Pondering the implications of Saito’s surgery

Fan Confidence Poll: April 6th, 2009
Projecting the league community style

When the Traveling A-Rod Circus makes its way up to Boston this year for the first time, the Yanks’ third baseman is sure to be greeted with a louder-than-usual chorus of Bronx cheers. Not one to engender much love in the Hub, A-Rod and his off-season steroid revelations simply give the Fenway Faithful more ammunition. I have to wonder though if this isn’t some huge act of hypocrisy perpetrated by baseball fans throughout the nation.

Yesterday, as I was procrastinating work on an appellate brief browsing my usual baseball sites, I came across an article on Takashi Saito from the Oct. 3, 2008 edition of the Los Angeles Times. Saito, now the Red Sox set-up man was with the Dodgers at the time, and the article is about a medically groundbreaking procedure Saito received last July when he suffered what should have been a season-ending tear of his elbow’s ulnar collateral ligament.

Generally such an injury leads to Tommy John surgery, but in Saito’s case, it led to an injection of a medicine designed to greatly enhance his body’s natural healing process. That almost sounds like Human Growth Hormone, but it’s not. Here’s how the LA paper described the process:

Saito credited his unlikely recovery from a partially torn ulnar collateral ligament in his elbow that he suffered in July to a cutting-edge medical procedure, which, to his knowledge, had never been tried on a major league pitcher. To this day, team physician Dr. Neal ElAttrache can’t definitively say that injecting platelet-rich plasma into Saito’s elbow is what allowed him to avoid Tommy John surgery. ElAttrache also won’t guarantee how long the elbow will hold up or that Saito won’t have to have surgery in the future…

Trainer Stan Conte said he estimated that Saito had a 20% chance of pitching again this season and told management not to count on him being back. So when ElAttrache offered using PRP as an option, Conte was open to the idea.

Within a week of hurting his elbow, Saito had blood drawn and spun to isolate the platelets, which clot and promote healing. The platelets, 10 times more concentrated than in normal blood, were injected into the site of the tear in the elbow. ElAttrache said he used PRP in the past to repair tendons, but never ligaments.

So what’s the difference? Medically, Saito’s doctor took something found naturally in his body — platelets — concentrated them into a super-high dosage and then reinjected the platelets into the site of Saito’s injury. When a baseball player injects himself with a steroid, as far as my medical knowledge goes, he is basically doing the same thing. He takes a super-high dosage of testosterone, something found naturally in the body, or a synthetic substance and injecting into his body to promote quick healing and an unnatural edge.

Of course, what Saito did doesn’t run afoul of medical ethics, U.S. law or baseball rules. So the Red Sox fans will cheer him — or ignore him — as he contributes during the season, and A-Rod who went looking down illegal paths for that edge will get booed. It’s quite the conflict in baseball’s PED policy. How and where do you draw the line between acceptable forms of over-medicating?

Fan Confidence Poll: April 6th, 2009
Projecting the league community style
  • Marc

    Well I guess the main question is did MLB have rules against this procedure that Saito had. I get where your going with this, but PED’s use is against the rules in baseball. But is this procedure against any rules MLB has?

    • whozat

      Um…there was no specific rule against what ARod took at the time, was there? It falls under the blanket “no PEDs” clause, if anything. How is this any different?

      • radnom

        It was administered legally by a doctor. You can get HGH legally, the rule is against illegal PEDs, there is nothing stopping you from getting an accepted medication if you actually need it. I don’t get why people don’t understand this.

      • Ed

        Um…there was no specific rule against what ARod took at the time, was there?

        Yes there was.

        How is this any different?

        Steroid use/possession is a felony. This procedure is allowed by the FDA.

        • steve (different one)

          right, i think by mentioning A-Rod (and a Red Sox), we are taking the discussion off its intended course. or maybe not the intended course, but the more interesting course at least.

          the question is where do you draw that line?

          what about Lasik? what about TJS? what about the sudden preponderance of professional athletes taking prescription drugs for ADD (no idea if this is legit or not, just asking the question)?

          steroids (and A-Rod) are clearly on the “wrong side” of the line. where does this fall?

          • whozat

            “the question is where do you draw that line?”

            Yes, this is much more what I was getting at. Steroids are hormones that occur naturally in our body. If ARod had had this still centrifuged out of his own blood and concentrated for later reinjection, would that make you feel different about it? Why?

            • http://pinstripealley.com Edwantsacracker

              The procedure sounds very similar to blood doping that cyclists often do. Spinning down your blood and injecting extra red blood cells, so that your body can use oxygen more efficiently.

