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Volume 61, Numbers 3 & 4
2003-2004
Athletic Ergogenic Aids
Adam Bernstein, M.D., Jordan Safirstein, M.D., and Jeffrey E. Rosen, M.D.
T
he term “ergogenic” stems from the Greek roots –
“Ergon” and “genes,” meaning “work” and “born,”
respectively. Any means of enhancing energy
production or utilization may be described as an ergogenic
aid.1 Ergogenic aids have classically been classified into
five categories: mechanical, psychological, physiologic,
pharmacologic, and nutritional.2 The present use of the term
“ergogenic aid” usually revolves around the physiologic,
pharmacologic, and nutritional categories.
While ergogenic aids have been linked to athletic “doping,” the terms are not synonymous. Doping is a term used
by the International Olympic Committee (IOC) to describe
the administration or use of a substance by a competing
athlete with the sole intention of increasing in an artificial
and unfair manner his or her performance in competition.3
Not all ergogenic aids are banned by the IOC. A partial
listing of substances banned by the United States Olympic
Committee is found in Table 1.2,3 Table 2 provides a list of
commonly used athletic ergogenic aids.
Anabolic-Androgenic Steroids
Anabolic-androgenic steroids (AAS) are testosterone derivatives that exert anabolic (tissue building) and androgenic
(masculinizing) influences on the body.3 Since the discovery
of the chemical structure of testosterone in 1935, attempts
to separate the anabolic and androgenic effects of AAS
Adam Bernstein, M.D., is a Senior Resident, NYU-Hospital for
Joint Diseases Department of Orthopaedic Surgery, New York,
New York. Jordan Safirstein, M.D., is a Resident, Department
of Internal Medicine, Albert Einstein College of Medicine, New
York, New York. Jeffrey E. Rosen, M.D., is in the NYU-Hospital
for Joint Diseases Department of Orthopaedic Surgery, New York,
New York.
Reprint requests: Jeffrey E. Rosen, M.D., NYU-Hospital for Joint
Diseases Department of Orthopaedic Surgery, 303 Second Avenue,
Suite 2, New York, New York 10003.
have been unsuccessful.3 Athletes have been using AAS
since the 1940s in efforts to improve their performance.2
Concerned with widespread abuse of AAS among athletes,
the IOC banned AAS use in the early 1960s.2 The Anabolic
Steroids Control Act was legalized in 1990, making it a
felony to possess or distribute AAS for non-medical purposes
in the United States.3,4 Oral, parenteral, transdermal, and
intra-nasal forms of AAS are available. The vast majority
of AAS used by athletes is thought to be obtained on the
“black market,” as only an estimated 10% to 15% of AAS
used by athletes for performance enhancement are obtained
by prescription.3
AAS are believed to exert their main effect by increasing anabolic processes and inhibiting catabolic processes
via specific receptor mediated responses within the target
cells.5 Effects of AAS include: the anabolic build-up of
muscle mass, the androgenic development of secondary male
sexual characteristics, an anti-catabolic reversal of cortisol’s
action, and a direct psychological effect thought to allow
a more intense and sustained workout.2,5-8 Early studies of
AAS and athletes produced mixed results.5,6 More recent
reviews support the notions that AAS can provide significant increases in muscle mass and strength in athletes.2,5,6 In
order to maximize the effects of AAS on strength and power
athletes, an adequate diet and exercise regimen is needed.5
There seems to be little advantage gained while using AAS
in the untrained individual.5,9 Benefits obtained from AAS
are more established in strength-dependent sports. Data
supporting increased aerobic capacity and improved endurance with AAS use is limited and inconclusive.4 AAS effect
on endurance sports is currently an area of great interest
given the large number of endurance athletes who still use
AAS.4,10
An intricate terminology describing the dosing practices
of athletes has evolved. Athletes will commonly use AAS
over 6 to 12 week “cycles.”4 “Pyramiding” describes a
Bulletin • Hospital for Joint Diseases
Table 1 Partial List of Substances Banned by the United
States Olympic Committee
Prohibited Classes of Substances
Stimulants
Narcotics
Anabolic agents
Diuretics
Peptide hormones, mimetics and analogues
This is not an exhaustive list of prohibited substances – many
substances not appearing on this list are considered prohibited under the term “and related substances.”
