Tommy John Surgery – The alternatives to UCL reconstruction surgery
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Tommy John Surgery – The alternatives to UCL reconstruction surgery
If you are reading this article you are likely a baseball pitcher or a parent of one who needs to explore the options for the treatment of a partially torn or ruptured ulnar collateral ligament in the elbow. You have probably spent a great deal of time researching these options. Later in this article we will present evidence for a non-surgical option for partial tears that may help you increase fastball velocity.
You have seen numerous major league baseball players undergo the surgery. Many with good success, many without good success. The great reality of your situation however is that these Major League Baseball players have a huge medical staff behind them and availability to 24/7 healing technology. This is usually not the treatment follow up that a 16 or 17 year old or mid-20s independent or low level minor league or semi-pro player gets.
How to treat a UCL injury is confusing
Despite all the advantages, many major league players did not have good success with elbow surgery. Below we will explore the research which examines why these players did not return to the level of play they wanted to after the surgery. So where does this leave you?
So you know you are not alone, let’s share some of the thoughts our patients have shared with us over the last 26 years:
- I wanted to avoid the surgery so I took time off, it didn’t help, now I am really behind and I have to get the surgery.
A baseball pitcher will often tell us that the pain on the inside of their elbow first became “annoying,” during an “easy lob” warm up. As the pain progressed, anxiety and worry was enough to get the player to the specialist. Doctors are usually not eager to go right to a surgical procedure in a young athlete because the recovery time is so long. A period or rest is usually suggested, normally a few months. If this suggestion is made during the mid-season, this is unfortunately when the player usually tries to “suck it up,” and keeps pitching and tries to make it to the off season. Likely doing more damage to the ligament.
- After a few months, the problem is still there
The ball player has now rested his elbow for a few months. A gentle program of return to throwing is given. A few sessions, go well. Then you or your son tried to throw full strength, the pain is back. In the player’s mind they spent a lot of wasted time resting.
- At this point you want to explore more urgent options.
For most parents and athletes we see, the first option explored is the: “I don’t want the surgery but don’t see any other way.”
- The choice to move onto “Tommy John Surgery,” is now predicated on whether if insurance will cover it. Or you may be exploring the “Alternative internal brace surgery.”
Complete rupture or partial tear. Understanding the difference may get you back on the field faster. Can you even pitch without a UCL?
If you have a complete rupture or “disintegration” of the UCL in your elbow, and you are going to continue to play baseball, surgery is likely the way back. However, you can pitch without a UCL.
New York Met right hander RA Dickey won the 2012 Cy Young award with a 20-6 mark and 230 K’s. He did this by perfecting his knuckleball and not having a UCL in his pitching arm. Dickey was born without a UCL in his elbow joint. This missing UCL was discovered accidentally by Texas Ranger team doctors from a TEAM USA photo.
So it is possible to pitch without a UCL. If you are a knuckleballer. The UCL however, does provide what every pitcher wants VELOCITY.
In this next segment we will discuss Tommy John surgery for complete ruptures and inner brace surgeries for partial tears. Later in this article we will discuss possible non-surgical alternatives and possibly why stem cell therapy DID NOT WORK for some high profile players and why it did.
The research on the reality of Tommy John and Inner Brace surgeries – Let’s start with Tommy John.
First let’s look at the surgery for non-pitchers
February 2018, the Journal of shoulder and elbow surgery, (1) doctors at New York University Hospital for Joint Diseases publish these observations that was reflective of the data collected on 35 Major League Baseball positional players who underwent medial ulnar collateral ligament reconstruction.
- Individual statistics for the 2 seasons immediately before injury and the 2 seasons after injury included wins above replacement (WAR), on-base plus slugging (OPS), and isolated power (ISO).
- Of the 35 athletes who underwent surgery, 7 did not return to their preinjury level of competition (return to play rate of 80%).
Look at this:
- In comparing preinjury with postinjury statistics, players exhibited a significant decrease in plate appearances, at-bats, and WAR 2 seasons after injury but did not demonstrate declines in WAR 1 season after injury
This is of significant interest to us. Season two worse than season one. How come? The UCL injury was the result of repetitive motion, i.e., throwing a baseball. After two years the player performance significantly diminished. Below we are going to show you the evidence that these surgeries, in many cases, does not succeed because other tissue was damaged
- Of all positional players, catchers undergoing surgery demonstrated lowest rates of return to play (56%) along with statistically significant decreases in home run rate, runs batted in, and ISO.
