What Is Upper Extremity Deep Vein Thrombosis?

Upper extremity deep vein thrombosis (UEDVT) involves blood clots in the deep veins of the upper limb, such as the subclavian, axillary, or brachial veins. Although it is more rare than its lower extremity DVT counterpart, it still accounts for approximately 5–10% of all DVT cases (Mintz, 2017).

Venous Thoracic Outlet Syndrome (vTOS) as a Cause of UEDVT

vTOS refers to compression of the subclavian vein at the thoracic outlet, particularly at the costoclavicular junction between the first rib and clavicle. This compression can lead to stagnation of the blood in the veins and endothelial injury, predisposing individuals to a blood clot (Yuen et al., 2022). Paget-Schroetter Syndrome (PSS), also known as effort thrombosis, is a form of vTOS typically seen in younger, active individuals and is characterized by upper extremity DVT resulting from repetitive upper limb movements (Hoexum et al., 2023). Several basketball players in recent years have been diagnosed with this condition, including Damian Lillard, Victor Wembanyama, and Brandon Ingram.

Pathophysiology

The development of UEDVT in vTOS involves elements of Virchow’s triad:​

• Venous stasis (blood pooling): Due to compression of the subclavian vein.
• Endothelial injury: From repetitive arm movements causing trauma.
• Hypercoagulability: May be present in some individuals.​ 

These factors collectively increase the risk of thrombosis in the affected limb (Hoexum et al., 2023) 

Physiotherapy in Prevention, Assessment, and Treatment of vTOS

Role of Physiotherapy

Physiotherapy is extremely beneficial in the non-surgical management of vTOS. It aims to alleviate symptoms, improve posture, and enhance functional mobility (Thompson et al., 2025).​

Assessment Techniques

Physiotherapists assess for:​

• Postural abnormalities: Such as forward head posture and rounded shoulders. This can lead to compression of those blood vessels in the subclavian space.
• Muscle imbalances: Particularly tightness in the scalene and pectoralis minor muscles which can further compress those blood vessels (Thompson et al., 2025).
• Range of motion limitations: In the cervical spine and shoulder girdle as restrictions in ROM and immobilization can reduce blood flow and contribute to venous stasis (Thompson et al., 2025).​ 

Special tests used include:​

• Adson’s Test: Assesses for compression of the subclavian artery by extending the neck and rotating the head toward the symptomatic side while monitoring the radial pulse.

• Roos Test (Elevated Arm Stress Test): Involves the patient abducting and externally rotating the shoulders while opening and closing the hands for several minutes to reproduce symptoms.

• Wright’s Test: Evaluates for compression of the neurovascular bundle by assessing pulse changes with hyperabduction of the arm.

Treatment Strategies

Physiotherapy interventions focus on:​

• Postural correction: Through exercises that strengthen the scapular stabilizers and stretch tight anterior chest muscles.
• Manual therapy: To mobilize the first rib and soft tissues around the thoracic outlet.
• Neuromuscular re-education: To promote proper movement patterns and reduce strain on the thoracic outlet.​

Physiotherapy interventions aim to reduce compression on the neurovascular structures and alleviate symptoms associated with vTOS (Thompson et al., 2025). 

Collateral Veins and Post-Thrombotic Syndrome (PTS) After Upper Extremity DVT

Collateral Vein Formation

In response to venous obstruction from thrombosis, the body may develop collateral veins to bypass the blockage and maintain venous flow. These veins can become prominent and visible under the skin especially in the shoulder, and upper chest regions. Certain symptoms may occur alongside this physical presentation including swelling, heaviness, and discomfort in the affected limb if collateral circulation is insufficient (Martinez 2025).

