Since Vioxx was pulled from the market three years ago, Masters athletes have searched for alternatives for their aching joints

Nikolaj Owcharuk, now 54, played professional soccer as a goalkeeper in the North American Soccer League and elsewhere. "I played 10 years of professional soccer without hurting my knee," Owcharuk said. "Then when I became a coach, I hurt it on the practice field."

After two surgeries on his knee, he used Vioxx to mitigate the pain during his rehabilitation. It worked very well. But when he began hearing about the drug's apparent relation to heart attacks and strokes, he stopped using it.

Others were forced to give up the drug almost exactly three years ago on Sept. 30, 2004. That's when Merck & Co. announced it would withdraw Vioxx from the market. The drug giant made the drastic move after a study showed an increased risk of heart attack and stroke in users of the drug.

Vioxx was part of a much hailed class of pain killers known as Cox-2 inhibitors. These drugs received high marks, because these pills, when used daily not only relieved pain but also were easier on the stomach, which can suffer damage with long-term use of other similar drugs. "Vioxx was a superstar," said William Bryan, M.D., an orthopedic surgeon.

By spring of 2005, the controversy had spread to Vioxx rivals, leading Pfizer Inc. to withdraw its Cox-2 drug, Bextra. Today, only Pfizer's Cox-2 drug Celebrex is on the U.S. market, but it carries the Food and Drug Administration's strictest so-called "black box warning," which outlines in black ink a notice to doctors about the serious risk of potential heart problems.

Without Vioxx, athletes such as Owcharuk have found alternative treatments to ease their knee pain so they can continue playing the sports they love. With varying results, athletes are exploring alternatives such as the following for treating knee pain:

Getting in shape
Osteoarthritis, in many cases, results from too much body weight being placed on the knees and other joints. With this in mind, doctors often recommend an exercise and weight loss regimen to combat knee pain. "We first approach weight and diet," said Stan Dysart, M.D., an orthopedic surgeon. "I like (my patients) to have the proper strength, flexibility and conditioning. I like them to be in good aerobic shape with activities that have less impact on their joints. That might be walking or using a StairMaster or elliptical machine."

Many Masters athletes, who don't need a doctor's orders to exercise, use serious weight training to strengthen the muscles around the knee and take the pressure off the joint itself. Bill Pontius, 57, is a Masters sprinter. He hurt his knee hurdling in 2004. He's had ACL surgery and he still uses Olympic-style weight training to stay in shape. He strengthens his quadriceps with leg exercises such as squats, but he uses minimal weight to lessen the strain on the joints.

NSAIDs
Despite his knee surgeries, Owcharuk remains active in age-group soccer as a goalkeeper. He also plays basketball, bikes and even downhill skis. "I just stay away from the moguls," he said.

To help combat the stress of these sports, he says he takes 400 to 800 milligrams of Advil, or ibuprofen, which is a nonsteroidal anti-inflammatory drug. Aspirin and naproxen (Aleve or Nuprin) are two other common NSAIDs. Orthopedics recommend these over-the-counter drugs to help their patients control pain. But these drugs have heart and other risks as well. FDA advisors slapped warnings on those pills during the Vioxx and Celebrex advisory hearings in 2005.

Glucosamine and chondroitin supplements
Glucosamine and chondroitin are supplements marketed by companies such as NOW Foods, Advocare and Schiff Nutrition International. Often taken together, the products are intended to strengthen cartilage. "Glucosamine and chondroitin actually rebuild cartilage," said Luke Bucci, Ph.D., VP-research for Schiff Nutrition International. "And that's something no drug or medical treatment can do yet."

Masters sprinter John Simpson, 41, first injured his knee playing football for Baylor University. He began taking a glucosamine supplement in 1998 and has seen his knee pain dissipate. "It works fine," he said. "You can't tell the difference at first, but it takes awhile to get into your system."

