THORACIC OUTLET SYNDROME IN AQUATIC ATHLETES

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Shoulder pain is the most common musculoskeletal complaint among competitive swimmers.27, 28, 29, 37 Numerous reports have documented not only the basic impingement syndrome as the most common cause of shoulder pain in swimmers, but also have documented the underlying instability of the glenohumeral joint which predisposes to inflammation of the subacromial bursa and tears of the glenoid labrum.27, 28, 29, 46 Impingement syndrome also is well known among waterpolo players (swimming and throwing), divers (overhead position of the shoulder), open water (or marathon) swimming, and, to a lesser extent, synchronized swimming.

Although often overlooked, the differential diagnosis of shoulder pain in aquatic athletes should include thoracic outlet syndrome (TOS). Several cases serve to illustrate.

Section snippets

Case 1

LW is an 18-year-old, right-handed, white, collegiate female competitive diver who complained of a 3-month history of increasing pain about the left shoulder, with radiation of numbness and tingling to the ring and small fingers of the left hand. The patient also complained of tightness and discomfort about the clavicle. Motor and sensory examination of the left upper extremity was unremarkable. She demonstrated a full, painless range of motion of the cervical spine.

Initial evaluation by a

Case 2

ES is a 22-year-old, left-handed, white male waterpolo player who complained of a 2-year history of pain about the right shoulder, described as a “shoulder strap” pain radiating to the forearm, and ring and small fingers of the right hand. Physical examination revealed a full range of motion of both shoulders and the cervical spine, whereas his neurologic examination was considered normal. Radiographs of the cervical spine and shoulder also were normal.

Following a corroborative neurologic

Case 3

SP is a 24-year-old, nationally ranked competitive female swimmer who complained of right shoulder pain, with radiation of numbness and tingling to the ipsilateral small and ring fingers that was aggravated by hard swim training. She also complained of pain anterior and posterior to the clavicle on the affected side. Because her symptoms prevented her from full practice, she was advised to discontinue her competitive swimming career.

In 1995, Katirji and Hardy15 reported a “classic neurogenic

HISTORY

Entrapment of the neurovascular structures in the area of the neck has been described under a series of names by different authors. In the past, anatomists and physicians had described the existence of an extra rib emanating from the lower cervical vertebrae. Galen (Greece), Versalius (Belgium), and Hunald (Germany) all reported anomalies of the cervical spine, resulting in an extra structure extending from the cervical transverse process to the normal first rib. Gruber reported a

ANATOMY

The major vessels (subclavian artery and vein) exit the mediastinum and pass through and around the scalene muscles (Fig. 1). The subclavian artery passes posterior to the anterior scalene muscle, whereas the subclavian vein normally passes anterior to the scalenus anticus. Both are in close association with the first rib, to which all of the scalene muscles are attached.

The brachial plexus, forming from the C5 to the T1 nerve roots, also gains access to the axilla by passing posterior to the

SYMPTOMS

Symptoms of thoracic outlet syndrome vary widely according to the specific structure being compromised as the neurovascular structures pass from the thorax to the axilla. The neurogenic symptoms are, however, the most common, and are those that seem to have the most effect on the aquatic athlete.

Freestyle, butterfly, and backstroke all require a controlled, repetitive “power” motion at the very extreme of abduction and external rotation of the shoulder (Fig. 5). Hand entry is the beginning of

DIAGNOSIS

There are, perhaps, fewer diagnoses in medicine that are as difficult to confirm as thoracic outlet syndrome. As indicated, a careful history from the athlete will elicit a symptom complex different from that of primary shoulder pain or cervical nerve root compression.

Several tests on physical examination may corroborate the diagnosis. Adson's maneuver (Fig. 9) is performed by pulling down on the patient's arm during deep inhalation and with the head turned toward the affected side;

DOUBLE CRUSH THEORY

Some mention must be made of a concept introduced by Upton and McComas44 in 1973, which stated that proximal nerve compression will render distal portions of the same nerve less tolerant of compression forces. Under this generally accepted theory, carpal tunnel syndrome or cubital tunnel syndrome is more likely to occur in a patient with TOS. It also would imply that an aquatic athlete presenting with signs and symptoms consistent with a distal peripheral nerve compression syndrome should be

NONSURGICAL TREATMENT

Once the diagnosis of TOS is made, a decision must be made regarding treatment, and the choice will be between surgical and nonsurgical approaches. A nonsurgical approach is always preferable; a surgical solution is reserved for those athletes with more severe, recalcitrant symptoms. Alleviation of the symptoms of TOS with nonsurgical measures has been reported as ranging from 50% to 90%.19, 20, 31, 33

Nonsurgical treatment is based upon several assumptions:

  • 1

    Most TOS symptoms are

SURGICAL TREATMENT

The primary goal of any surgical approach to thoracic outlet syndrome is excision of the first rib, and a cervical rib or band, if present, with relief of any soft tissue constrictions about the neurovascular structures. Considerable controversy* exists among those authors who prefer a supraclavicular approach to this area, and other authors who advocate a transaxillary approach to the first rib. Almost all reported series of either approach describe a rather high complication and recurrence

SUMMARY

Thoracic outlet syndrome is a well-recognized group of symptoms resulting from compression of the subclavian artery and vein, as well as the brachial plexus, within the thoracic outlet. Symptoms are related directly to the structure that is compressed. Diagnosis is difficult because there is no single objective, reliable test; therefore, diagnoses of thoracic outlet syndrome is based primarily on a set of historical and physical findings, supported and corroborated by a host of standard tests.

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    *

    From the Division of Orthopaedic Surgery, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii

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    Copyright © 1999 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.