              I guess the line is that it was done by a doctor. But then again, Andy claimed that he only used HGH when he was injured and trying to get back. He was wrong in doing that. But if he went to his doctor and his doctor prescribed him HGH to help heal the injury would it have been ok? I think so.

              I think the wrongness comes from the fact that these guys are doing it themselves, and they are buying it illegally, and they are sneaking around doing it. Nady has nothing to be ashamed of so he told everyone.

          • Ed

            what about Lasik?

            The net effect isn’t any different than glasses or contact lenses. It’s just fixing your vision to its natural levels. It’s certainly safer than having players wear glasses.

            what about TJS?

            It’s just fixing an injury. The supposed velocity increase from the surgery is explained by two things:

            1) Pitchers gradually lose velocity as their ligament is tearing. The ligament tear usually isn’t an instantaneous event, it builds over time, gradually worsening until the player reaches his pain limit and can’t continue.

            2) Players not of the Pavano mold usually work pretty hard in their rehab and often finish it in better shape than they were before the surgery.

            what about the sudden preponderance of professional athletes taking prescription drugs for ADD (no idea if this is legit or not, just asking the question)?

            That is a legit question. But I think it’s an issue with society in general, not just athletes.

            • steve (different one)

              The net effect isn’t any different than glasses or contact lenses.

              Lasik can correct your vision past the point of contacts. i’ve had it done. wearing contacts that would correct my vision to the same level would give me a massive headache.

              • http://twitter.com/tsjc68 tommiesmithjohncarlos a/k/a Ridiculous Upside

                True.

                Lasik surgery has advanced to the point that it’s possible to give Lasik patients vision better than possible with any other type of corrective lens and better than the majority of society.

                Lasik doesn’t require a prescription and steroids do. Other than that, they’re ethically similar. In both medicine and in sports.

    • Jack

      I think Ben is trying to ask why it isn’t against the rules.

      • andrew

        Yea, he is. I’m currently taking a class on the ethics of human enhancement, and almost every single one of the highly regarded philosophical minds who have written on the topic of steroids have concluded that the only thing distinguishing steroids from being accepted is due to the law. Steroids, in essence, are no different than any other enhancement. Lasik was mentioned earlier, but there are also other advantages that athletes have such as training at higher altitudes or being naturally born with high red blood cell counts or greater lung capacity. Taking steroids can be dangerous if used improperly, but so is Tylenol, driving your car, or going for a swim.

    • rbizzler

      It is not really a question, per se, but more of a statement on the PED rules in baseball being somewhat arbitrary. These same rules are put in place, in part, because of public opinion that is ill-informed about the specifics of the individual substances that players are using to gain an advantage.

      Ben is not railing against the procedure, but pointing out that it certainly falls into a grey area.

      • whozat

        Yeah, it’s like cyclists who pull out some blood, have it hyper oxygenated, and then reinject it later to boost stamina.

        • http://twitter.com/tsjc68 tommiesmithjohncarlos a/k/a Ridiculous Upside

          And it’s interesting that you bring up blood doping, because in terms of medical science, blood doping and platelet rich plasma are very, very similar procedures (extract blood, centrifuge it, put blood back into the body), but blood doping (since it’s been around longer) is banned by WADA and the IOC. And baseball derives its steroid policy ethics from the examples of those international sporting bodies.

          It’s a very thin hair to split to say that extracting and enriching an athlete’s own bodily fluids is okay for shortening healing time and recovering strength but not okay for improving athletic stamina and strength, IMO.

  • CountryClub

    Hines Ward had the same thing done to his knee in between the AFC championship game and the Super Bowl. He had a sprained knee. Surgery was never going to be needed, but the injection helped the healing process. He was on the field in two weeks when it normally take 3 – 5.

  • jonathan

    This is the Gray Area of Sports Medicine, because platelets when activated secrete among other things Platelet Derived Growth Factor (PDGF). This Growth factor promotes recovery and repair, blood flow to the area and regeneration. I wonder if it would be ok to inject yourself with cells that produce HGH?

    • http://twitter.com/tsjc68 tommiesmithjohncarlos a/k/a Ridiculous Upside

      Again, the growth factors in HgH and those created in the PRP procedure (PDGF and IGF-1) are very similar. So, if HgH is banned, I can’t see a compelling reason to not ban PDGF and IGF-1 as well, which would ban the PRP procedure.

  • Ed

    Well, I say take HGH out of the discussion because it doesn’t actually do anything. HGH as a PED is just snake oil.

    Steroids push the body past its normal checks and balances, forcing it to create muscles it doesn’t want to make, throwing all sorts of things out of whack in the process. You’re messing with your body, which prolonged use shows pretty clearly isn’t a good idea.

