UTK Special 1/18/24

The CRISPR Problem

I’ll start with a couple stories. First, I’ve had I don’t know how many parents email me over the years, asking who their son should go to about his sore elbow, and why it happened, and what they can do. Inevitably, someone asks a variation on “Should he just have Tommy John surgery now and get it out of the way?”

There’s so many things wrong with this. First, no one has elective ligament reconstruction. No football dads think their kid should just “go ahead and get a new ACL”. Add in the revision rate and having it done earlier means the second one comes earlier if the root causes aren’t fixed. Those revision rates are going up, though the success rates are as well, in part because of the ages both are done now.

Advances such as augmented reconstruction might change this equation some, though I’d suggest the first thing someone does before having InternalBrace put in would be to try an external brace. So the answer is not only always no, there’s no evidence that any orthopedic surgeon has performed a prophylactic elbow reconstruction.

Second, back around the time I wrote The Juice and steroids were supposedly everywhere (they weren’t, and aren’t), someone at a Prospectus Pizza Feed asked me whether Tommy John surgery or something like Greg Maddux’s mid-season LASIK surgery should be considered “performance enhancing.” I don’t remember my exact answer, but so many things are performance enhancing and we draw an odd line at things that aren’t “natural.” Both Tommy John surgery and LASIK are medical miracles that get someone back to standard. (When I had my LASIK over a decade ago, I went from drastically far-sighted to 20/15 overnight.)

I won’t get into the ethics of it, but I’ve never been an enhancement absolutist. To be an NFL lineman, you have to do things that are definitely not natural. To play in the NBA, you have to be genetically one of the outliers, often with the later physical problems that entails*. If you want to draw the line with things like HGH and testosterone, fine, but insulin-based enhancement is “natural” and probably more effective than most steroid regimens. The physical beating that NFL players in particular take is brutal.

I’ll go one more example here and say what if Rowdy Tellez showed up to Pirates camp down 50 pounds. Let me be clear that Tellez is an MLB-quality player, more athletic than most of you and certainly me, but that he’s always been very open about his physique, using it as a strength rather than a weakness. But here he is in Bradenton, looking more like Andrew McCutchen than a “Beefy Boy” and when asked why he’s in the Best Shape of his Life, he answers simply “Ozempic.”

We’ve had vegan ballplayers and keto ballplayers and alcoholic ballplayers. We’ve had Mark Grace and Jim Leyland sneaking smokes in the dugout as recently as the 1990’s. What would be different about a perfectly legal, widely used drug that would allow a player to drop weight? Someone out there is thinking “CC Sabathia dropped weight and didn’t pitch well.” Can you actually tie those two together? Would dropping weight help Tellez, or anyone? I don’t know, but I doubt it’s going to be another decade before we find out.

Which, finally, brings me to the point I want to make here. I read medical journals for fun - I know, I’m weird - and look for studies that have an application to baseball, or sports in general. A lot of times there are things that start out as intended for sports. Augmented and/or fertilized reconstruction will help many people through reduced rehab times, but there’s no doubt it was first considered for the athletic market. Other times, things bubble up, such as research on hip anatomy that led to a fix for hip labrums. Those were largely due to the large market for hip replacements in the elderly population, but it led to players like Chase Utley coming back and having a solid post-surgical career.

Recently I found one where a study funded by a large pharma company was looking at the effects of a CRISPR based therapy on the damage that Psoriatic Arthritis (PsA) does to ligaments. If you’re not familiar with CRISPR, please go back to the top and watch the video, but the simplest answer is that it’s a gene editing technique. For someone with PsA, they’ve long had debilitating autoimmune problems that are often not in control. In some cases, even expensive biologic medicines don’t help and their bodies break down their connective tissue, leading to brutal pain and dangerous instabilities.

Using CRISPR and similar techniques, this study was able to show that they could reduce the damage in ligaments and tendons and in some cases reverse it. The study suggested that further work needed to be done, but that they believed that early intervention could not only bring the damaged tissues back to normal, but could be strengthened in some cases. This wasn’t the focus or intent of the study, but there it was deep in the text.

In the PED world, anything that can be used, will be used. Indeed, bodybuilders and weightlifters will likely be the first ones to self-test this if they get the chance. But imagine a biologic pharmaceutical that enhances ligaments and tendons, either before or after surgery. That is not just theoretical now and perhaps inevitable. How sports and society deal with it needs to be thought about now. It could be as simple as how SARMs were dealt with, preventively added to banned lists and testing protocols, or it could be much more nuanced, since genetic testing isn’t something the MLBPA or any other association has agreed to on a regular basis.

One of the most exciting things about writing about sports science and sports medicine is that there’s always something new. Sometimes it’s a step, sometimes it’s a leap. Editing genes could be a Bob Beamon moment, the absolute outlier of leaps. This gene editing is not a genie lightly let out of the bottle.

*Scot Pollard is a friend and he’s currently awaiting a heart transplant, as detailed in this article. Unlike a kidney or bone marrow, you can’t match for one of these, but I’d ask everyone who can to check your match status and consider donating. For hearts and other organs, consider being an organ donor if possible.