The pain principle

Every six months, New York Yankees pitcher Randy Johnson gets injected with a substance in his right knee that allows him to pitch without pain. With the injections, Johnson can work out longer and harder and stay fresh at 43 years old despite the complete lack of cartilage in his knee.

And this treatment – the one that seems to turn back Johnson's clock – is completely legal by Major League Baseball's standards and endorsed by trainers and doctors around the game.

How baseball reconciles Johnson's therapy with the murky world of performance-enhancing drugs is largely a matter of semantics. Doping doctors claim that treatments such as Supartz – Johnson's preferred brand of hyaluronic acid, a substitute for the synovial fluid that keeps joints lubricated – are for therapeutic uses. Drug companies go to lengths not to call hyaluronic acid a drug.

Because with a condition such as osteoarthritis, where cartilage stops producing fluid, breaks down and causes bone-on-bone grinding, the goal is to return users to their previous levels of comfort.

For athletes, however, the five once-weekly shots taken twice a year not only prolong, but save careers.

"I know when I need those shots just by the swelling and the soreness in my knee," said Johnson, the left-hander who has won 56 games since he starting taking Supartz in 2003. "Doctors have told me here and in Arizona that I'll be a likely candidate for a knee replacement when I'm done playing, but for now I just get by on those shots, and, hopefully, they won't fail me for when I need them again.

"I've had pretty good results with them."

To determine its list of performance-enhancing drugs, the World Anti-Doping Association considers three criteria: Does the substance enhance performance, is it a significant health risk and does it violate the spirit of sport (i.e. is it cheating)?

With viscosupplementation – the medical name for hyaluronic-acid treatments – athletes have shown they perform at higher levels with the treatment than they could without. Taken in the strictest sense, then, hyaluronic acid is a substance that enhances performance.

Studies have shown hyaluronic acid to be safe, which rules out No. 2.

The third criterion is the vaguest. One person's cheat is another's opportunist. There is a growing movement that considers the use of human growth hormone (hGH) as part of a larger hormone-replacement therapy. Essentially, patients take injections of hGH to return to their previous levels of testosterone – just as Johnson claims Supartz has his knees feeling better than they have in years.

"Without it, my knee would bother me," Johnson said. "It would swell. But the reason why it doesn't swell now is that buffer's in there. If I didn't have that, there would be more swelling and irritation, and I'd have to have my knee drained like it was in the past.

"I could pitch (like that). How effectively and how long, I don't know."

Less pain. Increased performance.

Sound familiar?

This is not an indictment of Johnson or any of the other dozen or so baseball players known to have taken hyaluronic acid as much as it is a showcase of the conundrums created in the intersecting world of modern medicine and baseball. What enhances performance and what rediscovers status quo? And in cases with aging athletes, is achieving what was previously there all of a sudden enhancing performance?

"I think there's a general consensus among all the parties as to what therapy is," said Dr. Gary Wadler, a doping expert with WADA. "Basically, it's to take someone who has an illness and injury to get them back to baseline, to where they were before."

Wadler sees hyaluronic acid on the same plane as surgery – a medical procedure in hopes of repair once all other options, such as Tylenol, ibuprofen or ultrasound, have been exhausted. If a pitcher comes back throwing harder after Tommy John surgery, the reasoning goes, he got lucky.

Nowhere in WADA's code does it specifically define therapy, nor does it address the vagueness of its criteria to choose what enhances performance and what doesn't, leaving decisions instead to a board. When a treatment such as hyaluronic acid is approved by the Food and Drug Administration for general use, it will usually receive WADA's rubber stamp, even if there are critics elsewhere.

"I think they're expensive placebos," said Dr. David Felson, the chief of Boston University's Clinical Epidemiology Research Training Unit and a frequent detractor of hyaluronic acid since its FDA approval. "I think the data for the pivotal trial that led the FDA to approve the therapy shows no compelling evidence that it works. I don't know why Randy Johnson is helped."

Hyaluronic acid was discovered in 1934 by scientist Karl Meyer. He found it in cow eyeballs. Later, high concentrations of hyaluronic acid were found in the red combs on top of roosters' heads. Drug company Pfizer began breeding its chickens to grow extra-large combs – so big, in some cases, that they could no longer keep their heads up, according to a New York Times story three years ago.

The rooster combs are synthesized into a gel that, when injected into the knee, serves as temporary cartilage. After exhausting other therapy options following knee surgery in 2003 – the year after he won his fifth Cy Young Award – Johnson tried Synvisc, which he didn't like, then went to Supartz and has stuck with it since.

His right knee, which takes the brunt of the force when his 6-foot-10 frame lands with each pitch, was shot. Years of wear and tear, plus numerous surgeries, left the inside mangled, and Johnson said he would have tried anything within reason to salvage it, because that also meant saving his career.

"I was never leery of it," Johnson said. "It makes pretty good sense. It's very safe. Your body absorbs it. It works."

Despite Felson's claims of a placebo effect, there are legions of believers in hyaluronic-acid treatment, including Johnson's manager.

The pain in Joe Torre's left knee was unbearable throughout July. He walked gingerly, looking more old man than confident leader. Today, he can lock his knees without them locking up on him.

"When I called and said I'm hurting, he said we could try this," Torre said. "We did three weeks running, and thank goodness. I like just getting up on the road and walking down the street. For a time, I couldn't even do that."

To the medical community, Johnson and Torre are triumphs of science, proof that treatments that weren't around in the United States even 10 years ago ease life and extend livelihoods. Repairing, and in some cases improving, knees, elbows and shoulders – three of the essential joint structures for baseball players – is a feat, while anything to do with testosterone levels faces social and political stigmatization.

"What is doping anyway?" Felson said. "When do we label something as doping and medication? My guess is that it has to do with treating pain and treating disease, which are acceptable, instead of taking someone who doesn't have pain."

Felson's definition lacks the ambiguity of WADA's, and it would seem to pass the sniff test until applied to players' workouts. In order to keep up, most players tax their bodies in the gym. As they age, they cannot lift the same amount of weight they did 10 years earlier, and when they try, their bodies scream. This is not something Tylenol, ibuprofen or ultrasound can remedy, and when players lose their fitness, they are in greater danger of losing their careers. In that vein, shouldn't they have access to an alternative treatment that would allow them to work out longer, just as hyaluronic acid does so many others?

"Sometimes," Wadler said, "it's more complicated than that."

No. It used to be complicated sometimes. Now it always is.