Injuries to the ulnar collateral ligament (UCL) of the elbow can have a significant impact on professional baseball players' careers. While surgical reconstruction (commonly known as Tommy John surgery) has been the traditional treatment, nonoperative options such as ortho-biologics have gained popularity in recent years. With most athletes opting for surgery without giving enough time for tissue repair, it's essential to investigate if the use of ortho-biologics can restore normal tissue structure and biomechanical properties. Although most reconstruction techniques have less biomechanical strain than a natural ligament, modern techniques like collagen-dripped internal braces are getting closer to the typical biomechanical strain of the tissue. Furthermore, novel reconstruction approaches are more closely associated with the natural anatomical structure of the ligament.

The Emergence of Ortho-biologics

Platelet-Rich Plasma (PRP) therapy has gained popularity as a treatment option for various medical conditions, including sports injuries, osteoarthritis, and chronic tendinitis. Such interventions involves taking a blood sample, separating the platelets using a centrifuge, and then injecting them back into the injured site. There are two main types of PRP, which are leukocyte-rich and leukocyte-poor.

Leukocyte-rich PRP is prepared by centrifuging the blood sample and then using a second centrifugation step to separate out the white blood cells (leukocytes) from the platelets. This type of PRP is believed to have a higher concentration of anti-inflammatory properties. Leukocyte-poor PRP, on the other hand, is prepared using a single centrifugation step and does not involve the removal of white blood cells and a higher concentration of growth factors, which makes it a popular choice for treating conditions such as osteoarthritis and sports related injuries.

A study conducted by Ahmad et al. (2014) compared the outcomes of nonoperative treatment with and without PRP in professional baseball players with UCL injuries. The results showed that both groups had similar rates of return to play, but the PRP group had a significantly shorter time to return to play, lower rate of subsequent surgery, and reported less pain and better functional outcomes. However, a 2019 cohort study by Chauhan et al. found that players who received PRP had a longer delay in return to throw compared to those who did not receive PRP.

From 2011-2015, out of 977 professional baseball players, 433 elected for operative treatment while 544 elected for nonoperative treatments. The overall survival rate of the native UCL for all players was 50% after 1 year and declined to 43% by 3 years. Age >25 was the only significant predictor of not returning to play, and older players were more likely to receive PRP before rehabilitation. Thus, while nonoperative treatment with PRP therapy may be a viable option for professional baseball players with UCL injuries, there is still much variability in its use and effectiveness. A survey of the MLB Team Physician Association found that 48% utilized leukocyte poor PRP, 40% utilized leukocyte rich PRP, and 12% did not utilize PRP injections as part of the treatment process.

Things to Consider

The healing of a UCL tear, whether it is proximal or distal, depends on the severity of the injury and the individual patient's circumstances. Generally, proximal tears tend to have a better healing potential than distal tears. However, the extent of the injury, the patient's age, health, and activity level, and the type of treatment they receive will all influence the healing process. Conservative treatment such as physical therapy, bracing, and rest may be sufficient for minor UCL injuries, while more severe cases may require surgical intervention. It's crucial for patients with UCL tears to receive a proper diagnosis and individualized treatment plan from a qualified medical professional.

A question I have for the future is if the method of treating the ligament with orthobiologics restores normal tissue structure and biomechanical properties. We know from UCLr that the biomechanical strain in most reconstruction techniques is less than that of a natural ligament. Although certain modern techniques, such as the use of a collagen-dripped internal brace, get close to the typical biomechanical strain of the tissue. We also know that the ligament adapts over the course of the season. When we examine the ligament with MSK ultrasonography and analyze its behavior in season, we can see that the ligament thickens and the elbow becomes more lax at 30 degrees over the season. During the offseason, laxity and stiffness both diminish and restore to baseline measures.

As a clinician, I am fascinated and sometimes wonder about the possibility of changing the environment of the native ligament through the use of platelet-rich plasma (PRP) or other orthobiologics.

Could we potentially create a scenario in which the ligament restores normal tissue quality and stiffness, thereby enabling it to withstand throwing and potentially avoid the need for surgical intervention?

Nerd Out With Me 😀