Aging Athletes

Now that we are ensconced in the 21st century, both the
medical profession and the general public are faced with certain
obvious and critical problems. Our population is aging rapidly as a
variety of public health measures and other less well understood
factors have come into play. At the beginning of the 21st century, the
United States has roughly 35,000,000 people who are 65 years of age or
older. Although much of this group is healthy and consuming health
resources at a reasonable rate, we do understand that with increasing
age comes an increasing use of health care facilities, personnel, and
money. Much of this commitment of personnel and money comes near the
end of a person’s life span. It then behooves the medical care industry
and our country to encourage good health in this aging population for
as long as possible.

How would this relate to sports medicine? A variety of
studies done in several countries have shown that daily physical
activity is one of the major keys, if not the major key, to both
longevity and good health. Although there are many physical activities,
which are both productive and healthful and are not sports related,
many of the injuries suffered doing those same activities are similar
to those occurring in sport and other recreational activities. These
activity-related injuries can be well cared for by following the usual
sports medicine regimens, which are based on trying to return people
back to action as soon as feasible. We also realize that all population
groups are becoming physically more active as they enjoy better overall
health and have more time and perhaps income to enjoy the later life.

Physical activity is excellent in controlling heart
disease and non-insulin-dependent diabetes mellitus, two major causes
of disability and early death. Studies have shown that people who
practice regular physical activity live longer, have fewer chronic
conditions and illnesses, and have a much shorter period of disability,
which is compressed into the last months of life, compared with those

who
do not stay active. Thus, the group of “potentially active senior
citizens” becomes an obvious focus for sports medicine activity.

We are all aging. Thus, the concepts expressed in this
chapter may be applicable to many, although when I was 40, I doubt I
would have called myself an aging athlete. I believe that the primary
focus of this chapter is for people over 50, with special emphasis on
the large number of active people in their 60s, 70s, and 80s. My basic
thought is that we, as health professionals, should pay as much
attention to the aging athlete—no matter what the chronological age—as
we would to their elite younger counterparts. Treatment and advice will
have to be tempered for the individual person and to some extent for
the age, but we must try to keep people going forward on the activity
scale. On the patient’s part, he/she must realize that some scaling
back of certain physical activities will lead to a more healthy
existence and more fun. Some body parts at age 60 are just not what
they were at 25, no matter how much we wish it or work at it. All of us
must have some idea of what aging does to the body as it relates to
sporting and recreational activities and what simple disuse does to the
same body. The latter we must advise against. The former we must be
aware of and deal with.

Many of the physical components, which we associate with
athletic activity, do change with age. Factors such as endurance,
power, strength, agility, quickness, and flexibility all play major
roles in athletic performance and all are gradually diminished by the
aging process. Even an active person must accept this, but the question
is, “How much diminution of our physical abilities should we accept?”

Endurance is a factor in many athletic pursuits. We know
that endurance has two important aspects, the more obvious being the
cardiovascular and the less obvious being the muscular response. Many
people are born with the DNA potential that gives them a high VO_2max
and, if they train hard, they will develop excellent endurance. For
others less DNA advantaged, the key will be to train harder and make
the heart and the lungs respond to training. Thus, endurance is largely
subject to our control. As we age, the heart and the lungs undergo
certain changes. From age 25 on, there is a gradual decline in the
resting stroke volume of the heart. This, with a decline in the
achievable maximum heart rate, will produce a reduction in cardiac
output. The return to a baseline rate after exercise slows with
increasing age. The pulmonary system also undergoes changes. There is a
gradual decrease in lung compliance, an increase in tidal volume, an
increase in residual volume and, consequently, a gradual decrease in
the VO_2max. Each of these changes will reduce the ability to
increase endurance. Disease of any sort for the heart and lungs may
accelerate these changes.

Although these previously described changes have a
negative effect on athletic performance, the good part is that, even
with gradual aging, we can positively affect many of these parameters.
Cardiovascular training can increase both the cardiac output and the
maximum heart rate, provided that the heart is structurally sound. This
can happen even with people who are past the age of 60 and who have not
previously trained. Endurance training also positively affects the VO_2max significantly by decreasing the expected lowering of VO_2max.
A question often asked by patients is, “How much exercise must one do
to effect these positive changes?” Although cardiovascular exercise at
high levels is obviously most effective in producing changes, it
appears that even moderate exercise done for 30 minutes a day for 4
days a week will produce positive results with regard to the heart and
lungs. The point is that exercise must be done on a regular basis.

