Yesterday, Yankees fans received the official confirmation that everything sucks right now when it was ruled that Masahiro Tanaka had a partially torn UCL in his pitching arm. Tanaka will be out for at least six weeks, and could be looking at potential Tommy John surgery sometime down the road. Even that mere six-week absence could be enough to torpedo the Yankees' playoff chances in 2014, even with weak AL East competition at the moment.
The one bright side to the news was that the three doctors who looked at Tanaka's MRI said that it was only a partial tear, about 10% or so. While this figure still doesn't sound very encouraging to the average person without a medical degree, it is slightly encouraging because other UCL tears are typically much worse than that. When doctors looked Ivan Nova's MRI earlier this year, they did not really hesitate to say that he needed Tommy John surgery. The Mets' Matt Harvey had a tear that was worse than Tanaka, too. Thus, the three doctors all ruled in consensus that he should receive a platelet-rich plasma (PRP) injection, and that afterward he should start a throwing program that could potentially bring him back to the mound in six weeks if all goes well. If Tanaka does not react well to the injection, then Brian Cashman said that they might have to go ahead with the Tommy John surgery.
The first reaction from most fans to UCL tears these days seems to always be "Just get the surgery done and over with" since there isn't a great track record of success with PRP. People would rather see the athletes go immediately under the knife in an effort to see the athletes back on the field as soon as possible. However, this point of view is too rudimentary and ill-informed. Not all UCL tears are created equal, so just because most previous UCL tears have led to Tommy John surgery after the arms did not take to PRP does not mean that no UCL tears will ever respond to it.
The biggest point in PRP's favor was a medical study published in the American Journal of Sports Medicine last July that offers a favorable opinion on PRP (emphasis mine):
METHODS: Thirty-four athletes with a partial-thickness UCL tear confirmed on magnetic resonance imaging were prospectively followed. All patients had failed at least 2 months of nonoperative treatment and an attempt to return to play. Baseline questionnaires, including the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) and Disabilities of the Arm, Shoulder and Hand (DASH) measures, were completed by each patient before injection. Baseline ultrasound measurement of the humeral-ulnar joint space was assessed with 10 lb of valgus stress on the elbow. Each patient received a single type 1A PRP injection at the UCL under ultrasound guidance. The same treating physician at a single institution performed all injections with the same PRP preparation used. Patients completed a course of guided physical therapy and were allowed to return to play based on their symptoms and physical examination findings. Outcome scores, including KJOC and DASH scores, were collected after return to play and were compared with baseline scores. Ultrasound measurements were collected at final follow-up and compared with preinjection values.
RESULTS: At an average follow-up of 70 weeks (range, 11-117 weeks), 30 of 34 athletes (88%) had returned to the same level of play without any complaints. The average time to return to play was 12 weeks (range, 10-15 weeks). The average KJOC score improved from 46 to 93 (P < .0001). The average DASH score improved from 21 to 1 (P < .0001). The sports module of the DASH questionnaire improved from 69 to 3 (P < .0001). Medial elbow joint space opening with valgus stress decreased from 28 to 20 mm at final follow-up (P < .0001). The difference in medial elbow joint space opening (stressed vs nonstressed) decreased from 7 to 2.5 mm at final follow-up (P < .0001). One player had persistent UCL insufficiency and underwent ligament reconstruction at 31 weeks after injection.
CONCLUSION: The results of this study indicate that PRP is an effective option to successfully treat partial UCL tears of the elbow in athletes.
The study proved that it's not a fruitless endeavor to undergo PRP therapy. If three doctors who are looking at player with millions of dollars at stake all think that Tanaka should at least try PRP, then he should go ahead and do it.
As fans who are mostly without medical degrees and definitely without access to Tanaka's MRI, we are completely unqualified to say that a player should just have Tommy John surgery and not bother with PRP. Tanaka's 2015 would be lost anyway even if he had to get Tommy John surgery six weeks from now regardless, so it really can't hurt to try to rehab it if doctors think it's possible. Cardinals ace Adam Wainwright pitched with a partially torn UCL for about five years, and Ervin Santana has had a partially torn ACL since at least early 2009. Doctors felt they could pitch for awhile despite the injuries. If there is some path of previous success with partially torn UCLs, it's at least worth exploring.
Furthermore, many fans seem to take Tommy John surgery for granted these days, too. It does not have a 100% success rate. Yes, the rate is high, but ask Daniel Hudson how easy it is to recover from Tommy John surgery. He last pitched in June of 2012 and has had two Tommy John surgeries since then in an effort to get back. He's still recovering from the second. Reliever Ryan Madson had Tommy John surgery in April 2012, and has yet to fully recover or pitch more than one inning in professional baseball. Sometimes, there are cases like the Braves' Kris Medlen and Brandon Beachy. Both players had Tommy John surgery and returned to pitch effectively for about two years, only to have their UCLs act up again. Both underwent their second Tommy John surgery this spring. Josh Johnson also had his second Tommy John surgery in three years this spring. The Yankees' own prospect Manny Banuelos had Tommy John surgery in October 2012 and he just started pitching again this year. His ERA and WHIP in Double-A Trenton so far is an ugly 5.33 and 1.382, respectively. It's just a long, difficult road back that is obfuscated by the occasional resounding successes from the likes of John Smoltz and Stephen Strasburg. Pitchers do often make it back, but their careers afterward are a mixed bag of positive and negative results.
It does seem likely that Tanaka will have to undergo Tommy John surgery, but there are so many obstacles associated with the surgery and grueling rehab that it is absolutely worth it to try and avoid it if at all possible. If three doctors all think that PRP is a route worth exploring, then Tanaka absolutely should do it. Additionally, even if it fails, it doesn't mean that it was a poor decision to try therapy in retrospect. These doctors have millions of reasons to take their decisions into careful consideration, and they are far more informed than you or me. Trust them.