Prohibited Methods
Blood doping
Pharmacological, chemical and physical manipulation
Use of substances and methods that alter the integrity and
validity of urine samples during drug testing
Classes Subject to Certain Restrictions
Alcohol
Cannabinoids
Local anesthetics
Glucocorticosteroids
Beta-Blockers
Caffeine
gradual escalation in the dose of AAS taken over a cycle.2,11
“Stacking” involves the use of more than one AAS, usually
with staggered cycles of the individual drugs.2-4 An “array”
describes the practice of using other drugs to counteract
side effects or enhance the effects of AAS.3 The practices
of cycling, pyramiding, and stacking are used by athletes in
an attempt to minimize the negative effects of AAS while
maximizing the desired enhancements.2,4 At the current time,
no solid scientific support exists for these practices.2,4,5
The adverse effects attributed to AAS abuse have been
historically overstated.4,12 The majority of AAS side effects
are considered minor and reversible following the cessation
of use.4 While the incidence of serious side effects from
AAS use has been low, devastating consequences have been
reported.13 Documented fatalities from myocardial infarction, stroke, and hepatocarcinoma have been attributed to
AAS use.2,3 The long-term effects of AAS use are generally
unknown.3,11
Dehydroepiandrosterone (DHEA)
Dehydroepiandrosterone (DHEA) is a precursor to testosterone produced primarily in the adrenal glands.4,14 Natural
sources of DHEA include wild yams. The FDA banned sale
of DHEA in 1996 due to insufficient evidence of safety and
value; however, DHEA remains a legal and popular item
sold as a nutritional supplement.14,15
The mechanism of action of DHEA is poorly understood
but most likely revolves around the conversion of DHEA
to testosterone in peripheral tissues.4,14 Preliminary studies
suggest that DHEA may have a broad range of clinical uses
including anti-Alzheimer and anti-Parkinson capabilities,
however randomized, double-blinded clinical studies are
Volume 61, Numbers 3 & 4
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165
lacking.5
DHEA is a pre-cursor to testosterone and theoretically
may enhance athletic performance in a manner similar to
AAS. Investigations of DHEA use and athletic performance
are scarce.14 Existing studies do not support a significant
increase in lean body mass, strength, or testosterone levels
with the use of DHEA in athletes.14,16-18
Long-term side effects of DHEA use are currently unknown but are probably similar to those associated with AAS
use.6,14
Androstenedione
Androstenedione is a testosterone pre-cursor produced in
the adrenal glands and gonads. Several professional athletes
have used this substance, bringing it to national attention.2
Androstenedione is found naturally in the pollen of Scottish
pine trees.19
Similar to DHEA, the mechanism of action and side effects attributed to androstenedione are poorly understood and
thought to be related to the conversion of androstenedione
to testosterone in the peripheral tissues.5
Despite manufacturers’ claims to the contrary, there is
little scientific evidence of the purported ergogenic effects
of androstenedione.2,5,16,20 Recently concerns have grown
over the unfavorable alterations in blood lipid and coronary
heart disease profiles seen in men using androstenedione as
an ergogenic aid.2,20,21
Dietary Supplements
The increased visibility of ergogenic aids in the last decade has occurred primarily because of the passage of the
United States Dietary Supplement Health and Education Act
(DSHEA) of 1994.22 Certain vitamins, minerals, amino acids,
herbs, and other botanical preparations can be classified as a
“dietary supplement” under the DSHEA guidelines. Dietary
supplements, as a result of DSHEA, are no longer under the
direct regulatory control of the FDA. In fact, substances sold
as a dietary supplement do not require FDA evaluation for
safety or efficacy, and do not have to meet quality control
standards expected of approved drugs.5 The content and
purity of dietary supplements are not regulated and can
vary widely.5,23 Since androstenedione and DHEA have been
found to occur naturally in plant sources, these testosterone
precursors can be labeled as “dietary supplements” and sold
legally over-the-counter.
Ephedra
Dietary supplements containing Chinese ephedra, also
known as Mahaung, are marketed as performance enhancers
and weight-loss aids.24 Ephedra species of herb have been
used for over 5,000 years for respiratory ailments.25 Currently, ephedrine alkaloids are found in hundreds of prescriptions and over-the-counter products, such as antihistamines,
decongestants, and appetite suppressants.24-26 Ephedra and
related ephedrine alkaloids are sympathomimetic agents that
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Bulletin • Hospital for Joint Diseases
Volume 61, Numbers 3 & 4
mimic epinephrine effects.
