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Hughes Clues

The Yankees may have finally figured out what's ailing Phil Hughes. (AP)

The Yankees appear to be getting closer to an explanation for Phil Hughes' dead arm. After two days of testing, they announced after Wednesday's game that the 24-year-old righty may be suffering from a circulatory problem. From Joe Girardi's press conference:

"One of the tests they did with Phil showed — and we’re not saying he has it and we’re not saying he doesn’t — a real low-level risk of thoracic outlet syndrome, which is basically a circulatory problem… We’re sending him to a specialist in St. Louis to either rule it out or rule that he does have it."

The diagnosis isn't official yet. On Monday, Hughes will meet with Dr. Robert William Thompson, an expert in TOS. At Baseball Prospectus, injury expert Corey Dawkins briefly explained the affliction:

Thoracic outlet syndrome (TOS), in the simplest terms, occurs when there is compression of the nerves and/or blood vessels somewhere in between the neck and the armpit. TOS is believed to be either congenital – such as being born with an extra rib – or developed as a result of poor posture and multiple other factors. Many times TOS is not recognized until other medical conditions present as a result of the TOS (such as blood clots from decreased blood flow or nerve damage from the compression).

Today, Dawkins elaborates about the causes and treatment of TOS (the article is free, so dig in). He also finds an injury in Hughes' back pages which may be related:

Hughes did have a rib injury in 2008, but it was a stress fracture. While this would not provide a direct cause for the TOS, indirectly it may very well have played a role. If the stress fracture caused him to change his mechanics, there were likely some soft tissue changes throughout the upper extremities that would not have been noticeable visually, but which certainly could have prompted major changes underneath the skin, including atrophy of certain muscles while others grew bigger and tighter.

As we said before, TOS is diagnosed clinically and not through imaging. One of the difficulties of making the diagnosis is that the manner in which it presents is very individualized. The compression could be on either the nerves, the artery, or the veins as they pass through the constricted space. Commonly, an athlete reports neurological symptoms — such as numbness or tingling in the hand and fingers — in the absence of an injury, unlike "stingers," which arise when there is a clear force applied to the nerves. There can also be reports of fatigue or weakness that do not resolve with physical therapy and rest.

If the blood vessels are compressed, different symptoms such as swelling, color changes, or fatigue can set in. Often, especially in the early stages, the symptoms only occur during sport-specific activities — in this case, pitching. That is probably why the Yankees and Hughes had such a hard time figuring out what was going on. X-rays, MRI, EMG, and nerve conduction studies all play a role, but they should be used more as a means to rule out other pathologies than to rule in TOS.

At the Texas Leaguers site — the source of much of the PITCHf/x data I routinely cite and should thus credit — one Trip Somers noted the link between pitching mechanics and TOS back in 2009:

Pitchers are a high risk group for TOS compared to position players because of the quantity and intensity of their throws but also because of the way they turn their heads toward the plate. With the previous image in mind, take a look at Matt Harrison [here].

When the head and neck turn away from the compression site, the brachial plexus and subclavian blood vessels are pulled into the narrowing gap between the rib and clavicle.

While the initial treatment for TOS is conservative — rehab via physical therapy — surgery looms as a possibility if the condition doesn't improve. If that's the case, it's not a particularly rosy scenario for Hughes. The surgery is a 12-hour ordeal which generally involves the removal of the offending rib, and the recovery is long; Tommy John surgery-length absences from the major league scene, with about a year between appearances, appear to be somewhat common. The list of major league baseball players who have undergone surgery to correct the problem is not an All-Star team; it includes Hank Blalock (2007), Jeremy Bonderman (2008), Aaron Cook (2004), Matt Harrison (2009), Noah Lowry (2009), John Rheinecker (2008), Kenny Rogers (2001), Jarrod Saltalamacchia (2009) and Kip Wells (2006). Additionally, both David Cone, who was sidelined by an aneurysm in 1996, and J.R. Richard, who suffered a devastating, career-ending stroke in 1980, are believed to have suffered from variants of TOS.

As Somers noted, the Rangers have five representatives on the list, including Rogers, who was the first of the bunch to undergo the surgery back in August 2001; the team's proximity to an expert, Dr. Gregory Pearl, may be related to that odd cluster. Rogers threw over 200 innings the following season, and returned to put together of the most productive stretches of his career until 2007 — not missing a single rotation turn during that time — when he underwent surgery to remove a blood clot in his shoulder and repair surrounding arteries, which may have been related to his earlier woes. That aside, he is by far the most successful of the post-TOS cases.

Cook, Harrison and Bonderman were all around Hughes' age when they were diagnosed. The Rockies' Cook put together a handful of passable years as a perpetually injury-prone groundballer after his surgery, and the Rangers' Harrison, another groundballer, is off to a fast start after spending parts of three seasons getting lit for a 5.39 ERA. He's the only one in BP's injury database that I could find who made a same-season return, though it was just the Arizona Fall League to which he returned.* The Tigers' Bonderman, a power pitcher who had already begun to struggle by the time he was diagnosed — he was coming off a 5.01 ERA — didn't manage another full season in which he was both healthy and effective (combined 5.31 ERA in 252.2 innings) before stepping away from the game this winter. The New Jersey Star Ledger's Mark Carig gathers more details on the unfortunate lot, and adds a few more names to the rolls.

Though the pieces of the puzzle fit together, it's still possible that Hughes doesn't have TOS after all. That would deepen the mystery as to why he continues to suffer from his dead arm, though it would also open up the hope that he could avoid surgery or an epic rehab and return in time to help the Yankees this season. Fingers crossed.

*As the New York Post notes, Blalock returned to the majors in late 2007 but was limited to DHing and pinch-hitting.