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Pearls and Pitfalls

Blood Clots and Plane Flights

Eichner, E. Randy

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Current Sports Medicine Reports: May 2009 - Volume 8 - Issue 3 - p 106-107
doi: 10.1249/JSR.0b013e3181a608ed
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INTRODUCTION

A common question is whether and when an athlete on crutches or in a cast can fly with the team, as for example the recent case of a basketball player casted after surgery for a Jones fracture. No firm, evidence-based guidelines exist, and each case is unique. But we do know this: even in athletes, despite active lifestyles, deep venous thrombosis (DVT) is a potential risk after injury, surgery, or casting - and long plane flights can compound this risk. Considered here are typical cases and pearls on dodging clots on planes.

DVT AND PULMONARY EMBOLISM: EXAMPLES FROM MEDIA REPORTS

The most recent example is Kamila Skolimowska, 26, an Olympic gold medalist in the hammer throw at age 17 yr, in the Sydney Games. She collapsed and died of pulmonary embolism (PE) in February 2009 as she was warming up to lift weights. This was approximately halfway through a 3-wk training camp in Portugal; presumably she had arrived by plane from Poland less than 2 wk before she collapsed. Her father said her left leg was swollen 5 d before she collapsed, and a doctor said the day before she collapsed, she complained of calf pain and shortness of breath. The only therapy mentioned was massage.

In 2006 in Texas, a football player, 17 yr, collapsed and died at home of PE 5 d after knee surgery. In 2005 at an Arizona college, a female basketball player with a history of asthma died of PE after what news reports characterized as several days of shortness of breath, coughing, and chest discomfort that may have mimicked asthma. Knee surgery 9 months earlier had led to less activity and weight gain. In 2002 in Texas, two football players died of PE: one a high school senior, 17 yr, who had been casted for several weeks after an ankle fracture and collapsed in the locker room; the other a college freshman, 18 yr, who collapsed in his dormitory room approximately 1 month after a season-ending knee surgery. In 2000 in a college in the northeast, a female gymnast, 20 yr, who was returning to training after knee surgery, collapsed in the weight room and died of PE. Two years earlier, a female skier, 30 yr, tore an anterior cruciate ligament, was put in a knee immobilizer for 6 d, and approximately 1 wk later, during physical therapy, died of PE (4). Another example is a U.S. military commando, 41 yr, who twisted his ankle in Afghanistan, had a long flight home - he was a tall man, and his legs were cramped on the plane - and developed DVT and PE soon after arriving home.

Cramped conditions or frequent flying are likely culprits in other recently noted cases. In 2003, NBC television newsman David Bloom, 39, died of PE while covering the Iraq War. He had spent much of the prior 2 wk working, eating, and sleeping in an armored military-recovery vehicle. He slept with "knees propped up." In 2007, ESPN sideline reporter Bonnie Bernstein was hospitalized with DVT that she attributed to oral contraceptives, a family history of clots, and frequent flying.

EXAMPLES FROM THE MEDICAL LITERATURE

Examples of DVT in athletes in the medical literature also tend to fit within Virchow's triad of pathogenesis: stasis, increased coagulability, and damage to the intima of the vein (1). A high school wrestler developed DVT and massive PE after undergoing rapid, major dehydration twice in 1 wk, losing 12% of his body weight (2). Two male marathon runners developed DVT - and one had PE - approximately 1 wk after running a marathon; one case was initially misdiagnosed as a muscle strain and hematoma of the calf, the other was initially misdiagnosed as a Baker's cyst (8). An older male skier developed DVT 1 d after a draining day of telemark skiing (11). Anecdotes tell of DVT after muscle contusion, for example, a quadriceps contusion in a professional football player, and there is a recent case report of traumatic DVT after a popliteal contusion in a soccer player (3).

