Working Diagnosis:
"Effort-thrombosis related to venous thoracic outlet syndrome" i.e. Paget-Schroetter syndrome.

Treatment:
After definitive diagnosis, treatment included compression, limited overhead activity, and to remain non-contact for sports. He was started on anticoagulation (apixaban) and referred to Vascular Surgery for right brachial plexus neurolysis and paraclavicular right first rib resection, which was performed soon thereafter.

Outcome:
The patient had residual exertional swelling at 3-month follow-up but otherwise improved symptoms. Follow-up US showed chronic obstruction with partial recanalization of the right subclavian vein but was otherwise non-acute. He was advised to stop apixaban following the full 3-month course, returned to activity with no contact restrictions, and played the 2025 football season.

Author's Comments:
Paget-Schroetter syndrome, or "effort-thrombosis," most often occurs in young adults due to repetitive vascular endothelial microtrauma to the axillary-subclavian vein beneath the clavicle and first rib. Treatment involves venography, thrombolysis, anticoagulation, and/or surgery. Contrast venography, although invasive and inaccessible, is the diagnostic standard. Ultrasound is the preferred alternative due to its high sensitivity (97%), specificity (96%), accessibility, and safety profile. CT/MR-Venography are adjuncts if ultrasound is negative despite high clinical suspicion, though little data exists to validate these. In this case, US and CTA produced false negatives, thus questioning the upper extremity deep vein thrombosis diagnostic algorithm.

Editor's Comments:
Paget-Schroetter syndrome is more likely in sporting events requiring continuous and forceful upper extremity movements, specifically retroversion, hyperabduction, and extension of the arm, such as wrestling, baseball, gymnastics, and swimming. Anatomic abnormalities, such as cervical ribs, congenital bands, and lateral insertion of the costoclavicular ligament are risk factors for Paget-Schroetter syndrome development.

References:
1. Alahmadi MH, Baril DT. Paget-Schroetter Syndrome. [Updated 2025 Jul 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482416/

2. Czihal M, Hoffmann U. Upper extremity deep venous thrombosis. Vasc Med. 2011;16(3):191-202. doi:10.1177/1358863X10395657

3. Joffe HV, Goldhaber SZ. Upper-Extremity Deep Vein Thrombosis. Circulation. 2002;106(14):1874-1880. doi:10.1161/01.CIR.0000031705.57473.1C

4. Patel P, Braun C, Patel P, et al. Diagnosis of deep vein thrombosis of the upper extremity: a systematic review and meta-analysis of test accuracy. Blood Advances. 2020;4(11):2516-2522. doi:10.1182/bloodadvances.2019001409

5. Taha K, Breslín T, Moriarty J, Ali S, Bernhard Louw. Diagnosing Paget-Schroetter Syndrome Using Point of Care Ultrasound (POCUS). pocus. 2022;7(1):131-133. doi:10.24908/pocus.v7i1.15364

Return To The Case Studies List.