Clinicians

Diagnosis

In patients with suspected DVT/PE, the diagnostic algorithm in the outpatient or emergency setting begins with the Wells score, a clinical prediction rule calculated from the presence of specific components of the patient history and physical examination. The Wells score is the most widely used clinical prediction rule for DVT and PE  due to its high sensitivity (0.92) for risk stratifying the clinical (non-athletic) populations from which it was derived. However, symptoms that accompany DVT/PE (i.e., lower limb pain, swelling, tachycardia, and shortness of breath) may be absent or mimic conditions more commonly expected in athletes such as overtraining, musculoskeletal damage, or Baker’s cysts, resulting in missed or delayed diagnosis.

We recently conducted a critical analysis of the ability of the Wells score to identify DVT/PE in athletes through a review of published case reports and found that the Wells score had a 100% failure rate in identifying athletes with DVT and/or PE, resulting in a delayed diagnosis of ~20 days. Interestingly, in the this analysis, D-dimer was reported in nine of the cases reviewed, with a mean of 1566±758ng/dL, which is three times greater than the cut point to rule out DVT/PE. Although D-dimer has a low positive predictive value (0.4) and can be elevated in other conditions such as liver disease and aortic dissection, the probability of endurance athletes presenting with such comorbidities is not likely. Thus, it appears that even in the absence of high probability, D-dimer testing remains a practical, cost-effective test to safely triage athletes to either additional testing or discharge. In addition to clinical risk stratification and D-dimer, portable ultrasound devices may become a promising tool to triage athletes who initially present with signs/symptoms of possible DVT in point-of-care settings.

Awareness

Published case reports and anecdotal evidence continue to demonstrate that DVT/PE can and do occur in otherwise healthy athletes. While regular physical activity is recommended for the prevention of DVT/PE, strenuous and sustained endurance activity exposes athletes to perturbations that may deleteriously increase risk for DVT/PE, including repetitive microtrauma, endothelial damage, dehydration, and periods of inactivity surrounding intense competition. Increased awareness and education among clinicians and athletes, alike, may ultimately improve recognition of signs and symptoms of DVT/PE.

Shared commonalities among DVT, PE, and combined DVT/PE case reports included recent history of competition or high intensity exercise, oral contraception, contact trauma, and recent travel (or Competition, Contraception, Contact, and Confinement). Although these patient level variables have yet to be validated, knowledge of these preliminary risk factors may help sway a clinician’s degree of belief and prevent underestimating the likelihood of DVT/PE among endurance athletes.

Return-to-Play Guidelines

There are very few published guidelines to inform clinicians on the management of the athlete following initial or recurrent VTE. Berkowitz and Moll recently published an excellent article summarizing the current state of the literature for athletes who participate in non-contact sports and propose a novel therapeutic approach to the treatment of athletes who participate in contact sports that require anticoagulation. 

Resources

Zaleski AL, Taylor BA, Pescatello LS, Thompson PD, Denegar C. Performance of Wells Score to Predict Deep Vein Thrombosis and Pulmonary Embolism in Endurance Athletes. Phys Sportsmed. 2017 Jul 21: 1-7. PMID: 28707499

Berkowitz JN, Moll S. Athletes and blood clots: individualized, intermittent anticoagulation management. J Thromb Haemost. 2017 Jun;15(6): 1051-1054. PMID: 28301715