Painful Arm Mass-Weight Lifting

Abstract

HISTORY: A 29 year old male reports acute onset of pain and palpable mass in his right distal bicep while weight lifting 2 weeks prior to presentation. He reports a dull ache that has persisted despite heat and ibuprofen. He developed bruising which resolved. He has continued lifting. He has no paresthesia, weakness, or radiculopathy. He has no exertional pain. He has a known history of multiple aneurysms diagnosed at the age of 7 with negative genetic testing. PHYSICAL EXAMINATION: There are no overlying skin changes or deformity. There is a tender, non-pulsatile 2cm mass within the medial distal bicep with firmness of the surrounding soft tissues. Active range of motion at the shoulder and elbow are full and symmetric. Pain cannot be recreated with manual muscle testing. Brachial and radial pulses are symmetric and equal. Right ulnar pulse is difficult to palpate. Allen’s test reveals reduced right ulnar blood flow. Lower extremity pulses are symmetric and equal. Cervical spine motion is normal. Spurling’s test is negative bilaterally. DIFFERENTIAL DIAGNOSIS: Superficial phlebitis Intramuscular hemorrhage Biceps or brachioradialis muscle tear Neoplasm (vascular, sarcoma, nerve sheath) Brachial artery aneurysm or pseudoaneurysm TEST AND RESULTS: Bilateral extremity angiogram - Right arm: multiple aneurysms proximal to the antecubital fossa, the largest measures over 1.5 cm. Aneurysms at the origin of the ulnar and radial arteries without distal abnormality. Left arm: 1.5 cm aneurysm proximal to the antecubital fossa. Right mid vertebral artery aneurysm (1.4 cm); prior coil embolization of the left vertebral artery. Lower extremities: 33 discrete aneurysms. Pseudoaneurysm at the proximal anastomosis of the aorto-bi-iliac graft that measures 4 cm proximally and 2.2 cm on the right iliac limb. FINAL WORKING DIAGNOSIS: Multiple aneurysmal disease of unknown origin TREATMENT AND OUTCOMES: This case highlights provocative issues of a rare vascular disorder with no literature related to physical activity recommendations. Increased intravascular pressure related to heavy resistance likely accelerates disease progression, and as such, the athlete was advised to refrain from weightlifting. Vascular surgery was consulted for evaluation of abdominal aortic pseudoaneurysm and right vertebral artery aneurysm.