After a two-year stretch of confusion, frustration, internet conspiracies, and unpredictability, Markelle Fultz, the Philadelphia 76ers’ 2017 No. 1 draft pick who suddenly couldn’t shoot a basketball, was finally diagnosed with thoracic outlet syndrome (TOS). This ailment, often untraceable even by MRI, is the cause of Fultz’s inability to shoot a basketball properly from any distance, according to agent Raymond Brothers.

But TOS is a very real, frustrating, and difficult-to-describe ailment. That may explain why it took so long to diagnose.

I spoke with Dr. Jacques Hacquebord, a peripheral nerve surgery specialist and assistant professor in Orthopaedic and Plastic Surgery at NYU Langone Health, to understand how TOS is discovered, why the disorder can be mentally straining on patients, why Fultz was able to do everything on the court but shoot, and why surgery for TOS is dangerous.

Read more from SBNation.

Thoracic outlet syndrome is not this confusing

I had a really difficult time reading this article. It may have been intended to clarify and simplify TOS for sports fans who are not doctors. In my opinion, it likely accomplished just the opposite. In fact, I found it difficult to organize my comments, as the article goes in different directions and glosses over important details with broad generalizations.

The anatomy of the thoracic outlet is well-understood

On one end, you have these nerves that come out of the spine. At the other end, you have the nerves that go down into your arm, and they go to specific muscles. Between the nerves that leave the spine, and nerves that go into specific muscles and provide sensation, that whole region is called the brachial plexus, where the nerves are flowing in and out together.

TOS involves the brachial plexus, but it’s an undefined diagnosis. In reality, the region where those nerves could be potentially compressed or irritated is a large region.

The article creates the impression that the thoracic outlet is a large and poorly-defined area. In fact, the thoracic outlet is small, specific, and quite well-defined. The brachial plexus is complex but small, and is only a part of the thoracic outlet. The boundaries and anatomic structures of the thoracic outlet have been understood and defined for well over a century. In fact, an interested person can review the history of TOS and easily find descriptions of the brachial plexus and surrounding structures from Galen and Vesalius, as early as 150 A.D. I know, because I have done that. Have a look at our ‘History’ page.

TOS is not undefined. TOS occurs when compression or tension on the brachial plexus causes neurogenic symptoms. TOS specialists need to know the anatomy in detail so they can understand what is causing entrapment of the brachial plexus.

TOS is well-understood

The diagnosis for it is notoriously difficult, and for many, you can’t find a focal area of compression because the MRI imaging or ultrasound imaging is inadequate. Or, maybe because there isn’t a focal area of compression that can be found because it doesn’t anatomically exist.

First, TOS is diagnosed by experienced specialists in experienced centers around the country (and around the world). This doesn’t occur through a single doctor, a single medical center, or a single city. While there is no uniform agreement on the best diagnostic test, TOS specialists use MRI, ultrasound, CT and other tests on a regular basis. And while there are multiple specialists and centers with different opinions and experience, they all diagnose TOS confidently according to their standards and experience. TOS specialists have understandable disagreements as they learn more about the disease, and as they work to move forward on diagnosis and treatment. But nobody considers the diagnosis of neurogenic TOS out of reach.

Second, MRI is not ‘inadequate.’ A physician can easily find peer-reviewed articles supporting the value of MRI and other forms of imaging in the diagnosis of thoracic outlet syndrome. I have read thousands of TOS cases personally. And we have used MRI for the diagnosis of other nerve entrapments in the body for decades.

Third, if a patient does have neurogenic TOS, by definition there exists a focal area of compression or tension on the brachial plexus. That is the confirmed and agreed-upon pathology of TOS. Nobody argues that. We should ask, why would a surgeon operate if there is no anatomic abnormality?

It is the nature of surgery to alter anatomy or to remove pathology. There is no sense in diagnosing a patient with neurogenic TOS and then refuting the diagnosis by saying there is no compression of the brachial plexus. By definition, patients with neurogenic TOS have compression of the brachial plexus.

Contradictory statements about TOS

There are some patients, 100 percent, you know they have TOS. You can see the nerves compressed, you can see the anatomical variant they have, like an accessory rib or hypertrophied muscles or compression by the vessels. You can see it, you can find it, and you can treat it surgically.

This statement apparently contradicts several other statements in the article. If ‘MRI imaging or ultrasound imaging is inadequate,’ or if a point of compression ‘doesn’t anatomically exist,’ as previously stated, how is the patient diagnosed with neurogenic TOS? How would a doctor see nerve compression or a cervical rib? On what basis would a surgeon make a decision to operate? How would a surgeon know what structures are normal or abnormal?

In reality, a surgeon wouldn’t just go in and muck about. They would know what they are dealing with ahead of time, plan the surgery, and then go in and focus on known abnormalities.

TOS specialists each have their preferred workups that include various diagnostic tests. Surgeons perform surgery only on those patients who are most likely to have compression of the brachial plexus. If a surgeon feels there is no anatomic abnormality, they won’t operate.