Multiple studies of isolated ephedrine alkaloids have
shown no significant enhancement of power or endurance
at dosages considered to be safe.24,27-31 In contrast, the combination of caffeine with ephedrine has been associated with
improvements in performance and may promote metabolic
effects that are conducive to body fat loss.26,32
The actual content of ephedra alkaloids in 20 ephedracontaining dietary supplements was studied using highperformance liquid chromatography.33 Ten of the twenty
supplements exhibited marked discrepancies between the
label claim for ephedra content and the actual alkaloid
content. Between 1995 and 1997, 926 cases of possible
Mahuang toxicity were reported to the Food and Drug Administration.34 A temporal relationship between Mahuang
use and severe complications including stroke, myocardial
infarction, and sudden death was established in 37 of the 926
cases. In 36 of these 37 cases, the Mahuang use was reported
to be within the manufacturers’ dosing guidelines.
Ephedra and related ephedrine alkaloids are currently
banned by the U.S.O.C. and cannot be recommended for
general use given their association with potentially lifethreatening side effects.2,34
Creatine
Creatine use in athletes has grown as a result of a 1992
study that showed that creatine supplementation produced
a 20% increase in skeletal muscle creatine concentration.2,35
In the phosphorylated form, creatine serves as an energy
substrate that contributes to adenosine triphosphate (ATP)
re-synthesis during high-intensity exercise.36 Creatine remains popular with power and resistance athletes as it is
thought to produce increases in strength, muscle mass, and
to delay fatigue.2,14,36
Creatine is synthesized from amino acids primarily in the
liver, pancreas, and kidney and is excreted by the kidneys.
Creatine is found in skeletal muscle, cardiac muscle, brain,
retinal, and testicular tissues.2,37 The interest in creatine as
an ergogenic aid revolves around its ability to participate
as an energy substrate for muscle contraction.14 Creatine,
which easily binds phosphorus, can act as a substrate to
donate phosphorus for the formation of ATP. Furthermore,
creatine-phosphate (PCr) can help buffer lactic acid because
hydrogen ions are used when ATP is regenerated.14,36,38 This
role of creatine in exercise is governed by the following
reaction:
PCr + ADP (adenosine diphosphate)  Creatine +
ATP.(metzl)
Creatine kinase
Normally PCr stores deplete within 10 seconds of short,
high-intensity exercise.14,39 Increasing the level of PCr in
skeletal muscle, in theory, should result in the ability to
sustain high-power output longer and lead to a greater re-
2003-2004
synthesis of PCr after exercise.14 The beneficial effects of
creatine in response to resistance training are most likely
mediated by the following sequence: increased muscle
creatine concentration, increased training intensity, which
lead to an enhanced physiologic adaptation to training with
increased muscle mass and strength.36
Studies evaluating the effectiveness of creatine as an ergogenic aid are mixed.2,36,40 Multiple reports do conclude that
short-term creatine supplementation significantly enhances
the ability to maintain muscular force and power output during high-intensity exercise.2,36,41,42 Data on results of creatine
supplementation with highly trained athletes is inconclusive.
While some papers report improvements with creatine use
in highly trained individuals with regards to high-intensity
exercise, many show no improvements.2,36,43
Most investigators agree that creatine supplementation
does not seem to enhance aerobic-oriented activities.2,36,44
Human muscle is thought to have a maximum concentration of creatine that it can hold.14,45 There appears to be
no additional benefits of increasing creatine supplementation above this storage capacity of muscle as the excess is
simply excreted by the kidneys.2,46 Humans have differing
baseline levels of muscle creatine.14 Accordingly, athletes
with lower baseline levels of creatine may be more sensitive to creatine supplementation than those with a relatively
higher baseline creatine level.14,36 The terms “responder” and
“nonresponder” have been used to describe two groups of
athletes: those with relatively low baseline creatine levels
that may show significant performance enhancement with
creatine supplementation, and those with high baseline
creatine levels that do not show marked improvements with
creatine supplementation.14,36,47 These differences in creatine
concentrations are thought to play a significant role in the
varied results on performance found in the literature examining creatine supplementation.14
Reported side effects from creatine use have been
scarce.2,14 The major reported side effect associated with
creatine use is weight gain, which is thought to be primarily a
result of water retention.2,14,48 Some reported longer-term side
effects include dehydration, muscle cramping, nausea, and
seizures.2,49 Given the relative lack of studies, caution still
remains about the long-term effects of creatine usage.14 As
creatine use among younger athletes continues to increase,
concern is growing over the lack of studies that examine the
