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Drugs in Sport

Lance Armstrong: The Fall of a Hero

27 Oct, 12 | by Karim Khan

Guest blog by Professor Phillip Sparling

Please see Professor Sparling’s related call to action. Here’s the link – a petition written to Lance Armstrong.

I’m grieving.  October 2012 will forever be imprinted in my memory as the month of damning revelations and the demise of Lance Armstrong.  I’m not naïve about the use of drugs in sport and know it’s particularly prevalent in professional cycling.  Yet, like many, I believed in Lance.  His story was uniquely inspiring and his good works unrivaled.  We wanted to believe him.  His comeback story was heroic.  And so the legend grew.  Sadly, we were duped.  Millions like me are deeply disappointed.

We must not allow this to jade us.  Impressionable youth to seasoned athletes, all are watching us, awaiting our reactions.  For my part, I’ll strive to emphasize the positive that sport provides – the limitless possibilities for joy and learning inherent in play and competition – and the importance of integrity.  Colleagues, let’s redouble efforts to lead by word and deed, and leave no doubt about our core commitment to ethical behavior in sport and in life.

A comforting thought from William Shakespeare, Macbeth: Come what come may, time and the hour run through the roughest day.


Phillip B. Sparling, Professor Emeritus, Georgia Institute of Technology School of Applied Physiology, Atlanta, Georgia, USA

PS: Nice piece from the Sydney Morning HeraldLance-betrayed-the-higher-principles-of-sport-but-saga-cant-shake-power-of-participation- Click here for it. 

Guest Blog: Peter Brukner on Drugs and the London Olympics

20 Aug, 12 | by Karim Khan


A couple of days ago, London 2012 would have been regarded as a drug-free Olympics – that was before shot put gold medalist Nadzeya Ostapchuk (Belarus) tested positive for the anabolic steroid metenolene in samples taken both before and after her London competition. That was the first positive test by a medallist in London but two other athletes were kicked out of the Games for failing drug tests — Syrian hurdler Ghfran Almouhamad and US judoka Nicholas Delpopolo. In addition, the International Olympic Committee announced a number of positive pre-Olympics tests during the course of the Games.

The positive tests announced during the Games were:

Name Country Sport Banned substance
Ghfran Almouhamad  Syria 400m hurdles Methylhexaneamine (stimulant)
Victoria Baranova  Russia Women’s sprint Testosterone
Kissya Cataldo  Brazil Single sculls EPO
Nicholas Delpopolo  United States Judo Cannabis
Luiza Galiulina  Uzbekistan Artistic gymnastics Frusemide (diuretic)
Hassan Hirt  France 5000 m EPO
Amine Laâlou  Morocco 1500 m Frusemide (diuretic)
Marina Marghiev  Moldova Hammer throw Frusemide (diuretic)
Nadzeya Ostapchuk  Belarus Shot put (gold medal) Methenolone (anabolic steroid)
Diego Palomeque  Colombia 400 m Stanozolol  (anabolic steroid)
Hysen Pulaku  Albania Weightlifting Stanozolol  (anabolic steroid)
Alex Schwazer  Italy 50 km walk EPO
Tameka Williams  Saint Kitts and Nevis 100 m/200 m “Blast Off Red” (? Stimulant)

Pre-Games bans

The World Anti-Doping Agency reported that more than 100 potential Olympians were stopped from competing at the Games because of doping.

Some medal hopefuls had been caught before leaving for London, such as defending 50km walking champion Alex Schwazer of Italy, Moroccan 1500m hope Mariem Alaoui Selsouli and Turkish weightlifter Fatih Baydar. Belarussian hammer thrower Ivan Tikhon, a three-time world champion in 2003, 2005 and 2007, was also excluded from competing before the Games as a result of drug tests dating back to the 2004 Olympics and 2005 world championships.

Six track and field athletes suspended were caught in “biological passport” tests, which measure changes in an athlete’s blood profile. Another three were apprehended in re-tests of samples from last year’s world championship. Inna Eftimova, of Bulgaria, tested positive for synthetic growth hormone, while the samples of the Ukrainians Nataliya Tobias and Antonina Yefremova both contained traces of synthetic testosterone. All three have been banned for two years.

The Moroccan runner Abderrahim Goumri, who finished third in the London marathon and second in the New York marathon in 2008, was among the six athletes who had irregularities in their “biological passports”. The others were: Russians Svetlana Klyuka, who finished fourth in the 800m at the Beijing Olympics; the 2011 European indoor 800m champion Yevgenia Zinurova; and Nailya Yulamanova; long-distance runners Irini Kokkinariou of Greece; and Turkey’s Meryem Erdogan.