Now let’s look at the pitchers
Tommy John finished his playing career with the New York Yankees at age 46, 15 years after his legendary surgery
Is Tommy John Surgery a successful procedure. Here is the debate and an opinion from the Toronto Blue Jays
In March 2018, in the Journal of shoulder and elbow surgery, (2) Scott Peters, Major League Assistant Physical Therapist with the Toronto Blue Jays lead a study that presented findings on how successful Tommy John surgery was in getting players back to pre-injury level. The researchers of this study examined previously documented cases and found that the evidence for the surgery’s success was based on low-level and high-biased reporting.
- The evidence demonstrates overall Return-To-Sports proportion is higher than Return-To-Sports at pre-injury level. In other words, you can get back, but not as good.
- Return-To-Sports at pre-injury level outcomes were lower in professional players, particularly Minor League Baseball compared with collegiate and high school players.
- Pitching performance significantly decreased postoperatively in most studies.
These are realities you must explore in understanding the surgery.
Many in the medical community are saying those who had great success with Tommy John Surgery may owe their “coming back stronger,” “more velocity,” simply to the rehabilitation process
Pitchers who have had Tommy John Surgery and had results that may not be as successful as hoped face a new reality, multiple surgeries. Sports Illustrated ran a story in 2015 “Why 2-3 Tommy John surgeries could be new reality for some pitchers.”
Some baseball people have begun to question whether the surgery is actually bad for pitchers. In fact, many in the medical community are saying those who had great success with Tommy John Surgery may owe their “coming back stronger,” “more velocity,” simply to the rehabilitation process, these pitchers were forced to take a year or two off, it gave their pitching arms time to heal not only the surgery, but micro tears in the shoulder and wrist.
Below are some stunning statistics in regards to Tommy John Surgery. If you are reading this article as a baseball enthusiasts, please allow me to explain to the non-baseball audience this most famous and iconic of baseball related surgical procedures.
The surgical procedure is named for the iconic baseball player, then Los Angeles Dodger Tommy John. In this procedure – a surgical graft procedure – the ulnar collateral ligament is replaced with a tendon from elsewhere in the body (often from the forearm, hamstring, hip, knee, or foot of the patient). The procedure is common among collegiate and professional athletes in several sports, most notably baseball.
Why 2-3 Tommy John surgeries is not a good reality – MLB doctors look for a better way
Major League pitchers who undergo more than one Tommy John surgery have a low rate of return to MLB play and have shortened careers after return.
In a presentation lecture at the American Academy of Orthopaedic Surgeons Annual meeting 2014, presenters suggested that pitchers who returned to the Major League Baseball level maintained performance in several statistics such as earned run average and walks/hits per innings pitched; however, pitchers returned with a significantly decreased workload.(3) Study highlights:
- There have been 215 ulnar collateral reconstructions performed on Major League Baseball pitchers.
- There is a significant proportion of players (18%) who do not resume major league career.
- For those that return, a high proportion return to the disabled list, both for arm conditions (in general) and specifically for elbow pain (47% and 23%, respectively).
- Moreover, many performance statistics showed a decline following surgery, most notably in ERA, WHIP, opposing batting average, innings pitched, percentage of fastballs thrown and fastball velocity.”
In the Journal of Elbow and Shoulder surgery, the Los Angeles Doctors, Dr. Jobe, and doctors at the Hospital of Special Surgery in New York released these 2016 findings:
- Since 1999, 235 MLB pitchers have undergone Tommy John surgeries;
- 31 pitchers (13.2%) underwent revision surgery, and
- 37% underwent revision within 3 years of the index procedure.
- Twenty-six revisions had more than 2 years of follow-up;
- 17 pitchers (65.4%) returned to pitch at least 1 major league game, whereas only 11 (42.3%) returned to pitch 10 or more games.
