Working Diagnosis:
Effort induced thrombosis (Paget-Schroetter Syndrome)

Treatment:
- Hospital admission 48 hours for thrombolysis <br>- Anticoagulation for 2 months <br>- Axillary surgery with first rib resection <br>- Followed by 2 months of anticoagulation

Outcome:
- 4 months off from start of treatment until full return to sport

Author's Comments:
The three most validated treatment options for Paget-Schroetter Syndrome are thrombolysis with surgical decompression followed with post-operative anticoagulation or no anticoagulation and thrombolysis with long term anticoagulation and surgery only if symptoms persist/rethrombosis. Treatment without thrombolysis and with just anticoagulation has shown more than 50% of patients develop chronic residual symptoms and should not be thought of as a standard of care option. Time from symptom onset to treatment is important as patients treated greater than 2-6 weeks after onset of symptoms had poorer symptom resolution and devloped chronic residual deficits usually unresponsive to surgery.(1)(2) In order to decide whether non-surgical or surgical options (+/-) anticoagulation are the treatment of choice for a patient, three factors must be consider : Symptoms (pain, function, swelling) recorded after thrombolysis treatment, age of the patient and timeframe for return to sport. Younger patients (&lt;28 years old) were found to have 50% higher likelihood of reoccurrence of symptoms than older patients. (3) Thrombolysis with surgical decompression resulted in a quicker return to sport, especially with surgery and no post-operative anticoagulation, however there can be the possibility of limited function (3%) without 2 months of post-operative anticoagulation, therefore type of sport (high-impact vs low-impact), timing of competition, and athletic level must be considered.(1)(2) Important to note that surgery can have a complication rate as high as 15-20% (brachial plexopathies, pneumothoraces). 50-60% of non-operative patients will qualify for surgical treatment based on worsening symptoms over the following year. There was no significant outcome difference between athletes (collegiate) and non-athletes in terms of reoccurrence rates with non-operative treatment.(3) <a href="CaseStudyImages/CS6CS5CS4CS3CS2CS1Si-302.jpg" title="Case Photo #6" data-lity><b>Case Photo #6</b></a>

Editor's Comments:
Fairly common presentation that should be in the forefront of every sports medicine physician&#039;s mind. This case highlights this syndrome and all the various treatment options, combined in one case! Pictures are worth a thousand words here.

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