Friday, June 13, 2014

Platelet-Rich Therapy: The Future for Some UCL Injuries or Fraud?

Platelet-Rich Therapy: The Future for Some UCL Injuries or Fraud?

            As everyone is well aware, we have seen an epidemic of UCL injuries, which almost ultimately lead to Tommy John surgery, which is the layman’s term for ulnar collateral ligament reconstruction. The brief history lesson regarding Tommy John surgery is Dr. Frank Jobe performed the first UCL reconstruction on Tommy John in 1974, allowing John to continue pitching after the then experimental surgery was proven to be successful. The UCL is located on the elbow towards the body, as opposed to away from the body. We have seen twenty two Tommy John surgeries done for major league player, not counting minor league or college arm, the most through mid-June in baseball history. I am not a doctor, so I cannot go into great detail as to why these injuries happen beyond constant use of the arm, which should make sense considering it happens largely to players, high velocity pitches, which causes strain on the arm over a period of time, and throwing secondary pitches at an early age. Jo Innes wrote more extensively on Tommy John surgery here.Twins prospect Miguel Sano is one of the rarities that are a player who suffered a torn UCL and was forced to undergo Tommy John surgery.

            In my Cubs draft write-up, I was intrigued by the case of Cubs sixth round selection Dylan Cease, who suffered a partially torn UCL in high school as a senior, which caused his draft stock to fall rather rapidly. Unlike a fully torn UCL, which requires surgery to compete at any athletic level again, a partially torn UCL has other potential options before Tommy John surgery. Dr. Robert F Kacprowicz states that the one way to treat a partially torn ulnar collateral ligament, which he calls an acute UCL tear, without surgery, is with three to six months of physical therapy, cold packs on the elbow, and nonsteroidal anti-inflammatory drugs, such as aspirin. Most recently, this was attempted with the aforementioned top prospect Miguel Sano, but did not prove to be successful as Sano had Tommy John surgery on March 12, 2014. Like many other pitchers, Matt Harvey attempted to go down the physical rehabilitation path in September when he had a partially torn UCL, but ended up having Tommy John surgery in late October after a fruitless physical rehabilitation attempt. One notable pitcher who suffered a torn UCL is Cardinals ace Adam Wainwright, who pitched for nearly five years with a partially torn UCL, but that is a rarity in every sense of the word. Physical rehabilitation may be somewhat successful for the average individual, but the vast majority of major league players, notably pitchers, do have to get Tommy John surgery. Tommy John surgery generally allows a pitcher to return back to form, as we have seen with Stephen Strasburg, Jordan Zimmermann, Chris Carpenter, and John Smoltz among others. Regardless of the success rate, Tommy John surgery can sideline a pitcher for a year or longer, depending upon the rehabilitation and possible setbacks after the surgery.

            Dylan Cease chose not to undergo Tommy John surgery and decided for a relatively new route in partially torn UCL recovery, Platelet-Rich Therapy. Carina Storrs describes Platelet-Rich Therapy as taking thirty milliliters of the patient’s blood, spinning it in a centrifuge to separate the platelet-rich plasma, then taking the platelets and injecting them into the injury location. This relatively new type of treatment for injuries made news in the past few years, with Kobe Bryant and Tiger Woods having used the treatment for knee injuries. Studies on its effectiveness in general, let alone athletes, have been mixed to say the least. While no platelet-rich therapy studies have been done directly looking at its effect on a partially torn UCL due to how new the procedure really is, a new study done on platelet-rich therapy focusing on epicondylitis, best known as tennis elbow, seems to indicate that one should not be too hopeful of the procedure, as  people given platelet-rich therapy fared no better than those given the placebo, saline. On the other hand, another study found that platelet-rich therapy helped individuals with osteoarthritis in the short term. The osteoarthritis study, while not ligament/muscle-based, is one of the few studies that examine platelet-rich therapy and its effectiveness in humans. One study looking platelet-rich therapy in healing ACL injuries, found that those who use the therapy after surgery had significantly more stable knees six months following the surgery. A Lyras, Kazakos, and Verettas study looked at the effects of platelet-rich therapy in rabbit tendons and found that the rabbits received a statistically significant increase in tendon strength early in the platelet-rich therapy process, but the rabbits receive the therapy had the same level of strength as those who did not receive the therapy four weeks later.

