Right Upper Extremity Swelling And Shoulder Pain After Extended Time Playing Pickleball

HISTORY: A 22-year-old male, right-hand dominant, presented to the clinic with pain in the right shoulder and swelling from his shoulder down to his fingers, onset 2 days before presentation. This was preceded by prolonged pickleball play lasting six hours. Patient had been to urgent care a day prior where he was diagnosed with a shoulder strain and given IM ketorolac, 60 mg once; oral prednisone, 50 mg daily; and oral ketorolac, 10 mg four times daily. The patient denied any medical or surgical history and denied the use of substances. No reported contributing family history. PHYSICAL EXAMINATION: Examination of the right upper extremity revealed pitting edema from shoulder to phalanges. No tenderness to palpation of the extremity. Range of motion was restricted in passive and active elbow extension on right, otherwise unremarkable. Strength, reflexes, and sensation were normal and equal bilaterally. Radial pulses were normal and equal bilaterally. DIFFERENTIAL DIAGNOSIS: Venous thromboembolism Internal derangement of the shoulder capsule Thoracic outlet syndrome TEST AND RESULTS: Right upper extremity venous duplex ultrasound: - occlusive thrombus in the cephalic and basilic veins extending to axillary and subclavian veins Chest CTA with pulmonary embolism protocol: - no evidence of pulmonary embolism or arterial occlusive disease FINAL WORKING DIAGNOSIS: Right upper extremity venous thoracic outlet syndrome complicated by Paget-Schroetter Syndrome (venous thrombosis) TREATMENT AND OUTCOMES: Sent to emergency department, started on heparin, transferred to advanced vascular facility. Successful mechanical thrombectomy and angioplasty. During admission, dynamic venous duplex ultrasound of right upper extremity was performed and revealed narrowing of subclavian vein with overhead movement, consistent with venous thoracic outlet syndrome. Transaxillary first rib resection was performed the next day. Recurrence of thrombosis day 5 of admission, successfully treated with mechanical thrombectomy with angioplasty. Discharged on apixaban 5 mg, orally twice daily, activity as tolerated. Outpatient hematology workup did not reveal any hypercoagulable conditions. At 3-month follow-up patient had fully returned to normal activity.