The Old Athlete

Galen said it first and more recently, the American Heart Association, that you have a
fixed number of heart beats in a life time. 2.5 billion.
 

“The first accurate measurements of body mass versus metabolic rate in 1932
showed that the metabolic rate R for all organisms follows exactly the 3/4 power-
law of the body mass, i.e., R M3/4.
Called Kleiber's Law.
It holds good from the smallest bacterium to the largest animal (see Figure 01).
The relation remains valid even down to the individual components of a single cell
such as the mitochondrion, and the respiratory complexes (a subunit of the
mitochondrion).It works for plants as well. This is one of the few all-
encompassing principles in biology” (www.universe-review.ca/R10-35-
metabolic.htm)
What needs to be further investigated are pharmacological methods to minimize
aging such as use of the Polypill, growth hormones, and testosterone supplements
• Physiological changes of ageing 

• Care of the older athleteExercise programmes for older people 

• Injuries and problems of older athletes 

• Ongoing care 

• Nutrition 

• Athletic performance 

• Conclusion

It is difficult to define what an “older athlete” is. Masters competitions start at age 25 for
swimming and at 35 to 40 for athletics. People of all ages regularly compete in marathons.
James Tomkins at age 43 was in the Australian Rowing 8 at Beijing 2008 Games. Unheard
of not so long ago.
In pre-history, man rarely needed to consider the ageing process. Life was short and the
hunter gatherer did not live long beyond a decrease in ability and performance.
In the modern day, athletic performance has become less vital for life, but has remained
important into old age. Older people have an interest in maintaining health and some go
further to maintain a competitive edge.
Sports medicine for older athletes is not only about competitive performance. The benefits
of exercise are many but so, unfortunately, are those who do not partake of them. The goal
is as much to encourage a healthy active lifestyle as it is to help the older competitor (Fig.
1).
Physiological Changes of Ageing
Along with the awareness of our own mortality, we have an understanding that our bodies
will age. Ageing is a universal process, causing progressive structural and functional loss.
There are theories of why we age. Leonardo da Vinci, after careful anatomical studies,
concluded that thickening blood vessels were the cause. Even today, the cause of the aging
process remains unknown.
Ageing causes a decrease in the number, function and regeneration of cells. This leads to
structural and functional changes in the older person. Fig. 2 shows the physical changes of
ageing that are affected by exercise. It clearly shows that the loss of function is due as
much to disuse and inactivity as to ageing itself.
What needs to be further investigated are pharmacological methods to minimize
aging such as use of the Polypill, growth hormones, and testosterone
supplements.
1
Figure 2
Regular exercise slows the effects of age on body systems
 

System                        Ageing Changes                          Effect of Exercise
     

Muscle ∙          mass and strength lost slowly ∙        can be minimalised with

         with ageing   exercise

     

  ∙                    power decreases  

   
     

Bone ∙          mass loss after age 35,  

         increases after age 55 ∙        bone loss reduced by 

    regular exercise and good 
nutrition 
  ∙            trabecular bone lost before
 
         cortical
 
   
 
  ∙          faster loss in post­menopausal
 
         women
 
     

∙          decrease in total body calcium  

 
     

  ∙          loss of elasticity (may increase ∙        weight bearing exercise

Cartilage osteoarthritis may slow changes

  ∙            greatest risk in knee, hip,   

  ankle, impact WILL worsen 

          spinal facets degenerative arthritis if already 

  present. The more joints are 
used( cyclic loading) the 
 
quicker they wear out and 
need to be replaced.
     

Ligaments  ∙         lose elasticity with age ∙        stretching before and after

and tendons       (increase in sprains and strains)         exercise maintains

            flexibility

  ∙         decreased flexibility  

    ∙       regular use maintains

  ∙         loss of flexibility and range of        strength and suppleness

  motion  

        may increase joint and muscle  
      injury  

 
  ∙         decrease in conduction velocity  ∙         reaction times are faster if

Nervous and maintained by use

System        number of neurons/axons

∙         slower reactions and speed

∙        loss of vision and hearing
2
Figure 2 (Cont’d)
 

System                          Ageing Changes                                      Effect of Exercise
Cardiovascular ∙          lower VO2 max   ∙        exercise can maintain 

