“Pitching” PRP: Repairing athlete’s elbows without surgery

Published On: Oct 23 2012 11:28:06 AM CDT

BACKGROUND:  Ulnar collateral ligament injury of the elbow is a sprain (tear) of one of the ligaments on the inner side of the elbow. The ulnar collateral ligament (UCL) is a structure that helps keep the normal relationship of the humerus (arm bone) and the ulna (one of the forearm bones). This ligament is injured in throwing types of sports or after elbow dislocation or surgery. It may occur as a sudden tear or may gradually stretch out over time with repetitive injury. This ligament is rarely stressed in daily activities. It prevents the elbow from gapping apart on the inner side. When torn, this ligament usually does not heal or may heal in a lengthened position (loose). Sprains are classified into three grades. In a first-degree sprain, the ligament is not lengthened but is painful. With a second-degree sprain, the ligament is stretched but still functions. With a third-degreesprain, the ligament is torn and does not function. (Source: Washington Orthopaedics & Sports Medicine)

SIGNS:  Symptoms include pain and tenderness on the inner side of the elbow, especially when trying to throw; a pop, tearing or pulling sensation noted at the time of injury; swelling and bruising (after 24 hours) at the site of injury at the inner elbow and upper forearm if there is an acute tear; inability to throw at full speed; loss of ball control; elbow stiffness; inability to straighten the elbow; numbness or tingling in the ring and little fingers and hand; clumsiness and weakness of hand grip. (Source: Washington Orthopaedics & Sports Medicine)

TREATMENT:  For those who have an acute rupture of the ligament or those who have failed therapy and wish to continue throwing competitively, surgical reconstruction (rebuilding the ligament using other tissue) is usually recommended. This procedure is known as the “Tommy John” procedure, named for the player whose career was saved when the ligament was reconstructed by Dr. Frank Jobe. The ligament reconstruction can be performed using a variety of soft tissue grafts obtained from the patient, but is most commonly carried out using the palmaris longus tendon from the forearm. Because this tendon provides biomechanical characteristics that are similar to those of the native ligament, and because there are no consequences from its absence, it makes an ideal ligament substitute. Some patients do not have a palmaris longus tendon and therefore require an alternative graft for reconstruction, such as one of the toe extensors. (Source: Washington Orthopaedics & Sports Medicine

NEW TECHNOLOGY:   PRP therapy offers a promising solution to accelerate healing of tendon injuries and osteoarthritis naturally without subjecting the patient to significant risk.Blood is made of RBC (Red Blood Cells), WBC (White Blood Cells), Plasma, and Platelets. When in their resting state, platelets look like sea sponges and when activated form branches. Platelets were initially known to be responsible for blood clotting.For the treatment, doctors take a small vial of a patient's blood, about 30 milliliters, and spin it in a centrifuge to separate the platelet-rich plasma from the other components. Then they inject the concentrated platelets at the site of the patient's injury. (Source: Orthohealing.com)

Preston Wolin, M.D., Director Spetsmedicine at Weiss Memorial Hospital talks about PRP, a new way to help injured athletes.

What is PRP? How is it changing the way you might help athletes with different injuries?

Dr. Wolin: PRP stands for platelet rich plasma. The idea behind PRP is to use the body’s own natural healing mechanism to get muscle, tendon, and ligament injuries to heal without having to do surgery. Basically what’s done is the patient’s blood is taken from them, just like if you went to any laboratory or doctor’s office, and placed in a tube. The tube is spun down and it will pull out the parts of the blood that are very rich in what are called growth factors, and we know that the tiny cells that have those growth factors are called platelets. The process extracts the platelets, removes the part of the blood that is not going to help in the healing process, and gives us the factors which we can put back into the injured area to promote the healing.

It seems like it is a concentrated amount of those platelets that kind of supercharge the healing?

Dr. Wolin: Exactly right. 

You said it was in muscles, tendons, and ligaments, correct?

Dr. Wolin: Yes.

Why is this a better idea for some versus Tommy John?

