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May 13, 2011

Collateral Damage

Stemming the Tide

by Corey Dawkins and Marc Normandin

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Bartolo Colon, NYA (Stem cell therapy)
Despite the potentially life-altering benefits of stem cell research and its potential real-life applications, negative attention and fierce debate have surrounded its ethics, cost, and effectiveness. The majority of the controversy arises from the use of fetal or embryonic stem cells for research and/or transplantation into another human.

This story on Bartolo Colon and the use of stem cells raised as many eyebrows throughout baseball as it did questions about the effectiveness of Colon's procedure and the obligation of a player to accept that his career has come to an end. Because Dr. Joseph Purita—the orthopedic surgeon who treated Colon—admitted to using HGH in procedures on the general public, MLB was forced to launch an investigation into both him and his practices. He claims not to have used HGH on professional baseball players—since it's illegal, and all—and for now we'll just have to take him at his word.

Even though a large part of the focus of Colon's story elsewhere will be on the HGH part of the procedure, the real news should be the use of stem cells in sports medicine. In the world of sports medicine, embryonic and fetal stem cells are not used; instead, mesenchymal stem cells (MSCs), found in the patient's bone marrow, adipose tissue, synovium, and muscle tissues, are used.

Among the many properties of MSCs, sports medicine physicians focus on the ability of these cells to transform themselves into many different tissue types and their effectiveness in doing so. Sometimes they can transform themselves into cell types that aren't quite what the doctor ordered, but in general they tend to transform into what is needed at that particular location. Colon's injury to his rotator cuff represented a perfect scenario to use these MSCs.

Colon had a partial rotator cuff tear and ligament damage in his elbow when he met with Dr. Purita. He agreed to perform these injections, and in April of 2010, Colon began the process of returning to a major-league mound. Colon had been fighting injuries the last several years and was essentially out of baseball prior to the procedure.

One of the key reasons for Colon's near-exit from baseball was his partial rotator cuff tear. The rotator cuff tendons can't regenerate their normal tensile strength, but instead lay down scar tissue—it's better than nothing, but still mechanically weaker than the normal tendon. Tearing often happens close to the bony attachment itself in a zone where there is relatively little blood supply, and also where several different types of tissue transition to bony tissue. Rotator cuff repairs, even if the repair is done perfectly, still leave the zone of different tissues and low blood supply with scar tissue (making it mechanically weaker than the normal shoulder). This is one of the reasons why rotator cuff repairs have a higher failure rate than ACL or Tommy John surgeries.

Dr. Purita essentially inserted the MSCs into the area, allowing them to turn into all of the different types of tissue needed at that weak spot. When MSCs first began to be used for tendon healing in sports medicine, doctors would just inject the MSCs into the area. Now the MSCs are often modified with genes–one of them being MT1-MMP–or supplemented with PRP injections that act as catalysts and greatly enhance tissue regeneration versus scar tissue formation, ultimately leading to higher tensile strengths.

The population size of these treatments in elite pitchers is relatively small, but the results are highly encouraging. MSCs have been used successfully for years with AIDS and cancer patients, so at the very least we know that the treatments are safe. Ultimately, Dr. Purita may have gotten lucky with the players he has performed this on, but so far Colon looks to be a changed man.

After averaging 89.6 mph on his fastball in the previous years for which we have PITCHf/x data, Colon is averaging 92.3 mph with his four-seamer this season. His slider has more movement and a more pronounced spin, and he—well, his pitches, anyway—look closer to the Colon of old than anyone would have thought possible. It's possible that this procedure transformed Colon from the butt of many a spring training joke about the Yankees rotation into an above-average hurler—those 8.9 strikeouts per nine and a command of his pitches that he hasn't had since a season four teams and six years ago are better than any advertisement Dr. Purita could buy.

The only thing more surprising than Colon's resurgence is that fellow Yankee and even more oft-injured pitcher Mark Prior hasn't asked for a referral yet.

