Never Too Old to Play
Keeping aging athletes in the game has become a new challenge for physicians.
By Jeanne Mettner
In the 1960s, Father Time was an athlete’s archenemy. One significant injury—be it to the knee, hip, foot, or back—could end a career. Doctors then rarely disavowed patients of the notion that they should “hang up” their skis or tennis shoes as they aged. But a half-century later, that has changed. Today, even the oldest baby boomers continue to participate and compete in sports, and they expect their doctors to keep them in shape.
According to the Centers for Disease Control and Prevention, the number of middle-aged and older adults participating in organized sports is growing. Statistics from long-distance running illustrate the trend. From 1983 to 1999, the number of people age 50 and older who ran in the New York Marathon grew faster than the number of younger athletes competing in it. Of the runners who finished the Boston Marathon in 2005, nearly 55 percent were 40 years of age or older. The nonprofit organization Running USA, which tracks trends, found the number of people age 55 years and older who have finished marathons more than doubled between 1992 and 2008, from 32,500 to 76,500. Although statistics about the number of people age 50 and older who participate in sports recreationally are scant, clearly gyms, dance studios, and sports clubs are catering to that crowd.
The Notion of Motion
Our efforts to remain physically fit as we age can reap significant benefits. “All the information we have seems to indicate that, for the most part, the aging active person tends to fare better than their nonactive counterparts across the board,” says Robby Bershow, M.D., a fellow in primary care sports medicine at Hennepin County Medical Center.
Regular physical activity is routinely touted for primary and secondary prevention of coronary heart disease, hyperlipidemia, hypertension, and diabetes, and for primary prevention of breast and colon cancer. “The evidence on the benefits of physical activity for managing chronic conditions is voluminous,” says Jamie Peters, M.D., a physician with Fairview Sports and Orthopedic Care in Minneapolis. “For that reason alone, it would be great if all older adults could think of themselves as athletes because the result of pursuing physical fitness could have tremendous societal benefit.”
Research also shows that people who remain physically active lose less muscle as they age. The results of two separate studies, one published in the August 2009 American Journal of Physiology, Regulatory, Integrative and Comparative Physiology and the other in the January 2010 Journal of Aging and Physical Activity, showed that women and men in their 70s who participated in routine cycle training three times a week for 12 to 16 weeks improved muscle function and muscle mass.
For older adults, though, the most appealing benefit of physical activity may be its combative effect on cognitive decline. In a longitudinal study involving more than 1,700 people older than 65, the incidence rate of dementia was 13.0 per 1,000 person-years for those who exercised three or more times per week compared with 19.7 per 1,000 person-years for those who exercised less. (Results were published in the January 17, 2006, Annals of Internal Medicine.)
Exercise may even affect the physiological process of aging. As people grow older, the nucleotide sequences at the end of white blood cell chromosomes get shorter. The length of those sequences, often referred to as leukocyte telomere length, or LTL, is used to determine a person’s biological age. In 2008, researchers at King’s College in London measured the LTL of 2,400 twins in their late 40s to determine whether individuals who were more active in their leisure time were aging more slowly. The investigators found that the men and women who were less physically active had significantly shorter LTLs than those who were more active.
According to Mayo Clinic anesthesiologist and exercise physiology researcher Michael Joyner, M.D., any physical activity is better than none. “If you look at the best predictor of five-year all-cause mortality, it’s physical fitness,” Joyner says. “The payoff starts even with a limited amount of physical activity; you don’t have to be out there running Grandma’s Marathon to see the effects.”
The Body Doesn’t Lie
Older athletes may have better overall health than their inactive peers, but they are not immune to the physiological changes that occur with aging. In a consensus statement published earlier this year by the American College of Sports Medicine, an expert panel outlined the changes that all aging adults undergo: Maximal oxygen uptake (VO2 max) and cardiac output decline. Muscle mass declines at a rate of 1.25 percent per year after age 35. Peak strength declines at an accelerated rate after age 70. “There are certain things you cannot turn the clock back on, but you still have to keep moving,” says Dave Thorson, M.D., a primary care and sports medicine physician with Family Health Services Minnesota, who served on the panel. “I tell my patients, ‘I’d rather have you wear out than rust out.’ Motion is lotion.”
