Published 6/1/2008
Michael F. Schafer, MD; Mary Ann Porucznik

“If you’re not cheating, you’re not trying”

Use of performance enhancers has implications for orthopaedic surgeons

If you’re an orthopaedic surgeon who serves as a team physician, you’ve had to address the issue of performance-enhancing drugs (PEDs). No matter what the sport, or what the level of play, PEDs have made inroads among athletes—so much so that in some locker rooms, “if you’re not cheating, you’re not trying.”

PEDs, once almost exclusively associated with athletes, have also become more widespread in the general population. A recent series in Sports Illustrated outlined the breadth of the problem, which encompasses not only players but also media personalities, police and paramilitary personnel, and ordinary Americans who want to look, feel, and live “at the top of their game.”

That means that if you haven’t yet encountered PED use among your patient population, you’re likely to in the near future. In addition, the Congressional scrutiny of the use of PEDs by athletes and proposed legislation regulating their sale is also likely to have an impact on patients with a legitimate need for these drugs.

This issue of AAOS Now takes a look at the most commonly used PEDs, the recent investigations into their use in professional sports, current and proposed legislation—particularly regarding testing at the high school level, and resources available to teams, team physicians, coaches, and athletic trainers.

What are PEDs?
Who hasn’t seen an advertisement for the performance enhancer Viagra®? But the use of PEDs extends far beyond the bedroom. Major League Baseball’s drug prevention and treatment program lists more than 100 substances, including the following:

  • more than 50 types of anabolic androgenic steroids, including androstanediol, stanozol, and testosterone and its various derivatives
  • more than 30 types of stimulants, including amphetamine and its analogs, ephedrine, and related substances
  • human growth hormone (HGH)
  • insulin-like growth factors
  • erythropoietin and related compounds
  • at least 2 dozen diuretics and masking agents such as epitestosterone, probenecid, and plasma expanders
  • miscellaneous anabolic agents and hormone modulators (such as mechano growth factors, estrogen modulators, and gonadotrophins)

Currently, the most commonly used drugs to enhance musculoskeletal performance are testosterone, androstenedione, anabolic steroids, and human growth hormone. Although ephedra-based dietary supplements—which have also been used by athletes to reduce fatigue, lose weight, and improve mental alertness—were banned by the U.S. Food and Drug Administration (FDA) in 2004, their place is being taken by an increase in the use of drugs to treat attention-deficit hyperactivity disorder (ADHD) amoung athletes.

How widespread is the use of PEDs?
Last year, former Sen. George Mitchell presented the results of his independent investigation into the use of steroids and other PEDs among major league baseball (MLB) players. The report documented the “widespread illegal use of anabolic steroids and other performance enhancing substances” and named more than 80 players implicated or identified as users.

The Mitchell Report was just the latest in a series of investigations into the use of PEDs, particularly steroids, in sports. In 2003, more than 30 elite athletes—including Olympian Marion Jones and MLB players Barry Bonds, Jason Giambi, and Gary Sheffield—testified before a grand jury investigating the use of an “undetectable” steroid being distributed by the Bay Area Laboratory Cooperative (BALCO). Recent best-sellers such as Jose Canseco’s Juiced: Wild Times, Rampant ’Roids, Smash Hits, and How Baseball Got Big allege steroid use by several MLB players.

Ongoing investigations by the House Committee on Oversight and Government Reform and the Department of Justice may still result in punishments and prosecutions.

PED use has also been documented among Olympic athletes, weightlifters, football players, NASCAR drivers, and competitive cyclists. In addition, actors, recording artists, scientists, military personnel, and, increasingly, ordinary Americans are reaching for PEDs to maintain musculoskeletal flexibility, enhance mental functioning, or improve performance.

Nor is this usage always illegal. In many cases, PEDs are prescribed by physicians—often for conditions that have nothing to do with sports. According to one team physician, the number of players diagnosed as having ADHD has skyrocketed. Ritalin, the most common drug used to treat ADHD, enhances concentration and may help athletes cope with jet lag or late-night double headers.

