PRP partial UCL cover

prp for partial ucl tears of the elbow

introduction

Ulnar collateral ligament (UCL) injuries of the elbow are very common among overhead athletes and sports medicine providers will likely run across multiple cases each season.  Due to the time of recovery, more studies are being conducted to further evaluate non-operative management including PRP and certain rehabilitation protocols.

The anterior bundle of the ulnar collateral ligament (UCL) is the primary stabilizer against valgus forces within the functional range of 30° to 120° of elbow flexion [1]. During the throwing motion, substantial valgus loads placed on the elbow during the late cocking and early acceleration phases often exceed what may be required to damage the ligament [5]. These phases of the throw can generate up to 64 N of valgus force and 300 N of shear force is experienced across the structures of the medial elbow [5].

anatomy of the UCL illustration

Baseball pitchers are most often affected by UCL tears and injury rates are increasing [2].  Repetitive valgus stress on the elbow joint can lead to insufficiency of the anterior band of the medial ulnar collateral ligament (MUCL), with either an acute or insidious onset. Analysis of statistics from professional baseball players have shown statistically significant changes in earned run average (ERA), walks plus hits per innings pitched, innings thrown, and win percentage in the games preceding recognition and treatment of their MUCL injuries [6].

Reconstructive surgery is the most common treatment approach for UCL tears, but increasing evidence shows that surgical repair and conservative treatment are viable options for certain athletes. A surgical repair of the ligament will require approximately 6 months of rehabilitation before returning to competition.

Platelet-rich plasma (PRP) contains a variety of growth factors with laboratory research showing evidence of an accelerated healing process and improved tissue healing [3-4]. PRP has been studied clinically in treatment of various orthopedic conditions and its usage has been increasing in frequency for musculoskeletal conditions.  It is easily obtained with little risk to the patient [4].

In 2001, Rettig and colleagues. provided the first large series of patients treated with nonoperative management for MUCL injuries. In their cohort, only 42% of patients returned to play at an average of 24.5 weeks of rehabilitation [7]. However, this study did not discriminate between complete and partial disruptions of the MUCL. This initial study was one of the landmark studies showing non-operative management can be successful.

Podesta and colleagues described a grading system for MUCL injuries based on magnetic resonance imaging (MRI) [8]. Grade 1 injuries consist of edema in and around the ligament without structural disruption and grade 2 injuries consist of partial ligamentous disruption.  Grade 3 injuries are complete ligamentous disruptions.

The study by Podesta and colleagues showed that a single leukocyte-rich PRP injection was a safe adjunct to nonsurgical management in partial MUCL tears, with 88% (30/34) of patients returning to their prior level of competition after an average rehabilitation course of 20 weeks. In that protocol, patients were given the PRP injection after 8 weeks of nonoperative management.  The average return to play was 12 weeks. Medial elbow joint space opening with valgus stress decreased from 28 to 20 mm at final follow-up [8].

The location of the tear (proximal versus distal) has shown recently to affect clinical outcomes.  One review of seven separate case series that included a total of 169 athletes that underwent nonsurgical management of UCL injury reported 83% (n = 140) were able to return to play (RTP) and 72% (n = 121) were able to return to same level of play (RTSP). Those with proximal UCL tears had a RTSP rate of 82% (n = 56) compared to 42% (n = 13) of those with a distal tear. Proximal tears were associated with higher rates of successful outcomes in RTP and RTSP [9]. 

Shohei Ohtani UCL

Figure 1.  Shohei Ohtani of the Angels recently underwent UCL reconstruction for the second time.

Frangiamore and colleagues emphasized that tear location should be strongly considered and discussed with throwers when deciding between operative and nonoperative management of a UCL injury, with proximal tears resulting in higher odds of success. Furthermore, this study also found that high-grade tears were more likely to fail nonoperative management [11].

Another study by Deal et al. evaluated a protocol for non-operative management of partial UCL tears and ordered a follow up MRI [10]. Immediately upon diagnosis, the patients were placed in a hinged elbow brace that provided varus force to offload the MUCL. The patients received 2 injections of autologous PRP spaced 2 weeks apart.  Immediate physical therapy was instituted in the brace, which included hip, core, scapula, shoulder, elbow, and wrist exercises. An MRI was then done after four weeks.

Elbow MRI Partial UCL Tear

Figure 2. Pretreatment magnetic resonance arthrogram showing a proximal medial ulnar collateral ligament tear.  Adopted from [10].

Twenty-two out of twenty-three (96%) patients demonstrated stability of the MUCL after treatment and returned to play at the same or higher level of competition. Patients were released to play at 6 weeks, though the mean time to return to play was 82 days. The posttreatment MRI showed full reconstitution in 20 of 22 (91%) patients who successfully returned to sport [10].

A recent 2019 study with 34 athletes also had a positive outcome.  Trephination along with a PRP injection was performed over the UCL after these athletes had at least two months of rest and then physical therapy.  Twenty-six of 30 athletes were able to return to sport with pre-injury level of play within six months after the procedure, at an average time of 12.4 weeks [13].    Four athletes did require a UCL reconstruction for persistent UCL insufficiency.  This study concluded an ultrasound-guided PRP injection following trephination can be an effective treatment option for both partial and complete UCL tears of the elbow, especially proximal tears [13]. 

Interestingly, a survey of American Shoulder and Elbow members revealed that only 36% of questioned physicians reported using PRP in UCL injuries, and only 16.6% of respondents claimed to use leukocyte-rich PRP [12].  This did occur in 2017 and more data has been published since that time.  