    VO2 max  

  ∙          less anaerobic endurance  

     

  ∙          lower cardiac output and maximum  ∙        can stop endurance 

heart rate loss
 
   
 
∙          increased risk of coronary artery  ∙        slows decline in 
 
disease maximum heart rate
 
   

∙          slower return of heart rate to resting  ∙        aerobic exercise more 

value effective than anaerobic may 
decrease risk of CAD
 

∙          increased vascular resistance

 
Respiratory  ∙          decreased compliance ∙        regular exercise 

System   reduces respiratory changes 

  ∙          reduced airflow  

     

  ∙          increased effort of breathing  

 
Some ageing body systems have implications on the way older people exercise (Fig. 3).
Refer to the section Guidelines for Exercise for further recommendations.
Figure 3
Exercise implications for some ageing body systems
 

System                          Ageing Changes                                      Effect of exercise
     

Renal ∙            glomeruli loss decreases filtration ∙          Ensure fluids

System   ∙        Avoid very hot weather

  ∙          loss of total body water (higher risk of ∙        Break up workout

         dehydration.  

 
Skin ∙          Thinning of skin decreases thermal  

  Insulation ∙        Use sunscreens, hats
     

  ∙          Skin becomes more fragile ∙        Well fitting footwear

     

  ∙          Epidermis looser – predisposes to   

  blisters  
   
∙          Reduction in defense to UV radiation
Thermo ∙          Reduced heat dissipation ∙        Heat tolerance may be 

Regulation   less

     

     

Presentation ∙            Slower healing ∙        Longer rest periods after 

  injury 

In general, functional reserves decrease with age. To attain the same performance, the
older athlete must push closer to the body’s limits.
Care of the Old Athlete
The aspects to consider are:
• Exercise for older people

• Injuries and problems of older athletes

• Previous sporting activity – ongoing care of athletes as they age

Exercise Programmes for Older People 
Goals of an Exercise Programme
• The ultimate goal of an exercise programme is to improve quality of life. It aims to:

• improve aerobic capacity

• increase strength and energy

• improve balance 

• increase self-esteem

• improve sleep patterns

• improve independence

• provide social interaction and enjoyment

 

Exercise Evaluation
Any older person starting an exercise programme should be evaluated for risk factors that
make them prone to injury or may limit their activity.
History
The history should include previous and current medical conditions, medication, current
nutritional status and previous injuries. Risk factors for coronary artery disease and diabetes
mellitus should be identified. A less rigorous exercise programme is recommended for those
with two or more risk factors.
4
Cardiovascular Screening
A cardiac stress test should be performed if the patient has one of the following:
 

• recent myocardial infarction or coronary artery bypass surgery (Fig. 4).Major risk
factors for cardiovascular disease (obesity, hypertension, hypercholesterolaemia,
family history, smoking). 

• A pacemaker-fixed rate or demand 

• Use of chronotropic/inotropic medication 

• At least 70% of the maximum heart rate based on age should be achieved.

Stress testing is unnecessary for gentle exercise (non-competitive swimming, walking,

bowls).
Echo studies of the carotids and heart are useful.
Musculoskeletal Evaluation
The older athlete is more prone to musculoskeletal injury and is slower to recover than a
younger athlete. Musculoskeletal evaluation is therefore important.
Evaluate:
Muscle strength – Most injuries to the mature athlete involve the lower limbs. Assessment
of knee and ankle is therefore necessary. The athlete should be able to generate enough
force to lift at least half his/her body weight.
Flexibility – The ankle should have at least 10° of dorsiflexion. The hip should have at least
a 60° arc of motion. Check for hip flexion contractures, iliotibial band tightness and rectus
femoris tightness.
Deformity and joint pain – Check for hallux valgus, genu valgum, femoral anteversion,
arthritis and discrepancies in leg length.
Sensory Testing
Check for sensory deficits in the limbs, vision, hearing and colour perception.
Exercise Prescription
A good exercise prescription should include intensity, exercise mode, duration, frequency
and progression.
Intensity
 

Intensity is an important variable in exercise prescription. There are several ways to

determine intensity levels.

1. VO2 max : VO2 max represents the ability of an athlete to extract oxygen from the
environment and use it to generate ATP during work. Training is induced during
exercise at 40 – 85% VO2 max. 

