There is a first time for everything, and on Thursday night at Citi Field, Major League Baseball will see another first, as the Mets' Matt Harvey takes on the Braves' Jaime Garcia, marking the first time two pitchers who have undergone surgery to correct neurogenic thoracic outlet syndrome will face each other in the big leagues.
The condition is rare. Fewer than 20 MLB pitchers have been diagnosed with thoracic outlet syndrome and have had the surgery to correct it. Most notable are Harvey, Garcia, Phil Hughes, Tyson Ross, Christopher Young and Chris Carpenter. All have a similar story of loss of velocity, general discomfort on the mound, tingling down their pitching arm and into their fingers, fatigue and achiness, and a long and arduous process of misdiagnosis and treatment that does not correct the problem before TOS is discovered as the culprit. But the increasing number of MLB pitchers being diagnosed with the problem has done a lot to increase awareness about TOS.
"It's really terrific to see these two high-level MLB pitchers will not only be back pitching, but also facing each other in their first starts of the new baseball season, both having undergone the ordeal of dealing with neurogenic TOS," said vascular surgeon Dr. Robert Thompson of the TOS Center at Washington University Medical Center in St. Louis, who performed the surgeries on both Harvey and Garcia. "One comes in hoping to show his old team that he's back to previous form, the other is hoping to show his new team just what he's capable of. It's a testament to the extraordinary determination, tenacity, patience and confidence in their own ability that each of these guys has exhibited to see them come back to peak performance."
Garcia said he spent a lot of time talking to Carpenter, his teammate in St. Louis from 2008-12, about the surgery -- which involves the removal of a rib -- and recovery. Garcia also had left shoulder surgery and Tommy John surgery, but he said recovery from TOS surgery was totally different.

"It's a hard procedure and a hard comeback," Garcia said. "It was a tough time going through it because there's not a lot of history with it. It's a tough thing for teams to approve and for players to go through. But I can say, the preparation, dedication and all of the hard work saved my career."
Garcia had his surgery in July 2014, and he pitched well in both '15 and '16, compiling a 20-19 record from 2015-16 for the Cards. He had a strong spring this year, going 1-1 in five starts, with 15 strikeouts and a 3.20 ERA in 19 2/3 innings.
Harvey's surgery was last July. He struggled to find his former velocity this spring, going 0-4 in five starts, with 16 strikeouts and a 5.89 ERA in 18 1/3 innings. But Garcia understands the process and the struggle.

"Seeing [Harvey] pitch now tells me the guy put in the work," Garcia said. "Sometimes you expect surgery just to work magic. But once you go through surgery and take some things out of your body, your body is going to change and you're going to have to adapt. The fact that he is pitching on this stage is a testament to all the hard work he put in."
Harvey and Garcia are drastically different pitchers, and with the small sample size of pitchers who have had TOS, it remains to be seen how pitching style affects recovery.
The right-handed Harvey relies mostly on his four-seam fastball, which has historically hovered in the high 90s, though he was topping out around 92 mph this spring. Garcia, a lefty, throws a four-seamer and a sinker, but both pitches top off at 91 mph, and he also relies heavily on low-80s changeups and sliders.

"Whether one is a right-handed high-heat four-seam fastball pitcher or a left-hander that relies on nasty movement and a deceptive sinker, they have each had to overcome a challenging journey taken by only a handful of other athletes," said Thompson. "To pause and think that for all that each of these two guys has been through, perhaps the one other person in the stadium that can truly appreciate what is has taken for them to arrive at this moment is the other guy on the mound."
The thoracic outlet lies at the lower part of the neck, beginning just above and behind the collarbone and extending into the upper arm and chest. Thoracic outlet syndrome results when the nerves and blood vessels in this area are compressed.
Neurogenic TOS, in which the brachial plexus nerves that serve the entire arm and hand are compressed, is by far the most common type of TOS. It makes up between 85-95 percent of cases -- including Harvey's and Garcia's. During TOS surgery, both the first rib -- which attaches behind the first thoracic vertebrae at the base of the neck, angles down and connects to the sternum just below the collarbone -- and the scalene muscles are removed to ensure there will be enough room for the nerves in the thoracic outlet.