Over 33 chronic disease states and health disorders, including obesity and type 2 diabetes, are grouped into what is known as sedentary death syndrome. All these conditions are positively affected by 30 minutes of brisk exercise daily. In addition, only 30% of aging is based on genetics, with 70% on lifestyle. Therefore, a large majority of aging is controlled by individual health behaviors. Exercise is a powerful tool for healthy aging of the body and the mind. Courses of short- and long-term exercise provide benefits to musculoskeletal and cardiovascular health and can prevent age-related brain structural and functional losses. This review examines the evidence in support of mobility as an inexpensive and effective protective factor in maintaining brain health and preventing cognitive decline in aging adults.
A PubMed search was performed for articles in English from 1990 to 2012. Reference lists were also reviewed and relevant articles obtained.
Level of Evidence:
Evidence suggests that maintaining a high level of cardiopulmonary fitness and mobility exhibits protective effects on structural changes that occur with aging in areas of the brain associated with memory, attention, and task completion. Chronic exercise is also associated with preservation of overall cognitive functioning and prevention of dementia.
In combination with other preventative measures, physical mobility can assist in preventing or slowing cognitive decline in aging adults.
mobility; exercise; aging; master athlete; cognitive function
Aging changes the biology, healing capacity, and biomechanical function of tendons and ligaments and results in common clinical pathologies that present to orthopedic surgeons, primary care physicians, physical therapists, and athletic trainers. A better understanding of the age-related changes in these connective tissues will allow better patient care.
The PubMed database was searched in December 2012 for English-language articles pertaining to age-related changes in tendons and ligaments.
Level of Evidence:
The mature athlete faces challenges associated with age-dependent changes in the rotator cuff, Achilles tendon, lateral humeral epicondylar tendons, quadriceps tendon, and patellar tendon. The anterior cruciate ligament and the medial collateral ligament are the most studied intra-articular and extra-articular ligaments, and both are associated with age-dependent changes.
Tendons and ligaments are highly arranged connective tissue structures that maintain joint motion and joint stability. These structures are subject to vascular and compositional changes with increasing age that alter their mechanotransduction, biology, healing capacity, and biomechanical function. Emerging research into the etiology of age-dependent changes will provide further information to help combat the age-related clinical complications associated with the injuries that occur to tendons and ligaments.
tendon; ligament; age-related; biomechanics; rotator cuff; Achilles tendon; ACL
Femoroacetabular impingement (FAI) alters hip mechanics, results in hip pain, and may lead to secondary osteoarthritis (OA) in the maturing athlete. Hip impingement can be caused by osseous abnormalities in the proximal femur or acetabulum. These impingement lesions may cause altered loads within the hip joint, which result in repetitive collision damage or sheer forces to the chondral surfaces and acetabular labrum. These anatomic lesions and resultant abnormal mechanics may lead to early osteoarthritic changes.
Relevant articles from the years 1995 to 2013 were identified using MEDLINE, EMBASE, and the bibliographies of reviewed publications.
Level of Evidence:
Improvements in hip arthroscopy have allowed FAI to be addressed utilizing the arthroscope. Adequately resecting the underlying osseous abnormalities is essential to improving hip symptomatology and preventing further chondral damage. Additionally, preserving the labrum by repairing the damaged tissue and restoring the suction seal may theoretically help normalize hip mechanics and prevent further arthritic changes. The outcomes of joint-preserving treatment options may be varied in the maturing athlete due to the degree of underlying OA. Irreversible damage to the hip joint may have already occurred in patients with moderate to advanced OA. In the presence of preexisting arthritis, these patients may only experience fair or even poor results after hip arthroscopy, with early conversion to hip replacement. For patients with advanced hip arthritis, total hip arthroplasty remains a treatment option to reliably improve symptoms with good to excellent outcomes and return to low-impact activities.
Advances in the knowledge base and treatment techniques of intra-articular hip pain have allowed surgeons to address this complex clinical problem with promising outcomes. Traditionally, open surgical dislocations for hip preservation surgery have shown good long-term results. Improvements in hip arthroscopy have led to outcomes equivalent to open surgery while utilizing significantly less invasive techniques. However, outcomes may ultimately depend on the degree of underlying OA. When counseling the mature athlete with hip pain, an understanding of the underlying anatomy, degree of arthritis, and expectations will help guide the treating surgeon in offering appropriate treatment options.
hip pain; joint preservation; hip arthroscopy; femoroacetabular impingement
Middle-age and elderly participants in athletic activities frequently encounter the chronic disabling process of osteoarthritis. Knowledge of the treatment of knee osteoarthritis is needed to keep the master athlete active.
