TEMPE, Ariz. – On the day he hoped would save his elbow, Garrett Richards laid face down on a table with his back exposed. A doctor guided a needle into the iliac crest of his pelvic bone and began to extract bone marrow. Richards was wide awake, the blessing of local anesthesia saving him from physical pain but not the anxiety that crept into his head: Is this really going to work?
Within a few minutes, the harvested marrow was hurried to a centrifuge, spun to separate the good stuff, mixed into a slurry of platelet-rich plasma and readied to inject into Richards’ damaged right elbow. Rather than the standard tear across his ulnar collateral ligament, Richards’ ran lengthwise along the middle of his UCL, a rare manifestation of an increasingly commonplace injury that almost always ends with Tommy John surgery. Not in this case. While he could have chosen that route, he wanted to explore first the efficacy of the aforementioned good stuff: stem cells.
Today, Garrett Richards is darting 98-mph fastballs again. “I feel as good as I ever have throwing a baseball,” he said Monday from Tempe Diablo Stadium, where the Los Angeles Angels, perhaps the most Tommy John-addled team in baseball, expect to break camp with Richards as their opening day starter. The 28-year-old is the latest player to turn to orthobiologics, the class of treatments that includes stem cells and PRP, in hopes of healing an injury. While clinical studies have shown great success with those who use orthobiologics, they are not yet a panacea for the pervasive elbow injuries in baseball for two reasons: They work only on partial ligament tears, like Richards’, and medical studies have yet to validate their efficacy independent of other treatments run concurrently.
The lack of knowledge as to how orthobiologics work inside the body – while the proteins in stem cells and platelets are believed to regrow damaged tissue, doctors have yet to isolate best practices for particular injuries – speaks to the difficulties in true medical advances. Still, the desire of Richards and others to avoid surgery lends orthobiologics enough credence to warrant further studies.
“I truly think this kind of treatment has significant potential,” said Dr. Neal ElAttrache, a longtime orthopedic surgeon at the Kerlan-Jobe clinic in Los Angeles who introduced orthobiologics to Major League Baseball when he injected PRP into the elbow of Dodgers reliever Takashi Saito in 2008. “There’s no question biologics are here to stay and biologic manipulation is the frontier of treatment in what we’re doing. The problem, as I see it, is that the marketing and clinical use has far exceeded the science behind it.”
Translation: Once the use of PRP and stem cells found traction in the media, pro athletes and weekend warriors alike sought their use, even if the success stories skewed anecdotal. Bartolo Colon resurrected his career after a stem cell injection in 2010 and is still pitching today at 43. Others did so without the fanfare or publicity. Richards faced a choice after being diagnosed with a partially torn UCL last May: Undergo Tommy John surgery and, at earliest, return following the 2017 All-Star break or follow the advice of Dr. Steve Yoon, a partner of ElAttrache’s at Kerlan-Jobe, and try to salvage the ligament with stem cells.
“Science, bro,” Richards said. “I’m a believer now.”
Two weeks before Richards began his treatment, teammate Andrew Heaney had looked to avoid Tommy John via stem cells. Richards figured they’d rehab together every step of the way and be back in time for the fall instructional league. Then at the end of June, a scan showed Heaney’s elbow wasn’t healing, and he would need reconstructive surgery. Already Tyler Skaggs had taken nearly two years to return from his 2014 surgery, and six weeks after Heaney’s, starter Nick Tropeano went down. Like Heaney, he is expected to miss the 2017 season.
It made Richards’ recovery that much more imperative. His first checkup, six weeks in, showed regrowth in the torn area via ultrasound. By August, he started throwing, and come October, when instructional league was in full bloom, so too was Richards. He didn’t hesitate to pump his fastball and rip off one of his spin-heavy breaking balls. As far as pure, raw stuff goes, few in baseball can match Richards.
He was convinced science was working, bro, though the skepticism about orthobiologics generally remains, and understandably so, in the medical community. In May 2013, a paper published in the American Journal of Sports Medicine found 30 of 34 overhand throwers with partial UCL tears who used PRP had returned to their previous level of competition. This was reason for celebration. If a player could avoid the 14-month-plus recovery from the surgery, better for him as well as the team.
Another study arrived in 2016 that didn’t cast doubt on the value of orthobiologics so much as offer a different avenue: rest. The 28 players used everything from electrical stimulation, ultrasound, laser therapy, massage and other soft-tissue work. And when paired with rest, their return to previous level came in at 84 percent. It was almost exactly as effective as PRP.
This reinforced ElAttrache’s concern: Neither of those studies had a control group against which to measure, so the numbers, while impressive, could not isolate what helped and what didn’t. This chicken-or-egg question struck ElAttrache just the same when Saito returned and went on to pitch five seasons.
“Maybe it was the injection,” ElAttrache said. “Or maybe it was that we shut him down and let him heal.”
He doesn’t know, and that’s an important distinction as orthobiologics grows exponentially. In 2004, voters in California pledged to provide $3 billion for stem-cell research and create the California Institute of Regenerative Medicine. It remains a benefactor for an industry trying to find its place in the United States.
Across the world, stem cells have far greater potency. U.S. law prevents doctors from manipulating the cells in any way. They are extracted and put back into patients’ bodies as is. In Switzerland, for example, doctors will harvest stem cells, manipulate them to promote greater healing capacity and then inject them. At least one star pitcher this offseason sought a stem cell injection in the United States, according to sources, while another veteran traveled halfway across the world to Zurich, seeking the comparative lack of regulations just as Peyton Manning did in 2011 to help heal a neck injury that eventually needed surgery.
The future of orthobiologics domestically doesn’t end with the FDA loosening rules on stem cell usage. Doctors see significant promise in stem cells from a baby’s umbilical cord or a mother’s placenta, both of which can be frozen. Already they’re capable of harvesting stem cells from old patients and engineering the cells into an immature state. The possibilities going forward are endless.
For right now, they’re going to play themselves out in Anaheim. The danger zone for re-injury after using orthobiologics tends to fall between April and June, though Richards can’t imagine falling prey again. In addition to the 13-week break from throwing he took over the summer, Richards spent 10 more weeks in the offseason letting it heal further.
During his down time, Richards studied his own delivery to find even the slightest inefficiencies. He had three numbers in mind. The first was 85. That’s the percent at which he said he’ll throw his fastball, though because of improved mechanics he expects it won’t hinder his velocity. The second is 100. That’s the pitch limit the Angels will foist on Richards, and he’s not one to fight. The third is 200. That’s the number of innings Richards wants to pitch this season. He did it in 2015 and sees no reason he can’t again.
If he can throw 85 percent, keep his pitch count below 100 and get those 200 innings, it will play publicly as another validation of orthobiologics. Just the same, if Richards’ elbow gives out eventually, his association with stem cells could perhaps give those considering it pause. Richards pays no mind to this. He just wants to be great.
So much so, in fact, that it’s going to cost him. Inside the Angels’ clubhouse, a chart, labeled 1 through 13, is taped to the side of a locker. It’s a list of shame with the price buying lunch for the entire team. Players, coaches, P.R. directors, even manager Mike Scioscia are on there. Next to No. 6, it read: “G. Rich – Ace.” He had made the mistake of saying aloud what he believed to be true: that he’s the ace of the Angels.
Fulfilling that depends on plenty of things, none as important as his elbow, and Richards knows that. He’ll do everything he can to take care of it, to nurture it, to fight against its natural gift of velocity that puts him at such risk. To make sure that next time he’s on a table in the doctor’s office, it’s not with his elbow opened up and another season lost.
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