The nine suspensions came after it was revealed that the Moroccan 1,500m runner Mariem Alaoui Selsouli had also tested positive for a banned diuretic. The 28-year-old had been the hot favourite to win 1,500m gold in London when she ran three minutes 56.15 seconds to win the Paris Diamond League at the Stade de France earlier this month. A silver medallist at the world indoor championships this year, she has already served a two-year suspension for doping and now faces a lifetime ban under World Anti-Doping Agency (WADA) rules.

Italian race-walking hero tests positive for EPO

The most interesting story among this group was from Italian walker and 50km gold medallist from Beijing, Alex Schwazer, who unusually among those who test positive, admitted doping. Schwazer, told his doping tale in great, and sometimes disturbing, detail. His story clashed starkly with the athlete’s clean-cut image that is highlighted in a ubiquitous Italian advertisement for Kinder chocolate bars set in the idyllic Alps where he lives.

After studying how to take and buy the drug on the internet, he said he flew to Turkey in September 2011 for three days, exchanged 1500 euros for Turkish lira, went to a pharmacy and bought EPO over the counter. He kept the drug in his refrigerator and told his girlfriend, figure skater, Carolina Kostner that they were vitamins.

He said he took the EPO only in the month leading up to the Games, that he had acted alone, and denied that he had taken performance enhancing drugs before the Beijing Games. He challenged the Olympic authorities to re-examine his blood from four years ago.

He gave the following description of the test that found him out.  “I took the last injection on July 29, I remember because it was my mother’s birthday. I went back home to get a document I needed for the Olympics. On the 30th the doorbell rang and I was sure it was anti-doping controllers. I could have told my mother to not answer or say I was not in and nothing would have happened since it’s possible to miss two in a year. But I did not have the strength to lie any more. And I wanted it all to end. I am so ashamed but I am also glad I can start my life again”.

Kenyans test positive

Three Kenyan athletes also tested positive leading up to the Games including Hamburg Marathon winner Rael Kiyara for nandrolone (anabolic steroid) and 2012 Boston Marathon runner-up Jemima Sumgong for traces of cortisone. Sumgong was treated for a hip injury in an Italian clinic, and her use of the banned substance may ultimately be determined as inadvertent.

Mathew Kisorio, history’s third fastest half marathoner (58:46) and a fourth-place finisher at the 2011 World Cross Country Championships, reportedly tested positive for an anabolic steroid at the Kenyan Championships in Nairobi on June 14. Doping expert Hajo Seppelt, in an interview with the German media outlet ARD,  translated (roughly), claimed statements by Kisorio “give the impression that not only he is affected, but it [taking performance-enhancing drugs] is a common phenomenon in Kenya.”

Seppelt says Kisorio told him that doctors like the one who treated him “can be seen in places where preferred athletes live, such as in the training camps in the highlands. His observations on this practice [administering banned drugs] are, that this is not an isolated phenomenon, but is widespread all over Kenya.”

Kisorio has admitted to drug-taking and “apparently hopes that he gets, through the elucidation of the facts, a reduced ban by [Athletics Kenya],” explains Seppelt. “Therefore, he has gone on the offensive and has spoken to us.”

Kisorio “claims that he was incited by his doctor,” reports Seppelt. “The doctor has apparently given him injections of banned substances and also tablets. One of these tablets led to the alleged positive test.”  Kisorio was found to have taken steroids, notes Seppelt, but “he also speaks of seemingly EPO injections, i.e., blood doping, and also of [doping] products that stimulate the mind.”

Seppelt maintains that the complete lack of positive drug tests by the Kenyan Olympic team is “nothing special. In the competition controls only the dumbest get caught, because the [doping] products are already out of the [body] by then.” But Seppelt asserts “nonetheless, the credibility of the Kenyan athletics is shaken” and that East African distance-running success cannot be attributed solely to “the highland, good food and the running culture. It also plays an important role. But you must realize that certain substances are also a part.”

Previous drug cheats in London

Gold medallists at the London Games who had been involved in previous doping offences included Alexandre Vinokourov, the winner of the cycling mens road race, Tatyana Lysenko,  the winner of the womens hammer throw and Asli Cakir Alpketin winner of the womens 1500 metres. Other competitors involved in previous doping cases included American athletes Justin Gatlin and LaShawn Merritt.

Ostapchuk’s positive test

Ostapchuk’s positive test in London should not have come as a big surprise. She had been competing in her third Olympics having finished fourth in Athens in 2004 and won bronze in Beijing four years ago. In the past few years, the New Zealander Valerie Adams has dominated the womens shot, beating Ostapchuk several times. Ostapchuk won the World Championship in 2005, but finished runner-up behind Adams in both 2009 and 2011 and took bronze at the Beijing Olympics in 2008.

