June 28, 2013

Overthinking It

Dylan Bundy, Elbow Injuries, and the Evidence That PRP Works

by Ben Lindbergh

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When the news broke yesterday that Orioles prospect Dylan Bundy would have to have Tommy John surgery, most of you probably wondered why he hadn’t had it sooner.

It’s been almost three months since we became aware of an issue with Bundy’s elbow. The first reported red flag, “mild tightness,” was followed by an MRI that showed no structural damage, a few weeks of rest, a visit to Dr. James Andrews—who prescribed more rest and a platelet-rich plasma (PRP) injection—and several more weeks out of action. Bundy recently resumed a throwing program, but he suffered a setback that sent him back to Dr. Andrews and, ultimately, the operating room.

All of this sounds familiar, since we’ve seen this pre-surgery sequence before. And it’s extra frustrating for fans when a promising player spends half a season circling the drain; as disappointing as it is to lose someone like Bundy for a year or more, it’s even more galling to think that the timetable for return was pushed back by a doomed attempt to escape the inevitable. Orioles blog Camden Chat summed up the feelings of many Baltimore fans on Tuesday, saying:

If it ends up that Bundy does need the surgery, that will be a bitter pill to swallow, given that he has not been right since spring training. If he'd needed the surgery all along but went under the knife in March, he could be ready to go for next season.

Instead, Bundy will be sidelined until at least mid-2014, even assuming that everything goes smoothly. (The prognosis for Tommy John patients has improved, but as Ryan Madson has found out the hard way, a complete recovery isn’t assured.) Even aside from the risk, the O’s had every reason to exhaust the non-surgical options before sending Bundy’s UCL to the scrap heap: The rehab process is painful, time-consuming, and stressful, the Orioles need pitching help now, and Bundy isn’t accruing service time while he’s on the DL, since he was optioned to the minors before he got hurt. But to believe that Baltimore’s conservative approach was a smart one, you need to see some sign that PRP can help heal an injured UCL. Otherwise, you might well ask why the Orioles would waste time that Bundy could have used to start working his way back.

Over at Sports Illustrated’s “Strike Zone” blog, Cliff Corcoran listed several cases in which PRP failed to prevent surgery and noted how hard it was to find examples where it worked, concluding:

PRP may be effective in relieving the discomfort of tennis elbow or other inflammatory and osteoarthritic conditions, but it’s not going to heal a tear.

At this point, it seems all that PRP treatments are doing is delaying players’ surgeries and thus extending the period of time during which they are either diminished or altogether absent.

The same thoughts have crossed my mind. Like everyone else, I tend to fear the worst when I hear about elbow issues, as I discussed with Paul Sporer and Corey Dawkins on Effectively Wild in April after Chad Billingsley’s attempt to forestall surgery with his own rest, rehab, and PRP program failed. (Sam Miller and I brought up that instinct again on today’s episode.)

But sometimes our instincts are off. As a counterpoint to our collective fatalistic attitude about elbow injuries, allow me to present a paper with the attention-grabbing title, “Treatment of Partial Ulnar Collateral Ligament Tears in the Elbow with Platelet-Rich Plasma.” Authored by five doctors from the Kerlan-Jobe Orthopaedic Clinic in Los Angeles, including the late Lewis Yocum, the paper was presented at a meeting of The American Orthopaedic Society for Sports Medicine in February and published in The American Journal of Sports Medicine in May. You’ll need a subscription to read the full article, but the abstract is available online.

In short, there is evidence that PRP works on the injury Bundy had, and this paper provides it. The “background” section of the abstract acknowledges that prior to the paper’s appearance, there were “no published reports of clinical outcomes of partial ulnar collateral ligament (UCL) tears of the elbow treated with PRP.” Now there’s at least one, and it offers pretty strong support for the PRP procedure.

The paper charts the progress of 34 athletes with a partial-thickness UCL tear—like Bundy’s—confirmed on MRI. All 34—27 of them baseball players, 16 of whom pitched—“had failed at least two months of nonoperative treatment and an attempt to return to play.” They were subjected to a battery of tests, questionnaires, and measurements designed to provide a pre-PRP baseline that their progress could be compared to after the procedure. And then they received their injections.

The results were encouraging. After an average follow-up time of 70 weeks, 30 of the 34—88 percent—“had returned to the same level of play without any complaints.” On average, it took them 12 weeks to get back into games, and the same tests they’d taken prior to PRP confirmed their improvement. Only one of the 34 had ligament reconstruction surgery in the period spanned by the study. It’s important to note that there was no control group, so we don’t know how many of the 34 might have made it back with rest and rehab but without PRP. But we do know that with PRP, almost all of them avoided going under the knife. Based on those results, the paper concludes that “PRP is an effective option to successfully treat partial UCL tears of the elbow in athletes.”

Team doctors and trainers aren’t stupid, and they probably wouldn’t continue to waste time (and many millions of dollars) and stake their reputations on an experimental procedure with no history of success. The instances when the rest-and-rehab approach didn’t pan out tend to stick in our minds more easily than the successes, and since players’ PRP use isn’t always public knowledge, we don’t necessarily know when it works out. But what data we do have suggests that PRP is often worth the wait.

The next time I hear that someone is experiencing elbow soreness, I’ll probably still catch myself assuming a season-ending injury. But there is some reason to hold out hope. And if rest, rehab, and PRP don’t pay off, we can’t conclude that they weren’t worth trying.

Thanks to Corey Dawkins for tipping me off to the study.

Ben Lindbergh is an author of Baseball Prospectus. Follow @benlindbergh
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