Recreational Runner with Right Shoulder Pain and Cyanosis


Mary Tierney, Parminder Nizran, George Pujalte

mtierney@hmc.psu.edu; pnizran@hmc.psu.edu; gpujalte@hmc.psu.edu

Penn State Milton S. Hershey Medical Center

HISTORY: A 25-year-old female presented to the emergency department with right shoulder pain for 3 days. Pain was 10/10 in intensity associated with swelling, numbness, coldness, and cyanosis, which worsened whenever she ran. No recent trauma. She was being followed by Rheumatology for the last 6 months for a positive ANA and anticardiolipin. Symptoms improved with warming, gabapentin, and narcotics.

PHYSICAL EXAM: Normal vital signs. Patient appeared anxious and in pain. Right arm was held at her side, fingers were noted to be purple, hand was swollen and cold to touch over the dorsal and ventral aspects, extending to the mid forearm. She had decreased sensation of the right hand over the median nerve distribution. She had 3/5 weakness of the right arm and tenderness over the right shoulder and right trapezius muscle. There was limited internal rotation and abduction of 70 degrees actively over the right shoulder. She had palpable radial pulses as well as palpable ulnar and superficial palmar arches. Her left shoulder exam was normal.

BROAD DIAGNOSIS: Thoracic outlet syndrome; reflex sympathetic dystrophy; thrombosis; conversion disorder.

RESULTS AND STUDIES: Repeat ANA negative, low immunoglobulin G (IgG) and immunoglobulin M (IgM), positive IgM fraction at 22. Normal white blood cell count, and normal C-reactive protein. Venous duplex initially ordered to rule out a thrombus was negative. MRI of the shoulder showed tendinopathy and partial tear of the supraspinatus tendon. MRI of the brachial plexus and CT angiography of the chest were negative. CT of the neck showed diffuse enlargement of the right trapezius muscle. A repeat ultrasound of the upper extremity with repetitive arm motions was positive for mild venous stasis and reduced phasity of venous flow.

WOKRING DIAGNOSIS: Thoracic outlet syndrome with an unusual mixed presentation of neurologic, venous, and arterial manifestations.

TREATMENT/OUTCOME: Patient underwent a successful surgical resection of the right first rib, with resection of hypertrophied anterior scalene and subclavius muscle. As of this writing, she is currently undergoing rehabilitation and gradually regaining functional mobility of her right arm.

No grant funding was used for this case report.

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