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 CBSSports.com, 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.
Interesting stuff
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