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Assessment: On examination oedema, cyanosis, and superficial vein distension around the supra-clavicular fossa and chest wall might be noticed. Distal pulses are not affected, although some abnormality and discomfort around the supra-clavicular pulse may be found. Signs and symptoms need to be recorded in relation to exertion of the upper extremity during the examination. The signs and symptoms associated with Paget-Schroetter syndrome may mimic patterns more commonly associated with adverse neural mechanics, and indeed neurodynamic testing may well be positive in this condition given the association with the subclavian vas- cular structure around the brachial plexus. A working diagnosis of reflex sympathetic dystrophy, or shoulder-hand syndrome might also be inaccurately given. Photoplethysmography and colour Duplex ultrasound imaging may reveal the presence of a thrombo- sis in the subclavian-axillary venous system. Management: Acute management may involve anticoagulation therapy together with the cessation of any significant medication. Thrombolytic and surgical intervention are not routinely indicated in the management of upper limb deep vein thrombosis (13). This medical management will address only one component of Virchow’s triad, ie. the hypercoaguable state. The physical therapist may have a role in addressing the other two. For example, the localised sta- sis may be affected by a first rib dysfunction in a hockey player with excessive upper quadrant flexion/protraction during a period of exertion. Likewise, vessel wall trauma could be a result of poor tho- racic outlet mechanics, soft tissue hypertrophy, aberrant motor pat- terning during repetitive arm activity etc. Successful management requires a harmonious combination of medical and therapeutic care.

Clinical assessment Vascular examination at rest may be entirely normal. It is there- fore easy to assume the absence of vascular pathology and attempt to ‘fit’ the patient into a neuromusculoskeletal ‘box’. As with the lower limb, courses of treatment are tried based on an

Condition

Subclavian - axillary artery occlusion

Subclavian aneurysm

Posterior circumflex humeral artery injury

Hand trauma

Pain Behaviour localisation

Supra- clavicular fossa, arm

Supra-clavicular fossa, arm

Shoulder, arm, hand

Related to effort and arm position

Related to arm effort, general increase in activity (eg. running)

Effort induced with abduc- tion/lateral rotation of gleno-humeral joint

Hand

Upper limb effort, increases with exposure to cold

Upper limb deep vein thrombosis

12 SportEX

Arm, shoulder

Effort of upper quadrant, arm, shoulder complex position

incomplete diagnosis eg. a ‘muscle imbalance’ programme. Unfortunately, the timing of vascular diagnosis is of utmost importance and the longer the diagnosis is left, the worse the pathology can potentially get. Numerous case reports demonstrate serious complications of vascular pathology which could have been avoided had the first contact clinician (often a physiothera- pist) picked up the signs upon initial assessment. Simple clinical assessment techniques can guide the clinician and attempt to refute a vascular hypothesis at an early stage.

Observation and hand examination Blanching of the hand is a sign of any arterial occlusion of the upper extremity. In the case of the athlete, this blanching will only be brought about by performing the activity to the onset of symptoms. During this performance, the clinician may quite sim- ply observe the hand (being the most distal segment and there- fore most sensitive to occlusion) for colour changes. Nail bed cap- illary refill time is easily measured by squeezing the nail bed and recording the time it takes for colour to return (which should be immediate). Non-pitting oedema may be observed in severe venous obstructions (ie. Paget-Schroetter syndrome). This is often associated with characteristic skin mottling and peripheral cyanosis. Digital pulses can be palpated by the skilled practition- er although the use of the handheld Doppler is more reliable for peripheral examination. The Allen test is a test for competency of the radial, ulna and palmar arteries. The clinician occludes the radial and ulna arteries at the palmar surface of the wrist while the patient repeatedly opens and closes their hand. Release of one artery while observing the return of colour into the hand will indicate the competency of the vessel. The test is then repeated with release of the second artery.

Pulse palpation Palpation of relevant pulses is simple and a quick way of gaining

Description

Pain, fatigue, weak- ness, coldness

Ache, pain, fatigue, weakness, coldness

Pain, transient weakness, early fatigue, distal dysthesia

Cold sensitivity, fin- ger numbness, finger coolness, local ischaemic pain

Arm ache, swelling, coldness

Clinical sign

Loss of distal pulses in provacative position, reduced systolic pressure on exertion (AABPI), early fatigue (IFI)

As above, pulsatile supra/infra- clavicular mass

As above, transient loss of pulse in abduction/lateral rotation

Changes in segmental systolics, increased cold intolerance

Oedematous arm, cyanosis, superficial venous distension on chest wall