SAEM Clinical Image Series: Pitching Pain

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