The results of aging relative to muscles and tendons can
be seen even in people who are in their 30s. The problem begins with
changes in the connective tissue, which include an increase in collagen
crosslinks, a thickening of the basement membrane, and a decrease in
the elastin of the connective tissue. Each of these changes makes the
collagen stiffer and therefore weaker. Ligaments and tendons are
primarily composed of collagen, and we would expect the structural
integrity of these tissues to be affected. This could be very important
if people expect to pursue certain stressful athletic activities
throughout life. As an example, the anterior cruciate ligament (ACL) of
a 50-year-old person has a markedly decreased ultimate load to failure
compared with a 20-year-old person. If people age 50 continue the same
activities that they did at age 20, one would expect a rash of ACL
injuries, even with lesser stresses. Tendons have an even less
impressive performance in the older athlete because they are subjected
to some acute but more often chronic stress. A variety of
tendons—including the Achilles, the wrist extensors, and the rotator
cuff—might develop tendinosis as the result of repetitive use in
certain sports and physical labors. Joint capsules, another tissue
composed largely of collagen, are subject to the same collagen problems
with resulting increased stiffness. For the patient, this can cause
decreased joint motion with or without injury, and decreased joint
motion may result in further injury and diminished performance.

Although the aging athlete can relatively easily
positively affect cardiovascular conditioning, it may be harder to
affect the collagen tissues. There are people whose genetic makeup
allows them to be as loose-jointed as younger athletes, and they will
always be looser than the tight-jointed individuals. However, the
tighter-jointed individuals can, with regular exercise and stretching,
increase capsular range of motion and musculotendinous flexibility and
maintain what they have. Seeger et al. have shown that slow sustained
stretching of muscle tendon units will increase flexibility to some
extent. Munn, using subjects aged 65 to 88 found a significant increase
in the range of motion of the subjects’ wrists, shoulders, knees,
ankles, etc., after a 12-week period of doing dance and flexibility
exercises on a regular basis. Compared with the controls, the study
group had increased flexibility.

With age, both males and females gradually lose muscle
strength and power. Both of these items factor strongly in athletic
performance, and muscle strength plays a major role in injury
prevention, such as decreasing falls. During the middle part of the
20th century, some experts believed

that
endurance could be maintained by exercise but that the maintenance of
strength was more difficult. Now, following some excellent studies, we
know that strength cannot only be maintained but can show a gain even
in an octogenarian group. Fiatarone, in 1993, published a landmark
study on the effects of exercise in patients ranging in age from 89 to
92, which showed an increase of 175% in quadriceps strength over an
8-week exercise period. Many people who have remained active may have
been intuitively aware that strength can be maintained, but this study
showed that even those who had not been active could restore strength.
Despite this knowledge, it can be difficult for even motivated and
active people to stay on a program to maintain optimal muscle strength.

The medical profession and the general populace are well
aware of the potential problems with bones with advancing age. Although
this is a bigger concern in females than males, over the age of 80,
many males will develop osteoporosis. The problem of osteoporosis may
prove to be even more severe in many female athletes of the 1970s and
1980s who were running many miles. We now understand that the primary
accretion of bone occurs in the 18- to 25-year-old period, and females
who run a lot, keep their weight down, and have menstrual problems will
have significant osteopenia as they come into their 50s. This means
that some older female athletes should choose sports carefully, and
those activities that have an inherent risk—such as skiing, rock
climbing, and others—could pose a problem for fractures in those with
osteopenia. Postmenopausal females will be more at risk than their male
counterparts.

There are other tissues of the body that have changes
from advancing age. The articular cartilage of joints gradually becomes
thinner, loses some of its ground substance, and loses some of the
water contained within. The cartilage cells become less numerous and
have a decreased ability to manufacture ground substance. There is a
loss of some resilience of the joint surface. The intervertebral discs
gradually become thinner and less resilient as they lose some water of
hydration. The knee menisci also are more subject to injury (tearing).
The meniscus contains fewer cells, the ground substance undergoes
changes, and there is loss of water content. The structural internal
integrity of the meniscus is lessened. The junction between the
meniscus and the surrounding joint capsule is weakened, and tears in
this region are more likely. None of these changes can be influenced in
a positive way by activity. Because of these changes, it is obvious
that there are certain physical activities that may be more harmful in
the older person than in the younger athlete. Meniscal tears are common
in the over 50 age group, and many of the symptoms previously thought
to be a result of “arthritis” are often the result of a torn meniscus.

Although there is a litany of changes that occur in the
human organism, overall the news is relatively good for the over 50
athlete to remain active and to continue to play certain sports. It
does not, however, mean that with exercise, your body at 50 and beyond
is the same as it was at age 28. It does mean that in order to have
good cardiovascular status, strength, and flexibility, one has to work
at it. Lack of physical activity is the prime enemy of the aging
athlete. Each single individual has to balance the known good effects
of sporting activity against the possible injuries that sometimes occur.

