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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 Richards, 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 August2014 -- 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."
Contributing: Gabe Lacques in Bradenton, Fla.
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