In London, Ostapchuk, 31, won the shot put with 21.36 metres, 66 centimetres better than Adams’ best mark. The results raised speculation of doping as Britain’s men’s shot put competitor Brett Morse hinted on Twitter that Ostapchuk was using illegal drugs. The tweet was deleted soon after.

Adams is now the Olympic gold medallist, but has missed out on the opportunity to celebrate her victory on the day and to receive her gold medal at the victory ceremony.

“Suspicious” performances

Whenever there is a surprise outstanding performance involving a dramatic improvement in a short period of time, the suspicion of drug use arises. Two cases that drew a great deal of attention in London. One was the Chinese swimmer Ye Shiwen who won the women’s 400 Individual Medley in world record time and famously swam the final freestyle lap faster than Ryan Lochte in the men’s event (a previously unheard of phenomenon); the other was and the Turkish 1-2 in the women’s 1500 metres (see below).

Shiwen bettered her previous PB by 5 seconds which led the US coach John Leonard to query the performance. A Chinese team mate tested positive for EPO earlier this year. The Chinese claimed Shiwen had been identified at a young age because of her large hands and feet, and her success was due to hard work.

Womens 1500 metres – surrounded by drugs

Asli Cakir Alptekin, who has served a two-year ban for doping offences, won Turkey’s first athletic gold  in the 1500m and was followed across the line by her fellow countrywoman Gamze Bulut. Both their histories are interesting

Asli Cakir was banned for 2+ years as a junior in 2004 on a doping incident. She ran the 3000m steeplechase in Beijing four years ago and failed to progress from the heats. By last year’s world championships in Daegu she had dropped down to the 1500m, but failed to qualify for the final. This year has been different though. She finished third in the world indoors in Istanbul and then at the Diamond League meeting she ran 3min 56.62 sec, a 7 second personal best. Then on the eve of the Games, Cakir Alptekin won the European championships.

Silver medallist Bulut who has just turned 20 years old, virtually came from nowhere. Before 2012, Bulut was a steeplechaser with a 10:13 PB to her name and a 4:18 in the 1500, both times from 2011. This year her times saw massive drops of 39 seconds (9:34) in the steeple and 17 seconds in the 1500 (4:01). Bulut had never been at a global championship in the past, but found her way on the medal stand her in London.

British 1500-meter runner Lisa Dobriskey, who in her whispery voice has been outspoken on this issue before, told BBC Radio 5 Live, “I’ll probably get into trouble for saying this, but I don’t believe I’m competing on a level playing field.” Dobriskey was fourth in the 2010 European Championships when one of the runners making the podium had previously been banned for EPO use and had once been arrested with vials of human growth hormone (HGH) in her luggage. In addition, Dobriskey was fourth at the 2008 Olympics in which the bronze medalist, Ukraine’s Nataliya Tobias, tested positive for testosterone at the 2011 world championships.

The women’s 1500m event has been surrounded by drug convictions in recent years. In addition to Alpketin who tested positive in 2004, Moroccan Mariem Alaoui Selsouli, the world leader and favourite for 1,500m the London Games, tested positive in July and faces a lifetime ban having returned only last year from a two-year doping suspension for EPO.

Also in July, three Russian runners, including major championship middle-distance medallists Svetlana Klyuka and Yevgenia Zinurova, were banned, while four years ago, seven Russians were caught including then-world leader and former indoor 1,500m world record holder Yelena Soboleva and former double world champion Tatyana Tomashova.  Tomashova, a silver medalist in the 2004 Athens Olympics, was later banned when it was discovered that she had tampered with a urine sample that was to be tested for drugs. She returned from the ban in April of 2011. Turkish athlete Süreyya Ayhan was the 2002 European champion in the 1500, but she received a lifetime ban after a positive test for steroids in 2007

Men’s 1500 m

In Beijing there was a surprise winner of the mens 1500 metres –  the Bahraini athlete Rashid Ramzi. Less surprisingly he subsequently lost his gold medal after testing positive for CERA an advanced version of EPO.

When Taoufik Makhloufi of Algeria won the London 1500 metres with a 3:30 personal best, having previously failed to make it out of the semifinals in the previous two World Championships, suspicions were again raised. However Makhloufi’s performance was not out of the blue as he had run a fast 3.30 1500 in Monaco earlier in the year. The most dramatic improvement in the 1500m final actually came from the Norwegian runner Henrik Ingebrigtsen who ran a personal best in finishing fifth.

