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Fisher AT, Lee JT. Diagnosis and management of thoracic outlet syndrome in athletes. Semin Vasc Surg 2024; 37:35-43. [PMID: 38704182 DOI: 10.1053/j.semvascsurg.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 05/06/2024]
Abstract
The physical demands of sports can place patients at elevated risk of use-related pathologies, including thoracic outlet syndrome (TOS). Overhead athletes in particular (eg, baseball and football players, swimmers, divers, and weightlifters) often subject their subclavian vessels and brachial plexuses to repetitive trauma, resulting in venous effort thrombosis, arterial occlusions, brachial plexopathy, and more. This patient population is at higher risk for Paget-Schroetter syndrome, or effort thrombosis, although neurogenic TOS (nTOS) is still the predominant form of the disease among all groups. First-rib resection is almost always recommended for vascular TOS in a young, active population, although a surgical benefit for patients with nTOS is less clear. Practitioners specializing in upper extremity disorders should take care to differentiate TOS from other repetitive use-related disorders, including shoulder orthopedic injuries and nerve entrapments at other areas of the neck and arm, as TOS is usually a diagnosis of exclusion. For nTOS, physical therapy is a cornerstone of diagnosis, along with response to injections. Most patients first undergo some period of nonoperative management with intense physical therapy and training before proceeding with rib resection. It is particularly essential for ensuring that athletes can return to their baselines of flexibility, strength, and stamina in the upper extremity. Botulinum toxin and lidocaine injections in the anterior scalene muscle might predict which patients will likely benefit from first-rib resection. Athletes are usually satisfied with their decisions to undergo first-rib resection, although the risk of rare but potentially career- or life-threatening complications, such as brachial plexus injury or subclavian vessel injury, must be considered. Frequently, they are able to return to the same or a higher level of play after full recovery.
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Affiliation(s)
- Andrea T Fisher
- Division of Vascular Surgery, Stanford University School of Medicine, 780 Welch Road CJ350, Palo Alto, 94304, CA
| | - Jason T Lee
- Division of Vascular Surgery, Stanford University School of Medicine, 780 Welch Road CJ350, Palo Alto, 94304, CA.
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Körfer D, Erhart P, Wortmann M, Dihlmann S, Grond-Ginsbach C, Kilian S, Asatryan A, Jung G, Schmitz-Rixen T, Böckler D, Hakimi M. Characteristics of patients with multiple arterial aneurysms. VASA 2023; 52:119-123. [PMID: 36601699 DOI: 10.1024/0301-1526/a001050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: The aim of this retrospective cross-sectional observational study was to determine differences of patients with multiple arterial aneurysms to patients with single arterial aneurysms. Patients and methods: Patients with the diagnosis of an arterial aneurysm from January 2006 to January 2016 in the department of vascular surgery Heidelberg were investigated. Excluded were patients with hereditary disorders of connective tissue or systemic inflammatory disease, as well as other arterial pathologies than true aneurysms. Patients with multiple aneurysms (defined by at least four aneurysms) were compared to patients with single aneurysms concerning age at initial diagnosis, sex and affected arterial site. To verify the findings, a replication of the study was performed at a comparable institution. Results: Of 3107 patients with arterial aneurysms, 918 were excluded. Of the resulting 2189 patients, 1238 (56.6%) patients had a single, 808 (36.9%) two or three, and 143 (6.5%) at least four aneurysms (group mult-AA). Nine hundred seventy-two patients (44.4%) had a single abdominal aortic aneurysm (group sing-AAA). Age at initial diagnosis differed between mult-AA (66.7±9.5 y) and sing-AAA (69.1±8.6 y) (p=0.0338). Within mult-AA, 138 patients (96.5%) were male, compared with 865 patients (89.0%) in sing-AAA (p=0.0041). The most frequent aneurysm localization shifted from the abdominal aorta and its branches in patients with a single aneurysm (n=1029; 83.1%) to pelvic and leg arteries in patients with at least four aneurysms (n=318; 63.2%). The replication of the study at the department of vascular surgery Frankfurt confirmed the younger age at initial diagnosis in mult-AA (67.3±12.5 y) compared to sing-AAA (70.9±9.6 y) (p=0.0259) and the distribution shift toward the arteries below the aortic bifurcation in mult-AA. Conclusions: Patients with multiple aneurysms are younger at initial diagnosis and differ concerning aneurysm localization compared to patients with a single aneurysm.