This article reviews the current scientific evidence regarding recommendations for the maturing athlete, specifically discussing the strengths and weaknesses of dietary and lifestyle modifications, physical therapy, bracing, supplements, pharmacotherapies, and biologics in the management of knee osteoarthritis.
Level of Evidence:
These treatment modalities can help keep the aging athlete active, which in itself plays an important role in reducing the symptoms of knee osteoarthritis.
knee; osteoarthritis; elderly; athlete; nonoperative treatments
Muscle physiology in the aging athlete is complex. Sarcopenia, the age-related decrease in lean muscle mass, can alter activity level and affect quality of life. This review addresses the microscopic and macroscopic changes in muscle with age, recognizes contributing factors including nutrition and changes in hormone levels, and identifies potential pharmacologic agents in clinical trial that may aid in the battle of this complex, costly, and disabling problem.
Level of Evidence: Level 5.
sarcopenia; aging athlete; muscle aging; SARMs
Acute cartilage injuries induce cell death and are associated with an increased incidence of osteoarthritis development later in life. The objective of this study was to investigate the effect of posttraumatic cyclic compressive loading on chondrocyte viability and apoptosis in porcine articular cartilage plugs.
Compressive loading of acutely injured cartilage can maintain chondrocyte viability by reducing apoptosis after a traumatic impact injury.
In vitro controlled laboratory study.
Level of Evidence:
Each experiment compared 4 test groups: control, impact, impact with compressive loading (either 0.5 or 0.8 MPa), and no impact but compressive loading (n = 15 per group). Flat, full-thickness articular cartilage plugs were harvested from the trochlear region of porcine knees. A drop tower was utilized to introduce an impact injury. The articular plugs were subjected to two 30-minute cycles of either 0.5 or 0.8 MPa of dynamic loading. Cell viability, apoptosis, and gene expression of samples were evaluated 24 hours postimpaction.
Cell viability staining showed that 0.5 MPa of dynamic compressive loading increased cell viability compared with the impact group. Apoptotic analysis revealed a decrease in apoptotic expression in the group with 0.5 MPa of dynamic compressive loading compared with the impact group. Significantly higher caspase 3 and lower collagen II expressions were observed in impacted samples without compressive loading, compared with those with. Compressive loading of nonimpacted samples significantly increased collagen II and decreased caspase 3 expressions.
In this porcine in vitro model, dynamic compressive loading at subphysiological levels immediately following impact injury decreases apoptotic expression, thereby maintaining chondrocyte viability.
Therapeutic exercises could be designed to deliver subphysiological loading to the injured cartilage, thereby minimizing injury.
compressive loading; osteoarthritis prevention; cartilage gene expression; chondrocyte viability; impact injury
Total hip replacement and total knee replacement are among the most successful and common surgical procedures in orthopaedics. These operations were traditionally reserved for older, sedentary patients. However, these are now being increasingly performed in patients expecting to return to athletic activities.
The peer-reviewed medical literature was searched via PubMed from the years 2000 to 2013. Those studies pertinent to modern hip and knee replacement in an athletic population were selected for inclusion.
Level of Evidence:
There is a lack of high-quality evidence in the peer-reviewed literature relating to the replacement of hips and knees in younger athletic patients. Although many patients undergoing joint replacement are active in recreational activities, a minority engage in high-impact sports. Following surgery, overall activities tend to increase, but high-demand athletic activities may be limited by pain, functional outcome, or activity restrictions imposed by health care providers.
Patients receiving hip and knee replacements should be counseled in that returning to high-impact and repetitive-loading athletic activities after surgery may shorten the life span of their implant.
