Forearm Compartment

and Thoracic Outlet

Syndrome in a
Collegiate Softball
Pitcher
JULIA VILLANI, LAT, ATC
Background

20 year old softball pitcher

Chief complaint right forearm pain during
and after pitching
Improper pitching mechanics: arm hitting
hip
Mild swelling, full ROM and strength
Previous history of pronator teres strain
Treated with rehabilitation and platelet
rich plasma injection
Differential Diagnosis

Flexor muscle strain

Tendinopathy
Forearm contusion
Nerve irritation
Chronic Exertional Compartment
Syndrome of forearm
Evaluation
Achy pain of the forearm during and Negative Electromyography and nerve
after pitching conduction test
Mild swelling Unremarkable X-ray
Normal ROM Pre and post exercise compartment
pressure check revealed significant
No muscular weakness
findings
Numbness in the 4th and 5th phalanx
MRI revealed mild edema in the
Positive Tinels sign at elbow margins of the flexor carpi ulnaris
Negative Allens test. muscle but no muscle or tendon tears
and no boney pathology
Treatment

Ulnar nerve decompression

Fasciotomy of the anterior/volar
compartment
8-week postsurgical rehabilitation
program: wound care, ROM, strength
and throwing progression
Cleared to return to full participation
and continued to be symptom free
for the following 16 months
Treatment Cont.
Patients neurological symptoms returned
middle of her senior season
Opted to continue with full participation and
treat symptoms conservatively
Repeat nerve conduction test and cervical MRI
normal
Referred to thoracic outlet specialist and
diagnosed with TOS
Surgical removal of 1st rib, anterior and middle
scalene
Resolution of symptoms
Uniqueness

Rate of exertional (chronic) forearm compartment syndrome is very

rare
Rate of thoracic outlet syndrome is rare
Prolonged timeline to diagnosis
Unusual mechanism, possibly due to improper throwing mechanics
Both conditions have very similar symptoms
TOS: Both: CECS:
Overhead Gradual onset Increased
movements Achy pain in arm intracompartment
Positive Pooling edema pressure during/after
supraclavicular Sensory loss activity
Tinel sign Repetitive motion Pain resolves with
Decreased skin Decreased/absent cessation of activity
temperature pulse Special tests: None
Special tests: Muscular
Allen's, Adson's, weakness
Roos

*Possible misdiagnosis and unnecessary surgical procedure

Literature Review
Chronic Exertional Compartment Syndrome (CECS) of Forearm
Level of Evidence: Case Reports, only 69 reported cases in literature
Rarity of condition and non-specific symptoms makes it hard to diagnose
Most common sports: motor bike sports, mountain climbing, weight lifting,
kayaking
Chronic exertional compartment syndrome often have increased resting
compartment pressures
Hypertrophy of forearm musculature and increased fascial thickness
Intracompartmental pressure measurement key in diagnosis
30mmHg or greater for dx
However there is no gold standard
Forearm compartment decompression effective in relieving the symptoms
Literature Review
Thoracic Outlet Syndrome (TOS)
Level of Evidence: Case Series, limited research
Disputed neurogenic TOS incidence is reported to range from 3 to 80 per 1000
people
Found in athletes due to muscular hypertrophy and repetitive arm movements
o Hypertrophy of the scalenus anticus muscle
o Swimming, rowing, baseball, softball, volleyball, weightlifting
Has been misdiagnosed as carpel tunnel syndrome
85% of patients returned to full participation after surgical intervention
 Conclusion

Limited knowledge on both forearm compartment and thoracic outlet

syndrome in regards to mechanism of injury, best treatment options, and
correct identification and diagnosis
Use this unique case to better guide diagnosis and treatment of upper
extremity neurovascular injuries in the future
A differential diagnosis of TOS should be included when considering CECS
and vice-versa

Summer 2013 Spring 2014 Fall 2014 Fall 2014 Winter 2014 Spring 2016 Summer 2016
8 wk rehab: Return of Dx w/
Muscle Return of Referral to Ulnar nerve
RPT symptoms: TOS:
Strain: tx symptoms: Team MD: decomp &
symptom Conservative 1st rib
w/ PRP Conservative tx dx w/ FCS fasciotomy
free tx removal
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