Working Diagnosis:
1. Right anterior and posterior circumflex humeral artery pseudoaneurysm with thrombosis of the RUE
2. Thoracic Outlet Syndrome

Treatment:
He initially was recommended to continue PT with working diagnosis of Little League shoulder, multidirectional shoulder instability, secondary rotator cuff tendonitis and ECU/wrist extensor tendonitis. He was recommended against volleyball or upper body activity for 2 weeks, with a return guided by symptoms and PT. He followed up in clinic 6 weeks after and had continued wrist pain, so a MRI wrist was ordered. At time of this follow-up visit, his shoulder pain had resolved. He also scheduled an appointment with an outside orthopedist to discuss a second opinion.

His father messaged the clinic a few weeks later reporting new RUE color changes and worsening paresthesias during a match. This was discussed with PT and a thoracic outlet syndrome (TOS) work-up was recommended. He was recommended to stop playing volleyball. Family deferred until seen by surgeon, who agreed with TOS work-up and recommended a MR shoulder to evaluate for potential labral tear.

After the previously mentioned imaging studies, interventional radiology performed a coil and plug embolization of the right PCHA and ACHA pseudoaneurysm and initiated catheter-directed thrombolysis. He was admitted for continued thrombolysis therapy. A repeat right upper extremity angiography at 48 hrs demonstrated stable occlusion of the embolized pseudoaneurysms and improved flow to the hand compared to initial angiography. He was discharged without complication and started on a one-month course of rivaroxaban.

Outcome:
He was held from volleyball for the one-month duration of his rivaroxaban. After that, he underwent PT for rotator cuff strengthening, scapular stabilization and returned to volleyball at his previous level with no residual symptoms.

Author's Comments:
This case demonstrated an unusual cause of arm pain in an overhead athlete. What was thought initially to be little league shoulder and wrist extensor tendonitis ended up being diagnosed as TOS, then a labral tear and, finally, TOS with anterior (ACHA) and posterior circumflex humeral artery (PCHA) pseudoaneurysms with thrombosis of the RUE. PCHA aneurysm/pseudoaneurysm is a relatively uncommon but recognized vascular overuse injury in overhead athletes. Common risk factors for development include duration of career, older age, repetitive overhead activity, and vascular anatomy. Repetitive abduction and external rotation causes mechanical stress and trauma to the PCHA as it courses through the quadrilateral space. A study by Daan van de Pol et al. showed a prevalence of PCHA aneurysms to be 4.6% in elite volleyball players. Only 18% of those were symptomatic. Career duration longer than 17 years was associated with a 9-fold increased risk and age over 27 years was associated with a 14-fold increased risk. There is no available literature investigating the prevalence of ACHA aneurysms. Prior case reports have been published focusing on PCHA aneurysm, but no case report was found documenting an adolescent overhead athlete with both PCHA and ACHA pseudoaneurysms.

Editor's Comments:
This case highlighted the importance of considering a vascular etiology in an overhead athlete with persistent upper-extremity pain, particularly when symptoms progressed to paresthesias and color change despite an initially reassuring musculoskeletal evaluation. Dynamic vascular imaging ultimately identified subclavian artery compression with anterior and posterior circumflex humeral artery pseudoaneurysms and associated thrombosis. Treatment with endovascular embolization, catheter-directed thrombolysis, short-term anticoagulation, and subsequent rehabilitation resulted in a successful return to sport.

References:
1) Van de Pol D, Maas M, Terpstra A, Pannekoek-Hekman M, Alaeikhanehshir S, Kuijer PP, Planken RN. Ultrasound assessment of the posterior circumflex humeral artery in elite volleyball players: Aneurysm prevalence, anatomy, branching pattern and vessel characteristics. Eur Radiol. 2017 Mar;27(3):889-898.
doi: 10.1007/s00330-016-4401-8. Epub 2016 Jun 2. PMID: 27255398; PMCID: PMC5306316.
2) van de Pol D, Kuijer PPFM, Terpstra A, Pannekoek-Hekman M, Alaeikhanehshir S, Bouwmeester O, Planken RN, Maas M. Posterior circumflex humeral artery pathology and digital ischemia in elite volleyball: Symptoms, risk factors & suggestions for clinical management. J Sci Med Sport. 2018 Oct;21(10):1032-1037. doi: 10.1016/j.jsams.2018.03.010. Epub 2018 Mar 28. PMID: 29628407
3) Kraan RB, Beers L, van de Pol D, Daams JG, Maas M, Kuijer PP. A systematic review on posterior circumflex humeral artery pathology: sports and professions at risk and associated risk factors. J Sports Med Phys Fitness. 2019 Jun;59(6):1058-1067. doi: 10.23736/S0022-4707.18.08579-1. Epub 2018 Jun 7. PMID: 29877677

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