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Thoracic Outlet Syndrome in Major League Baseball Star Pitcher

Stephen Strasburg, former major league baseball star pitcher, retired in September of 2023 after an unsuccessful return to pitching after multiple injuries, due to thoracic outlet syndrome.

Strasburg had Tommy John Surgery for the right elbow in the past, but then had treatment for thoracic outlet syndrome, including surgery in 2021. This was 2 years removed from his World Series winning MVP season on the Washington Nationals.

What is thoracic outlet syndrome?

It is a condition in which the nerves that supply the arm, coming from the cervical nerve roots, coalesce into divisions and chords in the brachial plexus, the nerves coalesce and traverse at the top of the chest, underneath the clavicle/collarbone and in the axilla or into the arm. A variety of conditions can cause thoracic outlet syndrome. High-performance throwing athletes certainly can get this and in particular, they can also have vascular problems. More pedestrian-type patients can acquire this condition through a variety of circumstances, either traumatic injury or repetitive overuse, or post-injury or post-surgery atrophy of musculature of the shoulder girdle, leading to some secondary nerve compression.

There are physicians and centers around the nation that claim to specialize in evaluating and treating patients with thoracic outlet syndrome. They often are general surgeons and vascular surgeons.

I started a nerve injury clinic, at University of California San Francisco when I was Professor and Chief of the Division of Hand and Upper Extremity and Microvascular Surgery in Orthopedic Surgery and Neurosurgery. I collaborated with physicians in neurosurgery and neurology to form this specialty clinic. We evaluated and treated many patients with upper extremity compressive nerve problems. In my private practice, I continue to treat patients with thoracic outlet syndrome.

I have a treatment algorithm that is focused on non-operative treatment through home exercises, with or without adjunctive physical therapy. The success rate is extremely high. This condition is often not diagnosed because there’s no single study such as an MRI or an electrodiagnostic study that is an associated condition. The consulting physician needs to be aware of this diagnosis and probe the patient through eliciting a history of the pain pattern, as well as doing a detailed physical examination including provocative tests for thoracic outlet syndrome. This diagnosis is separate and distinct from cervical neck problems and shoulder mechanical problems.

Sometimes patients come in as “arm cripples” with severe pain and dysfunction. I am a strong proponent of non-operative care for the vast majority of these patients. I do a full examination with advanced imaging and electrodiagnostic studies to fully evaluate patients if they fail to improve with non-operative treatment.

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