- Of those who returned to MLB competition, the average length of recovery was 20.76 months. Compared with controls matched for age and position, MLB pitchers undergoing revision surgery had a statistically shorter career after revision surgery (4.9 vs 2.6 seasons, pitched fewer innings, and had fewer total pitches per season.(4)
Appearing in the American Journal of Orthopedics, Brandon J. Erickson, MD wrote an editorial called the The Epidemic of Tommy John Surgery: The Role of the Orthopedic Surgeon. In this editorial Dr. Erickson discussed the realities of the surgery and rehabilitation period for young athletes and compared them to Major League Baseball pitchers.
Dr. Erickson cited that major leaguers even with an endless supply of rehabilitation facilities, trainers, etc, do not return to pitching competitively and consistently in the majors for more than 15 months after UCL reconstruction. The time commitment and rehabilitation required for these patients is staggering.
This is a reality lost on the parents of these children.
As mentioned above, some parents believe this surgery will help their child throw faster, longer, and more accurately. See below we are going to discuss the role of rest and reconstructive injection techniques.
In January 2018, doctors at the Mayo Clinic and the Hospital for Special Surgery in New York published in the Current reviews in musculoskeletal medicine (5) a summary of recent findings:
- Nonoperative options for UCL injuries include guided physical therapy and biologic augmentation with platelet-rich plasma (PRP). Platelet rich Plasma is injections of your own blood platelets as a healing solution.
- In some patients, repair of the UCL has shown promising return to sport rates by using modern suture and suture anchor techniques. (There are companies who produce “surgical kits,” which help standardize the surgery and the outcomes. The modern techniques of surgery attempt to improve on the tunnels in the bone that are drilled and the screw fixation of the transplanted tendon.)
- Proximal avulsion injuries (where the ligament has pulled a chip of bone off) have shown the best results after repair.
A brief introduction to the internal brace procedure, more will be discussed below.
- Currently, there is growing interest in augmentation of UCL repair with an internal brace.
- (Note the internal brace method is intriguing in its concept especially for a Prolotherapy doctor. Here there is no reconstruction surgery but rather, the damaged ligament is repaired with suturing techniques and the wrapped in a collagen based fiber tape as the internal brace. This sounds like the Prolotherapy concept. In Prolotherapy, injections of a simple dextrose liquid instead of suture repair the ligament. The Prolotherapy injections bring reparative collagen to the area and patch, rebuild, and strengthen the ligament. Contact me via email using the form at the bottom of the page to discuss this further).
The summary conclusion of this research presents today’s reality:
- The treatment of UCL injuries involves complex decision making.
- UCL reconstruction remains the gold standard for attritional injuries and complete tears, which occur commonly in professional athletes.
- However, non-reconstructive options have shown promising results for simple avulsion or partial thickness UCL injuries.
The Tommy John Surgery Epidemic: “elbow injuries are common and usually do not require surgery”
Let’s start looking at the numbers and make some connections.
In a paper from June 2016, the title of the research presentation says it all: “Disproportionate trends in ulnar collateral ligament reconstruction: projections through 2025 and a literature review.”(6)
Here we have doctors from the New York University Hospital for Joint Diseases saying some remarkable things which confirm the research listed below.
- “Medial ulnar collateral ligament injuries of the elbow that require surgical management are uncommon. There is growing evidence, however, suggesting that the incidence of UCL reconstruction procedures is rapidly increasing.”
- In other words elbow injuries are common and usually do not require surgery. Then , the researchers ask, Why are so many (a disproportionate number) of people getting surgery? – i.e., Tommy John Surgery.
They also noted that there was disproportionate numbers for patients between 15 and 19 years old. Prime baseball years for those with professional aspiration.
Why the disproportionate number of surgeries?: Because parents believe that the surgery will allow their sons to pitch better – this thinking has been cautioned against in many research findings we will now discuss.
Researchers from Columbia University in New York published their findings suggesting that perhaps the surgery is over-performed and that patient expectations of surgery is not what the surgery does. Listen to what they said:
“Reconstruction of the elbow ulnar collateral ligament, known as Tommy John surgery, is being performed with increasing frequency. . .
