Axillary artery compression and thrombosis in throwing athletes

Abstract

A 28-year-old major league baseball pitcher sustained an axillary artery thrombosis which was successfully treated with intraarterial urokinase. Subsequent angiography and duplex scanning with the arm elevated in the pitching position demonstrated inducible compression of the axillary artery by the humeral head as well as compression at the thoracic outlet. To determine the incidence of axillary and subclavian artery compression and to investigate the mechanism of injury, brachial artery blood pressures and duplex scans of the subclavian and axillary arteries were performed in both the neutral position and the throwing position in the 92 extremities of 19 major league baseball pitchers, 16 non-pitching major league players, and 11 nonathlete controls. A drop in blood pressure of greater than 20 mm Hg was noted in the position in 56% of extremities tested, with a loss of a detectable blood pressure in 13%. Compression of the axillary artery by the humeral head was documented in 83% of extremities, but in only 7.6% was a greater than 50% stenosis inducible. No statistical difference was found in the incidence of arterial compression between the three groups tested or between their dominant and nondominant extremities. Dissection of the axillary artery in two cadavers documented that abduction and external rotation of the arm causes compression of the axillary artery by the humeral head, which acts as a fulcrum. We conclude that the repetitive mechanical trauma of the throwing motion can cause intermittent compression and contusion of the axillary artery by the humeral head and predisposes the athlete who throws to thrombosis of the axillary artery.

Sonographic evaluation of the axillary artery during simulated overhead throwing arm positions

“…Consistent with the findings of Mochizuki et al (1994) and Rohrer et al (1990), the present study's data reinforces the risk of false positive outcomes with shoulder manoeuvres at the extreme of range. Uniquely, however, the present study's data extends this risk to include diagnostic tests performed at 1201 abduction.…”

“…Compressive injury of the axillary artery most commonly occurs in athletes performing repetitive overhead arm motion (Jackson, 2003 of such injury include baseball pitchers, handball, tennis, and volleyball players (Arko, Harris, Zarins, & Olcott, 2001;Fields, Lemak, & Benmenachem, 1986;Ishitobi et al, 2001;Rohrer, Cardullo, Pappas, Phillips, & Wheeler, 1990;Todd, Benvenisty, Hershon, & Bigliani, 1998;Vlychou, Spanomichos, Chatziioannou, Georganas, & Zavras, 2001). The proposed mechanisms for compressive trauma of the second and third portions of the axillary artery are a tight or hypertrophied pectoralis minor muscle (Dijkstra & Westra, 1978;Finkelstein & Johnston, 1993) and anterior translation of the humeral head (Dijkstra & Westra, 1978;Durham, Yao, Pearce, Nuber, & McCarthy, 1995;Vlychou et al, 2001) combined with repetitive overhead activity.…”

“…Clinically, it is postulated that this manoeuvre stresses the vasculature to accurately reproduce the signs (e.g., radial pulse disappearance) and symptoms (e.g., ischaemic pain, paraesthesia, anaesthesia, heaviness) of vascular compromise. Published case studies have used advanced imaging techniques (i.e., arteriograms, angiograms, ultrasound) to confirm suspected vascular compromise of the axillary artery and its branches, with patency of the arteries in a neutral upper limb position compared to a stenosed or occluded vessel in the hyperabducted position (Arko et al, 2001;Cormier, Matalon, & Wolin, 1988;Fields et al, 1986;Ishitobi et al, 2001;Kee et al, 1995;Nijhuis & MullerWiefel, 1991;Redler, Ruland, & McCue, 1986;Reekers, den Hartog, Kuyper, Kromhout, & Peeters, 1993;Rohrer et al, 1990;Schneider, Kasparyan, Altchek, Fantini, & Weiland, 1999;Todd et al, 1998;Vlychou et al, 2001). Imaging results influence the management of the condition which, in many cases, results in surgery.…”

“…For example, Mochizuki et al (1994) reported posterior humeral circumflex artery occlusion in the hyperabducted position in 80% of asymptomatic subjects using magnetic resonance angiography. Rohrer et al (1990) reported axillary artery compression in 83% of the 92 arms tested (baseball pitchers, athletes and non-athletes) but results were limited by incomplete blood flow assessments and poorly defined testing positions and subject groups. The hyperabduction manoeuvre is confused by varying descriptions in the literature; consequently, results are incomparable.…”

Coil embolization of a posterior circumflex humeral aneurysm in a volleyball player

“…During this manoeuvre, the relatively fi xed circumfl ex arteries are potentially subjected to compression by the humeral head. Cadaver dissections have shown that as the arm is moved into an overhead position, the axillary artery becomes compressed by the humeral head, which acts like a fulcrum [9]. Furthermore, sonographic investigations revealed that the glenohumeral joint is anteriorly translated during the overhead motion and that there is a correlation between such displacement and the degree of axillary artery compression and more distal fl ow-mediated vasodilation [10,11].…”