PART III – Clinical management

Increasing awareness among medical professionals through the dissemination of knowledge about this vascular injury will enable recognition, which is important to prevent the development of an advanced stage of the disease with serious ischemic complications. Invasive treatment options for PCHA aneurysms result in several months of rehabilitation and absence from volleyball activities. However, if PCHA pathology can be detected at an early stage, serious ischemic complications, irreversible tissue damage, and surgical ligation of the PCHA might be prevented. Since volleyball players are considered potentially at risk for developing critical digital ischemia in the spiking hand, analysis of the presence of PCHA pathology, and associated risk factors is warranted for prevention. Ultimately, establishing risk profiles of individual athletes would support clinical management.

 

The objectives of chapter 9 were fourfold: (1) to assess the prevalence of PCHA pathology in the dominant shoulder among elite volleyball players; (2) to determine its association with self-reported symptoms of digital ischemia in the spiking hand; (3) to assess possible personal- and sports-related risk factors, including dose-response relationship; and (4) to provide individual risk profiles for the clinical management of PCHA pathology based on prevalence, symptoms and associated risk factors. Two-hundred-seventy-eight elite indoor- and beach volleyball players completed the SPI-Q assessing symptoms of digital ischemia and associated risk factors, prior to SPI-US screening for the presence of PCHA pathology, namely aneurysms, dilatations, and occlusions. PCHA pathology was detected in 17 participants (6.1%). In total, 96 of 278 participants reported symptoms associated with ischemic digits (35%) which were not associated with PCHA pathology (OR=0.39; 95%CI 0.13-1.13). A total volleyball career duration of 17 years or more and an age of 27 years or more were associated with a 9-fold (OR 9.21; 90%CI 1.61-52.63) and 14-fold (OR 13.61; 90%CI 2.43-76.40) increased risk of PCHA pathology, respectively. Four risk profiles for elite volleyball players were formulated based on the combination of: (1) the presence of US-detected PCHA pathology (US+ or US−); and (2) symptoms of digital ischemia (Q+ or Q−); I) 1.1% US+Q+ (n=3), II) 5.0% US+Q− (n=14), III) 33.5% US−Q+ (n=93), and IV) 60.4% US−Q− (n=168). For each risk, profile recommendations for clinical management are proposed to optimize care for this potentially limb-threatening vascular overuse injury.

Related article: van de Pol D, Kuijer PPFM, Terpstra A, Pannekoek-Hekman M, Alaeikhanehshir S, Bouwmeester O, Planken RN, Maas M. Posterior Circumflex Humeral Artery Pathology and Digital Ischemia In Elite Volleyball: Symptoms, Risk Factors & Suggestions For Clinical Management. Submitted.. – article link expected soon

Chapter 10 describes a case of a 34-year-old elite male volleyball player with symptomatic emboli in the spiking hand from a partially thrombosed aneurysm of the PCHA in his dominant shoulder. At 15-month follow-up after cessation of volleyball activities, digital blood pressure values almost normalized and a novel Magnetic Resonance Angiography (MRA) protocol showed an unchanged PCHA aneurysm and resolution of central filling defects in the digital arteries with post-thrombotic changes. This case report is the first to show promising results of conservative management as an alternative to more invasive treatment modalities for this vascular shoulder overuse injury.

Related article: van de Pol D, Planken RN, Kuijer PPFM, Terpstra A, Pannekoek-Hekman M, Maas M. Non-operative management & novel imaging for posterior circumflex humeral artery injury in volleyball. Submitted.. – article link expected soon