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Thoracic Outlet Syndrome Deep Dive

So there we have it: Chuck Knoblauch… Rick Ankiel… and NOT Markelle Fultz! The list of talented athletes who developed the yips and watched their careers fall to pieces stayed the same length (we hope) with a new diagnosis of Thoracic Outlet Syndrome (TOS) for Philadelphia’s favorite first overall pick. Or is it Ben? Yeah, it’s Ben.

Or at least, that’s one way to look at it. The other, much darker way includes tales of doctor-shopping, psychosomatic disorders, and a desperate search to rustle up a physical excuse for a persistent mental disconnect. Why – if this is a physical issue and a fairly easy one to diagnose at that – do we just now have a diagnosis? And why did the most specific information, neurogenic TOS come only from Fultz’s agent? That’s the $8,339,880 question. But that’s less fun for all parties and causes a generally uneasy feeling about the size of the city of Philadelphia in the stomachs of Sixer Nation, so let’s stick with what we can know for now.

What is TOS?

Surprisingly to many, my first experience learning about Thoracic Outlet Syndrome didn’t actually come from a textbook. Believe it or not, the first mention of it came from a girl I went out with a few times during medical school. She told me 20 minutes into the first date that she had one of her ribs removed a few years back and kept it in a jar after the surgery. Um, what now? Why? To all of that, actually. Why? People love to tell you strange stuff (they do!) when they think you’re interested in it (I was!). So as is common practice for someone like myself, I went home, spent an hour reading everything I could find about TOS, and made her send me a picture of that rib. It was exactly as gloriously disgusting as you’re imagining it right now.

Thoracic Outlet Syndrome refers to the several different manifestations that can all arise from the same anatomical problem. There is a small opening between the clavicle and 1st rib called the “thoracic outlet” with several important structures running through it. The scalene muscles, subclavian artery and vein, and nerves of the brachial plexus all pass through this limited space, meaning inflammation of the area can lead to pressure on any of these structures.

This kind of inflammation can stem from several sources. Common causes include abnormal anatomy such as an abnormally small thoracic outlet space or an extra rib (more fun), repetitive aggravating motions and activities, or prior trauma (say, just hypothetically, a motorcycle accident) to the area. Neurogenic TOS specifically means the nerves that supply the affected arm are compressed in one of these vulnerable spaces. This potentially leads to pain, weakness, numbness, tingling, and limited range-of-motion of the affected limb. Diagnosis is fairly straightforward involving a physical exam, imaging, or nerve conduction studies.

So what caused Markelle’s newly-diagnosed TOS?

TOS most commonly occurs in younger, healthy adults ages 20-40. However, abnormal anatomy can’t really be ruled in or out in his case without more medical information. To be honest, we’re not likely to get that any time soon. In professional athletes, TOS most notably occurs in pitchers. Pitchers unsurprisingly perform repetitive, extremely stressful motions that stress the shoulder over and over (and Marshawn Lynch) again.

By all accounts, Fultz has been a gym rat for his entire life, and unless something changed rapidly upon joining the Sixers, there isn’t anything immediately apparent to suggest a new source of repetitive stress. Past trauma to the shoulder is anyone’s guess, but again, just now receiving the diagnosis is fairly perplexing. Sure, Fultz has been passing, shooting, and dunking his way around the league with… let’s say… “debatable” levels of success for a year and a half, but he’s had no visible signs of physical deficits or limitations. God forbid we forget his rookie year triple-double while we’re here. All of this said, however, pain can be a tricky thing. We may never know.

Where does Fultz go from here?

There are a few ways to treat TOS. The first-line treatment is typically anti-inflammatories (NSAIDS like ibuprofen, naproxen, etc.) along with physical therapy exercises. This can strengthen the nearby muscles, improve posture, and overall open up the thoracic outlet as much as possible. The second and more definitive option, provided there is a known and fixable cause, is surgery. It sounds nice, but there can always be complications, and that’s the last thing anyone wants. As I’m often told and in turn often tell others, “There’s no such thing as ‘minor surgery.’” A procedure has low but tangible risk of damage to any of the nearby structures. There should always be real consideration that the shoulder could never be the same.

I don’t want to spend too much time dealing in hypotheticals or being overly cynical. That being said, to my mind, the only way we’ll know conclusively if this is indeed a real, concrete, physical diagnosis is if Fultz ends up getting surgery at some point. That’s the undeniable and objective endpoint that removes all of the PR work in favor of MD work. If he were found to have an extra rib causing all this trouble, wouldn’t someone who stood to benefit from proving there is no mental component to this ongoing train wreck have made that extremely public knowledge? If I were his agent, I would. All of the above said though, he may not have an underlying cause known to benefit much from surgery. The injury could get better on its own with therapy as injuries often do. We may never know.

Examples from other professional athletes

So what about those pitchers we mentioned earlier? Chris Carpenter, Jaime Garcia, Matt Harvey, and Chris Young are just a few recognizable names of those who recently dealt with TOS issues. What can we learn from them, and how did they do before and after treatment? Data on recovery from TOS in those who depend on the return of a world-class level of function of their affected limb is severely limited for understandable reasons. There is enough rigorously-analyzed history, however, to at least be noteworthy.

Faculty from Washington University School of Medicine in St. Louis published a study in 2016 of 13 MLB pitchers who underwent surgery for Neurogenic (!) Thoracic Outlet Syndrome between 2001 and 2014. They analyzed performance metrics, both traditional and advanced, using PitchF/x data to compare performance before and after surgery. Small sample size, sure, but what they found is encouraging. “Pre- and post-operative career data revealed no significant differences for 15 traditional pitching metrics, including earned-run-average (ERA), fielding-independent-pitching (FIP), walks-plus-hits-per-inning-pitched (WHIP), walks-per-9-innings (BB/9), and strikeouts-to-walks-ratio (SO/BB). There were also no significant differences between the 3 years before and the 3 years after surgical treatment.”

There are obviously questions about how generalizable this data could be to someone like Markelle Fultz, but it’s comforting at least to note that in those who need it to work and work well, the surgery seems to do just that.

Best case scenario from history? It seems to be Chris Young. The former Mariners righty was headed out of the league, underwent surgery in 2013, and won MLB Comeback Player of the Year the following season in 2014. Worst case? Probably the unfortunate story of former Mets super-prospect Matt Harvey. He was an All-Star and finished fourth in Cy Young voting at age 24 in 2013. His surgery was in the summer of 2016. While it was on the heels of some other significant injuries to be sure (including requiring Tommy John surgery), he experienced worsening ERA, WHIP, BB/9, and SO/9 every single year after 2013 and bottoming out in 2017. TOS surgery was probably a drop in the bucket at that stage.

Only time will tell

Moving forward, it seems as if only time will tell what could happen from here and what the right decision is for the 76ers and Markelle Fultz. Would they trade him and rid the franchise of any additional future drama? Could they keep him and try to work through it all? Should they treat him like an expensive, domestic draft-and-stash while going Fultz-steam ahead (had to) with the rest of the solidly successful core for now? The implications of his impending rehab are huge!

Fultz’s trade value has never been lower. However, the ability of the team to absorb his need to sit out has never been higher. It’s an exciting and bizarre time to be a basketball fan, and the saga continues every single day. We may never know all the answers, but for now what we know is that this story is going to keep Philly fans on their TOS.

Adam Coey

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