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Case Study: A Blood Clot, an Athlete and Thoracic Outlet Syndrome

February 23, 2021

After a national tournament game with his Bryant University volleyball team, Jonathan Cloutier iced his left shoulder and massaged the area with his right hand.

“I felt pain in my left armpit. Suddenly, I could feel a vein popping out!” he said, still incredulous five years after the experience.

Team trainers couldn’t identify a cause, so Cloutier, now a 24-year-old data analyst, scheduled a trip home to Newington to see his primary care provider. Fearing a blood clot, the doctor sent him immediately to the Hartford Hospital Emergency Department.

“Doctors did tests and determined it was, in fact, a blood clot caused by thoracic outlet syndrome (TOS) from volleyball,” said Cloutier, who was referred to Dr. Parth Shah, a vascular surgeon and TOS specialist with Hartford HealthCare’s Heart & Vascular Institute.

TOS, Dr. Shah said, is created by the compression of nerves, arteries or veins in the thoracic outlet between the neck and armpit. It mainly affects athletes doing repetitive overhead arm movements. A middle blocker on volleyball teams for years, Cloutier was a classic patient.

“TOS starts as a very benign condition that worsens when the motion becomes more strenuous,” Dr. Shah said. “In Jonathan’s case, his hand turned blue and swollen because the clot blocked blood flow.”

Other athletes in danger of TOS, he said, include baseball pitchers, swimmers and tennis, basketball and hockey players.

“The majority are in high school or college, although there’s another spike in the 30s and 40s among people suffering from whiplash after a car accident,” Dr. Shah said. “When the issue is addressed with surgery and specialized physical therapy, athletes recover well and return to their sport with a very low rate of recurrence. In seven years, we’ve seen no patient with a recurrence.”

Sometimes, athletes suffer with the pain and press on, he said.

“There’s a knowledge gap – they are suffering but don’t know what to do. They swallow it and don’t complain,” said Dr. Shah, who noted that in the early stages of TOS, the symptoms always go away with rest.

The Heart & Vascular Institute TOS program, one of only a few nationwide with significant volume, relies on the multidisciplinary input of specialists in sports medicine, vascular surgery, neurosurgery, pulmonology, pain management and physical therapy. Neurosurgeon Dr. Joel Bauman of the Ayer Neuroscience Institute, for example, works closely with Dr. Shah to perform surgeries involving the brachial plexus, which is the bundle of nerves near the collarbone that are often affected in patients with TOS.

“Dr. Shah and I have been working together for several years to deliver the highest quality TOS patient care from a collaborative, multidisciplinary approach,” Dr. Bauman said. “We are committed to conservative, non-surgical care, but we are also confident in the benefits of TOS surgery in carefully selected patients.”

There are three types of TOS based on what is being compressed – nerve, vein or artery – and treatment depends on the type. For Cloutier, Dr. Shah inserted a catheter delivering clot-busting medication to clean out the clots, and later surgically removed one rib to ease compression.

With physical therapy, Cloutier returned to the volleyball court in six months. Dan Fisher, a physical therapist and site supervisor with the Hartford HealthCare Rehabilitation Network, said physical therapists work with patients like Cloutier to reduce symptoms and restore function.

This, he said, can be done through a variety of interventions designed to reduce the severity of their symptoms, restore range of motion, reduce strength deficits and correct any dysfunctional movement patterns that may have developed. If surgery is required, the rehab team, together with surgeons, has developed a protocol designed to help patients regain function safely and return to their regular activities.

“Treating TOS patients has been rewarding. It is not always a straightforward treatment plan as there are many areas of the body that can be involved when there is pain, numbness and/or tingling in the arm,” Fisher said. “All of these need to be assessed and addressed to achieve the best possible outcomes.”

Even though he’s left the collegiate circuit behind, surgery and rehab helped Cloutier recover to the point that he can continue playing in pick-up leagues year-round, which Dr. Shah called rewarding news.

“This can affect their quality of life significantly – they are unable to do anything involving raising the arm overhead like blow-drying hair, or sitting for long periods working at a computer. Their individual ergonomics are compromised,” he noted.

Once a year, Cloutier sees Dr. Shah for a checkup.

“As scary as it was, I feel very lucky this was discovered and treated,” he said.