Effort Thrombosis: An Unusual Disease in Athletes
Date: April 1, 2013
Trevor Kozlow wanted to join his college ROTC program. And though a competitive swimmer much of his life, he thought he needed more upper-body strength to get accepted into the program. So began an intensive, two-year regimen of lifting weights, overhead presses and push-ups.
One day at the college gym, Kozlow noticed his right arm was purple and swollen. “It had felt a little tingly, like I had slept on it,” he says, but the arm’s appearance frightened the 19-year-old. Ultrasound pinpointed the cause—a blood clot in his right subclavian vein. Diagnosed with thoracic outlet syndrome, Kozlow was put on an anticoagulant and referred to Julie Freischlag, The Johns Hopkins Hospital’s surgeon-in-chief and a national expert in the condition.
“Only about 3 percent of patients with thoracic outlet syndrome have its venous form,” says Freischlag. “They’re usually young men involved in strenuous athletic activity. As the anterior scalene muscle develops, it becomes so large that it presses on the vein.” The resulting effort-based thrombosis is an acute problem and requires surgery.
In August 2011, Kozlow underwent a scalenectomy with first rib resection, a typical approach to halt vein compression. Also part of his care was a short period on an anticoagulant and a venogram two weeks following surgery, to make sure the vessel was wide open. If it hadn’t been, Freischlag would have performed a balloon dilation. Fortunately, she says, even though vessels can narrow over time, the risk of a new clot there is very low.
As a precaution, Kozlow had the same surgery nine months later on the other side. “I was told there was a 60 percent chance that I could develop a clot in the vein on my left, and that could have been dangerous.”
Unlike Kozlow’s, most cases of thoracic outlet syndrome are neurogenic— the result of chronic repetitive arm movements or a traumatic injury that irritates nerves in the collarbone. Women are more likely than men to have the neurogenic form. “Some patients suffer with symptoms for years before getting a correct diagnosis,” says Freischlag. “So it is important for patients to have a duplex ultrasound performed at a certified vascular lab.”
Physical therapy for six to eight weeks helps a majority of patients with the neurogenic form of the disorder feel better. Some receive injections of lidocaine or botox in addition to physical therapy to relieve symptoms, which include pain and weakness in arms and hands, as well as swelling and tingling.
Freischlag and colleagues are now conducting a randomized study that compares surgery to repeated botox injections in patients with neurogenic thoracic outlet syndrome. She also heads a center of excellence in thoracic outlet syndrome at Johns Hopkins, which includes vascular surgeons, physical therapists and specialists in pain management. “It is most rewarding to see patients like Trevor get back to their active lives,” she says.
The young man, fully recovered, has now turned his athletic interest to running.
*For privacy, the name was changed.
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