With the news that Markelle Fultz has been diagnosed with thoracic outlet syndrome, there's a lot to untangle.
On Tuesday, we spoke with Dr. Mark Schwartz, medical director for Virtua Sports Medicine, to gain a better understanding of Fultz's condition (see story).
With physical therapy being the next course of action for Fultz in his rehab, we spoke with Josh Sabol on Wednesday. Sabol is a doctor of physical therapy and a sports certified specialist who works for The PrivatGym in Philadelphia. He's treated professional athletes and dealt firsthand with TOS.
Sabol is not treating Fultz.
Why didn't the Sixers diagnose this as TOS?
As has been mentioned, TOS is much more common in baseball pitchers than in basketball players. Sabol said this is because of the "repetitive, violent motion" pitchers use. While a jump shot is repetitive, it could hardly be described as a "violent motion."
This may be the reason the Sixers - and a host of other reported specialists - didn't reach this diagnosis.
"With a basketball player, that's not going to be at the top of your list," Sabol said in a phone interview. "Personally, I don't think [the Sixers] missed it or misdiagnosed him. I will tell you that the symptoms of thoracic outlet syndrome can be very variable. You can see one patient that has these symptoms and the other person has totally different symptoms but it's all classified under thoracic outlet syndrome. That's the other thing that makes the diagnosis a little more tricky."
John Clark of NBC Sports Philadelphia reported that Fultz has seen over 10 specialists over the past year. It does seem odd that through all the evaluations, this hadn't come up (according to Clark, one of the specialists mentioned TOS as a possibility but said it shouldn't stop Fultz from playing).
The circumstances are odd.
"It's surprising that it took [10 specialists] to get to the end diagnosis that they're hanging onto," Sabol said. "He's spent more time in doctor's office over the past two years than most of us have ever. That's why it was surprising that they come out with this diagnosis because you would think somewhere along the line, somebody would've at least mentioned this."
Scapular imbalance vs. thoracic outlet syndrome
The whole timeline of events isn't clear, but it's interesting to note how this all started and where we are now.
Fultz was diagnosed with scapular imbalance last season. He then missed 68 games of his rookie season. While Sabol said the term scapular imbalance is pretty vague as far as medical terminology, he did have an interesting way of defining it - especially for those who think Fultz's issue could just be the "yips."
"[Scapular imbalance is] just a broad term to say your shoulder blade is not moving correctly," Sabol said. "The treatment for that would come down to basically retraining him on how to move his whole shoulder girdle. In that case, it's usually a brain-to-muscle connection. You kind of have to re-educate someone on how to move their shoulder blade and their whole shoulder girdle."
Here's where things get more confusing. Fultz dealt with the scapular imbalance and missed time last season. This offseason, he claimed to be healthy and reportedly took 150,000 jumpers with trainer Drew Hanlen.
If the thoracic outlet syndrome has been the issue since last year, how could he have gotten that work in? How would he have hit four threes in his first seven games to start this season?
"There was a point during this season where he was healthy, he was playing and he kind of worked out the kinks in his shot, but then all of the sudden he started to decline again," Sabol said. "That's where things get confusing. His reported symptoms last season didn't sound like TOS. A scenario where he had TOS last season and it went away without mention of that diagnosis, then all of the sudden came back, doesn't seem like a common scenario. If it's truly TOS, I believe that is something that developed recently."
Fultz will now begin physical therapy with hopes of returning to the court. Sabol said it'll likely be a mix of soft tissue work to stop the nerve from being impinged, and since TOS affects the neck as well, breathing exercises and better positioning/posture could help.
Fultz will reportedly be out three-to-six weeks.
"(Within the first few weeks) you should see some type of change in symptoms," Sabol said. "If not, then you've got to change the treatment. With really any diagnosis, which holds true for thoracic outlet syndrome, I wouldn't say you would expect him to be 100 percent in three weeks, but you should at least see some improvement in his symptoms."
Surgery an option?
And what if the physical therapy doesn't work and Fultz is forced into a surgical option? Normally surgery would require the patient to have part of their first rib removed because that's where nerves normally get impinged.
While it's heavily a patient and case-dependent situation, Sabol said it should be a last resort.
"You see in baseball, it's usually a career-ending surgery for these guys," Sabol said. "They come back but their velocity is way down, they're not nearly as effective. Matt Harvey is the most recent example of that.
"Basketball, I'm not familiar with anyone that's had it and come back so it's hard, but to me, you want to make absolutely sure that you've exhausted all your conservative options before you go and start removing bones and structural things. I would tend to be much more on the conservative side so I would give it at least a few months before you just jump to surgery."
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Markelle Fultz has a new diagnosis, is out indefinitely