Brian Schiff’s Blog

One of the most difficult problems to treat in the clinic is chronic pain related to tendinopathy.  More specifically, the Achilles tendon, patella tendon and elbow extensors often present challenges for doctors and clinicians alike when it comes to effectively reducing or resolving pain.  Over time, people develop chronic inflammation or even little tears in the muscles running up to the lateral epicondyle.

There have been many studies done looking at PRP over the past 5-10 years.  The debate continues, however, with respect to its efficacy in terms of results, especially given the fact that patients must currently pay out of pocket for the procedure.  I have written two earlier posts on PRP that you may be interested in reading as a back drop for this one:

2011 – An Update on Platelet Rich Plasma

2011 – Platelet Rich Plasma and Rotator Cuff Repairs

Currently, my approach to treating these injuries involves an approach focused on soft tissue mobilization via instrument assisted soft tissue mobilization, stretching, strengthening and a trial of iontophoresis in most cases.  We also offer dry needling at our facility and this has been effective in reducing pain.  I will talk more about this point later as it relates to the prospective multi-center trial summarized by Mishra et al. in the February 2014 edition of the American Journal of Sports Medicine.

Before I get to the study, I thought it would be pertinent to provide some straightforward information on PRP as it is a question that comes up with patients on a regular basis.  Essentially, the process is as follows:

1. Collect 30-60 ml of blood form the patient’s arm

2. Blood is then placed in a centrifuge.  The centrifuge spins and separates the platelets from the rest of the blood.

3.  A syringe is then used to extract 3-6ml of the platelet-rich plasma

4. The concentrated platelets are then injected into the elbow (or site being treated)

The thought behind PRP is to increase the growth factors up to 8x, which promotes temporary relief and stops inflammation. The question is how successful and cost effective is this process?  Consider that opting for surgery will run between $10,000 and $12,000 figuring in costs for the surgeon, hospital/surgery center, anaesthesiologist, etc.  PRP injections will cost upwards of $1000, so one would think that would be a favorable option for insurers if surgery could be averted.

What about cortisone injections?  They are widely used as a survey of 400 members of the American Academy or Orthopedic Surgeons found that 93% had administered a corticosteroid injection for lateral epicondylar tendinopathy.  According to Bisset et al (Br  Med J 2006) and Lindhovius et al (J Hand Surg Am 2008) cortisone injections do provide short term pain improvements but also result in a high rate of symptom recurrence.  There are other potentially harmful side effects from injections including: reduced collagen synthesis, depletion of human stem cells, depigmentation, and enhancement of fatty and cartilage like tissue changes that can lead to tendon ruptures.

So, the big question is whether or not tendon needling with PRP is an effective treatment option for chronic tennis elbow suffers. Mishra and his colleagues set out to examine this with a double blind, prospective, multi-center randomized controlled trial of 230 patients.  In the study, the patients were teated at 12 different facilities over 5 years.  All patients had at least 3 months of pain/symptoms and failed conservative treatment.

Continue reading…

So, one of my biggest pet peeves as a PT is seeing athletes hurt as a result of poor coaching and training.  Overuse injuries provide lots of clients for my practice.  While this is good for business, I would really like to help prevent these injuries.  I need your help.  It all starts with education and a willingness on the part of health and fitness professionals to advocate strongly for our young athletes.

Consider the following scenario: a 14 y/o freshman left-handed pitcher presents for rehab to recover from Little League Shoulder. He was hurt on the second day of his high school’s fall conditioning program.  He was being forced to throw in excess of 200 feet.  His exact words were, “I was sore after day one, but I felt my shoulder explode on the second day of the program.”  Think this is a coincidence?  Hardly.

Another player from the same school (a sophomore right hander) is also in my clinic recovering from an avulsion fracture of his medial epicondyle that he too suffered on the second day of the same throwing workout.  I emailed the left-handed pitcher’s father with details about throwing biomechanics and how they decline with long distance throwing.  I also expressed my concern over the coach’s aggressive throwing program.  The father emailed back and said he too disagreed with the throwing program.  However, the coach simply told him his son had “not been properly coached” prior to getting to his program.  Are you kidding me?  Look at the images below to appreciate the type of damage done by overzealous throwing programs.

