Original Articles from the New England Society for Vascular Surgery
Axillary artery compression and thrombosis in throwing athletes*

Presented at the Sixteenth Annual Meeting of the New England Society for Vascular Surgery, Bretton Woods, N.H., Sept. 21-22, 1989.
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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 nonpitching 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. (J VASC SURG 1990;11:761-9.)

Section snippets

Case report

A 28-year-old right-handed major league baseball pitcher had a 36-hour history of right arm coolness and fatigue, which he noted after throwing more than 100 pitches in each of three consecutive starts over the previous 10 days. On physical examination his systolic blood pressure was 114 mm Hg in the left arm, but only 70 mm Hg systolic at the brachial position on the right and was detectable only with the aid of a Doppler ultrasonic stethoscope. The axillary artery pulse in the axilla as well

Methods

To establish the incidence of inducible axillary and subclavian artery compression and to study the mechanism of injury to the axillary artery, brachial artery blood pressures and duplex ultrasound scanning were performed in a group of professional major league pitchers, nonpitching major league baseball players, and nonathlete male controls. The studies were performed with the patient's arm in the neutral position and a position of extreme abduction and external rotation simulating the

Results

Ninety-two upper extremities were examined in 19 professional baseball pitchers, 16 nonpitching major league baseball players, and 11 nonathlete controls. A complete evaluation was possible on each subject in both arms.

The magnitude of blood pressure drop noted when the arm was moved from a neutral position to an extreme position of abduction and external rotation is categorized in Table I.

. Blood pressure drop with arm elevated in throwing position

Empty CellFall in blood pressure (mm Hg)
Empty Cell0-2021-40>40to 0Empty Cell

Discussion

Although in our study professional baseball pitchers were found to have the highest incidence of inducible arterial occlusion at the thoracic outlet and humeral levels, this was a common finding in all groups tested. The incidence of arterial compression as identified by a blood pressure drop of 20 mm Hg or greater with the arm in the throwing position was 56%, which is quite similar to the finding of Gergoudis and Barnes9 who documented the presence of inducible arterial compression in 60% of

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*

Reprint requests: Michael J. Rohrer, MD, Division of Vascular Surgery, University of Massachusetts Medical Center, 55 Lake Ave. North, Worcester, MA 01655.

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Copyright © 1990 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. Published by Elsevier Inc. All rights reserved.