- The public’s perception of Tommy John surgery may be incorrect with regard to the indications, operative technique, risks, recovery time, and benefits obtained from the procedure.”(7)
They developed a questionnaire to measure an individual’s perception of Tommy John surgery. 189 players, 15 coaches, and 31 parents completed questionnaires. Data were calculated and statistical analysis was performed.
- An incredible 30% of coaches, 37% of parents, 51% of high school athletes, and 26% of collegiate athletes believed that Tommy John surgery should be performed on players without elbow injury to enhance performance.
- Thirty-one percent of coaches, 28% of players, and 25% of parents did not believe number of pitches thrown to be a risk factor, and 38% of coaches, 29% of players, and 25% of parents did not relate pitch type (eg, curve balls) with risk of injury.
- Many players (28%) and coaches (20%) believed that performance would be enhanced beyond pre-injury level.
- Individuals underestimated the time required to return to competition. Twenty-four percent of players, 20% of coaches, and 44% of parents believed that return would occur in less than nine months.
Here is what the researchers concluded:
“This study is the first of its kind to investigate public perception of Tommy John surgery and has identified an alarming percent of players, coaches, and parents with misperceptions. Efforts should be made in our communities to better educate players, coaches, and parents regarding elbow ulnar collateral ligament injury in youth baseball players.”(7)
In other words, the perceptions of Tommy John surgery are very troubling.
The media’s role – glamorizing a surgery – spreading misconceptions
Researchers say that these misconceptions can be traced to media coverage. “The prevalence of medial ulnar collateral ligament (UCL) reconstruction is increasing in professional athletes and the delivery of baseball news by the media exerts a powerful influence on public opinion of the injury and surgery.”
These researchers then asked 516 members of the media a series of questions about the procedure.
- 45% did not know if an athlete needed an elbow injury as a prerequisite for UCL reconstruction and 25% believed the primary indication was performance enhancement.
- eighty percent recognized that pitching speed is typically reduced following surgery, but the remaining 20% felt that velocities actually increased compared with pre-injury velocities.
- Return to play: fifty-two percent overestimated the ability of pitchers to return to back to professional baseball and 51.2% believed return would occur in 12 or less months.
- Overuse injuries: less than half (48.4%) believed the use of pitch counts to be important in the prevention of UCL injury and 33.2% felt that throwing injuries were not preventable in adolescent baseball.(8)
Why would these players, parents and coaches believe this? Misconception of the surgery and how it is reported. There are studies that suggest incredible recoveries from the surgery. “Ulnar collateral ligament reconstruction with subcutaneous ulnar nerve transposition was found to be effective in correcting valgus elbow instability in the overhead athlete and allowed most athletes (83%) to return to previous or higher level of competition in less than 1 year.”(9)
How can you argue with surgical results like that? One doctor did. The doctor who invented the “Tommy John” procedure, Frank Jobe, M.D.
Dr. Jobe suggested that these results or increases in performance are generally due to two factors. The athlete’s increased awareness of training and conditioning and secondly – with increasing pitch load, pitchers velocity decreasing as the ligament becomes worn, frayed, lax. Following the procedure, and the months of down time, the procedure produces favorable results because they have a new “UCL”
The first is pitchers’ increased attention to conditioning. The second is that in many cases it can take several years for the UCL to deteriorate. Over these years the pitcher’s velocity will gradually decrease. As a result, it is likely that the procedure simply allows the pitcher to throw at the velocity he could before his UCL started to degrade.(10)
Alternative to Tommy John Surgery Repair of the Ulnar Collateral Ligament with Internal Brace Surgery.
Above we touched on briefly the concept of the Internal Brace Surgery as an option to complete UCL reconstruction. A March 2019 study in The Journal of orthopaedic and sports physical therapy (11) offers this brief explanation and benefit of the procedure.
- Historically, ulnar collateral ligament injuries have been treated with surgical reconstruction techniques, using a tendon autograft. A recently developed UCL repair procedure with an internal brace, utilizing collagen tape, is gaining popularity. The primary goal of this surgery is to enhance elbow joint stability while the ligament is healing and to allow earlier return to sport after UCL reconstruction.
In a partial tear situation, doctors are now recommending repairing the ligament, in this case with a collagen tape. The benefit of this surgery is the great reduction in surgical recovery time.
