Will a Nobel ever be awarded to someone in sports medicine or science

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					    DR J                                                                                                                                                                                                                                                           DR J




    Will a Nobel ever be awarded to
                                                                                                                                         world to making a unique discovery.       43(3), Spring 2000, pp. 406-448.           Which diseases in sports medicine
                                                                                                                                         Secondly, even if your abstract is                                                   might be caused by infection?
                                                                                                                                                                                   It is worth noting that the “New Germ
                                                                                                                                         rejected from your society’s annual                                                  The number one candidate, in my
                                                                                                                                                                                   Theory” does not pose a threat to the


    someone in sports medicine or
                                                                                                                                         conference (as it was – see the MJA                                                  view, would have to be “chondral
                                                                                                                                                                                   importance of public health, because
                                                                                                                                         article for evidence), it doesn’t mean                                               degeneration” in the knee joint,
                                                                                                                                                                                   of the ability for microorganisms
                                                                                                                                         you won’t end up winning a Nobel                                                     in particular. How many times do
                                                                                                                                                                                   to evolve rapidly. For example,
                                                                                                                                         Prize for the research. Thirdly, you                                                 you see a patient go in for a knee


    science?
                                                                                                                                                                                   the HIV virus is an infection which
                                                                                                                                         can be a touch on the eccentric (mad)                                                arthroscope for a meniscal tear, and
                                                                                                                                                                                   is known to mutate according to
                                                                                                                                         side, as Robin Marshall obviously                                                    in which the surgeon also finds grade
                                                                                                                                                                                   its environment. In Africa, where
                                                                                                                              By Dr J    was when he drank a helicobacter                                                     1-2 chondral degeneration in the joint,
                                                                                                                                                                                   unfortunately sexual practices are
                                                                                                                                         solution to give himself gastritis, and                                              followed by a rapid deterioration after
                                                                                                                                                                                   not generally very safe, HIV is far
                                                                                                                                         it may actually help you be a great                                                  the arthroscopy? A year later another
                                                                                                                                                                                   more virulent, as it is usually given
    It is a time for great celebration that   breakthrough in the field of antibiotics)     just won the FE Johnson Memorial             scientist. Fourthly, you might do well                                               arthroscopy is performed and this
                                                                                                                                                                                   ample opportunity to spread from
    we have just had two Australian           would rank as highly as any of the            Fellowship of the NSW Sporting               to think that infection could have                                                   time the patient has grade 4 chondral
                                                                                                                                                                                   victim to victim, even if the victims
    medical doctors awarded the Nobel         Nobel prizes awarded for medicine.            Injuries Committee for 2005, whereas         an undiscovered role in a common                                                     damage (that is, frank osteoarthritis)
                                                                                                                                                                                   die relatively quickly of the disease.
    Prize for medicine and physiology         Alexander Fleming is credited with            Justin Paoloni has already won the           condition where the ruling view is                                                   and a disability that will last a lifetime.
                                                                                                                                                                                   The strains of HIV which are seen in
    (Robin Warren and Barry Marshall).        discovering that the mould penicillium        David Garlick Memorial Scholarship           that is has no role.                                                                 Of course, the ruling dogma is that
                                                                                                                                                                                   Western countries have, by contrast,
    Their discovery was that the              could inhibit the growth of bacteria, but     for this work.                                                                                                                    the “early” chondral damage seen