    Stuff like this procedure are just boosting your natural healing process – the end result is the same thing your body would do naturally, just a little faster. You’re not coming out of it any better than you were pre-injury.

    • Moshe Mandel

      Doesn’t HGH do the same thing? (I dont know, but that was my impression).

      • steve (different one)

        so HGH does nothing at all?

        • Ed

          Nope, all medical evidence so far shows that it does nothing beneficial in people who have normal HGH levels. It can actually have negative effects such enlarged breasts in men and joint problems.

        • mtt

          http://www.annals.org/cgi/content/full/148/10/747
          It looks like the supposed benefits of HGH for athletic performance are hype, although this doesn’t mention anything about enhanced recovery.

          • Chris

            Except that the supposed benefits of HGH are in healing after an injury. That was not included in any of these studies (and I haven’t seen any studies that do include it).

    • http://twitter.com/tsjc68 tommiesmithjohncarlos a/k/a Ridiculous Upside

      So then, you’d say keep anabolic steroids and testosterone doping illegal, but legalize HgH and make the PRP procedure explicitly allowable?

      Isn’t part of the rationale for making steroids illegal the fact that they have long-term health detriments? By allowing the PRP procedure, and thus, decriminalizing HgH, aren’t you increasing the health risk to baseball players who will now needlessly jeopardize their health taking the HgH snake oil?

      Aren’t you jeapordizing the health of minor leaguers and amateurs who will start using HgH with greater frequency now that it’s legitimized?

      • Ed

        So then, you’d say keep anabolic steroids and testosterone doping illegal, but legalize HgH and make the PRP procedure explicitly allowable?

        That’s not at all what I said. I wanted to ignore HGH in this discussion here, because the perception of it and the reality of it don’t match, so it would just make the discussion more confusing.

        Both HGH and the PRP procedure should go through normal FDA rules. There’s no reason for HGH to fall under the extra scrutiny of PEDs. HGH should be treated just like any other drug – if you have a prescription, it’s legal, if not, it’s not. Treat it no differently than you would treat someone taking Vicodin or Valium without a prescription.

        The PRP is a medical procedure. Treat it like any other medical treatment. If the FDA is ok with it, there’s no reason not to allow it.

  • YanksFan

    Hines Ward had the same exact thing done for his knee this past year so that he could play in the Superbowl.

  • http://www.onedayonejob.com/ Willy

    We also hear about players’ getting cortisone shots all the time. That’s a steroid, but apparently it’s an ok steroid under MLB’s rules.

    We could even say that Tommy John surgery is a PES (Performance Enhancing Surgery). The same can be said for Lasik surgery.

    We want our players to have the best medical care so that they can stay healthy, but it’s very hard to determine at what point are they getting an unfair advantage. Almost all medical procedures and drugs come with risks, so you can’t say that these things are harmless compared to anabolic steroids or HGH.

    Even legality as a standard creates haziness, because a player could travel abroad to somewhere that these drugs, surgeries, or other interventions are allowed.

    I think that the goal of an anti-drug policy is to ensure that players aren’t forced to do things that they don’t want to do to keep up with the competition. Then again, who really wants to lift weights? It’s really hard to justify any standard, because there doesn’t seem to be a clear line here at all.

    • MattG

      Well said. This is what I was trying to write at the same time as you, but I think you said it better.

    • mtt

      While cortisone is a steroid, it’s effects on the body are well understood. Cortisone is injected because it suppresses the immune reaction that causes inflammation. It has no other “performance enhancing” capabilities. That’s why it’s allowable by MLB.

      • Chris

        The effects of testosterone on the body are well understood also. Just because it acts in a different way doesn’t necessarily make it better or worse.

        • mtt

          I would argue that, in fact, it does make cortisone better from a baseball stand point.

          • mtt

            Specifically, cortisone has a well documented medical use that is difficult to construe as performance enhancing. Though it is chemically a steroid, arguing that “cortisone is a steroid, too” is a straw man argument. I’d argue that it’s use is much more in line with other, non-steroidal anti-inflammatories.

            • http://www.onedayonejob.com/ Willy

              I’m not saying that cortisone is on the same level as an anabolic steroid, I’m just saying that is also a “steroid” that enhances performance. Cortisone can have serious side effects, but it seems to be much safer than those that increase testosterone. Still, players are put into a prisoner’s dilemma of choosing whether or not to get a cortisone injection.

              Caffeine and aspirin are also performance enhancing drugs. Should we ban them? Probably not.

