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AAOS Now

Published 5/1/2014
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Terry Stanton

Wisdom for the Weekend Warrior

Foot and ankle surgeons dispense advice for the aging athlete

The weekend warrior is a well recognized subset of orthopaedic patient. Once mostly seen among male patients, the warrior traits are now increasingly being seen among female patients.

Precise definitions vary, but generally, this patient is described as an “aging” (age 30 and older, by some reckoning) individual who continues to exercise and participate in sports avidly but often not systematically or judiciously, often in concentrated bursts of vigor.

Overall, the weekend warrior’s commitment to demanding physical activity has a beneficial effect on health. But often it also exacts a toll on bodies that are no longer as flexible or fast-healing as they were in high school. Common injuries and ailments include ankle sprains, tendinitis and tendon rupture (eg, Achilles), shin splints, shoulder/rotator cuff problems, and low back pain.

At the 2014 Specialty Day of the American Orthopaedic Foot & Ankle Society, four orthopaedic surgeons shared their observations about the weekend warrior, including the basic science behind the challenges of the aging athlete and ways to help these patients continue high levels of activity and exercise with a minimum of pain and down time. All active exercisers themselves, the panelists noted that orthopaedic surgeons who engage in weekend warrior behavior could also benefit from their remarks.

According to moderator Brian G. Donley, MD, of the Cleveland Clinic, the classic warrior is a person “who compresses weekly, moderate-to-vigorous activity into long durations (150 minutes or more) on only 1 to 2 days a week.” Typical sessions would be a 4-hour hike, 3 hours of yard work, or an afternoon of basketball. The pattern is most common in those aged 45 to 64 years.

Profile of a warrior
Bryan D. Den Hartog, MD,
of the University of South Dakota, said the typical “younger” warrior (mid-20s to 50s) was once a competitive athlete (in high school, college, or professionally), who had been in good shape and still has an internal drive and knows what it is to train and condition. The person may still want to compete at some level, and “physical expectations may remain high despite a decrease in training,” Dr. Den Hartog said, adding, “the mind may make appointments the body can’t keep.”

Generally, a marked decline in athletic performance begins around age 35. Whether performance changes are due to aging or lifestyle and whether a slowdown is inevitable or variable are under debate. Factors such as excessive glycosylation of soft tissues (ie, high-carbohydrate diet), dietary deficiencies, and lack of exercise may also contribute.

The decline occurs in areas such as the pulmonary system, in which maximum oxygen consumption decreases 1.5 percent a year, and the nervous system, as seen in a decrease in blood flow to the brain, decreased reaction time, deterioration of balance, and loss of muscle mass (sarcopenia).

Earlier studies concluded that sarcopenia occurs uniformly, with a muscle loss of 1 percent per year starting around age 40 and accelerating after age 65. However, Dr. Den Hartog said, these studies focused on sedentary older people. When studies included active older people—especially master athletes—the results were different. Participants had almost as many healthy, robust mitochondria in their muscles as people in their 20s.

“Many of the supposedly unavoidable and debilitating physiologic effects of aging may be avoidable,” Dr. Den Hartog said. “Being sedentary is much more of a risk factor for extreme declines in muscle mass, strength, and endurance than simply being past middle age. Decreased physical activity appears to be the key factor in producing sarcopenia.”

Bone loss and weight gain are also agents of decline. The extra weight exerts more stress on joints and surrounding tissues, leading to tendinitis, muscle strain, and stress fractures.

He noted that research on the recovery of functional performance in well-trained aging athletes is lacking and future studies should address this void.

The significance of inflammation
Samuel B. Adams Jr, MD,
of Duke University, discussed the basic science of the aging athlete, noting that much of the damage and decline that occurs is related to various local and systemic inflammatory processes. He introduced the concept of “inflamm-aging” to describe the common pathway for age-related pathologies, in which an increase in pro-inflammatory cytokines have a detrimental role (
Fig. 1).

