Upper Arm Pain - Lifting

Abstract

HISTORY: 21 y/o F presents to the ED with progressive left arm pain and weakness. Eight months prior, she was diagnosed with Thoracic Outlet Syndrome (TOS) complicated by left arm thrombus. Additional workup identified antiphospholipid antibody syndrome. Two months prior, she underwent surgical decompression. One month prior, angiography revealed continued evidence of TOS despite surgical treatment. Patient was referred to the ED for evaluation. She otherwise denied chest pain, shortness of breath, cough, recent travel history, fever, and trauma. PHYSICAL EXAMINATION: Vital signs within normal limits. Well appearing and comfortable. Left upper extremity skin with mild blue color mottling. Strength and sensation intact and within normal limits. Normal respiratory effort with normal, equal, and bilateral lung sounds. DIFFERENTIAL DIAGNOSIS: Cervical radiculopathy, Brachial plexopathy, Paget Schroetter Syndrome, Post-operative lymphedema, TOS, Upper Extremity DVT TEST AND RESULTS: APTT: 32.9, PT: 15.0, INR: 1.2 CTA Chest: Stenosis of left subclavian vein with the arm raised and widely patent with the arm down. 2.2 right neck cystic lesion L Upper Extremity US: Positional loss of normal flow in the subclavian and axillary veins with left arm raised. Nonocclusive thrombus cannot be excluded due to basilic vein only visible in arm up position showing it is only partially compressible FINAL WORKING DIAGNOSIS: Upper Extremity DVT and TOS TREATMENT AND OUTCOMES: 1) Patient is currently on Rivaroxaban with a plan for serial US. Several months after the ED visit, she reported bilateral LE paresthesias. RLE US was negative, and neurology recommended neuropathy evaluation with MRI of cervical spine and EMG. 2) TOS is diagnosed clinically, however advanced studies can suggest mechanisms of compression to tailor potential interventions. 3) Anticoagulation coupled with surgical decompression are usually necessary for young athletes with repetitive activity, irrespective of underlying hypercoagulability. 4) Rehab coupled with anticoagulation therapy has a critical role in initial conservative strategies and in post operative recovery. This includes addressing postural mechanics, sports-specific modifications, and targeted cervical and shoulder soft tissue therapies to help guide a return to play strategy.