Clayton Richard, age 31, was a natural athlete growing up, winning Indiana’s Mr. Baseball and Mr. Football awards his senior year at McCutcheon High School in Lafayette, Ind. Starting in 2008, he carved his niche on the pitcher’s mound for the Chicago White Sox and San Diego Padres, twice winning 14 games and pitching more than 200 innings. Yet, by 2013, he was out of baseball – unable to pitch without persistent shoulder pain.

Richard, a 6-foot-5 lefthander who started his major league career as a power pitcher, had a shoulder strain midway through the 2011 season while with the San Diego Padres. He had season-ending arthroscopic surgery and then performed well in 2012. But his shoulder problems persisted; he struggled early in the 2013 season and made only two pitches in a June 21 game before leaving with a shoulder injury.

In mid-July, a surgeon operated on his acromioclavicular (AC) joint. After recovering, Richard knew something still was not right; on days after practice pitching, his shoulder did not feel normal and it hurt to throw. His thoughts turned to a former teammate, Chris Young, who had undergone surgery for thoracic outlet syndrome (TOS), a condition caused by compression of the major nerves and/or blood vessels in the lower part of the neck. Richard decided to visit Young in San Diego and discovered he had every symptom his fellow pitcher described.

Richard then went to see Washington University vascular surgeon Robert Thompson, MD, who had performed TOS surgery on Young. Thompson confirmed Richard’s suspicions – he had neurogenic TOS, the same type that Young had. After testing, Richard underwent surgery in February 2014.

By the end of the 2014 baseball season – after months of rehabilitation – Richard was pitching in minor league games for the Arizona Diamondbacks. In 2015, he started and pitched well with Pittsburgh’s Triple-A minor league team, the Indianapolis Indians, and then exercised an upward mobility clause to sign with the Chicago Cubs. He started two games with the Cubs, posting a 7-2 win over the Miami Marlins in his first game, and is now pitching with the Cubs’ Triple-A Iowa affiliate.

“I’m feeling great and throwing the ball a little bit better every time I go out,” says Richard. “Feeling a little more confident with every game. It’s a fun process right now.”

Thompson says Richard’s symptoms while throwing were typical of neurogenic TOS: pain in the neck just above the collarbone, and numbness and tingling that would radiate down into the left hand. Yet Richard had minimal tenderness in the brachial plexus and few symptoms at rest, unlike most neurogenic TOS patients. So on a standard exam, a physician might conclude he was in pretty good condition.

This presented a problem in performing a standard test for neurogenic TOS: the injection of a local anesthetic into the anterior scalene muscle to interrupt muscle spasm. In most patients, this might alleviate tenderness and symptoms that are evident even at rest. But since Richard had no symptoms at rest, Thompson suggested after the injection that he go to a baseball practice facility and pitch. If the anesthetic blocked the symptoms, it was a clear indication he had neurogenic TOS.

“I gave him a call that night and told him it felt good throwing,” said Richard. “That was a Friday, and I had surgery the following Monday.”

During the surgery, Thompson removed the first rib and the two scalene muscles that attached to it; removed scar tissue around the brachial plexus nerves and mobilized each of the brachial plexus nerves; and released the tendon of the pectoralis minor muscle. This opened up the space all the way through the thoracic outlet for the brachial plexus nerves.

Like other patients, Richard underwent rehabilitation for 3-4 months after surgery at The Rehabilitation Institute of St. Louis. Specially trained physical therapists who work almost exclusively with TOS patients provided most of the therapy.

Over the past 15 years, Thompson has operated on about 20 major league baseball players with neurogenic, venous and arterial TOS. Yet professional and other high-level athletes make up only about 20% of his patients; most patients are young and may have occupations that require a lot of physical activity or may be involved in recreational sports.

Thompson is collaborating with a biostatistician to look at the performance data of major league pitchers who underwent surgery for neurogenic TOS before and after the surgery.

“It’s fun to see some of our patients get back to at least what they were performing before they developed TOS,” says Thompson. “I don’t mean to imply that everyone has a perfectly successful outcome, especially when the margins of error for a high-level athlete are pretty narrow. But 8 of the 8 I know who had neurogenic TOS came back and pitched.”