“Nuclear Factor-kappa B (NF-κB) signaling is the molecular culprit of inflamm-aging,” he said. NF-κB is a mediator in the systemic inflammation involved in tendinopathy in the aging athlete. It is a governing factor in systemic inflammation and the hallmark diseases of aging as well as in local inflammation from injury.

Age-related degradation of tendons is associated with hypovascularity and decreased biomechanical integrity. The mechanical stress of exercise leads to repetitive tendon injury and microtrauma; the local inflammatory response to the injury involves both cytokines and the matrix metalloproteinases (MMPs) 2 and 9.

“It seems that with increasing age, tendons participate in self-degeneration,” Dr. Adams said, since the MMPs are known to degrade type I collagen. “Soluble pain and inflammatory mediators are also important in tendinopathies, because they can contribute to pain both within the tendon and in the surrounding tissues with increased activity.”

He also noted that comorbidities associated with advancing age—such as variation in insulin, testosterone, or estrogen; thyroidectomy; and corticosteroids—increase susceptibility to tendon degeneration, particularly with tendons of the foot and ankle.

In the aging athlete, foot and ankle arthritis is often linked to a single traumatic event and the inflammatory cascade that follows. The incidence of posttraumatic arthritis is far greater in the ankle than in other joints, ranging from 65 percent to 80 percent, versus 10 percent in the knee and 2 percent in the hip.

Because ankle cartilage is actually better suited for wear and tear than some other joint cartilage, avoiding traumatic injury in the ankle is important for preventing arthritis. Ankle cartilage is inherently stiffer, with less water and more cross-links, than other joint cartilage. It also has a higher rate of cellular activity in collagen and proteoglycans, Dr. Adams said.

Vitamin D may not only help prevent stress fractures and contribute to fracture healing, but it also has positive neuromuscular effects on muscle mass, muscle strength, and balance, and possible benefits to other systems. In patients with foot and ankle injuries, 76 percent are vitamin D insufficient or deficient.

Dr. Adams recommended that patients maintain serum 25-hydroxyvitamin D concentrations above 30 ng/mL, with supplementation of vitamin D2 and D3. For bone pain and stress fractures, he advised a 6- to 8-week course of 50,000 vitamin D units weekly, then 800 units daily—accompanied by 1,200 mg of calcium daily—with follow-up at 3 to 4 months.

The chemical “cure”
Christopher W. DiGiovanni, MD,
of Massachusetts General Hospital, surveyed some of the pharmaceutical, nutritional, and endocrinologic strategies for the aging (55 years and older) athlete. He first noted that the determinants of aging in any individual involve both time and genetics as well as lifestyle choices and environmental factors. Although aging is not recognized as a disease or as any other medical condition, he said, “the world still wants to know: Can we reverse this process physiologically?”

Despite the number of agents touted for their anti-aging properties over the years, the answer is probably no, said Dr. DiGiovanni. “There is no super fruit,” he noted, and many other products—such as creatine, fish oil, resveratrol (red wine), glucosamine, and herbal supplements—are “nearly always useless, and often harmful,” he quoted from one government report.

Hormone replacement therapies are the current anti-aging craze. However, many of these products have a questionable harm-benefit ratio and still somewhat controversial effectiveness. Even testosterone derivatives and human growth hormone—both naturally occurring hormones that peak at puberty and then begin to drop dramatically with age—are approved only for documented physiologic deficiencies and known related clinical syndromes.

The confusion exists because there is no consensus on what constitutes either a legitimate “adult deficiency” or a “normal” lab value in someone who otherwise looks phenotypically “normal.” Even the various new anti-aging boards involved with the burgeoning clinical specialty of regenerative medicine do not endorse their use for performance enhancement.