The interesting aspect of the London 1500m final was the failure of all the favourites to perform on the day, although the defending champion and current World champion Asbel Kiprop was obviously injured. You would imagine that the way the race was run it would have suited a fit Kiprop who was the fastest 800m runner in the field. Makhloufi was the second fastest 800m runner in the final!

Will there be more positives?

Urine and blood samples taken at London 2012 and tested by scientists at the high-tech anti-doping lab in Harlow, east of London, will be stored for up to eight years. As American cyclist Tyler Hamilton, a 2004 time trial gold medallist, found out last week, cheats both past and present can be named, shamed and stripped of their titles even years later.

Experts say the liquid chromatography and mass spectrometry equipment used at the lab to screen samples for more than 240 banned substances in under 24 hours has provided the best anti-doping system officials could have hoped for.

A spokesman for the International Olympic Committee (IOC) said on the Saturday before the Games’ closing ceremony, that there had been 4,686 anti-doping tests so far, of which 3,729 were on urine samples and 957 had analysed blood.

Who gets caught?

The WADA Director General, David Howman, has drawn a distinction between “dopey dopers” who still have traces of banned substances in their system during major competition, and sophisticated cheats who are able to beat the system outside competition.

While strides have been made in the out-of-competition testing regime, including the introduction of the controversial “whereabouts” policy that requires elite athletes in every sport to make themselves available for spot testing at any time, there are huge concerns about whether they are doing enough to keep up.

Although sophisticated new methods are being developed to test for EPO and Human Growth Hormone, they are expensive and require refrigerated blood samples to be carried for sometimes thousands of miles to the labs capable of carrying out the tests. WADA is concerned the cost is preventing many countries carrying out as many tests for blood doping as they should be.

It is feared that of the 258,000 tests conducted annually, as few as 2% include the blood tests that can detect the use of Human Growth Hormone. In 2010 there were just 36 positives – a total WADA regarded as “disappointing”. Across sport, there are fears that one in 10 athletes is attempting to cheat but of those only one in five is being caught.

 Was London 2012 relatively drug-free?

There were very few actual positive tests from the 2012 Olympics. This relative paucity of positive drug tests could mean one of two things.

That we are winning the war against drugs and the extensive testing and prospect of retrospective disqualification had succeeded in putting athletes off.

Alternatively, as has always been the case, that the athletes, coaches and scientists have perfected the art of avoiding detection using regular low dosages of drugs and hormones that are too small to detect. There are certainly plenty of rumours of endurance athletes using daily low doses of synthetic blood products which maintain high red blood cell count rather than using EPO. Victor Conte of BALCO fame was in London (I thought he was in jail!!) and claimed that 60% of athletics medallists were taking drugs. Probably not the most reliable witness, but he certainly knows the drug scene!

I believe that the use of performance-enhancing drugs is still widespread in certain Olympic sports. History tells us that there have always been athletes and coaches trying to gain an advantage. History also tells us that they are invariably ahead of the drug testers, thus the relatively small number of positive drug tests at Olympics. Out-of-competition testing and the co-operation of customs and law enforcement agencies have helped catch some drug cheats, but I cannot believe there are not lots more out there getting away with it.

Dr Peter Brukner (@PeterBrukner) is an Associate Editor of BJSM and an Australian sports medicine physician, author and media commentator living in Liverpool, UK. Currently working with Sky Sports News and one of the sports physicians working with the Australian cricket team. This blog was reposted from Peter Brukner’s website  where you can find other blogs about the Olympics and sport and exercise medicine broadly.

Related BJSM papers:

Traditional Chinese medicine and sports drug testing: identification of natural steroid administration in doping control urine samples resulting from musk (pod) extract.  Mario Thevis et al.

Would you dope? A general population test of the Goldman dilemma. J M Connor, J Mazanov

Doping prevalence among preadolescent athletes: a 4-year follow-up. P Laure, C Binsinger.  Br J Sports Med 2007;41:10 660-663


Designer Bodies: Anabolic steroid use in high schools

2 Aug, 12 | by Karim Khan

By Dr Glen Hagemann

Sports Physician and President of the South African Sports Medicine Association (SASMA)


Last year Discovery Sharksmart  anonymously surveyed 9824 male pupils attending 20 high schools in South Africa regarding various lifestyle behaviours.  One section of the questionnaire related to the use of anabolic steroids, the results of which proved both interesting and somewhat surprising. The response rate to the survey was in excess of 85% meaning that the results could be seen as representative of the high school population surveyed. In the survey approximately 5% of the respondents acknowledged having tried steroids at some stage in their lives – this figure was lowest for grade 8’s (1.2%), as expected, and highest for grade 12’s (9.5%). It is possible that these figures are indeed an underestimation of the real situation as a result of under-reporting.