              There’s a long continuum of performance enhancers, and we do need to draw the line somewhere, but as medical and pharmaceutical technology get better and better, it will become much more difficult to determine what we as fans are ok with and what crosses the line.

              We usually frame this problem in terms of the players’ health. We don’t want them to be forced to do something that puts their health at risk because other players are getting an unfair advantage (or because the player wants to be the first to get the unfair advantage).

              But what will we do when we come up with medical treatments that have no side effects. Maybe it won’t happen, but if a player could be made 20% stronger with no risk to his health, would we want him to pop the pill? Or would we want our athletes to continue to be “like us,” which they really aren’t anyway?

  • Reggie C.

    Arent platelets and RBCs created in healthy bone marrow? Doesn’t that make this platelet therapy fundamentally different from endocrinological solutions (HGH and testoterone-boosted ‘roids)?

  • MattG

    The longer you look, the more examples you will find that make it really hard to understand the media perception of steroids. Stories like this just reaffirm what is the actual truth, albeit totally disregarded: the line between acceptable drugs and medical procedures is totally arbitrary.

    All arguments to the contrary are rationalization. “Steroids make the body do unnatural things.” So does laser eye surgery. So does TJ surgery. “Steroids are against the law.” So are amphetamines. So is ritalin, when ADD is purposely mis-diagnosed.

    Curt Shilling was permitted to have a surgical procedure for the purpose of pitching in one game, to his obvious detriment long-term. How much longer until high schoolers with 86 MPH fastballs start faking elbow pain, and finding doctors who will give them tighter elbow tendons?

    • Matt P

      The idea that Tommy John surgery makes people throw harder is a misconception. It actually doesn’t. The reason people throw harder after the surgery is due to three things: 1.) they were most likely injured before the need for surgery so their velocity was already down 2.) the rehab forces the pitcher to focus on strengthening their arm 3.) often a refocus on mechanics will clean up anything that they had been previously doing.

      • MattG

        That is interesting, but the idea that steroids make baseball players better might be a misconception as well. People just need to believe it is true for it to be dangerous.

      • whozat

        Ok, it doesn’t make people throw harder…however, it does take a pitcher who could not pitch anymore and make him able to pitch again. If anything that’s MORE extreme than taking HGH to heal faster. Why is it different? Because one comes in a syringe?

        • mtt

          Are you arguing that HGH should be allowed or that TJ surgery should be banned?

          • MattG

            I am arguing there should be no media outrage due to steroids. Athletes want to be great. There are no clear lines, and the outrage does not advance the conversation.

            • mtt

              My reply was meant for whozat.

      • Jake H

        Also that ligament is stronger because it doesn’t have the wear and tear.

    • Ed

      All arguments to the contrary are rationalization. “Steroids make the body do unnatural things.” So does laser eye surgery. So does TJ surgery. “Steroids are against the law.” So are amphetamines. So is ritalin, when ADD is purposely mis-diagnosed.

      Tommy John surgery is repairing an injury. You come out of it the same way you were pre-injury.

      Lasik is fixing flaws in your eye to bring it back to the level it should have been. You’re fixing degradation here.

      Steroids are actively fighting your body’s hormone balance, causing things to grow out of their normal proportions. You’re forcing your muscles to grow to sizes the body is naturally trying to prevent. It’s a big difference.

      • steve (different one)

        Tommy John surgery is repairing an injury. You come out of it the same way you were pre-injury

        but can’t they take the ligament and wrap it in a way that makes it stronger than before?

        i get the points about rehab and mechanics, but i don’t agree that it’s 100% myth that a TJS repaired elbow can’t be stronger than what occurs naturally.

        • mtt

          Well, I’m not a doctor, but I’m not sure that a tighter ligament necessarily leads to throwing harder. Also, the reason the rehab is so intensive is because there is no nerve feedback from the new ligament so a pitcher has to retrain his arm to throw without bio-feedback from the UCL ligament, which seems to me to be a major disadvantage.
          On the other hand, there seems to be a very low incidence of multiple TJ surgeries, so perhaps there is increased durability.

        • Ed

          but can’t they take the ligament and wrap it in a way that makes it stronger than before?

          Well, to attach it, you have to drill holes in the bones and weave the ligament through. The holes weaken the joint, and any stretching of a ligament past its normal limit weakens it. It would be pretty unlikely to come out of the procedure with a stronger than normal ligament. I wouldn’t be surprised if someone eventually came up with a synthetic ligament that was stronger (or maybe a cross-species transplant?), but with the current procedure it’s highly unlikely.

          i get the points about rehab and mechanics, but i don’t agree that it’s 100% myth that a TJS repaired elbow can’t be stronger than what occurs naturally.

