ALTERED HAEMODYNAMICS

an understanding of the vascular status early on in the examina- tion. The reduction or obliteration of distal pulses during or immediately after effort or arm positioning indicates arterial occlusion, but is non-specific to locality. A pulsatile mass is char- acteristic of aneurysm formation and should be examined for around the supra and infra clavicular pulses when subclavian aneurysm is suspected. A particularly prominent pulse which is non-pulsatile (eg. a mid brachial pulse) and different from the other side may be indicative of the artery passing over something hard and obstructive (eg. bony growth on humerus) and further investigation should be sought immediately.

Hand held Doppler ultrasound The use of this has been described previously (14) and this infor- mation is transferrable to the upper extremity. The nature of flow can be assessed at any point along the arterial tree and localisation of the occlusion may be improved. Differentiation between finger pulses examined with the Doppler unit is useful when attempting to determine whether the pathology is ulna or radial bias.

Arm to arm blood pressure index (AABPI) This test is not to be confused with the Ankle Brachial Pressure Index (ABPI). The test consists of measuring the systolic pressure on the relevant segment of the symptomatic arm and comparing this with the same systolic pressure on the normal arm.

In normal subjects this should be both pre and post-exercise. The test, as an index, lacks the validity and reliability of the ABPI for the lower limb as the amount of normative and pathological data is less substantial. It is therefore difficult to determine at what point disease is indicated. The principles of the tests are still clin- ically useful and as a guide a difference of between 30mm/Hg and 50mm/Hg between arms (systolic) could be used as an indication for reduced subclavian flow (15).

Key Sport investigation

AABPI, contrast arteriogra- phy MRA, Duplex flow study

As above, chest x-ray specificity

Volleyball, baseball, cricket, cycling, tennis

As above

Ischaemic fatigue index (IFI) The clinical reliance on systolic measurements and pulse palpation has been questioned by some who suggest that the presence of a pulse, or the normal status of systolic pressure does not exclude the presence of subclavian-axillary stenosis. An Ischaemic Fatigue Index (IFI) has been proposed as a more sensitive measure of upper extremity arterial flow dysfunction (16). This is a simple index using a grip dynanometer and asking the patient to repeat- edly grip and relax at a set rate until the onset of fatigue and ischaemic sensation. The number of flexions is then recorded. The true index is based on normative data which gives a set number of flexions for certain age groups and genders. The patient’s results are then compared against this data to give an index. This data has been acquired using a flexion force resistance of 1.82Nm it may, therefore, not be possible to use in the clinical environ- ment as a pure index. However, like the AABPI, this does have some clinical utility if used as a side-to-side comparison.

Alan Taylor, MSCP, is a clinical specialist in sports medicine at the Nottingham Nuffield Hospital and a former professional cyclist. He is currently involved in research into vascular flow problems in ath- letes in conjunction with Roger Kerry, MCSP, an extended scope prac- titioner at the York District Hospital. Both authors lecture widely on the diagnosis and management of vascular conditions. Address for correspondence: alan.taylor@nuffieldhospitals.org.uk

As above, x-ray

As above Duplex ultrasound scan, venography

As above, kayak, judo

Baseball, cricket, frisbee, cycling, rock climbing

Weight lifting, body building, hiking (backpacking), swimming, javelin, shot-putt, windsurfing

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