                                                                                                                                         One of my all-time favourite articles     become far milder, presumably due
    bacterium Helicobacter pylori is in       the Australian Sir Howard Florey (who                                                                                                                                           in the first arthroscopy constituted
                                                                                            There was an IOC Olympic Prize               I have ever read was called “A New        to the widespread institution of safe
    fact the major cause of stomach           has an institute named after him in                                                                                                                                             a joint “weakness” that after further
                                                                                            in sports science and medicine               Germ Theory” written by Judith            sex practices. Because there is less
    ulcers which can now be successfully      Melbourne) is considered to have been                                                                                                                                           “mechanical loading” deteriorated
                                                                                            which was awarded every two years            Hooper and published in The Atlantic      opportunity for the virus to spread
    treated with antibiotics. Those of us     most responsible for introducing the                                                                                                                                            to frank arthritis. Yes, I believe that
                                                                                            between 1996 and 2002, but not               Monthly in February 1999. This            from patient to patient, it ‘evolves’
    in sports medicine should greet this      antibiotic penicillin to clinical practice.                                                                                                                                     early wear of the knee joint can later
                                                                                            awarded in 2004 because of the               article focused on the theories of        to become more benign, as it would
    award with a similar level of elation                                                                                                                                                                                     become advanced wear, but in the
                                              Warren and Marshall deserve the               withdrawal of sponsorship from the           Greg Cochran and Paul Ewald, who          be disadvantageous to kill its hosts
    that we felt, for example, when Cathy                                                                                                                                                                                     average patient this normally takes
                                              highest of our praises for making a           Pfizer company. This award, if it is         believe (via Darwinian theory) that       before there was a chance to spread.
    Freeman won the 400 m at the Sydney                                                                                                                                                                                       20-30 years. How come it can happen
                                              discovery which vastly improves a             resurrected, may possibly be seen            any common medical condition which
    Olympics. Admittedly the Freeman                                                                                                                                               If, for example, the proponents of         to some poor victims in under 12
                                              common disease in clinical medicine,          as the “Nobel” equivalent in sports          has been around for generations
    gold might have warranted more                                                                                                                                                 the “New Germ Theory” are right            months when they don’t run a single
                                              for being prepared to challenge               science and medicine. Yet it would           but which substantially reduces
    instantaneous joy in that the ‘event’                                                                                                                                          about Type-II diabetes, that it might      step due to the fact that they have
                                              existing dogma about the causation            only be an equivalent for as long as         human fitness should be considered
    lasted less than a minute but there are                                                                                                                                        involve an infectious agent, then it       a knee effusion for the entire year?
                                              of peptic ulcer and, locally, for             it was considered impossible for a           an infectious disease until proven
    more than one hundred Australian                                                                                                                                               would still be important to push the       In my mind, the likely culprit is an
                                              conducting all of their work within           sports medicine researcher actually to       otherwise. For example, not only
    Olympic gold medallists yet only a                                                                                                                                             public health message about exercise       infectious agent and, sadly, the likely
                                              Australia (in the city of Perth). You         win a real Nobel Prize.                      do they believe that peptic ulcer is
    dozen Australian Nobel Prize winners.                                                                                                                                          and good nutrition. In a society           source of entry to the joint is the
                                              should take any chance you get to                                                          caused by an infectious agent, they
                                                                                            Those small-minded folk who think                                                      where there is a high population of        initial knee arthroscopy itself.
    The only Australian Nobel Prize winners   read about the story of Warren and                                                         assert that cardiovascular disease
                                                                                            that I have tenuous grip on reality                                                    overweight and obese people, if an
    in medicine and physiology are:           Marshall, including the free text in the                                                   must be too, along with diabetes,                                                    OK, some of you sceptics out there
                                                                                            would probably suggest to me that                                                      infectious agent can cause diabetes
                                              Christmas edition of the Med J Aust at                                                     rheumatoid arthritis, Alzheimer’s                                                    who may actually be medicos who
