Non operative treatment of UCL injuries- recent study

[Heezy1323]

Daily browser, infrequent poster here.
I am in the medical field and have read several threads over the past couple of years on TD that discuss Tommy John surgery and related topics. In these threads, there is often a sentiment that a pitcher should undergo TJ surgery sooner than later, and that non surgical treatment is rarely successful.

 Certainly, there is not an abundance of data to argue this either way. However, in the March issue of the American Journal of Sports Medicine (probably the most highly respected sports medicine journal) there is an article which discusses precisely this. I found the results interesting, and I thought others on this site may, too.

 It was done in Colorado in the Rockies organization. They looked at all UCL injuries from 2006-2011. In all, they came up with 43 elbows which met their criteria. 8 were complete tears on MRI, and underwent surgery. 35 were incomplete on MRI (which is the much more common finding). Of these, 28 were treated non operatively and 7 were treated operatively.

 Of the 28 non operatively treated elbows, 18 were pitchers. They were treated with a program including e-stim, mobilization, massage, ultrasound, laser therapy, cuff and periscapular strengthening. No PRP injections were used, as far as I can tell. They defined success as return to the same level of play for at least 1 season.

 Of these 18 pitchers, 94% were able to return to play for at least 1 season at the same or higher level of play. Those with incomplete tears treated operatively had a return to play rate of 86% at the same or higher level. Those with complete tears that had surgery initially had a return to play rate of 63% at the same or higher level.

 Overall, I believe this is a well-done study that may answer some questions posters on this site have had in the past. Obviously, those treated non-operatively had less severe injuries, so I don't think you can draw the conclusion that non-surgical treatment is better than surgery in all cases. But this does lend some support to non-surgical treatment in many cases.

 I hope some find this helpful. Happy to try to answer any questions folks may have. I'm sure there are other health care professionals or performance specialists on this site that will likely have an opinion as well.

 

 Below is a link to the study abstract:

 

http://ajs.sagepub.com/content/44/3/723.abstract

[Craig Arko]

Thank you very much for this. Both the data and the source link.

[biggentleben]

Very intriguing stuff. Thanks for the post and the link!

[h2oface]

Thanks, Heezy1323!

[Thrylos]

This is interesting indeed, but I'd love to see longer term data, like n+2, n+3 etc.  The idea here is that once a UCL is replaced it will last longer in the intermediate/long term than a UCL that has been rehabbed and still likely has micro tears

[jimbo92107]

"They defined success as return to the same level of play for at least 1 season."

 

As Thrylos indicated, surgery basically resets damage in the UCL area to nearly zero, including scars and micro-tears. Granted that the recovery rate may be shorter for non-surgical treatment, but I also would like to find out about the success rate for n+1, n+2 seasons, etc. 

 

We at TD have soured a bit on therapy because we have seen multiple instances where it did not work, where a previous partial tear came back, flared up or tore completely, requiring surgery. In a developing pitcher this can mean two year-long interruptions rather than one. 

 

Another confounding factor is player quality. We can't know from this information whether a pitcher popped his elbow from overwork or poor mechanics. Did they fix the mechanics post operation? Were the ones that didn't "succeed" fail because of the operation, or because they wouldn't have made it anyway, healthy elbow or not? Did some of the "failures" fail because the UCL tore again, or because the player couldn't learn to trust the repair? 

[Heezy1323]

 

This is interesting indeed, but I'd love to see longer term data, like n+2, n+3 etc.  The idea here is that once a UCL is replaced it will last longer in the intermediate/long term than a UCL that has been rehabbed and still likely has micro tears

Absolutely! I suspect that data will be forthcoming as time allows from this initial study. But we don't really have that data yet.

 Another way you could interpret this data is that surgery is more successful for incomplete tears than it is for complete tears... so should we be quicker to operate on partial/incomplete tears before they become complete? Difficult to answer because we really don't know how frequently incomplete tears progress to full tears over time. It seems like every time we answer a question, it is replaced with 5 more.

[Heezy1323]

 

"They defined success as return to the same level of play for at least 1 season."

 

As Thrylos indicated, surgery basically resets damage in the UCL area to nearly zero, including scars and micro-tears. Granted that the recovery rate may be shorter for non-surgical treatment, but I also would like to find out about the success rate for n+1, n+2 seasons, etc. 

 

We at TD have soured a bit on therapy because we have seen multiple instances where it did not work, where a previous partial tear came back, flared up or tore completely, requiring surgery. In a developing pitcher this can mean two year-long interruptions rather than one. 

 

Another confounding factor is player quality. We can't know from this information whether a pitcher popped his elbow from overwork or poor mechanics. Did they fix the mechanics post operation? Were the ones that didn't "succeed" fail because of the operation, or because they wouldn't have made it anyway, healthy elbow or not? Did some of the "failures" fail because the UCL tore again, or because the player couldn't learn to trust the repair? 

