Working Diagnosis:
Exercise-Triggered Primary Raynaud's Phenomenon

Treatment:
The athlete was allowed to continue running, with instructions to limit intensity and distance based on symptoms. He was instructed to warm his hands prior to and during runs. A trial of oral nifedipine was not initially successful. Advanced imaging to rule out vascular thoracic outlet syndrome was obtained, as well as a Rheumatology consult, given the atypical trigger of exercise. After thoracic outlet syndrome was excluded, the athlete was cleared for full participation. Improved hand warming compliance led to symptom resolution, and the nifedipine was discontinued.

Outcome:
The athlete remained asymptomatic with sole use of hand warming prior to and during runs. He was cautioned about cold weather running during the winter and to return if symptoms progress.

Editor's Comments:
Raynaud phenomenon is defined as an exaggerated vascular response to cold temperature or stimulation of the sympathetic nervous system (such as emotional stress). It is considered primary if the symptoms occur without evidence of other systemic disease/disorder.
Secondary Raynaud phenomenon has been frequently linked with SLE, systemic sclerosis, Sjögren's syndrome, dermatomyositis/polymyositis and hypothyroidism.
The exact prevalence of the disorder is difficult to assess given the lack of a true gold standard diagnostic test. Estimates from community based surveys have estimated the prevalence between 3-20% in the general population. It is more common in females, younger age groups (15-30 years of age) and in individuals with a family history.
This particular case is interesting in that the athlete denied symptoms with cold exposure and only had symptoms during exercise. Preliminary testing of the athlete did reveal a positive ANA, but a weakly positive ANA is common in the general population. The test most commonly used to distinguish primary from secondary Raynaud phenomenon the nailfold capillography. This athlete underwent this testing which was negative and thus making it less likely that he has secondary Raynaud phenomenon. All the remaining work up was negative. While not a commonly reported precipitant of Raynaud, exercise does involve sympathetic nervous system activation and thus could be a hypothetical trigger.

References:
Maverakis, Emanual, et al. "International consensus criteria for the diagnosis of Raynaud's phenomenon." Journal of autoimmunity 48 (2014): 60-65.

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