BACKGROUND

Sports injuries in the elderly commonly involve either fracture or soft tissue injuries, such as ligament and tendon injuries. Fractures have been extensively covered in previous chapters, so this chapter will focus on soft tissue injuries. There is scant literature specifically on the elderly athlete, but we will discuss injuries in multiple areas of the extremities. We have chosen pathologies that have at least a modicum of studies in an older population. Also, defining what is elderly, particularly when it comes to sports, is somewhat a matter of personal discretion, so rather than focus on a specific age cutoff in this chapter, we have focused more on the aging athlete.

Before discussing specific injuries, however, it is important to be mindful that although these injuries may occur during athletic participation, it is the changing environment and structure of the ligaments and tendons with age that place them at increased risk for injury.¹ Age related changes to the soft tissues also have implications for treatment options and outcomes.¹

With age, tendons undergo changes at the cellular level with fewer cells per muscle unit and a change in the composition of the extracellular matrix.² The healing ability on a cellular level and cell response is then compromised.³ On a macroscopic scale, tendons become more stiff and less able to respond normally to mechanical load.⁴ In addition, the blood supply to tendons can change over time.^5,6 Some tendons such as the rotator cuff or Achilles tendon already have watershed areas of poor blood supply at baseline.^7,8 All of these changes put tendons at risk for frank injury or to tendinopathic and degenerative changes, which ultimately can result in frank rupture of the tendon or can affect the ability of the tendon to heal.⁹

Ligaments are similar in that they also need to resist load, generally tensile. Ligaments also change over time making them less elastic and able to resist load.^10,11 Similar to tendons, there are age related changes on the cellular level as well, with less cellularity and alterations in the extracellular matrix.^12,13 In addition, there are changes to microarchitecture such as more disorganization of collagen fibres.¹⁴ Finally, aging ligaments may also have vascular changes. These age-related changes put ligaments at risk for rupture and affect the ability of the ligaments to heal.

In addition to tendon and ligament changes other important structures, such as muscle and bone, are experiencing age related changes, which can have an impact on the stresses to which tendons and ligaments are exposed. Muscle, for example, will have decreased mass, decreased turnover and healing capacity and change in fiber distribution and innervation.¹⁵ These lead to functional changes in the muscle and, consequently, changing requirements of tendons and ligaments.

Simple commonsense strategies may help prevent some injuries in older adults. It is recommended that older adults have a pre-exercise evaluation, especially if they intend to begin exercising after a period of primarily sedentary lifestyle.¹⁶ Increases in activity duration or intensity should be gradual over time.¹⁷ Warm-up and cool-down periods, or the use of ice or heat, may be beneficial; however, the evidence for this is weak.¹⁸ Evidence is also weak for stretching; however, it may be most beneficial after a workout.¹⁹

OUR EXPERIENCE AND SCOPE OF THE PROBLEM

At our institution, which is a dedicated outpatient orthopaedic facility, we see many aging athletes. We have searched our database to identify the top 50 ICD-9 and CPT codes both for patients over the age of 60 and for those over the age of 65 and effectively they are similar between the two. The most common problems for these patients are arthritis, spine issues, hand and wrist issues, and fractures. Common pathologies treated by orthopaedic sports medicine physicians are infrequent in the list, the most dominant being rotator cuff and anterior cruciate ligament (ACL) injuries.

We expect these pathologies, including sports related pathologies, to increase with aging populations. There was a significant increase in birth rate in many countries following the end of World War II, particularly in Western countries, which has brought about significant increases in the aging population. In the United States, this is the baby boomer generation, which totals over 75 million people.²⁰ Baby boomers began turning 65 years old in the year 2011, and their average life expectancy continues to rise, with estimates of between 80 and 85 years for this generation.²⁰ In Britain, one sixth of the population is currently over 65 years, and this is expected to rise to one in four, with an estimate of 19 million people over the age of 65 by 2050.²¹ As they age this generation is experiencing better health, which is improving relative to previous generations, so we expect that they will remain more active, resulting in more sports related pathologies in this population. According to the Outdoor Foundation, recreational activity participation in adults over the age of 50 may be as high as 50% and maintained at 30–40% for adults over 65.²² For older adults, the CDC recommends 150 minutes of moderately strenuous aerobic activity each week and muscle building activity on 2 or more days each week.²³

