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Athletic Gain at What Cost?


Those of us who care for athletes and interact regularly with coaches are acutely aware of the minuscule adjustments that can lead to improved performance. Athletes and those with a vested interest in their achievement are on an intense, continuous search to evaluate and experiment with new drugs, supplements, equipment, or procedures that may make a difference: Small improvements may be all that is necessary to give the athlete a chance to win. Undoubtedly, diverse superstitions are played out in the pursuit of improved performance. Otherwise, the scattered tactics now employed would yield more widely accepted techniques.

As team physicians or as office-based providers caring for athletes, we become involved in evaluating the safety of new methods. Questions can arise indirectly or directly. In the former case, a patient might describe his creatine regimen or her zone diet. In the latter, a coach might ask us to become involved in prescribing hyperbaric oxygen treatment for training. How do we give a balanced appraisal of safety and true ergogenic effects?

There seem to be three kinds of situations: those in which efficacy data are lacking but the health risk is clearly negligible (eg, some vitamin supplements), those in which efficacy data are irrelevant because the health risks are clear or the practice is illegal (eg, steroid abuse [see "When to Suspect Muscle Dysmorphia," page 19, and "Anabolic-Androgenic Steroid Abuse," page 67]), and—the largest group—those for which efficacy and/or safety data are unavailable or unclear (eg, creatine, prophylactic knee braces).

Before becoming overly confident of our right to criticize others, let's remind ourselves that our profession, despite every effort, still makes mistakes and errors in judgment. As many as 2021,000 fatal medical errors are made per year, according to the Institute of Medicine of the National Academy of Sciences in Washington, DC. We recommend treatments that we believe are appropriate and correct but that carry significant morbidity; an example is NSAID use, which has been estimated to contribute to $2 billion in hospitalization costs and 16,500 deaths annually among patients with arthritis (1). Promising procedures are popularized before full evaluation is completed (eg, autologous chondrocyte implantation). In other words, there often is no definitive answer about safety and efficacy.

What then guides us? First and foremost, every decision should be to preserve health, not to win events. It is one thing to try a risky treatment for someone with a grave illness, another to accept an unknown risk to improve a healthy person's athletic performance.

Meanwhile, though, it is essential to have credibility with athletes and coaches by answering their questions thoughtfully and by making a genuine attempt to evaluate new techniques or products. It is also essential that we establish trust. While our approach should be caring, it should also be honest and forthright. If we have concerns, we must voice them. Athletes must be aware of potential risks. We should not endorse products. We should educate athletes, institutions, and sport-governing organizations. If we feel there are potentially harmful consequences of a practice, we should oppose use of the device or pharmaceutical and not assume that another professional has made an evaluation.

These are difficult challenges, and pressures working the other direction are huge. Very often, though, we have a chance to make a difference by helping to shape a patient-athlete's thoughts and behaviors toward long-term health and away from winning at all costs. We must always be ready to take the challenge.

Gordon O. Matheson, MD, PhD


  1. Wolfe MM, Lichtenstein DR, Singh G: Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med 1999;340(24):1888-1899 [published erratum in N Engl J Med 1999;341(7):548]