early three decades ago, Richard Steadman, the acclaimed orthopedic surgeon and founder of the Steadman Clinic in Vail, Colo., struck up an enduring professional relationship with German alternative medicine specialist Dr. Hans-Wilhelm Muller-Wohlfahrt. The casual arrangement is as simple as sharing and referring high-profile patients, often professional athletes, back and forth across the Atlantic for surgery or non-surgical treatment.
Where it gets dicey and raises ire in the medical community is Muller-Wohlfahrt's reliance on injection therapies that include Actovegin, an amino acid preparation derived from calves' blood that is not approved by the U.S. Federal Drug Administration.
The German doctor is not the prominent sports clinic's lone flirtation with nontraditional practitioners. The clinic or its physicians, while eager to consider cutting-edge medical innovations, also have had relationships or referrals to a pair of doctors under investigation by U.S. law enforcement -- Toronto-based Anthony Galea and former longtime Pittsburgh Steelers physician Richard Rydze. Galea is to be sentenced Friday after pleading guilty to bringing unapproved and misbranded drugs (human growth hormone and Actovegin) across the U.S.-Canadian border, while Rydze, a proponent of using HGH as a healing agent, had his office raided by the FBI last spring and, according to federal authorities, remains under investigation.
"If you are sending patients out of the country to get something that is banned in the United States, I would think as a physician, which is what I am, it is unethical behavior," said Gary Wadler, a New York internist with an expertise in the field of drug use in sport. "I have difficulty with that."
Speaking of the three physicians, Dr. Marc Philippon, managing partner of the Steadman Clinic and a leading hip surgeon, said: "I would classify them as medical innovators. Validating treatments is critical for any innovator in the field of medicine. Look at Albert Einstein. When he created his theory of relativity, people thought he was nuts. If Einstein didn't prove his theory, he would be known as a quack.
"You need innovators, but they need to be surrounded with the right infrastructure."
While Philippon has in the past referred patients to Rydze, who like himself was at one point affiliated with the University of Pittsburgh Medical Center, he also has a connection to Galea.
On Oct. 2, 2009, less than two weeks before the Toronto doctor was arrested, Philippon wrote to the U.S. Department of Homeland Security supporting Galea's 0-1 visa petition -- based on extraordinary ability in the sciences -- that would have allowed him to work in the United States. Philippon wrote that Galea's "inspired approach drives his established excellence in the field and is the reason that he is consistently recognized as one of the top 1 to 2 percent of individuals working in the field of PRP (platelet-rich plasma therapy) and tendon regeneration. The importance of Dr. Galea's contribution to the enhancement of this exciting new field and its application to athletes' recovery with minimal risk and a quicker return to their sport cannot be overstated."
Philippon is sometimes referred to as the "hip doctor to the stars" after operating on dozens of top athletes, most notably Alex Rodriguez, Greg Norman and Mario Lemieux. Like Galea, he's also recognized for his work with PRP. The doctor said he's only twice met Galea, who earned his medical degree four years prior to Philippon from McMaster University in Hamilton, Ontario.
Philippon said the initial conduit between the two was chiropractor Mark Lindsay, who worked in a practice with Galea in Toronto and to whom Philippon had for many years referred patients for rehabilitation and post-surgery recovery. Before the 2009 baseball season, Philippon performed hip surgery on A-Rod, and later both Galea and Lindsay assisted in the New York Yankees slugger's rehabilitation.
"I know that many elite professional athletes held Dr. Galea in high regard and sought him out," Philippon said. "A few athletes that I treated also received nonsurgical treatment from Dr. Galea, but we did not treat those patients together or coordinate our care of patients."
Philippon added: "I am not aware of any patients who were under my care getting any illegal or banned treatments from Dr. Galea or any other doctor."
As he recalls events, Philippon, a pioneer in the treatment of sports-related hip injuries, said he was approached by someone in Galea's Toronto office asking if he'd support his visa request. He believes the letter was written by Galea's attorney at the time. He said he had no inkling then of Galea's legal transgressions and reviewed and signed the letter because he was hopeful that the doctor might come to the U.S. to validate his methods through evidence-based medicine.
"I still believe Dr. Galea has advanced the practice of PRP in important ways," Philippon said. "But knowing what I know now, following his guilty plea earlier this year, I would not have signed that letter."
