PRP & Tommy John Surgery

The Minnesota Twins’ Central Division title hopes took a major hit before the season even began when their All-Star closer, Joe Nathan, went under the knife to have season-ending ulnar collateral ligament reconstruction; more commonly known to baseball fans as Tommy John surgery. But it isn’t just Major Leaguers undergoing this operation; the number of young pitchers requiring elbow reconstruction has surged during the past decade. As UCL injuries increase and recovery time for Tommy John surgery remains protracted, doctors worry that athletes will turn to platelet-rich plasma therapy (PRP), an unproven treatment that has faced scrutiny from anti-doping officials.

PRP, a treatment that injects a concentration of a person’s own platelets into an injury to aid healing, first stepped into the spotlight when Pittsburgh Steelers safety Troy Polamalu received the treatment to speed the recovery of an injured knee ligament before Super Bowl XLIII. It was back in the news a few weeks ago when Tiger Woods said before the Masters that he had received PRP injections the year before to help recover from his knee operations and aid in healing his torn Achilles’ tendon. In July 2008, Los Angeles Dodgers pitcher Takashi Saito received PRP to treat a partial tear in his UCL—instead of undergoing Tommy John surgery he was back pitching later that season.

While Tommy John surgery has saved countless careers by restoring the elbow stability that provides pitchers their velocity and control, the recovery leaves hurlers sidelined for more than a season. Now more than ever an alternative treatment to surgery is needed to combat the number of young pitchers needing the operation, which has skyrocketed since 2000, according to Dr. James Andrews, America’s leading sport orthopedist. Instead of performing eight to nine Tommy John surgeries per year on young players as he did a decade ago, lately Andrews is doing 75 to 80 a year and he says 2010 “is worse than it’s ever been.”

With teams investing so much money in their pitchers and those early years being so important to a young player’s development, Saito’s experience with PRP makes the treatment that much more enticing, but doctors still haven’t confirmed its effectiveness. “Sometimes we get ahead of ourselves and everybody jumps onboard to start doing this stuff because they want to be innovative and get ahead of the game,” says Dr. Grant Jones, a professor of orthopedics at Ohio State University Medical Center. “So far we haven’t seen any adverse affects, but we need better studies before we start throwing PRP in everybody, which seems to be happening right now.”

Andrews, whose client list has included Drew Brees, Roger Clemens, Brett Favre, Peyton Manning and Michael Jordan, says he’s “applying PRP sparingly,” believing the science on the treatment to be “10 years away from being solid.” However, he sees promise in the practice for UCL injuries. “I’ve used it on some young throwers and have had some good response,” he says. “It may be the most revolutionary advancement in our field since the orthoscope.”

Despite early positive returns, questions surrounding PRP aren’t limited to its efficacy, as anti-doping officials have debated recently whether it should be banned altogether. In 2009 both the World Anti-Doping Agency and the U.S. Anti-Doping Agency barred PRP’s use, except in cases where a therapeutic-use exemption is granted. However, PRP differs from synthetic performance enhancers like steroids, in that it’s derived from blood drawn from the patient. The doctor uses a centrifuge to separate the patient’s platelets from the red and white blood cells and then injects the PRP around the injured tendon, ligament or muscle. Doctors isolate the platelets and introduce them to aid in tissue regeneration because “they are thought to be the main constituent of the blood that promotes the whole healing process,” says Jones.

Jones authored a paper earlier this year reviewing applications of PRP, finding that “there are several animal and laboratory studies that have shown the benefit of PRP, but in terms of the human literature, the data is still somewhat sparse in terms of its effectiveness.” While positive results were noted in his paper, where PRP aided in the healing of shoulders, knees and elbows, some trials, like those using PRP in ACL reconstructions, found little benefit from the treatment.

Seeing the limited scope of previous PRP trials, Jones is conducting a more comprehensive examination of the treatment, by studying its effects on patients with tennis elbow. As with UCL injuries, tennis elbow occurs from repetitive stress that leads to tears and strains in the tendon on the part of the elbow opposite the UCL. While the study remains a year from completion, Jones says “there does seem to be a trend toward PRP working thus far.”

If PRP fails to become an effective treatment for healing UCL injuries, the last hope to save a pitcher’s career will remain Tommy John surgery, which until 1974 wasn’t even an option. But that year Dr. Frank Jobe invented the operation that gave hurlers hope when he replaced Los Angeles Dodgers lefty pitcher Tommy John’s UCL with a tendon from his right arm.

Nearly four decades on, the operation remains very similar to the original, with a surgeon taking a tendon from a player’s wrist or hamstring, then threading it through holes drilled in the humerus and ulna to replace the UCL. And the operation has been effective. A 2007 study published in The American Journal of Sports Medicine found that 82 percent of Major League pitchers who underwent Tommy John surgery between 1998 and 2003 returned to baseball with little drop-off from their pre-injury performance; however, it took them an average of 18.5 months to do so. “We haven’t figured out ways to appreciably speed recovery up,” says Dr. David Geier, the Medical University of South Carolina’s director of sports medicine. “You’ve got to wait several months for the body to incorporate that ligament.”

While the surgery hasn’t changed, Andrews says that in the last seven to eight years doctors and trainers have come to better understand how the entire body works together to throw a pitch, which allows them to better prevent UCL strains or tears. So he’s spearheaded the STOP Sports Injuries campaign to educate young athletes on how to train properly, advocating building not just muscle around the elbow, but rotator cuff and core strength as well. Pitchers emphasizing total body strength will support their arm better during the pitching motion and mitigate the cumulative stress that pitching puts on the elbow. That’s important because the UCL “can withstand the stress of one throw, but you’re talking hundreds of pitches a week—it’s wear and tear over time,” Geier says.

Allowing players to rest will also ease that wear and tear, but Andrews says that doesn’t happen enough in youth sports right now. He’s seen pitchers throwing year-round and playing in multiple leagues at the same time, which fatigues pitchers and leaves them 36 times more susceptible to injury. To preserve pitchers’ elbows, they need limited pitch counts during a game, to have rest days between outings and to spend at least two months each year without pitching.

Without that rest and conditioning, and with PRP still unproven, the jump in the number of pitchers requiring Tommy John surgery will continue. And Andrews, a man who’s performed nearly 3000 of the operations, says pitchers should heed his warning about overusing their arm, conceding that “I can’t make that ligament any better than the good Lord made it.”

This article originally appeared on Popularmechanics.com

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