Kendrys Morales, LAA (Left ankle surgery)
When the Angels changed the original diagnosis from a fracture to a fracture/dislocation it certainly helped explain why Morales has been having so much difficulty in his rehabilitation. Fracture/dislocations are nasty injuries—a lot of the time, the foot is pointed the wrong way, and there ends up being severe damage to the bone and a lot of the ligaments and connective tissue in the area. A typical fracture of the ankle that requires surgery takes about three to four months to heal up, but Morales is now closing in on a year since his original surgery.

After Morales experienced continued difficulties while running, new imaging revealed the damage in his ankle: bone cysts, degenerative changes in the ankle, and extensive scar tissue. Until the surgeons go into the ankle, they won't know the full extent of the damage. Morales will have to undergo surgery on his left lower leg and ankle to remove scar tissue in hopes of salvaging as much cartilage as possible. If the damage is severe enough, he could have an even longer rehabilitation than the planned six months—and there is a chance that he'll never makes it back.

Dallas Braden, OAK (Left shoulder surgery–capsule)
Chris Young, NYN (Right shoulder surgery–capsule)
News of Chris Young's decision to undergo surgery for his re-tear of the capsule barely qualified as news, but the announcement concerning Braden came as more of a surprise. Braden will have surgery performed by Dr. David Altchek on Monday, a procedure that should end his 2011 season. This is why when an MRI is said to reveal no structural damage, you have to take the news with a grain of salt.

Johan Santana had a similar injury, and his recovery timeline called for a 10-12-month absence—you can expect the same for Braden and Young. The comps for isolated capsule tears aren't too numerous, but Chien-Ming Wang and Kelvim Escobar both underwent surgeries on their capsules within the last several years. You can see how well that went for both of them.

Flesh Wounds: Hong-Chih Kuo was placed on the 15-day disabled list with anxiety disorder, which can be truly debilitating at times... Peter Moylan will have surgery after all for his bulging/herniated disc. After going under the knife of Dr. Robert Watkins, he will be out for 12 weeks, assuming everything goes smoothly... Brian Schneider strained his left hamstring and was placed on the disabled list, just in time for Carlos Ruiz to come off of it today (if all goes according to plan)... Blake Hawksworth suffered another groin strain and was also diagnosed with right hip impingement. He is considered day-to-day and will change his workouts to avoid any painful activities from the impingement... Geovany Soto strained his left groin.

Corey Dawkins is an author of Baseball Prospectus. 
Click here to see Corey's other articles. You can contact Corey by clicking here

19 comments have been left for this article. (Click to hide comments)

BP Comment Quick Links

Greg Ioannou

Terrific explanation of Colon's treatment. Thanks!

May 13, 2011 06:30 AM
rating: 1
 
cdmyers

Thanks, I was waiting for your discussion of this treatment.

May 13, 2011 07:42 AM
rating: 1
 
Ryno23

Agreed. I just read the details of this treatment last night and was going to check today to see if you guys had written about it. Good timing!

May 13, 2011 08:48 AM
rating: 0
 
BP staff member Corey Dawkins
BP staff

Absolutely that's what we're here for

May 13, 2011 08:00 AM
 
cjgeisler
(199)

Could the same procedure used for Colon's injury also be used for Achilles tendon tears? I ask as it's an injury that seems to have a high level of reoccurence due to the weaker scar tissue as well. Thanks.

May 13, 2011 09:54 AM
rating: 1
 
BP staff member Corey Dawkins
BP staff

Absolutely. Depending on where the tear it, I.e. at the bone interface or in the middle of the tendon, different genes may be used. PRP is already having success and you could think of stem cell therapy a greater version of prp

May 13, 2011 11:12 AM
 
Lloyd Cole

Let me add my thanks for the Colon stuff. Really, really good.

May 13, 2011 10:36 AM
rating: 0
 
ramtax

The Morales thing makes me sick to my stomach. I feel so bad for the guy. What I can't believe is that I see players and teams continuing to do the same thing on walk-off home runs. Don't they learn?

