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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE January 2023 New Evidence on PRP Use in UCL Throwing Injuries by Rachele Jones, PTA, ATC, CAFS Clinical Scenario…What would you do? A 21 yr old male college baseball pitcher is FU with you after Fall short season due to persisting medial elbow pain. He’d developed symptoms after a small “pop” he felt on an errant throw after pitching 5 innings. The college’s team physician diagnosed a Gr II UCL injury after a physical exam and MRI. He’s been rehabbing with the team’s athletic trainers but progressing slowly. He’s eager to prepare for the Spring season where he was expected to be in the starting rotation. Valgus testing now shows 1+ laxity with good end feel; elbow ROM is WNL and pain free, manual resistance is good in all relevant muscle groups. A review of his exercise routine confirms local elbow/forearm/wrist traditional rehab stretches and PRE which he does consistently. I would: Advise him to continue the same course of care since he is progressing adequately. Recommend Physical Therapy evaluation with focus on biomechanical testing to determine underlying contributing factors affecting throwing mechanics, including a video throwing assessment. Recommend PRP injection as adjunct to simulate healing further, prior to including a formal Physical Therapy evaluation and rehabilitation program collaboration with his team’s ATC’s. Discuss surgical reconstruction options since long term likelihood of remaining successful non-operatively as a pitcher is low. Advise a position change due to anticipated long term challenges with pitching Current Evidence Aakash Chauhan, et al. Nonoperative Treatment of Elbow Ulnar Collateral Ligament Injuries with and without Platelet-Rich Plasma in Professional Baseball Players. The American Journal of Sports Medicine 2019; 47 (13) 3107-3119. SUMMARY: Ulnar Collateral Ligament (UCL) injuries are common for throwing athletes especially, but can also occur in other overhead sport athletes as well. Physicians and surgeons must determine best treatment recommendations for these cases, considering both non-operative as well as surgical options. PRP has become increasingly used to promote healing in especially tendon tissue injury but data is lacking regarding its efficacy with throwing athletes. Chauhan et al retrospectively studied 544 professional MLB and MiLB position players and pitchers diagnosed with UCL injury over four years who elected for non-operative care. While 54% of those players did RTP, the PRP group’s return to throwing (RTT) was delayed two weeks, they RTP at a lower rate and also had RTP delayed by 5 weeks vs the non-PRP group. Matching analysis showed MLB and MiLB pitchers in the non-PRP group had faster RTT and MiLB pitchers a faster RTP. Survivorship analysis was trending but not significantly different at 54- - - 44% non-PRP and 43- - ->37% for PRP groups over the subsequent three years before re-injury or UCLR became necessary. This study does not support the use of PRP for non-operative treatment of UCL injuries in high level throwers. These findings, however, are limited in applicability due to varied nature of the PRP injections, heterogeneity of physical therapy provided, and other lack of controls over factors that would need more constraint and/or grouping in a future RCT study. While survivorship was examined, the levels of performance compared to pre-injury were not closely examined and may be an important factor. Non-operative therapy was effective at helping UCL injured throwers back to playing 54% of the time, supporting its use as a key component to recovery from UCL injury. Quality therapy should include specialized biomechanical evaluation of not only local throwing body segments (elbow, shoulder…) but also key kinetic chain areas including the scapula, thoracic spine, hips and ankle/subtalar joints. Addressing key findings must be a part of skilled care in order to reduce abnormal stresses on the medial elbow. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading the summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) Background: Elbow ulnar collateral ligament (UCL) injuries are very commonly diagnosed in professional baseball players due to the repetitive valgus stresses and high level throwing. Orthobiologics, such as platelet-rich plasma (PRP) have shown promising results in nonoperative treatment, however, no studies have been performed on the benefit of non-operative treatment with or without PRP on professional baseball players. Method: Five hundred forty-four professional baseball (including major and minor league players) players were retrospectively selected out of the Major League Baseball Health and Injury Tracking System that were being treated for an UCL injury non-operatively within a 4 year span. Of these, 133 players received PRP injections before starting non-operative treatment. Player outcomes and Kaplan-Meier survival analysis (using a 1:1 comparison, matched by age, position, throwing side, and MLB or MiLB league status) were compared between the PRP group and non-PRP group. A single radiologist of extensive experience in MRI interpretation viewed and analyzed 243 MRI’s where location and severity of grade scale were provided. Results: Overall 54% of non-operative treatment players returned to play (RTP). Players that received PRP, however, had a longer return to throwing (RTT) by an average of two weeks, a lower percent of RTP (46% vs 57%), and 5 weeks delayed RTP (25wks vs 20wks) compared to the non-PRP group. The matched cohort showed MLB and MiLB pitchers in the non-PRP group had a faster RTT & MiLB pitchers a faster RTP. The use of PRP, MRI grade, and tear location were not statistically significant predictors for RTP or progression to surgery. The survivorship of non-operative treatment was not significantly different between PRP and non-PRP groups (54- - - >44% for non-PRP and 43- - ->37% for PRP groups over 1 - - >3 years). Author’s Conclusion: In this retrospective matched comparison study of pitchers and position players from both MLB and MiLB treated non-operatively the addition of PRP injection prior to treatment did not show any improvement in return to play (RTP) or ligamentous survivorship. While matching was possible regarding comparison of player positions, throwing side, age, and severity grade there was excessive variability with the preparation of the PRP, the time of injury to injection, injection protocols, and rehabilitation programs. The location and grade of the tear did not significantly affect the RTP outcomes of progression to surgery. Further prospective study is necessary to better define best practices for PRP use with UCL injury treatment in elite throwing athletes. The Peak Performance Perspective Physicians and Orthopedists frequently see throwing sport related elbow ulnar collateral ligament (UCL) injuries. Most of these are likely high school/college athletes or post-collegiate adult league players, along with local professional players possibly. With the advancement and increased awareness of orthobiologics for the treatment of various orthopedic injuries, PRP likewise becomes a potentially viable option in addition to non-operative physical therapy for UCL elbow injuries. This study provides some insight to assist in clinical decision making around non-operative treatment. Ulnar collateral ligament injuries are most common in “overhead” athletes, usually with throwing sports such as: baseball, softball, javelin, and also paddle/racquet sports. Pitchers are the most frequent player position affected due to the increased dynamic and repetitive valgus stress on the elbow. Two interventions most commonly implemented are physical therapy or surgery. With the advancement of orthobiologics, platelet rich plasma (PRP), rich in proteins with healing and growth factors, which when administered to tissues that are injured and especially when less vascular (such as a UCL), is expected to produce a faster recovery by stimulating healing. The findings of Chauhan et al were not as expected. Results did not support improved outcomes with inclusion of PRP to non-operative rehabilitation, however, it did demonstrate that non-operative physical therapy, despite the admitted heterogeneity in this retrospective study, was effective at helping up to 57% of non-op treated players back to playing again. The PRP group as a whole did have a two week delay (7.3 weeks vs 9.1 weeks) in return to throwing (RTT) and five week delay from 20.1 to 25.4 weeks for return to play (RTP). Some inherent delay was due to post-injection rest orders and not simply a poorer recovery. Being a retrospective analysis, the rehab protocols used were not standardized, which is a weakness of the study but also a strength of sorts, lending external validity to real-world variability within physical therapy and athletic training. The lack of true “best practices” rehab progressions for non-op UCL care and RTT/RTP guidelines does contribute to the inability to optimally compare the data in these groups. Variability also existed in PRP type, timing, and volume. For athletes in the semi-professional and professional sports, timelines are crucial to either keeping their jobs or advancing them to post-season depending on their position and string status. From this study by Chauhan et al the most significant predictor of those having re-injury or subsequent UCLR was those > 25yo, MLB pitchers and players in the MLB. Those players' best option of return to play was those with less severity of tear at proximal site and those under 25yo. Over three years of non-operative care in the PRP treatment group the survival rates were 43% (1yr), 37% (2yr), 37% (3yr). The survival rate of non-PRP group over three years was 54% (1yr), 47% (2yrs), 44% (3yr). Position/field players had a better overall return to play and less incidence of re-injury or surgery compared to pitchers. Other studies have shown a 67-95% RTP rate following UCLR. The study did an excellent job going beyond simple group comparisons and included matching as a one to one comparison with position of player, severity of injury (grade), location of injury, age of athlete, and level of performance (whether major league or minor league player) to reduce confounding variables from affecting statistical findings (e.g. MLB players tend to be older, therefore having more “reps” on that elbow, more potential for recurrent/chronic UCL injury vs a younger player in MiLB). It may have been under-powered, however, in the low numbers for matching, especially regarding RTP and eventual UCLR. As mentioned above, the heterogeneity of physical therapy does mimic the real world in rehabilitation. Unfortunately, as a study, with one desired goal being that it could be reproduced if need be, the heterogeneous PT approach fails to define the exercises and types utilized, progression standards, frequency, use of manual therapy, and use of modalities done with these players. It is also not clear the extent of differences between PRP and non-PRP physical therapy. Variability can be great, acceptable and necessary, providing freedom to individualize treatments based on specific findings and contributing factors noted in one athlete that are not present across the board. The authors’ inclusion of MiLB players also provides somewhat more relevant data when physicians are considering their more typical patient profile seen locally in Rochester - high school/college aged players. Those younger players in the study typically have less “mileage” of throwing on the elbow and fewer prior injuries to the elbow, throwing arm and body - making them a better comparison group for typical UCL patients here in Rochester versus the MLB player group. Future studies will require being more specific/consistent in their biologics details (types of injection, how many injections, timeframe from injury to injection…etc.) along with at least