Monday, September 8, 2014

Torn Ligaments and Platelet Rich Plasma- Examples from the Sports Headlines

Ever since Ichiro Suzuki entered MLB and lit the league on fire with the Mariners in 2001, enroute to Rookie of The Year and MVP honors, top Japanese baseball players have been highly sought after commodities across the league. The latest, and some say best yet, right-handed pitcher Masahiro Tanaka, became available at the end of last year. Carrying his team on the strength of his sparkling 24-0 record and 1.27 ERA to a league title and earning himself his second Sawamura Award (the Japanese equivalent of the Cy Young) in 2013 was enough to convince the New York Yankees to shell out a record breaking seven year contract worth $155 million. The contract is the largest ever given to a player coming from Japan, and the fifth largest contract for a pitcher in Major League history.

Much like Ichiro in 2001, Tanaka stormed out of the gates, posting a 12-3 record with a 2.10 ERA with 127 strikeouts in 16 starts through the end of June. However after his second start in July, Tanaka was placed on the disabled list with what was termed elbow inflammation. A MRI later revealed that Tanaka had suffered a partially torn ulnar collateral ligament (UCL). The UCL was made infamous in the baseball world by legendary pitcher Tommy John, for whom the surgical procedure was first performed on (by Frank Jobe) and named after. Tommy John surgery involves reconstruction of the UCL and while the recovery from this surgery improved over the years, on average it still takes at least an entire year before being able to pitch again, and it is often said that it takes two years to get back to pre-injury performance. It's easy to see why avoiding this option would be preferred by both the Tanaka and the Yankees, who are still dreaming of making the playoffs.

Ligaments are bands of tough, flexible, fibrous tissues that hold together a joint. When it comes to ligament tears, there are 3 different subtypes: partial-thickness tears, full-thickness tears, and complete tears. A partial-thickness tear is when in one plane of the ligament, some of the ligaments are torn. In this case, the structural integrity of the tendon remains mostly intact because there are still many intact fibers in the same plane as the tear along with the fibers in all of the other planes to hold the joint together. A full-thickness tear is when in one plane of the ligament, all of the fibers are torn. With these types of tears, the structural integrity of the can still remain intact, because fibers in all of the other planes can still hold the joint together. A complete tear is when in every plane of the ligament, all of the fibers are torn. With these types of tears, the structural integrity is completely lost.  This same classification scheme can be used for tendon tears as well.

Unfortunately with complete tears, surgery is essentially the only treatment option. In the case of a partial thickness tear, this is something that should heal naturally. Formal physical therapy is also recommended to help stabilize the joint and ensure proper healing of the tendon. For full-thickness tears, this is something that can heal naturally when supplemented by physical therapy.

However, depending on the extent of the damage, it may be the case that there are not enough fibers left intact for the tendon to heal properly, and surgery is required. It appears that based on reports of him considering Tommy John surgery, the injury that Tanaka sustained was of the full thickness variety . Rather than going this route and having to endure the over year long recovery process, he and the Yankees decided to avoid surgery and attempt to rehab his elbow in the hopes that he would be able to return to pitch at some point this year. Tanaka underwent an extensive exercise and controlled throwing program to strengthen his elbow and to help the tendon heal properly.

Another aspect that was added to Tanaka's rehabilitation that is less commonly used is the use of platelet rich plasma (PRP). We have discuss this type of treatment in a previous blog post, and it falls under the category of proliferative therapy. The idea behind this kind of treatment is that it will improve the healing and strengthen the ligament faster and better than the body would on its own. Thus allowing Tanaka to come back faster than he would have otherwise. After undergoing this procedure in mid July, Tanaka was able to play catch in the outfield by the beginning of August before progressing to throw 49 pitches in a simulated game on August 28th. Despite having to be temporarily shutdown due to soreness after that throwing session, he was able to return to the mound on September 6th throwing a 34 pitch bullpen without any complications, giving both him and the Yankees more confidence that he might be able to pitch in a game this year. That would put his theoretical recovery time at around 3 months as opposed to the 12-18 month that would have been required had he opted for surgery.

