Shoulder Pain - Baseball

HISTORY: 20 y.o. male college baseball LHP w/chronic right shoulder pain. Onset 9 months prior during a bench press. Pain is achy, throbbing, waxes & wanes in the superior shoulder. Present at rest, worse w/exertion. Tugging in the pecs area & fullness/heaviness in shoulder girdle w/ hyper abduction of the right arm. No swelling, neck pain, night pain, numbness, tingling. Previously diagnosed w/rotator cuff & pectoralis strain w/unremarkable MRI. PT, HEP w/o improvement. PHYSICAL EXAMINATION: Right shoulder minimally enlarged vs left. No swelling. B/l full active ROM. Pectoralis symmetric b/l. Mild pain at coracoid process & mild scapular dyskinesis w/both central cord flexion & abduction. Strength 5/5 b/l and w/adduction of b/l arms. Mild pain w/Hawkins/Neer's. No pain w/Speed's Yergason's. Negative O'Brien's, dynamic labral shear, Adson's, Roos. Right subclavian bruit w/hyper abduction. Faint increased venous collaterals w/in right brachial & deltoid region. Right radial pulse minimal decrease w/hyper abduction maneuvers (Adson and Wright). DIFFERENTIAL DIAGNOSIS: 1. Posterosuperior Internal Impingement 2. Rotator Cuff Tendinopathy 3. Scapular Dyskinesis TEST AND RESULTS: MR angio RUE: severe brachial vein stenosis w/superficial venous collaterals. Vascular duplex venous RUE: Brachial vein hypoplastic from the distal to mid upper arm. Vasc thoracic outlet maneuvers: absence of provocative subclavian artery compression. IR diagnostic venography & intravascular US: moderate narrowing of the right subclavian vein at the thoracic outlet in neutral position which worsened to severe narrowing/compression w/abduction. FINAL WORKING DIAGNOSIS: Long segment right brachial vein stenosis; Right venous thoracic outlet syndrome; Pectoralis minor syndrome; Scapular dyskinesis TREATMENT AND OUTCOMES: 1. Brachial vein stenosis non-contributory to sx. 2. Deferred surgery for TOS given minimal compression of venous return & no distal sx. 3. Right pectoralis minor tenotomy performed. 4. Started PT 5 wks post-op. By 8 wks achieved full strength (5/5) b/l shoulders & full right shoulder AROM. 5. At 8 wks post-op cleared to progress through PT back to full baseball activity. 6. Once able to throw to 90’ w/o pain and hit 30 baseballs w/o pain will be cleared for full baseball participation.