Although it’s possible for some athletes to sail into their 70s with no physical discomfort, it’s highly unlikely. “A lot of the injuries that were once seen primarily in an elite segment of the physically active population—competitive athletes, college athletes—are now developing in people who are older and have more free time or resources to be more regularly and vigorously physically active,” Bershow says. Sports medicine physicians say it’s no longer unusual to see an 80-year-old tennis player with tendonitis, a 70-year-old marathon runner with hip problems, a 73-year-old triathlete with knee pain, or a 70-year-old ski racer with shoulder pain.
The bulk of the problems older athletes experience are musculoskeletal and the result of overuse. According to Elizabeth Arendt, M.D., an orthopedic surgeon with the University of Minnesota, such injuries fall into two categories. “One is overuse of the joint and cartilage, which is part of the aging process and blends into something that we think of as degenerative joint disease,” she says. “The other is overuse of soft tissues, which can lead to the kind of tendonoses and tendonopathies we see in the shoulder, elbow, patella, and foot.”
Regardless of the type, overuse injuries can have a profoundly detrimental effect on the aging athlete, according to Peters. For older adults, a joint that aches from repeated activity may cause a compensatory movement—a limp or decreased use of the injured part of the body. This can lead to further problems such as muscle weakness in the affected area. “Those physical adjustments to pain—particularly the modified gait—are more common in an aging athlete than in someone in their 20s who can get through the injury without initiating that maladaptive change,” he says. “While it may seem like a good quick fix, it leads to a whole host of other issues involving balance and muscle atrophy.”
Treating the Pain, Training the Psyche
Unlike 25 to 30 years ago, when physicians were more likely to sideline older patients with sports-related injuries, the objective now is to keep them as active as possible for as long as possible. “Along with that has come a shift in patient thinking, from ‘I exercised, I hurt, I’m stopping’ to ‘I exercised, I hurt, and I’m going to see a doctor so I can keep the activity going,’” Bershow says.
In some cases, physical therapy or a modification of activity may be all that’s needed to keep the older athlete in the game. But treating sports- related injuries in older athletes can involve aggressive interventions such as joint replacement procedures, injections, meniscal repairs, and use of artificial cartilage. Not surprisingly, a sizeable portion of these procedures are being performed on baby boomers. According to the American Association for Orthopaedic Surgeons, baby boomers had 20 percent of the 220,000 hip replacements and 15 percent of the knee replacements performed in the United States in 2003. The authors of a study on hip and knee arthroplasty published in the Journal of Bone and Joint Surgery in April 2007 predicted that total hip and total knee revisions will grow by 137 percent and 601 percent, respectively, between 2005 and 2030.
Sometimes, however, “fixing” the problem (doing surgery or prescribing physical therapy) is not the most difficult aspect of dealing with older athletes. A bigger challenge, Thorson says, is helping patients set realistic expectations about what they can and cannot do. “They may still have the mindset that they should be able to do what they did when they were in their 20s,” he says, “and it can be extremely difficult for them to change their expectations.”
Thorson’s approach is to start by asking what they did, say, in college versus what they are doing now. “If they were playing tennis two hours a day every day in college and now they play four hours on a weekend and are having pain or are frustrated with their speed or performance level, I ask them to articulate precisely at what level they want to be.” He says having that conversation can help patients understand that they cannot expect to perform at the same level they were at when they were younger and training more intensely. Once they realize they have to adjust their expectations, he says, they can do so in a way that allows them to still enjoy their sport.
Although the growing number of older athletes is going to affect all physicians’ practices in the future, the specialties that will feel the effect most acutely are primary care sports medicine and orthopedic surgery. It appears some fields are gearing up to meet the demand. The U.S. Department of Labor has projected that the number of sports medicine physicians, athletic trainers, and physical therapists will grow by 20 percent between 2008 and 2018. And an article in the March 2010 issue of Annals of Family Medicine reported that 106 of the 282 ACGME-accredited fellowship programs listed on the American Academy of Family Physicians website are sports medicine programs. The average fill rate for those programs between 2005 and 2009 was 94.3 percent.