Strength-of-Recommendation Taxonomy (SORT):
total hip arthroplasty; total knee arthroplasty; mature athlete; functional outcome
As America’s baby boomer population matures, there is an increasing interest in supplements that can delay or oppose the aging process. This antiaging movement has exploded over the past decade. While most supplements are not supported by scientific literature or government controls, a number of products have been the subject of significant scientific inquiry. Hormone replacement therapy, including testosterone and growth hormone, has mixed results, and antioxidative strategies are supported by basic science but lack clinical evidence-based outcomes. While the process of aging has become better understood leading to more rational approaches to combat its effects on health, the clinician is reminded to carefully discern between the science and marketing that is available in this area.
baby boomer; performance-enhancing drugs; ergogenic aids; antiaging
The mature athlete’s shoulder remains a challenging clinical condition to manage. A normal natural history of the shoulder includes stiffness, rotator cuff tears, and osteoarthritis, all of which can become increasingly more symptomatic as an athlete ages.
Level of Evidence:
Rotator cuff pathology increases with age and activity level. Partial tears rarely heal, and debridement of significant partial tears results in poorer outcomes than those of repair. Repair of partial-thickness tears can be accomplished with completion and subsequent repair or in situ repair. The most successful result for treatment of osteoarthritis in the shoulder remains total shoulder arthroplasty, with more than 80% survival at 20 years and high rates of return to sport. Caution should be taken in patients younger than 60 years, as they show much worse results with this treatment. Adhesive capsulitis of the shoulder can be successfully treated with nonoperative management in 90% of cases.
Mature athletes tend to have rotator cuff pathology, osteoarthritis, and stiffness, which may limit their participation in athletic events. Age is a significant consideration, even within the “mature athlete” population, as patients younger than 50 years should be approached differently than those older than 65 years with regard to treatment regimens and postoperative restriction.
rotator cuff; glenohumeral arthritis; aging shoulder; adhesive capsulitis; aging athlete
Articular cartilage has a unique functional architecture capable of providing a lifetime of pain-free joint motion. This tissue, however, undergoes substantial age-related physiologic, mechanical, biochemical, and functional changes that reduce its ability to overcome the effects of mechanical stress and injury. Many factors affect joint function in the maturing athlete—from chondrocyte survival and metabolism to structural composition and genetic/epigenetic factors governing cartilage and synovium. An evaluation of age-related changes for joint homeostasis and risk for osteoarthritis is important to the development of new strategies to rejuvenate aging joints.
This review summarizes the current literature on the biochemical, cellular, and physiologic changes occurring in aging articular cartilage.
PubMed (1969-2013) and published books in sports health, cartilage biology, and aging.
Keywords included aging, athlete, articular cartilage, epigenetics, and functional performance with age.
Level of Evidence:
To be included, research questions addressed the effect of age-related changes on performance, articular cartilage biology, molecular mechanism, and morphology.
The mature athlete faces challenges in maintaining cartilage health and joint function due to age-related changes to articular cartilage biology, morphology, and physiology. These changes include chondrocyte loss and a decline in metabolic response, alterations to matrix and synovial tissue composition, and dysregulation of reparative responses.
Although physical decline has been regarded as a normal part of aging, many individuals maintain overall fitness and enjoy targeted improvement to their athletic capacity throughout life. Healthy articular cartilage and joints are needed to maintain athletic performance and general activities. Genetic and potentially reversible epigenetic factors influence cartilage physiology and its response to mechanical and injurious stimuli. Improved understandings of the physical and molecular changes to articular cartilage with aging are important to develop successful strategies for joint rejuvenation.
articular cartilage; aging; athlete; exercise
Fazarale JJ, Magnussen RA, Pedroza AD, Kaeding CC. Knowledge of and compliance with pitch count recommendations: a survey of youth baseball coaches. Sports Health. 2012;4(3):202-204. Original DOI: 10.1177/1941738111435632
Currently, no consensus exists for grading the severity of concussions. Identification of risk factors that may affect concussion risk and the likelihood of prolonged recovery can be of value to providers who manage concussion.
Relevant studies were identified through MEDLINE (1996-2011) using the keywords concussion, postconcussive syndrome, and risk or risk factor. Targeted searches for specific risk factors were conducted with additional keywords, such as gender and migraine. Manual review of reference lists was also performed to identify pertinent literature.