2. Maximum heart rate (HRmax): HRmax can be calculated using (220 – age) + 15.
Intensity can then be expressed as a percentage of HRmax 55.90%. HRmax is the
level recommended by the American College of Sports Medicine to induce training. 

3. Metabolic Equivalent Units (METs): A MET represents the VO2 at rest

(35mL/kg/min). The maximum MET level (MML) is the maximum intensity level for
an athlete. This can be determined by exercise testing. Optimum intensity
recommended is 40-85% MML. The work intensity of different activities (in METS)
can be read off pre-existing tables. This allows the athlete to choose an activity most
suited to his/her target MET level (Fig. 5).
Figure 5
MET
 

      Activity                      METs
   

Level walking at            3.0

4 km/h  

             8.4

Jogging at 8 km/h  

           10.0

Swimming, 30 metres/  

minute  

    6.0 – 10.0

Tennis  

    7.0 – 15.0

Soccer

 
Exercise
Rhythmic activity utilising large muscle groups is preferred. Some weight bearing is also
recommended.
Duration
16-60 minutes continuously at a moderate intensity is ideal.
Frequency
A minimum of 3 to a maximum of 5 days a week (except obese athletes who require a daily
low intensity programme).
Progression
Increase intensity, duration and frequency as fitness improves. Aim to keep the heart rate in
the desired training range. Only one variable should be increased in any session.
Guidelines for Exercise
The DOs and DONTs of exercise for mature athletes are shown in Figure 6.
Figure 6
 

Guidelines for exercise in the older athlete
                       

                         Dos                              DONTs
   

    set realistic goals    high impact activities

∙         ∙        

   

    exercise within the limits of the    extremely hot, humid conditions causing

    exercise tolerance test    dehydration (especially if on diuretic therapy)

   

∙        ∙       

∙         

    exercise aerobically using large muscle    Extreme cold (causing frostbite,

    groups (jogging/cycling/swimming)    Hypothermia, cold­induced angina and

     Bronchospasm)

∙         

    incorporate weight bearing activities ∙        

    into their programme (for prevention of   
osteoporosis)    the Valsalva manoeuvre (especially if
∙           hypertensive/coronary prone)

∙         

    wear appropriate clothing and footwear ∙        

∙         

o           high levels of pollution (athletes with

   increase activity gradually    chronic airways limitation)

∙         

  ∙        

   have rest periods during exercise  

     abrupt changes in amount/intensity of

∙           training

   warm up and cool down sufficiently  

  ∙        

∙         

     prolonged sun exposure (predisposing

   treat injuries quickly and adequately    to skin cancers  

∙       

   exercise with a partner
7
Injuries and problems of older athletes
Injuries
Figure 7 shows the aetiology of exercise=related injuries in the aged. Many are running or
walking related with fewer trauma injuries from contact sports. Overuse injuries for 70% of
injuries seen in the ageing athlete. These tend to progress slowly. Be neglected by the
athlete and present late. They may b slow to respond and have been self-treated by the
athlete.
Locations of injury in the old resemble those in the young, with knee, foot and lower leg
being the most common (Fig. 8). The strength and flexibility with age leads to less impact
absorption in the lower limb. More knee and foot injuries are the result. Overuse
superimposed on tissue degeneration lead to shoulder, tendon and ligament injuries.
Osteoarthritis symptoms are common in older athletes and may actually be due to another
problem. The prevalence of osteoarthritis in the aged can be misleading. Misdiagnosis
can occur often – injury conditions (such as meniscal tear of extra-articular soft tissue
damage) are labeled osteoarthritis, resulting in appropriate treatment.
Diagnosis
• History – common features are: 

• →aggravation by activity 

• →pre-existing condition 

• →trauma or increased intensity of training 

• Physical examination

These suffice for 70-84% of injuries in this group.

