Research Review By Dr. Jeff Cubos©

Date Posted:

November 2009

Study Title:

Neurovascular problems in the athlete’s shoulder

Authors:

Thompson R & Driskill M

Author's Affiliations:

Section of Vascular Surgery, Washington University School of Medicine & The Rehabilitation Institute of St. Louis

Publication Information:

Clinics in Sports Medicine 2008; 27: 789–802.

Background Information:

Although rare, conditions involving the neurovascular components of the upper extremity occasionally present themselves in high level athletes. While these cases may be challenging to detect, they must always be considered not only for their ability to limit athletic performance, but also due to their potential to cause limb-threatening consequences.

Early recognition, proper initial treatment, and urgent surgical referral increase the likelihood of rapid return to pre-injury levels of performance (several months) and more importantly, decreases the likelihood of serious complications.

Pertinent Results:

This review set out to identify and differentiate the major neurovascular conditions that affect the upper extremity in athletes, including the various treatment strategies that underlie successful management. Discussed in this review were: thoracic outlet syndrome, subclavian and axillary artery aneurysms, digital ischemia, and effort thrombosis of the subclavian vein. The etiology, clinical presentation, and treatment strategies pertaining to these conditions are outlined below.

Neurogenic Thoracic Outlet Syndrome
  • Described as arm and/or hand pain, numbness, and paresthesia resulting from compression, irritation, and chronic injury affecting the brachial plexus (roots) at the scalene triangle and/or within the subpectoral space.
  • Predisposing factors include cervical ribs and/or abnormalities of the scalene and pectoralis muscles (hypertrophy), as well as any structure impeding the normal pathway of the neural structures as they pass through the above spaces.
  • Physical examination reveals exacerbated symptoms with direct palpation and arm elevation.
  • Aside from the potential identification of cervical ribs, diagnostic imaging is usually normal.
  • Conservative treatment involves rest, soft tissue therapy, and the use of muscle relaxants and anti-inflammatory medication for 4-6 weeks.
  • Surgical management of thoracic outlet decompression may be warranted and utilizes a transaxillary or supraclavicular approach. Such treatment may involve first rib removal, scalene resection, brachial plexus neurolysis, and/or pectorailis minor tenotomy. The transaxillary approach generally results in less cosmetic defects and a more rapid recovery, but also a higher recurrence rate of symptoms requiring reoperation.
  • Since those cases that warrant surgical management are often associated with extensive upper extremity disability, advanced neurogenic thoracic outlet syndrome is rarely seen in the competitive athlete.
Subclavian Artery Aneurysms
  • Stenosis and subsequent aneurysm formation of the subclavian artery are typically associated with cervical ribs and atypical first ribs.
  • Post-stenotic dilatation and degeneration of the arterial wall often results in ulceration, thrombus formation, and subsequent embolization that travels to the distal arteries causing symptoms of exertional arm fatigue and/or acute digital ischemia. Note: patients are often asymptomatic until emboli formation.
  • Management involves immediate course of anticoagulants upon suspicion to limit thrombosis while diagnostic studies are performed to assess blood pressure and the (radiographic) presence of cervical ribs.
  • A requisition for contrast-enhanced arteriography is also required to investigate the occlusion, artery compression, and aneurysm formation.
  • Surgical management is preferred over intra-arterial thrombolytic therapy and consists of: 1) thromboembolectomy for the distal arteries followed by 2) direct treatment of the aneurysm (decompression, aneurismal resection, and graft reconstruction). Autologous grafts (vs. prosthetic grafts) are preferred in young athletes due to their higher mobility.
  • Prompt, effective management generally results in full return to activity within several months.
Axillary Artery Aneurysms and Occlusions
  • Seen most exclusively in baseball pitchers, this condition occurs when the humeral head translates forward during end-range extension and elevation, resulting in compression and stretching of the axillary artery (near the origin of the circumflex humeral branches) combined with fixation against the tendon of the pectoralis minor.
  • Extreme repetitive motion in this area results in three possible injury outcomes: arterial wall disruption and subsequent aneurismal degeneration, hyperplasia of the intima with subsequent stenosis and thrombosis, or less commonly, arterial dissection.
  • Symptoms are similar to that of subclavian artery aneurysms and include exertional arm fatigue and/or acute digital ischemia.
  • Initial management is similar to that of the subclavian artery and involves an immediate course of anticoagulants followed by diagnostic imaging. However, arteriography with the shoulder in elevation may need to be performed to account for positional obstruction.
  • Surgical management involves axillary artery mobilization, (affected) segment reconstruction, and preservation/reimplantation of one of the branches of the axillary artery.
  • Prompt, effective management generally results in full return to activity within three months.
Digital Ischemia with or without Thromboembolism and Vasospasm
  • The most common condition affecting upper extremity arteries in the general population.
  • Symptoms typically include numbness, tingling, cold and painful sensations, while signs include cyanosis or pale discoloration and delayed capillary refill.
  • Depending on the site of occlusion (proximal or distal), radial and ulnar pulses may be absent or decreased, and blood pressure may be diminished (proximal occlusions).
  • Differential diagnoses include proximal and distal sources (along the arterial pathway) of thromboembolism, as well as local occlusion secondary to trauma or resulting from primary vasospasm. In addition, systemic diseases associated with digital vasospasm must be ruled out.
  • Again, position specific, contrast-enhanced arteriography is often required, with particular inclusion of the affected hand in the examination procedure.
  • Two common lesions in baseball include digital artery thrombosis and digital artery thromboembolism.
  • Digital artery thrombosis- results from localized repetitive trauma associated with index and/or middle finger pressure when gripping and throwing the ball.
  • Digital artery thromboembolism- is typically seen in catchers and results from chronic repetitive trauma to the base of the hand. Also known as “hypothenar hammer syndrome”, the ulnar artery degenerates local to the hamate bone.
  • Theoretically, digital artery spasm may also be seen in baseball players due to the rampant use of vasoconstrictive tobacco products.
  • Management is based on the results of the diagnostic studies and begins with surgery for proximal and/or distal artery lesions if present. If necessary, operative management is followed up with digital ischemia-specific treatment (environmental exposure control, anticoagulants, and vasodilators). Intra-arterial infusion of thrombolytic agents and cervical sympathetic blocks/sympathectomy may also be necessary in more complex or persistent cases.
  • Due to the necessity of specificity of diagnosis and subsequent treatment, outcomes of this condition have yet to be confirmed.
Effort Thrombosis of the Subclavian Vein
  • Also known as Paget-Schrotter syndrome and likely the most commonly seen vascular disorder in young competitive athletes, especially those with scalene hypertrophy.
  • Considered a form of TOS since this condition involves compression of the subclavian vein between the clavicle and first rib.
  • A primary “mechanical” condition that results from a combination of positional compression and arm exertion in elevation.
  • Progression involves the formation of scar tissue, collateral vessels (venous), and subsequently thrombosis, which may propagate distal to the site of formation. Note: pulmonary embolism may also develop!
  • Although symptoms may take months or years to develop, the effort thrombosis syndrome may suddenly appear consisting of swelling, cyanosis, pain, heaviness and/or fatigue.
  • Effort thrombosis should be suspected in young athletes presenting with sudden onset of arm swelling and cyanosis. Note, this should also be considered in athletes with an unexplained pulmonary embolism.
  • Particular attention should be paid in overhead athletes (throwers, weightlifters, swimmers).
  • Definitive diagnosis is made by catheter-based contrast venography, which also allows for thrombolysis, the preferred initial plan of management. Note: anticoagulants should also be administered upon immediate suspicion to prevent thrombosis.
  • Thrombolysis is ideally followed up by periclavicular decompression (first rib and/or scalene/subclavious removal) and collateral venolyis, and the restoration of normal subclavian venous flow through reconstruction.
  • Prompt, effective management including urgent surgical referral is essential for full return to activity (within several months) as treatment duration has been shown to directly correlate with the time interval between initial diagnosis and operation (1).

