A New Baseball Season Means New Thoracic Outlet Syndrome Cases
We are one month into a new major league baseball season. Like many baseball fans, I am excited and intrigued by the new rules, by the surprising rookies and teams, and by the promise of success every team enjoys in a new season.
However, as a thoracic outlet syndrome specialist, I am also intrigued by the growing awareness of neurogenic thoracic outlet syndrome among these very gifted and hard-working athletes. Over the past decade or two, I have watched with interest as awareness of NTOS has grown in the sport. Every year, it seems more players are receiving the diagnosis of neurogenic thoracic outlet syndrome than in prior years. I am hopeful that this trend continues, and with it increasing awareness of thoracic outlet syndrome in the general community.
Thoracic outlet syndrome (TOS) is a group of related disorders that occur when compression of blood vessels or nerves occurs in the space between the collarbone andthe first rib (the thoracic outlet), accompanied by a broad range of symptoms. When the nerves are compressed and the patient is symptomatic from this compression, neurogenic thoracic outlet syndrome is present. Neurogenic thoracic outlet syndrome is by far the most common type of TOS.
Baseball players are susceptible to developing neurogenic thoracic outlet syndrome due to the repetitive stresses and high loads placed on their dominant shoulder and arm. This is especially true for pitchers.
Pitching a baseball requires a string of coordinated, synchronous and sequential motions.
The pitching motion is generally recognized as having 6 distinct phases:
- Windup
- Stride
- Cocking
- Acceleration
- Deceleration
- Follow-through
While the pitching motion is beyond the scope of this article, a few key elements can be emphasized. Pitching involves one of the fastest human motions (perhaps the fastest). Different muscles are activated during different phases of the pitching motion, resulting in a number of different injuries. Shoulder injuries are the most common injury in pitchers, while elbow injuries are the second most common injury. There exists scant literature on the causes or incidence of brachial plexus injuries in baseball pitchers.
Why Are Baseball Players Prone To Developing Thoracic Outlet Syndrome?
Baseball players may be at a higher risk of TOS due to the unique demands and mechanics of the sport. The following factors may contribute to thoracic outlet syndrome in baseball players.
Repetitive Motion and High Forces
Many overhead athletes are at increased risk for developing thoracic outlet syndrome. These include not only baseball players, but swimmers, volleyball players, and rock climbers, among others. Some of these athletes perform numerous repetitive overhead activities such as throwing or swimming strokes. Other athletes assume overhead positioning during periods of maximal muscle contraction, such as rock climbers. Some athletes experience both mechanisms.
Baseball players often perform repetitive overhead motions at maximal exertion when throwing the ball. Baseball pitchers, in particular, perform a high percentage of repetitive overhead actions under maximum stress. As a result of these actions, these athletes experience unusual and asymmetric stresses. These mechanisms may cause abnormal positioning of the scapula and supporting muscles, which in turn leads to abnormal clavicular positioning. If the clavicle approaches the first rib too closely, it may cause compression of the brachial plexus and neurogenic TOS. Less commonly, compressionand damage to the subclavian artery or subclavian vein may occur with a blood clot resulting in arterial or venous thoracic outlet syndrome. In summary, the repetitive and large stresses faced by high-performance baseball players can cause strains on specific muscle groups or compression/tension on the brachial plexus, resulting in swelling, inflammation, scar tissue formation, or abnormal shoulder positioning. These processes may lead to the compression of nerves and blood vessels in the thoracic outlet. If not promptly recognized and adequately addressed, neurogenic thoracic outlet syndrome may develop.
Poor or Inconsistent Throwing Mechanics
Improper throwing mechanics can place excessive strain on the shoulder and neck muscles, increasing the risk of developing TOS.
Poor Pitching Mechanics may Include:
- Inadequate warm-up or insufficient stretching
- Insufficient stretching
- Inconsistent mechanics arm positioning during the throwing motion
- Different motions are required for different pitches
- Different mechanics are used in a full wind-up pitch versus the abbreviated 'stretch' pitch when men are on base.
At the elite level, baseball pitchers push themselves to the edge of their performance envelope. One can imagine how difficult it is for these athletes to maintain consistent form through every throwing motion. In addition, a pitcher may maintain good throwing mechanics early in a game, only to lose this consistency under conditions of fatigue later in a game. Further, the stress of competition at this high level, often in front of a considerable crowd and a national television audience, may distract from typical performance.
Scapular Dyskinesia
Normally, the shoulder blade, collarbone, and upper arm bone move in a predictable pattern, known as scapulohumeral rhythm. Disturbance of this pattern, also called 'Scapular dyskinesia,' may develop in baseball players. This abnormal movement can lead to increased pressure on the structures of the thoracic outlet, the rotator cuff, or the labrum.
Hyperabduction
Hyperabduction of the arms refers to positioning of the arm greater than 90 degrees away from the resting neutral position. Hyperabduction is a necessary part of the throwing motion. Hyperabduction can cause compression of the thoracic outlet structures by bringing the collarbone and first rib closer together.
Trauma
Many athletes suffer from broken bones during their career. In overhead athletes, a broken and healed collarbone, for example, may predispose to developing thoracic outlet syndrome.
Treatment of Thoracic Outlet Syndrome
A small number of studies in baseball pitchers shows that some pitchers may stabilize their performance, but are unlikely to regain the level of performance prior to developing symptoms.
Summary
Baseball players, particularly pitchers, face a higher risk of developing thoracic outlet syndrome. Fortunately, the disease is being recognized more commonly and earlier, which may result in better treatment outcomes.
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