The results of the survey are not only surprising in that they reveal the relatively frequent use of anabolic steroids, but also because the main reason reported for steroid use is for self-image reasons, and not for enhancing sporting performance, as is the common perception. Two thirds of the pupils who had used steroids stated that they did so primarily to “look good”, while only a third did so to perform better on the sports field. Incidentally, the main source for obtaining steroids by schoolboys was reported to be from gyms.

We then looked at the association between steroid use and other lifestyle factors, using a statistical measure called “the odds ratio”. This ratio measures the strength of the association between two behaviours; the higher the odds ratio, the stronger the association.  We found that steroid use and a perceived excessive pressure to perform on the sports field had an odds ratio of 2.5. Other associations with steroid use in order of increasing strength are: physical violence (odds ratio = 4.2), suicidal thoughts (odds ratio = 4.4), recreational drug use (odds ratio = 5.5) and hard drug use (7.2).

The finding that steroid use has the strongest association with recreational and hard drug use, and the weakest association with sports performance, suggests that steroid use in our schools is a “lifestyle” or social problem; it is more of a social behaviour undertaken for social reasons, similar to the use and abuse of mind altering drugs like marijuana, ecstasy and cocaine. With this in mind then, it was easier to understand why half of the nearly 10,000 respondents indicated in the survey that they did not consider the use of steroids as “cheating”; the notion of cheating is only relevant to a sporting context.

In this material world of designer clothes, shoes, accessories and electronics, have some of our youth reached a point where the use of body altering drugs like anabolic steroids to produce designer bodies is just an extension of this culture?

The South African Sports Medicine Association (SASMA) is one of 8 international member societies that partners with BJSM. See the South Africa focussed issue of BJSM (June 2012) by clicking here.


Ruling from the Court of Arbitration for Sport brings consistency, but anti-doping debate will rumble on.

30 Apr, 12 | by Nick Smallwood

The CAS has ruled that the British Olympic Association cannot exclude dopers who have served their bans from future Olympic teams. The decision pushes Dwain Chambers back into the spotlight. He has kept a low profile over the past few months, although his agent, barrister Siza Agha, has been eloquent on his behalf:

“Redemption is an integral foundation… of any democratic society. It is not recognised in dictatorships, Greek mythology and the British Association bylaw.”

Well, the BOA bylaw has been deemed “noncompliant” with World Anti-Doping Agency rules. If Dwain Chambers runs the qualifying time and achieves a top-two finish in the 100m trials, he will be given a spot on the British team.








In the words of head coach Charles Van Commenee, Chambers is “a  likeable guy and a damned fine athlete.” His willingness to share his story has helped anti-doping efforts and dissuaded other athletes from making the same mistakes. A home Olympics swansong would represent an unexpected chance for redemption on the running track. Although probably still Britain’s fastest man at thirty-three, Chambers would be outside shot to reach the 100m final. It has been his misfortune to get caught in the crossfire of an overheated and complex debate.

The question of what sanctions to impose upon drugs cheats is understandably an emotive one, particularly for the clean athletes who spend years pushing their bodies to their natural limits. Sebastian Coe and Daley Thompson, two of the senior statesmen of British athletics, have been outspoken in their support for lifetime bans.

Such a stiff sanction would be difficult to enforce. If you want to impose a lifetime ban, which will destroy an athlete’s career, then the proof of their guilt needs to be pretty devastating. For a variety of reasons, doping control scientists are not yet able to establish such a secure verdict in most cases. More frequent and stringent testing would help, but we should be wary of sacrificing the right to privacy in the name of clean sport.

There is also a strong case for distinguishing between accidental and deliberate cheating, particularly in cases like LaShawn Merrit’s. The 2008 Olympic 400m champion tested positive for a banned steroid and was given a short ban, as the court was convinced that he took it inadvertently when he tried the male enhancement product Extenze.

WADA has done part of its job by bringing consistency to doping sanctions, it now needs to consider whether these sanctions are tough enough. The vast majority of athletes and fans want competition on a level playing field. I hope that’s what we see in London this summer.