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Affiliation(s)
- Daniel Körfer
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - Philipp Erhart
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - Markus Wortmann
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany.,Department of Vascular Surgery, Endovascular Surgery and Transplant Surgery, Klinikum Stuttgart - Katharinenhospital, Germany
| | - Susanne Dihlmann
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - Caspar Grond-Ginsbach
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - Samuel Kilian
- Institute for Medical Biometry and Informatics, University of Heidelberg, Germany
| | - Ara Asatryan
- Department of Vascular and Endovascular Surgery, University Hospital Frankfurt, Germany
| | - Georg Jung
- Department of Vascular and Endovascular Surgery, University Hospital Frankfurt, Germany.,Department of Vascular Surgery, Lucerne Cantonal Hospital, Switzerland
| | - Thomas Schmitz-Rixen
- Department of Vascular and Endovascular Surgery, University Hospital Frankfurt, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - Maani Hakimi
- Department of Vascular Surgery, Lucerne Cantonal Hospital, Switzerland
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Garraud T, Pomares G, Daley P, Menu P, Dauty M, Fouasson-Chailloux A. Thoracic Outlet Syndrome in Sport: A Systematic Review. Front Physiol 2022; 13:838014. [PMID: 35755427 PMCID: PMC9214221 DOI: 10.3389/fphys.2022.838014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/26/2022] [Indexed: 11/13/2022] Open
Abstract
Thoracic outlet syndrome (TOS) is a rare and heterogeneous syndrome secondary to a compression of the neurovascular bundle in the thoracic outlet area. Muscle hypertrophy is recognized to induce vascular or neurogenic compression, especially in sports involving upper-arm solicitation. Athletes represent a distinctive population because of a specific management due to an ambitious objective, which is returning to high-level competition. We evaluated the scientific literature available for the management of TOS in athletes. Article research extended to March 2021 without other restriction concerning the date of articles publication. The search was performed independently by two assessors. A first preselection based on the article titles was produced, regarding their availability in English or French and a second preselection was produced after reading the abstracts. In case of doubt, a third assessor’s advice was asked. Case reports were selected only if the sport involved was documented, as well as the level of practice. Cohorts were included if data about the number and the sport level of athletes were detailed. Seventy-eight articles were selected including 40 case reports, 10 clinical studies and 28 reviews of literature. Baseball pitchers seem to be highly at risk of developing a TOS. The surgical management appears particularly frequent in this specific population. The prognosis of TOS in athletes seems to be better than in the general population, possibly due to their better physical condition and their younger age. Some studies showed interesting and encouraging results concerning return to previous sport level. Literature shows a strong link between TOS and certain sports. Unfortunately, this syndrome still lacks rigorous diagnostic criteria and management guidelines for athletes.
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Affiliation(s)
- Thomas Garraud
- Hôpital Privé du Confluent, Rhumatologie, Nantes, France.,Service de Médecine du Sport, CHU Nantes, Nantes, France
| | - Germain Pomares
- Institut Européen de la Main, Luxembourg. Luxembourg.,Medical Training Center, Hopital Kirchberg, Luxembourg. Luxembourg
| | - Pauline Daley
- Service de Médecine du Sport, CHU Nantes, Nantes, France.,CHU Nantes, Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, Nantes, France
| | - Pierre Menu
- Service de Médecine du Sport, CHU Nantes, Nantes, France.,CHU Nantes, Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, Nantes, France.,Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, France.,IRMS, Institut Régional de Médecine du Sport, Nantes, France
| | - Marc Dauty
- Service de Médecine du Sport, CHU Nantes, Nantes, France.,CHU Nantes, Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, Nantes, France.,Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, France.,IRMS, Institut Régional de Médecine du Sport, Nantes, France
| | - Alban Fouasson-Chailloux
- Service de Médecine du Sport, CHU Nantes, Nantes, France.,CHU Nantes, Service de Médecine Physique et Réadaptation Locomotrice et Respiratoire, Nantes, France.,Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, France.,IRMS, Institut Régional de Médecine du Sport, Nantes, France
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De Maeseneer MG, Kakkos SK, Aherne T, Baekgaard N, Black S, Blomgren L, Giannoukas A, Gohel M, de Graaf R, Hamel-Desnos C, Jawien A, Jaworucka-Kaczorowska A, Lattimer CR, Mosti G, Noppeney T, van Rijn MJ, Stansby G, Esvs Guidelines Committee, Kolh P, Bastos Goncalves F, Chakfé N, Coscas R, de Borst GJ, Dias NV, Hinchliffe RJ, Koncar IB, Lindholt JS, Trimarchi S, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, Björck M, Labropoulos N, Lurie F, Mansilha A, Nyamekye IK, Ramirez Ortega M, Ulloa JH, Urbanek T, van Rij AM, Vuylsteke ME. Editor's Choice - European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg 2022; 63:184-267. [PMID: 35027279 DOI: 10.1016/j.ejvs.2021.12.024] [Citation(s) in RCA: 204] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 01/12/2023]
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Keller RE, Croswell DP, Medina GIS, Cheng TTW, Oh LS. Paget-Schroetter syndrome in athletes: a comprehensive and systematic review. J Shoulder Elbow Surg 2020; 29:2417-2425. [PMID: 32868012 DOI: 10.1016/j.jse.2020.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/23/2020] [Accepted: 05/04/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Paget-Schroetter syndrome (PSS) is a rare condition of axillosubclavian vein thrombosis often seen in athletes with a history of repetitive external rotation and abduction of the shoulder. The purpose of this review was to analyze the literature and characterize PSS in the athletic population, including risk of PSS by sport. We also provide a comprehensive review of PSS to inform clinicians on the pathophysiology, detection, and management of the condition. METHODS Four databases were reviewed to identify cases of PSS occurring in athletes. Data on patient demographics, reported sport, diagnosis, treatment, management, return to sport, and complications were extracted and analyzed by 2 independent reviewers. RESULTS Of the 123 cases of PSS identified, baseball and weight lifting had the highest incidence (26.8% and 19%, respectively), followed by swimming, football, and basketball. The average return to sport was 4.7 months, and 26.7% of subjects reported complications, most commonly pulmonary embolism. CONCLUSION In athletes presenting with upper extremity pain and swelling with a history of playing baseball or weight lifting, PSS should be higher on a clinicians differential diagnosis list. Swimmers, football, and basketball players are less likely to present with PSS but are still more likely than other types of athletes to develop the condition. Clinician awareness of PSS in athletes is critical to avoid delays in treatment and misdiagnosis, and to allow for a timely return to sport with minimal complications.
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Affiliation(s)
- Rachel E Keller
- Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Boston, MA, USA.
| | - Damari P Croswell
- Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Boston, MA, USA; Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA
| | - Giovanna I S Medina
- Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Boston, MA, USA
| | - Timothy T W Cheng
- Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Boston, MA, USA
| | - Luke S Oh
- Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Boston, MA, USA; Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA
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