Orthopaedic Care of the
Aging Athlete
Abstract
Increasing numbers of middle-aged and older adults participate in
sports, and athletes wish to remain active as they age.
Understanding the anatomic, physiologic, and psychosocial
differences between older and younger athletes can help aging
athletes maintain function. Athletic capacity may be sustained
well into advanced age, and many of the physiologic consequences
of aging may be mitigated or reversed by regular exercise. Most
injuries in older athletes are chronic and overuse injuries that
result in diminished flexibility and endurance. In addition, many
aging athletes have medical and musculoskeletal problems that
mandate tailoring athletic activity to the patient’s general health
and functional requirements.
T
raditionally, physical decline
has been regarded as a normal
part of aging. Although the rate of
aging varies, organ functions gradu-
ally become impaired and decline,
thus increasing vulnerability to en-
vironmental stresses, metabolic dis-
turbances, and disease.
1
Recent evi-
dence, however, suggests that this
deterioration is not inevitable and
that the so-called effects of aging
may be more a result of a sedentary
lifestyle and long-standing disuse.

ical fitness. Currently 60 nations
have adopted the declaration of the
present decade as the Bone and Joint
Decade.
Because older persons today are
increasingly physically active, or-
thopaedic surgeons need to under-
stand the anatomy and physiology
of aging in the older athlete and
be able to differentiate “normal”
from pathologic aging. Treatment
should be tailored to meet the pa-
tient’s functional requirements as
well as treat musculoskeletal prob-
lems, such as osteoarthritis, which
affects nearly one in three middle-
aged and older adults.
6
The treat-
ment plan also must be tailored to
accommodate any physical or cogni-
tive limitations the patient may
have.
Andrew L. Chen, MD,
Simon C. Mears, MD, PhD, and
Richard J. Hawkins, MD
Dr. Chen is Attending Orthopaedic
Surgeon, Littleton Orthopaedics,
Littleton, NH. Dr. Mears is Assistant
Professor, Department of Orthopaedic

old.
7
Peripheral vascular resistance
increases because of atherosclerosis,
vessel-wall rigidity, and baroreceptor
tone. Pulmonary efficiency decreases
because lung compliance and tho-
racic cage elasticity decrease, and gas
exchange becomes limited.
1
The net
result is an increased risk of acute
myocardial events, particularly in
sedentary persons who begin inten-
sive training rather than gradually in-
creasing their exertion level.
Various changes characterize a de-
cline in renal function. The number
of glomeruli decline from a range of
500,000 to one million at age 40 to
half that number by the seventh de-
cade.
8
From the second to eighth de-
cades, renal blood flow and the
glomerular filtration rate decrease
by half, and the specific gravity of
urine decreases from an average of
1.032 to 1.024, with a relative in-
crease in water excretion.

Increased residual volume
Increased ventilation-perfusion ratio
Improved gas exchange
Decreased sense of breathlessness
Strengthening of respiratory muscles
Renal Progressive loss of glomeruli
Decreased renal perfusion
Decreased glomerular filtration rate
Decreased specific gravity of urine
Increased renal blood flow, mainly
via increased cardiac output
Neurologic Impaired hearing, short-term memory, cognition, judgment
Decreased coordination, balance, fine-motor skills
Increased motor response time
Decreased visual-spatial orientation
Altered sensation and proprioception
Decreased peripheral nerve conduction velocity, amplitude,
motor unit recruitment
Improved sport-specific skills
Improved coordination, balance
Improved visual-spatial orientation
Ophthalmologic Decreased visual acuity and accommodation
Diminished peripheral vision, contrast sensitivity
Impaired ability to adapt to low-light situations
None
None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a
commercial company or institution related directly or indirectly to the subject of this article: Dr. Chen and Dr. Mears. Dr. Hawkins or the
departments with which he is affiliated has received research or institutional support from Steadman-Hawkins Research Foundation. Dr.
Hawkins or the departments with which he is affiliated has received royalties from Hardcore Books and DePuy. Dr. Hawkins or the departments
with which he is affiliated has stock or stock options held in Arthrocare Sports Medicine. Dr. Hawkins or the departments with which he is

