#thoracic outlet syndrome
Last week, former Ultimate Fighting Championship (UFC) Welterweight Champion Matt “The Terror” Serra, decided to hang up his gloves and retire from the sport of Mixed-Martial-Arts (MMA).
In an interview with Newsday, Serra recalls the beginning of what ultimately sealed his fate to walk away from the sport he loved.
The beginning of what would prove to be a crazy ride started when Serra felt a pain in his left arm after a Brazilian Jiu-Jitsu session at one of his academies on April third. The scrappy 39 year-old chalked it up as nothing more than a pulled muscle, and didn’t give it much more thought.
Two days later, while working as a corner man for one of his fighters, the pain was back and worse than before. By 2 a.m. he couldn’t even lift his hand to touch his neck, that’s when he finally decided to drive himself to the emergency room at Winthrop University Hospital in Mineola, New York.
After a few tests, two blood clots were found in his arm and another in his lungs. Doctors put Serra on blood thinners to address the clot in his lungs. For now he’ll be injecting himself in the abdomen with a high dose of Lovenox (a drug that prevent blood from clumping up as is flows through your body), every day for at least the next three months. A thankful Serra recalls:
“Then I got freaked out. You don’t catch that [and] after the lung, that stops your heart or your brain. Then you’re done. I’m very fortunate to, basically, be here. Sounds kind of morbid. If I didn’t catch that – I was about to go to bed. I’m like, man, something’s not feeling right.“
Last week, while giving an interview to the MMA Hour’s Ariel Helwani (May 27th, 2013), Serra was asked what exactly the name of the medical condition was that landed him in the emergency department, and in classic Serra fashion he responded with:
“I have a weird disorder, or whatever you wanna fuckin’ call it. It’s some kind of… what is it called? The boom-boom syndrome. Ah, I forgot the fuckin’ name of it. My wife knows.”
So, instead of bugging Serra’s wife with your questions, we here at Injury-Duty figured it’d be a perfect opportunity for us to help clear things up.
What finally got Serra to make a visit to the emergency department was the pain in his arm, which was the result of blood clot, as we now know. But, what caused the blood clots in the first place you ask? Well, to better understand that, lets take a quick Injury-Duty anatomy crash-course.
On both the left and right sides of your upper chest, you have a relatively snug space between your collarbones (in medical jargon, your clavicles) and your first ribs (click for an image), which sits right behind the collarbone. In that space run three important structures:
- Brachial plexus: This is essentially a thick bundle of nerves responsible for taking all signals from your brain to your arm (and vice versa).
- Subclavian artery: This artery’s job to supply your arm with “fresh” (or oxygenated) blood.
- Subclavian vein: This vein’s job to remove “used” (or deoxygenated) blood from your arm, and return it to your lungs where it can pick up more oxygen.
After a thorough evaluation by his medical team, Serra was diagnosed with what is known as thoracic outlet syndrome (TOS), which is just a fancy way of saying that the “snug space” we described above (known as the thoracic outlet) is being smooshed. What is doing the smooshing? It can be do to a lot of things, but here is a list of the most common causes:
- A broken first rib or collarbone
- Neck muscles that are too large (from such things as bodybuilding. We’re pretty sure this is what Serra would say happened.)
- Extending the arm above the head for a long period of time (during sleep or while unconscious)
- A congenital anomaly (nerd speak for having something in your body that developed abnormally)
- Tumor (pretty rare)
As for what exactly is being smooshed, well here are the most common suspects:
- Brachial plexus (i.e. Neurologic type of TOS)
- Subclavian vein (i.e .Venous type)
- Subclavian artery (i.e. Arterial type)
The symptoms a patient might have due to TOS are divided into categories, all depending on what exactly is being smooshed:
- Neurologic (meaning involving the nerves): Most common, making up about 95% of all cases.
- Venous (meaning involving the veins): Responsible for 4% of all cases.
- Arterial (meaning involving the arteries): Rare. Occurring only in about 1% of all cases, but is potentially the most serious of the three types.
Serra’s case was actually pretty “text-book”. The quickness with which the pain, swelling and bluish discoloration of his arm hit are classic hallmarks of the venous type of TOS (again, the smooshed subclavian vein variety). These patients are typically males, in their late 20s to early 30s who have participated in some form of strenuous physical activity with the affected arm (insert masturbation joke here… come on. You know you were thinking it in your head).
The trouble with smooshing the subclavian vein (or any vein, actually) is that doing so causes a sort of back-up of blood. And, since veins are under pretty low amounts of pressure, it doesn’t take much to clamp down on one. For example, this is why it’s advised when on a long trip (a plane flight for example) that you stand up and stretch every two hours or so. The simple action of your knees being bent (along with the pressure of the seat your in pushing down on the veins in the back of your knees) can cause blood flow to slow down. What’s the problem with that you ask? Well, when allowed to sit around in one place for too long, blood likes to clump up and form a clot. Trouble is, when the clots are able free themselves up, or whatever it was that was sloshing the vein to begin with is moved, these clots are free to plug up another spot in your body, and too often that spot is in the lung, this is known as a pulmonary embolus (PE). Sometimes the PE is small and easily managed, but it is not uncommon for larger one to kill a patient, quickly.
Once the blood clots in Serra’s arm and lung were confirmed (probably using venography) he was likely given tissue plasminogen activator (tPA), often referred to as the "clot buster”, to help breakdown the clots that had already formed. And, to prevent new clots from forming, he was started on Lovenox (a drug that prevents blood from clumping up as is flows through your body).
