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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.

2
In Western industrialized coun-
tries, the average life expectancy in-
creased from 47 years in 1900 to 75
years in 1988. Increased life expect-
ancy and a post-World War II baby
boom has contributed to a rapidly
growing older population; according-
ly, the number of persons older than
age 85 years grew 232% from 1960
to 1990, compared with a total pop-
ulation growth of 39% during the
same period.
3
By 2010, 25% of the
American population will be older
than age 55 years, and more than
50% of the population will be older
than 35 years.
4
In 1996, the American Academy
of Orthopaedic Surgeons established
the Committee on Aging to address
orthopaedic care of the elderly. Geri-
atric care has since received more
attention at national orthopaedic
meetings,
5
with an emphasis on pre-
venting injury and promoting phys-

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

Surgery, Johns Hopkins Bayview
Medical Center, Baltimore, MD. Dr.
Hawkins is Clinical Professor,
Department of Orthopaedic Surgery,
University of Colorado, Boulder, CO,
University of Texas, Southwestern
Medical School, Dallas, TX, and
Steadman-Hawkins Sports Medicine
Foundation, Vail, CO.
Reprint requests: Dr. Chen, Littleton
Orthopaedics, 81 Bethlehem Road,
Littleton, NH 03561.
J Am Acad Orthop Surg 2005;13:407-
416
Copyright 2005 by the American
Academy of Orthopaedic Surgeons.
Volume 13, Number 6, October 2005 407
Physiologic Effects of
Aging
Systemic Changes
Age-related changes occur at the
molecular level and affect the perfor-
mance of virtually every organ sys-
tem in predictable, well-documented
ways (Table 1). For example, reduc-
tions in maximal heart rate, myocar-
dial contractility, and stroke volume
decrease cardiac performance so that
oxygen utilization in the 60-year-old
is typically 80% of that of a 20-year-

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.

8
This is
exacerbated by insensible losses dur-
ing exercise as well as alterations in
the sensitivity of the thirst mecha-
nism, rendering adequate hydration
Table 1
Physiologic Effects of Aging
System Effects of Aging Modification With Regular Exercise
Cardiovascular Decreased maximal heart rate
Decreased myocardial contractility
Decreased stroke volume
Decreased oxygen utilization
Atherosclerosis
Decreased vascular compliance
Diminished microcirculation
Decreased vascular tone and baroreceptor function
Increased cardiac output
Increased oxygen utilization
Diminution of atherosclerotic plaques
Enhanced vascular compliance
Enhanced microvasculature
Enhanced vascular tone
Pulmonary Decreased elasticity
Decreased compliance
Weaker respiratory effort
Increased pulmonary vascular resistance
Altered alveolar gas exchange
Decreased total lung capacity, vital capacity, and
inspiratory/expiratory airflow

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

affiliated serves as a consultant to or is an employee of US Surgical Sports Medicine, DePuy, Arthrocare Sports Medicine, and Encore Medical.
Orthopaedic Care of the Aging Athlete
408 Journal of the American Academy of Orthopaedic Surgeons
a challenge.
8
Intravascular deple-
tion, which typically precedes thirst,
can affect cardiac output, athletic
performance, cognitive function,
and metabolic function in advanced
stages of dehydration (Table 1).
Central and peripheral nervous
system change can impair hearing,
memory, balance, motor skills, sen-
sation, proprioception, and cogni-
tion.
1
Extrapyramidal and vestibular
dysfunction may impair coordina-
tion and balance. Sensorimotor coor-
dination also may be affected by un-
derlying dementia, cerebrovascular
disease, cognitive dysfunction, de-
pression, and medications. Peripher-
al nerve dysfunction may be exacer-
bated by diseases such as diabetes
mellitus and may result in decreased
conduction velocity, amplitude, mo-
tor unit recruitment, and altered
motor unit potentials. Even in the

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.

Although physical exercise can in-
crease osseous thickness and
strength as well as levels of calcium,
nitrogen, hydroxyproline, and DNA
in bone,
10
physicians nonetheless
should be vigilant for injuries to os-
teoporotic bone, particularly when a
patient older than 50 years begins a
new training regimen.
Ligaments and Tendons
With age, collagen undergoes so-
called maturational stabilization, in
which the number of reducible col-
lagen cross-links stabilizes, thus in-
creasing thermal stability, decreasing
fiber compliance, and reducing solu-
Table 2
Musculoskeletal Manifestations of Aging
Area Effects of Aging Protective Modifications/Treatments
Bone Progressive loss of mineral density
“Tubularization” of diaphyseal bone
Regular exercise
Well-balanced diet
Vitamin D and calcium supplementation
Hormone therapy (women)
Medical therapy (eg, bisphosphonates)
Ligaments
and tendons