possible side effects specific to this age group.14,38
Human Growth Hormone
Human growth hormone (hGH) is a polypeptide produced
in the anterior pituitary gland. After its release from the
pituitary, hGH can exert its effect in all cells of the body
via tissue specific receptors. Human growth hormone is
shown to promote protein anabolism, carbohydrate tolerance, lipolysis, natriuresis, and bone and connective tissue
turnover.4,50
Potential benefits of hGH abuse in athletes revolve around
Stimulants
Amphetamines
Sympathomimetics
(OTC decongestants)
Caffeine
Cocaine
Agonists (Beta2)
(GREEK BETA)
Narcotics
Central nervous system stimulant
Reduce fatigue
Improve reaction times
Increase alertness and aggression
(Endurance sports)
Create vasoconstrition and higher blood
pressure
(Milder) centeral nervous system effects (see
above)
(Aid in fat loss, e.g., ephedrine use by
female body builders, also endurance sports)
Delay of fatigue by enhancing muscle
contractility
Enhance performance on short, intense
periods of exercise
Sparing of muscle glycogen levels
(Various sport activities, endurance sports)
Possible distortion of perception of enhanced
performance and reduce strength
(Ergogenic effects in sport are inconclusive;
accumulation more likely from recreational
use by athletes)
Improves activities dependent on aerobic
function
Promotes muscle growth
Reduction in body fat
Used as alternative to anabolic steroids
(see below)
(Endurance sports, sports with an “appearance”
aspect, like weight lifting)
Pain reliever
(Variable use across athletic activities)
How Substance has been Employed
by Athletes (Sport Example)
Milder doses: insomnia, irritablity, tremor,
increase in aggressive behavior, restlessness
Higher doses: tachycardia, sweating, arrhythmias
higher blood pressure; can impede ability to
to reduce body temperature
Chronic use: danger of amphetamine psychosis
Abuse in endurance sports: contribute to heatstroke
Headache, dizziness, hypertension, irritability,
some anxiety tachycardia
Higher doses: mania or psychosis; possible
cerebral hemorrhage/stroke
Mild: insomnia, irritablitiy, GI disturbances
More severe: peptic ulcer, seizure, coma,
arrhythmias, hallucinations, death
Note: complex pharmacology
Abuse can effect: hypertension, seizures, psychosis,
negative impact on glycogenolysis, myocardial
toxicity/intense exercise (possible ischemia,
arrhythmias, sudden death)
Beta2 adrenoreceptors: higher doses allow Beta1
adrenoreceptor stimulation
At higher doses: Beta1 adrenoreceptor stimulation:
hand tremor, tachycardia, arrhythmias, insomnia,
headache, nausea
Anabolic effects (related to high dose): example of
clenbuterol-myalgia, dizziness, nausea, periorbital
pain, and/or asthenia (also see below)
Absence of pain could exacerbate underlying or
mask new condition
High doses: coma and stupor, possible lethal from
respiratory depression
Withdrawal symptoms following dependence:
sweeting, nausea, insomnia, anxiety, aching
muscles, and others
More severe - cardiovascular collapse
(Milder) centeral nervous system effects
Antagonist of adosine receptors
Inhibits phosphodiesterase type enzymes,
resulting in activation of cyclic AMP, link
between receptor activity and cell response
Includes inhibition of various
neurotransmitters, such as dopamine
Bronchodilation (also used for asthma) by
stimulation of Beta2 adrenoreceptors in
respiratory tract (smooth muscle)
Also anabolic effect (see below)
Higher doses: stimulate Beta1 adrenoreceptors
(with side effects)
Interaction with brain receptors sensitive to
endorphin transmitters (also affecting
emotions)
Adverse Affects*
Release: various neurotransmitters
Inhibition: uptake of neurotransmitter
Direct impact: neurotransmitter receptors
Inhibition: monamine oxidate activity
Activation of alpha-1 adrenoreceptors in
vascular smooth muscle, decrease in mucus
secretion
Effects on central nervous system, similar
to amphetamines, but weaker (see above)
Mechanism of Action and Effects
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(continued on next page)
Prohibited Classes
of Substances
Table 2 Ergogenic Aids in Athletes
167
Prohibited Classes
of Substances
Anabolic androgenic
steroids
Diuretics
Human Growth Hormone
Erythropoietin
Peptide hormones,
mimetics and analogues
Improve lean body mass/strength
Reduction of body fat
Relative to training, enhances recover time,
promotes energy and aggressive performance
Concomitant drugs (hGH, hCG)* have been
taken to enhance anabolic effects or to
minimize adverse effects (diuretics, opiates,
among others) or to maximize intensity of
training (added stimulant). No solid evidence
to support above practices.2,4,5
(Strength-dependent/Endurance sports)
No sport enhancing effects
Reduce weight
Manage fluid retention
Increase urine to dilute other doping agents
Increase muscle mass
Spares muscle glycogen
More intense training may be possible
Quicker recovery following training
(No support for enhanced performance3,52,53)
Increases oxygen capacity of red blood cells
An alternative to blood doping
(Endurance sports)
Acquire substances which provoke other
agents that have ergogenic attributes, such as
