What are the possible causes and management options for upper arm swelling towards the elbow after bowling?

Upper Arm Swelling Towards Elbow After Bowling: Differential Diagnosis

The most critical diagnosis to exclude in upper arm swelling after bowling is effort thrombosis (Paget-Schroetter syndrome), a primary upper extremity deep vein thrombosis that occurs in young athletes performing strenuous upper extremity activity and can lead to pulmonary embolism if missed. 1, 2

Primary Differential Diagnoses

Effort Thrombosis (Paget-Schroetter Syndrome)

• Primary upper extremity DVT accounts for approximately one-third of all UEDVT cases and occurs due to venous thoracic outlet syndrome from repetitive strenuous upper extremity use 1
• Presents with ipsilateral upper extremity edema, pain, paresthesia, and functional impairment 1
• Unilateral swelling indicates an obstructive process at the level of the brachiocephalic, subclavian, or axillary veins 1
• Can present with vague symptomology and may have negative initial diagnostic testing, as demonstrated in a collegiate pitcher case where initial Doppler ultrasound was falsely negative 2
• This is a medical emergency requiring immediate vascular evaluation 2

Muscle Strain/Contusion (Biceps Brachii)

• Bowling generates significant forces and torques on upper limb muscles, making the biceps brachii vulnerable to overuse injury 3
• The biceps muscle shows maximum activity during ball release and follow-through phases of bowling 3
• Recurring dynamic contractions can lead to biceps tendonitis and shoulder pain commonly observed in bowlers 3

Common Extensor Tendon Injury (Lateral Epicondylitis)

• Overuse tendon pathology affecting the lateral elbow, though typically presents with lateral elbow pain rather than diffuse upper arm swelling 4, 5
• Less likely given the swelling pattern described, but possible if combined with other pathology 4

Soft Tissue Infection/Cellulitis

• Soft-tissue swelling can result from increased capillary permeability due to infection or inflammation 1
• Would typically present with erythema, warmth, and systemic signs 1

Lymphatic Obstruction

• Can cause upper extremity swelling due to lymphedema or malignancy 1
• Less common in acute athletic injury but should be considered if other causes excluded 1

Initial Diagnostic Approach

Immediate Clinical Assessment

• Look for unilateral swelling (suggests venous obstruction), pain with palpation in supraclavicular region, inability to account for pain with ROM/strength testing, and history of strenuous upper extremity use 2
• Assess for signs of infection: erythema, warmth, fever 1
• Evaluate for palpable cord suggesting superficial thrombophlebitis (rarely causes diffuse arm swelling) 1

Initial Imaging

• Plain radiographs are usually appropriate as the first imaging study to exclude fracture or bony abnormality 1

If Radiographs Normal and DVT Suspected

• US Duplex Doppler of the upper extremity is the initial imaging modality of choice for suspected UEDVT 1
• Sensitivity and specificity above 80% for UEDVT diagnosis 1
• Evaluates jugular, axillary, basilic, cephalic, and brachial veins effectively 1
• Dampening of cardiac pulsatility or respiratory variation on Doppler examination indicates central venous obstruction 1
• Critical pitfall: Initial ultrasound can be falsely negative; if clinical suspicion remains high, proceed to venogram CT 2

If Radiographs Normal and Soft Tissue Injury Suspected

• Ultrasound or MRI without IV contrast are equivalent appropriate options for assessment of suspected tendon, ligament, or muscle injury 1
• Ultrasound has moderate agreement with MRI for tendon pathology (sensitivity 64.52%, specificity 85.19%) 1, 4

Management Based on Diagnosis

If Effort Thrombosis Confirmed

• Immediate referral to vascular surgery 2
• May require first rib resection and anticoagulation 2
• Delay in diagnosis increases risk of pulmonary embolism 1, 2

If Muscle Strain/Tendon Injury

• Relative rest with activity modification (continue activities that don't worsen pain) 4
• Cryotherapy for 10-minute periods through wet towel 4
• NSAIDs (topical preferred to avoid GI risks) 4
• Counterforce bracing during activities 4
• Eccentric strengthening exercises after acute phase (2-8 weeks) 4

If Soft Tissue Infection

• MRI with and without IV contrast is usually appropriate for better delineation of fluid collection and areas of necrosis 1
• Antibiotic therapy and possible surgical drainage 1

Critical Pitfalls to Avoid

• Do not dismiss the possibility of effort thrombosis based on negative initial ultrasound alone; venogram CT may be required 2
• Do not attribute all upper extremity swelling in athletes to musculoskeletal injury without excluding vascular compromise 2
• Failure to recognize unilateral swelling as a red flag for venous obstruction 1
• Overreliance on corticosteroid injections for presumed tendinitis, which may weaken tendons and mask serious pathology 4