Now and Later

The story has been told and retold, so many times and in so many versions that it has acquired the aura of an urban legend. In his book Death in the Locker Room II: Drugs and Sports, Bob Goldman attributes the original concept to fellow physician-author Gabe Mirkin. According to Goldman, in the early 1980s Mirkin offered this Faustian bargain to over 100 elite runners: “If I could give you a pill that would make you an Olympic champion—and also kill you in a year—would you take it?” More than half of those questioned responded in the affirmative. Incredulous and suspicious that the responses might reflect a mania unique to runners, Goldman made a similar proposal to high-level competitors from a variety of sports. In Goldman’s adaptation of the scheme, the athlete would enjoy 5 years of limitless success before death would supervene. His canvass of 198 world-class athletes uncovered 102 who said they would gladly accept his offer. Goldman acknowledges that some of the athletes who answered yes may have done so because they recognized that the magical drug was only hypothetical. However, it seems likely that many competitors would accept this proposal even if they believed its stipulations to be genuine. Many young people inhabit a universe in which the present is the paramount reality, and 5 years hence so distant as to be largely theoretical. They also tend to believe in the limitless potential of science. If the wizards of pharmacology could develop a substance capable of imparting unequaled performance, it would be logical to assume that they could also discover an antidote to its fatal side effects before 5 years had run its course. An article in this month’s AJSM again reminds us that athletes, at least younger athletes, are much more concerned with their performance in the here and now than their convalescence in the there and later. In “IKDC or KOOS? Which Measures Symptoms and Disabilities Most Important to Postoperative Articular Cartilage Repair Patients?”, Hambly and Griva used an Internet bulletin board to poll a sampling of patients recovering from articular cartilage repair surgery on their knees. Their methodology mimicked the 2007 study of Tanner et al, which investigated the ability of 11 different outcomes instruments to assess the symptoms and disabilities important to patients with anterior cruciate ligament (ACL) ruptures, meniscus tears, and osteoarthritis. Tanner et al concluded that the WOMAC scale, progenitor of the KOOS, was the best disease-specific instrument for osteoarthritis. Because chondral defects are often a precursor of more generalized osteoarthritis, Hambly and Griva hypothesized that the KOOS would elicit the symptoms and disabilities that are important to postoperative articular cartilage repair patients. Like Tanner et al, Hambly and Griva constructed a composite questionnaire that incorporated items from the scales being compared. The patients were asked to record whether each item reflected a symptom that they experienced and also to rate how important that parameter was to them personally. The results revealed that the patients, who averaged 35 years of age, were most concerned with symptoms that might impede higher levels of function, such as sports. Symptoms that might affect more basic activities of daily living were not experienced by most patients or not much of a concern to them. The authors concluded that current performance limitations and activity restrictions are more important to this population of patients than symptoms that do not restrict their function, even if those symptoms might presage eventual deterioration. In retrospect, it is not surprising that the KOOS, which was developed from a pilot study of patients who averaged 56 years of age, was not the ideal instrument to evaluate the issues that concern a group of 30-somethings. Apparently, cartilage repair patients, or at least those who responded to Hambly and Griva’s call for volunteers, have a kinship with the elite athletes surveyed by Bob Goldman: Their overriding concern is the ability to function optimally now, rather than what might loom beyond the horizon. Like the would-be Olympic champions, they probably believe that some medical genius will conjure up a cure to combat any ills that might occur in the future. A peek into what that future might hold for ACL patients is provided by “Prevalence of Tibiofemoral Osteoarthritis 15 Years after Nonoperative Treatment of Anterior Cruciate Ligament Injury” by Neuman et al. This is one of a series of reports from Lund, Sweden, on a cohort of 100 patients with ACL ruptures. The organizers of this study “encouraged and persuaded” their patients to try initial nonoperative treatment, which was defined to include any needed meniscectomy without ligament reconstruction. Notably, professional athletes, those not willing to decrease their activity level, and patients with “psychosocial disorders” were excluded from participation. Nonoperatively treated patients were urged to abandon sports such as soccer and team handball, and most of them underwent neuromuscular training. Thus, while it does not present a true natural history of untreated ACL rupture or strictly compare surgical with nonoperative treatment, the series does tell us what can be expected when ACL injuries are treated by one particular algorithm. According to the study’s guidelines, ACL reconstruction was offered to patients who experienced more than one significant reinjury episode, felt restricted by giving way to an unacceptable activity level, or sustained DOI = 10.177/0363546503262911