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

Decreased mitochondrial volume
Increased collagen content
Degenerative ultrastructural changes
Decreased muscle flexibility
Regular exercise, muscle training
Pre-exercise stretching
Hormonal supplementation*
Nutritional supplementation*
* = routinely used, anecdotal success, but long-term benefits have not been clearly established
Andrew L. Chen, MD, et al
Volume 13, Number 6, October 2005 409
bility. Hormonal abnormalities (eg,
corticosteroid excess, diabetes mel-
litus) increase collagen cross-linking
and maturation, thereby adding to
the stiffness of connective tissues.
10
In addition to ultrastructural changes
within the collagen fibers, age-related
losses in water content and gains in
elastin fibril thickness contribute to
connective-tissue stiffness. Physical
activity increases the cross-sectional
area of ligaments and tendons but en-
hances collagen turnover and remod-
eling, thus retarding the process of
maturational stabilization.
Meniscus
With age, biomechanical perfor-
mance and the ability to dissipate

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-

tion and mechanical loading greatly
facilitate these processes, and the ar-
ticular cartilage responds by hyper-
trophy. Conversely, when a joint is
deprived of mechanical loading,
even for relatively short periods of
inactivity, disuse atrophy and dimin-
ished metabolic activity can occur in
the hyaline cartilage.
11
Softening, fis-
suring, and fibrillation of the bearing
surfaces occur with repetitive joint
loading and microtrauma to me-
chanically compromised articular
cartilage.
10
Therefore, although inac-
tivity may lead to disuse atrophy,
high-impact repetitive activities to
diseased, degenerated cartilage may
destroy the joint.
1
Skeletal Muscle
Age-related declines in muscle
function are thought to have the
greatest impact on functional capac-
ity. Muscle weakness in the elderly
is largely the result of sarcopenia
rather than changes in contractility,

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

Muscles may
stiffen because of increased actin-
myosin cross-linking and changes
in the extracellular matrix. Studies
of reflex inhibition have shown
the latter to be of primar y impor-
tance.
13
Stabilization of collagen
within myotendinous units also in-
creases musculotendinous stiffness.
This loss of flexibility is thought to
increase the risk of injury.
10
So-called Anti-aging
Agents
Various endogenous mediators be-
come depleted with age (Table 3).
Clinical studies have failed to dem-
onstrate that replacing them is safe
and beneficial in otherwise normal-
ly aging persons.
14
Replacing defi-
cient growth hormone, for example,
increases muscle mass, decreases
body fat, and improves oxygen utili-
zation and physical endurance; how-
ever, comparable benefits have not
been demonstrated in persons with

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-

creasing the hematocrit to supra-
physiologic levels carries theoretic
risks of intravascular hyperviscosity
and vascular sludging, which in-
crease the risk of ischemic and
thrombotic events, hypertension,
and hyperkalemia, particularly in
older persons with underlying med-
ical problems.
17
Nutritional supplements to coun-
teract the effects of aging have
gained enormous popularity. Vita-
mins A (beta carotene), C (ascorbate),
andE(α-tocopherol) are antioxidants
Orthopaedic Care of the Aging Athlete
410 Journal of the American Academy of Orthopaedic Surgeons
thought to scavenge free-radicals
produced during exercise and there-
fore limit oxidative stress and free-
radical damage.
18
L-carnitine is a qua-
ternary amine thought to regulate
muscle glycogen breakdown and
limit lactic acid formation, thus im-
proving endurance and muscle per-
formance.
18
Creatine, an amino acid derivative

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.

20
Musculoskeletal Injury
and the Aging Athlete
Acute Traumatic Injuries
Despite age-related structural and
functional declines, older athletes ex-
perience a lower incidence of acute
traumatic injuries than do their
younger counterparts.
1,21,22
This has
been attributed to the older athlete’s
participation in less violent sports
and greater experience, as well as the
lower intensity of competition. San-
delin
21
reported that only 1% of pa-
tients who required hospital care for
acute sports injuries were older than
55 years. Although age-related losses
in bone density increase bone fragil-
ity,
10
acute fractures represent a small
Table 3
So-called Anti-aging Agents
Agent Intended Effects Potential Adverse Effects/Disadvantages
Growth hormone Increased muscle mass
Decreased body fat

