MLB Injuries

Matt Harvey & Tyson Ross-Thoracic Outlet Syndrome-Dr. Morse

Photographer: David Hahn/Icon Sportswire

Thoracic Outlet Syndrome victims: Matt Harvey & Tyson Ross

Two Opening Day starters in 2016, several months later, both pitchers dealt with shoulder injuries and ended up requiring surgery to fix the issue. Which two pitchers are we talking about here? The Mets’ Matt Harvey and new Texas Rangers SP Tyson Ross, formerly of the Padres. First I will dive into the mysterious topic of Thoracic Outlet Syndrome, and then I will discuss how it personally affected each player’s career.

What is Thoracic Outlet Syndrome? While not as prevalent as the now-ubiquitous Tommy John surgery, thoracic outlet surgery (TOS) is not exactly rare. After all, over the past few years the following pitchers have underwent the procedure: Matt Harvey, Mike Foltynewicz, Phil Hughes, Jaime Garcia, Chris Carpenter, Josh Beckett, Clayton Richard and Chris Young (Padres RHP). The disease can actually be much more complicated than described, but for simplification purposes, I will try to provide a simple overview for you.

Exactly what happens in thoracic outlet syndrome? Simply put, the thoracic outlet is the space between the clavicle, also called the collarbone, and the first rib. This area is a narrow passageway where there are blood vessels, muscles and nerves – the collection of nerves is commonly referred to as the brachial plexus. If a person has weak shoulder muscles in the upper part of their chest, and these muscles are not able to keep the collarbone in place, then the collarbone can slip forward and downward, thereby compressing, and placing additional pressure on the nerves and blood vessels found underneath it.

What are the symptoms of thoracic outlet syndrome? Compression of these nerves and blood vessels can cause of variety of symptoms, including limited range of motion, and swelling or discoloration of the affected arm. Pressure on the brachial plexus nerves can result in a vague aching pain, often neck, shoulder, arm or hand. Compression of the nerves leads to pain, numbness, or tingling on the inner aspect of the forearm, as well as the fourth and fifth fingers of the hand. Compression of the blood vessels leads to decreased blood flow to the arm. This is turn, leads to fatigue, feelings of cold sensation in the hand or fingers, and sometimes even swelling and redness. Another important comment to note, especially in athletes, is that overhead activities such as throwing for pitchers can worsen compression of both the nerves and the blood vessels. This is often why pitchers develop this vague sense of numbness, tingling, and aching of the arm, but find it difficult to describe. With the different possibilities of symptoms, athletes can present with a constellation of symptoms that are unique to them.

How do you get thoracic outlet syndrome? This is a complicated question, but to keep it simple, in the case of athletes, TOS is typically due to repetitive arm movements, trauma (like hockey), or anatomical variations (like a cervical rib).

How is thoracic outlet syndrome diagnosed? Initially, the team’s trainer will evaluate the athlete, and then if the symptoms are concerning enough, the athlete will then see the team’s medical doctor. One simple test that doctors can use to help identify TOS is the elevated arm stress test. For the test, the athlete raises their arms over their head, then open and closes their fists for approximately three minutes. If this reproduces the symptoms, then the diagnosis of thoracic outlet syndrome can be made. If physical exam does not reveal the issue, then diagnostic testing is usually the next step, which often includes medical imaging, such as MRI, CT, X-Ray, or ultrasound, as well as nerve conduction studies, typically clarifies the situation.

How is thoracic outlet syndrome treated? There are basically two treatment paths to choose from, surgery and no surgery. Typically, the nonsurgical approach is started first, which incorporates physical therapy to help strengthen the muscles around the shoulder, NSAIDs, like ibuprofen and naproxen can help reduce the swelling and pain, weight loss (if applicable), and certain lifestyle changes. If all of the nonsurgical options fail to relieve the symptoms, surgery is the final option. Thoracic outlet syndrome surgery involves removing a portion of the first rib, thereby releasing the muscles in the upper chest and neck, and freeing up the compression that was causing all of the symptoms.