For risk factors of concussion, history of prior concussion and female sex have the most supporting evidence. Sports with consistently high risk for sustaining a concussion include football, men’s ice hockey, and women’s soccer. Younger athletes appear to be more susceptible to concussion, but data are limited and inconsistent. Protective equipment does not definitively alter concussion risk, though it protects against other injuries. Symptoms such as long headaches, migraines, amnesia, and multiple symptoms appear to be associated with prolonged recovery. Younger age may also increase the risk of prolonged concussion.
High-quality evidence for risk modifiers in concussion remains sparse. Prior concussion, collision sports, female sex, and women’s soccer are the strongest known risk factors. Evidence for most other factors is inconclusive.
concussion; postconcussive syndrome; risk factors; risk modifiers
Instability resistance training (IRT; unstable surfaces and devices to strengthen the core or trunk muscles) is popular in fitness training facilities.
To examine contradictory IRT recommendations for health enthusiasts and rehabilitation.
A literature search was performed using MEDLINE, SPORT Discus, ScienceDirect, Web of Science, and Google Scholar databases from 1990 to 2012.
Databases were searched using key terms, including “balance,” “stability,” “instability,” “resistance training,” “core,” “trunk,” and “functional performance.” Additionally, relevant articles were extracted from reference lists.
To be included, research questions addressed the effect of balance or IRT on performance, healthy and active participants, and physiologic or performance outcome measures and had to be published in English in a peer-reviewed journal.
There is a dichotomy of opinions on the effectiveness and application of instability devices and conditions for health and performance training. Balance training without resistance has been shown to improve not only balance but functional performance as well. IRT studies document similar training adaptations as stable resistance training programs with recreationally active individuals. Similar progressions with lower resistance may improve balance and stability, increase core activation, and improve motor control.
IRT is highly recommended for youth, elderly, recreationally active individuals, and highly trained enthusiasts.
strength training; power; balance; core training; trunk
There are significant data comparing elite and nonelite athletes in anaerobic field and court sports as well as endurance sports. This review delineates specific performance characteristics in the elite athlete and may help guide rehabilitation.
A Medline search from April 1982 to April 2012 was undertaken for articles written in English. Additional references were accrued from reference lists of research articles.
In the anaerobic athlete, maximal power production was consistently correlated to elite performance. Elite performance in the endurance athlete is more ambiguous, however, and appears to be related to the dependent variable investigated in each individual study.
In anaerobic field and court sport athletes, maximal power output is most predictive of elite performance. In the endurance athlete, however, it is not as clear. Elite endurance athletes consistently test higher than nonelite athletes in running economy, anaerobic threshold, and VO2max.
elite versus nonelite athlete; performance characteristics; endurance athlete
Enhancing core stability through exercise is common to musculoskeletal injury prevention programs. Definitive evidence demonstrating an association between core instability and injury is lacking; however, multifaceted prevention programs including core stabilization exercises appear to be effective at reducing lower extremity injury rates.
PubMed was searched for epidemiologic, biomechanic, and clinical studies of core stability for injury prevention (keywords: “core OR trunk” AND “training OR prevention OR exercise OR rehabilitation” AND “risk OR prevalence”) published between January 1980 and October 2012. Articles with relevance to core stability risk factors, assessment, and training were reviewed. Relevant sources from articles were also retrieved and reviewed.
Stabilizer, mobilizer, and load transfer core muscles assist in understanding injury risk, assessing core muscle function, and developing injury prevention programs. Moderate evidence of alterations in core muscle recruitment and injury risk exists. Assessment tools to identify deficits in volitional muscle contraction, isometric muscle endurance, stabilization, and movement patterns are available. Exercise programs to improve core stability should focus on muscle activation, neuromuscular control, static stabilization, and dynamic stability.
Core stabilization relies on instantaneous integration among passive, active, and neural control subsystems. Core muscles are often categorized functionally on the basis of stabilizing or mobilizing roles. Neuromuscular control is critical in coordinating this complex system for dynamic stabilization. Comprehensive assessment and training require a multifaceted approach to address core muscle strength, endurance, and recruitment requirements for functional demands associated with daily activities, exercise, and sport.
trunk muscles; kinetic chain; exercises; neuromuscular control
Sudden cardiac death (SCD) events are tragic. Secondary prevention of SCD depends on availability of automated external defibrillators (AEDs). High school athletes represent a high-risk group for SCD, and current efforts aim to place AEDs in all high schools.