    • Warren and Marshall in 2005 for                                                       sports medicine experts should stick                                                   in these people, from an evolutionary
      their discovery of Helicobacter         http://www.mja.com.au/public/                 to the task of proving to the Australian     disease and many cancers, etc.                                                       have treated patients with chronic
                                                                                                                                                                                   perspective it can afford to be a far
      pylori,                                 issues/183_11_051205/van11000_                Government that we actually exist as a                                                                                            effusion post-arthroscopy may be able
                                                                                                                                         If you consider this concept to           nastier agent, as the potential pool of
                                              fm.html                                       distinct area of medicine before anyone                                                                                           to tell me that:
    • Peter Doherty (along with Rolf                                                                                                     be preposterous, remember that            victims is huge (and from the agent’s
                                                                                            starts worrying about winning the            mainstream gastroenterologists have       viewpoint it will not affect its spread    1. Whenever you have sent a knee
      Zinkernagel, a Swiss working            With respect to the field of sports
                                                                                            Nobel prize for a sports medicine study.     only accepted in the last decade that     if a few victims die of the disease). In      effusion in this scenario off for a
      in Australia) in 1996 for their         medicine, a recent Nobel award
                                                                                            Even though we tend to equate sports         Helicobacter pylori causes peptic         a society (which unfortunately is now         culture it has always come back
      discoveries in immunology,              has major relevance (Paul Lauterbur
                                                                                            medicine with sports injuries, if we start   ulcers. There is some evidence that       a hypothetical one) where everyone            negative AND
                                              and Peter Mansfield in 2003 for the
    • John Eccles (along with Hodgkin                                                       to think along the sports and exercise       various chlamydia organisms are           exercised regularly and ate moderate
                                              discovery of magnetic resonance                                                                                                                                                 2. If you have ever happened to treat
      and Huxley of the UK) in 1963 for                                                     medicine paradigm, perhaps it won’t          associated with cardiovascular disease,   amounts of food, if you were a
                                              imaging). In 1998 three Americans                                                                                                                                                  a patient in this scenario with a
      his discoveries regarding nerve                                                       be long before we see an exercise            although this has not yet been proven     diabetes-causing virus you would
                                              (Furchgott, Ignaro and Murad) shared                                                                                                                                               standard antibiotic (eg, Amoxil)
      cells,                                                                                medicine Nobel laureate. Researchers         to nearly the same degree as the          quickly mutate to a more benign
                                              the Nobel Prize for medicine for their                                                                                                                                             it hasn’t helped with the knee
                                                                                            such as Jeremy Morris, Ralph                 helicobacter/peptic ulcer connection.     form. It would be very costly to kill
    • Frank Macfarlane Burnett (along         discoveries with respect to the role                                                                                                                                               effusion.
                                                                                            Paffenbarger and Stephen Blair must          For a summary of of the Atlantic          your victims due to the difficulty in
      with Peter Medawar) in 1960 for his     of nitric oxide in the cardiovascular
      discoveries in immunology, and          system. Their work has probably
                                                                                            surely be close to that elusive Nobel        article, please refer to: http://www.     finding replacement victims (given         This is where a read of the story of
                                              inspired that of George Murrell and
                                                                                            for their work proving that exercise can     injuryupdate.com.au/forum/                that the virus might need a high-fat       Marshall and Warren is extremely
    • Howard Florey (along with Fleming                                                     prevent heart disease and cancer.            showthread.php?p=1066#post1066.           host environment in which to live).        valuable. They only managed to
                                              Justin Paoloni who have discovered
      and Chain of the UK) in 1945 for                                                                                                   And for a more formal reference, try      Therefore, even if there are infectious    culture Helicobacter pylori when
                                              that nitrates can improve the clinical        If we switch back to Marshall and
      the discovery of penicillin.                                                                                                       Cochran GM, Ewald P and Cochran           agents that cause diabetes that we         one of their plates was accidentally
                                              outcome of tendinopathy, which                Warren, there are lessons for us to
    In terms of the impact on improving                                                                                                  K (“Infectious Causation of Disease:      are yet to discover, we can limit their    left in a laboratory over the Easter
                                              may one day be worthy of a major              learn. Firstly, that you can be an
    the human condition, the discovery of                                                                                                An Evolutionary Perspective) in           spread by increasing rates of exercise     break. Normally in pathology if a
                                              international award in the field              Australian and living and working in
    penicillin (which was the biggest ever                                                                                               Perspectives in Biology and Medicine      and improving nutrition.                   culture is not positive after 48 hours,
                                              sports medicine. George Murrell has           Australia and still beat the rest of the