Now that the medical team had figured out what exactly was going on, the next step was to figure out how to prevent it from happening again. For that, the treatment for TOS is surgery, with the goal being to remove whatever it is that’s responsible for smooshing the vein in question. And, because the structures that are being smooshed in patients with TOS can vary, surgeons have preferences as to where they feel the best place to enter the body is to correct the problem. In Serra’s case (venous TOS), many doctors believe that the transaxillary approach (in simple terms, that means through the armpit. Yes, sounds odd, but take a look at the picture to get a better idea). This approach allows for the surgeon to best see the important structures that may be playing a role in the problems being caused. The surgery was done almost exactly one month after Serra had initially presented in the emergency department with arm pain.
Had Serra opted to not have surgery, chances are pretty much 100% that he’d have another clot form (even if he continued to use medications that prevent his blood from clotting).
- Is TOS enough to force somebody into retirement: Generally speaking, no. Serra will likely be allowed to return to physical activity in 6-8 weeks. But, he is 39 years old and has a successful BJJ gym he runs, which both are likely factors that went into his decision to leave the sport.
- Will he have to worry about contact sports now?: No, he will not have to alter his training or recreational activities after his surgery.
On behalf of one Long-Island based team to the another, we here at Injury-Duty would like to wish Matt Serra a speedy recovery all the best in his future endeavors!
I don’t generally post about my personal life here and I definitely do not want to turn this into a medical blog, but I did wish to write at least one post about some of my health problems and how I’ve been dealing with them.
A major reason why it took me so long to write G&G is that I suffer from what I originally thought was Carpal Tunnel Syndrome but turned out to be Thoracic Outlet Syndrome (TOS), specifically neurogenic TOS. After two and a half years of physical therapy I decided to have the surgery. Around this time I started looking for anything I could find on the Internet from people who’d had this procedure, and it frightened me that seemingly everyone who’d ever blogged about it had difficult recoveries. I realized that if an operation goes well then there’s not much to be said about it, but resolved that if everything went okay for me then I’d at least tell Tumblr that much.
I had the surgery a little over a month ago, and things have in fact been more or less okay. It’s still painful for me to spend much time on the computer, which is why I haven’t been on Tumblr recently, but for most other everyday activities I’m doing better than I’d expected. It remains to be seen how things will go in the long term, but I have already seen an improvement in some of the nerve-related problems I was having before the surgery.
I’ll go into more detail about my recovery behind the cut for the sake of others who are planning to have this operation.
I’d been told to expect to spend 1-3 night in the hospital, with a 4-6 week recovery after that and definitely no driving or going back to work for at least two weeks. I wound up spending two nights in the hospital and returned to work after four weeks, although I am fortunate enough to have decent medical leave through my employer. Had my livelihood depended upon it I probably could have managed to get back into the office a week or so sooner, although it would have been difficult.
There seems to be a lot of variation in how people’s recovery from TOS surgery goes, but for me the worst part of the first two weeks post-surgery was really the lingering effects of the anesthesia and other drugs. This was especially bad the first week. I was rather dimwitted and clumsy, and also very constipated. I’ll spare you the disgusting details, but getting through that was definitely the low point. All of this would have been the same for pretty much any major operation, though.
The worst TOS-specific problem was that it was difficult to get into a comfortable sleeping position. Actually, for several days I’d say there was no comfortable sleeping position possible. (I’ve heard that some people do better sleeping in a recliner, but I don’t have one so I wasn’t able to test this.) A body pillow helped some, and I was able to get several hours of sleep every night once I was home, but it was about 10 days before I slept through the night.
Because of the aforementioned dopiness, clumsiness, and inability to drive, plus weakness in the shoulder/arm, you will need someone around to help you at home and with errands for the first week or so. Two everyday tasks that will be difficult or even impossible at first are unplugging appliances and opening bottles. As far as basic self care like using the bathroom, taking a shower, brushing my teeth, and getting dressed, I was able to handle all of that on my own by the time I was out of the hospital. I would recommend easy to put on clothes like baggy t-shirts, sweatpants, and zip-up jackets, and for ladies a strapless bandeau style bra. Other items I’d suggest for comfort and convenience while recovering are a neck pillow like people use on airplanes, and a book stand. These are good for both actual books and tablet devices.
My post surgical pain has certainly been noticeable, but not horrific. I was given prescription painkillers but they made me anxious and contributed to my trouble sleeping (these are both rare but not unknown side effects) so I stopped using them after my first day home from the hospital. Fortunately my pain was manageable with Advil and Tylenol. The incision itself didn’t hurt much after the first couple of days…except when I sneezed. You’ll be warned to avoid sneezing, and that’s because for the first couple of weeks then a sneeze will leave you feeling like you’ve been shot in the chest. This did resolve itself and a month post-op I’m mostly just sore/numb around the incision. I’ve had more pain in my shoulder and arm, which feel like I tried to lift something WAY too heavy, but I’d rate this as at most a 6 and often only a 2-3 on the 10-point pain scale. If you have TOS you’ve probably already lived through worse.
I’ve been diligent about doing my stretches and returned to physical therapy two weeks after the operation. Some movements are still painful or difficult for me, but most things are gradually getting easier.
I don’t have much else to say on the subject, except to wish my fellow TOS-sufferers good luck with whatever treatment option you choose.
