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Thoracic Outlet Syndrome: a Texas Rangers epidemic

Kenny Rogers (2001). Hank Blalock (2007). John Rheinecker (2008). Matt Harrison (2009). Jarrod Saltalamacchia (2009). These are the five major leaguers from the Texas Rangers who have been diagnosed with thoracic outlet syndrome in recent history.

Aaron Cook (2004). Kip Wells (2006). Jeremy Bonderman (2008). Noah Lowry (2009). These are the four major leaguers from all other teams who have been diagnosed with thoracic outlet syndrome in recent history. [Note: There may be more, but there aren't many. This is all I could find.]

Texas Rangers 5, Everyone Else 4. The Texas Rangers also had a minor leaguer diagnosed with thoracic outlet syndrome - pitcher John Hudgins (2005).

The definition of an epidemic, according to Wikipedia, is "when new cases of a certain disease, in a given human population, and during a given period, substantially exceed what is 'expected,' based on recent experience."

Recent experience tells us that roughly 10 players have been diagnosed with TOS in the past 9 years. More than half of those players belong(ed) to a very specific population: the Texas Rangers.

Compression of the brachial plexus is a key symptom of TOS. Click for full-sized view.Thoracic outlet syndrome (TOS) is fairly common in overhead athletes like swimmers and baseball players. The overhead movement of the arm changes the orientation of the clavicle (collar bone) in such a manner that it may compress the brachial plexus (the nerve bundle the leads into the arm from the neck) and/or the subclavian artery and vein against the first rib.

The compression usually leads to numbness or pain in the affected arm, but it can also lead to blood clots like it did with Aaron Cook in 2004.

Undiagnosed TOS can have very serious health implications. In Cook's case, a clot broke away from the compression site in his shoulder and traveled to his lungs resulting in a pulmonary embolism.

Diagnosis is clearly very important when it comes to TOS. The Texas Rangers, however, have experienced quite a large number of TOS cases in recent years. Here's a brief look at a few reasons why this may be the case.

Access to expert opinion

Dr. Gregory Pearl, of Texas Vascular Associates, is a well-respected vascular surgeon who happens to live in the Metroplex. Dr. Pearl was involved with the TOS cases for Rogers, Blalock, Harrison, and Saltalamacchia - and likely Hudgins and Rheinecker as well. This relationship history and his proximity to the ballclub makes it far easier for Texas Rangers to be diagnosed with TOS.

Kenny Rogers provided the club with a first-hand example of what TOS can do to a pitcher's performance. When Rogers returned with an extra 4-5 mph on his fastball, Dr. Pearl was probably put on speed dial.

Throwing mechanics

Putting pressure on the brachial plexus? Click for full-sized image.Pitchers are a high risk group for TOS compared to position players because of the quantity and intensity of their throws but also because of the way they turn their heads toward the plate. With the previous image in mind, take a look at Matt Harrison.

When the head and neck turn away from the compression site, the brachial plexus and subclavian blood vessels are pulled into the narrowing gap between the rib and clavicle.

For low intensity throws where the head doesn't turn, TOS is less of a concern.

Training methods

Of particular note are position players Hank Blalock and Jarrod Saltamacchia, each of whom had TOS in his throwing shoulder. To discount their mechanics entirely would be foolish, but I found no reports of TOS diagnosis in any other position player. This suggests, perhaps incorrectly, that something behind the scenes has made a significant contribution.

Weight lifting can produce stress far in excess of what an intense throw can produce, but it's practically impossible to properly perform any exercise and cause thoracic outlet compression at the same time. When bad form enters the equation, though, all bets are off.

Dynamic exercises may contribute an intertial element in a manner similar to that of throwing a baseball. Even these, when performed properly, aren't likely to be significant contributors. As with weight lifting, if they are not performed correctly, they become a risk for TOS and a number of other potential problems.

If training is to blame, it's likely a series of exercises rather than a single one that results in thoracic outlet compression.

Blind, stinking luck

Not to be overlooked is random chance. It is entirely possible that the Texas Rangers have simply been unlucky. It is possible that each affected player was genetically at risk for TOS and would have been diagnosed no matter what team he was playing for. It may be nothing more than luck that has brought these players to Arlington.

So which is it?

