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CHAPTER 10

The Older Athlete

Greg Sassmannshausen

In This Chapter

Physiologic effects of aging Athletic activity after total joint arthroplasty Hip replacement Knee replacement Shoulder replacement

Over the past 20 years, the number of middle-aged individuals active in sports has undergone unprecedented growth. This has led to chronologically older patients subjecting their bodies to stresses seen previously only by their younger counterparts. A resultant increase in injuries previously reserved for younger athletes or injuries unique to the older athlete has occurred. While these patients continue to remain active, the physician must be aware of the physiologic changes that occur with aging that may predispose to more frequent injury, altered healing responses, and potential delay in recovery. This may require alternative treatment techniques and rehabilitation for soft-tissue injuries affecting the musculotendinous junction and ligaments.

As the average life expectancy of the population increases, the prevalence of symptomatic arthritis also increases. Joint replacement surgery has provided very predictable results in providing pain relief and increased function.1,2 With this improvement in quality of life, patients continue to desire to remain physically active after arthroplasty. As joint replacement evolves with improvements in surgical technique, component design, and component materials, the indications for arthro-plasty have been expanded to younger, more active patients. Therefore, the demands on joint replacements continue to increase.

The purpose of this chapter is to make the physician aware of the physiologic changes of the musculoskeletal system with aging and the basic science of the aging soft-tissue response to injury and review common concerns with athletic activity after joint arthroplasty along with current recommendations for these activities. With better understanding of these processes, the physician should be able to make more timely diagnoses with appropriate and cost-effective treatment and rehabilitation in an attempt to return the mature athlete to the premorbid activity levels or activities that will not be detrimental to joint replacements.

EFFECTS OF AGING ON THE MUSCULOTENDINOUS UNIT, LIGAMENTS, AND BONE

Recently, a significant amount of basic science research has focused on the effects of aging on muscles, ligaments, and tendons. What was considered to be the physiology of "aging" is now being reevaluated as that of "disuse," with a very subtle distinction between the two.3 While the changes of disuse may be reversed, it appears that age-related losses cannot be recovered. At some point, irrespective of activity level, muscle function will decline, making the muscle susceptible to injury (Table 10-1).3 This is evident around the knee. The quadriceps of individuals older than 60 years are 25% to 30% smaller than those of 20-year-olds.4,5 Along with a decrease in size comes a concomitant decrease in muscle strength and endurance. Total muscle mass appears to decrease gradually from age 20 to 50 and then drop more markedly from age 50 to 90.6 Knee extensor muscles during jumping show gradually declining strength beyond age 30 and decline in endurance after age 20.7,8 This loss of muscle mass, strength, and endurance is likely secondary to a decrease in the number of muscle fibers associated with aging. In a cadaveric study of physically active, apparently healthy men who suffered sudden death, Lexell et al9 reported the vastus lateralis muscles of the older group of men had a 25% reduction in total number of muscle fibers compared to the younger group. The exact cause of this decrease in the number of muscle fibers remains unclear. However, with aging, there is a decrease in the number of motor units, which may explain the decrease in fiber number.10 This "functional denervation" appears to result in decreased synaptic contact with aging muscle and subsequent loss of myofiber function, resulting in loss of strength and endurance.10,11 The end result places the aging muscle at risk of

INTRODUCTION

• The number of older individuals remaining active in sports is increasing.

• Muscles, tendons, and ligaments all have been found to show a decline in biomechanical properties with aging.

• Appropriate exercise can slow or prevent some age-related changes.

• Injuries in the older patient may require different treatment than similar injuries in the younger patient.

• Joint replacement surgery presents unique considerations with regard to athletics, as overly aggressive activities may result in early loosening or failure of the prosthesis.

• Education of the older athlete is important in allowing exercise while decreasing the risk of injury or adverse effects to replaced joints.

Table 10-1 Effects of Aging on Muscle

Decreased muscle size and mass Decreased muscle strength Decreased muscle endurance Decreased number of muscle fibers injury while participating in sports activities. However, data suggest exercise and strength training by older people may reverse some of the alterations normally associated with aging muscle, providing a protective effect.12

Muscles commonly become injured during eccentric contraction in which higher forces are generated using fewer motor units.13 Typically, muscle failure occurs at the musculotendinous junction regardless of the rate of strain or architecture of the muscle.14 These susceptible muscle groups tend to cross two joints. Conditions that predispose to muscle strain include muscle fatigue, weakness, prior injury, or systemic diseases that cause muscular or tendinous degeneration.14-16 Therefore, the aging patient may be predestined to muscle strains if activities are performed that require significant eccentric contractions, including sprinting and cutting.

