Warning Signs

It wasn’t a big deal at first. “It will go down,” Michelle Hoffmann said of the swelling in her arm as she sat inside the Mater Dei gym waiting for basketball practice to begin. “I need to do my homework. This is silly, this is dumb.”

But her teammates’ wishes prevailed, especially after the shocked look on their faces that afternoon more than a year ago, when Hoffmann’s arm swelled to nearly twice its normal size and she felt numbness in her fingers.

Hoffmann didn’t know that she was in the throes of Paget-Schroetter Syndrome, a clotting of the vein running below the clavicle. More commonly, it is called “Backpack Syndrome,” because those who carry heavy loads on their shoulders, such as backpacks and equipment bags, are especially susceptible to it. Hoffmann, active in sports her entire life, had been lugging around catchers’ gear or schoolwork since she was 10.

“I was amazed they had a name for it,” said Hoffmann’s softball coach, Ed Ulloa.

More amazing, they found, is that carrying a backpack filled with textbooks could, potentially, be disabling.

Now, nearly a year after the most extraordinary event in Hoffmann’s life ended, the 16-year-old sophomore says, “It’s important for people to know that this can happen.”

A Big Week

Monday, March 1, 1999, was a great day. The week before, Hoffmann had been called up from the junior varsity basketball team to join the varsity for the playoffs. She had also found out that, despite being a freshman, she had made the varsity softball team. “My grades were awesome--I was so happy,” Hoffmann recalled. “I was blown away.”

Her euphoria was short-lived, however. Like other athletes similarly afflicted, including tennis champion Rod Laver and Colorado Rockies pitcher Mike Cather, as Hoffmann’s muscles developed, they pulled her first rib upward. The repetitive nature of carrying a heavy load over her right shoulder pinched the vein between the rib and collarbone.

This formed a clot that restricted Hoffmann’s blood flow and caused her arm to swell. In extreme circumstances, the clot could have broken loose and lodged in her lungs or heart.

“It’s generally not life-threatening,” Hoffmann’s physician, Dr. Hugh Gelabert, said. “But it could cause potential lifelong disability in the arm.”

The day her arm began swelling, basketball teammates pushed her toward the school trainer, who initially suspected an insect bite was to blame. Basketball Coach Ollie Martin refused to let her play and urged medical treatment.

“Something wasn’t right,” Martin said. “I had never seen anything like that, the swelling, without any reason.”

At Hoag Memorial Hospital Presbyterian, Dr. Heather Brian recognized the severity of Hoffmann’s condition.

Hoffmann was taken by ambulance the next day to UCLA Medical Center, where Gelabert took over.

By now, Hoffmann’s arm was cold, blue and nearly numb. To reduce the swelling, she was given intravenously a blood thinner called Urokinase, which came at a hefty price--$5,000 per half-liter bottle--covered by insurance. She required eight bottles to dissolve her clotting.

She remained in the intensive care unit until week’s end, and on March 5, doctors removed Hoffmann’s pinky-sized first rib. By doing so, pressure was taken off the vein, allowing blood to drain from her arm. Hoffmann spent another day in the hospital and missed two more weeks of school.

Full recovery was expected in 4-6 weeks, but a follow-up examination revealed another clot. Doctors allowed her to attend a basketball awards ceremony that night, March 24, but the next day she again started therapy to dissolve the new clot. The following day she underwent an angioplasty procedure to restore blood flow. Hoffmann would need a second angioplasty and was on prescribed blood thinners for the next 12 weeks.

Back in Action

Hoffmann’s softball season, once so promising, was restricted to cheering from the dugout. It wasn’t until June 24, three weeks after Mater Dei’s appearance in the championship game, that she was cleared to resume normal activities.

She played junior varsity basketball this past winter, and again made the softball team, where she split time at catcher.

It has been an eye-opening experience since Michelle’s mother, Colleen, picked her up from school and watched her daughter throw the backpack over the shoulder of her swollen arm before taking her to the emergency room.

“Looking back, it just seems so unbelievable that something so serious could be the result of something people do every day of their lives,” Michelle Hoffmann said.

Her backpack always weighed at least 10 pounds, sometimes as much as 25. She also lugged catcher’s gear, a helmet and two bats over her shoulder.

“I’ve always carried equipment, probably five or six days a week since I was 10,” she said.

She now tries to keep her backpack as light as possible, but with the rib removed, there’s no threat of a recurrence.

She has played in 18 games this season, and is batting .269 with six RBIs and seven runs. Her team, seeded No. 1 in the Southern Section playoffs, plays at Camarillo today in a semifinal, hopeful of returning to the championship game at Mayfair Park in Lakewood.

If the Monarchs do reach the title game, Hoffmann won’t be limited to spectator status like last season.

“I think I did take things for granted,” she said. “This really helped me to grow as a person, and realize how important my health is, and to be thankful for the small things in life, my friends, my family.”

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Backpack Syndrome

A pinched vein sidelined Mater Dei’s Michelle Hoffmann last year. Here is a look at the condition caused by lugging around heavy loads:

* Name: Known as Paget-Schroetter syndrome after the physicians who initially reported it, the thrombosis of the subclavian vein is commonly known as “backpack syndrome.”

* Definition: The subclavian vein, which runs below the clavicle and serves to drain the arm of blood, is pinched between the clavicle and the first rib, restricting flow and forming a blood clot.

* The symptoms: Sudden swelling and discoloration of the arm, achiness, pain.

* The danger: Permanent disability may occur if normal blood flow is not quickly restored.

* Treatment: Thinners are used to dissolve the clot, and the rib that is pinching the vein is removed.

* At risk: Individuals in their 30s and younger are commonly at risk. Often afflicts those who are active and otherwise healthy if they engage in overuse of an upper arm. Most common among volleyball, tennis, baseball and softball players, and weight lifters.

SOURCE/Dr. Hugh Gelabert, Associate Professor of Surgery, UCLA School of Medicine