Dr. Wolin: We know that Tommy John surgery, which is an operation where the ligament on the inside of the elbow is reconstructed, is a very successful operation but it is an operation that takes at least a year to come back from for a pitcher. If we can change that timeframe from a year or more down to several months then that is a huge benefit to a pitcher, especially a young one like Eddie.

Koby Bryant went to Germany. Brian Urlacher apparently went to Germany. Is this the same thing? What’s the difference?

Dr. Wolin: There are different proprietary means of administering platelet rich plasma, there are different preparations, and there are a different number of injections that are given. So while the actual consistencies are closely held proprietary secrets, in a general way this is the same technology.

Why go to Germany? Are they giving them more? Is that the secret?

Dr. Wolin: I think it has to do with an individual’s perception of what the success rate are at any given location where they will have the treatment. Professional athletes clearly have a large stake in their futures and if one practitioner is able to produce successful results, then that is going to tend to produce more athletes going to that same place. Having said that, it is also true that there are a number of places where a number of professional athletes have had very successful results following platelet rich plasma or related types of therapies.

Could you talk about helping Eddie through the process?

Dr. Wolin: When you are dealing with a young athlete, it is very important that you take the time to tell them, their parents, their coach about what the injury is and what their prospects for recovery are. Now in Eddie’s case, he came to me after having seen another doctor who had recommended that he have the Tommy John operation. While I said he could have that operation, there was another alternative to the operation that could get him to the same place, which was basically taking him from his injured state back to his pre-injury state of being able to be a baseball pitcher. 

Is it for everyone? or is this for certain athletes with certain kinds of injuries?

Dr. Wolin: Let’s take Eddie, for example. Eddie had a type of tear of his ligament that was a partial tear, not a complete tear, and so we know that PRP is best for partial tears of the ligaments and we know what location of tear heals better than others. You have to be realistic with the patient where if you do not believe that the PRP is going to work and that the surgery would be better you have to be honest and be able to tell them yes, some people are doing it for a complete tear, but our best evidence is that partial tears are the ones that heal best.  

Can it be repeated?

Dr. Wolin: Some people do repeat the PRP therapy. Where we are right now I would say that, for example, with Eddie De La Riva if one PRP injection did not work probably another one is not going to work.

And in that case would Tommy John be his next best option then? 

Dr. Wolin: Probably Tommy John would be the next best option, yes. 

How many kids from 12 to 18 are coming in with these kinds of injuries who either want to get Tommy John or are looking into PRP?

Dr. Wolin: Actually, I am seeing an astounding number of young baseball pitchers who have this injury. I would say over the course of the last 5 to 10 years with the exponential growth in youth baseball and travel baseball we are seeing more and more young baseball players unfortunately with these types of injuries. While the volume of Tommy John surgeries has also gone up exponentially, what we really ought to try to do is to try to find an alternative that can give those young athletes a chance to take a step back and heal before returning to play. If we can avoid surgery, I think especially for those young athletes, we have had a major impact on their lives.

How young is too young when it comes to doing this kind of procedure? 

Dr. Wolin: Well usually the patients who have these problems with the ligaments are kind of a self-selected group. The injuries occur usually after completion of their growth, so the bottom age for this type of injury is somewhere around 14, maybe 15. The youngest Tommy John operation I have ever done unfortunately was on a 15-year-old. So, anywhere from that age group up we see these patients.

Has it grown much over the last 5 to 10 years? 

Dr. Wolin: Yes. The number of patients that I and other sports medicine physicians are seeing with this particular problem has really exploded.

Are you seeing more people coming in and inquiring about PRP because they are hearing about it through the grape vine from either friends or other athletes who have gotten it? 

Dr. Wolin: Yes.

What is the rate of you saying having this is what you should do versus Tommy John?

Dr. Wolin: It depends on the type of tear. It also depends on when you get a chance to see them. Many athletes that I see will have had a prior injury that might have been a partial tear, but the athlete will continue to throw and that partial tear becomes a complete tear. So when it becomes a complete tear, the PRP really is not as good of an option. If we can see these patients earlier, I think the chances of having successful results with the PRP will also go up.

