Arm Pain and Discoloration in a 15yo Swimmer

Abstract

HISTORY: A 15yo swimmer presented with intermittent right shoulder pain, swelling, and purple discoloration. 8 months prior to presentation, the pt was swimming and noticed a gradual onset of right shoulder pain. When she got out of the pool, she noticed slight right arm swelling and purple discoloration from her shoulder down. It took approximately 2 days for her symptoms to completely resolve. She took 1w off swimming and then returned. The next swim again resulted in right arm pain, swelling, and purple discoloration. The pt stopped swimming at that time. Over the next 6 months, she notes intermittent similar but less severe symptoms with most physical activity including softball and basketball. She reports occasional symptoms with no specific activity, and cannot identify a common motion or arm position that brings the symptoms on. Between episodes, she denies any arm swelling, shoulder pain, or discoloration. She is otherwise healthy, and denies left arm symptoms, preceding injury, chest pain, SOB, or persistent swelling of the right arm. PHYSICAL EXAM: Exam reveals a well appearing young female in no acute distress. Shoulders appear symmetric. She has tenderness over the anterior shoulder and AC joint. She has full active and passive ROM of the shoulder. No tests for impingement, RTC syndrome, labral pathology, or instability produce symptoms. Active flexion of shoulder to 165 degrees for 5 minutes did not produce symptoms. During US of the shoulder, with the pts arm at her side and slightly externally rotated, she developed mild mottling of the arm, slight swelling, and pain. She had 2+ radial pulses and no sensory deficits. DDx: Venous thoracic outlet syndrome Neurogenic thoracic outlet syndrome Rotator cuff syndrome Cervical radiculopathy Brachial plexus injury TESTS AND RESULTS: MR Arthrogram: No pathologic findings. RUE Venography: Occlusion of the right subclavian vein with abduction of the right shoulder. Patent subclavian vein in neutral position FINAL WORKING DIAGNOSIS: McCleery’s Syndrome (intermittent subclavian vein occlusion without thrombosis) TREATMENT AND OUTCOMES: Pt is scheduled to undergo surgical thoracic outlet decompression