pitching pain

A twenty-year-old right-handed male presented to the emergency department with a past medical history of right coracoid impingement, and three months of increasing right shoulder pain that became suddenly worse. He had a right shoulder arthroscopy nine months ago and played a full season as his baseball team’s pitcher over the past four months. He endorsed no exacerbating symptoms other than movement and has only taken naproxen over the counter for this pain. He denied any family history of clotting disorders.

Vitals: 37.1°C; HR 88; RR 16; BP 135/83; O2 sat 100 %

Skin: Over the right shoulder, axilla, upper arm, and pectoral region there is diffuse superficial venous congestion.

Extremities: Full active and passive range of motion in the right shoulder

PT: 13.7 seconds

INR: 1.1

PTT: 27.7 seconds

Upper Extremity Doppler Ultrasound: findings of a deep venous thrombosis

Paget-Schroetter syndrome, or venous thoracic outlet syndrome

Paget-Schroetter syndrome accounts for approximately 5 % of thoracic outlet syndrome presentations, with the vast majority being neurogenic [1].

Venous thoracic outlet syndrome most often causes deep venous thrombosis in the subclavian or axillary veins on the side of the dominant hand.

Several anatomical variations contribute to thoracic outlet syndrome, such as scalene muscle hypertrophy, cervical ribs, or an abnormally healed clavicle fracture [2].

In the absence of any of these conditions, treatment in patients determined to be good candidates for surgery includes resection of the first rib on the affected side.

Take-Home Points

  • Paget-Schroetter syndrome is a rare venous form of thoracic outlet syndrome that is classically present in baseball pitchers.
  • Referral to surgery is an important adjunct to thrombolytic therapy in the treatment of upper extremity deep vein thrombosis when Paget-Schroetter syndrome is suspected [3].

  1. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg. 2007;46(3):601-604. doi:10.1016/j.jvs.2007.04.050. PMID: 17826254
  2. Meena M, Harish S, Kewlani JP, Gupta N, Meena VK. Paget-Schroetter Syndrome. Chin Med J (Engl). 2015;128(19):2694-2695. doi:10.4103/0366-6999.166040. PMID: 26415814
  3. Alla VM, Natarajan N, Kaushik M, Warrier R, Nair CK. Paget-schroetter syndrome: review of pathogenesis and treatment of effort thrombosis. West J Emerg Med. 2010;11(4):358-362. PMID: 21079709

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2020 SAEM Annual Meeting | Copyrighted by SAEM 2020 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

Cooper March, B.S.

Cooper March, B.S.

Medical Student
Vanderbilt University School of Medicine
Cooper March, B.S.

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Lawrence Stack, MD

Lawrence Stack, MD

Professor
Department of Emergency Medicine
Vanderbilt University Medical Center
Lawrence Stack, MD

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