Why does thoracic outlet syndrome after a pitcher’s effectiveness? Well, if a pitcher is dealing with numbness and loss of feeling in his fingertips, he is going to really struggle with squeezing the ball and have difficulty digging their nails into the ball’s threading. Most pitchers require putting a certain amount of pressure on the ball in order to get the movement and topspin they need to be effective. The pitches’ velocity, location and spin rate would likely be negatively affected too as a result. The repetitive overhead throwing motion required to pitch is only going to make the compression of the blood vessels and nerves worse. As with all of the pitchers mentioned earlier that underwent TOS, surgery is often the only answer to alleviating these symptoms and getting the pitcher back on the mound.

Matt Harvey

Let’s start off by talking about the Dark Knight, as he has been called – the Mets’ Matt Harvey. Harvey is a 27-year-old RHP originally drafted by the Mets with the 7th pick in the first round of the 2010 June Amateur draft out of UNC Chapel Hill. Harvey broke into the majors in a big way in 2012, posting a 2.73 ERA with 10.62 K/9 over 59 innings for the Mets. The following year, 2013, Harvey completed his breakout season, with a 2.27 ERA and 9.64 K/9 over 178 innings, and getting selected to start the All-Star game. Toward the end of his first MLB season, Harvey was already arguably one of the top pitchers in all of baseball. Then on August 26, 2013, Harvey was diagnosed with a partial UCL tear of his pitching elbow and placed on the DL. Ugh.

Harvey had Tommy John surgery, performed by the famous Dr. James Andrews in October of 2013. After a 550+ day layoff, he returned on March 6, 2015 in a big way, throwing 96 MPH in his debut. Harvey had a very solid comeback 2015 season, winning 13 games, with a 2.71 ERA over 189.1 innings, 8.94 K/9, posting a 4.4 WAR season. Typically teams like to ease guys back into action after a major elbow surgery, but the Mets’ weren’t the most cautious with Harvey after his return from TJS. He pitched in a total of 216 innings that year, including the postseason which saw the Mets make the World Series – the most ever for a pitcher in their first season back from TJS.

Despite dealing with a blood clot in his bladder in spring training of 2016, Harvey was given the nod for the Mets’ Opening Day starter in a World Series rematch with Kansas City. The first part of the 2016 season didn’t go exactly according to plan for Harvey and the Mets. He held a 4.86 ERA, 1.46 WHIP over 17 starts before being placed on the 15-day DL with right (pitching) shoulder soreness on July 6, 2016. He visited Dr. Robert Thompson, a vascular surgeon in St. Louis and the nation’s leading surgeon in Thoracic Outlet Surgery (TOS), to determine the cause of his shoulder soreness.

After his appointment with Dr. Thompson, Harvey was diagnosed with symptoms consistent with thoracic outlet syndrome on July 7, 2016, and the decision was made to go ahead with season-ending Thoracic Outlet Syndrome surgery. Jon Heyman of Fangrag Sports reported that Harvey had been dealing with numbness and without complete feeling in his arm and fingertips of his pitching hand – one of the most common symptoms of TOS – since spring training. Surgery was the best option. Dr. Thompson performed the surgery on Harvey on July 18, 2016, with the goal of having Harvey back to start the 2017 season. Harvey reported significant relief immediately after the procedure, and resumed playing catch in early October. In mid-December 2016, Harvey reported that he no longer felt the tingling that he had felt previously, before his TOS, when he threw.

Harvey, after a 244-day layoff from thoracic outlet surgery, stated that he was completely healthy heading into spring training, acknowledging that he was entering the season with a lot of confidence. Today, March 5, Harvey made his spring debut, yielding four runs in 1 2/3 innings against the Cardinals, giving up a three-run homer, four hits overall, while striking out three and not walking anyone. Reports surfaced just hours after the start that Harvey complained of a stiff neck afterwards, admitting that the stiffness was there before he had even took the mound. It is hard to tell if this stiffness is just Harvey working out the kinks, breaking up the scar tissue from surgery, or if he has just slept on his neck the wrong way last night. Either way, this is definitely something to keep an eye on. If he is able to get back on track, and pitch like the ace he was in 2013, and to a lesser extent in 2015, the Mets could have a potentially scary rotation this year, with Thor and deGrom rounding out the three-headed monster.

