An injection before the cup final: glucocorticoids, salbutamol and a supplement
A 27-year-old international midfielder with well-controlled asthma (salbutamol 100 µg MDI, up to 10 puffs during a match) develops acute severe lumbar pain 5 days before a cup final. The team doctor proposes intramuscular betamethasone 12 mg plus local anaesthetic to 'settle it and get him through', and asks you to sign the paperwork. The player also mentions he has been taking a pre-workout supplement bought online, and asks whether his inhaler use is 'a problem' given he used 10 puffs in the semi-final. He is desperate to play; the club has a significant financial stake in the result. You are the tournament's medical officer, not the club doctor.
1. Is the intramuscular betamethasone permissible for the final? What options would you offer?
Read the worked answer
No - not as proposed. All injectable routes of glucocorticoids (intramuscular, intravenous, intra-articular, periarticular, peritendinous) are prohibited in competition, as are oral and rectal routes. Inhaled, topical (dermal) and most other non-injectable routes are permitted. A 12 mg IM dose before a final is a straightforward anti-doping rule violation, and the player carries strict liability whatever the doctor advised.
Options.
- Do not give it and treat with permitted measures: relative rest, physiotherapy, paracetamol, a permitted NSAID if there is no contraindication, and modified training. Topical dermal NSAID or glucocorticoid is permitted.
- Give it out of competition with a planned washout if the clinical indication is strong and the player will not compete while prohibited - but that is incompatible with a final in 5 days.
- TUE route: possible in principle for a genuine medical need, but it requires evidence that no permitted alternative exists and that the substance restores health rather than enhancing performance. A pre-final 'pain-killing' injection is very unlikely to be approved, and TUE decisions take days to weeks. Retroactive TUEs are limited to defined circumstances such as emergency treatment or no prior opportunity - a planned injection is not one.
Your role. You are the tournament medical officer. Decline to sign, document the advice, and put it in writing to the club and player. Therapeutic enthusiasm is not a defence.
2. Address his salbutamol use and the supplement question.
Read the worked answer
Salbutamol. Inhaled salbutamol is permitted, with thresholds: no more than 1600 µg over 24 hours, not exceeding 600 µg over 8 hours, and a urinary threshold of 1000 ng/mL. Ten puffs of 100 µg = 1000 µg - inside the 24-hour limit but close to it, and only if not repeated later in the same day. Advise:
- Use with a spacer and a written asthma action plan; frequent reliever use signals poor control, so review the preventer and check inhaler technique rather than accepting 10 puffs as normal.
- Keep a record of doses and declare salbutamol on the doping control form.
- Note that the urine threshold can be exceeded with high doses, dehydration or impaired renal clearance; the threshold is not a target.
The supplement. Explain strict liability: the athlete is responsible for what is in his body, and 'bought online' is the archetypal contamination story (undeclared stimulants, prohormones, SARMs). Advise:
- Stop it now and keep the packaging and batch number.
- Only use products with independent third-party batch testing, and even then with caution.
- Check every ingredient against the prohibited list, and use the national anti-doping organisation's check service.
- Report symptoms or adverse effects, and be aware that a contaminated supplement can end a career even when nobody intended to cheat.
3. The club escalates and the player says he will take the injection anyway. What do you do?
Read the worked answer
Hold the line, but manage the process properly.
- Written advice, same day, to the player (copy to the club doctor): the injection is prohibited in competition, the player carries strict liability, and you have advised against it. Keep it factual, not accusatory.
- Explain the consequences concretely: a provisional suspension, loss of the final result, a multi-year ban, and reputational and financial damage far exceeding one match.
- Offer a route: an urgent specialist assessment of the back, a realistic rehabilitation plan, and permitted analgesia. Give the player a way to say no to the club.
- Do not sign or endorse any document that implies medical clearance for the injection.
- Declare a conflict of interest and inform the tournament's medical lead, because you are being pressed by a team with a financial stake.
- If you believe the injection will be given regardless, escalate to the tournament's anti-doping officer and governing body; there is a duty to protect the athlete and the integrity of the competition, and confidentiality does not extend to covering an anticipated rule violation.
- Check your own position: as tournament medical officer, your duty is to the event and the athlete's health, not to the club's result.