Doctors writing in the BMJ (British Medical Journal) Case Reports (12) also report on the benefit of this procedure.
- “Injury to the UCL is increasingly common and can lead to instability, especially in athletes involved in overhead throwing.
- Conventional treatment is reconstruction using tendon autograft but performance levels are often restricted after long periods of rehabilitation.
- Modern surgical techniques have led to renewed interest in repair of the ligament, with the aim of restoring native anatomy. This has the benefit of retained proprioception and no graft harvest morbidity. Furthermore, augmentation of the repair with an Internal Brace protects the healing ligament, while allowing early rehabilitation and accelerated return to play. “
Non-Surgical Alternatives to Tommy John Surgery and Internal Brace Surgery.
In our clinics we offer regenerative medicine techniques that include Prolotherapy, Platelet Rich Plasma Therapy, and Stem Cell Therapy. We typically do not offer stem cell therapy to athletes. In fact we rarely offer this treatment unless the situation of joint degeneration is significant.
Many of the patients we see, and we will estimate that 1 in 10 of our new patients have received a stem cell treatment that failed from another health care provider. Why does this treatment fail? Most times we find inappropriate use, over expectation of what the treatment can do, or simply the treatment is offered as a one shot wonder treatment. Extensive elbow ligament damage cannot be repaired with a one shot wonder treatment, realistically speaking. While some professional athletes such as Bartolo Colon reported great results and a resurrected career with stem cell treatment, other like Garret Richards did not and had to have Tommy John Surgery. In this article we will not discuss the wonders of stem cell therapy. We will discuss a realistic and simple injection technique called Prolotherapy.
The goal of Prolotherapy is to do what the internet brace surgery does but without the surgery.
In the videos below you will see Prolotherapy treatment and PRP treatment.
Prolotherapy is the use of a simple dextrose to heal a partially torn ligament. How does it work? If you are a pitcher, as your UCL starts to breakdown, you loose velocity on your fastball. As the breakdown and wear and tear continues you start feeling pain on the inside of your arm.
Fastball Velocity and ligament injury
In this section we are going to talk about velocity. First, this is how our research team explained Prolotherapy in the journal Clinical medicine insights. Arthritis and musculoskeletal disorders.(x)
Prolotherapy has been used in clinical practice for more than 80 years to treat various chronic musculoskeletal conditions. Prolotherapy is a practical and effective therapeutic strategy to treat ligament damage including partial tears and resulting looseness or laxity of the ligament.
Note: This is how you lose velocity.
- The UCL is like a strong, thick rubber band. If you can imagine a bow and arrow. If the bow has a lot of tension, the arrow flies long and strong. If the bow loses its tension, the arrow loses speed, it flies off wobbly. To get the arrow to fly right you need to put tension in the bow. To regain velocity you need to put tension back in the UCL with repair.
Note: This is how Prolotherapy may bring velocity back
Prolotherapy is a nonsurgical regenerative injection technique that introduces small amounts of an irritant solution to the site of painful and degenerated tendon insertions (entheses), joints, ligaments, and in adjacent joint spaces during several treatment sessions to promote growth of normal cells and tissues. Irritant solutions most often contain dextrose (d-glucose), a natural form of glucose normally found in the body. In severe cases, autologous cellular solutions may also be needed, such as platelet-rich plasma (PRP), bone marrow, or adipose tissue (stem cell treatments)
- “A major goal of prolotherapy in chronic musculoskeletal conditions is the stimulation of regenerative processes in the joint that will facilitate the restoration of joint stability by augmenting the tensile strength of joint stabilizing structures, such as ligaments“
The mechanism of action behind prolotherapy is not completely understood. However, current theory holds that the injected proliferant mimics the natural healing process of the body by initiating a local inflammatory cascade, which triggers the release of growth factors and collagen deposition.
In other words, the treatment tightens your ligament, braces your ligament by initiating natural collagen deposits on the ligament damage. This restores tension strength.
Using Prolotherapy and PRP injections together
- PRP treatment re-introduces your own concentrated blood platelets into your elbow.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.
In the Journal of Prolotherapy, we provided this basic definition of how PRP could help.
