Stem cells could make cru­cial save

An­gels pitcher skipped surgery for new ther­apy

USA TODAY US Edition - - SPORTS - Jorge L. Or­tiz @jorgelor­tiz Con­tribut­ing: Gabe Lac­ques in Braden­ton, Fla.

TEMPE, ARIZ . Gar­rett Richards’ first thought when he found out about his torn el­bow lig­a­ment in May was to sched­ule Tommy John surgery as soon as pos­si­ble.

It made sense, con­sid­er­ing the lig­a­ment-re­place­ment pro­ce­dure has be­come the stan­dard fix for such in­juries. Plus, the Los An­ge­les An­gels ace was fa­mil­iar with the op­er­at­ing room, hav­ing had surgery for a rup­tured patel­lar ten­don he suf­fered on Aug. 20, 2014, to­ward the end of a break­out sea­son.

Richards knew how to han­dle the seem­ingly in­ter­minable months of re­hab, and he wanted to get the clock started on his re­turn.

But a con­ver­sa­tion with An­gels head phys­i­cal ther­a­pist Bernard Li con­vinced Richards to con­sider other al­ter­na­tives, and in mid-May he tried a rel­a­tively novel treat­ment in which stem cells taken from bone mar­row in his pelvis were in­jected into the dam­aged area.

Richards did not pitch again the rest of the year ex­cept for a stint in the in­struc­tional league, but he has been back on the mound throw­ing bullpen ses­sions since the first day of An­gels camp and re­ported no prob­lems.

This week­end, Richards an­tic­i­pates pitch­ing in a game for the first time since May 1, when his aching el­bow forced him from a start af­ter four in­nings.

“It’s nice to know I’ll be able to start the sea­son this year and kind of pick up where I left off,” Richards said.

A cou­ple of lock­ers away, fel­low starter An­drew Heaney had a dif­fer­ent tale to tell.

The promis­ing left-han­der also went down with a torn ul­nar col­lat­eral lig­a­ment early in the sea­son, af­ter mak­ing one start. Their ail­ments were the two big­gest blows to an An­gels ro­ta­tion that was dec­i­mated by in­juries, doom­ing the club to a 74-88 record and a fourth-place fin­ish in the AL West.

Heaney also tried stem cell ther­apy, two weeks be­fore Rich- ards, both un­der the su­per­vi­sion of team doc­tor Steve Yoon. Heaney’s lig­a­ment didn’t heal, though, and af­ter ex­pe­ri­enc­ing dis­com­fort throw­ing af­ter his re­hab, he had Tommy John surgery July 1. He has been ruled out for the 2017 sea­son.

“They tell you it’s 50-50. It ei­ther works, or it doesn’t,” Heaney said of the stem cell pro­ce­dure. “Ob­vi­ously, me and Gar­rett are pretty much the proof of that rule.”

Even with less-fa­vor­able odds than re­con­struc­tive surgery, which has an 80% suc­cess rate for re­turn­ing to ac­tion and 67% for pitch­ing 10 games or more, stem cell ther­apy is gain­ing ac­cep­tance as an op­tion for pitch­ers with par­tial UCL tears. The re­cov­ery time is shorter — three to five months in­stead of 12 to 18 — and the treat­ment less in­va­sive.

There are lim­i­ta­tions. Bi­o­log­i­cal ap­proaches based on stem cells or platelet-rich plasma (PRP) won’t re­pair a com­plete tear of the lig­a­ment. The lo­ca­tion of the in­jury and its ex­tent fac­tor into the chances of suc­cess. And play­ers whose lig­a­ments don’t re­cover, then have to have surgery, ex­tend­ing their win­dow of time for re­turn­ing to ac­tion.

Even then, the idea of heal­ing with­out go­ing un­der the knife is be­com­ing in­creas­ingly ap­peal­ing. New York Yan­kees ace Masahiro Tanaka treated the small tear in his el­bow lig­a­ment with PRP and re­ha­bil­i­ta­tion in 2014, sit­ting out 10 weeks but coming back to pitch in late Septem­ber.

He’s 26-11 with a 3.26 ERA over the last two sea­sons, rais­ing the pro­file of PRP — a pro­ce­dure in which the player’s own blood is used to pro­mote heal­ing of the in­jury — as a non-sur­gi­cal al­ter­na­tive.

Now Richards looms as the test case for stem cell treat­ment to fix par­tial UCL tears, which make up about 60-70% of th­ese in­juries. If the hard-throw­ing right-han­der can re­turn to his old form — he was a Cy Young Award can­di­date be­fore his knee in­jury in Au­gust 2014 — other pitch­ers in his sit­u­a­tion are bound to at least con­sider the route he took.

“I hope this opens an­other path for guys,” Richards said. “Ob­vi­ously, if you can pre­vent be­ing cut on and hav­ing surgery, that’s the No. 1 pri­or­ity. I hope guys don’t just jump right into Tommy John, that they at least ex­plore this op­tion.”