Physiotherapy Management of Collateral Veins Post-UEDVT

Physiotherapy plays a crucial role in managing the symptoms associated with collateral vein development and preventing complications such as post-thrombotic syndrome (Martinez 2025) Interventions include:​

• Compression Therapy: Compression sleeves or tensor bandage can help reduce edema, alleviate discomfort, and support venous return. The efficacy of compression therapy is much less established the in upper extremities than in the lower extremities, but it still remains a commonly recommended approach. ​
• Exercise and Mobility: Exercise programs that include limb elevation, aerobic activities, and resistance training can enhance venous return and reduce symptoms. 
• Manual Therapy: Techniques such as soft tissue mobilization and manual lymphatic drainage can also assist in managing swelling and improving tissue health.​
• Patient Education: Education on the importance of regular movement, proper limb positioning, and adherence to compression therapy can help patients manage their condition effectively

Post-Thrombotic Syndrome (PTS) After Upper Extremity DVT

PTS is a long-term complication of DVT characterized by chronic pain, swelling, and skin changes in the affected limb. If the compression of the subclavian vein is not promptly addressed, this can result in PTS (Schleimer et al., 2016). Sustained venous hypertension resulting from residual vein obstruction, valvular reflex, where there is abnormal, backwards flow of blood, and venous wall remodeling are the pathophysiological causes (Martinez 2025). In the upper extremity, PTS can result in symptoms such as heaviness, pain during arm elevation, and muscle cramps. The incidence of PTS is more common in lower extremity DVT, but still exists following an upper extremity DVT. A systematic review titled “Prevalence of post-thrombotic syndrome in a cohort of upper extremity vein thrombosis,” they found a prevalence rate of 14.1% with higher rates observed in patients with a history of stroke and reduced limb movement (Herve et al., 2022)

Role Of Physiotherapy

Physiotherapy management is a crucial component in both the prevention and management of PTS (Schleimer et al., 2016). Prevention strategies include: 

• Early Mobilization: Encouraging movement of the affected limb as soon as possible after DVT diagnosis can enhance venous return and reduce the risk of PTS.
• Postural Correction: Addressing postural abnormalities, such as forward head posture and rounded shoulders, can alleviate compression at the thoracic outlet, reducing the risk of recurrent thrombosis.​
• Education: Informing patients about the importance of limb elevation, avoiding prolonged immobility, and recognizing early signs of PTS is vital.
• Manual Therapy: Techniques such as soft tissue mobilization and joint mobilizations can address musculoskeletal contributors to thoracic outlet compression  

References

Hervé, H., Toquet, C., Ploton, G., Connault, J., Gautier, G., Raimbeau, A., Bergère, G., Hersant, J., Durant, C., Artifoni, M., Brebion, N., Kubina, J.-M., Pistorius, M.-A., & Espitia, O. (2022). Prevalence of post-thrombotic syndrome in a cohort of upper extremity vein thrombosis. Journal of Vascular Surgery: Venous and Lymphatic Disorders, 10(1). https://doi.org/10.1016/j.jvsv.2021.04.006 

Hoexum, F., Hoebink, M., Coveliers, H. M. E., Wisselink, W., Jongkind, V., & Yeung, K. K. (2023). Management of paget-schroetter syndrome: A systematic review and meta-analysis. European Journal of Vascular and Endovascular Surgery, 66(6), 866–875. https://doi.org/10.1016/j.ejvs.2023.08.065 

Mintz, A. (2017, November 16). Upper Extremity deep vein thrombosis. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2017/11/09/13/30/upper-extremity-deep-vein-thrombosis 

Schleimer, K., Barbati, M. E., Gombert, A., Wienert, V., Grommes, J., & Jalaie, H. (2016). The treatment of post-thrombotic syndrome. Deutsches Ärzteblatt International. https://doi.org/10.3238/arztebl.2016.0863 

Tauqeer, S., Arooj, A., & Shakeel, H. (2024). Effects of manual therapy in addition to stretching and strengthening exercises to improve scapular range of motion, functional capacity and pain in patients with shoulder impingement syndrome: A randomized controlled trial. BMC Musculoskeletal Disorders, 25(1). https://doi.org/10.1186/s12891-024-07294-4 

Thompson, R., Gelabert, H., & Teijink, J. (2025, March 22). Thoracic outlet syndrome. Thoracic outlet syndrome - Symptoms, diagnosis and treatment | BMJ Best Practice US. https://bestpractice.bmj.com/topics/en-us/592 

Yuen, H. L., Tan, E., Tran, H., & Chunilal, S. D. (2022). Idiopathic upper extremity deep vein thrombosis: A systematic review. European Journal of Haematology, 109(5), 542–558. https://doi.org/10.1111/ejh.13842