Pitchers are probably the most injury-plagued players in baseball, but Harvey may have particularly poor “protoplasm”. He underwent Tommy John surgery in 2015, which is a repair of the ulnar collateral ligament at the elbow. This is named after the LA Dodgers pitcher who first underwent the procedure in 1974. While about 79% of velocity actually comes from a pitcher’s leg and torso, the shoulder, elbow, and hand can be injured when the pitcher starts using poor mechanics with prolonged use and without adequate rest and recuperation. Turns out, undergoing Tommy John tends to make pitchers better post-surgery because they focus more on their legs to prevent re-injury.
However, in 2016 and 2017, Harvey also started noting his velocity was down and he couldn’t find his release point. His fingers started tingling. He was soon diagnosed with thoracic outlet syndrome (TOS).
TOS is not common but known to occur in pitchers. Amongst the average population, it affects about 1 person for every million. Less than 20 major league pitchers have been known to have undergone TOS surgery, including Phil Hughes, Jaime Garcia, Chris Young, Tyson Ross, and Chris Carpenter. Chris Archer of the Pittsburgh Pirates was just diagnosed in 2020 and underwent surgery in June.
There are two main types of TOS. It’s a relatively controversial syndrome from the neurosurgical perspective. Usually, the patients are young, tall, and thin women with cramping, tingling, and weakness of the arm. They may have shoulder pain and first undergo various shoulder or neck procedures without success. Symptoms are often worse with overhead activities and manifest as pain with tingling in the forearm and ring/ pinky fingers. TOS is commonly associated with a high cervical rib or an extra rib, which occurs in about 1% of the population. Compression can also be from neck muscles. Certain examination maneuvers, which tend to place the arm overhead, can help diagnose. However, mainly normal patients, without TOS, can have these provocative maneuvers too. TOS is difficult to diagnose because many patients have normal findings and exams.
Vascular TOS occurs from the compression of the subclavian artery or vein. Neurogenic TOS, which comprises about 95% of the cases, occurs from the compression of a bundle of nerves called the brachial plexus. A 3rd type, considered “non-specific” TOS, typically follows injuries like car accidents. For this, there are no standard diagnostic criteria and many doubt its true existence.
Treatment is usually physical therapy for about 3-6 months, as long as there’s no weakness or numbness. However, in severe cases, the compression is surgically relieved. Either the cervical rib is removed, the 1st rib is removed, or the muscles/ band causing compression are decompressed. Numbness and pain often improve, although atrophy of muscles tends not to.
There’s actually a return-to-play protocol for MLB pitchers following TOS surgery. It’s about 3-4 days in the hospital, followed by 3-4 weeks of therapy, light tossing at 6 weeks, and all-clear around 12 weeks.
In Matt Harvey’s case, he reportedly had a high first rib angled down to his collarbone compressing his brachial plexus… neurogenic TOS. Pitchers may have a higher frequency of TOS due to the repetitive over-the-head motion in pitching. If they have a smaller-than-normal thoracic outlet to start, a repetitive strain with scarring or acute injury could occur.
A study in 2017 assessed 14 MLB pitchers undergoing TOS surgery. 77% returned to MLB after an average ~ 11 months following surgery. Pre and postoperative career data showed no significant differences in traditional pitching metrics, including ERA, WHIP, and strikeout-to-walk ratios.
Pitchers, being fairly obsessive-compulsive beings, have been known to make earrings, necklaces, or even carry the removed ribs in their pockets following the surgery. It’s hard to decide if watching a pitcher swallow with a big hog in his lower lip, grab his crotch every few seconds, or have a surgically removed rib on his person is more gross???