By some measures, these hormones have indeed demonstrated some “anti-aging” effects, but controversy continues over both the extent of the benefit and the degree of possible harm. Nonetheless, Dr. DiGiovanni suggested that at least some aspects of the growing data promoting chemical reversal of the physiology of aging may have merit and are compelling enough to warrant serious consideration.

He proposed that orthopaedists caring for a progressively older population shift their thinking—paying “less attention to fixing what is already broken and focusing more on preventing things from breaking down to begin with.” He reflected that the AAOS should feel obligated to keep abreast of all emerging science (and hucksterism) behind the rapidly evolving anti-aging movement in the United States. In recent years, this movement has given rise to board-certified providers and various accreditation bodies, including the American Academy of Anti-Aging Medicine.

“We can’t change our patients’ chronologic age,” said Dr. DiGiovanni, “but it seems we can modify or perhaps even ‘reverse’ their physiologic age. The question is, should we be ‘red-lining’ them physiologically?

“As of right now, diet and exercise appear to be beneficial at any age, but the rest of this remains controversial from a risk-benefit perspective,” he continued. “We cannot ignore that we have entered into a new dawn—an obsession with regenerative medicine—and the concept of promoting ‘health’ span rather than ‘life’ span. This anti-aging medical movement has quickly become a multibillion dollar industry. Although certain highlights of this young science appear to hold some impressive promise for the future of our patients, the levels of evidence remain weak and the potential for complications real. We must continue to be vigilant in asking ourselves, as we look for our fountain of youth, is there really ‘better living through chemistry?’”

The cold reality
Dr. Den Hartog shared his prescription for dealing with the “cold reality” of decline: Work assiduously and intelligently at fitness maintenance. He advised those seeking to maintain a competitive sports level to practice fairly intensively to maintain aerobic capacity and performance with age. He suggested short, hard, repeated bursts of exercise, such as sprinting for a quarter mile, resting a few minutes, then sprinting again.

“The hard reality of aging for most athletes is that they simply cannot work out and race as often,” he said. “For reasons science has not fully explained, the body needs more rest. Athletes need to start slowly, find a sport, and give it time. It must be sustainable!”

In evaluating patients, including those with injuries, Dr. Den Hartog recommended that the orthopaedist determine the patient’s physiologic and metabolic status, as well as his or her “set points.” Deficiencies in diet or training should be identified and addressed, and the physician should determine if the patient’s conditions warrant a tailored rehabilitation.

“Most sports injuries can be prevented or treated with a combination of preparation, targeted exercise, and conditioning—and common sense,” he said.

“Ultimately, it is up to the patient to get it done, but as orthopaedists, we are uniquely qualified to point the way,” he continued. “Science has proven that life does not begin at 40, but it also has demonstrated that it does not have to end there.”

Disclosure information: Dr. Donley—Extremity Medical, Infoslate, Belvoir Publications, Journal of Bone and Joint Surgery–American, Foot & Ankle International; Dr. Den Hartog—OrthoHelix Surgical Designs, FootInnovate.com; Tornier, BME; Dr. Adams—Extremity Medical; Dr. DiGiovanni—BESPA, Biomimetic, Extremity Medical, Wright Medical Technology, Curamedix, Performance Orthotics, Wolters Kluwer Health–Lippincott Williams & Wilkins, Springer, Elsevier, (European) Foot and Ankle Journal, Foot & Ankle International.

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Bottom Line

  • Much of the aging population seeks to continue to be active, and many are “weekend warriors” who compress moderate to vigorous activities into a few days.
  • As they age, all individuals experience declines in functional body systems and decreases in muscle mass, but the rate and extent of the changes are affected by factors besides chronologic age.
  • Injuries to tendons and joints are closely related to various local and systemic inflammatory reactions, and arthritis in the foot and ankle is most often the result of a traumatic event rather than wear and tear.
  • Most supplements and biologic agents that claim to “reverse” aging are not supported by reliable or convincing evidence of effectiveness.
  • Active and athletic patients—regardless of their age—should be advised about proper training techniques.