There are certain other aspects of aging that play a
huge role in those who want to continue to be active. Overall, general
health and chronic diseases are usually not major factors in younger
athletes but in the over 50 age group, they will be a major concern.
For many people who have been active all their lives, they probably
have a pretty good idea of their general health and how to deal with
any concerns. The bigger concern for physical activity participants and
the medical profession is that group of people who decide at a later
age to take up sports. We want to encourage this latter group because
it will promote good health but we must be sure that they are able to
be active, to compete, etc. For active people, I would encourage them
to have a general physical examination every several years even if they
are doing well. For people who have not previously been very active,
they must have a thorough physical, paying particular attention to the
cardiovascular and pulmonary systems and to major joints. Although
people may be active up to a point with a heart or lung problem or
diabetes, these conditions impose certain restrictions that should be
obeyed.

A major item for all older athletes is previous injury,
which causes present problems. There are many sports played at a
younger age with a high potential for injury (such as football,
gymnastics, wrestling, skiing, and other outdoor activities) that cause
many athletic people to come into their older years with significant
problems. The most significant sports involve the back and knee with
the shoulder and hip following.

We all recognize the importance of aggressive and
prolonged rehabilitation in the treatment of sports injuries. We
usually think of this in terms of the elite or competitive athlete
wanting to lose as little time as possible from competition. However,
aggressive and long-term rehabilitation may be even more important in
the aging athlete than it is the younger one. The time away from sports
in the older person and the subsequent loss of conditioning, both
cardiovascular and muscular, may make it difficult to return to
previous activity levels—not just athletic activities but those of
daily living. The older athlete is starting from a lower baseline level
of overall conditioning. It is unlikely that either his muscle strength
or cardiovascular condition is at the level of the younger person. This
makes it imperative that the sports medicine doctor, who must be a
believer in aggressive therapy even in the older age groups, be the
overseer of the physical therapy program. It is also important to set
up a program taking into account that the older athlete may not be able
to rehabilitate in precisely the same way that the younger athlete does.

Although many aspects of surgery are the same in the
aging athlete as in his/her younger counterpart, in other instances,
there are significant differences. In each instance, our stated aim
should be to return the afflicted patient to previous athletic and
daily activity levels. Yet, in the older athlete, we realize that this
may not prove entirely feasible. We may have to have both the surgeon
and the patient take a realistic view of what can be expected. Overall,
the less complicated the surgery and the shorter the expected
rehabilitation period, the better, but sometimes major procedures are
all that will accomplish the job.

As in the young athlete, the meniscus in the aging
athlete is prone to tears, which with activity are even more likely to
occur in the older group than in the 20- to 40-year-old age group. In
the older group, there is going to be no chance to repair the meniscus,
and most tears will be posterior horn degenerative tears. The remaining
meniscus will not have the internal structure of the 20-year-old, and
surgeons must refrain from trying to resect meniscal tissue back to
“normal” tissue because it will be a total removal by then. The state
of the joint articular surface may be very different than that of the
younger patient, and the surgeon may have to make decisions regarding
the surface. If the articular cartilage is down to bone in certain
areas, the possibility of cartilage cell transplants or multiple drill
holes must be considered. However, this is not going to be a spur of
the moment decision and is a likely follow-up to meniscal surgery.
Minimal articular cartilage debridement is often done in association
with meniscal resection. Various procedures to “smooth” the articular
cartilage have been advocated but, as yet, long-term results have not
proven the effectiveness over minimal debridement.

The previous state of the articular surface and what you
do to it will have a great effect on how well the patient will do after
a meniscal procedure and may slow up the return to activity. Patients
have to be aware of this possibility before surgery to avoid later
disappointment and friction with the surgeon. The older athlete may
compare himself/herself to a younger person having the “same” procedure
or what he/she remembers from previous years. The athlete has to
understand the potential for degeneration of the joint surface.

Another anatomical area commonly involved in the older
athlete is the rotator cuff. Tendinosis and/or tears, major or minor,
are frequently seen. Several aspects of this deserve special mention.
The tissue to be repaired may not be very good, and some surgical
accommodation may have to be made to obtain a good closure of the cuff
and thus a potential for return to good shoulder function. With this in
mind, the surgeon will have to consider which procedure, open repair,
arthroscopic repair, or arthroscopic debridement would be best for that
particular patient. Another aspect to consider is that many of the
aging athletes who have had shoulder problems have had trouble for
quite a while. As a consequence of this, there is a major loss of
shoulder strength. This means that the return of strength is going to
be hard to achieve and will necessitate a long rehabilitation period,
even 1 to 2 years to gain a final hoped-for result.

An aging population is going to put tremendous strains
on our health care system. Anything that the medical profession can do
to improve the health of the over 50 population will affect the system
both significantly and positively. Active people have fewer major
illnesses and demand less health care resources than those who are
inactive. Events of the past 25 years have demonstrated that people can

continue
to be very active and athletic into their 60s, 70s, and 80s. Although
there may be a physical price to pay for this activity at times, sports
medicine practitioners are well suited to care for such problems and to
encourage the general populace to maintain sports activities. Many of
the effects on the body previously thought to be a result of aging are
actually because of disuse. Sports medicine is in a unique position to
increase the well-being of many aging people by keeping them active and
thus healthy.