How quick is it?

Dr. Wolin: The procedure itself takes about 25 minutes.

What other injuries would you use it for? Where else in the body is it best versus having more invasive surgery?

Dr. Wolin: In terms of soft tissue injury, it seems the platelet rich plasma is going to have its major benefits; the hamstring for example, which is a common injury we see in explosive sports like soccer or football. We also see use for PRP in more overuse type injuries, say runners with Achilles tendon problems; that has been successful. In and around the elbow, problems with the tendons, what is called tennis elbow, but it is not only for tennis. You see golfers who have “tennis elbow” and there is also a problem on the other side of the elbow; if the tennis elbow is on this side of the elbow, the golfer’s elbow is supposed to be on this side of the elbow. Again, you can see tennis players or golfers with either one, but the main point is that those soft tissue injuries are amenable to treatment with PRP. 

Is the recovery time about the same for all those different injuries? Do you see the recovery time for ankles, elbows, hamstrings being about 2 months? 

Dr. Wolin: Well, it depends on the injury and it depends on the grade of the injury. The one thing that most patients don’t know about before they come in is that after the PRP injections, there has to be a structured therapy program because we have to give the body a chance to heal. For example, in Eddie’s case, a pitcher, we do not even want them throwing for at least a month. Then they will start beginning at very short distances and increasing those distances. When they go through that whole process and they are asymptomatic or do not have pain, that is when we allow them to return to sport. It is a similar process whether it is a hamstring; it is an Achilles tendon; it’s a tennis elbow, etc. So in addition to the physician who does the PRP injection you have to have a skilled physical therapist who understands the protocol.

What are the results? Can someone get back to 100% after PRP?

Dr. Wolin: What we know, for example in the elbow, if you would take an elite group of throwing athletes, pitchers who have partial tears of their ulnar collateral ligament, the chance of them being able to come back to the same level that they were experiencing before they started throwing is roughly 80%. Though the study population that I am quoting is relatively small, it is about 20. There is follow-up now on those athletes who have gone back and thrown, so those results are very encouraging. If we get the right patients, especially if we get them early enough, if they are identified properly, if they have the proper rehabilitation from physical therapists and athletic trainers, cooperation from their organizations whether it be a professional team or collegiate team or a high school team, the chances of them being able to return to their same level of activity before they got hurt is quite good.

What’s new about PRP?

Dr. Wolin: A couple of things. I think especially with regard to the ulnar collateral ligament, the Tommy John injury, we now have some good evidence that it works. The second is an understanding by the rest of the public that this technology is available and that it can be of benefit to them. So definitely it has moved from something where the elite or only the professional athlete will have it to one where the weekend warrior will know about it and they will come into the office asking about it.

Why is it so controversial?

Dr. Wolin: Well I think in general anything new, especially in sports medicine, can generate a lot of interest but it can also generate a lot of controversy. There are also a lot of different types of PRP. There a lot of different companies that have different products, they are not all the same. Some have different concentrations of different types of cells and one of the issues that we are having from a scientific basis is trying to compare the results of different types of platelet rich plasma. Scientifically, there is an ongoing discussion as to which one of those preparations is the best. As far as whether or not it is what we call a performance enhancer, such as in anabolic steroids or in blood doping that you see in cycling, I look at platelet rich plasma as a means of getting the body to heal a problem rather than actually enhancing performance. As far as we know the value of this treatment is in treating an injured part, it is not trying to make an uninjured part perform better.

Are there any dangers to the athlete or the everyday Joe who gets this procedure done?

Dr. Wolin: I think they are relatively small. Any procedure where you have a needle placed can theoretically cause an infection, but it is extremely unlikely. The physician has to be knowledgeable about the anatomy; it is important to get it exactly in the right place. In my office we will always use an ultrasound machine to show us where the needle is going so we know that it goes exactly to the place where it is supposed to go rather than, if you will, kind of touching and guessing as to where it should be. Under those circumstances I think the chance of anything bad happening is extremely small.

