Neurovascular Problems in the Athlete's Shoulder

This review is a summary of my submission to Research Review Service. The information below was derived from Thompson & Driskill’s Neurovasular Problems in the Athlete’s Shoulder, recently published in Clinics in Sports Medicine. For a greater understanding of the following information, including the etiology and  management strategies of the various conditions, I strongly encourage you to read my full review.

Background Information

• Although rare, neurovascular conditions of the upper extremity occasionally present themselves in elite athletes. These may be challenging to detect, but are certainly important for their potential to cause limb-threatening consequences. Early recognition, proper initial treatment, and urgent surgical referral increase the likelihood of rapid return to pre-injury levels of performance and more importantly, decreases the likelihood of serious complications.

Neurogenic Thoracic Outlet Syndrome

• Arm and/or hand pain, numbness, and paresthesia that results from compression, irritation, and chronic injury affecting the roots of the brachial plexus.
• May be caused by cervical ribs and hypertrophy of the scalene and pectoralis muscles.
• Exacerbated with direct palpation and arm elevation.
• Severe cases rarely seen in elite athletes

Subclavian Artery Aneurysms

• Stenosis and aneurysm formation of the subclavian artery.
• Typically associated with cervical ribs and atypical first ribs.
• Thrombus and subsequent embolization, travelling to the distal arteries causing symptoms of exertional arm fatigue and/or acute digital ischemia.
• Full return to activity generally within several months.

Axillary Artery Aneurysms and Occlusions

• Most exclusively in baseball pitchers.
• Humeral head translates forward during end-range extension and elevation, resulting in compression and stretching of the axillary artery combined with fixation against the tendon of the pectoralis minor.
• Extreme repetitive motion
• Symptoms are similar to that of subclavian artery aneurysms and include exertional arm fatigue and/or acute digital ischemia.
• Full return to activity generally within three months.

Digital Ischemia with or without Thromboembolism and Vasospasm

• Numbness, tingling, cold and painful sensations
• Cyanosis or pale discoloration and delayed capillary refill.
• Radial and ulnar pulses may be absent or decreased, and blood pressure may be diminished
• Digital artery thrombosis: due to localized repetitive trauma associated with index and/or middle finger pressure when gripping and throwing the ball.
• Digital artery thromboembolism: seen in catchers and results from chronic repetitive trauma to the base of the hand.
• Digital artery spasm: seen in baseball due to the rampant use of vasoconstrictive tobacco products.

​Effort Thrombosis of the Subclavian Vein

• Paget-Schrotter syndrome: the most commonly seen vascular disorder in young competitive athletes.
• Compression of the subclavian vein between the clavicle and first rib.
• Combination of positional compression and arm exertion in elevation.
• Involves the formation of scar tissue, collateral vessels, and subsequently thrombosis
• Swelling, cyanosis, pain, heaviness and/or fatigue.
• Suspected if presenting with sudden onset of arm swelling and cyanosis, especially in overhead athletes (throwers, weightlifters, swimmers).
• Urgent surgical referral is essential for full return to activity