Shoulder Pain and Swelling - Swimming

Abstract

HISTORY: A 47-year-old healthy right-handed male swimmer presented with two months of insidious onset right arm pain and swelling particularly around his deltoid and biceps. His symptoms occurred after swimming but never during exertion, and they did not resolve with two weeks of rest, naproxen, or heat. He denied numbness, tingling, weakness, neck pain, decreased range of motion, and right shoulder trauma. PHYSICAL EXAMINATION: His posture was notable for rounded shoulders, head-forward posture, and protraction of the right scapula compared to the left. He had significant scapular dyskinesis with arm movements, but cervical and shoulder range of motion were full. He had intact bilateral upper extremity strength and radial pulses. O’Brien’s and Hawkins’ tests were positive, but Speed’s and Neer’s tests were negative on the right. DIFFERENTIAL DIAGNOSIS: 1. Shoulder impingement 2. Glenohumeral labral tear 3. Thoracic outlet syndrome 4. Cervical radiculitis 5. Scapular dyskinesis 6. Rotator cuff tendinopathy TEST AND RESULTS: 1. Right shoulder ultrasound: No tendon pathology, bursitis, impingement, or hematoma 2. Upper extremity duplex (recommended 2 months after failed PT, but patient did not pursue until 8 months after presentation): Acute right subclavian deep vein thrombosis 3. Right upper extremity CT angiography (1 month later, after thrombectomy): Narrowing of the right subclavian vein in the neck and upper chest, with obliteration of the venous lumen when the arm is hyperabducted and extended FINAL/WORKING DIAGNOSIS: Paget-Schroetter syndrome (thoracic outlet syndrome with exercise-induced thrombosis) TREATMENT AND OUTCOMES: 1. Four-week trial of self-directed scapular retractions 2. Two-month trial of formal physical therapy including scapular retractions, postural education, rotator cuff strengthening, and scalene stretching 3. Delay in diagnosis because lost to follow-up 4. Thrombectomy and three months of anticoagulation 5. Right first rib resection and scalenectomy 6. Range of motion and scapular stabilizer strengthening 7. Two months post-operatively, persistent symptoms while swimming 8. Recurrent occlusion of right subclavian vein which improved with balloon angioplasty 9. Two weeks after angioplasty, recurrent occlusion of right subclavian vein when shoulder abducted 45°