In 2001, a female college soccer player, 22 yr, had a nonfatal PE. She had two genetic risk factors for hypercoagulability and was on an oral contraceptive pill. A female triathlete, 25 yr, developed DVT soon after an elective abortion, after cycling 20 miles and standing several hours in knee-deep water; the initial diagnosis was calf muscle strain (10). A cross-country runner taking a third-generation oral contraceptive containing desogestrel developed PE that presented as pleuritic chest pain and undue dyspnea (5). Recent case reports note DVT risks in elite female skiers heterozygous or homozygous for factor V Leiden, a point mutation in the factor V gene that leads to hypercoagulability. These skiers get one dose of low-molecular-weight heparin before long plane flights (6,7).

BORN TO CLOT?

Approximately 5% of Europeans carry factor V Leiden, and another 2% carry a prothrombin variant that also predisposes to DVT. Less common inherited DVT risks are deficiency of antithrombin III, protein C, or protein S, or an abnormal fibrinogen molecule. Oral contraceptives, especially third-generation pills, also boost DVT risk. Add up all these risks (9), and it seems some athletes are "born to clot." For them, long plane flights - with cramped seating, inactivity, and dehydration - can be a clotting hazard. Below are pearls on dodging clots on planes. The same tips apply to long car or train trips.

PEARLS FOR PREVENTION ON PLANES

Get leg room. Book an exit row or aisle seat. This allows you to stretch out and move your legs.

Get moving. Hourly, walk the aisle. Or stand and do toe lifts. Spread toes, wiggle feet. Fidget a lot. Blood in motion will not clot.

Wear baggy clothes. Avoid tight jeans, girdles, knee braces - anything that can crimp leg veins. Do not sit long cross-legged. Avoid footrests that press hard on calves.

Hydrate. Keep your blood thinner by drinking water and juices. Go light on caffeine and alcohol.

Eat low fat. A fatty meal briefly floods your blood with triglycerides, which can promote clots by activating platelets and other clotting factors.

Wear flight socks. Flight socks apply pressure at the ankles and gradually lessen pressure up the calf. They minimize blood pooling (stasis) in the legs.

Blood thinner? Some experts advise - for individuals who are high risk - a single pre-flight injection of low-molecular-weight heparin.

References

1. Bates SM, Ginsberg JS. Treatment of deep-vein thrombosis. N. Engl. J. Med. 2004;351:268-77.
2. Croyle PH, Place RA, Hilgenberg AD. Massive pulmonary embolism in a high school wrestler. JAMA. 1979;241:827-8.
3. Echlin PS, Upshur RE, McKeag DB, Jayatilake HP. Traumatic deep vein thrombosis in a soccer player: A case study. Thromb. J. 2004;2:8.
4. Eichner ER. Clots and consequences in athletes: Can we prevent pulmonary emboli? Sports Med. Dig. 2003;25:1-9.
5. Harmon KG, Roush MB. Pulmonary embolism. Sifting the risk factors. Phys. Sportsmed. 1998;26(12):53-6.
6. Hilberg T, Moessmer G, Hartard M, Jeschke D. APC resistance in an elite female athlete. Med. Sci. Sports Exerc. 1998;30:183-4.
7. Hilberg T, Moessmer G, Hartard M, Jeschke D. Clinical sciences and orthopaedics: Case report homozygous APC resistance in an elite athlete. Int. J. Sports Med. 1998;20:198-200.
8. Mackie JW, Webster JA. Deep vein thrombosis in marathon runners. Phys. Sportsmed. 1981;9(5):91-6.
9. Merering C, Howard T. Hypercoagulability in athletes. Curr. Sports Med. Rep. 2004;3:77-83.
10. Roberts WO, Christie DM. Return to training and competition after deep venous calf thrombosis. Med. Sci. Sports Exerc. 1992;24:2-5.
11. Williams JS Jr, Williams JS Sr. Deep vein thrombosis in a skier's leg. Phys. Sportsmed. 1994;22(1):79-84.
© 2009 American College of Sports Medicine