The prevalence of AEDs and emergency planning for sudden cardiac arrest (SCA) in Vermont high schools is similar to other states. Understanding specific needs and limitations in rural states may prevent SCD in rural high schools.
A survey was distributed to all 74 Vermont high school athletic directors. Outcome measures included AED prevalence, AED location, individuals trained in cardiopulmonary resuscitation (CPR) and AED utilization, funding methods for AED attainment, and the establishment of an emergency action plan (EAP) for response to SCA.
All schools (100%, 74 of 74) completed the survey. Of those, 60 (81%) schools have at least 1 AED on school premises, with the most common location for AED placement being the main office or lobby (50%). Larger sized schools were more likely to have an AED on the premises than smaller sized schools (P = 0.00). School nurses (77%) were the most likely individuals to receive formal AED training. Forty-one schools (55%) had an EAP in place for response to SCA, and 71% of schools coordinated AED placement with local emergency medical services (EMS) responders.
In Vermont, more than two-thirds of high schools have at least 1 AED on school premises. However, significant improvement in the establishment of EAPs for SCA and training in CPR and AED utilization is essential given the rural demography of the state of Vermont.
Rural high schools inherently have longer EMS response times. In addition to obtaining AEDs, high schools must develop a public access to defibrillation program to maximize the chance of survival following cardiac arrest, especially in rural settings.
automated external defibrillators; sudden cardiac arrest; emergency action plan
Anterior cruciate ligament (ACL) reconstruction is a safe, common, and effective method of restoring stability to the knee after injury, but evolving techniques of reconstruction carry inherent risk. Infection after ACL reconstruction, while rare, carries a high morbidity, potentially resulting in a poor clinical outcome.
Data were obtained from previously published peer-reviewed literature through a search of the entire PubMed database (up to December 2012) as well as from textbook chapters.
Treatment with culture-specific antibiotics and debridement with graft retention is recommended as initial treatment, but with persistent infection, consideration should be given to graft removal. Graft type likely has no effect on infection rates.
The early diagnosis of infection and appropriate treatment are necessary to avoid the complications of articular cartilage damage and arthrofibrosis.
anterior cruciate ligament; infection; graft type
Anterior cruciate ligament (ACL) rupture is a significant injury in National Basketball Association (NBA) players.
NBA players undergoing ACL reconstruction (ACLR) have high rates of return to sport (RTS), with RTS the season following surgery, no difference in performance between pre- and postsurgery, and no difference in RTS rate or performance between cases (ACLR) and controls (no ACL tear).
NBA players undergoing ACLR were evaluated. Matched controls for age, body mass index (BMI), position, and NBA experience were selected during the same years as those undergoing ACLR. RTS and performance were compared between cases and controls. Paired-sample Student t tests, chi-square, and linear regression analyses were performed for comparison of within- and between-group variables.
Fifty-eight NBA players underwent ACLR while in the NBA. Mean player age was 25.7 ± 3.5 years. Forty percent of ACL tears occurred in the fourth quarter. Fifty players (86%) RTS in the NBA, and 7 players (12%) RTS in the International Basketball Federation (FIBA) or D-league. Ninety-eight percent of players RTS in the NBA the season following ACLR (11.6 ± 4.1 months from injury). Two players (3.1%) required revision ACLR. Career length following ACLR was 4.3 ± 3.4 years. Performance upon RTS following surgery declined significantly (P < 0.05) regarding games per season; minutes, points, and rebounds per game; and field goal percentage. However, following the index year, controls’ performances declined significantly in games per season; points, rebounds, assists, blocks, and steals per game; and field goal and free throw percentage. Other than games per season, there was no significant difference between cases and controls.
There is a high RTS rate in the NBA following ACLR. Nearly all players RTS the season following surgery. Performance significantly declined from preinjury level; however, this was not significantly different from controls. ACL re-tear rate was low.
