A Closer Goes Down With an Axillary Blood Clot

May 12th, 2017
axillary clot injury

Jeurys Familia, The Mets’ 27-year-old closer, was diagnosed with an arterial blood clot in his right shoulder yesterday. Though he’ll likely be out for a while, if not the duration of the season, Familia is fortunate that this was caught now. Further testing is underway to determine if surgery is indicated.

Familia, whose command was an issue this season, especially so in his first blown save this week, said “I just didn’t have it today.” But it proved so much more than that once he was examined by team physicians.

The NY Daily News reported that a scout had noted that Familia’s velocity had been down this season and his “splitter had less drop”, leaving the ball up far too much. He had pitched Monday, Tuesday and Wednesday, this week, his second three consecutive game stretch of the season and 11th appearance out of the 18 games played since his return from suspension. Last year Familia closed on three consecutive days six times and risk of overuse was discussed in the media.

Others Who Have Been There

Blood clots in the axillary artery or compression in the thoracic outlet are not as uncommon as one may think in a population of young, otherwise healthy overhead athletes. The Mets know this all too well, with Matt Harvey having had surgery 2016, and Dillon Gee in 2012.

Symptoms of a clot in the region of the shoulder can include arm fatigue, complaints of a “dead arm”, or numbness and tingling in the arm or hand. All of these symptoms can also have alternate causes.

The significance of a blood clot cannot be overstated. If dislodged, clots can cause stroke or heart attack. J.R. Richard, who might have been the most dominant pitcher in 1980 when he began to complain of arm fatigue, suffered a severe stroke when his symptoms were initially ignored by the medical team and then his clot went undetected on physical exam. For Richard’s account of his ordeal, read this.

Cause and Effect of Axillary Vascular Issues

The repetitive and extreme demand that the young overhead athlete places on his or her shoulder causes the developing skeletal system to adapt. Pitchers in particular succeed in part because of these adaptations: increased external (outward) rotation at the shoulder, an altered position of the head of the humerus and of the joint itself (which become more retroverted), and laxity in the front of the shoulder. Not only do these changes impact the stability of the shoulder, but they have also been shown to place the muscles, other joint components as well as the vascular structures at greater risk of injury.

When the ability of any tissue to withstand the demand placed upon it is exceeded, the dynamic is altered and results in tissue failure and injury. Damage can be acute but also progressive and chronic. The torque and shearing forces produced during the pitching motion are so extreme as to make injury more likely.

A study that examined the effects of throwing on upper extremity arterial blood flow found that “pitchers with signs of shoulder laxity had a significant decrease in arterial blood flow compared with throwers with no evidence of laxity. This vascular insufficiency probably occurs because of the repetitive positional compression onto the third portion of the axillary artery as the humeral head translates anteriorly during the late cocking phase of throwing.”

Aneurysms and Thoracic Outlet Syndrome

Other studies using ultrasound concurred with the above, finding that “intermittent compression can cause chronic changes in downstream vascular sufficiency and potentially lead to an axillary artery aneurysm or thrombus in the overhead throwing athlete.”

An aneurysm is an enlargement caused by the weakening of the walls of an artery. A thrombus is a clot that forms in the blood vessel thereby disrupting blood flow. When such a clot dislodges and travels through the bloodstream it is called an embolus.

In 1996, David Cone, a pitcher on the NY Yankees, was diagnosed with an axillary aneurysm. In his case clots formed in the area and broke away causing symptoms in his hand and fingers. For more on aneurysms in pitchers read here.

Thoracic Outlet Syndrome (TOS) entails the compression of the neurovascular bundle (nerves and/or blood vessels) that lies in the area known as the thoracic outlet.

The boundaries of this space are the clavicle (collarbone), the first rib, the subclavius and scalene muscles of the neck as well as the costoclavicular ligament (which connects the first rib to the clavicle). This positional compression, causing reduced blood flow or neurologic symptoms down the arm and to the hand, is more likely to be symptomatic amongst elite overhead athletes. Matt Harvey had surgery last year to treat the condition by removing a rib.