absence of known neurologic dis-
ease, the elderly have a 30% to 50%
reduction in vibration and position
sense at the ankles
9
(Table 1).
Musculoskeletal Changes
Musculoskeletal changes (Table 2)
include those in bone, connective tis-
sue, and skeletal muscle.
Bone
The apparent age-related de-
crease in bone mineral density re-
sults not from a qualitative defect of
mineralization but rather from a
quantitative loss of trabecular
density. Men lose bone mass at a
rate of 0.5% to 0.75% per year after
age 40, whereas women lose bone at
more than twice that rate (1.5% to
2% per year) before menopause and
up to 3% per year after menopause.
10
Moreover, female athletes involved
in intensive training since child-
hood are at especially high risk of
osteoporosis because many experi-
enced delayed menarche, oligomen-
orrhea, or secondary amenorrhea re-
lated to their training and diet.

Decreased fiber compliance
Stiffness of ligaments and tendons
Increased susceptibility to catastrophic failure
Decreased glycosaminoglycan concentration
Decreased collagen fiber bundle thickness
Decreased vascularity
Regular exercise
Pre-exercise stretching
Meniscus Intrasubstance degeneration
Loss of ability to dissipate stress
Increased propensity to degenerative tears
Débridement of unstable degenerative
tears*
Articular
cartilage
Decreased concentration of chondroitin sulfate, relative
increase in keratan sulfate (nonosteoarthritic)
Relative increase in chondroitin sulfate (osteoarthritic)
Chondromalacia (cumulative damage)
Microfracture for selected full thickness
chondral lesions
Débridement of unstable chondral lesions*
Glucosamine and chondroitin sulfate*
Hyaluronate viscosupplementation*
Skeletal
muscle
Sarcopenia
Decreased type I and II muscle fiber loss
Volumetric loss of individual fiber size
Progressive muscle denervation

stresses decline in meniscal tissue,
increasing its susceptibility to hori-
zontal cleavage tears. Peripheral
tears may heal in a limited fashion,
with metaplasia of the fibrous tissue
into fibrocartilage, whereas central
and degenerative intrasubstance
tears demonstrate a poor capacity for
healing.
10
Repetitive loading may
propagate these degenerative tears
through progressive microtrauma.
Articular Cartilage
Articular cartilage consists pri-
marily of type II collagen embedded
in a matrix of proteoglycans, water,
glycoproteins, and other proteins in
small amounts, interspersed with a
sparse population of chondrocytes.
With age, the concentration of chon-
droitin sulfate relative to that of
keratan sulfate decreases in nonar-
thritic articular cartilage, whereas it
increases in osteoarthritic articular
cartilage.
10
Because nutrition and re-
moval of metabolic waste occur by
diffusion in articular cartilage, mo-

and weakness may be reversible
with exercise. Age-associated mus-
cular atrophy arises from the equal
loss of type I and II fibers and, to a
lesser extent, losses in fiber volume.
Denervation, increased total col-
lagen content, decreased mitochon-
drial volume, and other degenerative
ultrastructural changes in muscle fi-
bers also occur with age.
10
Muscle
activity may mitigate these effects
and improve biochemical and oxida-
tive capacity. Traditionally, peak
muscle strength was thought to oc-
cur at age 30 years, decline 15% per
decade between age 50 and 70 years,
and decline 30% per decade after age
70 years. It is now evident that reg-
ular, intensive muscle training can
minimize or reverse age-related de-
clines in muscle mass well into the
eighth decade of life.
12
The musculotendinous unit also
loses flexibility with age, which is
believed to be influenced by both in-
activity and genetics.
1