But the story is quite different for orthopedic surgeons. By 2016—the time when aging baby boomers will need more joint replacement surgeries—the United States will be experiencing a significant shortage of orthopedic surgeons. According to studies presented at the American Academy of Orthopedic Surgeons in February 2009, the consequences could mean that 72 percent of persons needing total knee replacements and 50 percent of those needing total hip replacements may not be able to get those procedures in a timely manner. The presenters suggested that general surgeons and primary care sports medicine physicians may need to become trained in total joint replacement surgeries to meet the demand.
There is no guarantee, however, that this strategy alone will alleviate the projected shortage. The personnel challenges, as well as the ethical dilemmas surrounding the costs and benefits of performing such procedures in older athletes, have prompted some physicians to ask the bigger question: Should we be putting our health care resources into doing total knee replacements on 78-year-olds because they cannot run anymore? Says Thorson, “That’s up to society or the individual patient to answer, but someone has to answer it, and someone has to pay for it.”
Physicians already are grappling with such issues as they make decisions about treating aging athletes. That may not be such a bad problem to have, however. “If the worst thing that happens to a physician is that they are seeing a bunch of physically robust 60- and 70-year-olds who worry because they have some tendonitis, from my vantage, that sure beats the multiple challenges associated with a patient who is sedentary and has a host of comorbidities such as heart disease and diabetes,” Joyner says. MM
Older athletes sometimes share the same ambitious goals as their more youthful counterparts. But the reality for these competitors is that their bodies aren’t the same as when they were in their 20s. Older athletes lose muscle mass, may experience degeneration of their joints, and sometimes have to cope with medical issues such as hypertension or high cholesterol. For those reasons, they need to be realistic about what they can and cannot do. To help aging athletes safely stay in the game, physicians should emphasize the following:
• Pain does not signify gain. But it does means something. “If it subsides after a night’s rest, it’s probably O.K.; if it doesn’t, advise the patient that it should be attended to,” says Elizabeth Arendt, M.D., an orthopedic surgeon with the University of Minnesota.
• Listen to your body. A swollen joint shouldn’t be ignored, says Arendt. “The patient may not know what’s wrong, but swelling may signify that something’s out of balance or out of harmony with a joint, and it usually merits investigation.”
• Strengthen the core. “Addressing core strength is key to maintaining patients’ ability to pursue physical activity as they age,” says Jamie Peters, M.D., a physician with Fairview Sports and Orthopedic Care in Minneapolis. Core strength exercises can include leg lifts, abdominal work, or activities such as yoga and tai-chi. “If people can maintain their hip stabilizers and abdominal stabilizers as they age, it can help them avoid the muscle imbalances and abnormal gaits that would otherwise occur in response to injury or discomfort,” he says.
• Do resistance and strength training. Resistance and strength training promote balance, stave off accelerated loss of muscle mass, and prevent muscle weakness. The physicians interviewed for this article noted that strength training is important for all aging adults, but especially for women, who are more prone to osteoporotic fractures.
• Think of household chores as exercise. Arendt is particularly passionate about informing patients of the significant musculoskeletal challenges that weekend house projects pose: “Painting a house, for example, mandates eight to 16 hours over two days—climbing up and down ladders, lifting, climbing, bending. If it’s something the body is not used to experiencing, that kind of exercise load can cause musculoskeletal maladies that linger for months.”
• Ramp up slowly. The more time a patient spends away from a chosen activity, the more time it will take to get back into it. Also, the more likely it is that he or she will need some guidance doing so. Help can come from an athletic trainer, physical therapist, nurse, or physician. One way to help patients progress safely is with an “exercise prescription,” which guides them in the type, intensity, and frequency of physical activity they can pursue. The ideal exercise prescription is one that addresses cardiovascular health, musculoskeletal health, and balance.
“Adding the exercise prescription in the primary care setting is a challenge, but it is something that the medical community can encourage as part of the primary care preventive counseling session,” says Robby Bershow, M.D., a fellow in primary care sports medicine at Hennepin County Medical Center. “The earlier we start age-wise, the more benefit it could produce.”
Jeanne Mettner is a Minneapolis freelance writer.