Is there a role for biologics in the treatment of elbow injuries in athletes?
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Approach on case-by-case basis
The role of biologics, such as PRP, in treating elbow injuries of overhead athletes shows potential, but the evidence is still early stage.
In players with certain injury types, such as low-grade partial-thickness injuries that are proximal along the UCL, nonoperative treatment can be extremely effective. However, biologics, such as PRP, may improve treatment success with low risk.
A second scenario in which biologics may be effective is when the athlete cannot undergo reconstructive surgery due to logistical reasons. Examples include athletes with mild/moderate symptoms who are preparing for an upcoming season or those whose careers have limited longevity (eg, rising high school or college seniors), such that undergoing a 1-year postoperative rehabilitation is unreasonable. Therefore, even when the injury to the ligament may be high-grade or distal — injuries that typically benefit from surgical intervention — we may try PRP in the hopes of improving symptoms enough to allow for a return to play, even if for just one season.
Finally, in-season injuries may be amenable to biologics-enhanced nonoperative treatment, but there must be enough time available for post-injection rest (4 to 6 weeks) in order to maximize likelihood of treatment success.
Hopefully, our understanding of biologics with regard to treating throwing-related injuries will continue to grow. Until then, we should approach these modalities on a case-by-case basis.
Eric C. Makhni, MD, MBA, is clinical associate professor in the division of sports medicine and the department of orthopedic surgery at Henry Ford Health System in Detroit and team physician for the Detroit Lions and Oakland University.
Limited supportive data
There are some limited data to support a possible use of biologic agents for elbow conditions. The most common elbow problems in athletes are attritional soft tissue injuries due to repetitive use. These include overuse tendinopathy involving the elbow extensor tendons, elbow flexor tendons and, less commonly, biceps or triceps. Injury to the UCL is another common injury, and although this may be due to a single traumatic event, there is typically preexisting accumulated microscopic damage to the tissue from repetitive overuse. Symptoms associated with these conditions are often due to the associated inflammatory response and blood-based agents, such as PRP, may have a positive role via their production of immunomodulatory and anti-inflammatory mediators. In this way, these substances can be “symptom modifying,” but there are little data to suggest that they are “structure modifying,” ie, that they can stimulate regeneration/healing of structurally normal tissue. The existing literature is limited based on the heterogeneity of these orthobiologic agents and the lack of controlled clinical trials.
Variability in the underlying cellular and molecular pathology in the injured tissue (ie, acute vs. chronic pathology) also contributes to the heterogeneity in tissue response to orthobiologics and consequent clinical outcomes. Lastly, variability in mechanical stimulation of the healing tissue due to different rehabilitation activities also has a critically important effect on patient outcomes.
Scott A. Rodeo, MD, is a sports medicine surgeon at Hospital for Special Surgery in New York and an Orthopedics Today Editorial Board Member.
PRP useful for UCL injuries
Biologic injections play an integral role in nonoperative treatment of elbow pathologies in my practice. I currently most often utilize leukocyte-poor PRP due to its availability and cost, but am transitioning to leukocyte-rich PRP for tendinous conditions with the hope of improved healing rates. I find PRP particularly useful in partial UCL injuries, as well as lateral and medial epicondylitis. Although less common, injections of the distal triceps, as well as intra-articular injections for elbow osteochondral defects, can be considered. Further, I utilize PRP to soak osteochondral allografts to hopefully accelerate healing. Typically, I perform three total PRP injections into the pathologic tendon, separated by 1 week. PRP has not been successful in my hands for significant tears of the medial or lateral forearm extensors. Similarly, I do not use PRP in unhealthy or complete UCL tears. I have not augmented surgical repairs of the lateral extensor compartment or UCL repairs or reconstructions due to already high healing rates and successful outcomes.
Data show PRP treatment in elbow tendinous pathologies is successful. Several high-level studies have shown PRP to be superior to steroid injections in lateral epicondylitis and data that support PRP injections in partial UCL injury continue to increase. I use MRI to establish the extent and location of the pathology to determine whether biologics may be beneficial to avoid surgical intervention or speed up recovery. Previously, I used landmark guidance and patient symptoms to guide injection location, but now use ultrasound more commonly. PRP makes up the majority of biologic treatments of the elbow in my practice. Other biologics, such as bone marrow aspirate, have not been extensively studied in the elbow and currently do not play a substantial role in my practice. Multiple different biologic options and preparations make evaluation of the current data difficult; however, I see significant promise with PRP treatment in partial UCL injuries and in lateral and medial epicondylitis cases.
James P. Bradley, MD, is clinical professor in the department of orthopaedic surgery at University of Pittsburgh Medical Center and practices at Burke and Bradley Orthopedics in Pittsburgh.