Age­less vet­eran Bar­tolo Colon was the first pitcher widely known to have un­der­gone stem cell ther­apy as he sought to re­cover from el­bow and shoul­der ail­ments in 2010. At the time, the ethics of the pro­ce­dure were ques­tioned, es­pe­cially be­cause the doc­tor who per­formed it, South Florida-based Joseph Pu­rita, ac­knowl­edged us­ing hu­man growth hor­mone in previous treat­ments, though not in Colon’s.

Since then, the use of stem cells has be­come more main­stream. They are the fo­cus of Yoon’s prac­tice.

“As more and more peo­ple start to use it, you’re get­ting a bet­ter sense for what it can and can’t do,” Yoon said. “Base­ball def­i­nitely has opened up to it quite a bit, and as we see some of the suc­cesses like with Gar­rett, we’re get­ting a bet­ter un­der­stand­ing that there’s a lot of po­ten­tial here with th­ese types of treat­ment.”

Yoon calls stem cell ther­apy a “su­per PRP” be­cause it com­bines the cu­ra­tive prop­er­ties of that treat­ment with more heal­ing agents and says it can be used on ten­don tears, mus­cle tears and strains and even to ad­dress de­gen­er­a­tive joint dis­ease.

How­ever, much re­mains un­known about the ben­e­fits of stem cells. Lyle Cain, an or­tho­pe­dist who has per­formed Tommy John surg­eries and stem cell treat­ments at the An­drews Sports Medicine & Or­thopaedic Cen­ter in Birm­ing­ham, Ala., said most of the re­search has been anec­do­tal, not sci­en­tific.

“We still don’t have a good un­der­stand­ing even four or five years into it ex­actly what the stem cells do, what their method is,” Cain said. “The the­ory is there’s prob­a­bly a chem­i­cal re­ac­tion where it re­leases chem­i­cals in the cell that help the heal­ing process.

“The stem cells aren’t nec­es­sar­ily put in there with the thought they’re go­ing to be­come lig­a­ment, but there’s prob­a­bly a cel­lu­lar chem­i­cal mech­a­nism that helps the heal­ing re­sponse.”

And as Heaney dis­cov­ered, they’re not al­ways ef­fec­tive. His tear was lo­cated far­ther down the arm, which re­duced his chances of suc­cess with stem cell ther­apy. Richards was a bet­ter can­di­date be­cause his in­jury, though deemed “high grade,” was lo­cated within the lig­a­ment, like a slit on a rub­ber band.

But be­cause Heaney was look­ing at likely miss­ing most or all of 2017 even if he had surgery right away, he de­cided to try stem cells. The tim­ing of the in­jury plays a ma­jor role in whether pitch­ers con­tem­plate al­ter­na­tives to surgery, with the more con­ser­va­tive ap­proach often rec­om­mended if it hap­pens early in the sea­son.

Heaney said he doesn’t re­gret tak­ing that route and would have been up­set if he had un­der­gone the lig­a­ment-re­place­ment op­er­a­tion right away, only to find out he could have re­turned to ac­tion quicker through an­other means.

“I’m glad it worked for him,” he said of Richards. “It would have been re­ally aw­ful if it hadn’t worked for ei­ther of us. Then we’d both look like idiots.”

Their peers are pay­ing at­ten­tion. In a ma­jor league pitch­ing com­mu­nity where about a quar­ter of its mem­bers have had Tommy John surgery, in­ter­est in the ef­fec­tive­ness of al­ter­na­tive cures is high.

The Los An­ge­les Dodgers’ Bran­don McCarthy was not a can­di­date be­cause his lig­a­ment tore clear off the bone but said he had heard pos­i­tive re­ports about stem cell treat­ment, not so much about PRP.

The Pitts­burgh Pi­rates’ Daniel Hud­son, a vet­eran of two Tommy Johns, is en­cour­aged as well.

“It’s sup­posed to help re­pair the tis­sue. Be­fore, lig­a­ments just won’t re­pair them­selves,” Hud­son said. “It might keep a lot of guys from go­ing un­der the knife.”

That’s Cain’s hope. He reg­u­larly treats UCL tears on high school, col­lege and mi­nor league play­ers with stem cells or PRP, but re­al­izes there’s height­ened pres­sure on ma­jor lea­guers to re­turn to the field.

If more of them can do it with­out vis­it­ing an op­er­at­ing room, it would rep­re­sent a ma­jor ad­vance­ment for the play­ers and the in­dus­try.

“There will be cer­tain lig­a­ments that are dam­aged enough that we don’t have an an­swer; they have to re­con­struct,” Cain says. “But I think over­all, if you look 15 years down the road, I sus­pect we’ll be do­ing a lot more non-sur­gi­cal treat­ment than sur­gi­cal treat­ment.”


Gar­rett Richards has been throw­ing bullpen ses­sions since the first day of the An­gels camp and re­ported no prob­lems.

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