DIFFERENTIAL DIAGNOSIS

VASCULAR ISSUES IN SPORT PART 2: THE UPPER LIMB

©1999 Primal Pictures Ltd

● Subclavian-axillary artery aneurysms ● Posterior circumflex humeral artery occlusion ● Vascular trauma in the hand

Venous lesions include: ● Upper limb deep vein thrombosis - Paget-Schroetter syndrome

Anterior Posterior

Subclavian artery

Axillary artery Brachial artery

Radial collateral artery

circumflex arteries

Differential diagnosis

Figure 1: Overview of the arteries of the upper limb

By Alan Taylor, MSc, MCSP and Roger Kerry, MMACP, MCSP

Introduction Athletes demanding repetitive and strenuous activity of the upper limb expose themselves to a wide variety of injury. Commonly these injuries involve, or are at least diagnosed as involving, the neurological and musculoskeletal systems. The last few years has witnessed increased awareness by medical and sport practitioners towards the risk of vascular injury in the sporting upper limb. A vascular component to upper quadrant sports injuries must be considered in the differential diagnosis of athletes reporting upper limb symptoms. Vascular insufficiency in the upper limb is often misdiagnosed and the long-term consequences of this can be serious (1). Early retirement from sport through failed mis- guided treatment is a common consequence. Limb threatening thromboembolic events are more serious sequelae.

This article presents a number of vascular syndromes which sports practitioners can include in their differential diagnosis of upper limb injuries. The conditions are rare compared to musculoskele- tal conditions, but nevertheless represent an area where present clinical knowledge might be strengthened by further inquiry. Reports of arterial flow issues affecting the subclavian-axillary system include: ● Subclavian-axillary artery occlusion

1. Subclavian-axillary arterial occlusion Definition: Arterial occlusion in the subclavian-axillary region may be of an external or internal etiology. External occlusion involves compression of the artery from the surrounding muscu- loskeletal structures. Within the region of the thoracic outlet the muscular structures which can cause compression are the anterior scalene, subclavius and pectoralis minor (1). Hypertrophy or more subtle muscle imbalance dysfunctions can result in the occlusion of distal blood flow and create local and peripheral altered haemodynamics (2). Bony structures include the costoclavicular space, the presence of a cervical rib, or an anomalous first rib (3). Occlusion via these mechanisms can be a result of repetitive upper quadrant activity or direct trauma. Internal occlusion is related to atherosclerotic disease. A number of series regarding distal throm- bosis from subclavian-axillary inducible occlusion (ie. transient and as a result of the throwing action and glenohumeral instabil- ity) have been reported (4). Presentation: Pain around the supra-clavicular fossa and arm is seldom considered to have a vascular origin, especially in the younger population. The clinical presentation for arterial occlu- sion mimics various neuromusculoskeletal conditions including: ulna nerve injury; glenohumeral pathology; cervical dysfunction; ‘tennis elbow’; localised hand pathology; and non-vascular thoracic outlet syndrome (TOS). A description of distal symptoms including weakness, fatigue, coldness and neurological dysthesia related to activity are common. A Raynaud’s-type intolerance to cold would also alert the clinician to an arterial cause. Assessment: Vascular examination is normal at rest. Clinical examination must be performed in comparable positions as well as post-effort. Examination might reveal reduced or absent distal pulses during positional change, therefore classic ‘thoracic outlet’ tests (Adson’s, Allen’s, Halstead’s manoeuvre, etc.) could be positive. Negative positional tests do not exclude an arterial cause as the exertion component may be more significant than the positional in some cases. Examination of the digits might reveal a prolonged capillary refill time in different positions/levels of exertion together with some cooling of the extremity. Positional arteriography would confirm a diagnosis. Arm to Arm Brachial Pressure Index (AABPI) and Ischaemic Fatigue Index (IFI) (see below) may be used. Management: Repetitive external trauma to a vessel can result in pathological changes to the intimal layer of the artery. Therefore, in chronic cases which have failed to respond to previous treat- ment, medical or surgical intervention is required. Antiplatelet therapy is a conservative option. Exercise moderation or cessation

SportEX 9