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Understanding Markelle Fultz’s Neurogenic Thoracic Outlet Syndrome Diagnosis

After months of twists and turns, Philadelphia 76ers guard Markelle Fultz might finally have a bit of clarity regarding his problematic shoulder. Since the start of his rookie season, the former number one overall pick has struggled with his shooting mechanics. His troubles resulted in consultations with an assortment of trainers and specialists and a wide range of public scrutiny. He tried a cortisone injection during his first preseason and missed 68 games of his rookie season with scapular dyskinesis, a muscle imbalance of the shoulder. A bit of improvement was quickly erased by an apparent backslide with Fultz adopting a bizarre free throw routine just weeks into his second season with the Sixers.

Fultz recently left the team to meet with yet another shoulder specialist where he spent the last few days being thoroughly evaluated. ESPN’s Adrian Wojnarowski is now reporting that the meetings resulted in a diagnosis of Thoracic Outlet Syndrome (TOS).

The thoracic outlet region is formed by the first rib, the clavicle (collarbone), and the neighboring musculature. A bundle of nerves known as the brachial plexus runs through this narrow passageway along with arteries and veins known as the subclavian vessels. The brachial plexus is the structure injured when a player has suffered a “stinger” or “burner” following increased tension or direct impact. TOS, however, is a collection of issues that result when these structures become pinched or impinged in three potential locations. Multiple reasons for an impingement in the area also exist including multiple anatomical variations present from birth. These defects include having an extra rib in the area or an elongated cervical vertebra. Repetitive motion and trauma can also result in TOS with symptoms that may be slow to develop.

TOS is a relatively common in Major League Baseball, especially for pitchers. Matt Harvey, Tyson Ross, and Phil Hughes all missed time in recent seasons due to TOS-related issues. However, the condition is seemingly rare in basketball and Fultz’ diagnosis marks the first such incident in the InStreetClothes.com/SMART database.

It’s important to note there are multiple types of TOS with the classification often dictating treatment. Fultz’ case is being described as neurogenic TOS, meaning it involves the brachial plexus. Symptoms from this most common type of TOS range from weakened grip strength to headaches. It can also lead to fatigue of the arm and in some prolonged cases, muscle atrophy and diminished fine motor skills.

Due to the wide range of symptoms, a TOS diagnosis is often difficult to find. A comprehensive exam that incudes physical evaluation, multiple imaging techniques, and tests to examine the electric activity of the muscles and nerves is often required.

Treatment is often dictated by the reason for the impingement. Conservative (non-operative) treatment is often preferred though surgery may be necessary if the symptoms remain following therapy. Congenital defects, like the presence of an extra rib, are often removed with surgery. Unfortunately, a number of complications can arise following surgical intervention though those rates appear to be linked to the surgeon and their adopted approach.

It seems as though Fultz will try to avoid surgery and proceed with conservative therapy, including physical rehabilitation. Wojnarowski reports Fultz is expected to spend the next three-to-six weeks progressing through treatment. Hopefully the diagnosis and new approach to therapy will yield some sort of results for the once promising point guard and allow him to avoid a trip to the operating room. Time will tell if Fultz can return to a high level of play but for the first time in awhile there appears to be a faint light at the end of the tunnel.