate for triaging athletes with known DVT/PE. When performed, D-dimer adequately facilitated the additional diagnostic testing required for a timely diagnosis of DVT/PE in athletes. Improving awareness of an atypical presentation of thrombotic events in athletes may reduce the widespread underestimation of DVT/PE among athletes and facilitate the additional testing required for a timely diagnosis.

Upper Extremity Deep Vein Thromboses: The Bowler and the Barista

Effort thrombosis of the upper extremity refers to a deep venous thrombosis of the upper extremity resulting from repetitive activity of the upper limb. Most cases of effort thrombosis occur in young elite athletes with strenuous upper extremity activity. This article reports two cases who both developed upper extremity deep vein thromboses, the first being a 67-year-old bowler and the second a 25-year-old barista, and illustrates that effort thrombosis should be included in the differential diagnosis in any patient with symptoms concerning DVT associated with repetitive activity. A literature review explores the recommended therapies for upper extremity deep vein thromboses.

SCREENING FOR REFERRAL BY A SPORTS PHYSICAL THERAPIST REVEALS AN EFFORT THROMBOSIS IN A COLLEGIATE PITCHER: A CASE REPORT

BACKGROUND AND PURPOSE

Screening for referral, regardless of setting, is the responsibility of all physical therapists. A serious condition that sports physical therapists may encounter is upper extremity (UE) deep venous thrombosis (DVT), which can result in the important and sometimes fatal complication of pulmonary embolism.

CASE DESCRIPTION

A 22 year-old male right-hand dominant collegiate pitcher was referred for physical therapist evaluation and treatment secondary to acute right UE pain and swelling. The athlete described the onset of these symptoms as insidious, denying any form of trauma. The athlete had undergone testing, which included UE Doppler ultrasound of the bilateral UE veins and a computed tomography (CT) scan of the chest without contrast; both of which were deemed negative. He was subsequently diagnosed with thoracic outlet syndrome and referred to the team physical therapist. After examination, the physical therapist hypothesized the athlete was presenting with a possible vascular compromise. Findings leading to this decision were: 1) insidious onset, 2) inability to account for the athlete's pain with ROM, strength, neurological, or provocation testing, 3) significant swelling of the right UE (arm and forearm), 4) increased discomfort with palpation in the supraclavicular region, and 5) history of strenuous UE use.

OUTCOMES

The athlete was referred back to the orthopedist. A venogram CT was ordered, which revealed an axillary and subclavian DVT and the presence of venous collaterals. The athlete was referred to a vascular surgeon who performed a right first rib removal. The athlete was able to complete post-operative rehabilitation and successfully return to competitive throwing the following spring.

DISCUSSION

The delay in the initial diagnosis may have been due to the vague symptomology associated with venous complications and negative findings upon initial diagnostic testing.

CONCLUSION

This case report highlights the importance of subjective and physical examination findings and use of diagnostic testing for timely identification of an UE DVT. Ultimately, the physical therapist in this case was able to screen for referral, which led to the correct diagnosis and allowed the athlete to safely and successfully return to sport. Physical therapists should include effort thrombosis in their upper quarter differential diagnosis list for athletes who perform strenuous UE activity.

LEVEL OF EVIDENCE

4.

Do Basketball Players Have a High Risk of Pulmonary Embolism? A Scoping Review

PURPOSE

Pulmonary embolism (PE) is a serious preventable disease that requires urgent care. In recent years, there have been several reports in the media about basketball players experiencing PE. The aim of the present study was to assess whether there is a need for in-depth studies to determine whether basketball players constitute a group particularly at risk of PE and to describe some hypotheses to be investigated.

METHODS

We reviewed original articles about PE among professional and amateur basketball players in the scientific literature (PubMed) and the Internet (Google search) for the seasons 2010-2011 to 2014-2015, both of which were included. We used search strategies that included some combination of PE-related terms. Rates of PE were calculated and were compared with those obtained from other studies.

RESULTS

Of the 15 cases detected, the majority were men (66.7%), mean ages being 28.8 yr among males and 20.4 yr among females. We focused on six cases which, were detected among National Basketball Association and Asociación de Clubes de Baloncesto basketball players, resulting in an average incidence of 1.27 and 2.06 cases per 1000 players per year in the National Basketball Association and Asociación de Clubes de Baloncesto, respectively. This incidence is much higher than that observed in general population studies for the same age group.

CONCLUSIONS

Basketball players seem to have a higher risk of PE than their peers from the general population. More studies are needed to confirm these findings and identify factors predisposing them to PE to contribute to its prevention.

Acute wiiitis representing as thrombosis of the inferior vena cava and left pelvic veins

Deep venous thrombosis as a result of venous wall injury provoked by trauma is a common finding. It often occurs in patients with sportive overstraining, caused by over fatigue of the body structures. In 2007, the entity of “acute wiiitis” was first described in a letter to the New England Journal of Medicine. Acute wiiitis sums up all affections, mainly skeletal and muscle affections, provoked by playing Nintendo Wii, a very common and loved video-game system. Deep venous thrombosis as a consequence of Nintendo Wii has not been described so far. We present a patient with a massive free floating thrombus of the left pelvic veins originating from the gluteal veins and reaching into the inferior vena cava after playing Nintendo Wii.

Paget Schroetter Syndrome: A case study of the chiropractor's role in recognizing and comanaging an important condition

OBJECTIVE

To emphasize the importance for health care professionals to be knowledgeable of a relatively rare form of thoracic outlet syndrome, known as Paget Schroetter syndrome. The etiology, key signs and symptoms, and the importance of immediate referral are highlighted and an introduction to manual therapists' role within a multidisciplinary team is provided.

CLINICAL FEATURES

Healthy athletes aged 15-30 are most commonly affected with 60-80% of patients reporting a history of repetitive or vigorous overhead activity prior to symptom onset.

INTERVENTION AND OUTCOME

Manual therapists have a role in recognizing, referring, and providing symptomatic relief with soft tissue therapy, correcting abnormal biomechanics, manipulations, mobilizations, and a rehabilitative program, as seen in this case report.

CONCLUSION

Early recognition and referral of Paget Schroetter syndrome are essential for optimal recovery. Manual therapists may prove to have a role in decreasing the need for surgical decompression and accelerating resumption of regular activities.