Thursday, May 11, 2017
This is the story of Jeurys Familia, the 27-year-old pitcher for the New York Mets. After pitching poorly and coaches concern about the power and velocity of his pitches, he was off to the doctor who found a blood clot in his axillary artery that is the main supply of blood to his pitching arm.
Blood clots in an artery are supposed to happen in patients who have longstanding risk factors for atherosclerosis, including high blood pressure, high cholesterol, diabetes and smoking. Plaque, a waxy, cholesterol deposit builds up on the inside of the artery wall causing it narrow. If that plaque ruptures, the artery can be completely occluded by a thrombus (clot) and blood supply is lost beyond the obstruction. This is the mechanism that causes a heart attack or stroke. The situation is a medical crisis and the patient or family needs to recognized the symptoms so that patient can get emergency care to open the blocked artery and restore blood flow.
Young, elite athletes aren’t supposed to develop arterial blood clots. Being young and healthy is protective for diseases of old age, except there are other reasons for an artery to narrow, and when it does, blood flow can slow enough to form the begins of a blood clot that can slowly grow and impeded blood flow. There are a couple of case reports in the medical literature that explain why pitchers can develop clots in their throwing arm.
A pitcher puts plenty of torque on the shoulder with each overhead throw of a ball and if the muscles, tendons, and ligaments can’t keep the shoulder joint stable, overtime it will become lax or a little loose. Studies o show that after 50 throws, pitchers with shoulder laxity have slower and less blood flow than a pitcher with normal shoulder anatomy and function. These studies show that part of the axillary artery gets compressed with each throw and then gradually recovers between pitches.
As the arm is abducted, or raised up away from the body, there is less black dye flowin the artery
Over time, the risk of clot formation increases but symptoms are vague and can be misinterpreted as being caused by nerve compression. Athletes will present with complaints of cold intolerance, hypersensitivity, pain, numbness, or arm fatigue during or immediately after practice and competition. And this may be a reasonable alternative diagnosis since the nerves to the arm pass right next to the axillary artery in the armpit. Nerve damage was the cause of the pain and numbness of another Mets’ pitcher, Matt Harvey, whose problem was due thoracic outlet syndrome, where a rib pressed onto the nerve. He required surgery to remove part of the rib to make room for the axillary artery and nerve to pass into the arm.
But physical examination should detect a cooler hand or arm that may be slightly discolored and pulses may be difficult to feel at the wrist. Those would be classic finding, but many patients don’t read the textbook and physical findings may resolve relatively quickly if the axillary artery opens enough on its own after being in spasm. The finding may be missed by the trainer or doctor if the physical exam happens after the symptoms have resolved. As the artery further narrow, symptoms persist longer and longer, until they are more obvious and the artery more compromised with increase clot formation.
It’s still early in Mr. Familia’s assessment to decide what treatment will be required. Imaging of the shoulder joint (likely MRI) and the arteries (CT angiography) will need to be done to look at the anatomy of the shoulder and blood vessels and assess the blood flow to the arm. If the axillary artery is scarred, then the damaged part of the artery needs to be cut away and replaced. While it may take weeks to allow the area to heal, if blood flow is re-established to normal levels, the goal will be to allow him to throw again at the major-league level.
The lesson to be learned is that symptoms that might be from artery damage or occlusion shouldn’t be ignored, whether it is a heart attack and chest pressure/pain, or a stroke with weakness, slurred speech and confusion or an arm that turns a little blue and hurts.
This entry was tagged Axillary artery, clot thrombus, Jeurys Familia, Matt Harvey, New York Mets, occlusion, thoracic outlet syndrome
Tuesday, September 13, 2016
First rib displacement, not a fracture or a broken bone. Philadelphia Eagle coach, Doug Pederson, talking about an injury sustained by his receiver, Zach Ertz. The trainer thought he had strained a shoulder, but later decided that it was a first rib issue. Sometimes it’s difficult to appreciate the type of injury based on a medical report relayed by a coach, but it is helpful to understand that the source of pain is not always where the pain is felt.
The body is sometimes evil in trying to trick patients and doctors by having a diagnosis made that misinterprets symptoms.
- In the back of every doctor’s mind is the fact that a leaking abdominal aortic aneurysm is masquerading as renal colic, an awful waxing and waning pain from kidney stones. Not treating a kidney stone leaves you with a very unhappy and painful patient, but missing a leaking aneurysm leaves a very dead patient.
- Indigestion can be just that, an irritated stomach and esophagus, uncomfortable because of acid buildup. But woe is the patient and doctor who forgets that indigestion is also a common symptom of angina or pain due to narrowing of blood vessels to heart muscle. Inferior myocardial; infarction, a heart attack that affects the bottom part of the heart is notorious for causing GI complaints.
- Bell’s Palsy looks frightening; one side of a patient’s face stops working and droops. It’s due to inflammation of a peripheral nerve (the 7th cranial nerve) and is not due to a stroke. The way that the face muscles are wired, in Bell’s, the patient cannot wrinkle their forehead on the affected side but in the midst of a stroke, the patient’s forehead can wrinkle and move, but the lower two thirds of the face may be weak or paralyzed.
Thoracic Outlet Syndrome
In the case of thoracic outlet syndrome, shoulder and arm pain may be due to narrowing of the space between the collarbone and the first rib. That space is filled with the brachial plexus, (the bundle of nerves that allow the arm, wrist and hand to feel and move), the subclavian artery that sends blood to the arm and the subclavian vein that returns blood to the heart. If the space narrows enough, symptoms of numbness tingling, pain, and weakness in the neck, shoulder, arm and hand may develop; but the cause of the symptoms isn’t where they are felt but instead are due to not having enough real estate around the first rib. Sometimes, surgery is needed to remove the first rib and allow enough room for that important stuff to live peacefully. Matt Harvey of the New York Mets and Kyle Zimmer of the Kansas City Royals both had surgery to fix thoracic outlet syndrome this summer.
The injury suffered by Zach Ertz may potentially cause his first rib to narrow the thoracic outlet space.
In the world outside of the NFL, the patient complaint allows the doctor and patient to develop the differential diagnosis, a list of ailments that might be the cause of the symptoms. Sometimes, that list is short; imagine an ankle injury where the list might include an ankle sprain or fracture. Sometimes the list is long; an infant who is colicky. Common things are common and colic would be good bet, but other potential diagnoses might include issues within the abdomen like a hernia, intussusception or testicular torsion. Colic doesn’t have to come from the abdomen and children can be irritable because of a corneal abrasion, pneumonia, meningitis or food intolerance. Not every diagnosis is evident and it sometimes takes work to sort things out.
For that reason, the trainer is allowed to miss the diagnosis on the first patient touch, examining the player in full pads on the field, in front of 70,000 fans and with too many television cameras zooming on the scene. As the game progressed, Mr. Zach likely was repeatedly evaluated and the diagnosis came to light. The medical lesson to be learned is that the body is a complicated machine and one needs to be wary of the tricks it can play on unsuspecting patients and doctors.
This entry was tagged differential diagnosis, Doug Pederson, first rib, thoracic outlet syndrome, Zach Ertz