What Do We Know About Ryan Braun’s Unprecedented Thumb Fix?

Last week, Ryan Braun had a cryotherapy procedure at the Kerlan-Jobe Clinic in Los Angeles to heal his injured thumb. Today was supposed to be Braun’s follow-up appointment with his physician, Dr. Vernon Williams, although I have yet to see any new reports.  The news that Braun had taken steps to correct the injury was reassuring – not only because the 2011 MVP just concluded his least productive season, but because previous reports said Braun’s surgical options were unappealing.

Cryotherapy may be a better option, but when we first heard of it all we knew was that it is a minimally invasive procedure with no track record of success for baseball players:

[Dr. Williams] inserted a needle at the base of Braun’s right thumb to essentially freeze a troublesome nerve that forced Braun to alter his mechanics, rendering him to swing, as Braun put it, “one-handed.”

“This is a technique they have done with other athletes, but not with a baseball player,” Brewers assistant general manager Gord Ash said. “So I wouldn’t call it experimental, but we are obviously breaking some new ground here.”

Asked to assess the procedure’s likelihood of success, Ash said, “I don’t think anybody can tell us that.”

So how confident can we be that our hometown hero will return to his former greatness? As concerned fans, few care more about Braun’s health than we do.  We’ve previously analyzed Braun’s healthcare options, in particular his hand specialist’s below average online ratings.  What can we learn about Braun’s new physician and the efficacy of cryotherapy?

Interestingly, the “Jobe” in Kerlan-Jobe refers to Dr. Frank Jobe, the pioneer of “Tommy John” surgery, so the clinic’s reputation precedes it.  As of this writing, Kerlan-Jobe’s Yelp score is three stars out of five based on a pretty decent sample size of 66 reviews.  While not spectacular, I tend to think online reviews skew negative since folks are more motivated to write if they had a bad experience instead of a positive one.

After a cursory analysis of the negative reviews, most of them are not about the quality of clinical care but delays caused by too many patients being scheduled in one day, and a few about the cost of services. These kinds of problems are mostly caused by the structural inefficiencies of the U.S. healthcare market, not necessary anything Kerlan-Jobe can control.  A three-star rating strikes me as pretty solid.

As for Dr. Williams himself, his clinic profile says he specializes in neurology/concussions and pain management, and apparently he makes regular media appearances.  The links indicate he’s been quoted in numerous stories about football-related concussions.  Like Braun’s other hand specialist, Dr. Williams’ Healthgrades scores are below average.  At this point, I think I’m willing to give these doctors the benefit of doubt when it comes to low online ratings.  I’m reasonably persuaded that Dr. Williams knows what he’s doing based on this recent “Inside MMA” appearance.  (Bowties are cool.)

We probably have little reason to worry about the competency of Braun’s clinical team, but what about cryotherapy itself? Try as I might, I couldn’t find a description of “cryotherapy” on the Kerlan-Jobe website.  The clinic’s Hand Nerve Injury and Repair page lists three surgical options: end-to-end approximation, grafting, and conduits.  I guess cryotherapy for nerve damage is not a procedure you just walk in off the street and ask for.

To be sure, cryotherapy is commonly used for wart removal.  It is also used to treat some types of cancer by freezing and killing abnormal cells.  Information on using cryotherapy to fix nerve damage is harder to come by.  Indeed, even a simple Google search for “cryotherapy nerve damage” is thwarted since nerve damage is a possible complication of the procedure.  It’s also way too easy to find information on cryotherapy for athletic injury pain management, but that’s mostly about using ice packs and cold compresses on sprained ankles and the like.

This MedicineNet page appears to describe how cryotherapy might have been used in Braun’s case:

What conditions can be treated with cryotherapy?

Cryotherapy can be used to treat conditions that involve irritation of an isolated nerve. In general, such conditions include benign nerve growths (neuromas) and pinched nerves (nerve entrapments). Specific examples include nerve irritation between the ribs (intercostal neuralgia), cluneal nerve entrapment, ilioinguinal neuroma, hypogastric neuromas, lateral femoral cutaneous nerve entrapment, and interdigital neuromas. Many forms of nerve entrapment can often be treated with cryotherapy.

What are the side effects of cryotherapy?

While cryotherapy can reduce unwanted nerve irritation, it sometimes can leave the tissue affected with unusual sensations, such as numbness or tingling, or with redness and irritation of the skin. These effects are generally temporary.

That’s all well and good, but as they say in healthcare, where’s the evidence in the literature?  A fairly good reference is the 2000 article “Cryosurgery for chronic injuries of the cutaneous nerve in the upper limb” that appeared in The Journal of Bone & Joint Surgery (click here for PDF in you’re so inclined).  In that study, patients were all treated for hand injuries by having a cryoprobe placed directly on the damaged nerve.  Although it was a small sample size (six patients), all rated the outcome of the procedure as good or excellent.  Certainly we would prefer a larger sample, but it’s better than nothing.

For a more recent development in the field, just last year the FDA cleared a new medical device called iovera° for direct to nerve cryotherapy.  One wonders if that’s the tool Dr. Williams used on Braun.  If you go to iovera°’s success stories page, a brief testimonial appears from former Los Angeles Dodgers pitcher Darren Dreifort.  It’s short on specifics, but I get the impression Dreifort didn’t receive treatment until after retiring.  In any case, it’s not exactly discouraging this type of cryotherapy has earned the endorsement of one former ballplayer.

Ultimately, there’s not a great deal of information on the procedure Braun underwent or whether he can return to normal function.  The little data we have is, shall we say, mildly promising.  We can probably assume Braun and the Brewers did their research before settling on cryotherapy, so he’s had access to the best treatment modern medicine has to offer.  Of course, in one hundred years from now we’ll look on modern medicine like it was the bloody dark ages.  Let’s try not to think about that.

(Image: Jacquelyn Martin/AP)