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Injury Breakdown: Examining Thoracic Outlet Syndrome

By Abby Sims
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New York, NY (WFAN) - Phil Hughes, NY Yankees right-handed starter, is reportedly beginning to feel better after a cortisone injection for what is presently being termed an inflammation in his shoulder.  Hughes has been on the DL since mid-April with complaints of deadness in his pitching arm, and his most recent attempt to throw a bullpen session (on April 25th) was aborted after only about a dozen pitches.

Hughes underwent a series of tests, most specifically to rule out Thoracic Outlet Syndrome (TOS), a condition that is not as uncommon as we've been led to believe, particularly amongst competitive overhead athletes – baseball & tennis players as well as swimmers especially.  Thoracic Outlet Syndrome entails the compression of the neurovascular bundle (nerves and blood vessels) that lies in the area known as the thoracic outlet.  The boundaries of this space are the clavicle (collar bone), the first rib, the subclavius and scalene muscles as well as the costoclavicular ligament (which connects the first rib to the clavicle).

The structures that lie within this space are those affected by compression of the thoracic outlet.  These most often include the subclavian artery & vein (which bring blood to and from the arm, head and neck), and the C8 & T1 nerves of the brachial plexus, both of which lie between the anterior (front) and middle scalene muscles.  Compression most often occurs in the area under the first rib and can be contributed to by tightness in the surrounding muscles (the scalenes & pectoralis minor).  Postural issues, trauma, or exertion, as with exercise, all can alter the thoracic outlet space, compromising the structures within. Even everyday tasks such as carrying heavy things or particularly weighty shoulder bags can trigger TOS.

Symptoms of numbness or tingling in the arm or hand are due to compression or tightness of the median & ulnar nerves, which are branches from the brachial plexus. Loss of strength in the hand is also common (intrinsic weakness).  Swelling in the upper extremity may be indicative of thrombosis (the formation or presence of a blood clot (thrombus) in a blood vessel) of an axiallary vein.  In some cases, thoracic outlet syndrome is exacerbated by recurrent anterior shoulder instability, and it is often the cause of the "dead arm syndrome."

Jarrod Saltamacchia recovered from successful surgery for TOS, as did pitchers, Kenny Rogers, Matt Harrison and Jeremy Bonderman; others, like third baseman, Hank Blalock and the pitcher John Rheinecker had various issues in the aftermath of TOS surgery and are now free agents.  You may also recall that David Cone had surgery for an arterial aneurysm (a localized enlargement of an artery caused by a weakening of the artery wall) in 1996, and Arizona Diamondback (and former Yankee), Ian Kennedy, had similar surgery 13 years later.  An aneurysm in the blood vessels of the thoracic outlet is a variant form of TOS.  In one of the saddest cases, the pitcher J.R. Richard suffered a massive stroke after being untreated in spite of complaining of various symptoms (that implied Thoracic Outlet involvement) for some time.  His stroke appears to have originally been due to exertion thrombosis.  When a blood clot dislodges and travels through the blood vessels it is known as an embolus.  An embolus that travels to the brain, blocking its access to oxygen, results in stroke.

So, though it is considered very treatable, it is probably a good thing that Phil Hughes does not have Thoracic Outlet Syndrome.  Surgery would have presented inherent risks and resulted in losing him for much of the balance of this season.  However, sometimes the known is better than the unknown.  Now it is wait and see…

Follow Abby on Twitter @abcsims

And read more on Thoracic Outlet Syndrome from these sources:
Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome).
The relationship between dead arm syndrome and thoracic outlet syndrome.
A rare cause of thoracic outlet syndrome Arterial and Venous Injuries in Athletes.  Findings and Their Effect on Diagnosis and Treatment

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