Pitcher’s Predicament: Left Arm Pain In Youth Baseball

HISTORY: A 16-year-old junior high school pitcher presents for left arm swelling first noticed nine days ago with resolution and recurrence earlier today. The patient is a left-handed pitcher who has continued to throw and pitch despite the swelling nine days ago and has noted a purple discoloration on his arm as he continued to play off and on as this swelling and discoloration resolved with rest. Aside from today, the most recent episode was two days ago. He denies any chest pain or shortness of breath. No trauma to the area, no history of deep vein thrombosis or clotting disorders. PHYSICAL EXAMINATION: Alert white male with normal appropriate mentation with normal speech in logical sentences. Neck supple with no masses or lymphadenopathy. No JVD noted. Clavicle, ribs, and scapula nontender. Left upper extremity with noted swelling of forearm and upper arm with no point tenderness and able to move all digits of hand without numbness, tingling. Normal range of motion and strength. DIFFERENTIAL DIAGNOSIS: 1. Effort Thrombosis 2. Little Leaguer’s Shoulder 3. Shoulder Instability 4. Cellulitis 5. Lymphadenitis TEST AND RESULTS: X-Ray of Humerus and Forearm: — There is no acute fracture or dislocation of the left humerus and forearm Venous duplex Ultrasound of Upper Extremities: — Left upper extremity thrombus is seen extending from the distal subclavian vein into the proximal brachial and basilic veins Transthoracic Echocardiogram: — No obvious intracardiac thrombus seen — Qualitatively normal chamber sizes and normal global biventricular systolic function FINAL WORKING DIAGNOSIS: Paget-Schroetter Syndrome (effort-induced axillo-subclavian vein thrombosis). TREATMENT AND OUTCOMES: 1. Decompression surgery and removal of first rib. 2. Initiation of anticoagulation with Xarelto. 3. Gentle left arm isometric exercises started 3 weeks post injury. 4. Range of motion and left arm strengthening exercises started 8 weeks post injury. 5. Returned to sport 6 months post injury when he had full, painless ROM, normal strength and able to meet the demands of his sport.