ACHILLES TENDON

The aging Achilles tendon strongly demonstrates all the above tendon changes. It has also been shown to have a change in reflex with a decrease in motoneuronal excitability.²⁴ As a mature athlete is attempting to be active, these changes in Achilles architecture and function mean the Achilles is less able to respond to athletic demands and possibly can place the tendon more at risk for rupture. How best to manage Achilles tendon ruptures has become even more complicated with recent systematic reviews suggesting similar results between surgical intervention and an accelerated rehabilitation program.^{25,26 and 27} Therefore, indications for surgery are not exactly clear but should consider the patient’s overall activity level before injury and desired level of functional return. At our institution, the majority of elderly patients with Achilles ruptures are not active in athletics, but rather seek a return to normal daily activities. In our experience, these patients generally do well with a non-operative approach with accelerated rehabilitation, supporting the findings of Soroceanu et al.²⁵ and van der Eng et al.²⁶

For those patients who do undergo surgery, the literature suggests generally good results as well (Table 45.1). In particular, percutaneous repair has been analysed in the elderly. In a cohort of 27 patients over the age of 65 years, Maffulli et al. demonstrated an improvement in the postoperative Achilles tendon Total Rupture score (ATRS) compared with the preoperative score and all patients were weight bearing by the eighth week.²⁸ Carmont et al. also found improvement in the ATRS within the first year following percutaneous repair.²⁹ Their data included five patients greater than the age of 65 who demonstrated similar or better results to their younger counterparts. In a study looking at both open and percutaneous Achilles repair involving 434 patients over the age of 60, the results were also good with the patients returning to their pre-injury activities and a mean American Orthopaedic Foot and Ankle Society (AOFAS) score of 93.1 points.³⁰ It should be noted, however, that there are reports of complications. Nestorson et al. demonstrated just that with complications in 11 of 25 patients older than 65 years; comorbidities, however, were common in their patient population.³¹ To date, no studies have looked at return to sports. Most studies would suggest while patients may see improvement compared to their preoperative functional state, there is not a return to pre-injury function following Achilles tendon rupture, regardless of treatment option.^{28,29,30 and 31}

ANTERIOR CRUCIATE LIGAMENT

In general, anterior cruciate ligament reconstruction (ACL-R) has been shown to produce good results in an older population (Table 45.2). Studies looking only at older patients report good outcomes scores, return of function and improved stability.^{32,33,34,35,36 and 37} Blyth et al. demonstrated an improvement in International Knee Documentation Committee (IKDC), Lysholm, Cincinnati and Tegner scores, as well as on examination, in a group of 30 patients over the age of 50 at mean follow-up of 46 months.³⁵ In studies directly comparing younger and older patients, there are similar findings between the groups. Osti et al. compared 20 patients over the age of 50 and 20 patients under the age of 30 and found similar improvement on physical examination and in IKDC and Lysholm scores with no difference between groups for final scores.³⁸ In our own patient population, we evaluated 19 consecutive patients over the age of 50. The majority (90%) returned to the same level of sports participation, but more slowly than younger patients with a mean of 11 months for the older patients to return; there were no failures.³⁹

Many studies in older populations have also looked at ACL graft options. Generally, studies have demonstrated good results regardless of graft choice including patellar tendon (BTB), hamstring (HT) and allograft options.^{34,36,40,41 and 42} Struewer et al. directly compared BTB and HT autografts and, at 2 years, found no differences between groups for IKDC, Tegner and Lysholm scores or for grading of osteoarthritis.⁴⁰ Barrett et al. compared allograft BTB with autograft BTB and demonstrated good improvements for both groups.⁴¹ It was noted, however, that allograft patients returned to sports sooner, but had a higher risk of failure.⁴¹

Kinugasa et al.⁴³ performed second look arthroscopy on 102 patients of all ages and found those over the age of 50 demonstrated less robust healing of the ACL HT autograft; clinical outcomes were comparable. The literature does suggest, not surprisingly, that worse outcome are achieved in the face of more advanced degenerative change. Blyth et al., at medium-term follow-up, found poor outcome scores in patients with Outerbridge grade 3 or 4 degenerative changes present at time of surgery.³⁵ Interestingly, Kim et al. found cartilage degenerative associated pain with activity improved with ACL-R; the patients’ pain at rest was no different following ACL-R.⁴⁴

