Unique treatment regimen for effort thrombosis in the nondominant extremity of an overhead athlete: a case report

Abstract

Objective: To advise athletic trainers on the potential for effort thrombosis to occur in nonthrowing athletes and to underscore the importance of early recognition and treatment.

Background: An 18-year-old offensive lineman presented with a 1-day history of diffuse shoulder pain with no specific history of injury; swelling and erythema involved the entire left upper extremity. He was immediately referred to the team physician, who suspected deep vein thrombosis and sent the athlete to an imaging center. Duplex ultrasound was obtained on the day of presentation, and he was admitted to the hospital that evening.

Differential diagnosis: Deep vein thrombosis, thoracic outlet syndrome, shoulder tendinitis.

Treatment: Anticoagulation with heparin was administered at the hospital, and he was sent home the next day on subcutaneous enoxaparin sodium, followed by a 5-mg daily dose of oral warfarin sodium. Oral anticoagulants were continued for a total of 4 weeks. The athlete began upper body lifting and was released 5 weeks postinjury to gradually return to football without restrictions.

Uniqueness: Effort thrombosis is typically seen in the dominant arm of athletes, and the current treatment protocol calls for thrombolysis or surgical intervention. This athlete, whose position required repeated elevation of his arms in forward flexion, sustained the injury in his nondominant arm, was treated with anticoagulation only, and had a full return to football. At 18-month follow-up, he had no recurrence of symptoms.

Conclusions: Early recognition and treatment of athletes with effort thrombosis is paramount to a successful clinical outcome and prompt return to play.

Keywords: Paget-Schroetter syndrome; football injuries.

Figure 1. Costoclavicular area. Narrowing of costoclavicular gate (see circle) results in impingement of artery and vein.

Figure 2. In the Adson maneuver, A, the clinician extends the patient's arm on the affected side and monitors the radial pulse. B, As the patient extends the neck and rotates the head toward the same side, the clinician gradually elevates the arm. With the patient taking a deep inspiration, a decrease in the radial pulse indicates compression of the subclavian artery.

Figure 3. In the Wright maneuver, the patient hyperabducts the arm to 180° with the elbow slightly flexed, and the clinician monitors the radial pulse. Loss of the radial pulse constitutes a positive test.