Simpson seems to be doing fine himself. He placed second in the M40 100 meters in the USA Masters Outdoor National Championships in August. Some doctors, however, remain skeptical about supplements. "When there are studies of these nutritional supplements, they are studied by a commercial sponsor so there are few unbiased studies," said Calvin Brown, M.D., associate professor of rheumatology at Rush University Medical Center in Chicago. "I tell my patients to try it but I cannot guarantee they are going to get their money's worth. If it works, fine, but if not, neither of us is surprised."

Knee braces
After his knee surgeries, Owacharuk said he was not fit to play the sports he loves. "I was like a lame horse," he said. "If I was a horse, they'd shoot me." But now Owcharuk is a big believer in knee braces. He uses a Don Joy knee brace, which is used by NCAA offensive linemen to prevent ACL injuries. "If I didn't have that brace, I'd barely be walking," he said.

Owcharuk credits the device with allowing him to continue skiing, cycling and playing basketball and soccer. "After seven, eight, nine, 10 days of skiing, I don't have a noticeable giddy-up (limp) wearing the brace," he said. "It really supports; it feels a lot better."

John Martin, Don Joy's market manager-osteoarthritis bracing, said that his company's braces are designed to provide additional stability to the knee. Moreover, the mechanical design of the brace "offloads" some of the weight from the knee, reducing wear of the cartilage.

When coaching young soccer goalies, Owcharuk wears the lightweight brace and often dives to his left and right demonstrating the proper technique. The brace isn't noticeable when he's wearing goalkeeper's pants, Owacharuk says. When he's wearing shorts, he wears the red, white and blue model. "I look very patriotic when I'm diving around in this," he said.

Bob Kolvitz wears his knee brace when he plays second base in high level 50-plus softball. He tore his ACL about 12 years ago and never had surgery. He uses the brace to stabilize the knee. He also takes Advil and keeps his quads strong by lifting weights, but he credits the brace with giving him an extra decade -- so far -- of playing softball.

Hyaluronic acid
Hyaluronic acid is part of what naturally provides lubrication and viscosity in the human knee. Over the past decade, doctors have begun injecting HA into patients to provide easier motion in their knees. HA goes by many brand names: Euflexxa, Hyalgen, Orthovisc, Supartz and Synvisc. The latter four are derived from an avian
source, usua lly rooster coxcomb. Euflexxa is bioengineered.

"The modality I'm starting to use in a large way is hyaluronic acid, and Euflexxa is currently the product I'm using exclusively," orthopedic surgeon Dysart said. "Euflexxa is the only bioengineered product of the group… I use the product that's non-avian and more pure."

Owacharuk, who is always looking for methods to preserve his knee and reduce pain, is looking into having the injections.

Low-impact sports
Doctors often advise their patients to abandon running on the roads for other, less high-impact aerobic sports. Many Masters athletes have taken their doctors' advice. David Pain, the man who is credited with staging the first Masters track meet, eventually gave up his beloved sport for cycling because it was easier on the knees.

Similarly, the late Parry O'Brien, a one-time Olympic shot putter, gave up track and field because of joint problems. He became a Masters swimmer.

And Dean Smith gave up competitive running because of his balky knees. Now he's a rower, a national champion in the men's 80-84 bracket.

More Cox-2's?
Now there's a backlash against the backlash, and Vioxx-like drugs are making a comeback. In the Cox-2 class, Celebrex's annual sales are rising by double-digit percentage increases. At least two other drug-makers are considering launching new Cox-2 drugs.

One such maker, Novartis AG, has completed a safety study of almost 20,000 patients of its Cox-2 drug known as Prexige and awaits FDA approval of the pill to market it within the year. "We still believe in the risk-benefit profile of these drugs," said Novartis spokesman John Gilardi.

It's possible Vioxx may return one day. "I don't think it was the ogre it was made out to be," Bryan said. Masters athletes may be among the most likely patients to consider taking the risk, some doctors say. For one, they tend to be in shape and healthy. And, as long as they do not have other risk factors for heart attack and stroke, doctors say they should be able to take Celebrex.

"People are looking to see if patients have cardiovascular risk when they prescribe one of these (Cox-2) drugs," said Rush's Brown. "Active people have less cardiovascular risk."