some rehab and RTT/RTP guidelines for physicians and therapists to consider when applying to real world patients seen in the office. Athletes and providers alike are seeking the best but oftentimes also the fastest means to an excellent outcome of getting them back on the field. This study does not give any parameters on performance. It is unknown if they were able to resume a normal velocity and number of throws or pitches, have fewer errors, hit cutoffs, throw all the various pitches like prior, have an acceptable or even better ERA, number of strikeouts per inning or game, RBI’s, and batting average among others. Most players will look to the fastest means back to playing. While the PRP group did show a delayed RTT/RTP it would provide some counter-argument if their performance were better improved. Unfortunately the PRP group showed a higher reinjury/eventual UCLR rate though not statistically significant. As physicians and certainly therapists we should ask “What is the leading cause of UCL injuries?” There is no muscle in the elbow that solely prevents a valgus load in the frontal plane that can simply be “strengthened” in rehab with the expectation of excellent prevention of abnormal UCL forces. Is it merely in the overuse of velocity forces/torques? To what extent do poor mechanics play a role for this athlete? Does the player exhibit underlying kinetic chain limitations affecting optimal mechanics and force generation/deceleration? It’s critical that therapists examine the kinetic chain of the throwing/overhead athletes - including a 3D functional shoulder, wrist, scapula, thoracic spine, hip/pelvis, and foot-ankle assessment. Physicians and surgeons should expect these as a standard part of excellent care. In some cases, specifying these on the prescription may be necessary. Early opening of the trunk, lead leg foot plant alignment, poor trunk and hip mobility-strength-power among others all can lead to “all arm” mechanics and other faulty movements that overload elbow valgus, creating UCL overload. Some of these may best be captured by assessing throwing video the athlete already has or can be done using our Spark Motion Analysis in the clinic. Throwing mechanics issues can often be traced back to those underlying kinetic chain limitations noted above. The pectoralis minor length, serratus anterior stabilizing capacity, posterior cuff/capsule status, thoracic rotation ROM especially, hip rotational ability, and STJ eversion abilities all directly relate to throwing mechanics needed for each of the phases. Late cocking and acceleration must especially be examined due to being the most provocative to the UCL, causing the most valgus strain on the elbow because the UCL is most stretched at 30 deg flex and 120 deg of elbow extension are when the tissue is most taught where injury is more likely. Once areas of need are identified then a functional biomechanical exercise progression can be determined and initiated. Class IV laser therapy also can be an excellent treatment to stimulate tissue healing. Manual therapy is often useful/necessary along with therapeutic taping techniques. The case below illustrates a baseball thrower who did undergo a PRP injection prior to his physical therapy program. The Peak Performance Experience Victor said: “My elbow is now pain free and I’ve started my return to throwing program to become a 3rd baseman.” History: 20 yo male baseball pitcher injured self approximately one year ago while pitching in a game. He felt a pop in his medial elbow and had had significant pain 6/10. This has been an ongoing issue since May 2021 and pt has received PT intermittently for the last year and a half between school baseball seasons. Pt received a PRP injection November 23, 2022 (10wks ago). Subjective: Patient reported intermittent medial elbow pain 2/10. Symptoms are increased by throwing and opening a tight jar. Patient self reports being at 90% overall function and Quick DASH scale 23% limitation Quick DASH Sport 25% & work 6% limitation. Objective: Patient showed decreased pectoral minor, hip and trunk mobility, rotator cuff and scapular weakness. See below re Eval and Re-Eval findings. Initial Evaluation (L/R) ReEval 4wks (Pre-PRP inj) ReEval - 10wks (post PRP inj) Self Rating 90% overall function 100% Quick DASH 23% 0% Quick Dash Sport 25% 0% Pain scale 2/10 max 1/10 max 0/10 pec Minor moderate moderate DNT Thoracic Rotation 38 deg / 42deg 52 deg / 45 deg 51 deg / 35 deg Hip IR prone ROM DNT 33 deg / 32 deg DNT Hip ER ROM 20 deg / 17 deg DNT Isometric strength nER 12.8 kg / 11.6 kg nIR. 13.7 kg / 12.6 Kg nER 12.0 kg/ 12.3 kg nIR 16.2 kg/ 16.3 kg nER 10.9 kg nIR 11.2 kg AbdER 11.3kg to 12 kg Functional strength: biceps 20# 26x 24x 25# 23x /24x 25# 8x Cable Row 50# 36x 30x 50# 20x 19x OH press 12# 36x 32x 12# 28x 25x Treatment: Exercise - Mobility, strengthening, explosive, speed/ reactionary function. Kinetic chain stretching of hip IR & ER, Thoracic Rot & Ext, Pec Minor, Shld IR, Calcaneal Eversion. PRE’s including open and closed chain with resistance tubing & medicine balls, weights. Impact/speed based drills - utilizing multiple angles in a dynamic arcing pattern and static angles (Included: diagonal chops & lifts, rebounder, perturbations/ rhythmics stabs @ multiple angles for scapular stabilizers with internal and external forces i.e.: body blade, or therapist perturbations). Outcome: Interestingly, the patient has progressed to subjectively being pain free and now able to advance to a graduated return to throw program despite some of his testing parameters actually not yet reaching pre-PRP levels. These measures have, however, continued improving since the decline that followed during the rest period post-PRP injection. A throwing program has been implemented, week 1 of 6. Additionally, the Pts throwing program has changed as he transitions from a pitcher to 3rd baseman. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester, and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com