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

Intravascular hyperviscosity
Vascular sludging
Increased risk of thrombotic events
Hypertension
Hyperkalemia
Nutritional
supplements,
antioxidant vitamins
(A, C, E)
Free-radical scavengers
Limit oxidative stress
Minimize free-radical damage
Hypervitaminosis
Questionable benefit in individuals with
well-balanced diets
L-carnitine Limit lactic acid formation
Regulate muscle glycogen breakdown
Improved endurance and muscle
performance
Cost
Questionable benefit in individuals with
well-balanced diets
Creatine Increased availability of phosphocreatine
Increased pH buffering capacity of muscle
Increased muscle strength and endurance
Muscle hypertrophy
Weight gain
Dehydration
Muscle cramping
Nausea

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-

ceps tendons tend to occur in
middle-aged and older athletes. Most
patients who experience these inju-
ries report recent changes in their
training regimens, although prodro-
mal symptoms are uncommon. His-
tologic evaluation of these injuries
typically reveals disorganized ten-
don remodeling, relative avasculari-
ty, and intrasubstance tendon degen-
eration (the latter also is known as
angiofibrotic hyperplasia.
25
Chronic and Overuse
Injuries
Commonly, injuries in older ath-
letes are related to overuse and
repetitive microtrauma. A 3-year
prospective evaluation of injury pat-
terns found that overuse injuries ac-
counted for 70% of injuries in veter-
an athletes (aged >60 years) but for
only 41% of injuries of young ath-
letes (aged 21 to 25 years).
23
Dehaven
and Littner
24
observed that, by the
seventh decade of life, the five most

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

Lateral epicondylitis, or ten-
nis elbow, occurs most commonly in
middle-aged persons and is related to
overuse of the wrist extensors.
Subacromial Impingement
and Rotator Cuff Tears
During repetitive shoulder mo-
tion, the rotator cuff can impinge on
the coracoacromial arch. This may
result in inflammation and tendi-
nopathy,
29,30
which can be exacerbat-
ed by age-related hypovascularity of
the supraspinatus tendon.
31
There-
fore, rotator cuff tendinopathy like-
ly represents a combination of me-
chanical attrition of the cuff and
progression of incompletely healed
microtears, possibly as a result of hy-
povascularity.
Subacromial decompression and
rotator cuff repair is very successful
in older patients.
32,33
Yeletal
32
re-

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.

10
This ef-
fect may be exacerbated by previous
injury or surgery, such as prior men-
iscectomy in the knee, which dimin-
ishes the ability of the joint to dissi-
pate loads.
Treating Osteoarthritis
Oral Therapy
Oral glucosamine and chon-
droitin sulfate preparations have re-
cently gained popularity. They are
purported to be chondroprotective
and to promote articular cartilage re-
pair.
35
Glucosamine is thought to act
as an anti-inflammatory agent by
promoting synthesis of proteogly-
cans and glycosaminoglycans. Pro-
teoglycans form the ground sub-
stance in the extracellular matrix of
connective tissue; of these, the gly-
cosaminoglycan hyaluronic acid is
vital for the function of articular car-
tilage. Chondroitin sulfate is be-
lieved to influence the synthesis and
metabolism of glycosaminoglycans,
increase total proteoglycan produc-
tion by healthy cells, and inhibit the

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

procedures, concerns remain regard-
ing their efficacy and cost. The most
common adverse reaction, occurring
in up to 20% of cases, is mild pain or
swelling at the site of injection.
Rarely, granulomatous inflamma-
tion can result in long-term sequelae
and compromise clinical success.
36
Moreover, although hyaluronate vis-
cosupplementation may partially re-
store the lubricating properties of
synovial fluid, the procedure is not
intended to treat severe cartilage
loss definitively.
Recent studies have questioned
the efficacy of arthroscopic débride-
ment, lavage, and chondroplasty for
osteoarthritis of the knee. In a ran-
domized trial of 180 patients, Mose-
ley et al
37
reported no “clinically
meaningful differences” in pain or
functional scores at 2 years among
those who received arthroscopic
débridement, lavage, or placebo (ar-
throscopic portals alone). However,
both the methods for patient selec-
tion and the statistical analysis in

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

may be effective in the early stages
of osteoarthritis, but this is often not
well tolerated by athletes who want
to continue rigorous activity.
Abrasion chondroplasty and sub-
chondral drilling of chondral defects
was developed to promote vascular
stimulus for the influx of primitive
mesenchymal cells.
39
Subsequent
histologic evaluation demonstrated
fibrous metaplasia of the accumulat-
ed clot that ultimately resulted in
the formation of fibrocartilage.
Rand
40
compared the results of abra-
sion chondroplasty with débride-
ment alone for full-thickness os-
teoarthritic articular defects of the
knee and documented a 77% initial
improvement rate in the débride-
ment group compared with only
39% in the chondroplasty group.
Moreover, 32% of the chondroplasty
group were worse at 3-year follow-
up, with 50% eventually needing
joint replacement with a prosthe-
sis.

