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

Treatment:
- Hospital admission 48 hours for thrombolysis
- Anticoagulation for 2 months
- Axillary surgery with first rib resection
- 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 (<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) Case Photo #6

Editor's Comments:
Fairly common presentation that should be in the forefront of every sports medicine physician'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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