For BJSM podcast with WADA head Alan Vernec and Deputy Editor Babette Pluim click here. (Follow @DocPluim)

See also leading Sports Ethics expert Mike McNamee’s 2011 comments on doping and sport here

And discussion of the challenges of doping test (for B-2 agonists) in asthma here

Doping in Professional Cycling: The Lance Armstrong Controversy

24 Jan, 11 | by Karim Khan

The Sports Illustrated article, The Case against Lance Armstrong, is stirring controversy. The in-depth expose details allegations of banned-substance use, and involvement in an organized doping operation. Armstrong is under investigation by the U.S. Food and Drug Administration in a federal grand jury inquiry in Los Angeles. Here are some highlights of the SI report:

  • The Texan gained access to a drug, in clinical trial, called HemAssist, developed by Baxter Healthcare Corp. In animal studies, HemAssist boosts the blood’s oxygen-carrying capacity, without as many risks as EPO.
  • Syringes and drugs with labels written in Spanish were found after an airlines custom search.
  • Armstrong’s testosterone-epitestosterone ratio was reported to be higher than normal on three occasions between 1993 and 1996
  • Stephen Swart, a New Zealander who rode with Armstrong on the Motorola squad in 1995, describes the Texan as the driving force behind some of the team members deciding to use the banned blood booster EPO. “He was the instigator,” Swart tells SI. “It was his words that pushed us toward doing it.”
  • There is an ‘electronic information’ trail linking Armstrong to controversial Italian physician Michele Ferrari as recently as 2009

Armstrong’s spokeperson said the article contains ‘old news from the same old, discredited sources.’ Armstrong, the seven-time Tour de France winner, also responded to the article by stating, “I have nothing to worry about on any level.”

Related BJSM Articles:

Doping is a threat to sporting excellence. June 2010

Confidentiality, disclosure and doping in sports medicine. October 2009

Tour de chaos. June 2007

Switch off the light on cycling, switch off the light on doping.

November 2007

Caffeine/Sleeping pills in sport captures national media attention in Australia

14 Jul, 10 | by Karim Khan

On July 5th, a prominent Australian Rules football player suffered an ‘adverse reaction’ to sleeping pills after a game. Drug testing confirmed that the player had not taken any banned drugs and there was no suggestion of that. The media ran stories of players being on a cycle of caffeine ‘uppers’ followed by sleeping pill ‘downers’ as a part of the weekly cycle. TV File footage showed ‘No Doz’ tablet being available to players in the rooms immediately prior to a game. A few former players acknowledged that taking caffeine tablets was part of some players’ routines. Note that Australian Rules football is largely played in one time zone and the player in question was not from a team that regularly travels across time zones.

Australasian College of Sports Physicians President, Andrew Garnham raised important questions on this issue in his weekly newsletter (shared here with permission):

This episode raised many questions. Who should be commenting? What are the boundaries of privacy and confidentiality in such a situation? Could there be any legal implications of comments? Will commenting help to better inform the general public and everyone assocaited with the sport? Does caffeine help performance in AFL football, as it is played in 2010? Are sleeping tablets really necessary after games, especially at night? Do the players fully understand these issues? How much can a club control the medical treatment of an individual? Are the objectives of the performance staff and medical staff at the club correctly aligned? I do think the hot question of whether caffeine tablets should be banned is easily dispensed with.

Feel free to contribute to this discussion by posting a comment below.

E-letter: Question regarding the use of autologous PRP injections for tendinopathies

23 Jul, 09 | by Karim Khan

The following is a letter to BJSM from Ralph S. Bovard MD:

Dear BJSM,

I have a question regarding the use of autologous platelet rich plasma (PRP) injections for tendinopathies of various sorts.  This procedure has been gaining favor with sports medicine clinicians for use in athletes with tendon injuries that are slow to respond or resistant to conservative therapies.  Despite the fact that it would appear to be a seemingly innocent matter of re-injecting one’s own spun down blood products, the World Anti-Doping Agency (WADA) most recent 2009 Prohibited List, if taken literally, would make it an illegal procedure for international competition or national competition under any NGB’s who endorse WADA.  The culprit substances in this case would be growth hormone (GH), Insulin-like Growth Factors (IGF-1), and Mechano Growth Factors (MGF’s).

The relevant section from the code is included below:


The following substances and their releasing factors, are prohibited:
1. Erythropoiesis-Stimulating Agents (e.g. erythropoietin (EPO), darbepoietin (dEPO), hematide);
2. Growth Hormone (GH), Insulin-like Growth Factors (e.g. IGF-1), Mechano Growth Factors (MGFs);
3. Chorionic Gonadotrophin (CG) and Luteinizing Hormone (LH) in males;
4. Insulins;
5. Corticotrophins;
and other substances with similar chemical structure or similar biological effect(s).

[Comment to class S2:
Unless the Athlete can demonstrate that the concentration was due to a physiological or pathological condition, a Sample will be deemed to contain a Prohibited Substance (as listed above) where the concentration of the Prohibited Substance or its metabolites and/or relevant ratios or markers in the Athlete’s Sample satisfies positivity criteria established by WADA or otherwise so exceeds the range of values normally found in humans that it is unlikely to be consistent with normal endogenous production.