Age has a significant influence on tendons, with a resultant increased potential for injury (Table 10-2). Starting from the third decade of life, aging results in multiple changes in the collagen within the tendons, including decreased cross-link maturation, an increased amount of insoluble collagen, and decreased collagen turnover.17,18 Proteoglycan and water content decrease along with a reduction in vascularity.19 Systemic illnesses or medications may also contribute to tendon calcification, mucoid degeneration, and tendinosis. These age-related changes affect the biomechanical behavior, resulting in stiffer, less compliant, and weaker tendons susceptible to injury. Similar to muscle, exercise may actually slow the decline in biomechanical properties associated with aging.19

Aging also has significant effects on the biomechanical properties of ligaments. The stiffness and ultimate tensile load for the anterior cruciate ligament from donors aged 22 to 35 were nearly three times as high as those from older specimens aged 50 to 60.20 This change in mechanical properties is thought to be secondary to a decrease in collagen fibril size and changes in collagen cross-linking that occur after skeletal maturity.21

The effects of aging on bone are well understood, with progressive loss in bone mineral density after the third decade of life. This provides unique challenges when surgical procedures

Table 10-2 Effects of Aging on Tendons and Ligaments

Decreased collagen cross-linking Increased amount of insoluble collagen Decreased proteoglycan and water content Decreased collagen turnover Decreased stiffness Decreased ultimate tensile load require stabilization of soft tissues to bone. Significant osteope-nia often requires surgeons to alter fixation methods, allowing for adequate repair stability in order to tolerate the rigors of postoperative rehabilitation.

Once injury has occurred, aging affects the healing potential for both muscle and tendon. While muscle can regenerate after injury in older patients, the morphology and function of the reparative tissue differ from those of younger people.22 Aging results in reduced capillary density, decreased availability of reparative cells, altered responses of cells to cytokines and growth factors, and systemic endocrine changes leading to decreased efficiency of muscle or tendon repair.23-25 These factors may delay healing and alter biomechanical properties of the healed tissue, leading the treating physician to adjust rehabilitation and potential return to sporting activities.

ATHLETIC ACTIVITY AFTER TOTAL JOINT ARTHROPLASTY

As the life expectancy in the United States continues to increase, the number of patients with symptomatic arthritis requiring arthroplasty is also on the rise. The main goals of joint arthroplasty are pain relief and increasing function. With this increase in function, patients often become more active after arthroplasty. Joint arthroplasty leads to significant improvements in exercise duration, maximum workload, and peak oxygen consumption.26 Data show that activity, rather than age or body weight, is the main factor in predicting implant survival.27,28

Specific concerns following joint arthroplasty dictate recommendations for postoperative athletic activities. Early implants faced failure with catastrophic wear. However, improvements in conformity, appropriate polyethylene sterilization and thickness, and component design have improved wear characteristics. With repetitive cycles and increased joint reaction forces, the generation of wear debris and secondary osteolysis remains a concern with increased sporting activities after arthroplasty.27 Traumatic complications, such as dislocation or fracture, may be increased with athletic activity. Often this may be secondary to a postoperative patient attempting new athletic activities as preoperative pain has resolved and function has increased. Therefore, it is recommended that patients not attempt new high-level athletic activities postoperatively unless they were facile at them pre-operatively.29

TOTAL HIP ARTHROPLASTY

Total hip arthroplasty has become a successful, reproducible treatment for symptomatic arthritis with 90% good to excellent results for 10 to 20 years after surgery.2,30 These results are consistent for cemented and ingrowth femoral components.2,30

With such success, patients continue to expect more after surgery, including resumption of physical activity. However, with increased physical activities come increased joint contact forces, ranging from two to three times body weight during walking, with a further increase of 43% with easy running.31,32 This increase in activity has been demonstrated to cause increased polyethylene wear and earlier deterioration of functional results.27,33 Because of this, new alternative bearing surfaces have been developed to help combat the potential of component wear and osteolysis (Fig. 10-1). However, the potential complications of the alternative bearing surfaces may be catastrophic in some cases and in other situations remain unknown.