May 13, 2011 11:08 AM
rating: 2
 
BP staff member Corey Dawkins
BP staff

Yeah up until Kendrys' injury, I couldn't really blame guys for doing it. I mean nothing major happened before on walk offs. After seeing what it did to him, I would be almost be walking across the plate.

May 13, 2011 12:38 PM
 
dianagram

Hmmm .... I think that explains why scoring (homers) is down. (sorry, couldn't resist)

May 13, 2011 12:41 PM
rating: 0
 
BP staff member Corey Dawkins
BP staff

yeah that was kind of a lay up for you

May 13, 2011 13:01 PM
 
Asinwreck

I am stunned you resisted an adipose joke when referring to Colon's case.

May 13, 2011 20:25 PM
rating: 1
 
Marc Normandin

Don't worry, I made one on the podcast for my Red Sox site. Don't want to recycle material like that!

May 13, 2011 23:18 PM
rating: 0
 
nemonc

Intriguing article on Colon's stem cell treatment. What I'm having a hard time understanding is whether HGH was used in conjunction with stem cells. Granted this is still experimental treatment and the evidence is anecdotal, but this brings up the question: PEDs have been used for illicit purposes by athletes, but when it's indicated in treatment of proven injuries or maladies, will professionals be resigned to second best therapies because the best therapies involve banned drugs? One example that came to mind was Neftali Perez's suspension for being on Adderal (amphetamine salts) for ADD (granted he didn't bring it before the commissioner's office, & if it was for PED purposes it didn't help in getting him to even replacement level). Is MLB's position for the foreseeable future be: TS, Neftali; deal with your ADD with some third rate therapy or not at all, or withdraw from baseball to be a normal functioning person. Another in the past were Beta-agonist inhalers for asthmatic athletes.
Granted, there are doctors with low thresholds for prescribing--witness the 'pain' clinics; medical board disciplinary lists are rife with MDs with poorly documentation & dubious indications.
Thought on this therapeutic dilemma, now & the future?

May 14, 2011 18:29 PM
rating: 1
 
BP staff member Corey Dawkins
BP staff

Many times they are used in conjunction with the stem cells.

There is a process to obtain medical waivers to use these drugs and it is the athlete's responsibility to bring them up. It's in the Joint Drug Agreement and it's called the Therapeutic Use Exemption. The NCAA and other professional sports have these waivers in place as well.

Beta-agonist inhalers can be used if it has been proven that he is asthmatic and requires the use of the inhaler. Same with other medications on the banned list.

In terms of my personal, and these are my personal opinions only, if the drugs bring the player back to normal then it should be allowed as long as it doesn't enhance other areas. So local therapies are ok such as the use of the MSCs but if the MD wanted to use HGH or others systematically (pills for instance), I don't think it's appropriate.

If they find out a way to limit the HGH to stay in that particular area, I feel that it is ok in those instances.

There are other ways to get similar results without necessarily using banned substances.

May 15, 2011 16:14 PM
 
worldtour

Maybe I'm late to the party (or missed batting practice), but what's PRP?

May 15, 2011 05:40 AM
rating: 0
 
worldtour

Oh, platelet rich plasma (second item Google returned).

Now isn't it illegal to inject yourself with your own blood in baseball? Or am I thinking of the Olympics?

May 15, 2011 05:41 AM
rating: 0
 
BP staff member Corey Dawkins
BP staff

Blood doping is illegal in the Olympics and other sports such as the Tour de France to gain an advantage of oxygen carrying capacity.

Blood doping is different from PRP. Blood doping involves removing blood and reinjecting it into the blood stream. PRP is blood spun down and then having the platelets injected locally into the damaged area.

May 15, 2011 16:17 PM
 
BrewersTT

@ramtax re Kendry Morales's injury and players modifying their behavior: a similar thing occurred in football when a player jumped in the air to celebrate and came down wrong. Players still do the same thing, though, and I think this reflects their belief that it was just a rare, fluky kind of thing. On the other hand, as you suggest, it's a pretty needless risk.

May 16, 2011 09:43 AM
rating: 0
 
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