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AAOS Now

Published 9/1/2009
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Jennie McKee

Keeping master’s athletes in the game

Strategies for helping aging patients stay active

Aging may be inevitable, but many people 55 years and older aren’t willing to simply get old. Just look at the success of golfer Tom Watson, who — at age 59 — came within a stroke of winning the 2009 British Open.

“Our practices are filled with older patients who want to stay active,” said Vonda J. Wright, MD, director of the Performance and Research Initiative for Master’s Athletes at the University of Pittsburgh. “When we treat them, we must realize that their bodies are unique—not bad sequels of their 20-year-old selves.”

One in every four Americans (26 percent of the population) was born between 1946 and 1964. Far from being couch potatoes, these “baby boomers” enjoy participating in sports and exercise and are accustomed to having things “their” way. If something hurts, they want it fixed—fast—so they can continue their active lifestyles with the goal of increasing longevity and quality of life.

These athletes can benefit from strength training programs and physical therapy to condition the entire body and help avoid overuse injuries, according to a panel of experts at the 2009 annual meeting of the American Orthopaedic Society for Sports Medicine.

Maintaining knee function
“How frequently do you run? Do you play tennis regularly? How long do you intend to continue competing?” Asking the injured master’s athlete these kinds of questions will give you a sense of the patient’s expectations for frequency of exercise and level of intensity and will help you shape a treatment plan.

Other considerations are the patient’s general fitness level and body mass index (BMI), said Riley J. Williams III, MD, who treats master’s athletes with knee injuries.

“Numerous articular cartilage and ligament repair studies have shown that BMI has a distinct effect on outcomes,” he explained.

Aging causes a significant loss of muscle mass and can negatively affect the bones, tendons, ligaments, and cartilage. As a result, patients seek treatment for degenerative deficiencies and diseases.

“I use radiographs to assess alignment, as well as cartilage-sensitive magnetic resonance imaging to analyze the general health of the knee,” he said. “Osteoarthritis is by far the most common abnormality present in these patients.”

Nonsurgical treatment plans for osteoarthritis can include activity modification, nonsteroidal anti-inflammatory drugs and other oral medications, viscosupplementation, and bracing.

“Physical therapy is another option,” emphasized Dr. Williams. “It isn’t a throw-away strategy. Physical therapy can really have a positive effect on lower extremity strength and function.”

Less common conditions include meniscus tears, ligament ruptures, and muscle weakness.

“Meniscal tears and ligament rupture can be treated similarly in both younger patients and master’s athletes if the joint is relatively unaffected by degenerative disease,” said Dr. Williams.

“A number of studies in peer-reviewed publications have shown that arthroscopically-assisted anterior cruciate ligament (ACL) reconstruction can be an effective treatment strategy in patients older than 40 years,” he continued. “On the other hand, meniscal reconstruction is not a treatment strategy I would recommend in the master’s athlete if condyle architectural changes are present in the knee.

“Cartilage restoration, osteotomy, and unicompartmental arthroplasty all are stalwarts within my type of practice,” he added.

Treating the hip
When a neighborhood game of softball or a round of golf turns painful for the senior athlete, a hip condition is often the culprit. Sports that involve rotating the trunk at a high velocity can lead to problems with the hip as well as the lumbar spine.

“Hip disorders can go undiagnosed for a long time,” said J.W. Thomas Byrd, MD. “Secondary problems can mask the original injury or condition.”

During the differential diagnosis, orthopaedists should look for secondary conditions common among older patients, such as degenerative disease of the lumbar spine, gluteal tendonitis, recalcitrant trochanteric bursitis, conventional hernias, and visceral disorders. Stress fractures, which can be a consequence of postmenopausal disorders or senile bony changes, should also be considered, as should malignancies.

“Although metastatic disease is most common, don’t forget about tumors in the hip area, which can gain considerable size before they are detected because of the deeply situated anatomy,” cautioned Dr. Byrd.