PEDs and young athletes
A recent public television report focused on the impact of PEDs and young athletes, specifically those who participated in the East German state-sponsored sports program in the 1970s and 1980s. Young swimmers, weightlifters, and track-and-field athletes who were given anabolic steroids and vitamins as part of their training regimen became world record holders and Olympic gold medalists. But in later life, they also faced increased risks of cancer, gender identity issues, and severe musculoskeletal problems.

The use of steroids among teen athletes may be decreasing. According to the 2005 National Youth Risk Behavior Survey, 4 percent of high school students admitted using illegal steroids, down from 6.1 percent in 2003. A new survey, however, showed the extent to which teens are willing to go to achieve their dreams, as the following statistics show:

  • 6 percent of 12th grade males reported using steroids
  • Among those who admit using steroids, 80 percent said they believed the drugs could help them achieve their athletic dreams
  • 65 percent of steroid users would be willing to use a pill or powder, including dietary supplements, if it guaranteed they would reach their athletic goals, even if it might harm their health
  • 57 percent of users said they would use it even if it could shorten their lives
  • About 6 in 10 users believe that professional athletes have the right to use steroids, and they think that using anabolic steroids for athletic purposes is legal. Additionally, about 60 percent of users said that professional athletes influenced their (or a friend’s) decision to use PEDs

Within the past 2 years, four states have established steroid screening programs at the high school level. (See “High school steroid screening,” on page 10 for details.) In addition, several government and nonprofit groups have established educational programs that may be used with students, including the following:

  • Cheating your health, sponsored by the U.S. Anti-Doping Agency (www.usantidoping.org)
  • Powered by me!, an educational campaign developed in Maryland (www.poweredbymemd.com)
  • ATLAS (Athletes Training & Learning to Avoid Steroids), developed by the Oregon Health & Science University

Editor’s note: This is the first of two articles on the use of performance-enhancing drugs. In the second article, AAOS Now will talk to team physicians, representatives from major league sports, and others about how to address the problem. If you would like to share your experiences in counseling or treating athletes who are considering or have used performance-enhancing drugs, e-mail your comments to aaoscomm@aaos.org

Michael F. Schafer, MD, is a member of the AAOS Now editorial board; he can be reached at MSchafer@nmff.org

Mary Ann Porucznik is the managing editor of AAOS Now. She can be reached at porucznik@aaos.org

Did you know?

  • 15 million—the number of Americans who use performance-enhancing drugs, according to one estimate
  • $1 billion plus—the amount of money spent annually in the United States on legal (prescribed) human growth hormone (HGH)
  • 2.4 million—the number of prescriptions for testosterone filled by U.S. pharmacies in 2004
  • 3 million—the number of Americans who use anabolic steroids
  • 750,000—the estimated number of children who have used steroids and HGH
  • 97%—the percentage of teen respondents to a poll conducted by Sports Illustrated who said they would not try steroids or HGH even if they knew the substances would make them better athletes

High school steroid screening
Four states have established steroid screening programs at the high school level; additional states, including New Mexico and Indiana, are considering programs.

New Jersey

  • First state to establish a program, which is currently in its second year
  • Applies only to athletes who belong to teams in statewide tournaments
  • Random testing of 500 athletes
  • Penalty for positive result: forfeit of 1 year of eligibility in sport
  • No positive results found in first year of testing


  • Testing begins with 2008-2009 school year
  • First voluntary program; adopted by Illinois High School Association
  • Random testing of athletes competing in sectional, regional, and championship games
  • Penalty for positive result: 1-year suspension from sports


  • Covers more than 40,000 athletes in all sports
  • Random testing of 3 percent of all athletes
  • Established in response to state government action
  • Penalty for positive result: First time—30-day suspension from sport; second time—1-year suspension; third time—permanent ban


  • Currently in first year of testing
  • Random testing of 1 percent of weightlifters and football and baseball players
  • Established in response to state government action
  • Penalty for positive result: 90-day suspension

Read the next story in this series...www.aaos.org/aaosnow/jul08/cover1

View a slideshow on Ergogenic Drugs in Sports