normal levels of the hormone.
15
Androgens and androgenic pre-
cursors, such as testosterone, dehy-
droepiandrosterone (DHEA), andro-
stenedione, and androstenediol,
have been advocated to restore mus-
cle mass and strength, increase vital-
ity and libido, decrease oxidative
stress, maintain coordination, and
diminish erectile dysfunction. These
beneficial effects, however, have not
been observed in hormonally normal
individuals.
15
Moreover, benefits
may be offset by the following:
downregulation of testosterone syn-
thesis, accumulation of estrogenic
compounds, unfavorable changes in
blood lipid levels and other cardiac
risk factors, increased risk of pros-
tate disease, and disruption of the
equilibrium between plasma cortisol
and testosterone levels.
16
Athletes have used recombinant
human erythropoietin to stimulate
erythropoiesis and increase oxygen-
carrying capacity and endurance. In-

found in skeletal and cardiac muscle
and in retinal, testicular, and brain
tissues, is important in production of
adenosine triphosphate. Creatine is
thought to increase the production of
phosphocreatine and the pH buf-
fering capacity of muscle, thereby
enhancing muscular strength and en-
durance. In addition, increased intra-
cellular creatine and phosphocreatine
concentrations may promote fiber
hypertrophy and water retention,
which may benefit those with sar-
copenia.
19
Adverse effects of creatine
supplementation are secondary to
fluid imbalance and include extracel-
lular fluid retention, intravascular de-
pletion, dehydration, muscle cramp-
ing, nausea, gastrointestinal distress,
and possible renal dysfunction.
Nutritional supplementation has
not been shown to enhance perfor-
mance in athletes who train regular-
ly and maintain a well-balanced diet.
In addition, unbalanced diets and ex-
cessive supplementation that substi-
tute for regular meals can have ad-
verse effects.

Improved oxygen utilization
Improved physical endurance
Increased insulin-resistance
Increased free-radical formation
Increased cancer risk
Androgens (eg,
testosterone, DHEA,
androstenedione,
androstenediol)
Increased muscle mass
Increased strength
Increased vitality
Increased libido
Decreased oxidative stress
Decreased erectile dysfunction
Maintenance of visual-spatial coordination
Downregulation of testosterone synthesis
Testicular atrophy
Aggressive behavior
Accumulation of estrogenic compounds
Unfavorable alterations in blood lipid profile
Increased cardiac risk
Increased prostate disease
Dysequilibrium between plasma cortisol and
testosterone
Recombinant human
erythropoietin
Increased hematocrit
Increased oxygen-carrying capacity
Increased muscle endurance

Gastrointestinal distress
Renal dysfunction
DHEA = dehydroepiandrosterone
Andrew L. Chen, MD, et al
Volume 13, Number 6, October 2005 411
proportion of aging athletes’ acute
traumatic injuries.
23,24
Among aging athletes, acute mus-
cular strains predominate. The myo-
tendinous junction is especially vul-
nerable to injury because the
terminal sarcomeres of muscle fiber
are less extensible than the middle
sarcomeres.
10
Moreover, weakened
or fatigued muscles are less able to
absorb energy or stretch in response
to eccentric muscle activity. The fre-
quency with which these muscle-
strain injuries are seen likely reflects
the decrease in musculoskeletal
flexibility of older athletes as well as
their greater participation in endur-
ance sports, such as long distance
running, that result in muscle fa-
tigue and predisposition to injury.
10
Ruptures of the Achilles and quadri-

common athletic injuries are related
to degeneration and repetitive inju-
ry. Chronic or overuse injuries also
have been shown to result in pro-
longed disability in older persons.
Kallinen and Markku
26
observed
that 20% of such injuries in older
male athletes lasted more than 2
years and altered their training or
competition.
Tendinosis
Tendinosis is common in older
athletes and results from repetitive
loading and cumulative microtrau-
ma to the tendons, which are stiffer
and heal more slowly than those of
younger athletes.
10
Rotator cuff ten-
dinopathy, medial epicondylitis, and
inflammation of wrist tendons are
the most common tendinoses in old-
er golfers;
27
Achilles tendinitis is the
most common among older jog-
gers.
28

