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When looking back at the evolution of sports medicine, there is no doubt that the future can only manifest itself in an exponential entanglement of science, legality, and ethics. Science will move on the offence and push through with new discoveries and revelations. Progressing faster than ethics and legality, it will lay the trail for the race. Ethics and legality will run to catch up.

Breakthroughs in genetics present us with a promise and a predica-ment. Although we may be able to treat and prevent a host of debilitating diseases, our newfound genetic knowledge may also enable us to manipu-late our own nature. We will be able to enhance our muscles, memories, and moods, and to choose the sex, height, and other genetic traits of our children.

Many believe that sports medicine will make its most significant future contributions in the area of prevention. Injury prevention is gaining ground in the study of the body’s neuromuscular adaptations. For exam-ple, a study of specific preseason neuromuscular training in soccer players demonstrated a significant decrease in the incidence of anterior cruciate ligament tears.¹In addition, Janda and colleagues reported that serious injuries in recreational softball are reduced by 98 percent when break-away bases are used.²

However, because the risk of injury will never be eliminated entirely, future research will address alternative therapies as well. In an interview, sports medicine pioneer Frank Jobe was asked what he thought would be the next breakthrough in medical technology to help prevent pitching injuries, especially shoulder injuries. Jobe suggested that stem cell research

would be a key technology. He also mentioned that regrowth of cartilage in joints to treat injured knees, elbows, or shoulders could really help degener-ative conditions in a way that is not well done today.³

T^ISSUE E^NGINEERING

Tissue engineering is a technology based on the development of bio-logical substitutes for the repair, reconstruction, or regeneration of tissues.

Most tissue engineering has been tested and applied in bone and cartilage research. Other research involves the development of biocompatible materials that do not corrode in the body or set off an immune reaction and tissue rejection.

Scientists are devising ways to grow tissue grafts in Petri dishes to be transplanted to patients. The combination of tissue engineering and gene therapy will create more powerful muscles, stronger tendons, and more durable joints.

GENE THERAPY

Gene therapy is the insertion of genetic material into an individual’s cells or tissues to treat a disease. Clinical trials indicate its potential use-fulness in the treatment of metastatic skin cancer and diseases of the bone marrow system.

The birth of Dolly the cloned sheep in 1997 brought to many people terror at the prospect of cloned human beings. Cloning is now a regular attendant in news issues, especially around election season. The mere mention of cloning can immediately stir controversy. Many people want to argue the point, despite a grievous misunderstanding of the technol-ogy that not all cloning deals with human embryos. In fact, most cloning is performed with bacteria or cultured mammalian cells (e.g., mouse muscle cells).

Andrew Kilbarger (eight years old) received three injections in his right arm and became one of six boys participating in the first U.S. gene therapy trial for muscular dystrophy. Andrew, like other muscular dys-trophy patients, lacks the gene that controls production of a protein called dystrophin. Other scientific progress on muscular dystrophy, cou-pled with the successful completion of the first gene therapy clinical trial, has led to three more clinical trials planned for the immediate future.

Gene Therapy in Sports Medicine

Alleviating muscular dystrophy and reversing the debilitating muscle loss — can this same therapy be used to improve athletic performance?

Gene therapy is important to sports medicine because it enables the transfer of desired genes into target tissues. This scientific advancement will be important for healing. Researchers have developed a synthetic gene that, when injected into the muscle cells of mice, prevents and even reverses natural muscle deterioration. The gene not only repairs wasted or injured muscles but also strengthens healthy ones. Because of the nature of gene therapy, therapeutic substances are steadily produced by local cells at the site of injury or inflammation.

Genetically enhanced athletes are easy to imagine. The widespread use of steroids and other performance-improving drugs in professional sports suggests that many athletes will be eager to avail themselves to genetic enhancement. Alas, gene therapy will likely be misused.

Genetic enhancement is possible for brains as well as brawn. In the mid-1990s, scientists managed to manipulate a fruit fly memory-linked gene, thus creating flies with photographic memories. More recently, researchers produced smart mice by inserting extra copies of a memory-related gene into mouse embryos. The altered mice learn more quickly and remember things longer than their normal counterparts. The extra gene remained active even in old age, and the improvement was passed on to the offspring. All this brain research will hopefully make athletes think about the ramifications of human use.

DESIGNER DRUGS

The arms race is on. Every athlete wants arms as long as Michael Jordan’s and as muscular as Mark McGwire’s. Since the 1980s, human growth hormone has been approved for children with a hormone deficiency that makes them much shorter than average. This agent is very effective at increasing the height of healthy children, too. By 1996, such off-label use accounted for 40 percent of human growth hormone prescriptions.

Seeking to expand its market, Eli Lilly & Co. recently persuaded the U.S.

