What could be causing left arm swelling in a patient three years post rotator cuff surgery?

Left Arm Swelling Three Years Post Rotator Cuff Surgery

The most critical concern with left arm swelling three years after rotator cuff surgery is upper extremity deep vein thrombosis (DVT), which requires immediate ultrasound duplex Doppler evaluation to rule out this potentially life-threatening complication. 1

Immediate Diagnostic Approach

First-Line Imaging

• Obtain ultrasound duplex Doppler of the upper extremity immediately to evaluate for DVT, which accounts for up to 10% of all diagnosed DVTs and can present with ipsilateral upper-extremity edema, pain, and paresthesia 1
• US has diagnostic sensitivities and specificities above 80% for detecting upper extremity DVT and can be performed at bedside 1
• The examination should assess the jugular, axillary, basilic, cephalic, and brachial veins using both grayscale imaging (to visualize echogenic thrombus and assess vein compressibility) and Doppler flow patterns 1

Risk Factors to Consider

• Advanced age, previous thrombophlebitis, postoperative state, hypercoagulability, heart failure, cancer, trauma, and extrinsic compression all increase UEDVT risk 1
• Unilateral swelling specifically indicates an obstructive process at the level of the brachiocephalic, subclavian, or axillary veins 1

Differential Diagnosis Beyond DVT

Complex Regional Pain Syndrome (CRPS)

• CRPS (reflex sympathetic dystrophy) is a recognized complication of shoulder surgery that can present with arm swelling 1, 2
• Risk of developing CRPS increases with prolonged shoulder dysfunction and can manifest years after the initial surgery 2
• This diagnosis should be considered if DVT is ruled out and the patient has associated pain, temperature changes, or skin changes

Late Surgical Complications

• Frozen shoulder (adhesive capsulitis) is a common complication after rotator cuff repair, occurring in a significant percentage of patients 3
• While typically presenting earlier, late-onset stiffness can contribute to lymphatic or venous congestion 3
• Complications occur in up to 38% of shoulders undergoing rotator cuff repair, with major complications affecting final results in 16% 3

Infection Considerations

• Deep infection, though less common, remains a possibility even years post-surgery and can present with swelling 3
• Look for associated warmth, erythema, fever, or systemic symptoms
• Diabetes increases infection risk after rotator cuff surgery, though evidence is mixed regarding overall complication rates 1

Lymphatic Obstruction

• Lymphedema from surgical disruption or malignancy can cause upper extremity swelling 1
• Consider oncologic evaluation if other causes are excluded, particularly given the patient's age and time since surgery

Critical Clinical Assessment Points

Physical Examination Findings to Document

• Assess for palpable cord or induration suggesting superficial thrombophlebitis (though this rarely causes diffuse arm swelling) 1
• Evaluate for signs of venous obstruction: cyanosis, prominent superficial veins, temperature differences 1
• Check for signs of infection: warmth, erythema, fluctuance, fever
• Assess shoulder range of motion and strength to evaluate for frozen shoulder or rotator cuff re-tear 3
• Examine for signs of CRPS: skin changes, temperature asymmetry, allodynia 1, 2

Timing Considerations

• The three-year interval makes acute surgical complications less likely but does not exclude them 4, 3
• Late complications can occur, and imaging findings do not always correlate with symptoms 5
• Rotator cuff re-tears can occur and may contribute to altered biomechanics affecting venous or lymphatic drainage 4

Management Algorithm

1. Immediate ultrasound duplex Doppler - This is non-negotiable given DVT risk 1
2. If DVT confirmed: Initiate anticoagulation per standard protocols
3. If DVT excluded: Obtain standard radiographs to assess for hardware complications, arthropathy, or other bony abnormalities 5
4. Consider MRI if radiographs are unrevealing and metal burden is low, or CT if significant hardware present 5
5. Evaluate for systemic causes: Check for heart failure, liver disease, renal disease, malignancy 1

Common Pitfalls to Avoid

• Do not assume the swelling is simply "post-surgical" without imaging - DVT can be life-threatening if it leads to pulmonary embolism 1
• Do not delay imaging for "conservative management" - the three-year interval makes this an acute change requiring investigation
• Do not rely solely on clinical examination - UEDVT can be asymptomatic or have subtle findings 1
• Remember that post-operative imaging abnormalities do not necessarily correlate with symptoms, so clinical correlation is essential 5