Right Shoulder Pain In A Female Water Polo Player

HISTORY: A 33 year old water polo athlete, with history of focal glomerulosclerosis in remission, presents with right shoulder pain, limited range of motion, fullness sensation, and edema of entire right upper extremity for 2 weeks. Patient was practicing intensively in the upcoming weeks for a league competition when she started to develop symptoms gradually. At first, the patient thought it was a muscular strain and scheduled appointments for physical therapy. Despite this, symptoms persisted, making water polo practices difficult every day. PHYSICAL EXAMINATION: Upon inspection there were prominent anterior shoulder superficial veins. Right shoulder tenderness to palpation, limited range of motion secondary to pain and fullness sensation, and edema of the entire right arm. Circumference of the right upper extremity was greater than the left. Sensation and strength were intact. No focal neurologic deficits noted. DIFFERENTIAL DIAGNOSIS: 1. Right rotator cuff injury. 2. Right shoulder muscle strain. 3. Right shoulder labrum injury. 4. Effort Thrombosis. 5. Thoracic outlet syndrome. TEST AND RESULTS: - Right upper extremity venous duplex: acute right subclavian vein deep vein thrombosis. - Chest CT Angiogram: Normal Chest CT Angiogram. - Right upper extremity venogram: distal partial non-occlusive chronic thrombus at subclavian vein, with adequate flow into superior vena cava. - Hyper-coagulable state work up and pregnancy test: Negative. - Antiphospholipid syndrome evaluation: Negative. FINAL/WORKING DIAGNOSIS: Effort Right Subclavian Vein Thrombosis. TREATMENT AND OUTCOMES: 1. Vascular surgery evaluation. 2. Complete anticoagulation with Apixaban for 6 months. 3. Avoid contact / collision sports during anticoagulation. 4. Resumed upper extremity exercises 3 months into treatment. 5. Return to Water Polo practice after completion of anticoagulation.