Clinical Application & Conclusions:

As many health care providers work in primary care settings and outpatient clinics, we may be the first point of contact to athletes presenting with neurovascular-type symptoms of the shoulder, arm, and hand. The treatment strategies of the above neurovascular conditions generally exceed the scope of practice of manual medical practitioners however, the recognition of such signs and symptoms are paramount in the facilitation of proper and immediate care.

As such, the above article stands as an effective and concise review of the major conditions and their management strategies that in general, can be summarized as: 1. Immediate anticoagulant therapy; 2. Diagnostic studies and; 3. Urgent surgical referral.

A dedicated plan of management, however, that includes manual therapy and rehabilitation techniques as outlined by Dr. Thistle in “The Disabled Throwing Shoulder Part 2” and “Internal Shoulder Impingement - Review” (see Related Reviews below) for the scapulothoracic and rotator cuff complexes may also play a role in the care of these conditions, although this suggestion is merely theoretical, outside the context of this paper, and must be validated by future research.

Study Methods:

This paper was a narrative review of the literature. Despite the low level of evidence for this type of paper, it is appropriate for this topic due to the state of the current literature on these conditions in athletes.

Study Strengths / Weaknesses:

Not applicable.

Additional References:

  1. Sanders R, Rosales C & Pearce W. Creation and closure of temporary arteriovenous fistulas for venous reconstruction or thrombectomy: description of technique. Journal of Vascular Surgery 1987; 6 (5): 504-505.