Thoracic Outlet Syndrome in Baseball Pitchers: A Comprehensive Look Through an Ecological Dynamics Lens

Introduction

Thoracic Outlet Syndrome (TOS) is a complex condition that affects a significant number of baseball pitchers, often leading to serious complications that can derail careers. Traditional medical approaches, including surgical interventions such as first rib resection (FRR), have demonstrated efficacy in restoring function and relieving symptoms. A recent study by Creisher et al. (2024) examined the outcomes of FRR combined with completion intraoperative venography and found promising results, showing an 86.3% symptomatic relief rate and a 97% primary patency rate at one year.

While these findings reinforce the effectiveness of surgical intervention, they also highlight the need for a more integrative approach to prevention and rehabilitation. By incorporating principles from ecological dynamics and biotensegrity, we can develop a more sophisticated understanding of TOS in pitchers and craft training interventions that address the root causes of this condition.

What is Thoracic Outlet Syndrome (TOS)?

TOS occurs when the neurovascular bundle (which includes the brachial plexus, subclavian artery, and subclavian vein) becomes compressed between the clavicle and the first rib. In pitchers, this often results from repetitive throwing motions that cause structural adaptations and excessive muscular tightness in the pectoral, scalene, and subclavius muscles.

There are three types of TOS:

1. Neurogenic TOS (nTOS) – Compression of the brachial plexus, leading to pain, numbness, and weakness in the throwing arm.
2. Venous TOS (vTOS) – Compression of the subclavian vein, which can lead to effort thrombosis (Paget-Schroetter Syndrome), swelling, and circulatory complications.
3. Arterial TOS (aTOS) – Compression of the subclavian artery, which can result in ischemic symptoms and aneurysm formation.

The study by Creisher et al. (2024) specifically focused on venous TOS (vTOS) and highlighted that completion intraoperative venography is a valuable tool for assessing postoperative vascular patency and guiding treatment decisions. Their findings suggest that even in cases with residual stenosis, FRR provides excellent long-term outcomes.

However, while surgical decompression is often necessary in advanced cases, a preventative and rehabilitative approach grounded in ecological dynamics may reduce the need for surgery altogether.

The Ecological Dynamics Perspective on TOS

From a traditional biomechanical standpoint, TOS is often attributed to structural deficiencies such as rib abnormalities, postural imbalances, or hypertrophy of surrounding muscles. However, ecological dynamics presents a different framework for understanding the condition. Instead of focusing solely on structure, this perspective considers how movement behaviors emerge in response to environmental constraints and task demands.

Biotensegrity and Motor Coordination Failures

One of the key principles within ecological dynamics is biotensegrity, which emphasizes the role of the entire musculoskeletal system in distributing stress and maintaining functional integrity. Rather than isolated muscles being the primary contributors to movement, it is the coordinated function of muscle chains, fascia, and skeletal structures that determines efficiency and durability.

From this perspective, TOS in pitchers is not merely a structural impingement issue but rather a breakdown in motor control and adaptive movement strategies. Specifically:

• Inefficiencies in preflexive responses (automatic stabilizing actions that occur before conscious muscle activation) can allow excessive strain on the neurovascular bundle.
• Deficiencies in scapular coordination and trunk rotation can increase reliance on secondary stabilizers (such as the scalenes and pectorals), leading to compression of vascular structures.
• A lack of variability in movement solutions forces pitchers into repetitive, high-risk postures that accumulate stress over time.

In short, TOS may be less about anatomical compression and more about the inability to adapt to changing constraints dynamically.

Training Implications: Beyond Structural Fixes

If TOS is largely a product of motor control deficits, then treatment and prevention should focus on expanding the pitcher’s movement adaptability rather than simply stretching tight muscles or strengthening weak ones.

1. Task-Specific Variability
   • Instead of rigid mechanics training, pitchers should engage in constraint-led drills that force adaptive movement solutions.
   • Examples: Throwing under perturbation (e.g., unstable surfaces, resistance bands, variable ball weights) to encourage preflexive control.
2. Dynamic Stability Over Postural Correction
   • Traditional TOS rehab often emphasizes postural alignment (e.g., “shoulders back, chest up”), but ecological dynamics suggests that stability should emerge from dynamic interactions, not static positions.
   • Training should incorporate high-speed, time-pressured movements that reinforce functional stability under load.
3. Scapular Kinematics and Proximal Control
   • The scapulothoracic joint must function efficiently to prevent excessive load transfer to the neurovascular bundle.
   • Drills incorporating reactive scapular loading (e.g., rapid perturbations in push-up or overhead positions) help improve neuromuscular readiness.
4. Ecological Strength Training
   • Rather than traditional isolated strengthening (e.g., rows, face pulls), pitchers should train in integrated, multi-plane movements that replicate game demands.
   • Example: Loaded carries with overhead perturbations to develop preflex-driven shoulder stability.

Conclusion: A Holistic Approach to TOS in Pitchers

While the findings of Creisher et al. (2024) confirm the effectiveness of first rib resection (FRR) for venous TOS, they also highlight the reactive nature of surgical intervention—it addresses symptoms but does not fundamentally change how pitchers move. An ecological dynamics perspective provides a more proactive and sustainable solution by focusing on movement variability, preflexive stability, and dynamic adaptability.

Key Takeaways:

1. TOS is not just a structural issue—it is a movement system problem linked to poor motor control and adaptive variability.
2. Surgical intervention (FRR) is highly effective but should be a last resort.
3. Preventative training should emphasize dynamic stability, perturbation-based drills, and adaptable motor solutions.
4. Ecological dynamics provides a comprehensive framework for enhancing pitcher resilience and reducing injury risk.

By shifting our focus from static corrections to dynamic adaptability, we can help pitchers build robust, injury-resistant throwing mechanics and sustain long, healthy careers in baseball.

If you or someone you know is suffering for Thoracic Outlet Syndrome, pleas call us at 866-787-4533 and set an appointment to initiate recovery and resurgence to even greater levels of performance.

References:

Creisher BA, Jackson J, Sica S, Rossini E, Biscetti F, Ali M, Salvatore D, Abai B, Nooromid M, DiMuzio PJ. Analysis of completion intraoperative venography during first rib resection for venous thoracic outlet syndrome. J Vasc Surg Venous Lymphat Disord. 2024 Sep;12(5):101936.

Funakoshi, T., Furushima, K., Miyamoto, A., Kusano, H., Takahashi, T., Inoue, A., & Shimokobe, H. (2024). Thoracic outlet syndrome in overhead athletes. JSES International, 8(3), 620-629.

Sullivan, R. (2025). Integrated Anatomy of Pitching, Lakeland, FL.