One glance at his right arm and Drew Warth knew something was wrong. Swollen and purple, his arm was nearly twice the size of his left. But how? Why?

Summer football practice had just ended, and Drew, the starting quarterback on his high school team, had put in a full workout. Right-handed, Drew had thrown thousands of passes before that day, but never with this after effect.

At first, team trainers thought he overused it during summer workouts in return to action after the COVID-19 pandemic put a halt to workouts and practices. But when ice, rest and elevation didn’t improve the situation, Drew’s parents, Shelly and Darrin, decided to seek medical attention.

“The [team] trainer was keeping an eye on it,” said Shelly. “And he called me and said, ‘Hey, this could be a blood clot. This could be life-threatening. We really need to get him looked at.’”

The family met with doctors and specialists near their home in Northern Kentucky. They performed tests and suggested a variety of possible diagnoses. Everything was explored, from blood clots and muscle strains to a thoracic outlet condition. But nothing was conclusive.

A few days later, when the swelling moved to Drew’s shoulder and chest, his parents brought him to the Cincinnati Children’s Emergency Department (ED). 

Feeling Optimistic Following a Thoracic Outlet Syndrome Diagnosis

That’s when they met Kevin Little, MD, director of the Pediatric Hand and Upper Extremity Center at Cincinnati Children’s, who was consulting in the ED that day. 

He met with Drew and his family, ordered tests and soon confirmed a diagnosis of Paget Schroetter Syndrome, a specific type of Thoracic Outlet Syndrome where a blood clot forms in the main vein that drains blood flow from the arm.

“[Cincinnati] Children’s was the first place that no doubt figured out what it was and went to action—instead of just talking about it,” said Drew. “And they were more optimistic.” 

Other doctors had told Drew, then a junior, that he might never play football again. Not Dr. Little. He’s treated many patients with Thoracic Outlet Syndrome over the years and assured Drew that there was a very good chance he’d return for his senior season. 

“We have a lot of patients that we’ve done the surgery on,” said Dr. Little. “And 90 to 95% of them are getting back to their previous level of sports participation.” 

Drew felt his spirits lifted by his doctor’s confidence. He liked his odds. 

“It was a sad time, and I was not in the best spot mentally, but Cincinnati Children’s made me feel a lot better and reassured me that I’d be OK and get back on the field,” said Drew. 

Explaining the Condition and Specifics Behind the Surgery

Taking time to explain the condition and the need for surgery carefully, Dr. Little wanted Drew, like all his patients, to be aware of every step along the journey.

“I try to start from the beginning and explain what’s going on and why the symptoms are happening the way they are,” said Dr. Little. “And then I explain what we can do about it and how the recovery is going to be.”

In Drew’s case, his condition was due to reduced blood flow. When he moved his right arm above his head—which he did all the time as part of his throwing motion— his collarbone would rotate backward and compresses the vein between his collarbone, his first rib and a muscle in his neck called the anterior scalene muscle.

The compression was “to the point where [the arm] was completely cut off from blood flow when [he lifted] his arm above his head,” said Little.

To correct it, Little detached Drew’s anterior scalene muscle completely, including parts of the middle scalene and posterior scalene muscles. Then, he removed 90% of Drew’s top right rib, providing more space for the blood vessels and nerves in order to improve the blood flow.   

Following surgery and physical therapy, Drew felt stronger than ever before. And by the time he returned for his senior season, Drew could throw the ball farther and better than before.

A ‘Night and Day’ Difference After Surgery

“Drew just felt like a new person,” said Shelly. “He didn’t even know he had all that stuff going on inside him, and then, after the surgery, the difference it made was like night and day.” 

As Dr. Little explained, this additional power was likely due to Drew’s new ability to build up his arm strength after the surgery with more blood flow and less nerve compression. 

“He could never build up enough strength because he was always compromising the function with that tight space,” said Little. 

“When we do the surgery, we’re just detaching the muscles that go from the neck to the ribs. We’re not affecting anything that goes to the shoulder. So all the muscles making the shoulder and the arm work are still normal and not detached.” 

Little explained that other muscles in the chest would take up the slack for the detached scalene muscles. Also, Drew’s 11 other ribs, each with muscles between them, were unaffected by the surgery allowing him to breathe normally, even with heavy exercise.

Drew completed his physical therapy quickly and, by winter 2021, he was ready to resume throwing. 

“I was ready to go straight from [physical therapy],” he said. “I picked up a football as soon as I left there and was ready to go for my senior season.”  

Leading the Cooper Jaguars to a 7-4 record this past season, Drew threw more touchdowns, for more yards, with fewer interceptions and a higher completion percentage than during his sophomore year. 

And his football days are not over. Drew recently signed his letter of intent to play football at Thomas More University next year.

He credits Cincinnati Children’s with making it possible. 

“I’ve had a lot of improvements this year. And just my throwing motion feels entirely better,” said Drew. “It used to hurt to throw a football. And thanks to [Cincinnati] Children’s Hospital, that’s not the case anymore.”

(Published February 2022)