October 05, 2015 - Dr. David Chao
Monday Morning MD: Stem cells and PRP are not magic
Kiko Alonso, Victor Cruz and Breshad Perriman all were in the news for receiving the latest medical treatments. Does this mean they will be ready to go soon? Eagles star LB Alonso had surgery and stem cells were injected into his damaged ACL. Giants standout WR Cruz had PRP injected into his ailing calf muscle. Ravens first-round pick Perriman had his knee scoped for his PCL injury and stem cells were injected. Despite the cutting-edge care, don’t look for any of them to be ready in the next week or two. Neither stem cells nor PRP are quick fixes. Although both show promise, they are not yet completely proven. In addition, both processes take time to work. There may be an early anti-inflammatory effect, but true healing takes much longer. PRP typically takes 2-6 weeks to see any change. For stem cells to grow into ligaments or cartilage, it takes much longer than that.˛ Stem cells are baseline cells that can in theory grow to become new tissue like cartilage, ligaments and tendons. Platelet rich plasma (PRP) is concentrated blood that is high in platelets and growth factors. Only stem cells taken from the bone marrow or fat of the same patient may be re-injected. Blood is taken from the player, spun down and PRP is re-injected into the injured area. This is not blood doping and is permitted in sports. Only same patient procedures, where tissue or cells are not modified, are legal in the United States. Of note, these procedures are costly and not covered by standard insurances. PRP is widely used in the NFL. Some teams have a centrifuge in the training room to facilitate the injection process. I would not be surprised if it is revealed that Ben Roethlisberger had PRP for his recent MCL tear. The Steelers famously used it to treat Hines Ward and others prior to the 2009 Super Bowl. Around the league, it is widely used for muscle injuries and tendinopathies. Stem cells are less common and require an operating room as harvesting is a painful process. It is usually performed in conjunction with a surgical procedure and anesthesia. The good news is these players are doing everything they can to return to play. The bad news is if there was a tried and true procedure that worked, it would have been used already and long return timelines avoided. Stem cells and PRP show promise, but they are not magical and it still takes time. MMMD 1: Big Ben likely back sooner Despite losing to the division rival Ravens, the game provided some very positive news. The Steelers have a “no crutches” rule to be on the sideline and Big Ben was there to support his team and help with communications. Tony Romo on the Cowboys sideline with a sling indicates his clavicle is at least one month away from healing. Ben Roethlisberger sans crutches indicates he is under a month away from playing. The Pittsburgh QB was reported to have a grade 2 MCL (typically 2-4 weeks recovery) and a bone bruise. Media reported a 4-6 week or longer return, as bone bruises need time to heal. A significant bone bruise in or near a joint requires non-weight bearing status. The fact that Roethlisberger was allowed to walk around without crutches indicates the bone bruise is minor or not in a significant area. I know the quality Steelers medical staff. There is no way they would have allowed full-weight bearing if it was not safe or might delay healing. A CBS report confirms a late October return at four weeks. At this point, I wouldn’t be surprised if it were sooner with a knee brace. MMMD 2: Steve Smith breaks back It takes a lot for the Ravens star WR to exit a game. Now we know why he didn’t finish. Reports surfaced of four broken bones in his back. By video, the hit would not cause any risk to the spinal cord or nerves. It is likely a non-structural portion of the spine like the transverse processes. Tony Romo and Cam Newton had similar injuries last year and both only missed one game. Certainly it will be harder at WR to return that quickly, but the point is that Smith will be back sooner than later. Whether ribs also involved or not, the prognosis is the same. This is a very painful injury, but there is no need for surgery, no risk of paralysis and no need to wait for bone healing. It is a matter of function and pain tolerance. MMMD 3: Unfortunate injury on last play of the game No one wants to see a player injured, especially when it occurs on a meaningless last play with the team down by three touchdowns. To make matters worse, Cecil Shorts’ shoulder injury may end his season. By video, the Texans WR appeared to dislocate his left shoulder. Typically, the labrum is torn and needs surgery. Seattle safety Earl Thomas finished the season and played in the Super Bowl with a brace before offseason surgery. The brace required to keep the shoulder from re-dislocating restricts motion, which makes it very difficult to play for a WR. MMMD 4: High ankle injury spectrum Not all high ankle injuries have a player out 4-6 weeks. They tend to take longer than tradition low sprains and are very hard to support with tape or a brace, but severity varies greatly. By video Sunday, Michael Crabtree had a mild version and was able to return in the second half. Davante Adams' Week 2 high ankle had him out this week but with a chance for limited action next week. Antrel Rolle was carted off with a much more significant sprain and will miss several weeks or more depending on swelling. The most severe varieties of high ankle injuries are surgical. Bears center Will Montgomery walked off the field with his but was reported to have a fibula fracture. Rams LB Alec Ogletree will need surgery for his ligament tear/fracture. Although hope is being held out for a return later in the year, both are likely headed to season-ending IR. MMMD 5: Same injury, different affect Both Jay Cutler and DeMarco Murray played through hamstring injuries on Sunday. As expected, the lower extremity muscle strain had little effect on the strong-armed QB who led the Bears to victory with two TDs. In the 2014 playoffs, Aaron Rodgers had the arm strength to compensate for his calf strain, while Peyton Manning did not have enough to make up for his quad injury. A hamstring is much harder for a RB. Murray did break one 30-yard run but otherwise was held to six yards on seven carries. MMMD 6: Field conditions matter The NFL has experienced a lot of turf issues recently. The Rams game last week was delayed by a fireworks burn, the Texans changed their grass field to turf, the Raiders played their first two games on part of the dirt baseball diamond and the Steelers still curse the Hall of Fame game grass that may have contributed to losing Shaun Suisham (whose clutch FGs were sorely missed Thursday night) to an ACL tear. Cowboys RB Lance Dunbar simply planted to cut and his foot stuck in the Dallas turf. By video, he has a season-ending ACL and MCL tear and reports unfortunately are confirming the injury. On a slick FedEx field, four Eagles were injured during the Redskins game. Muscle injuries are more common when there is poor footing. Byron Maxwell (quad), Mychal Kendricks (hamstring), Brandon Bair (groin) and Jason Peters (quad), all left with muscle strains and did not return. MMMD 7: ProFootballDoc scorecard This week marks my two-year anniversary on twitter. The story of how I stumbled into social media has been documented. I have now written over 120 articles and give special thanks to my 30k+ followers. I have especially enjoyed the interactions with media and fans. The Cardinals announced a four-week absence for Michael Floyd after finger surgery on August 5th. I felt 6-8 weeks was more realistic. In the first three weeks of the season, he played but had only two catches for 30 yards. Now at eight weeks from injury, he doubled his season output with five receptions for 59 yards and should be back to full form. By video, Cowboys’ Lance Dunbar suffered an ACL and MCL tear, Rams’ Alec Ogletree will need high ankle surgery, Bears’ Will Montgomery broke his fibula and Texans’ Cecil Shorts dislocated his shoulder. Unfortunately, all four will likely land on IR. Steve Smith, Sr. thankfully will not have long-term issues from his back fractures. Antrel Rolle will miss time with a high ankle. Both Randall Cobb and Sam Bradford survived momentary scares to finish the game. Last week we ended with a 37-3 injury prediction record. Adding the above correct to the scorecard, makes the 2015 tally 46-3 to date. Follow David on Twitter: @profootballdoc Dr. David Chao is a former NFL head team physician with 17 years of sideline, locker and training room experience. He currently has a successful orthopedic/sports medicine practice in San Diego.