Coaches need to be more accountable to their training programs and philosophies.  Both of these players are missing no less than 3 months of baseball because the coach is clueless about the impact of aggressive long toss and how it may actually be detrimental to his players as opposed to actually improving their throwing technique/performance.

Click here for an article summary in JOSPT related to throwing biomechanics

So, how do we make a positive impact and prevent unnecessary injuries like the ones I have discussed?  I feel we need to look at the following strategies:

1. Educate parents and coaches through talks and seminars
2. Network with high school athletic trainers to ensure they have some feedback/input with respect to preventive training philosophies as well as a direct pipeline to coaches
3. Reach the athletes directly through arm care screenings, FMS evals and professionally directed throwing programs
4. Team with high profile baseball players or coaches who understand the game at the highest level and will spread the message in a positive and constructive manner
5. Participate in CEU course for coaches and present on throwing programs, shoulder strengthening and mobility training

Based on these two cases, I am brainstorming ways I can become more of a “voice” in the baseball community in my area.  It is tough to convince pushy parents and misguided coaches that young kids don’t need to throw curveballs or that pitchers should probably not be forced to throw over 200 feet in hopes of increasing arm velocity.  But, we need to step up and make a difference or more young kids will be suffering from tendinitis, Little League Elbow/Shoulder, labral tears or other overuse injuries.

Click here for an abstract reference with respect injury risk and innings pitched per year

As a father, coach, educator and physical therapist, my personal mission is to make a difference in the lives of those around me. I know many may simply be unaware that there is a better or safer way.  As the emphasis on early specialization continues to grow in our country, now is the time to take action and help stop many of these injuries.

The News and Observer (our local paper here in the Triangle) recently ran a great story on overuse injuries in young athletes.  I firmly believe this is one of the fastest growing injuries I see in the clinic and in many cases it is preventable.  One of the biggest issues now is this commonplace idea that gifted athletes should play the same sport year-round to get ahead.

I remember growing up as a kid and playing football, basketball and baseball in the fall, winter and spring.  While AAU basketball and Legion ball existed, most kids were still playing multiple sports.  Over my 15 years as a physical therapist I have witnessed several of these one sport stars see their playing time and bodies take a hit due to injury.

The American Orthopedic Society for Sports Medicine (AOSSM) and the American Academy of Orthopedic Surgeons (AAOS) state that overuse injuries account for nearly half of the 2 million injuries seen among high school athletes each year.  While soccer and swimming seem to send many athletes into PT, any repetitive throwing or overhead activity bears considerable risk for an eventual shoulder or elbow problem as well.  Some of the common injuries I typically see are:

• Patellofemoral pain
• Shin splints
• Rotator cuff injury
• Bursitis
• Shoulder instability
• Little League elbow

Little League Elbow (medial epicondylar apophysitis)

These injuries are just some of the most common ones I see.  In the article, the reporter focused on baseball and throwing.  With that in mind, consider research published in the American Journal of Sports Medicine this past February from renowned surgeon James Andrews that revealed players who pitch more than 100 innings in a calendar year are 3.5 times more likely to be injured.

He goes on to say that “these injuries are the result of a system that prepares genetically gifted athletes to play at the highest levels, but eliminates most players because their bodies cannot withstand such intense activity at such an early age.”  Sadly, he told the reporter that in 1998 he performed the Tommy John procedure on 5 kids high school age or younger, while in 2008 he did the same procedure on 28 children in the same age range.  This injury is usually caused by throwing too much too soon.