Can you overdo it and hurt your own healing system by putting in too many of these cells?

Dr. Wolin: I would say that with the standard procedure as currently being accepted, it is really a relatively small amount. We only put about 4 cc. If you take a regular syringe you are only looking at about that much and most of the time it is one injection. I think it is very unlikely that you are going to be harmed. Multiple injections, while they may not harm you, may not help you either.

What is the future for PRP?

Dr. Wolin: I think the future is first of all getting to understand it better in terms of identifying the correct PRP to place. I think we have to better define what we call the clinical problems, the areas where it works the best and where it unfortunately sometimes does not work so well. I think we have to know a little bit more about the rehabilitation. Can we push the envelope? Can we shorten that period of time when the athlete can return or do we have to lengthen it? Is there something different about, say for example, an 18 or 19-year-old pitcher as compared to a 35-year-old pitcher? It is all about getting to learn more about what is an extremely promising technology.

Do you see it as becoming more prevalent for the amateur and college athletes, or do you think it will be spreading to more of the weekend warriors, or are you seeing that trend already?

Dr. Wolin: I think that trend is already with us.

Are there different PRP treatments for the different injuries, or they are just different companies using different solutions for the same injury?

Dr. Wolin: I think as we look in the future, we need to look at whether or not one company has a better product or whether or not they all work equally well.

I was looking at the specialities from the American Orthopedics Society for Sports Medicine saying it just was deemed to be safe for cartilage as well as the ligaments, tendons, and muscles as well, Is that correct?

Dr. Wolin: Yes. That is another issue, and that has to do more with the aging athlete where cartilage starts to breakdown in the knee. What we are finding now is that this same technology that has been used for muscles and tendons and ligaments can also help in regard to cartilage.

Have you performed that?

Dr. Wolin: I have.

What were the results like?

Dr. Wolin: I would say it is early, but so far I think the results are quite encouraging. We are going to need to define PRP’s role in treating these problems. I think we have to be realistic with our own results and we have to be realistic with our patients. We cannot tell a patient that is a panacea for all of the problems that she or he may have, but what we can do is say on the basis of what we know so far whether or not PRP is a reasonable alternative.

Can you explain how it works?

Dr. Wolin: There is the femur, or the thigh bone. There is the tibia, the shin bone. Between the two bones of the knee are two washers, each of those is called a meniscus. Between the bones connecting them are structures and those are the ligaments. In the middle of the knee there are two of them that make a cross. One crosses from the back to the front and that is called the anterior cruciate ligament, and the other one stays in the back and that is called the posterior cruciate ligament. Now, on the ends of all of these bones, on the femur, on the tibia, on the kneecap, is a whitish material and that is called articular cartilage. It is the same material that you will see on the end of a chicken bone. It is normally white, it is normally smooth, and it is normally glistening. All of these things have to work together to produce a normal knee.

What happens when there is a subchondral defect then? 

Dr. Wolin: When there is a subchondral defect there is force that is applied to the bone below the surface, and subchondral means below the chondral surface or below the level of the articular cartilage. Commonly, it occurs either in the femur or it occurs in the tibia and almost always it is a result of an injury taking place to either the meniscus, where you lose the weight bearing portion of the meniscus, or you have an injury to the articular cartilage, the cartilage on the end of the bone, and the bone below it sees more stress. 

What kind of injury would cause that? 

Dr. Wolin: Any that results in injury to the meniscus, to the anterior cruciate ligament, and to the articular cartilage.

How long would it take until you really started feeling that you needed to have a procedure?

Dr. Wolin: Most injuries will get better after a while. That is what we call the honeymoon period, when you have not tried it out and you may not try to run, you may not try to cut. If you do develop one of these subchondral injuries you are probably going to notice it in say weeks and definitely over months. As time goes by you are going to notice it more and more.

Is it just sore or is it a sharp pain? What do the patients feel?