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

follow-up in the general population.
Valgus high tibial osteotomy is
indicated primarily for active pa-
tients with medial compar tment
arthritis with medialization of the
mechanical limb axis. Although tra-
ditionally this procedure has been
reserved for patients younger than
age 60 years, it is now being per-
formed on older, active patients of
younger physiologic age. It is an
excellent alternative to unicompart-
mental knee replacement, which
is indicated primarily for patients
with relatively sedentary lifestyles.
Sprenger and Doerzbacher
42
re-
viewed the results of 76 high tibial
osteotomies done over 18 years for
the treatment of varus gonarthrosis;
they reported 90% survivorship (the
percent that remain successful at 10
years). However, Nagel et al
43
report-
ed that, although 82% of patients
(28/34) were satisfied after high tib-
ial osteotomy, the average score on
the Tegner and Lysholm activity

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

arthroscopy for recurrent symptoms
resulted in no clinical benefit. The
authors concluded that hip arthros-
copy for the treatment of mild to
moderate primary osteoarthritis of
the hip is, at best, of only temporary
benefit.
45
Joint Replacement
In 1999, almost 550,000 knee and
hip replacements were performed in
the United States.
46
Although pros-
thetic replacement of the shoulder is
less commonly done than total hip
or knee replacement, the number of
shoulder arthroplasties performed
likely will increase as experience
and understanding of shoulder ar-
throplasty expand. In 1998, 15,266
shoulder replacements were per-
formed nationwide, including 8,556
hemiarthroplasties and 6,710 total
shoulder replacements.
46
Whereas
the traditional goal of prosthetic re-
placement was satisfactory pain re-
lief, the current measure of success

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

Society
46
Activity
Hip
Arthroplasty
Knee
Arthroplasty
Shoulder
Arthroplasty
Aerobics–high impact – 0 0
Aerobics–low impact + ++ ++
Baseball/softball – 0 0
Basketball – – 0
Bicycling–road + + ++
Bicycling–stationary ++ ++ ++
Bowling + ++ ++
Canoeing + + ++
Croquet ++ ++ ++
Dancing–ballroom ++ ++ ++
Dancing–jazz 0 ++ ++
Dancing–square 0 ++ ++
Fencing 0 0 0
Football – – –
Golf ++ ++ +
Gymnastics – – –
Handball – – 0
Hiking + + +
Hockey – – –
Horseback riding + ++ 0
Horseshoes ++ ++ ++

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

patients often place undue stresses
on the implant and are at higher risk
of injury because they lack sport-
specific skills or muscular condi-
tioning.
Despite continued improvements
in implant materials, design, and
prosthetic technology, implant fixa-
tion remains a critical factor limit-
ing athletic activity after total joint
arthroplasty. Youth, imparted load,
and activity have been shown to in-
crease the risk of failure; in patients
older than 65 years, the critical fac-
tor for implant survivorship is the
quality of initial implant fixation.
46
Increased activity also results in in-
creased cycling of the articular bear-
ing surfaces and the inevitable wear
and particle production. Moreover,
sports participation places the older
athlete at risk of traumatic compli-
cations, such as dislocation, implant
failure, and periprosthetic fracture,
all of which are challenging to man-
age successfully. Total joint arthro-
plasty presents a unique challenge in
the older athlete. From a technical
standpoint, patient age, activity lev-

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

place patients at risk of falling and
allow return to participation in
sports on a case-specific basis. We
discourage participation in contact
or high-impact sports, such as foot-
ball or gymnastics.
Summary
Growth of our aging population will
undoubtedly result in an increased
number of musculoskeletal prob-
lems. So-called normal age-related
changes must be differentiated from
pathologic ones. Treatment should
be tailored to the specific functional
requirements of the patient in the
context of the individual’s general
health and musculoskeletal com-
plaints. Although nutritional supple-
ments such as glucosamine, chon-
droitin sulfate, and creatine have
become popular, their effectiveness
has not been established. In addition,
although use of anti-aging agents
such as testosterone or growth hor-
mone also has grown, no beneficial
effects have been demonstrated in
otherwise normal aging persons. Re-
constructive procedures to address
full-thickness chondral damage con-
tinue to evolve; however, these

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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Orthopaedic Care of the Aging Athlete
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