Hip Replacement Xray

Figure 10-1 Total hip arthroplasty performed with a ceramic femoral head and acetabular liner. Ceramic components provide improved wear characteristics, as compared to traditional metals, with the potential for improved longevity in athletic individuals. However, these implants are more expensive, and fracture of the femoral head component has been reported.

Figure 10-1 Total hip arthroplasty performed with a ceramic femoral head and acetabular liner. Ceramic components provide improved wear characteristics, as compared to traditional metals, with the potential for improved longevity in athletic individuals. However, these implants are more expensive, and fracture of the femoral head component has been reported.

There is limited literature evaluating athletic activity after hip arthroplasty. In one study, 70% of patients returned to participate in sports after hip replacement.34 Low-impact sports after hip arthroplasty have not been shown to have a negative impact, with no difference in revision rates, and may provide potentially better outcomes as compared to patients not involved in sporting activities.34,35 However, for active patients with cemented hips participating in higher impact sports, the risk of revision surgery is more than two times higher compared to less active patients.36

Current recommendations for activities after total hip arthro-plasty discourage high-impact activities, while recommending low-impact activities. Surgeons must educate patients regarding risks of wear, loosening, and instability and must recommend athletic activities accordingly. A survey of 54 members of the Hip Society provides general guidelines for sport activities after hip arthroplasty (Table 10-3).29

TOTAL KNEE ARTHROPLASTY

Total knee arthroplasty has proven to be a consistent treatment providing improved function and pain relief for end-stage knee arthritis.1 Knee arthroplasty has been shown to be effective in patients younger than 55 years old, with the primary concern being loosening and wear leading to revision surgery.37 Both posterior cruciate ligament-sparing and -sacrificing designs have shown good long-term results in these younger patients.1,38 However, with the potential of revision surgery, the choice of a posterior cruciate ligament-retaining knee does result in less loss of bone stock during femoral resurfacing.

Surgical technique geared to appropriate limb alignment and soft-tissue balancing is a prerequisite for ensuring long-term implant survival. Patients with tibiofemoral joint lines restored to normal and appropriate implant composite thickness have better function and better implant survival.38

The return to sports after knee arthroplasty has been evaluated, noting 91% of patients returning to low-impact activities such as bowling and 21% returning to high-impact activities such as tennis.39 General recommendations after total knee arthro-plasty discourage high-impact activities while recommending

Table 10-3 Activity after Total Hip Arthroplasty: 1999 Hip Society Survey

Recommended/Allowed

Allowed with Experience

Not Recommended

No Conclusion

Stationary bicycling

Low-impact aerobics

High-impact aerobics

Jazz dancing

Croquet

Road bicycling

Baseball/softball

Square dancing

Ballroom dancing

Bowling

Basketball

Fencing

Golf

Canoeing

Football

Ice skating

Horseshoes

Hiking

Gymnastics

Roller/in-line skating

Shooting

Horseback riding

Handball

Rowing

Shuffleboard

Cross-country skiing

Hockey

Speed walking

Swimming

Jogging

Downhill skiing

Doubles tennis

Lacrosse

Stationary skiing*

Walking

Racquetball

Weight lifting

Squash

Weight machines

Rock climbing

Soccer

Singles tennis

Volleyball

*NordicTrack, Logan, UT.

From Healy WL, lorio R, Lemons MJ: Athletic activity after joint replacement. Am J Sports Med 2001;29:377-388.

*NordicTrack, Logan, UT.

From Healy WL, lorio R, Lemons MJ: Athletic activity after joint replacement. Am J Sports Med 2001;29:377-388.

Table 10-4 Activity after Total Knee Arthroplasty: 1999 Knee Society Survey

Recommended/Allowed

Allowed with Experience

Not Recommended

No Conclusion

Low-impact aerobics

Road bicycling

Racquetball

Fencing

Stationary bicycling

Canoeing

Squash

Rollerblade/in-line skating

Bowling

Hiking

Rock climbing

Downhill skiing

Golf

Rowing

Soccer

Weight lifting

Dancing

Cross-country skiing

Singles tennis

Horseback riding

Stationary skiing*

Volleyball

Croquet

Speed walking

Football

Walking

Tennis

Gymnastics

Swimming

Weight machines

Lacrosse

Shooting

lce skating

Hockey

Shuffleboard

Basketball

Horseshoes

Jogging

Handball

*NordicTrack, Logan, UT.

