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of aggravating activities is important. If medical or surgical inter- vention is not indicated, physical therapy to address the underly- ing musculoskeletal dysfunction, with careful monitoring of arte- rial markers should proceed.

2. Subclavian-axillary artery aneurysm Definition: An increase in diameter of the arterial wall which may be a result of repetitive trauma. Consequently, aneurysm formation may be a result of prolonged external forces related to mechanisms as described above. The risk of thrombosis and distal embolisation (ie. embolisation into the hand) is significant in this pathology. The continual pressure of flow, or the ‘toothpaste’ effect, into the aneurysm during repetitive activity is a mechanism of thrombosis. Presentation: Symptoms are commonly subtle and a vascular hypothesis is rarely considered (5). Clinical presentation is simi- lar to occlusion problems described above. The clinician should hold a high degree of suspicion if the patient reports a coolness of the fingers, loss of endurance during the activity, or a decrease in speed or control of the upper limb activity. Assessment: Positional and post-exercise testing of distal pulses, capillary re-fill time, and blanching of the hand provide quick and easily obtainable measurements. Segmental systolic brachial, wrist, radial and ulna pressures will support or negate a vascular diagnosis (6). Closer examination of the hand in terms of systolic finger pressures and Doppler measurements of finger pulses will help assess the extent of distal embolisation into the palmar arch of the hand. Pulsatile masses around the supraclavicular and infr- aclavicular sites may be present. Management: Catheter-driven thrombolysis has been reported as a means to dissolve clotting in distal vessels (2, 5). Surgical resection of the aneurysm may be considered if return to high level activity is the goal. Physical therapy directed at rehabilitation and addressing the underlying biomechanical cause is then implemented.

3. Posterior circumflex humeral artery injury Definition: The posterior circumflex humeral artery (PCHA) is a branch artery off the distal third of the axillary artery. Injury to this site includes external compression, thrombosis and aneurysm. The PCHA is considerably larger than the anterior circumflex artery and winds around the surgical neck of the humerus (7). Compression of the PCHA however falls outside the anatomical region of the ‘thoracic outlet’ and is usually associated with com- pression from the humeral head during elevation movements of the arm, most commonly abduction and external rotation. Because of its relationship to the humeral head, the PCHA can become pathological in cases of glenohumeral instability. The clinician should consider the presence of PCHA compromise when assessing glenohumeral instability patients who report distal symptoms. Presentation: Because of its association with true musculoskele- tal dysfunction, (eg. gleno-humeral instability) the clinical pre- sentation will be of that dysfunction (eg. localised gleno-humer- al intermittent pain, ‘clunking’ of joint). There will often be a report of transient weakness of the hand during throwing or an occasional ‘odd’ feeling in the hand. The therapist must be alert to differentiate between a neural or vascular cause. Assessment: Due to the distal site of this structure, the classic ‘thoracic outlet’ features (eg. anomalous first rib, cervical rib, ante- rior scalene hypertrophy) need not be present or associated with

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Posterior Anterior

circumflex arteries

Figure 2: Posterior circumflex humeral artery

this mechanism of injury. Rather, the nature and degree of gleno- humeral instability should be assessed. Functional demonstrations are used to reproduce the athlete’s symptoms. During these demon- strations transient pulse obliteration and muscular weakness may be noted. The use of the AABPI will provide an objective measure relating to the degree of unilateral arterial compromise. IFI may also have a role in assessment here. Distal changes to the hand will inform the extent of stenosis or thrombosis. Management: Management of this injury will be dependent on the chronicity of the condition. It is known that repetitive external trauma to a vessel (ie. repeated compression from the humeral head) can lead to pathological atherosclerotic changes on the intimal lining of the vessel (8). There are no true indicators as to the time scale when these changes occur and clinical judgement must be used to assess management priorities. Physical therapy addressing the gleno-humeral instability (ie. the underlying cause of the injury) may be initiated with close monitoring of the arte- rial signs. If these appear to display a trend towards improvement in line with improvement of other measures, then conservative treatment may be successful. However, if arterial signs remain, or worsen, during the rehabilitation period as all other measures are improving, then possible intimal pathology may be suggested and surgical exploration/restructuring indicated.

4) Vascular trauma in the hand Definition: Trauma to the vascular tissue in the hand can account for a number of signs and symptoms. By definition, and for the purpose of clarity, trauma may be direct contact trauma as a result of embolisation from a more proximal segment of the vascular sys- tem, or localised temperature exposure trauma. Direct repetitive blunt trauma of the hand in athletes follows a similar mechanism of injury to pathology seen in conventional occupational cases, for example, classic ‘white finger syndrome’ seen in patients who work with vibrating tools. Most commonly in athletes, such prob- lems are associated with sports involved in catching (eg. cricket, baseball), or blocking forces (eg. martial arts). The direct trauma may result in localised external vessel trauma causing ischaemic responses in the hand or digits. Distal ischaemia may also be a result of embolisation due to vascular pathology above the hand. The most common examples are found in athletes who perform