Food and Drug Administration to approve the company’s human growth hor-mone for healthy children whose projected adult height is in the bottom one percentile (less than five feet, three inches for boys and four feet, eleven inches for girls). This raises a big question about the ethics of enhancement.

If hormone treatments are no longer limited to those with hormone deficien-cies, why should they be available only to very short children? Shouldn’t all

short children be able to seek treatment? What about a child of average height who wants to be taller so he can make the basketball team?

For the physician, other concerns emerge. How can one accurately pre-dict the adult height of a child? What happens if the child is perceived to be short, undergoes growth hormone treatment, and later hits a growth spurt raising him to an unnatural height? Is being extremely short any dif-ferent from being excessively tall?

The use of steroids and other pharmaceuticals to gain a competitive edge in athletics has been a part of the sports world for a long time, and steroids are likely to remain on the forefront of sports medicine. They offer desirable traits for athletes, albeit at a high price.

The recent identification of tetrahydrogestrinone (THG), the first true designer androgen, as a sports doping agent reflects an alarmingly sophis-ticated, illicit manufacturing facility and an underground network of androgen abusers. Clandestine scientists are on the search for other designer drugs. Undetectable substances and substances that mask other illegal agents are the fruit of the labor. These scientists are on a tight dead-line in terms of the Olympics. They have four years to develop and distribute the agent before the next competition, and chances are that by the next set of games the agent will have been exposed and the scientists will need to have a backup ready to go.

Some athletes want bigger muscles, whereas some want bigger brains.

Current research in Alzheimer’s disease has opened the door for other doping strategies in sports. Therapies for Alzheimer’s disease and other memory disorders can enhance the thinking power of healthy people too.

Having a mental edge in sports is highly desirable.

Better Testing

While one group of rogue scientists searches for new and improved agents, others are looking for better ways to detect the illicit drugs. Over the past several years, scientific advances in the detection of sports doping agents and improved collaboration between sports organizations have enhanced the monitoring of fair athletic play. Although confirming the exis-tence of designer steroids is credited to the sports antidoping movement, antidoping agencies need to continue investing in research and depending on honest athletic participants to maintain fairness and safety in sports.

B^IONICS

Formed from the words biology and electronic, the word bionics is defined as the replacement or enhancement of organs or other body parts by mechanical versions. Bionic implants differ from mere prostheses

because they mimic the original function very closely, maybe even surpassing it.

At the 2005 annual meeting of the American Association of the Advance-ment of Science, Andrew Schwartz from the University of Pittsburgh described a study in which a monkey fed itself using a robotic arm, elec-tronically linked to its brain. The monkey was able to learn to control the arm, using ninety-six electrodes — each thinner than a human hair — attached to the monkey’s motor cortex, a region of the brain responsible for voluntary movement.

One day, this research may lead to permanent artificial prostheses for those who have lost a limb. Furthermore, it will increase the mobility and dexterity of those suffering from spinal cord injuries or nervous system disorders. Trials in humans are anticipated by 2009.

Monkey manipulates a robotic arm. Photo courtesy of Andrew Schwartz from the University of Pittsburgh.

The biggest hurdle to this research is the buildup of biological material on the electrodes. This type of corrosion causes the signal to and from the brain to degrade over time. On average, the electrodes in a monkey’s brain last only six months. Future research will unveil more biologically com-patible materials, as well as devices that transmit signals without wires.

These new materials or devices will enable the jump to human studies.

Other developments previously thought to be in the realm of sci-fi are already a reality. Such developments include the Flexfoot (a carbon-fiber prosthesis) and the knee joint that the Canadian runner, Earl Connors, is using to run the 100-meter in 12.61 seconds with an above-the-knee amputa-tion. In addition, researchers from the University of Southern California and the Doheny Retina Institute presented data on the first six patients implanted with a retinal prosthesis, more popularly referred to as an artificial retina.

After the surgery, patients were able to localize the position or count the number of high-contrast objects and to discriminate simple shapes and spa-tial orientation. Although the results were not perfect, they shed light on the hope for future research. Various trials are underway now.

Cochlear implants (bionic ears) are surgically implanted, electronic devices that provide a sense of sound to people who are profoundly deaf or severely hard of hearing. Unlike hearing aids, the cochlear implant does not amplify sound; instead, it works by directly stimulating auditory nerves inside the ear with electrical impulses. Cochlear implants restore the hearing of adults to a level allowing normal conversation, the use of the telephone, and even understanding with a limited amount of background noise.

As electronics continue to grow smaller, the quality of cochlear implants continues to improve. Future research will increase the number of elec-trodes on the array and improve the software. Tomorrow’s recipients may be able to hear at levels superior to that of the general population. However, other research in deafness may render the cochlear implant obsolete if a biological cure is developed.