Investigators that may be useful in the remainder are: x-rays, CT, blood chemistry, bone
scan and arthroscopy.
Treatment
Injuries in the older athlete are often managed conservatively.
 RICE

 Decrease activity level 15-25% until symptoms resolve

Rebuild training level slowly

Drugs (NSAIDS and others)
→“start low, go slow”

→older athletes use many regular medications – beware drug interactions

→prolonged therapy may be necessary due to slower healing in the aged

• Physiotherapy (exercises, ultrasound) 

• Exercise to build muscle strength (such as quadriceps in knee injury)

8
• Bracing (in achilles tendinitis, ankle instability) 

• Local corticosteroid (see Figure 17, Chapter 3)

Only 24% of injuries require surgery.

Specific sports have been studied and the effect of age on injury risk varies (Fig. 9).
Figure 9
 

Age effect on sports related injuries for specific sports
                       

                         Sport   Age effect on injury risk
   

Soccer   ↑ acute arm injury risk

   
   

Marathon/long   varies from no increased injury to sport most

Distance running   affecting injury risk

   

   

Running    no effect

   

   

Golf    more overuse shoulder injuries  in older golfers

   

   

Orienteering    more muscle ruptures in older athletes

     more acute injuries

   

   

Ball games    increased accident rates

 
Osteoporosis
Osteoporosis is the condition where the rate of bone absorption exceeds the rate of bone
formation. Bone mass begins to decline at age 40 in both sexes. Bone loss further
accelerates in women after menopause.
The ageing process contributes to osteoporosis by slowing the resorption and redeposition
of components of the bone matrix (Fig. 10). There is also an age-related decrease in total
body calcium. The result is an increase in fractures, especially of the hip and vertebral
column.
Osteoporosis poses major problems for the older person just beginning an exercise
programme. He/she should start slowly and cautiously, allowing time for the skeletal system
to adapt.
Studies have shown that regular physical activity (especially resistance-type activity) and
good nutrition can increase bone mineral content in all age groups. Beginning an exercise
programme, even late in life, can be beneficial to the skeleton. However, an excessive
amount of training seems to be detrimental to the skeleton, indicating that an optimal
amount of exercise may exist.
Bone density studies are important and consideration for bone sparing medication
given ( eg alendronate)
Ongoing care
Often the older athlete is a younger athlete to train throughout life. Former athletes may
have problems arising from pat sporting activity. There are some common consequences
from the “past sins” of a training history.
It is possible that increased osteoarthritis is found among former elite athletes (Fig. 11).
Power sport participants are more likely to have premature osteoarthritis. Endurance
running has also been considered as a factor in osteoarthritis. Other arthrosis, especially of
the hip and knee, seem to be more common in past athletes.
Soccer players and weight lifters have had more mild lumbar disc changes than non-
athletes, but the overall incidence of back pain is lower.
In general, previous injury during a sporting career can return as a chronic condition if the
older athlete does not take adequate precautions. Older athletes soon learn that the ageing
body is less forgiving than in their youth.
Other Issues
Nutrition
Whether to perform competitively or to improve general health, the older athlete’s exercise
programme requires a good diet.
The older athlete needs to maintain the same mix of food groups as that of younger
athletes. If involved in endurance training, carbohydrates need to be increased to 60-70%
of the diet (Fig. 12). Adequate protein is essential (vegetarian diets must be well planned).
Vitamin supplements can only be of assistance if the dietary intake is inadequate. Iron is
especially important for distance runners. All older athletes must pay attention to calcium
intake to support bone mineral density.
The Polypill is very useful and has been shown to extend life by 10 years in men
over 55..
Dehydration is more common in the aged. Drinking water prior to, during and post-exercise
reduced risk of heat and dehydration (see Chapter 4).
Athletic Performance
With the advent of masters competitions, older people are increasingly taking up or
returning to competitive sports. The age divisions of some sports reflect that peak athletic
performance tends to decrease with age (Fig. 13 and Fig. 14). Short distance running,
jumping and some throwing events are more affected. Long distance running decreases
less.
Conclusion
As the population ages, it becomes more important that the mature members of society
remain active and healthy to reduce health costs. Encouraging exercise and sporting
activity among older people will reduce the social and economic costs of an elderly
population in failing health.
Many Western countries are experiencing shortage in labour and are dependent on old
people to work longer.
Older people use sport for diverse reasons: health, social contacts and also high level
competition. The physician must be ready to advise each individual according to their
sporting goals and situation. With adequate advice and care, there is little reason why the
older person should not continue to enjoy the many benefits of sport.
11