ALTERED HAEMODYNAMICS

repetitive shoulder movement and develop subsequent vascular dysfunction around the shoulder region, as described above. This results in embolisation to the vessels of the hand, again produc- ing distal ischaemic patterns. Prolonged exposure to cold is a mechanism by which localised chronic hand ischaemia may be induced. This pathological mechanism is closely associated with neurological changes and careful examination is required to dif- ferentiate and separate pathologies. Some authors suggest that all such ischaemia be classified as localised Raynaud’s syndrome (9). Although perhaps over-generalising the pathology, this cate- gorisation would at least relate to the characteristic episodic attacks of digital artery vasospasm caused by cold stimuli in the absence of an underlying disease pathology. From our clinical experience, such localised phenomena has been witnessed in, for example, cyclists (riding for prolonged periods in winter without gloves, combined with digital artery pressure from hand position on the handlebars), and rock climbers. Presentation: Symptoms will classically consist of finger numb- ness, finger blanching, finger coolness and cold sensitivity (10). Complaints of ischaemic-type pain, which can be confused with neurogenic pain, will often be reported. The localisation of the symptoms will depend on which vessels are affected and will clas- sically be of radial or ulna aspect distribution. Single digits may be affected if the trauma is localised distally. Remember that there is an inseparable relationship between vascular and neural tissue and this is no more manifest than in the wrist and hand. Assessment: In the athlete it is unlikely that symptoms and signs will be present at rest. It is necessary to firstly establish the behaviour of symptoms and perform the physical examination in line with these functional patterns. Although angiographic evalu- ation has a role in digital examination, most cases can be assessed and a working diagnosis developed by establishing a history and using non-invasive clinical tests. Basic hand and digit observation is easily performed noting and recording changes in nail bed/fin- ger end colour and tangible differences in capillary refill times. Specific differentiation tests such as the Allen test can be per- formed to test the competency of the radial, ulnar and palmer arteries. Doppler examination is utilised to measure segmental systolic pressures in an attempt to specify the locality of the injury. This would mean measuring, for example, brachial, ulnar, radial and finger systolics. Palmer arch competency can also be recorded with the Doppler technique (11). Assessment of cold sensitivity with fingertip thermistors may form part of the assess- ment (2). As stated above, all testing should be done pre- and post-functional demonstration/exercise in all but the most severe of cases.

Management: Distal upper extremity arterial disease, unlike that of the lower extremity, is not frequently amenable to surgical repair. The role of the therapist is that of addressing any causative biomechanical dysfunction in the upper quadrant as well as pro- viding advice and guidance on protection of the hand and avoid- ance of cold exposure. This may include the assessment and alter- ation of hand equipment, for example, gloves, as well as the assessment of hand-on-handlebar position. Advice regarding reha- bilitating towards a specific level of activity combined with objec- tive measurements of the vascular dysfunction provide a logical and reasoned approach to the management of the hand patient. Medically, vasodilator infusion and intravenous heparin and dextran administration has been reported for short term management (10).

5) Paget-Schroetter syndrome - upper limb deep vein thrombosis Definition: Paget-Schroetter syndrome refers to the primary form of subclavian-axillary vein thrombosis and is also commonly referred to as ‘effort vein thrombosis’, or ‘effort thrombosis’, due to its association with physical exertion. The syndrome was first described following cases reported in 1875 by Sir James Paget and later in 1899 by Leopold van Schroetter. Paget-Schroetter syndrome is a deep vein thrombosis of the subclavian-axillary venous system, affecting the subclavian more commonly than the axillary vein. Although due to a high level of misdiagnosis, the true incidence of Paget-Schrotter is unknown, it possibly accounts for around 3-7% of all deep vein thomboses. The risk of pulmonary embolism from Paget-Schroetter is around 12% (12). The aetiolo- gy of Paget-Schroetter syndrome is in keeping with the time- honoured triad of Virchow, suggesting that stasis, vessel wall damage and a hypercoaguable state must exist in order for the development of a thrombus to occur. Sports requiring either prolonged static postures combined with a high level of exertion are considered as risks factors for this syndrome. The effort component relates directly to the pathology and is associated with hypertrophy of surrounding muscle tissue, high physiological energy demand and direct trauma to the vascular structures. Athletes involved in sports such as weight lifting and body build- ing are particularly at risk. Direct pressure on the supra-clavicu- lar/ brachial region can also be responsible for local stasis and vessel wall trauma. As such, load-bearing activities such as back- packing are considered risk factors. For the high level athlete, it should be remembered that intra-venous infusion results in vessel wall damage. Presentation: The typical clinical presentation is characterised by the youthfulness and healthiness of the patient. The patient most commonly complains of a quick insidious onset of arm pain with the possibility of associated supraclavicular fossa pain. The onset may also be related to over-activity of the arm, unusual position- ing or upper quadrant trauma. A thorough medical and family his- tory with focussed special questions is needed. The correlation to a hypercoaguable state must be considered and the clinician must establish what medication the athlete is taking. Oral contracep- tives and hormone replacement therapies are two common groups of medication which may affect the hypercoaguable status of the patient. The therapist must always be aware that the athlete may be taking relevant medication which they are not willing to reveal. Other risk factors include ‘traditional’ thoracic outlet syn- drome factors such as cervical rib, anomalous first rib, hypertro- phy of anterior scalene, subclavius, or pectoralis minor as well as endogenous factors such as activated protein C resistance and anticardiolipin antibodies (13). Swelling of the arm is a common manifestation and can indeed be the sole presentation. More often, pain and swelling accompany one another.

As Paget-Schroetter is a condition of venous obstruction, pain and swelling are a result of the muscular activity needed to increase venous pressure in order to meet the venous outflow (for a limit- ed time via collateral circulation), which is required to match arterial inflow. Pain and distal dysthesia are related to repetitive activity of the upper limb. Other symptoms may include peripher- al cyanosis. If pulmonary embolisation has developed then there may be a description of shortness of breath, pleuretic chest pain, haemoptysis and non-productive cough.

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