You know that pitchers run the risk of blowing out an elbow ligament.
But who would have thought they could lose a rib?
Thoracic outlet syndrome (TOS) is, unfortunately, a risk that comes with the unnatural art of throwing a baseball, and it has affected some big-name pitchers -- and their rib bones -- through the years.
Let’s learn more about this condition and why pitchers are particularly susceptible to it.
Here’s an FAQ on TOS.
What is thoracic outlet syndrome?
The thoracic outlet itself is the area between the neck and shoulder. TOS is a group of conditions caused by the compression of nerves or blood vessels in the thoracic outlet. The compression can cause shoulder and neck pain. It can also lead to numbness in the fingers, a weak grip, cold hands and swelling.
What is the cause of TOS?
There are many potential causes, such as whiplash or other trauma from a car accident, bad posture, pregnancy, heavy lifting or even the anatomical abnormality of having an extra rib.
But baseball pitchers are particularly susceptible to it.
Why are pitchers at risk?
For one, pitchers’ training methods enlarge the muscles in the neck and pectorals, crowding that thoracic outlet space and potentially leading to compression.
Also, the repetitive overhead motions of pitching -- especially at high velocity -- causes stress on the joints, muscles and soft tissues and can lead to abnormal positioning of the collarbone. If the collarbone shifts too close to the first rib, it can compress the nerves in that area, causing TOS.
Are there different kinds of TOS?
Yes. Most pitchers who deal with TOS have what’s called neurogenic TOS. That’s a compression of the nerves.
Another form is called venous TOS, which is compression of the vein between the collarbone and first rib. It requires quicker medical intervention than neurogenic TOS because of the threat of blood clots that can block blood flow in the arm or hand or to the lungs. However, surgically addressing venous TOS is generally seen as having a more predictable outcome than neurogenic TOS.
A third type of TOS is arterial, which involves the artery. That’s the rarest form, leading to coldness in the hand or even finger gangrene.
What are the symptoms of a pitcher with TOS?
The dreaded “dead arm” -- a sudden drop in velocity that doesn’t improve with rest -- could be a sign of TOS. Other symptoms might include difficulty gripping the ball or feeling the seams due to tingling in the fingers, a loss of command or arm fatigue.
How is TOS treated?
TOS can be treated first with physical therapy to strengthen and stretch the shoulder muscles and open the thoracic outlet, taking pressure off the blood vessels and nerves. For venous TOS, blood thinners and lifestyle changes can help manage symptoms.
Quite often, though, baseball pitchers diagnosed with TOS require surgery.
What does TOS surgery entail?
It’s called decompression. Typically, the first rib is removed, as are the neck muscles contributing to the compression.
Venous TOS patients (Phillies ace Zack Wheeler as an example) typically need a procedure to remove the blood clot first, prior to the decompression surgery.
What happens to the rib?
Some players have kept it as a souvenir.
Gross.
Yeah.
How long is the recovery?
Depends on the severity of the case and the type of TOS, but a typical recovery period for a pitcher is about nine or 10 months.
Do pitchers treated for TOS come back as effective as they were before?
A study published in the Orthopedic Journal of Sports Medicine in 2022 evaluated the cases of 26 MLB pitchers with neurogenic or venous TOS who underwent rib resection surgery between January 2001 to December 2019. Of those pitchers, 21 (81%) had a successful return to play, which is considered a high rate. For those who returned, the study did not find a notable difference in postoperative career length compared with controls, and that performance level was generally the same or better than prior to the surgery.
However, the study noted that the small sample size created by the relative rarity of TOS created the opportunity for error. Also, the study was not able to determine significant differences between neurogenic and vascular TOS, due to the limited number of vascular cases.
In the time since that study was published, we do have one prominent example since then of a player’s career derailed by TOS -- former National ace Stephen Strasburg. He had TOS surgery in July 2021, and returned to the mound 11 months later to throw just 4 2/3 innings in what would turn out to be his final big-league start. Despite the surgery, he continued to have chronic nerve issues and neck/shoulder pain.
Strasburg’s case was one of neurogenic TOS, which, again, is the more common condition.
Who are some other pitchers who dealt with TOS?
Success stories include Merrill Kelly, Alex Cobb, Josh Beckett and Kenny Rogers, all of whom were able to return from TOS at a high level.
On the flip side, Matt Harvey, Chris Carpenter and the aforementioned Strasburg are notable cases of pitchers who made it back to the mound but did not regain their command, velocity and/or effectiveness.
Can position players develop TOS?
Yes, because anyone can. Position player cases are rarer than pitchers but do exist. First baseman Jared Walsh (2022) and catcher Mike Zunino (also 2022) are examples. Both had All-Star seasons in their past, but neither performed at an elite level following the surgery.