Working Diagnosis:
Paget-Schroetter Syndrome - primary "effort" thrombosis of the upper extremity, associated with thoracic outlet syndrome.

Treatment:
He underwent 8 days of intravenous heparin and catheter-directed thrombolysis with tissue plasminogen activator. The patient was discharged on a therapeutic dose of twice-daily subcutaneous Lovenox. He underwent partial first rib resection one month after discharge and his Lovenox was discontinued after 3 months of therapy.

Outcome:
Patient was able to finish his senior season of football prior to surgery. He skipped his morning Lovenox dose on game days and avoided contact by running directly off the field after kicking. Weight lifting was prohibited. He had no complications and post-surgical imaging showed persistent but reduced clot burden. His D-dimer was monitored regularly and remained negative since discontinuing anticoagulation.

Author's Comments:
This case presents an unusual etiology for shoulder pain and swelling. Paget-Schroetter Syndrome is rare and can be dangerous if not detected. Treatment with oral anticoagulation alone carries a significant risk for acute pulmonary embolism. This patient received appropriate inpatient management but his symptoms did not resolve completely with direct thrombolysis and intravenous anticoagulation since his clot was extensive and likely greater than 14 days old. Surgical decompression of associated thoracic outlet syndrome seems to be standard of care, but there is discussion of whether it should be performed immediately or delayed until after extended anticoagulation. Anticoagulant therapy is generally continued after discharge for a minimum of 3 months. In this case, a patient-centered decision for return to activity precluded use of oral anticoagulation. Thankfully, his outcome was a positive one despite returning to a high-risk contact sport while using Lovenox.

Editor's Comments:
Paget-Schroetter Syndrome is rare but is most common in overhead athletes. This syndrome is one of the causes of vascular thoracic outlet syndrome. Patients often present with position numbness, tingling, pallor, and a deep dull ache that is not reproducible with palpation. Due to its vascular origin of pathology, Roo's test may be positive during physical examination. But, provocative testing on physical examination for thoracic outlet syndrome is neither highly sensitive nor specific. Confirmatory imaging studies include doppler and duplex ultrasound, angiography or venography, or MRA or MRV while the patient is placed in provocative positions. Treatment for Paget-Schoetter Syndrome is usually more aggressive and includes thrombolysis, first rib resection, and percutaneous transluminal angioplasty.

References:
1. Young, Jonathan R., MD, Hugh Gelabert, MD, and John Moriarty, MD. "Managing Paget-Schroetter Syndrome." Endovascular Today. N.p., Aug. 2014. Web.

2. Lillig, Karl A., MD, and Adam J. Doyle, MD. "A Comprehensive Review of Paget-Schroetter Syndrome." Journal of Vascular Surgery 51.6 (2010): 1538-547. 22 Mar. 2010. Web.

3. Vijaysadan, Viju, MD, Aphrodite M. Zimmerman, MS, and Rafael E. Pajaro, MD. "Paget-Schroetter Syndrome in the Young and Active." The Journal of the American Board of Family Medicine. N. p., Aug. 2005. Web.

4. van den Houten MM, et al. "Treatment of Upper-extremity Outflow Thrombosis." Phlebology. 2016 Mar;31(1 Suppl):28-33.

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