The Price of Carpal Tunnel Syndrome

By Dr. Ankur Verma

David Price. (Credit: Keith Allison on Flickr)

On May 9, 2018, one of those sports talking head shows was playing in the background as I tried to get some work done.  While they are usually useful as white noise as I try to be productive, I happened to glance at the screen and something that scrolled across the bottom caught my eye: David Price would be held out of his start that night for what was being called “mild carpal tunnel syndrome.

That’s odd.  In my residency, we dealt with carpal tunnel (CTS hereafter) on a regular basis.  Frequently, we would use electromyography to diagnose whether CTS was present in an individual and to what severity.  This information would assist surgeons on whether to do surgery or not.

David Price does not fit the usual mold of patients that complained of CTS-like symptoms that we saw in our clinic.

Since the missed start, reports have come out that Price’s CTS can be attributed to playing the video game ‘Fortnite’.  This has been a topic of much discussion among the aforementioned talking heads, but that’s neither here nor their for my purposes at this moment.

I’m more curious about what the implications of CTS in a pitcher could be.  It was the first time I could recall CTS interfering with a major league pitcher’s ability to perform his duties, much less costing him a start.

However, was my memory tricking me?

A search through ProSportsTransactions.com shows precisely one MLB player in the past from their database that was suffering from CTS enough to be placed on the disabled list (DL): Chad Gaudin, a pitcher on the San Francisco Giants, was placed on the DL on 8/20/2013.

A few interesting things about Gaudin.  He didn’t pitch for the rest of the season after being placed on the DL.  That offseason, he signed with the Phillies, but was released before the season began because of a failed physical.  He would later undergo a rare phrenectomy surgery and sit out the season.  The following offseason, he signed with the Dodgers and, despite pitching well in spring training, began to feel a numbness and tingling sensation in the fingers of his right hand.  Even though it was initially reported as “neck nerve irritation”, the right-hander subsequently underwent carpal tunnel release surgery.  Initial reports had him returning in a month, but he would instead spend the rest of the season rehabbing.  Gaudin never pitched again in the majors and has most recently bounced around a couple of Mexican League teams.

Chad Gaudin. (Credit: dbking on Flickr)

But let’s go back to that numbness and tingling he was experiencing that August day in 2013.  According to the linked article, his manager, Don Mattingly, said, “The only time he was able to reproduce the feeling was when he gets up on the mound.”

This makes sense to a degree.  CTS is compression of the median nerve as it courses through the carpal tunnel and is caused by repetitive hand and wrist movement, specifically wrist extension or flexion.  Repeated wrist extension/flexion can be caused by activities such as using a keyboard and, yes, gripping objects.  Symptoms tend to flare when these activities are done.

Median Nerve Compression in CTS. (Credit: BruceBlaus. Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.)

In actuality, though, most cases are idiopathic.  Poor prognostic factors include symptoms present for greater than 10 months per Physical Medicine and Rehabilitation Board Review, which would seem to apply to Gaudin’s scenario, considering that, at least publicly, we know that more than a year passed from the onset of his symptoms to going under the knife.

Most cases are idiopathic—okay.  And Gaudin could have had a mass or something else causing it.  I don’t know.  But humor me for a few minutes.  Repetitive gripping is a known cause of CTS.  There is weakness in thumb abduction and opposition (ability of thumb to touch the other fingers on the same hand).  While this study shows there is no correlation between grip and pinch strength and pitch type, it attributes the importance of palmar pinch (thumb pad to pads of index and middle fingers) in holding the ball when throwing a fastball, curveball, change-up and slider.  Refer to The Complete Pitcher for different types of grips.

Is it possible that CTS interfered with Gaudin’s ability to grip the baseball and affected his pitching?

Let’s take a look (all subsequent pitching data from BrooksBaseball):

First his pitch mix over the last 3 months leading up to his injury.

Chad Gaudin Pitch Mix

MonthFourseam%Sinker%Change-Up%Slider%
6/201363.306.739.4320.54
7/201357.627.0612.5822.74
8/201363.322.428.6525.61

No curves, but plenty of the other types.  Now let’s look at his velocity in the last 3 months up to the injury.

Chad Gaudin Velocity

MonthFourseam (MPH)Sinker (MPH)Change-Up (MPH)Slider (MPH)
6/201392.5891.8586.5480.25
7/201391.1690.4585.8379.82
8/201390.1489.5485.0379.86

Generally there is a drop in velocity across the board.  His fastball loses more than two ticks.  Is it possible Gaudin was starting to feel something at this point? Well, let’s look at the movement on his pitches. (I promise this is a David Price post, and not a Chad Gaudin post.  Well, maybe it’s both).

For Horizontal Movement, picture the change in the ball’s movement along the X-axis:

Chad Gaudin Horizontal Movement

MonthFourseam (inches)Sinker (inches)Change-Up (inches)Slider (inches)
6/2013-4.87-7.96-8.137.23
7/2013-3.74-7.56-7.317.50
8/2013-2.19-7.25-7.167.38

For Vertical Movement, picture the change in the ball’s movement along the Y-axis:

Chad Gaudin Vertical Movement

MonthFourseam (inches)Sinker (inches)Change-Up (inches)Slider (inches)
6/20137.794.150.170.82
7/20137.323.630.750.28
8/20136.633.681.030.65

Something’s up!  His pitches had less movement, and in the case of his fastball, a lot less.  Whether it was the CTS or symptoms that portended the eventual phrenectomy or the “neck pain”, something was going on.

Was there a similar trend with David Price?

David Price Velocity

MonthFourseam (MPH)Sinker (MPH)Change-Up (MPH)Cutter (MPH)
3/201892.7792.8584.6388.09
4/201893.6193.1985.1989.16
5/3/201892.6992.8385.3188.65

(Price uses a cutter instead of a slider, but same principles apply.  Also, he made one May start prior to missing his next one with CTS, so that’s the game included here.)

Eh…not much change in velocity.  What about movement?  This time, I put everything in one table, so hopefully it’ll be easier to see if there are any trends.

David Price Movement

 Horizontal (inches)Vertical (inches)
Fourseam
3/20185.617.43
4/20185.407.57
5/3/20185.598.56
Sinker
3/201810.635.44
4/20189.755.70
5/3/20189.656.76
Change-Up
3/20189.583.82
4/20189.433.09
5/3/20189.633.52
Cutter
3/2018-0.083.83
4/2018-0.344.49
5/3/20180.935.09

 

Not much there, either.  Well, it was worth a shot.

This was all likely moot anyway because Price came in on his first start after CTS on May 12 and tossed 5 1/3 serviceable innings with 6 strikeouts and 3 walks.  There wasn’t much of a change in his velocity or movement on his pitches in this start, either.  Most likely, he had an acute flare-up of his CTS that day, resulting in swelling and pain in his wrist that prevented him from pitching that day.  Mild CTS can be treated conservatively with hand splints, medications, injections, and ergonomic modifications.  Remember, all we know publicly is David Price had “mild” CTS, so this fits.  The reason for the CTS could’ve been anything and it’s not necessarily something we could’ve seen coming by his pitching indicators.  Whereas with Gaudin, his CTS was obviously bad enough to eventually require surgery, meaning he likely had muscle atrophy, severe pain, and/or failed conservative treatment (just speculating, but seems likely).

Suffice it to say, there’s not a lot of precedent in CTS affecting major league pitchers to glean sound conclusions.

If only we had more access to Price’s Fortnite stats.