ported a 94% satisfaction rate in pa-
tients older than age 65 years who
underwent subacromial decompres-
sion and rotator cuff repair; most
patients reported pain relief, inde-
pendent living, and a return to recre-
ational sports. In an evaluation of
avid middle-aged tennis players,
Sonnery-Cottet et al
33
suggested that
up to 80% are able to return to full
participation at their previous level
after rotator cuff repair of the domi-
nant shoulder.
Osteoarthritis
Most older athletes have trained
from a very young age, making them
vulnerable to osteoarthritis. Vingard
et al
34
observed that middle-aged
athletes who participate in high-
intensity physical loading are 8.5
times more likely to develop os-
teoarthritis of the hip than are age-
matched controls. Repetitive, high-
impact loading results in cartilage
microtrauma and degeneration of
the weight-bearing joints.

collagenolytic activity of chondro-
cytes. Chondroitin sulfate and glu-
cosamine are thought to diminish
joint pain and tenderness, improve
mobility, and sustain clinical im-
provement despite cessation of other
drug therapy. Although commercial
preparations of these compounds are
popular, debate continues concern-
ing their bioavailability in oral prep-
arations as well as the potential for
the placebo effect. Further investiga-
tion is needed to show whether
these agents can treat osteoarthritis
effectively.
35
Orthopaedic Care of the Aging Athlete
412 Journal of the American Academy of Orthopaedic Surgeons
Viscosupplementation and
Chondroplasty
Intra-articular hyaluronate visco-
supplementation has gained popu-
larity as a palliative treatment of
osteoarthritis of the knee. Viscosup-
plementation is intended to replen-
ish the hyaluronate component of
the joint, thus reestablishing the
rheologic properties of synovial flu-
id. Although previous investigations
have documented the safety of such

this study have been challenged.
Dervin et al
38
found that in 126 pa-
tients who under went arthroscopic
débridement for osteoarthritis of the
knee, improvement in quality of life
was less than expected; however, pa-
tients with medial joint-line tender-
ness and those with unstable menis-
cal tear improved significantly (P =
0.04 and P = 0.01, respectively).
Reconstructive Options
Numerous reconstructive options
have been described for the treat-
ment of full-thickness chondral le-
sions of the knee; these include
autologous chondrocyte transplanta-
tion, osteochondral grafts, and mosa-
icplasty. Although these procedures
are intended for the younger patient
with focal articular cartilage lesions
with otherwise healthy bearing sur-
faces, in general, these procedures
fall short of anatomic reestablish-
ment of the joint surface. Perhaps a
greater challenge is management of
the osteoarthritic knee, particularly
in older patients who wish to remain
physically active. Modifying activity

40
For these reasons, abrasion chon-
droplasty and subchondral drilling
has largely been supplanted by the
microfracture technique. In this
technique, subchondral penetration
is accomplished with an awl, which
is thought to be advantageous be-
cause it causes less thermal necrosis
of subchondral bone than drilling
does. Thus, the architectural integri-
ty (it is not just the strength but also
the shape that is important) of the
subchondral bone is maintained,
bone loss decreased, and the sub-
chondral osseous bed roughened for
better clot adhesion.
41
The clot that
forms has been shown to contain
pluripotential cells that can differen-
tiate according to signals elaborated
by cells in the surrounding chondro-
cytes.
38
Using the microfracture
technique, Steadman et al
41
reported
75% improvement at 3- to 5-year

scale dropped from 5.4 to 4.8.
Hip arthroscopy has been used to
address early osteoarthritis and la-
bral tears. McCarthy et al
44
reported
that in elite athletes, hip arthrosco-
py could safely and reproducibly di-
agnose and treat intra-articular hip
disorders, including labral pathology,
chondral lesions, and loose bodies.
Hip arthroscopy may be indicated in
older patients with osteoarthritis
who are either unwilling to modify
activities or who do not have suffi-
cient degenerative changes to under-
go prosthetic replacement. Arthros-
copy of the hip is an evolving
procedure with limited collective
experience. Helenius et al
45
reported
on 68 patients with mild to moder-
ate osteoarthritis of the hip treated
with arthroscopy. Three months af-
ter the procedure, 72% reported de-
Andrew L. Chen, MD, et al
Volume 13, Number 6, October 2005 413
creased hip pain; however , by 1 year,
this had declined to 26%. Repeat hip

