title: SCREENING FOR REFERRAL BY A SPORTS PHYSICAL THERAPIST REVEALS AN EFFORT THROMBOSIS IN A COLLEGIATE PITCHER: A CASE REPORT.
abstract: OBJECTIVE
  Screening for referral, regardless of setting, is the responsibility of all physical therapists. A serious condition that sports physical therapists may encounter is upper extremity (UE) deep venous thrombosis (DVT), which can result in the important and sometimes fatal complication of pulmonary embolism.
  
  
  METHODS
  A 22 year-old male right-hand dominant collegiate pitcher was referred for physical therapist evaluation and treatment secondary to acute right UE pain and swelling. The athlete described the onset of these symptoms as insidious, denying any form of trauma. The athlete had undergone testing, which included UE Doppler ultrasound of the bilateral UE veins and a computed tomography (CT) scan of the chest without contrast; both of which were deemed negative. He was subsequently diagnosed with thoracic outlet syndrome and referred to the team physical therapist. After examination, the physical therapist hypothesized the athlete was presenting with a possible vascular compromise. Findings leading to this decision were: 1) insidious onset, 2) inability to account for the athlete's pain with ROM, strength, neurological, or provocation testing, 3) significant swelling of the right UE (arm and forearm), 4) increased discomfort with palpation in the supraclavicular region, and 5) history of strenuous UE use.
  
  
  RESULTS
  The athlete was referred back to the orthopedist. A venogram CT was ordered, which revealed an axillary and subclavian DVT and the presence of venous collaterals. The athlete was referred to a vascular surgeon who performed a right first rib removal. The athlete was able to complete post-operative rehabilitation and successfully return to competitive throwing the following spring.
  
  
  CONCLUSIONS
  The delay in the initial diagnosis may have been due to the vague symptomology associated with venous complications and negative findings upon initial diagnostic testing.
  
  
  CONCLUSIONS
  This case report highlights the importance of subjective and physical examination findings and use of diagnostic testing for timely identification of an UE DVT. Ultimately, the physical therapist in this case was able to screen for referral, which led to the correct diagnosis and allowed the athlete to safely and successfully return to sport. Physical therapists should include effort thrombosis in their upper quarter differential diagnosis list for athletes who perform strenuous UE activity.
  
  
  METHODS
  4.
authors.affiliation: Western Kentucky University, Bowling Green, KY, USA.
authors.forename: William R
authors.initials: WR
authors.lastname: VanWye
authors.affiliation: Orthopedics Plus Physical Therapy, Bowling Green, KY, USA.
authors.forename: Jase
authors.initials: J
authors.lastname: Pinerola
authors.affiliation: Baptist Health, Lexington, KY, USA.
authors.forename: Karen Craig
authors.initials: KC
authors.lastname: Ogle
authors.affiliation: Western Kentucky University, Bowling Green, KY, USA.
authors.forename: Harvey W
authors.initials: HW
authors.lastname: Wallmann
keywords: Baseball; Paget-Schroetter syndrome; deep venous thrombosis; effort thrombosis; upper extremity thrombosis