Atypical Right Shoulder Pain in a Baseball Player: 149 May 27, 11

HISTORY: A 21 year old college baseball third baseman with a history of a nondisplaced right shoulder SLAP tear in 2012 presented with recurrent right shoulder pain in 12/2013, which was thought to be related to his previous conservatively managed SLAP injury. This intermittent pain continued to infrequently worsen after games, and he was reevaluated on 2/3/14 and 2/17/14 at which time his physical exam revealed only impingement signs. On 4/12/2014 during an away baseball game, he developed mild arm swelling, 4/10 right arm pain improving with rest and worsened with activity and new bilateral numbness and cool hands. His care was transferred to a nearby hospital. PHYSICAL EXAMINATION: Examination at the hospital revealed T 97, BP 104/70, HR 76, RR 18, SpO2 98%. He was in no distress, and his cardiopulmonary exam was normal. There was mild tenderness to palpation in his right axilla, and his pulses were equal and full throughout with appropriate capillary refill. There was full active and passive range of motion. His right arm and right hand showed evidence of venous congestion and discoloration. There was evidence of venous prominence in the arm and antecubital fossa and mild cyanosis. Neurologic testing was unremarkable. DIFFERENTIAL DIAGNOSIS: 1. Upper Extremity DVT 2. Thoracic Outlet Syndrome 3. Muscular Strain TEST AND RESULTS: US Doppler Arm Bilateral: -Right axillo-subclavian thrombosis, arm veins patent Right subclavian and central venogram: -Marked thrombus within the right subclavian vein at the junction of the first rib and clavicle. -Additional thrombus in peripheral subclavian vein and axillary vein. Repeat venogram: -No evidence of residual thrombus within the right subclavian vein. -Mild residual stenosis at the subclavian vein at the junction of the first rib and clavicle with supraclavicular fossa collaterals. Hypercoagulable laboratory work up: -Negative: Factor V, prothrombin, antithrombin III, protein C and S FINAL WORKING DIAGNOSIS: Paget-Schroetter Syndrome (Venous Thoracic Outlet Syndrome) TREATMENT AND OUTCOMES: 1. Rivaroxaban for three months 2. Catheter directed subclavian venous thrombolysis 3. Surgical 1st rib resection and partial scalenectomy. 4. Return to baseball decision - he was cleared to play when he had a full painless range of motion and was no longer on anticoagulation.