Elite archer with thoracic outlet syndrome: Park 2013

A 28-year-old Korean archer, an Olympic gold medallist then on the national team, had felt weakness and a dull ache in his right shoulder, on the drawing side, for two years. At full draw his grip lost strength and the little-finger side of his hand and forearm, the area supplied by the ulnar nerve, tingled and lost sensation, enough to disturb his aiming; at rest he had no symptoms and no neck pain. Orthopaedic surgeons at Konkuk University in Seoul diagnosed thoracic outlet syndrome: the nerves and the artery running from the neck into the arm were being squeezed between the collarbone, pushed backwards by the drawing position, and the first rib.

A contrast CT scan taken in a position resembling full draw showed the gap between the collarbone and the first rib reduced to 11.7 mm, against 29.9 mm on the opposite side held in a neutral position, and the cross-section of the subclavian artery down to 7.6 mm² from 19.4 mm² in the uncompressed segment, about 40% of normal. Nerve conduction tests found damage to the lower trunk of the brachial plexus, with minimal axonal injury. He had surgery: the first rib was removed through a cut in the collarbone, which was then fixed with a plate and screws. He was back in competition at 8 months, felt he had regained about 90% of his shooting ability at one year, left the national team to become a coach, and three and a half years after the operation was coaching and demonstrating without trouble.

This is a single case report written by the surgeons who treated the athlete. Diagnosis started with the physical examination: with the arm in a neutral position the radial pulse was strong, while provocation manoeuvres (mainly the Wright and Roos tests, less so the Adson test) weakened it. When the archer took up full draw the pulse dropped in the same way, but the symptoms came sooner and were stronger than in any clinical test. X-rays of the chest, cervical spine and shoulder and an MRI of the cervical spine ruled out the usual causes, such as a cervical rib, a tumour at the top of the lung, a disc herniation, or abnormal muscles and fibrous bands.

The CT scan was taken lying down, with the head turned to the left, the elbow bent and the right shoulder abducted and extended, to mimic the draw within the narrow space of the scanner; the symptoms returned during the scan. Distances and arterial cross-sections come from reconstructions in three planes. In theatre the surgeons put the arm back into the drawing position and saw the artery and nerves compressed together by the anterior scalene muscle and the first rib; after removing the rib they checked the pulse again in the same position. Rehabilitation involved six weeks in a brace, then passive mobilisation with a physiotherapist, strengthening from the tenth week and unrestricted shooting at four months, once the collarbone had healed.

A single athlete tells us nothing about how common this syndrome is among archers or who is most at risk: there is no comparison with other archers, healthy or symptomatic, or with people who do not shoot. The link with the draw is reconstructed: the symptoms appeared at full draw and the CT scan in a similar position showed the compression, but the gap between collarbone and rib is compared with the other side in a neutral position, not with the same side with the arm relaxed. The authors themselves acknowledge that the shooting position in the scanner was only approximate, and that the case says nothing about how the collarbone moves after years spent at full draw.

The 90% recovery of shooting ability is the athlete's own estimate, not a score, and it is not known how much it weighed in his decision to leave the national team. The paper says nothing about his shot (draw weight, draw length, anchor height, elbow position), so there is no way of telling whether anything in his technique played a part.

For archers the case makes one main point: full draw, with the drawing shoulder open and pulled back and the head turned towards the target, can narrow, at least in some people, the space through which the nerves and artery of the arm pass. The warning sign that led to the diagnosis was specific: tingling and loss of strength in the hand and weakness in the shoulder that appeared at full draw and went away at rest. The athlete put up with them for almost two years before seeking help.

It does not show that drawing a bow causes this syndrome in archers generally, nor that changing technique would prevent it: it is an isolated case, in an athlete who had shot at the highest level for years, and the authors themselves stop short of proposing the drawing position as a test for other athletes. Working out where symptoms like these come from is a doctor's job; the point of this record is to know they exist and that, in this case, the archer returned to shooting after surgery.