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Tag Archives: thoracic outlet syndrome

A Closer Goes Down With an Axillary Blood Clot

Jeurys Familia, The Mets’ 27-year-old closer, was diagnosed with an arterial blood clot in his right shoulder yesterday. Though he’ll likely be out for a while, if not the duration of the season, Familia is fortunate that this was caught now. Further testing is underway to determine if surgery is indicated.

Familia, whose command was an issue this season, especially so in his first blown save this week, said “I just didn’t have it today.” But it proved so much more than that once he was examined by team physicians.

The NY Daily News reported that a scout had noted that Familia’s velocity had been down this season and his “splitter had less drop”, leaving the ball up far too much. He had pitched Monday,Tuesday and Wednesday, this week, his second three consecutive game stretch of the season and 11th appearance out of the 18 games played since his return from suspension. Last year Familia closed on three consecutive days six times and risk of overuse was discussed in the media.

Others Who Have Been There

Blood clots in the axillary artery or compression in the thoracic outlet are not as uncommon as one may think in a population of young, otherwise healthy overhead athletes. The Mets know this all too well, with Matt Harvey having had surgery 2016, and Dillon Gee in 2012.

Symptoms of a clot in the region of the shoulder can include arm fatigue, complaints of a “dead arm”, or numbness and tingling in the arm or hand. All of these symptoms can also have alternate causes.

The significance of a blood clot cannot be overstated. If dislodged, clots can cause stroke or heart attack. J.R. Richard, who might have been the most dominant pitcher in 1980 when he began to complain of arm fatigue, suffered a severe stroke when his symptoms were initially ignored by the medical team and then his clot went undetected on physical exam. For Richard’s account of his ordeal, read this.

Cause and Effect of Axillary Vascular Issues

The repetitive and extreme demand that the young overhead athlete places on his or her shoulder causes the developing skeletal system to adapt. Pitchers in particular succeed in part because of these adaptations: increased external (outward) rotation at the shoulder, an altered position of the head of the humerus and of the joint itself (which become more retroverted), and laxity in the front of the shoulder. Not only do these changes impact the stability of the shoulder, but they have also been shown to place the muscles, other joint components as well as the vascular structures at greater risk of injury.

When the ability of any tissue to withstand the demand placed upon it is exceeded, the dynamic is altered and results in tissue failure and injury. Damage can be acute but also progressive and chronic. The torque and shearing forces produced during the pitching motion are so extreme as to make injury more likely.

A study that examined the effects of throwing on upper extremity arterial blood flow found that “pitchers with signs of shoulder laxity had a significant decrease in arterial blood flow compared with throwers with no evidence of laxity. This vascular insufficiency probably occurs because of the repetitive positional compression onto the third portion of the axillary artery as the humeral head translates anteriorly during the late cocking phase of throwing.”

Aneurysms and Thoracic Outlet Syndrome

Other studies using ultrasound concurred with the above, finding that “intermittent compression can cause chronic changes in downstream vascular sufficiency and potentially lead to an axillary artery aneurysm or thrombus in the overhead throwing athlete.”

An aneurysm is an enlargement caused by the weakening of the walls of an artery. A thrombus is a clot that forms in the blood vessel thereby disrupting blood flow. When such a clot dislodges and travels through the bloodstream it is called an embolus.

In 1996, David Cone, a pitcher on the NY Yankees, was diagnosed with an axillary aneurysm. In his case clots formed in the area and broke away causing symptoms in his hand and fingers. For more on aneurysms in pitchers read here.

Thoracic Outlet Syndrome (TOS) entails the compression of the neurovascular bundle (nerves and/or blood vessels) that lies in the area known as the thoracic outlet.

The boundaries of this space are the clavicle (collarbone), the first rib, the subclavius and scalene muscles of the neck as well as the costoclavicular ligament (which connects the first rib to the clavicle). This positional compression, causing reduced blood flow or neurologic symptoms down the arm and to the hand, is more likely to be symptomatic amongst elite overhead athletes. Matt Harvey had surgery last year to treat the condition by removing a rib.

 

 

Pitcher Facing Surgery For Thoracic Outlet Syndrome

Mets starter Shaun Marcum began the 2013 season with what was diagnosed as right shoulder impingement syndrome and ended it this week with another type of impingement – that of the Thoracic Outlet.

Ed Coleman reported that Marcum is slated for surgery next week after an MRI confirmed the diagnosis. He has struggled at the mound recently and reported recurrent symptoms of tingling and numbness in his pitching hand. This, according to Mets assistant GM, John Ricco, “was affecting his ability to grip the ball.” Thoracic Outlet is also sometimes implicated when a pitcher complains of a “dead arm”

Image used is from MedlinePlus.com

Thoracic Outlet Syndrome (TOS) is a condition that is not as uncommon as one might think, particularly amongst competitive overhead athletes – baseball & tennis players as well as swimmers especially.  It entails the compression of the neurovascular bundle (nerves and/or 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).

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.

The structures lying within the thoracic outlet that are most affected by compression include the eighth cervical and first thoracic  (C8 & T1) nerves of the brachial plexus – both of which lie between the anterior (front) and middle scalene muscles – and the subclavian artery and vein, which bring blood to and from the arm, head and neck. TOS involves neural compression more often than vascular.

Symptoms of numbness or tingling in the arm or hand are due to compression or tightness of the median and ulnar nerves, which are branches from the brachial plexus. Loss of strength in the hand is also common (this is due to weakness of the intrinsic muscles).  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 axillary vein.  Dillon Gee of the Mets had surgery last season for a similar clot in an artery. In some cases, thoracic outlet syndrome is exacerbated by recurrent anterior shoulder instability.

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. 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.

Shaun Marcum will likely make a complete recovery and return at full strength next season. It is good that he made his symptoms known and that action will be taken.

Follow Abby Sims on Twitter @abcsims.

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Thoracic Outlet Syndrome

hil 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 (http://newyork.cbslocal.com/2011/05/04/hughes-feeling-better-expected-to-start-throwing-soon/).  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 (http://twitter.com/#!/abcsims

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