If a laboratory reports, using a reliable analytical method, that the Prohibited Substance is of exogenous origin, the Sample will be deemed to contain a Prohibited Substance and shall be reported as an Adverse Analytical Finding.] The Prohibited List 2009 20 September 2008

It would thus seem that PRP is banned under “Class S2: Hormones and Related Substances”, rather than under “M1: Blood Doping”.  The re-delivery of blood is prohibited under blood doping; regardless of whether it is endogenous or exogenous.  There is no mention or attempt to discriminate between blood products that are re-injected immediately into soft tissues versus those that are shelved and re-infused by IV weeks or months later in the typical manner of “blood doping”.

The argument is made that while PRP indeed delivers  the athletes own growth factors to a musculoskeletal site, the platelets are concentrated to a level not normally achieved physiologically, and they are activated either chemically (via calcium addition) or mechanically (centrifugation) and thus degranulate  rapidly and deliver a bolus of factors never “normally” or physiologically achieved.

Given this stance it would seem that the use of platelet rich plasma injections is clearly prohibited.   Tendinopathies are not life threatening or otherwise serious medical conditions and as such the rational of applying for a therapeutic use exemption (TUE) would seem a difficult argument.   Yet how would PRP injections be detected other than by admission?  What is the opinion of the BJSM readership regarding this topic?

Thank you,

Raph S. Bovard MD

Hot Topic: The Truth Behind Doping Scandals

21 Jan, 09 | by Karim Khan


By John Orchard

One of the worst ever drugs in sport decisions – and there have been some shockers, such as Andrea Raducan losing a gymnastics Gold medal at the Sydney Olympics for taking a Sudafed tablet – was handed down by the International Tennis Federation late last week. Italy’s Filippo Volandri was banned for three months for ‘abuse’ of salbutamol, the drug better known as Ventolin, for treating an asthma attack.

Ventolin puffers are on the WADA (World Anti-Doping Agency) banned list, which in itself is bizarre given that they have not ever been shown to enhance sporting performance. However, there is sensibly an exemption process for asthmatic athletes to apply for which permits them to take salbutamol puffers if a doctor diagnoses asthma. Volandri at the time of this so-called doping incident had registered an exemption for salbutamol use which had been accepted by the International Tennis Federation (ITF) as valid.

The complaint of the ITF was that the recommended dose for Volandri on his exemption form was two puffs and the concentration found in his urine suggested a much higher dose. Volandri admitted that he had taken a much higher dose on the night before his drug test and had a completely reasonably explanation for having done so: he suffered a severe asthma attack in his hotel room and couldn’t breathe properly so continued to take his puffer until the attack subsided. This is more than just completely reasonable – Volandri would have possibly even died if he had not taken a high dose of Ventolin during such a severe attack. He was in a foreign city without recourse to an Italian speaking doctor and sensibly self-medicated to avoid being unable to breathe. The tribunal apparently accepted all of this, but still decided to suspend Volandri for 3 months (and fine him for most of his 2008 prizemoney and ranking points), because the dose he admitted taking was higher than the dose that he was registered to take on his WADA/ITF paperwork. Click to read the ITF’s outrageous press release and entire verdict. The rationale behind this draconian verdict can be seen, but the question is what the ITF/WADA could reasonably have expected Volandri to do in the circumstances (of a severe asthma attack)? Obviously their expectation is that he should not have self-medicated but instead, in Indian Wells USA at 3am have somehow found an Italian-speaking sports physician who was prepared to not only prescribe a higher salbutamol dose but who was also prepared to fax off a revised form to the ITF medical commission. Or perhaps take option B, which in the absence of such a doctor was to risk becoming one of the 5000 annual asthma deaths in the USA. At least in this instance he would have died as a cleanskin, rather than as a drug cheat.

Tennis has a chequered history of having let off 16 players in 2004 for positive drug tests for the anabolic steroid nandrolone. Nandrolone is a strongly performance-enhancing anabolic steroid and the rationale for not suspending the players who tested positive seems to have been that “the doping must have been inadvertent as it involved so many players”. So after having turned a blind eye to so many proven anabolic steroid positives, they are now coming down heavy on asthmatic taking their puffers during asthma attacks.

Other than WADA and the ITF, the international sports journalism community should also be ashamed that it has reported this case as a routine doping decision rather than one of the greatest scandals in tennis history. A young man’s life was saved by his sensible use of his own asthma medication but his career has been destroyed by a totalitarian doping agency. In August 2008, I wrote an article entitled “WADA is on the verge of losing the plot”. It has now officially been lost.

Book Review: Science and football V: the proceedings of the 5th World Congress on Science and Football

3 Oct, 08 | by Karim Khan


Science and football V: the proceedings of the 5th World Congress on Science and Football.

