The single most important anti-doping fact for anyone injecting athletes is that glucocorticoids are prohibited in-competition when given by any injectable route, as well as by oral and rectal routes, while out-of-competition use by any route is permitted. That one rule, combined with an understanding of washout periods and the exemption process, prevents most of the trouble that arises from treating athletes. For the sport and exercise medicine (SEM) clinician the relevant skills are knowing which injectables are prohibited and which are not, timing treatment around the competition calendar, documenting properly at the time of injection, and knowing when a therapeutic use exemption (TUE) is needed. The wider anti-doping framework, including the Code, the anti-doping rule violations and the exemption system in general, is covered in the related governance material; this page is specifically about injectables.
Which injectables are prohibited, and when?
Start with what is permitted, because it covers most of what a sport and exercise medicine clinician injects. Local anaesthetics such as lidocaine and bupivacaine are not prohibited and may be used, including by injection, in competition. Hyaluronic acid is not on the Prohibited List. Platelet-rich plasma and related platelet-derived procedures are not prohibited. None of these creates an anti-doping problem in itself, although what is co-administered with them always needs checking, since separately administered growth factors or growth-factor modulators that fall under the Prohibited List remain prohibited.
Glucocorticoids are prohibited in-competition by all injectable, oral and rectal routes, while local anaesthetics, hyaluronic acid and platelet-rich plasma are not prohibited. A method can be prohibited even when the substance is not, as with high-volume infusions. Correct at the time of writing; always check the current list.
Glucocorticoids are the exception that dominates practice. They are prohibited in-competition when administered by any injectable route, and the list of routes is deliberately comprehensive: intravenous, intramuscular, periarticular, intra-articular, peritendinous, intratendinous, epidural, intrathecal, intrabursal, intralesional, intradermal and subcutaneous. Oral routes, including oromucosal, buccal, gingival and sublingual, and the rectal route are also prohibited in-competition. Out-of-competition use by any route is permitted. Two further points are heavily examinable. First, a method can be prohibited even when the substance is not: intravenous infusions and injections totalling more than one hundred millilitres in any twelve-hour period are prohibited at all times, unless legitimately received in the course of hospital treatment, a surgical procedure or a clinical diagnostic investigation, and this applies even where the fluid infused contains nothing prohibited, which is why routine intravenous rehydration of an athlete is not a benign act. Second, a local injection can behave systemically: a periarticular or intra-articular glucocorticoid injection may inadvertently result in intramuscular administration, and where that is suspected the intramuscular washout period should be observed rather than the shorter local one. Because the Prohibited List is revised at least annually, the specific agent, formulation and route are always checked against the current list rather than from memory.
How are washout periods and exemptions handled?
A washout period is the interval between the last dose and the start of the in-competition period, which begins at 23:59 on the day before a competition the athlete is due to take part in, unless a different period has been approved for that sport. Its purpose is to allow the glucocorticoid to fall below the laboratory reporting level so that out-of-competition treatment does not produce an in-competition positive. Published washout periods vary by agent, dose and route, with local injections generally requiring a shorter interval than systemic routes, and some agents, notably longer-acting preparations, requiring substantially longer. Two cautions apply: the published periods are guidance based on licensed maximum doses rather than a guarantee, and sustained-release formulations may remain detectable beyond the stated period because absorption continues. Since the figures are revised, they are read from the current guidance rather than recalled, and the practical planning question is always the same: when is this athlete's next competition, and does the injection sit safely outside the washout for the specific agent and route chosen?
The pathway depends on local compared with systemic administration, competition level, exemption pool status and the relevant anti-doping organisation. In UK practice a local glucocorticoid injection needs a medical file compiled beforehand and a retroactive exemption only if an adverse analytical finding follows. Correct at the time of writing; check the current guidance.
Whether an exemption must be obtained in advance or may be sought retroactively is not universal: it depends on whether the glucocorticoid is given locally or systemically, on the athlete's competition level, on whether they sit within the national exemption pool or are defined as an international-level athlete by their international federation, and on which anti-doping organisation applies. In UK practice the position for local glucocorticoid injections is specific and important. Under the national policy, an athlete receiving a glucocorticoid by local injection is required to apply for a retroactive exemption only if they are tested in-competition and subsequently return an adverse analytical finding (AAF) for that glucocorticoid. Where the injection is given within the washout period, a medical file should therefore be compiled before proceeding, covering the history, examination, diagnosis, investigations, the medicine name, dose, route and duration of treatment, previously tried permitted treatments and the consequences of withholding treatment, so that a retroactive application would meet the required criteria. That policy does not extend automatically to systemic glucocorticoid treatment, and it does not remove the separate obligations of athletes within the national exemption pool or defined as international-level, who are generally required to obtain an exemption in advance and, in the latter case, to apply to their international federation.
Practical governance follows from this. Establish the athlete's competition level, their exemption pool status and the relevant anti-doping authority before injecting, rather than assuming. Check the specific product using an approved medication-checking database, and use the relevant exemption-checking tool or governing body process to establish whether an exemption is needed and to whom any application would go. Choose the agent and route with the competition calendar in mind, consider whether a permitted alternative such as a local anaesthetic diagnostic block would serve, record everything contemporaneously and give the athlete a copy. The record made on the day matters because it cannot be reconstructed convincingly afterwards, and a retroactive exemption is granted on clinical justification rather than as a formality. Responsibility rests with the athlete under the principle of strict liability, but a clinician who injects without checking has contributed to the problem, and support personnel have their own obligations under the anti-doping rules.
Exam Tips
•Glucocorticoids are prohibited in-competition by all injectable routes, including intra-articular, peritendinous, intrabursal, intradermal and subcutaneous, and by oral and rectal routes; out-of-competition use by any route is permitted.
•Local anaesthetics, hyaluronic acid and platelet-rich plasma are not prohibited, though any co-administered substance must still be checked, since separately administered growth factors or growth-factor modulators on the Prohibited List remain prohibited.
•A method can be prohibited even when the substance is not: intravenous infusions and injections totalling more than one hundred millilitres in any twelve-hour period are prohibited at all times, outside hospital treatment, surgery or clinical diagnostic investigation.
•A periarticular or intra-articular injection may inadvertently be given intramuscularly; where this is suspected, observe the intramuscular washout period rather than the local one.
•Washout is the interval from the last dose to the start of the in-competition period, beginning at 23:59 the day before competition; published periods are guidance based on maximum licensed doses, not a guarantee, and sustained-release preparations may be detectable for longer.
•Exemption timing is not universal: it depends on local compared with systemic administration, competition level, national exemption pool status and the relevant anti-doping organisation. In UK practice an athlete receiving a local glucocorticoid injection applies for a retroactive exemption only if tested in-competition and returning an adverse analytical finding (AAF), so compile the supporting medical file before injecting within a washout period.