- In basic terms, PRP involves the application of concentrated platelets, which release growth factors to stimulate recovery in non-healing injuries. PRP causes a mass influx of growth factors, such as platelet-derived growth factor, transforming growth factor and others, which exert their effects of fibroblasts causing proliferation and thereby accelerating the regeneration of injured tissues.
- Specifically PRP enhances the fibroblastic events involved in tissue healing including chemotaxis, proliferation of cells, proteosynthesis, reparation, extra-cellular matrix deposition, and the remodeling of tissues. Bottom line here is that PRP helps the healing process
Do you have questions about your elbow pain? You can get help and information from our Caring Medical Staff.
References for this article
1 Begly JP, Guss MS, Wolfson TS, Mahure SA, Rokito AS, Jazrawi LM. Performance outcomes after medial ulnar collateral ligament reconstruction in Major League Baseball positional players. Journal of shoulder and elbow surgery. 2018 Feb 1;27(2):282-90.[Google Scholar]
2 Peters SD, Bullock GS, Goode AP, Garrigues GE, Ruch DS, Reiman MP. The success of return to sport after ulnar collateral ligament injury in baseball: a systematic review and meta-analysis. Journal of shoulder and elbow surgery. 2018 Mar 1;27(3):561-71.
3 Makhni EC. Lee R, Morrow Z, Gualtieri A, Ahmad CS. Performance Metrics Before and After Tommy John Surgery in 160 Professional Pitchers AAOS Presentation Abstract
4 Liu JN, Garcia GH, Conte S, ElAttrache N, Altchek DW, Dines JS. Outcomes in revision Tommy John surgery in Major League Baseball pitchers. J Shoulder Elbow Surg. 2016 Jan;25(1):90-7. doi: 10.1016/j.jse.2015.08.040. [Google Scholar]
5 Clark NJ, Desai VS, Dines JD, Morrey ME, Camp CL. Nonreconstruction Options for Treating Medial Ulnar Collateral Ligament Injuries of the Elbow in Overhead Athletes. Current reviews in musculoskeletal medicine. 2018 Jan 15:1-7. [Google Scholar]
6 Mahure SA, Mollon B, Shamah SD, Kwon YW, Rokito AS. Disproportionate trends in ulnar collateral ligament reconstruction: projections through 2025 and a literature review. J Shoulder Elbow Surg. 2016 Jun;25(6):1005-12. [Google Scholar]
7. Ahmad CS, Grantham WJ, Greiwe RM. Public perceptions of Tommy John surgery. Phys Sportsmed. 2012 May;40(2):64-72. [Google Scholar]
8. Conte SA, Hodgins JL, ElAttrache NS, Patterson-Flynn N, Ahmad CS. Media perceptions of Tommy John surgery. Phys Sportsmed. 2015 Nov;43(4):375-80. [Google Scholar]
9. Cain EL Jr, Andrews JR, Dugas JR, Wilk KE, McMichael CS, et al.Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: Results in 743 athletes with minimum 2-year follow-up. Am J Sports Med. 2010 Dec;38(12):2426-34. Epub 2010 Oct 7. [Google Scholar]
10. Keri, Jonah (2007-09-13). “Interview With Dr. Frank Jobe“. ESPN.com.
11 Wilk KE, Arrigo CA, Bagwell MS, Rothermich MA, Dugas JR. Repair of the Ulnar Collateral Ligament of the Elbow: Rehabilitation Following Internal Brace Surgery. Journal of Orthopaedic & Sports Physical Therapy. 2019 Mar 12(0):1-9. [Google Scholar]
12 Wilson WT, Hopper GP, Byrne PA, MacKay GM. Repair of the ulnar collateral ligament of the elbow with internal brace augmentation: a 5-year follow-up. BMJ Case Reports CP. 2018 Dec 1;11(1):e227113. [Google Scholar]
13 Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A systematic review of dextrose prolotherapy for chronic musculoskeletal pain. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2016 Jan;9:CMAMD-S39160. [Google Scholar]
14 Ross Hauser, MD, Hauser M. Platelet Rich Plasma (PRP) injection technique. Journal of Prolotherapy. 2009;1(3):184.