Consider the following data on suggested pitch counts per game (source James Andrews, MD & Glenn Fleisig, MD):

• 8-10 y/o = 52 plus/minus 15 pitches
• 11-12 y/o = 68 plus/minus 18
• 13-14 y/o = 76 plus/minus 16
• 15-16 y/o = 91 plus/minus 16
• 17-18 y/o = 106 plus/minus 16

Unfortunately, I can personally relate to this blog post and story.  I was a promising young pitcher up until the point I threw my arm out in travel baseball at age 13.  The pain got so bad in my arm I could barely throw a ball 10 feet.  I remember the orthopedic surgeon telling me that I could not throw again the rest of the summer.  The pain (and memory of it) was so bad I elected to focus on position play and not to pitch again until my senior year of high school.  At that point, my arm was no longer the same as I had missed three years of practice and development.  Now, I too had become one of those kids whose body was never the same.

So, as a rehab and strength & conditioning professional, I want to help educate and promote better awareness to athletes, parents, coaches, trainers, AD’s, ATC’s and anyone who is involved in the care and training of young athletes.  Fortunately, people are taking positive steps to reduce overuse injuries.  One great initiative is STOP – Sports Trauma Overuse Prevention and you can learn more by clicking here to visit their website.

In the end, we must continue to educate everyone that the old motto of “No Pain, No Gain” is NOT the way to handle overuse injuries as this mentality may ruin the careers of young athletes or lead to an otherwise preventable injury and/or premature musculo-skeletal damage.  Pain truly is a warning signal the body gives us to detect mechanical problems and make changes in our training/activity level until we sort out the cause and solution.  I hope you will join me in supporting this mission and working hard at making sports fun, safe and free of overuse injuries for young athletes of all ages in the years to come.

References – The News & Observer – May 15, 2011

So, I recently blogged on platelet rich plasma (PRP).  I wanted to provide you with the latest up to date info on this procedure in regard to chronic tendinitis.  Many people suffer from lateral epicondylitis (tennis elbow).  This is a condition that affects the extensor tendons in the elbow.  Most experts link tendon injuries to hypovascularity (not enough blood flow) and repetitive micro-trauma thereby resulting in localized weakness and degeneration over time.

This may lead to eventual rupture but no one can predict that for sure.  Using PRP would hypothetically reverse the effects of chronic tendinopathy while stimulating healing at a microscopic level by initiating revascularization.  The info and data for this post was in large part taken from the American Journal of Sports Medicine (Nov. 09).

It is important to keep in mind if you are dealing with tennis elbow to understand the difference between acute injury and chronic pain.  Physiologically, healing enters the chronic phase in 22 days post injury.  However, from a clinical perspective, a physician may not consider elbow tendinitis chronic until after 3 months or more in some cases.  While PRP has shown positive results in several small case studies, the abundance of solid research is still lacking or too small to draw finite conclusions as to its efficacy.

With that said, let me share some data for people who were treated for tennis elbow with PRP:

• Mishra & Pavelko treated 20 patients out of a sample of 140 with elbow pain who met their inclusion criteria.  Of those 20, 15 were given PRP and 5 served as controls receiving only local anesthetic injections.  The PRP group noted a 60% improvement at 8 weeks, 81% at 6 months and 93% at the final follow-up (range b/w 12 and 38 months).  However, 3 of the 5 controls withdrew from the study early to seek other treatment which means the data can only be drawn from the PRP group.  Although flawed with a small group and attrition in the control group, this study was prospective and did include a control group.

What does this mean?  Well, if you have ever suffered from lateral epicondylitis or worked with those that have, you know how difficult this condition can be to resolve.  I know several people that opted for surgery to end the pain.  Conservative treatment often consists of ice, rest, stretching. strengthening and cross fiber massage.  Some use a Band-it brace and acupuncture as well.  In the end, it can be down right debilitating.

PRP may provide a better answer, but more research and larger trials are needed to confirm the overall efficacy of it.  If you are a chronic sufferer though, you may want to seek out an orthopedist who is proficient in this and take a look.  Aside from tendinitis, the effects on muscle strain, ligament tears and bone are also being studied.  High level athletes are using PRP to get back to play faster as one unpublished study with professional soccer players suffering grade II MCL injuries reports a 27% faster return to play after injury compared to controls when injected with PRP within 72 hours of the injury.

In the end, the optimal dosage and use of PRP has yet to be defined.  But it may certainly signal a new era of treatment of soft tissue injuries and speed the recovery from such injuries.