Conservative treatment of TOS works

The majority of people who have TOS do not undergo surgery, so it’s hard to know definitively if they actually have it. If they get treated for it with physical therapy, then the question is, are they better because TOS is resolved, or is it because they had some other process that was self-limiting or benefitted from therapy?

A majority of the time, patients get better. Do they get better because of physical therapy? Probably not. They got better because it’s a self-limiting disease process and they were going to get better anyway.

While it is true that most patients with neurogenic TOS do not go to surgery, that is because most patients respond to conservative treatment.

TOS specialists have developed, tested, and refined conservative treatment for patients with neurogenic TOS over many decades. There is extensive peer-reviewed literature regarding these treatments. This literature proves the success rate of conservative treatment of TOS. Almost all TOS surgeons and specialists send their patients with neurogenic TOS to conservative treatment for 6 to 12 months. And these surgeons mostly consider surgery only for those patients who have failed this treatment.

You might ask how a surgeon knows if surgery in any patient with neurogenic TOS has been successful. The surgeon would tell you that reduction of symptoms and restoration of activities of daily living defines success in any one patient. I strongly doubt that a surgeon or patient would consider improvement following surgery as mere coincidence.

Given these points, most TOS authorities would consider improvement after conservative treatment more than simple coincidence.

Finally, it is important to note that TOS is not considered a self-limiting condition. TOS patients need diagnosis and treatment. Nobody with TOS should just wait for it to go away.

Scapular motion is important in thoracic outlet syndrome

SB: In 2017, Fultz was diagnosed with scapular muscular imbalance. Did that lead to TOS?

JH: It’s not impossible that could’ve actually been thoracic outlet syndrome. The scapula has 12 or 13 muscles that attach to it or originate from it, meaning every one of those muscles plays some role in the motion of the scapula.

The scapula motion is incredibly important. One third of your shoulder motion where you raise your arm in the air comes from your scapula, not your shoulder. Moving your arm forward and backward, a huge part of that is coming from your scapula.

These statements are true and valuable. I fully agree that scapular motion is critical to the development of thoracic outlet syndrome. The scapula is quite mobile, in 6 directions. Movement of the scapula alters movement of the clavicle (collarbone). Since movement of the clavicle relative to the first rib may compress the brachial plexus, scapular motion should be evaluated. The fact that 17 muscles attach to the scapula should underline the complexity of this motion.

Markelle Fultz and thoracic outlet syndrome

I don’t know what he might be doing in physical therapy that he hasn’t done already. Many times when patients have a problem, and you don’t really know what’s really going on, the reflex is to say, ‘Well, let’s do some physical therapy.’

If a patient has what you think is TOS, but you don’t know where the compression is, you try therapy with the hopes that things get better. What exactly is that therapy going to be? I don’t know. And I don’t think a lot of other people know. They just try it because it’s morbid to go straight to surgery.

Operative management can be relatively morbid. You’re operating around the brachial plexus, around the subclavian artery and the carotid artery.

You expose the brachial plexus, and there’s typically an incision around the clavicle in the neck. For a brachial plexus surgeon, it’s a straightforward procedure, but you are operating around large blood vessels and operating around crucial nerves, so you have to be so incredibly meticulous and careful. A lot of it is done under the microscope.

TOS frequently are referred to physical therapists to start conservative treatment. Some physical therapists are specially trained and knowledgeable in treating patients with TOS. In fact, TOS patients should not see a physical therapist who does not have this skillset.

Markelle Fultz might have undergone any number of prior therapies that did not include TOS-specific physical therapy. In fact, he has started treatment with a very well-regarded physical therapist in Southern California with just such training. There is no reason to be dismissive of this new treatment, as Mr. Fultz may have previously had quite different treatment. And it should be noted that qualified TOS specialists do not order physical therapy as a ‘reflex,’ or with ‘hopes that things get better.’ TOS physical therapists are a valuable part of the TOS community, and there is no reason to minimize their work or effectiveness.

As regards TOS surgery, the complication rate is quite low in experienced hands, which can be clearly proven in the medical literature. Complication rates are higher when the surgery is performed by less-experienced surgeons. I have observed many surgeries, and I do not recall seeing a microscope used in any of these. There is clearly a proportion of TOS patients who fail conservative therapy, and who should proceed to surgery, without fear of astronomically high consequences.


In my opinion, this article is not well-organized or fully accurate, and is potentially counter-productive for those looking to understand TOS. It is not very consistent or cohesive, and it is difficult to follow the logic at several points. While there is some valuable information, there are also inaccuracies. Patients or doctors who read an article like this may be put off inappropriately from seeking a diagnosis or accepting treatment.

There are likely a lot of patients with TOS who don’t realize they have it. There are doctors who aren’t very familiar with TOS. It is incumbent on the TOS community to help raise awareness, to make resources available to patients and doctors, and to continue to raise the level of discourse, understanding and knowledge about TOS. We cannot afford to be intellectually lazy when there is a lot of literature available to us. We cannot afford to be cavalier in offering an opinion if we are out of our comfort zone.

I hope my comments and notes are helpful for those people looking to understand TOS more fully.

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