October 19, 2010

Playing With Arthritis

Phil Mickelson brings attention to a painful subject for golfers

For some people of a certain age, part of every morning is devoted to hearing reports from our extremities. Down below, there's a clicking in the old football knee. There's a grinding at the back of the skull, as if tiny mechanics inserted into the bloodstream have arrived with wrenches to twist the third and fourth cervical vertebrae into place. Some days, from toes to fingers to earlobes, it's all one big squeaking hinge.

Five days before the 2010 U.S. Open at Pebble Beach, Phil Mickelson had one of those days, only worse.

When he thought to get out of bed, he couldn't do it. He was immobilized by pain that radiated throughout his body. He felt it in an Achilles tendon, his left index finger and right wrist. Checking in with his hips and buttocks, ankles, elbows and shoulders, he heard screams.

Mickelson, a world-class athlete, accepts the truth of no pain, no gain. The work to create and sustain the athletic machine at the highest level puts extraordinary stress on the skeletal structure, particularly where tendons, ligaments and muscles come together to create a moving part. But on that day in June, he felt more than the usual run of aches and pains.

"Every time I would wake up in the morning," Mickelson told the media before the PGA Championship in August, "I couldn't walk."

Far as he knew, he hadn't actually been run over by a train, he just felt like it. He was 39 years old, not 69. He was an elite professional golfer, not a slacker chained to a desk. Making it all the stranger, the pain began soon after he told his wife, Amy, that he had never felt so strong and flexible. "Four days later, you know, it just -- it's crazy," he said.

For most of us, dealing with pain means we take two aspirin twice a day and soldier on. But when your life's work is at stake, when you're a one-man corporation earning millions, you call timeout. Maybe, late at night, you even find yourself thinking the pain is an intimation of mortality. So, at that scary moment, you do what Mickelson did. You take your aching shell of a body to the Mayo Clinic. There he was diagnosed with psoriatic arthritis.

Mickelson's announcement of his condition was cause for confusion. Psoriasis is familiar enough; it's an inflammation of the skin made visible by rashes. But psoriatic arthritis? Turns out it's the same disease except it attacks the body from the inside, setting fire to joints, sometimes inflaming the eyes, lungs and aorta. The cause unknown, it mostly flares up in the fourth or fifth decade of a person's life. Of an estimated 50 million Americans with arthritis, maybe one million have psoriatic arthritis.

Arthritis? Isn't that just grumpy old folks tolerating another visit from their obnoxious neighbor, Arthur Itis? Dr. John H. Klippel, a rheumatologist who is president and CEO of the Arthritis Foundation, asks us to know more. "The public perception too often is that it affects only old people, and it's only a nuisance," he says. "That's why Phil Mickelson is so important to education about arthritis. Here's a young guy with a disease that has been interfering with his life and profession in a major way."

The first question for Mickelson, the man: What to do now?

The first question for the golfer: What does it mean for your future?

The answers seem to have come quickly and positively. Psoriatic arthritis occurs when the immune system attacks good cells instead of bad. To deliver protein that inhibits such an assault, Mickelson injects himself weekly with Enbrel, a genetically engineered drug created by introducing human DNA into the cells of Chinese hamster ovaries. At the PGA Championship, Mickelson said he'd used the drug about two weeks, "and I seem to have some pretty immediate progress, so it's been great...And that's why I feel comfortable talking about it, knowing that long-term and short-term, things are fine."

To hear Mickelson pronounce everything fine is to remember that he is famous for his sunny spin on all topics. That makes the next question inevitable: Are things really fine?

Yes, really. So says Klippel. "In many people using Enbrel, the results are dramatic and seen very early. They not only improve, but the symptoms go away. Those people are fortunate. Enbrel has given them their lives back."

As for Mickelson's playing career, the doctor is also upbeat. Klippel says it's likely Mickelson has played while suffering from the disease and can be better now that the pain is gone. "If Phil's like other people with joint pain," he says, "it's likely he ignored it for some time in the hope that it would just go away."

Dr. Joel M. Gelfand, a researcher specializing in psoriasis at the University of Pennsylvania School of Medicine, agrees that Mickelson should be as good as ever -- with a caveat or two: "It depends how many joints are involved, whether there are signs of joint damage on an X-ray, and levels of inflammation in the blood measured by the C-reactive protein -- all of which tend to suggest that the disease is more likely to progress without treatment. That being said, most patients with proper diagnosis and treatment will do quite well."

The best news for Mickelson is that diagnosis and treatment came early -- especially the Enbrel, approved for public use in 1998. He apparently has been spared the worst of the painful odyssey made by Bob Murphy, the only other PGA Tour player known to have psoriatic arthritis.

Murphy's fifth victory on tour came in the 1986 Canadian Open. By then he was in such pain he didn't hit a practice ball that week; instead, to free up stiffened joints, he prepared with massages in the clubhouse spa.

"Then, in '87, BOOM!" he says. "I couldn't play at all."

He was 44. Years of unremitting inflammation had left him with six fingers he couldn't bend. He had done television commentary/reporting for CBS Sports and soon became a regular on-air personality. Having played just two events in two years but with the senior tour a possibility, Murphy says, "I was going to want to try."

He used several drugs, none effective, before finding a clinic that "treated arthritis in a different way, with massive doses of antibiotics." By 1992, "Lo and behold, I could move my fingers. I was going to be able to play."

In his first decade on the senior tour, he won 11 times and earned almost $7 million. "Once I had my hands back, my body, flexibility, the ability to practice, I could play," Murphy says. "I just didn't hurt any more."

Psoriatic arthritis, then, is not a career-ending disease, not with the advances in drug treatment since Murphy's agonies a generation ago. Mickelson said Enbrel has put his disease in remission, and he plans to take the drug for a year before stopping to see if the pain is gone forever. "If it does come back," he said, "I'll start the treatment again and should be able to live a normal life without having any adverse effects."

Murphy isn't so sure of that.

"Phil started treatment very early, so he's ahead of the curve," he says. "But will Enbrel alone eliminate the stiffness, the swelling, the pain? I'm on it now, too, and sitting here right now, I say, 'No.' He's going to have a lot of hard days, when it's not easy to go, when it takes a long time to get cranked."

So there'll be days, Murph, when a guy is 44 feeling like he's 64?

"Yep, without question."

Welcome to the club, Phil.