From Healy WL, lorio R, Lemons MJ: Athletic activity after joint replacement. Am J Sports Med 2001;29:377-388.

*NordicTrack, Logan, UT.

From Healy WL, lorio R, Lemons MJ: Athletic activity after joint replacement. Am J Sports Med 2001;29:377-388.

no- or low-impact activities. A survey of 58 members of the Knee Society provides general guidelines for sport activities after knee arthroplasty (Table 10-4).29

TOTAL SHOULDER ARTHROPLASTY

Total shoulder arthroplasty presents a different dilemma for athletically active patients. While the shoulder does not generally bear weight, some sports create significant stresses on the joint

Shoulder Replacement

nonetheless.29 Recreating appropriate glenohumeral anatomy is important, as changes in the retroversion of the humeral component may cause up to a 300% increase in shoulder joint reaction forces (Fig. 10-2).40

Few data exist regarding shoulder replacement in athletically active patients. A review of 24 patients after shoulder arthroplasty showed that 96% of patients were able to return to playing golf.41 These authors also noted no evidence of increase in radiographic lucencies between patients who did or did not play golf.

Figure 10-2 Total shoulder arthroplasty in a 62-year-old avid golfer. A, Anteroposterior radiograph. B, Axillary lateral radiograph.

Table 10-5 Activity after Total Shoulder Arthroplasty: 1999 American Shoulder and Elbow Surgeons Survey

Recommended/Allowed

Allowed with Experience Not Recommended

No Conclusion

Cross-country skiing*

Golf Football

High-impact aerobics

Stationary skiing

Ice skating Gymnastics

Baseball/softball

Speed walking and jogging

Shooting Hockey

Fencing

Swimming

Downhill skiing Rock climbing

Handball

Doubles tennis

Horseback riding

Low-impact aerobics

Lacrosse

Bicycling, road and stationary

Racquetball, squash

Bowling

Skating, roller/in-line

Canoeing

Rowing

Croquet

Soccer

Shuffleboard

Tennis, singles

Horseshoes

Volleyball

Dancing: ballroom, square, and jazz

Weight training

*NordicTrack, Logan, UT.

From Healy WL, lorio R, Lemons MJ: Athletic activity after joint replacement. Am J Sports Med 2001;29:377-388.

*NordicTrack, Logan, UT.

From Healy WL, lorio R, Lemons MJ: Athletic activity after joint replacement. Am J Sports Med 2001;29:377-388.

Current recommendations for young, active patients with symptomatic shoulder arthritis recalcitrant to nonoperative treatment is a modular uncemented humeral component with head sizes to allow adequate offset to achieve adequate tension on the soft tissues. Glenoid replacement is recommended with significant eccentric glenoid wear when there is adequate bone stock and an intact rotator cuff.

General recommendations for activity after shoulder arthroplasty are to avoid contact sports and high-impact loading sports affecting the shoulder. A survey of 35 members of the American Shoulder and Elbow Surgeons Society provides general guidelines for sport activities after shoulder arthroplasty (Table 10-5).29

CONCLUSIONS

The increasing activities of the middle-aged and older athlete, along with the age-related changes of the muscles, tendons, and ligaments, provide the potential for significant injury. The physician may see injuries typically found in younger patients, with the possibility of decreased healing ability or abnormally healed

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tissue. Therefore, the treating physician must be aware of the differences associated with aging tissues and their healing response and apply them to treatment and rehabilitative choices.

Most important to the treatment of injuries in the older athlete is prevention. Patient education and identification of medical conditions or medications predisposing to injury will assist the patient in choosing appropriate activities. If injury does occur, an honest discussion between the patient and physician regarding treatment options, published outcomes, and patient desires to return to premorbid activities will allow a timely and cost-effective treatment decision. On some occasions, this may include activity modifications or a lower demand sport.

As joint arthroplasty continues to improve and provide increased function, expectations of the athletic patient include returning to more demanding activities. These patient expectations must be addressed preoperatively and postoperatively with honest discussions regarding the potential for wear, loosening, or trauma about the replaced joint. With patient education about the risks associated with athletic activity, the ability of the patient to make a wise and appropriate choice of postoperative activities is improved.

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41. Jensen KL, Rockwood CA Jr: Shoulder arthroplasty in recreational golfers. J Shoulder Elbow Surg 1998;7:362-367.

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