testosterone with its effects or those that
increase muscle tissue
(Variety of activities)
How Substance has been Employed
by Athletes (Sport Example)
Table 2 Ergogenic Aids in Athletes (continued)
Adverse effects historically overstated.4,12
Majority are minor and reversible following
stoppage.4 Incidence of serious effects are
catastrophic, but low.13 Long term effects generally
unknown.3,11
Broad classes — cosmetic: masculinization and
gynecomastia; liver abnormalities: dysfunction,
tumor; infection/injection techniques: hepatitis
mycobacterial, HIV/AIDS; cardiovascular: may
increase risk of atherosclerosis; reproductive:
atrophy of testicles, decreased sperm producation;
psychiatric/psychological: mood swings,
depression and mania/hypomania
Diuretic use during exercise produces harmful
effects
Hypohydration: electrolyte disturbances can
compromise the muscles and heart
Side effects can worsen if accompanied by fatigue
and/or glycogen production
Adverse effects in sport are not well evidenced due
to short-term substance usage, where effects and
features of acromegaly do not occur
Little published research on EPO and athletes. In
patient use headaches, flu-like symptoms, joint
pain may occur (all of which appear to resolve).
Abuse risk involves too high a hematocrit. An
increase in hematocrit occurs which increases blood
viscosity, a state that can be exacerbated by
dehydration, possibly viscosity syndrome
(hypertension, decreased output, possible heart
failure). At a certain level of increased hematocrit,
a risk of cerebral or coronary occlusion.
Little published research in sports. Information
becomes constrained to studies of individual agent
effects, e.g., hCG may produce symptoms of
fatigue, headache, and mood swings, among others.
There are no published reports of adverse effects of
insulin use in sports.
A glycoprotein hormone. Manufactured mostly
in kidney. Endogenous production influenced
by a decrease in oxygen to the kidney. Result:
increased number of RBCs produced from
bone marrow and increased rate of RBCs into
blood circulation
hCG and LH provoke testosterone release
Insulin may ease glucose entry into cells and
promote bulking of muscle tissue
Adverse Affects*
Act on endogenous androgen receptors
Increase protein synthesis
Antagonist to glucocorticoid hormones/
anti-catabolic effects
Tissue building/anabolic effect
Virilizing/androgenic effect
Effect on kidney resulting in excessive loss
of fluid
Polypeptide hormone of pituitary gland.
Activates growth hormone receptors to allow
the producton of insulin-like growth factor-1
(IGF-1) with anabolic effects
Mechanism of Action and Effects
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Antioxidants
its anabolic effect on the body.4 Human growth hormone is
thought to increase muscle mass, and spare muscle glycogen
by stimulating lipolysis during exercise.2,3 The popularity of
hGH among athletes is furthered by the fact that hGH remains extremely difficult to detect by current drug screening
processes.3,51 Human growth hormone may be particularly
attractive to female athletes as the virilization side effects
associated with AAS use are not thought to occur with
hGH.4
There are no studies that demonstrate significant increases
in athletic performance with the use of hGH.3,52,53 Neither
human or animal studies show any significant strength gains
with supplemental hGH use in non-deficient individuals.4
The abuse of hGH is thought to be increasing despite the
lack of scientific evidence linking hGH to improved athlete
performance.3,52 A survey of high school males revealed
that as many as 5% reported past or present use of hGH.54
The purity of hGH abused by athletes may be poor as Drug
Enforcement Agency estimates project that up to 30% to
50% of the hGH products sold are phony.4,55
Adverse effects of exogenous hGH use are extrapolated
from the findings seen in patients with endogenous oversecretion of hGH.2 Adults with high levels of hGH are
at risk for the clinical syndrome of acromegaly. Medical
complications associated with acromegaly include: diabetes,
hypertension, coronary heart disease, cardiomyopathy, menstrual irregularities, and osteoporosis.2,4 High levels of hGH
in individuals with open physis may lead to gigantism.2
Beta-hydroxy-beta-methylbutyrate (HMB) is a metabolite
of the branched-chain amino acid leucine. HMB is theorized
to inhibit muscle breakdown during strenuous exercise but
its exact mechanism of action remains unknown.14,58 Studies
show that HMB supplementation may significantly lower
serum lactate dehydrogenase (LDH), lower serum creatine
phosphokinase (CPK) levels and delay blood lactate accumulation after endurance training compared to placebo.59,60
Furthermore, short-term HMB use has been shown to significantly increase strength gains with resistance-exercised
training over placebo in one double-blinded study.61
HMB is a relatively new ergogenic aid and published
results are considered preliminary.14,58 Although there is
evidence for a potential ergogenic advantage with HMB
use in resistance and endurance training, its use can not be
recommended until more studies are performed and potential
side effects are elicited.