Dr. Wolin: I have had patients tell me that it is like a toothache every time they try to walk on it. Certainly if they try to run or they jump on it, then it will get worse after and with repetitive activity.

When they come in and you find out that is the problem, what was the standard treatment for that?

Dr. Wolin: Most of the time if we eventually end up seeing that, doctors will say rest. Give it time. It is a “bruise” in the bone and it will heal.

But it doesn’t heal?  

Dr. Wolin: A lot of times it does not heal, especially if it is combined with other injuries. If you have a patient who comes in and tells you that they have had that problem for years, it is probably not going to heal. 

What is the next step?

Dr. Wolin: The next step is to identify that area, and the best way of doing that is an MRI scan.

A lot of people have to end up with total knee replacements, is that right? 

Dr. Wolin: Well, the standard answer has been to date that eventually those patients are going to need to have knee replacements because the problem will continue and there is usually loss of the cartilage on the end of the bone. So the traditional answer has been a knee replacement in many cases.  

That is a major procedure?

Dr. Wolin: It is a major procedure to the patient, first of all. It is a major procedure to the bone because what is happening is that the normal bone is being cut away with the cartilage overlying it and being replaced by basically some metal and some plastic.

What is the recovery time on something like that? 

Dr. Wolin: For a knee replacement? Well, patients are commonly in the hospital for 3 days. They will go home and they will stay at home for several weeks, or they may need to go to rehabilitation facility for 3 or 4 weeks, something like that. They will need rehabilitation and the structured rehabilitation can take anywhere from say 4 to 6 months. 

Are out for a while if you are an active person? 

Dr. Wolin: It is a significant time period away from normal activities. It is a longer period of time away from sporting activities, like golf or maybe tennis.

Do you find people just decide not to do it because of the time they will be out? 

Dr. Wolin: Yes. Another major factor is the sacrifice of not being able to go back and do the activities that they like to do. Most doctors who do knee replacements are going to recommend avoiding against loading sports where they will be jumping, they will be twisting, they will be cutting. Lower level sporting activities such as bike riding or golf are allowed, but something like returning to playing basketball is not generally accepted as an activity to do after knee replacement.

How long have you been working with subchondroplasty?

Dr. Wolin: I have been doing this now for about a year, and the experience that we have actually comes to us from Europe. There have been a large number of cases done in Europe, more than 500. There are centers where this is being done in the United States and there have been follow-ups of 2 years plus. For the right patient the subchondroplasty procedure does appear to be a very good and a minimally invasive alternative to either waiting for an extended period of time, or some type of reconstructive procedure that might involve a knee replacement or at least a partial knee replacement. 

Can you walk us through the process?

Dr. Wolin: Commonly patients will come with the symptoms that we talked about, this kind of deep toothache type pain and typically they will say that they hurt in the bone below the region of the joint; basically down here. There may or may not be some arthritic changes that you see on the x-ray, commonly not advanced arthritic changes that you see on the x-ray. Then they will have an MRI that will show that there is a collection of, in layman’s terms, “blood” in the region below the bone and what we have come to find out is that this is actually a stress reaction. It may not be an actual stress fracture, but what the MRI is telling us is that that bone is not supporting the load that is being placed on it. The idea in the past has been to take the stress off that bone, say for at least a partial knee replacement. However, what we found now is that there is another way of doing what we want to do, which is to give the patient relief, and that is to shore up the area by giving it more support. What is done is through small incisions is to place some cement directly into that area. When the patient is having the operation in the operating room, it is really important that you get the bone cement, which is absorbable by the way; the body is going to absorb the cement. You need to be sure that you are exactly in the right location. The patient, once they are asleep, has this jig that is applied to them and with an x-ray we can localize exactly the particular area that we want to put the cement in and it is going to show us that we are in the right place. When that pin is in the right place, we leave it there and then will place this little trocar directly over that area and we are going to put it in the bone so that we can inject the bone cement.



Preston Wolin, MD
Weiss Memorial Hospital
(773) 248-4150