Arm Swelling And Axillary Pain-non-competitive Older Athlete

Abstract

HISTORY: A 60 year old right handed, recreational athlete presented with 6 months of progressive arm swelling and discoloration, with associated axillary discomfort. These symptoms began after she increased her upper body weight lifting program. Symptoms now occur post exercise and nocturnal. The right arm is not involved. The left axillary pain, located near the left chest wall is described as tightness. She denied warmth, weakness and paresthesia. Past medical history was significant for osteopenia, Raynaud's phenomenon and cervical spine disc bulges found after an MVA in 1998. PHYSICAL EXAMINATION: The patient is a well developed female in no distress. Blood pressure 126/70 both arms, capillary refill 1 second, pulses 2+and equal, 76 bpm. Cervical spine exam revealed moderately reduced extension and lateral flexion; Spurling test negative. Dilated veins noted over the left anterior chest wall and upper arm with telangectasia; no cords. Left arm circumference was larger than right (upper arm 2 cm, forearm 4 cm). Neurological exam motor 5/5, DTR's 2+,gait normal, Babinski response downgoing, sensation intact. Axilla was nontender; no palpable adenopathy. Cardiopulmonary exam normal. DIFFERNTIAL DIAGNOSIS: 1. Thoracic outlet syndrome 2. Paget-Schroetter syndrome 3. Cervical arthritis 4. Cervical radiculopathy 5. Cervical disc disease 6. Brachial plexus neuritis TESTS AND RESULTS: Provocactive maneuvers: Adson Test (-), Allen test (-), overhead exercise test (+) with plethora/pain/increase venous engorgement. Cervical spine X ray: C5-6: discogenic disease and uncovertebral joint arthropathy with mild bilateral neuroforaminal narrowing, left >right.. CXR normal. Vascular consultation and upper extremity duplex venous ultrasound (-)thrombosis. Lab data: CBC/EKG -normal. FINAL/WORKING DIAGNOSIS: Thoracic outlet syndrome causing isolated venous flow restriction symptomology without thrombosis (previously not reported). The cervical spine DJD was the suspected trigger in the setting of a progressive weight resistance program. TREATMENT AND OUTCOMES: 1. Referral to occupational therapist. 2. Avoidance of overhead weight lifting positions. 3. Six week follow up revealed near complete resolution of symptoms and venous engorgement.