Stephen Strasburg details thoracic outlet syndrome surgery, recovery
For 10 seasons, Stephen Strasburg arrived at Nationals Park with a single-minded focus. There were batters, there were baseballs, and there were all the ways for him to beat his opponents, whether with a pinpoint fastball or a change-up that seemed to fade off the face of the earth.
His 2010 debut was a 14-strikeout gem that showed a wary fan base what was possible between the chalk lines of a diamond. His performance in the fall of 2019 delivered a title for Washington and made him MVP of the World Series. He was dominant when healthy.
But since 2019, when he raised a trophy above his head — when his arms were only heavy because of the long climb to the top — Strasburg has not felt comfortable on a major league mound. And last summer, he literally gave parts of his body to baseball, having had a full rib and two neck muscles removed in a surgery for thoracic outlet syndrome that threatens his career.
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He has not thrown a ball in more than three months. He’s not certain he will pitch again.
“Every time I’ve had an injury, I felt like I was going to be the best there is coming back,” Strasburg, 34, told The Washington Post this week. “… This is the one that’s still definitely a big question mark.
“I realize the clock is ticking. It’s been almost three years since I’ve been able to pitch competitively, and it’s not like I’m getting younger.”
‘It’s had some trauma’
To explain how he got here, to the point of not knowing what’s next, Strasburg goes back to 2018. The first sign of thoracic outlet syndrome was lingering tightness in his neck. He spent time on the injured list. After the season, he visited a specialist, who injected Botox into his neck to shut down the muscles and alleviate built-up scar tissue.
Strasburg then had his best offseason in years, wondering why he could do so many biceps curls and throw without an aching shoulder despite his extensive injury history. Even before the title run, he made more than 30 starts for the first time in a half-decade. He felt that maybe, just maybe, there was new life after all his health complications. But lurking beneath the surface, lending doubt whenever Strasburg stretched his neck or shook his right hand, was so much wear and tear on his neck, shoulder and the rest of his prized arm.
The coronavirus pandemic complicated his progress. When the sport returned from a shutdown, Strasburg felt a “zap” whenever he threw between simulated games. His hand tingled in the middle of the night, let alone whenever he pitched. A test revealed carpal tunnel neuritis, and Strasburg underwent surgery for it in August 2020. But he now believes the procedure could have delayed addressing the real issue of neurogenic thoracic outlet syndrome.
The condition stems from the compression of nerve roots in the brachial plexus, a nerve network above the collarbone that provides movement and feeling to the arm and hand. It is most commonly diagnosed in pitchers, with specialists citing repeated arm injuries and high-effort throwing as main causes.
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“Any time you don’t have a clear diagnosis of a structural issue, you look at the shoulder and structurally, everything looks clean and fine, to some degree it is a leap of faith,” said Chris Young, who underwent neurogenic TOS surgery in 2013, pitched for four more seasons and is now the Texas Rangers’ general manager. His experience is a success story for the relatively new procedure. Others have not been as fortunate.
“There’s something wrong here, there’s pain here, I don’t know what the root of the problem is, you’re telling me everything looks fine but I’m telling you there’s severe pain and I’m not able to throw a baseball,” Young continued. “So you either accept that, okay, your career is over because you had shoulder surgery and the damage is done. Or you say, okay, there may be an underlying cause of this that was actually the cause of the original pain.”
The season after carpal tunnel surgery, Strasburg’s problems came earlier and earlier in his starts. His neck was stiff. His shoulder was sore. He often took multiple cortisone shots, trying to last 100 pitches and stay on the field. But after five appearances, enough was enough. Strasburg flew to Texas to see Gregory Pearl, a leading surgeon for thoracic outlet syndrome, and had the procedure two days later.
This was July 2021. In the 14 months since, Strasburg has had three setbacks, tested positive for the coronavirus in April and this summer mourned the death of his father. He started for the Nationals on June 9 and immediately went to the injured list with a stress reaction in the second and third ribs on the right side of his body. Before landing there, he tried throwing a change-up after that lone outing in June, felt three pops in his shoulder and knew that meant trouble. He looks a lot like he did in his prime, a 6-foot-5 starter who detailed this saga in a T-shirt and shorts, his uniform for another daily rehab session. What plagues him is beneath his imposing figure.
“I’ve been doing very minimal exercises, and I’ve seen some improvements as far as the way my shoulder is sitting,” said Strasburg, who is at Nationals Park for every home game and coordinating with team medical staff when the club is on the road. “But I feel like the strength is not quite there, and I’m not really sure what the future holds.”
Strasburg’s most recent issue is with his upper brachial plexus. On a recent visit to Pearl, the doctor told him that TOS surgery doesn’t necessarily address the upper plexus — more the middle and lower — meaning Strasburg can only take time and hope it heals to full strength.
Those are the answers he’s working with at the moment: time and hope. Strasburg just doesn’t know how much of either he has left to pitch.
“All the way down my arm, it’s had some trauma,” he said, pointing to the shoulder, biceps and forearm that once made him the first pick in the draft and recipient of his current seven-year, $245 million contract that runs through 2026. “You can only do so much. It’s not like you can train your nervous system to just work better.