Among the other endorsement letters was one from Dr. Theodore Schlegel, an orthopedic surgeon and founding member of the Steadman Hawkins Clinic in Denver. He is also medical director for the Denver Broncos and associate team physician with the Colorado Rockies.
Schlegel praised the Canadian doctor's emerging "treatment of muscular skeletal disorders" in a Sept. 25, 2009, letter to the federal agency, adding: "Presently, the Steadman Hawkins Clinic in Denver has extended an offer to allow Dr. Galea to perform this treatment in our clinic. I'd personally serve as his sponsor."
The Steadman Hawkins Clinic in Denver is not affiliated with the original clinic in Vail, which last year modified its name to the Steadman Clinic. Dr. Schlegel, however, does serve on the scientific advisory board of the not-for-profit Steadman Philippon Research Institute in Vail.
Schlegel did not respond to multiple messages left with his office by "Outside the Lines" in recent months.
"My understanding is that the Steadman Hawkins Clinic in Denver -- which operates independently of and has no official relationship with the Steadman Clinic in Vail -- was looking into the possibility of bringing Dr. Galea to its practice," Philippon told "Outside the Lines." "We had no such discussions with Dr. Galea. I had contemplated inviting Dr. Galea to the Steadman Philippon Research Institute here in Vail at some point in the future to perform research on his PRP methods and validate what he was doing. He would have needed proper documentation before making that a reality."
Being open to fresh ideas and pushing advancements is neither a bad thing nor a foreign concept within the medical community. It was this mutual innovative zeal that led to the long-standing professional relationship between the Steadman Clinic's founder and the German practitioner Muller-Wohlfahrt.
In the late 1980s, Muller-Wohlfahrt traveled to the United States in search of a top orthopedic knee surgeon to whom he might refer patients who required surgical intervention, those who didn't respond to his injections of homeopathic medicines. The first athlete sent to Dr. Steadman's office was Germany's then World Cup-winning captain Lothar Matthaus. More soccer players, tennis stars and athletes from Europe have followed via Muller-Wohlfahrt's referral over the nearly three decades.
After Philippon joined the clinic in 2005, Muller-Wohlfahrt began referring his athlete patients who required hip surgery to the Vail clinic. Philippon, in turn, said he "occasionally" refers patients to the German doctor, mostly for follow-up treatment or rehabilitation after surgery.
"So over the years we just shared patients," said Steadman, a reconstructive knee surgery specialist. "If I have an athlete in Europe that I wanted to have conservative management, then I would suggest to see him."
Steadman estimated he receives five to 10 referrals a year from Muller-Wohlfahrt. The patients he in turn refers to Germany are typically European athletes and non-athletes who have a knee issue that falls short of requiring surgery. In some cases, European athletes are also sent to Muller-Wohlfahrt for post-surgery treatment.
Steadman is supportive of the homeopathic treatments, as well as the use of Actovegin, which is not approved for use by the FDA. The doctor was personally sold after traveling with his wife more than a decade ago to Munich, where Muller-Wohlfahrt administered a series of injections that significantly improved her range of motion after having had neck surgery.
Impressed with the result, Steadman said he asked his clinic's physical medicine doctor, Dr. David Karli, to spend time in Muller-Wohlfahrt's practice and upon returning to incorporate his techniques, sans the unapproved Actovegin. Because of the U.S. regulatory issues with Actovegin, Muller-Wohlfahrt said that he also discussed with Philippon using a synthetic form of the substance, but decided against it because of the time involved in doing the necessary scientific studies. He said it was after that that Philippon went about developing his expertise with PRP.
Steadman, however, goes so far as to compare the unapproved Actovegin favorably with platelet-rich plasma therapy, saying, "I haven't seen anyone who has had the same success that Dr. Wohlfahrt has had with PRP."
Philippon, the esteemed Colorado-based hip specialist and PRP proponent, is likewise comfortable championing the unconventional and unapproved.
"I support doctors like Dr. Wohlfahrt further exploring these new and evolving treatments within the rules and laws of their countries," Philippon said. "I support innovation in medicine, particularly when it is evidence-based, which is a critical topic … I have been, and remain, complimentary of Dr. Galea's work in PRP therapy. He, like Dr. Wohlfahrt, is an innovator, and our clinic is very much focused on innovation to give our patients the very best, safest, most effective care available.
"I believe that many respected doctors around the world feel the same way."
Mike Fish is an investigative reporter for ESPN.com. He can be reached at firstname.lastname@example.org.