Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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I have a steady flow of baseball players who come to see me for shoulder and elbow rehab. As a former pitcher whose playing career was altered by an arm injury at age 14, I have a particular interest in throwing injuries. My son is a 6’2″ left-handed pitcher that plays showcase baseball. He will be the subject matter of this post moving forward.
Many of the players I see for shoulder and elbow pain suffer from pathological GIRD (glenohumeral internal rotation deficit). While it is common to see throwers with less internal rotation on their dominant side, it is important to assess total shoulder motion to make sure their mobility is within 5 degrees of their non-dominant side. Asymmetry in total shoulder motion and shoulder flexion increase the odds of elbow injuries. Click here to see the correlation in professional pitchers. Additionally, insufficient external rotation gain on the throwing arm increases injury risk. Click here to read an abstract summarizing data within the same group of professional pitchers.
Given this information and my background, I have preached arm care for years to my son. For some background, my son has pitched since he was 9 years old. Since I have been a coach for his team in one capacity or another since he was 10, I have closely monitored and controlled his pitch counts, innings per outing and total innings per year. He has always been able to throw hard, but he had a big growth spurt in middle school and his velocity grew with that.
He now throws between 75-77 mph as a HS freshman. He is projected to be 6’5″ tall and weighs 170 pounds at this time. His showcase coach pitched in MLB, and we have two other organizational pitching instructors with big league experience who supervise his weekly bullpens. His total innings pitched for 2017 = 43. Research indicates anything over 100 significantly increases injury risk. With all that said, he has developed some medial elbow pain over the past 4 months. He has no history of arm trouble to date. My intention is for this post to serve as useful diagnostic and proactive intervention for those who may see and experience similar cases.
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.
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