An older athlete’s hip problems aren’t necessarily worse than those of younger athletes.

“We recently published 10-year follow-up data of a series of patients who underwent hip arthroscopy,” he said. “If we eliminate those with arthritis, the older patients did just as well as the younger patients. So the problem wasn’t age—it was arthritis.”

Dr. Byrd noted, however, that treatment strategies may need to be altered based on the patient’s age.

“For example,” he said, “the hip of a 60-year-old is less likely to mount much fibrocartilaginous healing response to microfracture.”

Cam-type femoroacetabular impingement, a common cause of joint breakdown in active individuals, can be corrected arthroscopically because the procedure has good results and a relatively low morbidity rate.

“For arthroscopic correction to be effective, reasonable joint space must be preserved,” he said. “Perhaps more important, however, is ensuring that the athlete has reasonable expectations of what may or may not be accomplished by the procedure.”

Keeping the shoulder strong
Although eventual muscle loss cannot be avoided, all master’s athletes can benefit from strength and flexibility training. Resistance training enhances the strength of older patients. In fact, it is just as effective in older patients as in younger people, when compared on a relative scale.

Master’s athletes should follow programs that develop their general and core strength, as well as local endurance and power.

W. Ben Kibler, MD, who treats older baseball players, noted that it’s critical for his patients to strengthen the shoulder.

“Decreased muscle capability translates to decreased force, velocity, and joint control; therefore, more muscle generating capacity is necessary at the shoulder itself,” he explained.

He advises young baseball players to participate in core stability training and strengthening in the off-season, and in an interval throwing program during the baseball season. Older baseball players, however, “need to train both during the baseball season and during the off-season to maintain and build their local shoulder strength.”

The American College of Sports Medicine (ACSM) recently published a position stand on the unique strengthening needs of older patients. The ACSM recommendations for increasing local strength and endurance involve lifting weights at a medium resistance level (40 percent to 60 per­cent of maximum weight the athlete can lift in one repetition) in sets of four to six repetitions at medium speed.

Strength training, however, won’t eliminate the development of osteoarthritis or injuries such as rotator cuff tears. Studies have found that total shoulder arthroplasty and hemi-arthroplasty have generally favorable outcomes; results are somewhat less favorable in patients with posttraumatic and rheumatoid arthritis.

More research on boomers needed
Extensive research has been conducted on issues affecting adolescent, female, collegiate, and professional athletes; however, master’s athletes have received little attention.

Dr. Wright explained that the University of Pittsburgh has devoted significant resources to studying and treating the senior athlete. The university also provides services that help older exercisers maintain or increase their physical performance while minimizing their risk of injury. She urged other institutions to develop a similar focus on aging athletes.

“I’m encouraged by recent studies that have explored whether activity level, rather than age alone, should be a consideration for ACL surgery,” she said. “I am also pleased that the AAOS will be publishing a textbook on the master’s athlete.”

Dr. Wright noted that it’s important for physicians to recognize older athletes’ vitality and their desire to stay active for as long as possible. Strength training, conditioning, and rehabilitation using a whole-body approach can help master’s athletes avoid injuries.

“I hope that the sports surgeons in our community will set the course for other orthopaedic surgeons,” she added.

Participants reported the following disclosures: Dr. Wright—no conflicts; Dr. Williams—Arthrex, Inc., Histogenics, Stryker, Smith & Nephew; Dr. Byrd—Smith & Nephew; Dr. Kibler—Alignmed.

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

References:

  1. Byrd JW, Jones KS: Prospective analysis of hip arthroscopy with 10-year follow-up. Clin Orthop Relat Res 2009 Apr 21 (Epub ahead of print)
  2. Byrd JW, Jones KS: Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement. Clin Orthop Relat Res 2009; 467(3):739-46.
  3. John EB, Liu W, Greogory RW: Biomechanics of muscular effort: age-related changes. Med Sci Sports Exerc 2009; 41:418-425.