PM1073: Circumferential Arm Swelling in an Elite Adolescent Baseball Player

Introduction: A 19-year-old male baseball player presented with exercise-induced pain of the right arm worsening over the course of three weeks. He was diagnosed with a right subclavian deep venous thrombosis (DVT) secondary to a specific type of thoracic outlet syndrome: Paget-Schroetter Syndrome (PSS). Baseball players have a higher incidence of this condition due to repetitive shoulder movement. It is crucial for providers caring for athletes with possible upper extremity overuse to be knowledgeable about the possibility for this condition. The purpose of this case report is to describe the diagnosis and management of PSS in an adolescent patient with known associated risk factors.

Case Description: A 19-year-old male baseball player presents with a complaint of exercise-induced right arm pain. It has been worsening over the course of three weeks and is associated with upper extremity stiffness and swelling. He initially attributed pain and swelling to recurrence of rhabdomyolysis, a condition he was diagnosed with earlier in his baseball career.

BP 149/70; HR is 130; Normal temperature, respiratory rate, and oxygen saturation. Apparent discomfort, visible chest wall veins, circumferential swelling and tenderness to palpation of right upper extremity, and anterior deltoid ecchymoses. Pain and paresthesia reproducible with abduction and external rotation of R shoulder.

Hemoglobin of 15.4 g/dL, platelet count of 278 10^9 / L, PT of 16.7 s, INR of 1.4, and aPTT of 33.4 s. An ultrasound of his right upper extremity demonstrated a nonocclusive deep vein thrombosis in the right infraclavicular subclavian vein.

Discussion: Paget-Schroetter syndrome (PSS) is a type of spontaneous thoracic outlet syndrome. It typically presents in athletes engaged in strenuous upper extremity activity, with some aspect of repetitive shoulder or neck flexion. It is associated with pitchers who repeatedly throw with overhead shoulder motion. PSS involves anatomic compression of a vein, resulting in repetitive injury and subsequent perivenous fibrosis. Fibrosis and frequent compression contribute to thrombosis, pain, and symptoms of venous congestion. Untreated, pulmonary embolism can result in 6-15% with PSS, residual venous obstruction in up to 78%, persistent symptoms in 41-91%, and permanent disability in in 39-68%.

Conclusion: This case improved awareness of an uncommon etiology for upper extremity pain in an adolescent patient. The patient’s history of rhabdomyolysis from excessive exercise led him to delay presentation for weeks and continued to exercise. His exam and labs demonstrated abnormal coagulation at time of presentation prompting an ultrasound. Persistent thromboses requiring first rib resection confirmed the diagnosis of Paget-Schroetter Syndrome; this can present acutely with increased exercise despite an etiology related to gradual muscular hypertrophy and perivascular fibrosis.
The thrombolysis and venoplasty and anticoagulation led to rapid resolution of symptoms and follow up ultrasound demonstrated resolution. He recovered without need for medication or exercise restrictions within 6 months.