Case Report 11/13/14 Tad DeWald, MD PGY-3

Disclosure Speaker has no relevant financial disclosures.

History A right-hand-dominant 23-year-old college male swimmer presented with persistent right shoulder pain, numbness, and paresthesia with radiation down the medial aspect of the right upper extremity. Patient stated that symptoms started gradually over a week and would only present during distances over 1,000 meters. Symptoms resolved when the athlete ceased activity.

History PMH:Negative Meds: None Social: No alcohol/tobacco use Functional: right-hand dominant, fully independent

5 Physical Exam 5 HEENT: NC, AT, PERRL, cervical spine non-tender, full AROM Resp: B/L CTA CV: +S1S2, RRR, No murmurs, gallops, or rubs. Abdomen: Soft, non-tender, non-distended, BS+ Skin: no rashes or ulcers Extremities: pulses 2+ throughout, no edema Neuro/MSK: 5/5 strength throughout, sensation intact, cervical spine non-tender, full AROM Patient demonstrated normal physical exam. However, patient’s symptoms were reproduced with his right arm fully abducted and externally rotated Equivocal Adson’s test.

Differential Diagnosis Thoracic outlet syndrome Peripheral nerve injury/compression Impingement syndrome Brachial plexopathy Radiculopathy Venous/Arterial Thrombus Rotator Cuff pathology Strain Sprain

8 Work Up US Duplex Venous US Duplex Arterial IR Angiogram MRI Electrodiagnostic studies 8

9 RUE Arterial Ultrasound 9 IMPRESSION: Neutral position of the arterial system was normal. During stress views, there was elicitation of symptomatology per the patient. No appreciable change however was demonstrated in the waveform patterns of the arterial system.

9 RUE Venous Ultrasound 9 IMPRESSION: Normal right upper extremity venous Doppler

9 IR Angiogram Upper 9 IMPRESSION: 1. No evidence of either venous or arterial thoracic outlet syndrome. 2. No angiographic abnormality in the neutral position. However, there is compression of the bilateral axillary arteries and circumflex humeral arteries with extreme abduction and external rotation.

9 MRI Right shoulder 9 IMPRESSION: No acute abnormality. No masses seen within the quadrilateral space. Neurovascular structures appear unremarkable.

9 Electrodiagnostic studies 9 Electrodiagnostic studies did not demonstrate abnormalities in the axillary, ulnar, or median nerves with normal EMG of corresponding muscles.

10 Clinical Course 10 Dx- Quadrilateral Space Syndrome Patient resumed activity and continued to swim competitively with modification in training duration and regimen, demonstrating improvement in symptoms. The athlete will be evaluated for possible surgical decompression in the offseason.

10 TITLE: Quadrilateral Space Syndrome in a Collegiate Male Swimmer: A Case Report. AUTHORS: Tad DeWald, MD, Geraldine Dapul, MD, Paul Withers, MD, Aashish Deshpande, MD, Parmod Mukhi, MD INSTITUTIONS: Wayne State University/Oakwood Hospital Systems

10 Thank you! 10 Discussion/Questions?