In truth, it's most likely a combination of these factors. Given the current state of exercise science, training methods are probably the least likely to blame.

Throwing mechanics and luck combined with having a "resident" expert have likely been equally responsible for the Rangers' having lapped the rest of Major Leage baseball in thoracic outlet syndrome diagnoses.

[Historical TOS Note: David Cone and J.R. Richard, both pitchers, were also known/beleived to have suffered from thoracic outlet syndrome, but both diagnoses were well before the "Dr. Pearl era."]

Reader Comments (8)

Thanks, this was very interesting. John Hudek had it. I believe one of the Tigers relievers too. It wasn't Todd Jones' injury was it?

November 23, 2009 at 4:14 PM | Unregistered CommenterJay

My son is a 17 year old left handed varsity pitcher who was diagnosed with TOS. The vascular surgeon was able to clear the clot through blood thinners, (heparin), clot busting drug (avaste), some roto rootering and eventually having a cardiac surgeon perform an angioplasty. The vein is now clear but still compressed at the rib location. They are contemplating altering or even removing the first rib so he won't have to be on blood thinners (lovenox and cumedin) for the rest of his life. Does anyone have an alternate procedure to alleviate the compression or has anyone undergone the first rib removal? I don't know if any of these players had to do this to create space around the vein.

July 4, 2010 at 3:43 AM | Unregistered CommenterJames Knochen

James, rib removal seems to be the most common treatment for this condition in Major League baseball players. A few have successfully rehabbed the condition through a combination of scapular mobility and scapular stability exercises.

I assume rehab has been suggested to you, and I highly recommend you go down that road before surgery (which will require rehab anyway). The downside if rehab doesn't work is that you will basically be paying for it twice (before and after) as well as whatever lost time your son has to deal with in his baseball career by delaying surgery. (I assume he's a baseball player.)

July 15, 2010 at 12:19 PM | Registered CommenterTrip Somers

My 17 yr old son had severe nerve compression had pretty much shut down any type of throwing.. He had surgery on Monday 11-1, Dr Pearl said the nerves were very compressed which was causing extreme pain in the elbow area.He spent one night in the hospital and was feeling good enough to get up and around the next day..We look forward to a positive outcome before baseball season starts..As things progress I'll update the site.

November 3, 2010 at 3:29 PM | Unregistered CommenterQuincy

How soon did your 17 year old son get back to throwing a baseball after the surgery? My 17 year old just had the surgery April 12th, 2011 and we're trying to determine when it is safe to throw a little bit. Thanks in advance for your input.

April 17, 2011 at 9:57 PM | Unregistered CommenterDave

Improper breathing, neck posture, throwing techniques will lead to thoracic outlet syndrome. It is fairly easy to treat with chiropractic adjustments, neck exerices and myofaascial release.

June 23, 2011 at 12:00 PM | Unregistered CommenterCharlotte Chiropractor

I had the rip reduction and the muscle cut out as well. I also had an AV fistula put on for roughly 3 months. I just started swinging and throwing last month. This was the best thing that has ever happened to me. Prior to the surgery I touched 82 from the outfield on a good. I took basically a year off and am now 85-87 from the outfield. So I would definitely recommend any aspiring baseball playes to have the rib reduction and to be so patient with how long the recovery time is.

April 2, 2012 at 10:05 PM | Unregistered CommenterKevin Roebuck

My son was 15 when he was diagnosed with a "clot on top of another clot," his Freshman year of high school. He had chiropractic adjustments before and after the clot with hopes that he wouldn't need the rib resection surgery. During his Sophomore year he had more complications with pitching, so played shortstop only, and decided to have the surgery after his baseball season was over. He began physical therapy about 8 weeks after the surgery and began some baseball mechanics. Still no pitching or heavy lifting until 3 1/2 months after surgery. When he began the throwing program he quickly realized the remarkable difference of how good his arm felt. "Loose, not so tight." He also noticed that his hand had more feeling in it, which meant more control of the ball out of the glove transfer. In January of his Sophomore year he was pitching 87mph and since his surgery he hasn't been clocked. For my son, it appears this has been a good decision to have the surgery. We used the Texas Rangers surgeon, Dr. Gregory Pearl.

October 2, 2012 at 10:04 PM | Unregistered CommenterJody

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