4    Sport Health                                                                                                                                                                                                     VOLUME 23 – ISSUE 4 • SUMMER 2005-06                  5
    DR J                                                                                                                                                                                                                           ANTI-DOPING AUTHORITY




                                                                                                                                     The new Australian Sports
    the plates will be discarded and a         by Vincent J, Podewell C, Franklin         Achilles tendinopathy patients have
    negative result recorded. Helicobacter     GW and Korn JH. This short                 cracked heels, presumably due to
    pylori managed to evade detection for      PubMed abstract states that Kingella       low-grade skin fungal infection
    many years because it takes longer         (Moraxella) kingii, a gram-negative        (see figure). A lot of the general


                                                                                                                                     Anti-Doping Authority
    than 48 hours to multiple on an agar       bacillus, was isolated as the cause        population also has low-grade fungal
    plate. When you think about it, based      of septic knee arthritis in an adult.      infection of the heel, but is it more
    on Darwinian theory, if you are an         Three previous cases (one adult and        common in Achilles tendinopathy
    infectious agent in modern times           two children) of septic arthritis due to   patients? I don’t know, but perhaps                                                                                                                             Adam Firth
    (such as a bacterium, virus or fungus)     Moraxella species have been reported.      one day in the future I will do a case-
    what would be the most important           All cases have been characterised by       control study to test this hypothesis,       The year 2004-05 has been a landmark in Australia’s anti-doping effort, Chairperson Brian Sando says in the latest -– and
    characteristic you could evolve to         difficulty in identifying the organism,    and on another occasion I might treat        probably the last -- annual report of ASDA before the Government turns it into ASADA, the Australian Sports Anti-Doping
    ensure your survival? The mainstream       indolent clinical course and slow          some of my non-response Achilles             Authority.
    thinking is that “antibiotic resistance”   response to antibiotic treatment.          tendinopathy patients with Lamisil to        Acting Chief Executive Kim Terrell points out in the report that the establishment of ASADA, implementing one of the biggest
    (or anti-viral resistance) is the major                                               see how they go.                             testing programs ever undertaken in Australia and the work on the 2006 Commonwealth Games will be high priorities for 2005-
                                               Does this (underlined section) sound
    evolutionary defence mechanism that                                                                                                06. For example, the Agency will conduct more than 7,000 drug tests in 2005-06 -- on average, that’s at least 19 athletes tested
                                               to you like the standard progress
    microorganisms have. What about                                                                                                    every day of the year.
                                               of a post-arthroscopy patient with a
    inability to grow on an agar plate in                                                                                              Sport Health here publishes extracts from the report on issues of special interest to its readers, such as no advance notice
                                               chronic effusion? What if there are
    a pathology lab? Wouldn’t that be                                                                                                  testing, trends in notifiable events and the prospects for an online athlete whereabouts system.
                                               actually dozens of organisms out
    a far more valuable characteristic
                                               there like Kingella kingii, which can
    to develop compared to antibiotic
                                               chew through knee articular cartilage
    resistance? If you are resistant to an
                                               but are difficult to identify and
    antibiotic, the humans will just hit you                                                                                         On 23 June 2005 the Australian              governing bodies in Australia sign on          or other law enforcement agencies
                                               don’t respond to standard antibiotic
    with a different antibiotic until they                                                                                           Government announced its intention          to use ASADA for such purposes.                where relevant to a possible anti-
                                               treatment? Apparently Kingella kingii
    nail you. However, if you refuse to                                                                                              to establish the Australian Sports                                                         doping policy breach;
                                               does not grow well in the laboratory                                                                                              It will be a condition of government
    conform to their belief that they must                                                                                           Anti-Doping Authority (ASADA),
                                               within 48 hours and if not transported                                                                                            funding and other support that              • power to present the prosecution
    be able to see you grow within 48                                                                                                which from early this year will take
                                               in blood culture bottles so, from                                                                                                 sports submit all their anti-doping           case before a tribunal (whether or
    hours on an agar plate in a pathology                                                                                            over from the Australian Sports
                                               a routine tap of the knee joint, a                                                                                                operations to ASADA, and ensure that          not ASADA investigated the case).
    laboratory, they probably won’t even                                                                                             Drug Agency (ASDA) as Australia’s
                                               Kingella kingii infection will generally                                                                                          their members and staff cooperate             This may include prosecuting
    know that you exist and therefore                                                                                                NADO under the World Anti-Doping
                                               return a negative result (just like                                                                                               fully with ASADA in the performance           adverse analytical findings in
    won’t be throwing any antibiotics in                                                                                             Code (WADC), but with significant
                                               Helicobacter pylori used to do with                                                                                               of its functions. It will also be a           respect of a sample tested by
    your direction in the first place.                                                                                               additional functions to ASDA in the
                                               peptic biopsies). For more info, read                                                                                             requirement that the sport accepts            ASADA; and
    If the bacteria (or other non-bacterial    http://www.medterms.com/script/                                                       fight against doping in Australian
                                                                                                                                                                                 any adverse finding of ASADA against
    microorganisms) which are most likely      main/art.asp?articlekey=33658.                                                        sport.                                                                                  • the ability to publish results of any