Many of the reports that I have seen reference this procedure done on Tanaka refer to it as just a PRP injection/shot, which is a bit of a misnomer. By referring to it as simply an injection or shot, it sounds like they collected his blood, separated the platelets, and simply injected them back into his elbow. While this could be an accurate description of what Tanaka underwent, I believe that what he went through quite a bit more sophisticated. While PRP is sometimes done this way, it is pretty obvious that Tanaka would want to make sure that the PRP was injected into the most beneficial location(s) to maximize the treatment's potential in supplementing his recovery. The best way currently available to ensure this is with ultrasound guidance, so Tanaka like had done a procedure that was similar to what would be carried out in our office.

When Drs. Hyman and Chimes perform proliferative therapy on a patient (either PRP or sugar-water prolotherapy), the injectate is carefully administered to specific parts of the affected tendon, often the area of most discomfort or damage, under ultrasound guidance. The advantages of ultrasound guidance has been discussed previously in this blog, but in short it allows for the procedure to be carried out with a higher degree of precision, improving the efficacy, and thus outcomes. When patients come to Lake Washington Sports and Spine and undergo proliferative therapy, there are getting world class care from nationally recognized physicians.

Wednesday, September 3, 2014

How to "Return to Play" after injury

Returning to play after injury

Returning to normal activity after pain or injury can be difficult. Many patients have questions about how much activity is appropriate and how soon until they can return to normal activity.

Here is a list of steps to follow and an example to give you a better understanding of how to safely return to your normal physical activity. 

Returning to play:

1. Start with regular light activity
2. Progress into body-weight supported drills
3. Progress into resistance training
4. Progress into sports specific drills, may include plyometric exercises
5. Progress into non-contact practice
6. Progress into contact practice
7. Return to play

Example: (for a runner, returning to running following an injury)

  •   Ok to start run-walking
  •  Would start with time based running (30 seconds running and 2 minutes walking)
  •  Start slowly by running 1 mile or for 12 minutes
  •  Slowly at first increase distance before shortening duration between bouts  (running 1 mile on day 1, increasing to 1-1/4 mile next session
  •  When up to 2 miles in distance, can start experimenting with shortening gaps between walking sessions  (instead of walking 2 minutes between runs, lower to 90 seconds)
  •  Key is to not run when fatigued or in pain
  •  If pain develops, then go back 2 steps

Tuesday, September 2, 2014

What to expect from physical therapy

One of the common treatment options that Drs. Chimes and Hyman recommend to patients is formal Physical Therapy (PT). When writing these referrals, they will often prescribe 12 sessions. 

Where does the number 12 come from?  It's an arbitrary number.  Different patients need different numbers of session, so 12 is a baseline number that helps for insurance approval.  The actual number of visits a patient needs is more complex, and will vary from person to person.  Many patients get better with a much smaller number (e.g., 4-6 sessions), while some more complicated injuries may take longer.

The purpose of this blog post is to give patients an idea of what to expect out of PT and how long they should continue with it in order to obtain optimum benefit.

  • The blue portion of the graph represents the period of "high benefit" where the gains are greatest, when a patient initially starts physical therapy.
  • It is important to understand that the first visit is likely to be more of an assessment and that true gains will begin accumulating in the visits that follow.
  • After about 2-5 sessions you should be able to get a sense as to whether or not you are on the right track.  This is the accelerated portion of PT, where the largest gains are often seen.  This is represented by the blue portion of the graph above, and may represent as few as 2 sessions, but sometimes may require as many as 10-20 sessions, depending on the patient.
  • Over time, as you attend more sessions, you may experience less benefit from each session. It is still very important that you continue with the therapy as these smaller gains help with "preventing injury recurrences", represented by the red portion of the graph.
  • At this point, it may be appropriate for you to increase the amount of time between appointments.  This will allow you to develop a "home maintenance program" while still periodically checking in with your PT to make sure home program is properly optimized.
  • However, eventually you will reach a point when you will begin to get "limiting returns" from your physical therapy sessions. This is a time when you have developed a sufficient base to return to activity while minimizing the risk of re-injury. This is represented by the green portion of the graph.
  • In regards to the question of how long you should attend physical therapy, ideally the sweet spot would be between red and green portions of graph, where you have learned how to prevent recurrences but have not reached a point of diminishing returns.
  • There isn't a magic number of visit that corresponds to this sweet spot. When you feel as though you may be approaching this point, discuss this with your physical therapist and/or physician and talk about transitioning to a home exercise program.
  • A physical therapy program is only as good as the effort a patient puts into it.  The bread and butter of any PT program is the home exercise program.  Patients who are fully participatory in their home program get better more quickly.  Listen to your PT!