“I wish I could. … There’s still a strong desire to figure out this puzzle.”
‘The thing that removes your rib’
Given all these hours to think about TOS surgery, Strasburg has whittled the complications to this: When he had Tommy John surgery in 2010, a surgeon repaired a torn ligament in his elbow. When he underwent TOS surgery, Pearl removed a rib and the two scalene muscles from his neck, creating an imbalance that has made it hard to repeat his mechanics in the aftermath.
Another tricky part of TOS is that a diagnosis often comes after many other options are explored. Also, no two rehab processes are the same.
“It’s not uncommon for us to get referrals from people on teams where we’ve had other players get treated,” said Robert Thompson, a vascular surgeon and the director of the Center for Thoracic Outlet Syndrome at Washington University in St. Louis. “The team personnel are familiar with the condition, and for them, they may not hesitate to make that referral call.
“Others may not be familiar with it, maybe a little bit worried about that condition or kind of even frightened to make that diagnosis. And some of it has to do with the potential surgical treatment, the uncertainty maybe of the recovery and rehab and the return to play.”
Young didn’t know about TOS until after he had a pair of shoulder surgeries. Shawn Hill, another major league pitcher, had had two Tommy John surgeries, a nerve relocation procedure and then TOS surgery in 2012, telling Young to look into “the thing that removes your rib.” For pitcher Carter Capps, the pain was so sudden and sharp he thought he was passing a kidney stone.
The top of his neck had been a bit more achy than usual, but not much beyond the standard toll of a long season. Basic tests on his neck and shoulder didn’t reveal much, either. Inside Capps’s body, though, a blood clot was building up, leading to a pulmonary embolism that called for TOS surgery in 2017.
Players who have had the procedure want an increased awareness of the general symptoms: pain in the neck and shoulders, tingling down the arm and into the hand. Thompson believes that, the longer a player waits to confront TOS, the recovery can get tougher because of increased age and mileage on the arm.
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Like Strasburg’s view of his carpal tunnel surgery, Clayton Richard, a former pitcher, believes he underwent an unnecessary shoulder procedure before visiting Thompson in St. Louis. Strasburg called carpal tunnel “a common misdiagnosis of TOS” and admitted he wanted to take the “path of least resistance” to return.
“It’s not that my second shoulder surgery was super detrimental or anything,” said Richard, who pitched in five seasons after undergoing TOS surgery in 2014. “But it did cost me some precious time in the back half of my career.”
“Unfortunately for this, unlike Tommy John surgery, there’s not an imaging study where you can see a tear of a ligament or a structural abnormality,” Thompson explained. “So we don’t have those kinds of tests that we would say are ‘objective.’ And the diagnosis, for the large part, depends on the clinical evaluation.”
‘It wasn’t for a lack of effort’
Through every injury — through his Tommy John surgery, through the infamous shutdown in 2012 — Strasburg has always trusted that anything could be fixed with consistent mechanics. His velocity dipped well before he lifted the Nationals to a title. He evolved as his arm did, leaning more on deft skill than a generational ability to overpower hitters.
But his ongoing recovery goes beyond mechanics, which he says have been “haywire” for almost three years. In so many ways, his body is shutting down, making him confront the limits of an arm that has defined his whole life. When he made a rehab appearance for the low-Class A Fredericksburg Nationals in May, he felt tightness between his wrist and thumb. He kept stretching his hand in the dugout, but it wouldn’t go away.
Strasburg’s reality, then, is both those pops in his shoulder and the smaller sensations that make it hard to pitch and live. Earlier this season, he couldn’t stand for long without his whole hand going numb. He was only comfortable when lying down, his right hand pressed against his chest. He grew used to using his left hand for basic tasks. Strasburg has pitched 1,525⅓ innings between the regular season and playoffs, each with the Nationals and only 31⅓ since 2019. His plan is to finish out the season trying to regain strength and range of motion in his shoulder. Then he will do another round of meetings with specialists to see if his outlook has improved. One of Strasburg’s worries, even before additional assessments, is the potential for long-term side effects.
“It wasn’t for a lack of effort or lack of putting in the work,” Strasburg said of his situation. “It’s just the way the cards are dealt sometimes.”
“My dad moved out here a year ago, and through this process, in a way I’m thankful that I was injured because I probably would have been on the road and not seen him,” Strasburg continued. “He passed away about three weeks after I initially had the stress reaction diagnosis. I was able to see him the day before. So being an only child and taking care of your dad’s affairs, that’s kind of been a focus for a big part of this stretch. Luckily, I was able to do a lot of that and be there with him, and spend some time with him toward the end, and now it’s back to focusing on the baseball aspect and seeing what I can do to get back to the mound — if I can.”
When Strasburg cleaned out his dad’s apartment in Northern Virginia, he found that his father had saved dozens of newspaper and magazine articles about him. There were stories going back to Strasburg’s days as a top draft prospect at San Diego State University. There was a fresh-faced Strasburg thriving for the Nationals.
There were all his accomplishments, all laid bare, making Strasburg wonder where the years went.
“Time has gone so, so fast,” he said. “A lot of guys that you played with have moved on and they’re in the next chapter of their lives. It’s crazy to think about how short baseball careers can be.”
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