EPO vs. a Cortisone Injection and the Future of Sport

Between Lance Armstrong’s fall from grace, doping accusations against baseball’s Alex Rodriguez, and a flurry of recent reports suggesting testosterone use in the NFL, it’s clear that cheating is a significant issue in modern sport, and unfortunately, likely more pervasive than most think. This isn't just in the professional ranks either; more and more amateur athletes are getting popped for doping in marathons, triathlons, and cycling events.  

I finally got around to reading Malcolm Gladwell's latest in the New Yorker; a predictably well-written essay raising questions about a 'level playing field' in sport and what it means to cheat. While I highly recommend reading the full article, the basic premise is to question why sport allows some advantages, both pre-determined and technologically driven (i.e., individuals with obscure genetics, cortisone shorts, Tommy-Jon surgery, Lasic, etc.), while disallowing others (i.e., EPO, blood transfusions, testosterone therapy).  The article prompted me to think about how/why these lines are drawn, and what it means for the future of sports.


For instance, what would happen if EPO (i.e., blood doping) or some new equivalent of it became as 'safe' as a cortisone shot? The situation gets real murky. Both are mechanisms allowing an athlete to train and compete harder than their own physiology would let them...so why allow one but not the other? Who is to say that inflammation induced by going too hard is much different than a reduction in hematocrit levels induced by going too hard? Both are the body’s natural processes of telling an athlete to back-off. The former uses pain as a signal (cleared by a cortisone shot) and the latter causing massive fatigue (fought with EPO). 


The downstream enforcement of cheating should be simple: if an athlete breaks a rule, regardless of his/her rationale, genetic baseline, etc., it is cheating, and the athlete must face that respective sport's penalty for breaking the rule. Things get more complicated further upstream, where decisions about what is and is not allowed are made, a process that will only get more complex as science and technology improve and athletes experiment with new ways of enhancing their bodies and minds. It used to be that pretty reliable guidelines could be used: if taking a certain substance had a great chance of harming an athlete, that substance would be banned. But with continual progress in the lab, it is extremely likely there will be an increasing number of substances and medical interventions that improve performance with minimal to no adverse health effects.  

Things get even more convoluted when athletes present with a legitimate clinical diagnosis, but one that may have been contributed to or caused by excessive training. My favorite example is the 43-year-old amateur triathlete who trains 20 hours a week on top of a highly demanding job and three young kids. He starts to feel fatigued all the time (who wouldn't), and goes to the doctor where a blood work-up shows his testosterone values are clinically low. Should he be able to start on testosterone therapy -- the recommended medical action -- even though if he reduced training by 50% his lab values would probably return to normal? Should the governing bodies of triathlon count on physicians to screen for "endurance training" when deciding how to treat these disorders? Is it up to the sport to do this? The questions are endless. 

This isn't just an issue for amateurs. Many elite endurance athletes are treated for hypothyroidism, a trend especially documented in elite runners. It seems an unlikely coincidence that the prevalence of hypothyroidism just happens to be so much higher in those that run for a living versus the general population. A recent article in the Wall Street Journal profiles a physician whose patient panel is dominated by professional runners, suggesting that perhaps it's something about the relentless training and physical stress inherent to their programs that causes hypothyroidism. So should treating this medical condition be considered cheating? And if it is, then what to do with someone who has underlying hypothyroidism unrelated to training? How to delineate between the two? Again, there are more questions than answers.


I could go on and on with examples, and they will only grow with continued progress in sports science, medicine and technology. In order to prevent an ‘anything goes’ circus in sports, it is extremely important that the governing bodies critically examine the process for deciding what constitutes cheating. It is a complex discussion and one that should be frequently revisited. No doubt, endless questions will be raised; the answers to which will define the future of athletic competition.