Within the next few years more research should come out regarding platelet-rich therapy for tendons and ligaments in humans, but for now the science is inconclusive, which naturally leads to the question why try it? One reason is strong anecdotal evidence, spread from athlete-to-athlete. Basketball player Kobe Bryant had the therapy done for his knee, then told Alex Rodriguez about the therapy, who publicly praised it for helping his knee also. Rodriguez told UFC President Dana White about the therapy, who claimed the procedure “100 percent” cured him of Meniere’s Disease. How much of their success is due to the platelet-rich therapy is unknown. As is well known, Bryant, Rodriguez, and Tiger Woods all continued to struggle with their injuries, despite getting the therapy and praising it. Platelet-rich therapy treatment is viewed as relatively safe. Other than a few hundred or thousand dollars, what does a player have to lose? The alternative, Tommy John surgery, takes a tremendous time to recover from, so players may view it as a quick solution. That is likely the situation Cubs draftee Dylan Cease was in, as Tommy John surgery would have kept him out the remainder of his high school season, hurt his draft stock potentially even more, and would have possibly kept him out of his entire freshman season at Vanderbilt if he were to choose to attend.

The mystery surrounding the procedure leaves him, along with other pitchers to get the therapy, as a question mark, both short-term and long-term. Chad Billingsley attempted the platelet-rich therapy route in 2013 after suffering a UCL tear, but fell victim to Tommy John surgery just starts into the 2013 season. Orioles catcher Matt Wieters had a platelet-rich therapy injection May 12, 2014 in his right elbow, but progress has not been seen in Wieters arm, so he is currently planning to discuss his options with Dr. James Andrews. Phillies pitcher Jonathan Pettibone decided to undergo platelet-rich therapy and a cortisone injection after suffering a torn labrum. In April, Chris Davis of the Baltimore Orioles received two platelet-rich injections to help with an oblique strain injury and has missed little time since then. According to, Marco Scutaro, who has yet to play on the year, underwent a procedure similar to platelet-rich therapy, but did not go into detail on what the procedure exactly was. Scutaro remains to be seen on the field. Listing these players and their conditions before and after platelet-rich therapy is nothing more than anecdotal evidence, but it has to raise some eyebrows as to its effective even to those who just want to see correlation.

With Platelet-rich therapy, arrows seemingly point in all directions. One guy says it helps, one guy says it does not help. One study is positive regarding its healing effects, another dismisses the effects when compared to a placebo. I think it is fair to say that there just is not enough data to make a strong judgment in either direction, although the correlation between those who attempt to get platelet-rich therapy and physical rehabilitation and future ligament or muscle issues is hard to overlook. After more research is conducted and platelet-rich therapy is proven to help speed up recovery, akin to human growth hormone, would it be added to the banned substance list? The better question is will they even be able to test for it, considering HGH testing is already poor, and this involves an individual’s own blood essentially being placed back in them. At this point in time though, it is fair to ask if it is likely someone like Dylan Cease will need Tommy John surgery eventually or if platelet-rich therapy is enough to hold him off for a while, akin to Adam Wainwright. This is just my guess, but Cease is likely going to need surgery sooner rather than later. As for what this means as far as the future of UCL injury treatment remains up in the air. In one year from now, we will have a much better idea with the number of platelet-rich therapy studies that are currently underway. At this point in time, one cannot call platelet-rich therapy a fraud, but it is certainly not been an empirical answer to partially torn UCL, which could decrease the amount of Tommy John surgeries done in the future.

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