TOMMY JOHN SURGERY

SUMMARY OF NON-OPERATIVE TREATMENT

• Rest from throwing
• Ice, NSAIDS
• PRP injections
• Strengthening program focusing on forearm, shoulder, leg, hip, core
• Progressive throwing program with symptoms resolve and exam normal
• Changing position to decrease stress on elbow (move from pitcher to first base)
• Pitching mechanics optimization

WHAT ARE YOUR GOALS?

Non-operative treatment requires careful consideration of the patient’s athletic expectations in addition to consideration of the degree of UCL injury. Seasonal and career timing are also important to consider. Athletes with low demands who are less serious about continuing with baseball may choose to play first base rather than a high-demand position such as pitching as they undergo non-operative treatment. Players with aspirations of playing at the collegiate or professional level, may opt for more immediate surgical reconstruction.

INITIAL NON-OP TREATMENT

Initial non-operative treatment for UCL injury consists of rest, ice, anti-inflammatory medication and, in some cases, use of an elbow brace. This is aimed at reducing pain and inflammation and allowing initial healing. We highly discourage cortisone injections into the area of the UCL. Platelet-rich plasma (PRP) is a treatment that can accelerate healing and improve the quality of healing.

PRP injections are used to treat ligament and tendon injuries and can enhance healing of UCL tears. PRP therapy is part of a relatively new field of medicine known as orthobiologics that includes the use of stem cells and emphasizes the latest technologies along with the body’s natural ability to heal itself.

Our blood is made of red blood cells, white blood cells, plasma, and platelets. Platelet-rich plasma is the name given to blood plasma with a high concentration of platelets that contains huge doses of bioactive proteins, such as growth factors, that are critical in the repair and regeneration of tissues. To extract these platelets, a small amount of blood is drawn from the patient and immediately undergoes centrifugation, a process in which mixtures are separated using centripetal force. This process separates out red blood cells, which carry oxygen, and the platelets and the plasma. The platelets with the plasma have all of the healing agents. Once we’ve done the separation, we extract the PRP that can then be injected back into the patient’s injured area. It is their own platelet-rich plasma — it isn’t taken from another person or derived in a laboratory.

Growth factors can dramatically enhance tissue recovery and the special proteins also initiate new blood vessel formation, bone regeneration and healing, connective tissue repair, and wound healing. There is little chance for rejection because the components used for treatment are extracted from a person’s own body. This makes the procedure entirely safe. The PRP injection also carries less chance for infection than an incision, with a considerably shorter recovery time than after surgery.

I began using PRP therapy as an option for professional athletes. Once we established that this approach was beneficial for the professional, I began offering it to young athletes. We have an even greater motivation to use a healing agent for younger patients. The younger a patient is, the less we want to operate, which is potentially career ending if it doesn’t work, or could possibly change the normal anatomy. We try to preserve a patient’s own anatomy and tissues and avoid surgery as much as possible.

I have researched the effects of injury in younger children and adolescents as compared to adults. Preliminary data shows that a sports injury in an adolescent has much greater impact on his or her emotional status and perception of quality of life. That makes sense because adults work and have other responsibilities. With students, their focus and energy are on school, socializing and, often, athletics. If you take away their ability to be involved in athletics, it affects their school and social environment. Young athletes have so much future and potential, and if we don’t provide the maximum benefit to them, they have a long life to feel the repercussions.

As Director of Biomechanics Research at the Center for Orthopaedic Research, I continue to explore the uses and benefits of PRP. We know that the platelet-rich plasma is working, but what we aren’t sure about yet is what the exact dosing should be. Is one injection enough? Are two injections better? Are three injections too many? So I’m involved in determining what the exact dose should be. Major League Baseball funded an ongoing study to determine the effects of repeated dosing and optimal timing between doses.

I participated in a clinical outcomes study with several colleagues to evaluate the effect of PRP injections on partial ulnar collateral ligament (UCL) tears in high-level throwing athletes. We reviewed the results of 44 baseball players (six professional, 14 college, 24 high school) treated with PRP injections whose mean age was 17.3 years. Of the 44 patients, 15 (34%) had an excellent outcome, 17 had a good outcome, two had a fair outcome, and 10 had a poor outcome. After injection, four (67%) of the six professional players returned to professional play. There were no injection-related complications. Our use of PRP in the treatment of UCL insufficiency produced outcomes much better than earlier reported outcomes of conservative treatment of these injuries. PRP injections may be particularly beneficial in young athletes who have sustained acute damage to an isolated part of the ligament and in athletes unwilling or unable to undergo the extended rehabilitation required after surgical reconstruction of the ligament.

The period of non-operative treatment with or without PRP is typically six weeks of no throwing. During the period of no throwing, physical therapy is started and designed to strengthen elbow, shoulder, hip and core muscles. When the physical examination determines no tenderness over the UCL and negative stress testing, a throwing program is initiated. Throwing mechanics are optimized and flexibility and strength is maintained in the lower extremities, trunk, and core muscles. Non-operative treatment typically takes three to four months before players are fully active.

Patients who wish to continue baseball but fail non-operative treatments, and maintain symptoms and the ability to throw are indicated for Tommy John surgery. A long and lengthy recovery is demanding both physically and mentally. Athletes need to be committed to achieving a favorable result.