Most viable therapies for kidney failure are based on the use of stem cells. However, bionic kidneys are in the works. Early experiments with dogs that had kidney failure demonstrated the possible effectiveness of a bio-artificial kidney and paved the way for the first use in ten kidney patients in an intensive care unit. Recently, a phase II clinical trial evalu-ated the device in 58 critically ill patients on dialysis. The results were impressive, but need to be confirmed in a larger study. This next phase of research is expected to take two to four years.

The goal of future research in bionics is to prolong life and promote well-being. These are honorable goals indeed, but sports medicine profes-sionals have to wonder about the possibility of the six-million-dollar man.

These available devices, along with other devices in the pipeline, serve to provide hope.

Other Developments

Most people normally do not consider animals to be a special group in sports medicine, but they are. Although it is not addressed in detail, the legal and ethical ramifications of sports medicine in veterinary science are outstanding and growing. Horse and dog racing are big businesses. Just as other types of sports, veterinary science faces its own challenges in sports medicine, namely doping. Veterinarians are key players in the emerging field of sports medicine for animals.

What about new hybrids of electronically embedded clothing? Sports bras that count heartbeats? The Keep on Moving jacket is futuristic work-out apparel that will track athletic performance using biometric sensors.

The jacket will boast a digital audio player and a virtual coach to monitor training levels and create a performance log, which can then feed back into home computer devices. The future will hold swimwear that actually makes you less resistant in the water and thus swim faster. Oh wait, that already exists.

Sports medicine meets veterinary medicine. Photograph compliments of Blue Ridge Equine Clinic, Earlysville, VA.

Every Harry Potter fan eagerly awaits for Quidditch game gear. Aside from computer games that simulate playing Quidditch, the only other Quidditch technology available today involves bicycles and unicycles instead of broomsticks.

Science moves faster than ethics and legality, and faster than moral understanding. Therefore, the future of ethics and legality of sports medicine is hard to discern. Bernstein and associates sought to define the ethical norms and ideals in sports medicine. They concluded that many unresolved areas remain in the field of ethics in sports medicine.⁴

Doping will continue to be questioned, as will stem cell research and cloning. What is wrong with producing designer athletes? In terms of human cloning, what is the problem with creating a child who is a genetic twin of a sports star or celebrity? These questions and others are difficult to answer, and there may be no right answer.

There are two types of athletic achievements, those through natural gifts, or those through perseverance and training. Fans appreciate players like Pete Rose, not blessed with great natural gifts but who strive with grit and determination to excel in the sport. However, fans also admire players like Joe DiMaggio, whose innate talents make the sport appear graceful and effortless.

Now, entertain an ethical supposition. Suppose we learned that both Rose and DiMaggio took performance-enhancing drugs. Would we be equally dis-illusioned by both players? Which player’s drug use would offend us the most? Are we likely to overlook the indiscretions of one type of player, namely, the weaker one, more than another? Effort is not everything. Very few believe that a mediocre basketball player who works and trains harder than Michael Jordan deserves more airtime or a bigger contract.

Economics can further twist the ethics. Perhaps genetic enhancement becomes widely accepted. Will everyone, athlete or otherwise, be able to afford the technology? Will society spilt between those who can and those who cannot? Some worry about the danger of creating two classes of human beings, those with access to enhancement technologies and those who must make do with their natural capacities. If enhancements are passed down through generations, the two classes could conceivably become subspecies.

The law of sports medicine is a rapidly developing field, too. Sports law establishes an important body of jurisprudence, defines the legal rights and duties of all parties, and protects the health and safety of ath-letes. The evolution of sports law draws important distinctions between the relevant duty of care owed to athletes because of the differing legal relationships that arise out of athletic participation at different levels of competition (e.g., high school, college, professional). Society must

identify and develop these emerging legal trends. It is critical to under-stand the history of the law of sports medicine in order to predict its future direction and to critique its progression.

This book, designed to show the true entanglement of science, legality, and ethics as they relate to sports medicine, will end with a call for ath-letes, coaches, physicians, fans, and the media to unite and respect all these issues for what they truly are.

NOTES

1. Heidt, R.S., Jr., Sweeterman, L.M., Carlonas, R.L., Traub, J.A., Tekulve, F.X. Avoid-ance of soccer injuries with preseason conditioning. Am J Sports Med 2000 Septem-ber;28(5):659–662.

2. The prevention of baseball and softball injuries. Review article. Clin Orthop Relat Res.

2003 Apr;(409):20–8.

3. ESPN interview from September 13, 2002. Text available at http://espn.go.com/mlb/

columns/bp/1431308.html.

4. Bernstein, J., Perlis, C., Bartolozzi, A.R. Normative ethics in sports medicine. Clin Orthop Relat Res 2004 March;(420):309–318.

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