          Well, Frank Jobe and James Andrews feel pretty strongly that it’s not possible. They’ve reiterated these points over and over, so I defer to their judgment.

          • Chris

            TJS actually replaces the ligament with a tendon. My understanding is that tendons are stronger than ligaments, so you’re fundamentally improving the strength of the joint.

          • steve (different one)

            ok, that was a super sloppy sentence on my part. you are right.

            but this is where the fundamental issue lies:

            define “pre-injury”, define “naturally”.

            Jobe has said that if your UCL is naturally weakening over the 5 year period before your surgery and your velocity is gradually decreasing because of that, the surgery can take you back to where you were before that 5 years of wear and tear.

            and that is a HUGE grey area, IMO.

            sure, it might just be taking you back “pre-injury”, but it’s also taking you back PRE-PRE-INJURY.

            if you threw 95 at age 22 gradually decreasing to 90 at age 27 before you needed the surgery, but then you could throw 95 again post-surgery…is it legitimate to say the “surgery made you throw harder than before?”

            that’s the grey area. i think you can argue it both ways.

      • http://twitter.com/tsjc68 tommiesmithjohncarlos a/k/a Ridiculous Upside

        Tommy John surgery is repairing an injury. You come out of it the same way you were pre-injury.

        TJS is taking a ligament from elsewhere in the body and putting it in the elbow.

        If you’re taking a ligament from a knee, hamstring, or forearm, a ligament that is fundamentally and inherently stronger than the elbow ligament being replaced, no, you’re not “the same way you were preinjury”.

        • http://twitter.com/tsjc68 tommiesmithjohncarlos a/k/a Ridiculous Upside

          Whoops, sorry, Chris is right above.

          If you’re taking a ligament tendon from a knee, hamstring, or forearm, a ligament tendon that is fundamentally and inherently stronger than the elbow ligament being replaced, no, you’re not “the same way you were preinjury”.

  • sabernar

    So why can’t a player have his testosterone removed from his body, concentrated, then reinjected?

    • Ed

      You’d mess up your body pretty bad if you did. Testosterone is needed normally by the body, so you’d be enhancing flow to one section while reducing flow to another.

      This procedure is about concentrating the cells of the immune system and injecting them into an injured site. You’re redistributing to an area of need. Doing this on a healthy person is a smart procedure. Doing this on, say, an AIDS patient, would probably kill them.

      • http://twitter.com/tsjc68 tommiesmithjohncarlos a/k/a Ridiculous Upside

        Yes, but what if you’re Bernie Williams, and you have testicles three times the size of a normal man? You’ve got more than enough testosterone there to impregnate the entire Upper West Side in one night; certainly you can spare some to inject into your biceps to make them a little stronger.

  • http://twitter.com/tsjc68 tommiesmithjohncarlos a/k/a Ridiculous Upside

    Patches O’Houlihan: Necessary? Is it necessary for me to drink my own urine?
    Peter La Fleur: Probably not.
    Patches O’Houlihan: No, but I do it anyway because it’s sterile and I like the taste.

    • steve (different one)

      this post was about as useful as a poopie-flavored lollipop!!

  • Andrae.H

    “Lasik is fixing flaws in your eye to bring it back to the level it should have been. You’re fixing degradation here.”

    The word ‘should’ is problematic because who is to say what your body ‘should’ do besides your body, if your eyes start getting worse as you grow old, thats nature saying your eyes ‘should’ be bad and if you get glasses, contacts, layzerEye w.e. thats going above what is actually natural for your body.

    if your matsui and your knee wants to fall off at 35 thats your body saying i dont wanna play baseball anymore. when he gets knee surgery thats him using science circumvent how it really ‘should’ be.

    • steve (different one)

      exactly. that’s the question that many of us are struggling with.

      Lasik is used to REVERSE the effects of aging. basically, my eyes got worse every single year for a decade. i went in for Lasik, and 10 minutes later, i had 20-20 vision.

      and in that respect, i would imagine that it is at least theoretically possible to use steroids in EXACTLY the same way.

      i’m not talking about taking steroids to blow past any of your body’s natural limitations. but i would have to think that you could take steroids in such a way (small doses combined with a workout regiment not designed to add mass) that all you are doing is eliminating the effects of aging for a few more years than someone not using steroids would.

  • Rich

    I think the difference between the two performance enhancing “procedures” is largely the result of their disparate history. If HGH had been unknown to medical science until last season, and a physician used it in an experimental context, narrowly targeted to attempt to heal a specific injury, it would be viewed similar to the way that PRP is at this point time.

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