Enhanced games and performance-optimized athletes: anticipating the orthopedic challenges, a narrative review

The Enhanced Games (EG) represents a controversial shift in competitive athletics by removing anti-doping regulations and allowing the sanctioned use of performance-enhancing drugs (PEDs) in pursuit of maximum performance. This unprecedented model may fundamentally alter sports culture, competition standards, and the medical landscape in which athletes train and compete. Of particular concern are the potential consequences for orthopedic and musculoskeletal health, as PED use, particularly anabolic agents and growth factors, can both enhance and compromise musculoskeletal function. Potential benefits include increased muscle mass or bone density. However, these must be weighed against heightened risks of tendon rupture, altered joint biomechanics, delayed fracture healing, and increased susceptibility to overuse or catastrophic injuries. Given the likelihood of more extreme physical demands and higher injury rates in EG participants, proactive preparation from the orthopedic and sports medicine community is essential. This narrative review focuses on the potential influences of EG on musculoskeletal care, gathering evidence on anticipated injury patterns, surgical and rehabilitative considerations, and long-term health outcomes. The goal is to provide insight for policymakers and care providers tasked with protecting athletes who choose to compete in these environments.   Cite this article as: Eftekhari M, Ryali R, Luk J, et al. Enhanced games and performance-optimized athletes: anticipating the orthopedic challenges, a narrative review. Acta Orthop Traumatol Turc. 2026; 60(4), 0824, doi: 10.5152/j.aott.2026.25824.