Edited by Thomas Reilly, Jan Cabri and Duarte Araújo.
Published by Routledge, 2005, pp 634.
ISBN: 978-0-415-48480-0 (paperback); 978-0-415-33337-5 (hardback); 978-0-203-41299-2 (electronic)

Target: Football elite and sub-elite sport science support

Appeal: Broad coverage necessary components sport science. As a sports physician it is not primarily targeted for me and so although it had components of interest, I would not personally purchase

In recent years, sport has by necessity evolved in many facets. Financial rewards have boomed. Information systems have fuelled intense exposure and scrutiny. Doping issues have come under intense publicity and accountability. All this intensifies need for sports to seek ethical advantage with evidence based front line measures.

To fulfill these demands is the immense expectation in sport science seeking that gain an edge in coaching, conditioning and medicine. To achieve this requires sport support services to be reliably informed. This is critical at the elite level to ensure peer parity and at the sub-elite level to provide exposure to elite concepts and portability to sub-elite programs as is practicable.

“Science and Football V: the proceedings of the 5th World Congress on Science and Football” is geared for sports science (conditioning and skill acquisition) rather than primarily sports medicine. It is ideal for coaching staff and strength and conditioning staff. Content is of sound background content for football medical support staff.

Authors are from a wide range of geographic national backgrounds, with strong emphasis on university sport science departments with particular interest in soccer reflecting its international predominance—but representing all codes. Content includes sections on biomechanics, fitness profiling, performance analysis, a small section on medical aspects, football conditioning, physiology and nutrition, paediatric issues and behavioural science.

Topics include coverage of those perennial “footballs”—stretching modes and benefits and relation to injury, warm-up, micronutrient levels and effect of diet and supplementation.

I believe this publication does deliver sound depth and a range of contemporary football sport science for coaching and conditioning support staff, as a summary for those fortunate enough to attend the conference, and as a reference for those particularly involved at the elite level of conditioning for high level teams. For those involved in sub-elite levels it provides an excellent insight into elite performance as a means of extracting ideas into the non-professional level.

P Baquie
Olympic Park Sports Medicine Centre,

Presentation 5
Comprehensiveness 5
Readability 5
Relevance 4
Evidence base 4

Book Review: Martindale’s Drugs Restricted in Sport

10 Sep, 08 | by Karim Khan

Martindale35_l bjsm

Martindale’s Drugs Restricted in Sport, Pocket Companion, 2008
Sean C. Sweetman (editor)
Publisher: Pharmaceutical Press, 2008
ISBN 978-0-85369-825-8
416 pages

“Martindale’s Drugs Restricted in Sport” is unique in its kind. It is the first pharmacopia that lists all the drugs that are on the WADA list of prohibited substances, drawing on the wealth of information and clinical expertise in the full reference work: “Martindale, the complete drug refeerence”. This is a great resource for sports medicine physicians, general practitioners and all other health care professionals working with athletes. It contains over 450 monograhs pertaining to individual drug substances that may be restricted in some or all sports, either in or out of competition.

The book is arranged alphabetically by drug substance. The international nonproprietary name or generic name is used, where one exists.

Other synonyms listed include British approved names, the French, Latin, Spanish, and Russian variants of generic names, names used in other European, Baltic, and Scandinavian countries, comon synonyms, and maufacturer codes.

The clinical profile is based on the full text of “Martindale: the complete drug reference” and describes the basis action and uses of the substance.

The WADA status indicates whether the substance is prohobited in or out of competition.

The WADA class gives an indication of the reason for the prohibition and gives more information about the range of substances covered in that class, plus any special circumstances. It is a great asset of the book that this is repeated with every substance, so you don’t need to go somewhere else to read all the information of the particular substances you are interested in. All the information is given right there where you need it.

A comprehensive index of over 15200 entries is to be found at the back of the book, and includes all names, synonyms, and proprietary (trade) names found in he tex. Even Cyrillic names are listed!

This is a great book for those of us who have been in the awkward situation where our athlete phones us, while away on a trip in Norway, Egypt or Russia, have gotten sick and are not sure of the medication the doctor has given him, and can only provide you, let’s say, the Russian trade name. What do you do?

The player is “strictly liable”, but is depending on you. And it is your name who will appear in the court case on internet for many years to go when you make a mistake. And there is no way you will find that Russian trade name on the WADA doping list!

So now there is a solution to all of these problems: Martindale’s Drugs Restricted in Sport Pocket Companion! The only thing missing is a short summary of the categories of the WADA list of prohibited substances and methods – it would be really helpful is that would be included at the front of the book as well.

Babette Pluim,
Sports physician

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