Erythropoietin (EPO)
Caffeine
Recombinant EPO (r-EPO) was approved by the FDA for
manufacture in 1989 after the EPO gene was cloned in
1985.14 Since its approval, r-EPO has been abused for athletic
personal gain as an alternative to blood doping.3,14 Recombinant EPO has largely replaced the practice of blood doping,
as r-EPO produces a dose-dependent increase in hematocrit.2
In theory, r-EPO should provide all of the benefits of blood
doping without the risks involved in blood transfusion.3
There are few studies evaluating the use of r-EPO in
healthy athletes; however, numerous studies have shown a
significant increase in work capacity due to r-EPO use in
patients with renal disease.14 Berglund and Ekblom reported
an increased maximal oxygen consumption and increased
time to exhaustion in male athletes after a 6 week trial of
r-EPO.56
The risks associated with r-EPO abuse involve the potential for dangerously high hematocrit levels.14 A resulting
hyperviscosity syndrome may lead to a decreased cardiac
output, hypertension, and potential heart failure.3 Furthermore, thrombosis could be manifest as myocardial infarction, pulmonary embolism, or cerebrovascular accidents.2,3
Although the use of r-EPO has been banned by the IOC since
1990, its use is extremely difficult to detect with current drug
screening measures.2,14
The antioxidant capabilities of certain vitamins are believed
by many to counter-act the production of free-radials that
occurs during exercise.14 Most of the research to date involves vitamin E, vitamin C, and beta carotene.2 The existing
literature does not support the notion that antioxidants have
significant ergogenic capabilities.2,14,57 There are currently no
recommendations for antioxidant use in athletes that exceeds
the normal adult recommended daily allowance (RDA).
Beta-hydroxy-beta-methylbutyrate
Caffeine is a methylxanthine occurring naturally in many
species of plants. Caffeine is thought to work through a
variety of mechanisms. The central nervous system effect
of caffeine is probably the result of adrenergic receptor
antagonism.3 Its use by athletes stems from the theory that
caffeine may delay fatigue by enhancing skeletal muscle
contractility and spare muscle glycogen levels by enhancing
fat metabolism.6 Multiple studies have reported an improved
endurance time with caffeine use.6,62,63 There is evidence that
caffeine use may enhance performance with more intense
short-duration exercise as well.2 The caffeine dosages most
associated with an ergogenic effect range in the literature
from 3 to 9 mg per kilogram of body weight.2,6
Side effects associated with caffeine use include anxiety,
diuresis, insomnia, irritability and gastrointestinal discomfort.2,6 Higher doses of caffeine ingestion can lead to more
serious consequences such as cardiac arrhythmia, hallucinations, and even death.2,3
The legal urine level of caffeine for athletes is 12 µg/ml
(IOC standards) and 15 µg/ml (National Collegiate Athletics
Association standards).6 An athlete would need to drink six
to eight cups of coffee in one sitting and be tested within 2
to 3 hours to reach urine levels over the IOC legal limit.3 The
amount of caffeine needed to produce ergogenic benefits is
potentially far less than that required to exceed the athletic
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Bulletin • Hospital for Joint Diseases
Volume 61, Numbers 3 & 4
legal limit.3
Summary
Claims championing exotic substances that produce healing
or ergogenic powers have been around for centuries. The
competitive, peer-pressured environment enveloping today’s
athletes and adolescences makes these groups particularly
susceptible to the uproar surrounding the current ergogenic
aid market. Presently, it seems that rumor and anecdotal
information overwhelms the available scientific data. While
there is evidence that some touted ergogenic aids do indeed
enhance performance, there are many unanswered questions
about product safety, efficacy, and long-term consequences.
A working knowledge of specific ergogenic aids is essential
for the treating physician in order to best advise patients and
athletes as to the possible benefits and risks of any substance
they may be using.
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