Consider the following medical procedure. A doctor removes blood from an athlete. He isolates and concentrates certain components and injects those components back into the athlete.

Is that legal? Is it ethical?

Now let’s replace “certain components” with specific examples.

First, the doctor isolates the platelets, concentrates them and injects them into a diseased area of tendon, ligament or muscle. Or the doctor isolates a natural antagonist of the protein IL-1, concentrates it, and injects it into an athlete’s aging knee.

Drawing bloodThe first example is better known as platelet-rich plasma (PRP). The second is Orthokine. The governing bodies of the professional sports allow these treatments.

Now let’s say that the doctor instead isolates the red blood cells, concentrates them, and places them back into the athlete. Since the presumed goal of this treatment is to increase the oxygen-carrying capability of blood and therefore increase endurance, this “blood doping“ process is illegal in sports.

There are many other examples of scientific or medical treatments that blur the lines between sports medicine and performance enhancement. For example, athletes can undergo Lasik, a procedure that reshapes the cornea, to improve eyesight. After injuries, athletes can use tissue from donors to replace torn ligaments in their bodies.

The distinction between legal and illegal treatments is arbitrary. It’s easy to say that some of them only treat injuries and medical conditions and help an athlete return to compete. The others work to actually improve performance, whether or not a medical condition or injury exists.

In that sense, one category is morally acceptable, while one isn’t. It’s appropriate to use science to heal but not to use some of the same treatments to enhance performance.

We are very close, however, to a time when there is essentially no difference. For example, when is using a medicine to slow the effects of age on an athlete’s body legal, and when is it illegal?

For years, pro athletes have rationalized (after they are caught, of course) their use of anabolic steroids or HGH as treatments to help them recover from injuries. They claim that their bodies don’t heal as quickly as they did when they were younger. That argument receives cynicism and no reversal of their suspensions.

If an athlete uses HGH or anabolic steroids or other treatment that we don’t even know about to rebuild muscle size after a knee or shoulder injury, or if he uses testosterone to restore his levels to what they were in his twenties, those uses are illegal.

Cartilage damage in the knee
Note the area of damaged articular cartilage (red arrow) surrounded by healthy articular cartilage.
On the other hand, athletes have been increasingly flying to Germany to undergo Orthokine treatments. Others receive a series of injections synthesized in the laboratory out of the combs of roosters. Those treatments aim to treat or reverse the wear and tear of the cartilage in their joints – the effects of long careers. Those treatments are currently both legal and ethical.

On the podcast B.S. Report with Bill Simmons, author Malcolm Gladwell observes that these standards seem to apply only to athletes.

“I am a baseball pitcher. I hurt my arm. And I have a reasonable expectation that through the use of human growth hormone, I can recover in one week instead of two weeks. That’s apparently illegal. Why is that illegal? Why is there a rule that says I can’t use cutting-edge medical technology to recover faster so I can go back to doing my job?”

He contrasts that example with a hypothetical 50-year-old construction worker who performs demanding physical labor. If he wanted to take human growth hormone or testosterone to help get out of bed every morning and do his job a little better, it’s doubtful that people would chastise him.

“It is only because we have a very, very particularized, and almost fetishistic notion of purity in sports that we insist that the athlete has to be treated separately from the construction worker, even though they both have the same physical needs,” Gladwell argues.

What about the philosophic argument that medical advances could prevent injuries? There is a common myth that surgeons perform Tommy John operations on pitchers with normal ligaments in their elbows to make them even stronger. That might sound preposterous. But if that procedure was actually done – not to improve performance, but to prevent injury later in a pitcher’s career – would the public dismiss the idea as quickly? I’ve seen many pitchers and their parents in my practice who would sign up immediately.

I’m not advocating that sports organizations stop testing for performance-enhancing drugs or make all of these treatments legal. But we are approaching a time when there is a very fine line between treatments to aid recovery from injury, preventing the effects of injury, and improving performance. Sports organizations, parents, coaches, athletes and society will have to decide where to draw that line.

Note: The following post appears in a modified format as my sports medicine column in the May 7, 2013 issue of The Post and Courier.