The indications for ACL-R are evolving. As the aging population increases and remains active, it is expected we will see more ACL injuries in older patients. There is a paucity of studies evaluating operative versus non-operative options in this population, so who would likely benefit from an ACL-R is not always clear. It does appear, however, that patients who wish to remain active, particularly those involved in cutting and pivoting activities, do well with ACL-R.⁴⁵ Care of these patients, therefore, warrants careful assessment of the patient’s activity goals and engaged conversation with the patients regarding both operative and non-operative management of ACL injury, and the associated rehabilitation is required.

MENISCUS

The number of patients undergoing treatment for meniscal injuries in the older population is increasing. Thorlund et al. reported the incidence of arthroscopic meniscal procedures in Denmark almost doubled between 2000 and 2011.⁴⁶ The largest relative increase (i.e. a threefold increase in incidence rate) occurred in patients older than 55. Abrams et al. reported on the number of meniscectomies and meniscal repairs in this population subset, and noted there has been an increase in the number of isolated meniscectomies performed in the United States over the past 7 years without a concomitant increase in meniscal repairs over the same time frame.⁴⁷ From 2006 to 2011, the authors noted a 4.7% rise in meniscectomies versus a 3.2% decline in meniscal repairs in patients aged 55–64. In patients older than 64 there was a 1.3% decline in meniscectomy and no meniscal repairs using a large patient database for the USA. Some of this increase is likely simply due to the increasing number of people in the elderly population.

Meniscal lesions in the aging population can be acute and/or traumatic, degenerative or both. Degenerative tears frequently occur in the absence of a distinct trauma but in the presence of other structural joint changes characteristic of knee osteoarthritis.^48,49 Thus, there is often a constellation of knee structural abnormalities characteristic of knee osteoarthritis, such as meniscal tearing, osteophytes, bone marrow lesions and cartilage damage. This set of findings is often noted on both radiographs and MRI examination of both asymptomatic and painful knees of middle-aged and older patients.^48,50 Other studies have shown a high incidence of meniscal tears even in asymptomatic knees.^{48,51,52 and 53} However, elderly patients may also have minimal degenerative change in the knee but consistent evidence of meniscal tear on history, examination and MRI.^{54,55 and 56}

Given the low rates of meniscal repair in the aging population, this section will focus on meniscal debridement in older individuals. When to perform arthroscopic partial meniscectomy in this population is hotly debated. Several randomized controlled trials (RCTs) published in the past decade have failed to show long-term benefit of arthroscopic interventions over and above that of placebo surgery, physiotherapy alone or physiotherapy combined with other medical treatments for patients with advanced osteoarthritis of the knee^{57,58,59 and 60} (Table 45.3). Poorer clinical outcome after meniscectomy has been associated with greater severity of cartilage loss, bone marrow oedema in the same compartment as the meniscal tear greater severity of meniscal extrusion, greater overall severity of joint degeneration, a meniscal root tear and a longer meniscal tear at preoperative MR imaging.⁶¹ For patients with minimal change or mild arthritis, the results of partial meniscectomy appear to be more positive.^{54,55 and 56,62,63 and 64} In particular, early return to activity and early outcomes are reported to be good.^54,62 The results generally deteriorate over time, but in some patients partial meniscectomy may have beneficial long-term effects.^55,62

The literature on partial meniscectomy surgery in the aging population emphasizes the need for careful patient selection. The appropriate patient can have very good results from partial meniscectomy, but poorly chosen patients can have poor results or be made worse following surgery. It is up to the physician to identify which patients’ symptoms, exam findings and imaging findings are more likely due to a meniscal tear versus other problems such as degenerative change.

Related posts:

Preoperative assessment and care of the elderly The management of osteomyelitis Other bone diseases in the elderly Proximal tibial fractures Femoral diaphyseal fractures Thoracolumbar and sacral fractures

Stay updated, free articles. Join our Telegram channel

Join