MRI Elbow partial UCL after PRP

Figure 3. Post-treatment MRI showing improvement in the UCL.  Adopted from [10].

Since Jobe et al. published their original paper describing MUCL reconstruction in 1986, many surgical techniques for repairing and reconstructing the MUCL have been described [14]. In professional baseball, an estimated one-third of pitchers have had surgical reconstruction of the MUCL [15]. With current surgical treatment, up to 95% of athletes can return to play at their previous level of competition or higher with a low rate of complications, but it is a season-ending procedure requiring a prolonged period of rehabilitation [15]. In 2014, two studies showed that professional pitchers who undergo MUCL reconstruction demonstrate lower ERAs, though their velocity decreased and the average of career length was about 4 years [17-18].

Summary

In conclusion, practicing clinicians must consider several factors when considering treatment plans for an athlete based on these results. The available research suggests that some athletes undergoing conservative treatment for partial UCL tears return to competition earlier and at higher rates when PRP is included in the treatment plan.  Patient selection and injury severity greatly influence treatment outcomes, so clinicians must be mindful of these factors when educating athletes and making treatment recommendations. Athletes with proximal-based, low-grade injuries appear to be most likely to succeed in a conservative treatment plan with PRP.

References

  1. Cain EL, McGonigle O. Return to play following ulnar collateral ligament reconstruction. Clin Sports Med. 2016;35(4):577–595. PubMed ID: 27543400 doi:10.1016/j.csm.2016.05.004
  2. Kim NR, Moon SG, Ko SM, Moon WJ, Choi JW, Park JY. MR imaging of ulnar collateral ligament injury in baseball players: value for predicting rehabilitation outcome. Eur J Radiol. 2011;80(3):422–426. PubMed ID: 21277722 doi:10.1016/j.ejrad.2010.12.041
  3. Dines JS, Williams PN, El Attrache N, et al. Platelet-rich plasma can be used to successfully treat elbow ulnar collateral ligament insufficiency in high-level throwers. Am J Orthop. 2016;45(5):296–300. PubMed ID: 27552453
  4. Deal JB, Smith E, Heard W, O’Brien MJ, Savoie FH 3rd. Platelet-rich plasma for primary treatment of partial ulnar collateral ligament tears: MRI correlation with results. Orthop J Sports Med. 2017;5(11):2325967117738238. PubMed ID: 29164165 doi:10.1177/2325967117738238
  5. Patel RM, Lynch TS, Amin NH, Calabrese G, Gryzlo SM, Schickendantz MS. The thrower’s elbow. Orthop Clin North Am. 2014;45(3):355–376.
  6.  Keller RA, Steffes MJ, Zhuo D, Bey MJ, Moutzouros V. The effects of medial ulnar collateral ligament reconstruction on Major League pitching performance. J Shoulder Elbow Surg. 2014;23(11):1591–1598.
  7.  Rettig AC, Sherrill C, Snead DS, Mendler JC, Mieling P. Nonoperative treatment of ulnar collateral ligament injuries in throwing athletes. Am J Sports Med. 2001;29(1):15–17.
  8. Podesta L, Crow SA, Volkmer D, Bert T, Yocum LA. Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich plasma. Am J Sports Med. 2013;41(7):1689–1694.
  9. Oakes, N., & Medina McKeon, J. M. (2020). Nonsurgical Management of Ulnar Collateral Ligament Injuries is Tentatively Successful in Overhead Athletes: A Critical Appraisal of Case Series. International Journal of Athletic Therapy and Training, 25(5), 213-220
  10. Deal JB, Smith E, Heard W, O’Brien MJ, Savoie FH. Platelet-Rich Plasma for Primary Treatment of Partial Ulnar Collateral Ligament Tears: MRI Correlation With Results. Orthopaedic Journal of Sports Medicine. 2017;5(11).
  11. Frangiamore S, Lynch T, Vaughn M, Soloff L, Forney M, Styron J, Schickendantz M. Magnetic resonance imaging predictors of failure in the nonoperative management of ulnar collateral ligament injuries in professional baseball pitchers. Am J Sports Med. 2017;45(8):1783–1789. PubMed ID: 28398820 doi:10.1177/0363546517699832
  12. Hurwit DJ, Garcia GH, Liu J, Altchek DW, Romeo A, Dines J. Management of ulnar collateral ligament injury in throwing athletes: a survey of the American Shoulder and Elbow Surgeons. J Shoulder Elb Surg. 2017;26(11):2023–8.
  13. Kato, Yuki, Shin Yamada, and Jover Chavez. “Can platelet-rich plasma therapy save patients with ulnar collateral ligament tears from surgery?.” Regenerative therapy 10 (2019): 123-126.
  14. Savoie FH, III, Trenhaile SW, Roberts J, Field LD, Ramsey JR. Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament. Am J Sports Med. 2008;36(6):1066–1072
  15. Keller RA, Steffes MJ, Zhuo D, Bey MJ, Moutzouros V. The effects of medial ulnar collateral ligament reconstruction on Major League pitching performance. J Shoulder Elbow Surg. 2014;23(11):1591–1598.
  16. Cain EL, Jr, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010;38(12):2426–2434.
  17. Erickson BJ, Gupta AK, Harris JD, et al. Rate of return to pitching and performance after Tommy John surgery in Major League Baseball pitchers. Am J Sports Med. 2014;42:536–543.

Jiang JJ, Leland JM. Analysis of pitching velocity in major league baseball players before and after ulnar collateral ligament reconstruction. Am J Sports Med. 2014;42:880–885