Working Diagnosis:
Left Popliteal, proximal peroneal, and mid peroneal Deep Vein Thrombosis in the setting of probable May-Thurner Syndrome

Treatment:
The athlete was admitted to the hospital after the positive Venous Doppler. She was started on enoxaparin sodium (Lovenox) and both hematology and vascular surgery were consulted. A CT venogram was obtained showing concerns for May-Thurner Syndrome. She was discharged home on enoxaprin for a 6-weeks and had referrals to vascular surgery and a women's health center placed.

Outcome:
The athlete elected to not return to the rowing team after this diagnosis. Studies have shown many players with deep venous thrombosis were treated with anticoagulants, surgery, or a combination of the two. Of the players in the study who were treated with anticoagulants, the average time of anticoagulant use was 4.3 months while the athletes that experienced a recurrent clotting event were placed on indefinite blood thinners.

Author's Comments:
May-Thurner syndrome (MTS) is compression of the iliac vein against the lumbar spine by the iliac artery, and results in venous stasis and deep vein thrombosis3. Mainly, this presents in women twice as much as in men. The symptoms are left leg swelling and pain. Risk factors are genetic and acquired. Acquired factors are medications, surgery, trauma, and long periods of immobility2. Our athlete did have immobilization; but it was thought that this was not enough to cause a large DVT in an otherwise healthy person. MTS was found in athletes like runners and basketball players but has not been reported in rowing athletes who are predisposed due to rowing positions that pull the knees to the chest.

Editor's Comments:
May-Thurner Syndrome, also called iliac vein compression syndrome, is an abnormality of the left lower extremity vascularity where the left iliac vein is compressed against the lumbar vertebral bodies of the right iliac artery resulting in endothelial damage and intimal wall thickening. Often this finding is asymptomatic, being present in 22-24% of the population, though this anatomic variant may become pathological in a prothrombotic state as compression of the iliac vein will cause increased stasis in the lower limb predisposing a patient to develop a deep venous thrombosis. Pathologic patients often present as young women in their 20s-40s who have recently experienced a period of immobilization or pregnancy. They will often report painless swelling of the left leg, left leg pain or heaviness, or the development of varicosities and/or venous ulcers due to the chronic stasis.

References:
1. Butros, S. R., Liu, R., Oliveira, G. R., Ganguli, S., & Kalva, S. (2013, October). Venous compression syndromes: Clinical features, imaging findings and management. The British journal of radiology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3798333/

2. Leitner , J. (2013, December). Groin pain in a young athlete. JAAPA. https://journals.lww.com/jaapa/fulltext/2013/12000/groin_pain_in_a_young_athlete.14.aspx
Mangla, A., & Hamad, H. (2024, March 11). May-thurner syndrome. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK554377/#:~:text=May%2DThurner%20syndrome%20is%20the,in%20the%20ipsilateral%20lower%20extremity

3. Bishop, M., Astolfi, M., Padegimas, E., DeLuca, P., & Hammoud, S. (2017, December). Venous Thromboembolism Within Professional American Sport Leagues. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK538430/

4. Kibbe MR, Ujiki M, Goodwin AL, Eskandari M, Yao J, Matsumura J. Iliac vein compression in an asymptomatic patient population. J Vasc Surg 2004;39:937-943.

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