There is a high RTS rate in the NBA after ACLR, with no difference in performance upon RTS compared with controls.
anterior cruciate ligament; ACL; National Basketball Association; NBA; knee injury
A healthy adolescent male soccer player sustained a radiograph-negative, effusion-negative physeal injury of the proximal tibia from a ground-level fall with traumatic occlusion of the popliteal artery. Orthopaedic evaluation and arteriography were delayed for 72 hours after the injury. He arrived at a tertiary referral center in multisystem organ failure secondary to lower extremity ischemic necrosis, septic pulmonary thromboembolism, and systemic shock. Emergent medical evaluation, a high index of suspicion, and a careful neurovascular examination are imperative after every closed knee injury in the young athlete.
pediatric knee; injury; dislocation; proximal tibia fracture; popliteal artery; occlusion
Knee injury among young, active female patients remains a public health issue. Clinicians are called upon to pay greater attention to patient-oriented outcomes to evaluate the impact of these injuries. Little agreement exists on which outcome measures are best, and clinicians cite several barriers to their use. Single Assessment Numerical Evaluation (SANE) may provide meaningful outcome information while lessening the time burden associated with other patient-oriented measures.
The SANE and International Knee Documentation Committee (IKDC) scores would be strongly correlated in a cohort of young active female patients with knee injuries from preinjury through 1-year follow-up and that a minimal clinically important difference (MCID) could be calculated for the SANE score.
Observational prospective cohort.
Two hundred sixty-three subjects completed SANE and IKDC at preinjury by recall, time of injury, and 3, 6, and 12 months postinjury. Pearson correlation coefficients were used to assess the association between SANE and IKDC. Repeated-measures analysis of variance was used to determine differences in SANE and IKDC over time. MCID was calculated for SANE using IKDC MCID as an anchor.
Moderate to strong correlations were seen between SANE and IKDC (0.65-0.83). SANE, on average, was 2.7 (95% confidence interval, 1.5-3.9; P < 0.00) units greater than IKDC over all time points. MCID for the SANE was calculated as 7 for a 6-month follow-up and 19 for a 12-month follow-up.
SANE scores were moderately to strongly correlated to IKDC scores across all time points. Reported MCID values for the SANE should be utilized to measure meaningful changes over time for young, active female patients with knee injuries.
Providing clinicians with patient-oriented outcome measures that can be obtained with little clinician and patient burden may allow for greater acceptance and use of outcome measures in clinical settings.
patient-oriented outcomes; Single Assessment Numeric Evaluation (SANE); International Knee Documentation Committee (IKDC); knee injuries
Injury to the low back can cause significant pain and dysfunction, which can affect an athlete’s performance and result in time lost from sport. A common conservative treatment is therapeutic core stabilization exercises, which can address pain and musculoskeletal dysfunction in patients with low back pathology.
MEDLINE and CINAHL were searched (from 1966 to March 2013) to identify relevant research. Keywords and keyword combinations searched included motor control exercise, segmental stabilization, core stabilization, transversus abdominis, multifidi, and low back pain.
There are 2 popular rehabilitation strategies to assess core function and promote core stabilization. Each has been developed based on biomechanical models of lumbar segmental stability and observed motor control dysfunction in patients with low back pain.
Controversy exists among clinical and research groups as to the optimal strategy for an athlete with low back pain.
core stabilization; motor control exercise; multifidi; low back pain; transversus abdominis
Therapeutic exercises are frequently prescribed to patients with low back pain. Numerous exercise programs for patients with low back pain have been described. Many of these treatment programs are based on 1 of 2 popular rehabilitation strategies: a motor control exercise approach or a general exercise approach.
PubMed clinical queries from 1966 to March 2013 for keyword combinations including motor control exercise, core stability exercise, therapeutic exercise, general exercise, global exercise, local exercise, transversus abdominis, segmental stabilization, and low back pain.
Randomized controlled trials that assessed the effects of a motor control exercise approach, a general exercise approach, or both for patients with low back pain that were published in scientific peer-reviewed journals.
Included studies underwent appraisal for exercise intervention and outcomes.
Fifteen studies were identified (8, motor control exercise approach without general exercise comparison; 7, general exercise approach with or without motor control exercise approach comparison). Current evidence suggests that exercise interventions may be effective at reducing pain or disability in patients with low back pain.
Stabilization exercises for patients with low back pain may help to decrease pain and disability. It may not be necessary to prescribe exercises purported to restore motor control of specific muscles.
core stabilization; low back pain; motor control exercise; multifidi; transversus abdominis