                                                                                                                                                                                 any of its athletes (or other persons
    to infect a knee after an arthroscopy                                                 The great thing about being involved                                                                                                 hearing where it is in the public
                                               One of my personal areas of clinical                                                  No doubt ASADA is motivated at              within the sport’s jurisdiction),
    happen to be resistant to amoxicillin                                                 in science is the thrill of watching                                                                                                 interest.
                                               expertise is the treatment of Achilles                                                least in part by the Australian cycling     ensures that infraction notices are
    and don’t grow on agar plates, then                                                   our knowledge base evolve. Fifteen         controversies of the past two years         served on such persons and enforces         The effect will be to have a common
                                               tendinopathy, and I occasionally think
    they can continue on their merry way                                                  years ago the internet didn’t exist and,   and the experiences in the United           penalties imposed in accordance with        procedure and consistent practices
                                               about whether an infectious agent
    eating through the layers of articular                                                25 years ago, no one suspected that        States with the BALCO scandals. Its         the sport’s anti-doping rules. The          throughout Australian sport in
                                               might be responsible for the failure
    hyaline cartilage whilst the doctors                                                  Helicobacter pylori was a common           enabling rules and regulations are          Government has used purse string            pursuing anti-doping rule violations
                                               of Achilles tendinopathy patients
    who are supposed to be treating the                                                   cause of peptic ulcer. If you are          not yet finalised and accordingly           control to good effect in forcing all       and enforcing anti-doping policies.
                                               to repair their degenerative lesions.
    patient nod their heads about the                                                     working in sports and exercise             this article can only make comment          Australian sports to sign on to the         Consistency between and within
                                               We know that tendon degeneration
    inevitability of cartilage breakdown. I                                               medicine, you are working in an area       on some features that have been             WADC and it can be expected that it         sports can only be a positive thing in
                                               is very common (eg, the Jill Cook
    can remember a case from my intern                                                    which, despite its snubbing by the         announced and in relation to such a         will pursue use of ASADA with the           reducing uncertainties that have in the
                                               studies on patella tendons) yet we
    year of a woman who had a persistent                                                  mainstream medical profession, is one      body generally.                             same intent.                                past been seen in anti-doping matters
                                               know that many people with tendon
    effusion after a knee arthroscopy and                                                 which is critical to the advancement                                                                                               in Australia and around the world.
                                               degeneration don’t get pain and                                                                                                   More specifically, in addition to
    was stuck on my orthopaedic ward                                                      of human health. Maybe we won’t
                                               many cure their own radiological
    for weeks due to severe knee pain.
                                               tendinopathy spontaneously.
                                                                                          see a Nobel Prize-winning discovery        ASADA’s powers                              ASDA’s existing powers, ASADA will          The most significant new features
    Eventually the pathologists isolated                                                  in sports medicine in our lifetime, but                                                have:                                       of ASADA are its investigative
                                               Could it be that those who don’t                                                      It has been confirmed that ASADA                                                        and prosecutorial functions. An
    Kingella kingii bacterium from                                                        maybe we will. What is assured is                                                      • power to conduct investigations on
                                               spontaneously cure possibly have an                                                   will replace ASDA in handling the                                                       independent, government-funded
    her knee, but it was thought to be                                                    that there will be new and successful                                                    the basis of information acquired
                                               infectious agent responsible for the                                                  responsibilities of sample collection                                                   body fulfilling such a role has been
    possibly a benign pathogen.                                                           ways to prevent and manage major                                                         from its drug testing and other
                                               ongoing degeneration? I’m not saying                                                  and testing, and education and                                                          sought by many sports organisations
                                                                                          sports injuries that are discovered in                                                   activities, or where it has received
    There is a case report which suggests      that this is necessarily the case, but                                                advocacy. It will also play a role in                                                   in this country for some time as
                                                                                          our lifetime, and that some of them                                                      information from any other person,
    this may be a cause of septic              I can hypothesise that it wouldn’t                                                    policy development relevant to sports                                                   the burden of anti-doping policy
                                                                                          will be discovered in this wonderful                                                     or on its own initiative;
    arthritis in J Rheumatol (1981 May-        be an in-your-face bacterium like                                                     doping, and most significantly will                                                     enforcement distracts time and
                                                                                          country of ours.
    Jun;8(3):501-3): “Septic arthritis due     Staphylococcus aureus, or someone                                                     act as the investigator and prosector       • power to receive, use and disclose        resources from developing their
    to Kingella (Moraxella) kingii: case       would have already cultured it.                                                       of all allegations of anti-doping rule        (where appropriate) information           sport, their competitions and their
    report and review of the literature”,                                                                                            violations relating to sports whose           from Australian Customs Service           athletes. This is particularly the case
                                               I regularly notice that many of my

6    Sport Health                                                                                                                                                                                                  VOLUME 23 – ISSUE 4 • SUMMER 2005-06                7

				
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