is effective return to functional ac-
tivities.
Total joint arthroplasty for os-
teoarthritis has been shown to pre-
dictably relieve pain and restore
functional mobility; today it is not
uncommon for patients to remain
athletically active after surgery
(Table 4). Although most patients
ultimately pursue lower-intensity,
lower-impact activities (eg, golf,
walking), many frequently inquire
about high-intensity, high-impact
activities (eg, alpine skiing, running)
that may result in excessive implant
wear or jeopardize implant fixation.
There are a number of measures of
success in prosthetic replacement,
but the primary one is patient activ-
ity level. Older athletes who have
achieved high levels of skill or con-
ditioning in a particular sport have
the best chance of safely resuming
such activities after prosthetic re-
placement; patients who have not
previously participated in a particu-
lar sport (especially high-risk activi-
Table 4
Athletic Activity After Joint Arthroplasty: Summary of the 1999 Surveys of
the Hip Society, the Knee Society, and the American Shoulder and Elbow

Ice skating 0 + +
Jogging – – ++
Lacrosse – – 0
Racquetball – – 0
Rock climbing – – –
Roller/in-line skating 0 0 0
Rowing 0 + 0
Shooting ++ ++ +
Shuffleboard ++ ++ ++
Skiing–cross-country + + ++
Skiing–downhill 0 0 +
Skiing–stationary (machine) 0 + ++
Soccer – – 0
Speed walking 0 + ++
Squash – – 0
Swimming ++ ++ ++
Tennis–doubles ++ + ++
Tennis–singles – – 0
Volleyball – – 0
Walking ++ ++ ++
Weightlifting–free-weights 0 0 0
Weightlifting–machines 0 + 0
++ = allowed, + = allowed with experience,0=noconclusion, – = not recommended
Orthopaedic Care of the Aging Athlete
414 Journal of the American Academy of Orthopaedic Surgeons
ties, such as alpine skiing) are at
increased risk for injury.
46
With new-
found pain relief and mobility, such

el, and sport-specific requirements
may affect implant selection, bear-
ing surface, use of cement or supple-
mental screw fixation, and measures
to enhance prosthetic stability.
In 1999, the Hip Society, the Knee
Society, and the American Shoulder
and Elbow Society all surveyed their
members on athletic activity after
joint arthroplasty
46
(Table 4). In
general, these surgeons allowed pa-
tients with total joint arthroplasties
to take part in unrestricted low-
impact activities, such as walking or
stationary bicycling. For low-impact
activities that may be deleterious to
implant longevity, such as cross-
country skiing, we prefer patients to
have had preoperative experience
with such activities to minimize the
risk of falling. Patients should avoid
athletic activity until adequate
strength, balance, and coordination
have returned. Hip replacement im-
poses additional restrictions on cer-
tain body positions that increase the
risk of hip dislocation. Therefore, we
are cautious about activities that

procedures are not ideally suited for
degenerative arthritis. Other non-
prosthetic surgical options, such as
high-tibial osteotomy or hip arthros-
copy, have had recent encouraging
results. As our understanding of the
associated indications and surgical
techniques continues to expand, an
increasing number of patients may
be able to delay or avoid joint re-
placement surgery. Advancements in
implant design, materials, and surgi-
cal protocol have enabled patients
with joint replacements to remain
physically active, albeit with certain
restrictions.
Because the success of functional
recovery and return to athletic par-
ticipation depends on the ability of
the patient to physically or mental-
ly comply with a given treatment
plan, it is essential that the physi-
cian individualize conditioning or
rehabilitative regimens based on the
patient’s known physical or cogni-
tive limitations.
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