Also absolutely correct. There are dozens of variables in play when you are trying to analyze this data, thus making it difficult to draw solid conclusions about any one aspect.

 To the 'soured on therapy' comment, I would say that there are certainly cases where this is true. There are also cases where a player successfully recovers with rehab without the public ever knowing what the specific injury was. That may not be easy to believe, but you'll just have to trust me- I've seen it happen a number of times.

 I wish that patients would come in with a blinking light on their elbow indicating it is time to operate. Unfortunately, more often it seems to be challenging decision that needs to be made on a case-by-case basis.

 Very astute comments- I appreciate and enjoy the conversation.

[nicksaviking]

Very interesting, and perhaps dampens some of the long standing concerns regarding Ervin Santana.

 

Perhaps someone could fill me in. As ligaments and tendons are not able to regenerate, what do these non-operative treatments actually do to prevent the full tear? Because all I can picture is a frayed cord and at some point frayed cords almost always give way under tension. These exercises sound like they may strengthen the anchor points, but again in my mental picture that's not going to make a difference in the fray. This must not be completely accurate.

[Heezy1323]

 

Very interesting, and perhaps dampens some of the long standing concerns regarding Ervin Santana.

 

Perhaps someone could fill me in. As ligaments and tendons are not able to regenerate, what do these non-operative treatments actually do to prevent the full tear? Because all I can picture is a frayed cord and at some point frayed cords almost always give way under tension. These exercises sound like they may strengthen the anchor points, but again in my mental picture that's not going to make a difference in the fray. This must not be completely accurate.

This is a somewhat complex explanation, so hopefully I can make it make some sense.

 

In a normal, healthy elbow during a pitch, the stress generated at the inside part of the elbow is actually greater than the measured tensile strength of the UCL. So essentially you are exceeding the capacity of the UCL with every pitch- a phenomenon Dr. Andrews calls 'red-lining' the UCL.

 So why doesn't the UCL snap with every pitch? Some of this force is dissipated by the use of other structures in the kinetic chain. These would include the forearm flexors, biceps, shoulder musculature, bony anatomy of the elbow and others.

 So in theory, the rehab angle seeks to 'protect' the UCL by strengthening these other contributors, and thereby dissipate the stress seen by the UCL itself.

 In addition, there is probably some limited capacity of the UCL to head in certain situations- something we are trying to augment with PRP and/or stem cell injections. Unclear at this point if these are truly helpful or not. The time resting from throwing allows (perhaps) for some healing.

 

[Pardon My Dinger]

How about spend more time developing (and talking about) stronger mechanics? 

[biggentleben]

 

How about spend more time developing (and talking about) stronger mechanics? 

 

Sure would work well once we convince everyone to max out their velocity in the 90mph range on average rather than upper 90s. An interesting tid bit was discussed on velocity recently on a Fangraphs podcast, and I couldn't tell you who the guest was as I tend to binge-listen to the podcast. I remember the guest referencing to Carson that in 1991, there were 4 teams that reported having at least one pitcher who recorded a timed 100 mph pitch on the season. 25 years later, there were enough pitches over 100 mph recorded in the majors for a pitcher to have led the league in relief innings pitched on nothing but 100 mph pitches thrown in the league last season. That's a drastic change.

[Pardon My Dinger]

I would argue that tommy John has become the crutch baseball leans on to cultivate young 100 mph talent. But it's not sustainable. The inverted w theory is the real deal, imo.

[biggentleben]

 

I would argue that tommy John has become the crutch baseball leans on to cultivate young 100 mph talent. But it's not sustainable. The inverted w theory is the real deal, imo.

 

I'd argue strongly against inverted W as any sort of causation, as would Mike Maddux, his brother Greg, Nolan Ryan, and Tom Seaver, all of whom have stated that it was exactly how they were taught to generate power, and how they did generate power over very long careers. With Mike, it's how he's taught pitching, and he's had extremely good rates of injury with the pitchers in his tutelage over the years. There could be some level of correlation, but I think part of the issue we have is that we're watching frame by frame on pitchers now and breaking down every second of a delivery. By all means, the lack of utilizing legs within delivery to generate velocity and movement rather than arms, the poor weight training still predicated on young pitchers in high school ranks (seriously most gymnastics coaches in high school understand weight lifting better than baseball coaches), and the over-emphasis of velocity over pitching skill has rapidly affected the health of arms.

[Hosken Bombo Disco]

Currently reading up on the inverted W -- lots of pics and gifs.

 

Here's an interview with a doctor who basically says every pitcher's UCL should break on every pitch.