Matt Harvey’s Timeline

August 26, 2013 – Diagnosed with a partial UCL tear
October 22, 2013 – Tommy John surgery, by Dr. James Andrews
July 6, 2016 – Placed on 15-day DL with right shoulder soreness
July 18, 2016 – Thoracic Outlet Syndrome surgery, by Dr. Robert Thompson

Photographer: Dan Sanger/Icon Sportswire

Tyson Ross

Tyson Ross, a 29-year-old RHP former San Diego Padres starting pitcher has been very solid over the past few seasons. In 2015, Ross put up a 3.26 ERA, with 212 strikeouts over 196 innings (9.73 K/9), but at times struggled with walks (3.86 BB/9), good for a solid 4.4 WAR season. Ross’ 2016 season did not start off according to plan – he got rocked by the Dodgers on Opening Day to the tune of 8 runs, 9 hits over 5 1/3 innings. Then, a few days later in his next bullpen session, Ross felt some discomfort in his pitching shoulder, and was placed on the 15-day DL with right shoulder inflammation on April 5th.

The initial MRIs of Ross’ shoulder were promising, as they revealed no structural damage, and the team was confident that Ross would be able to avoid surgery. Ross took significant time off, and several months went by before Ross made his first rehab start. The late August start ended abruptly as Ross continued to experience discomfort in his pitching shoulder. While the details are scarce, it appears that Ross underwent multiple tests, and sought several different medical opinions, but nothing has proved to be effective in alleviating his shoulder pain. Somewhere in between, the source of Ross’ season-long shoulder woes were identified, he was diagnosed with Thoracic Outlet Syndrome. Finally on October 13, 2016, after making just one Opening Day start and over seven months of wavering, Ross underwent surgery for Thoracic Outlet Syndrome by Dr. Robert Thompson in St. Louis – the same surgeon who repaired Matt Harvey’s shoulder a couple months earlier.

Ross was non-tended by the Padres in the offseason and signed a 1-year incentive-laden deal with the Texas Rangers. Ross has been rehabilitating his shoulder over the past couple of months after surgery, and last week, on March 3, Ross threw pitches off a half-mound for the first time since surgery. The plan is for him to throw off a regular mound tomorrow, March 6th, as he begins to ramp up his workouts in an effort to get back into shape. It sounds like Ross is approaching his rehab appropriately, trying not to rush but instead keeping the big picture in mind. If all goes according to plan, Ross might be able to make his Rangers pitching debut by late-May to early June.

Tyson Ross’ Timeline

April 4, 2016 – Ross pitched poorly during Opening Day vs. Los Angeles Dodgers
April 7, 2016 – Ross felt shoulder discomfort during a bullpen session
October 13, 2016 –Thoracic Outlet Syndrome surgery, by Dr. Robert Thompson

Fantasy tips:

Matt Harvey is a wild card for this upcoming fantasy season. He’s a high-risk, high-reward fantasy starter. I personally do not have much faith in him. The Mets will likely take it slower this time around, and he probably won’t pitch more than 120 innings this year. Don’t expect vintage Matt Harvey either. It is going to take time for him to get the feel for the ball again. I think a reasonable projection is a 3.80 ERA, 1.25 WHIP over 120 innings with a 8.5 K/9. Harvey is currently being drafted as the 34th SP off the board, with an ADP of 125. Personally, I would rather have Fulmer, Keuchel, Roark or Taillon, who all have similar ADPs, over Harvey – let someone else take the risk. If you already own him in a dynasty league, sell him to someone who hasn’t read this article and believes that Harvey will bounce back to his former ace status in 2017.

As far as Tyson Ross is concerned, he will probably not make his debut until May at the earliest. That gives him maybe 90-100 innings pitched of all goes well. Projections for him will look awfully similar to Harvey’s, about 3.80 ERA, 1.30 WHIP over 95 innings with a K/9 of 9.0. Ross is currently being drafted as the 78th SP off the board, with an ADP of 336. Instead of Ross, grab someone like Jharel Cotton, Junior Guerra, Tyler Glasnow or Andrew Triggs who all have a higher upside and safer floor than Ross. Dynasty league owners, let him ride in one of your DL slots until he’s activated and then either take the wait-and-see approach with him on the bench, or flip him for someone safer with similar potential.

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