Neuropathic Upper Extremity Pain In A Major League Baseball Pitcher

HISTORY: Patient is a 28 YO previously healthy male who presented to the clinic with right shoulder pain. He is a right-hand dominant professional baseball pitcher. The pain started during a starting appearance. Initially, the pain was in his armpit and radiated down to his hand. He subsequently lost feeling in his hand as well developed hand swelling. He was diagnosed with thoracic outlet syndrome (TOS) by another provider and underwent botulinum toxin injection to the anterior and middle scalene muscles with mild improvement in right-hand sensation. However, approximately 3 months later his symptoms returned when he started pitching again. Due to this, he presented to the clinic shortly after for a second opinion. PHYSICAL EXAMINATION: On exam, he was noted to have mild scapular dyskinesis with mild right-sided scapular protraction. He was also reported to have tenderness to palpation along the coracoid process. Lastly, he had a mildly positive Roos test on the right. Otherwise, he had normal strength and bilateral range of motion. All special tests including Empty can, Hawkins, Neers, Speeds, and Neers tests were negative. DIFFERENTIAL DIAGNOSIS: 1.Neurogenic Thoracic Outlet Syndrome (NTOS)2.Pectoralis Minor Syndrome3.Cervical Radiculopathy TESTS AND RESULTS: Given the nature of NTOS, he underwent a series of diagnostic blocks to understand his symptom generator. He underwent a diagnostic pectoralis minor block with 80% improvement in symptoms. Four days later, he underwent a diagnostic scalene block with some relief, however less then pectoralis minor. FINAL DIAGNOSIS: 1.NTOS due to pectoralis minor syndrome TREATMENT AND OUTCOMES: Given substantial improvement following diagnostic blocks, he underwent diagnostic arthroscopy with pectoralis minor release and suprascapular nerve decompression a week following the last block. Two weeks following surgical release he underwent botulinum toxin injections to his anterior and middle scalenes. At 4 months post surgery, he was 100% symptom-free and completing bullpen outings without return of any pain. Six months following surgery he returned to full participation in major league baseball. Fastball velocity reached 97 MPH during the 2024 season, which was greater than his previous top velocity of 95 MPH.