Selected Issues for the Master Athlete and the Team Physician

DEFINITION Team physicians often treat injured active patients aged 50 yr and older. There are various definitions of master athletes. For the purpose of this document, master athletes will be defined as active individuals aged 50 yr or older. They desire optimal levels of performance or wish to exercise for general health and have high expectations for sports medicine care, including return to sport or activity. In addition, to the more common general illnesses and injuries seen in athletes, master athletes can experience specific illnesses and injuries owing to their physiology. This may require customized treatment to address the complexity of these conditions. This document will examine selected illnesses and injuries commonly seen in master athletes. GOAL The goal of this document is to help the team physician improve the care of the master athlete by understanding medical and musculoskeletal factors common in this age group. To accomplish this goal, the team physician should have knowledge of and be involved with the following: physiological considerations, including cardiopulmonary function, muscle strength, and balance; medical considerations, including preparticipation evaluation and cardiovascular disease; and musculoskeletal considerations, including Achilles tendon rupture, lateral elbow and rotator cuff tendinopathy, lumbar spinal stenosis, and shoulder, hip, and knee arthritis. SUMMARY This document provides an overview of selected medical issues that are important to team physicians who are responsible for the care and treatment of athletes. It is not intended as a standard of care and should not be interpreted as such. This document is only a guide and, as such, is of a general nature, consistent with the reasonable, objective practice of the health care profession. Adequate insurance should be in place to help protect the physician, the athlete, and the sponsoring organization. This statement was developed by a collaboration of six major professional associations concerned about clinical sports medicine issues; they have committed to forming an ongoing project-based alliance to bring together sports medicine organizations to best serve active people and athletes. The organizations are the American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. EXPERT PANEL Facilitator: Stanley A. Herring, M.D., Chair, Seattle, WA Primary authors: W. Ben Kibler, M.D., Lexington, KY Margot Putukian, M.D., Princeton, NJ Delegates: Thomas W. Allen, D.O., Tulsa, OK John Bergfeld, M.D., Cleveland, OH Lori Boyajian-O'Neill, D.O., Kansas City, KS David Cosca, M.D., Sacramento, CA Rebecca Jaffe, M.D., Wilmington, DE Walter Lowe, M.D., Houston, TX David Thorson, M.D., Mahtomedi, MN MEDICAL CONSIDERATIONS FOR THE MASTER ATHLETE Physiology General considerations There are physiological changes that occur with aging, which include the following: ○Cardiopulmonary (cardiac output, blood pressure, V˙O2max, vital capacity) ○Musculoskeletal (reaction time, strength, muscle endurance, tendon structure, cartilage structure, bone mass, flexibility, fat-free body mass, balance) ○Metabolic (glucose tolerance, lipids, insulin sensitivity, metabolic rate) Physiological changes may be associated with many chronic conditions, such as diabetes, coronary artery disease, hypertension, osteoarthritis, bone loss, and overweight/obesity. Exercise may modify age-related changes. Medications used by master athletes may have significant adverse effects. Strength General considerations Independent of activity level, muscle mass declines with age; approximately 1.25%·yr−1 after age 35 yr. Muscle mass is directly related to peak strength but not necessarily to performance. There is an accelerated decline in peak strength after age 70 yr. Muscle power is lost at a greater rate than endurance capacity. Rates of decline of strength and performance are similar between men and women. There are genetic, chronologic, hormonal, nutritional, and behavioral (exercise) components to muscle aging. Resistance training (RT) may modify age-related changes. Physiology/pathophysiology Decrease in strength is due to: ○Decreased cross-sectional area (CSA) of type II (fast-twitch) muscle fibers (quality and quantity). With aging, the ratio of the CSA of type II to type I changes from 1:1 to 1:2 ○Decrease in contractile rate of force development, the ability to rapidly reach a given magnitude of muscle force during the initial phase of rising muscle force. Sarcopenia, age-associated loss of muscle mass, is usually characterized by the replacement of muscle fibers with fat and fibrosis. ○Contributing factors include disuse, metabolic, neuromusculoskeletal, and neurovascular conditions. ○Associated with functional decline often manifest in decreased knee extensor strength, postural imbalance, and decreased ability to safely navigate stairs and chairs. ○Increased fat infiltration is associated with glucose intolerance, diabetes mellitus, poor knee extensor strength, decreased muscle contractility, muscle fiber recruitment, and muscle metabolism. Treatment Age-related declines in strength can be delayed or diminished by consistent RT that slows the decline of muscle mass and strength more effectively than aerobic training (AT). The effects of consistent RT include the following: ○Delayed type II muscle fibers changes ○Increases in muscle strength ○Greater power per muscle volume Other effects of consistent RT: ○Decline in fat-free mass, increase in total body mass, reduction in oxidative stress ○Increased basal metabolic rate ○Improved insulin sensitivity and glycemic control ○Increase in bone mineral density It is essential that the team physician understand: There is an age-related decline in muscle mass and strength. RT modifies these declines, and this should be recommended. RT also modifies effects of other age-related medical conditions. It is desirable that the team physician Understand and implement an RT program Cardiovascular Considerations General considerations Regular exercise (aerobic, strength) may lower risk of fatal and nonfatal myocardial infarction, hypertension, and atherosclerotic heart disease. However, vigorous physical exertion may trigger myocardial infarction or sudden cardiac death in individuals with underlying heart disease. The risk of sudden death associated with high-intensity exercise is imprecise, but it increases with age. The benefits of regular exercise outweigh the risks. Treatment should be individualized based on cardiac condition. Use of cardiac medications is common in this age group. ○Medications can affect physical and cognitive performance; adverse effects should be considered. ○Athletes on anticoagulant medication should be counseled about the risks of sports participation, particularly contact and/or collision sports. Consistent RT may have a beneficial effect on cardiovascular health. Physiology Age-related changes include the following: ○Increased peripheral vascular resistance; regular exercise decreases peripheral vascular resistance ○Decreased V˙O2max ▪V˙O2max declines at the rate of about 10% per decade beyond age 25 yr; it declines steeply after age 60 yr. ▪With regular exercise, the decline may be as much as half the rate in master athletes as compared with nonathletes. ○Decreased cardiac output; exercise lessens this decrease ○Decreased ventilatory anaerobic threshold; exercise lessens ventilatory anaerobic threshold decrease The effects of consistent RT on cardiovascular physiology include the following: ○Decreased blood pressure ○Decreased resting HR ○Improved left ventricular function Cardiovascular conditions Sudden cardiac death Most sudden cardiac death is caused by atherosclerotic CAD. Other less common conditions that predispose to sudden death include the following: ○Hypertrophic cardiomyopathy (HCM) ○Valvular heart disease ○Dilated cardiomyopathies ○Myocarditis ○Dysrhythmias and conduction abnormalities Refer to "Mass participation event management for the team physician: a consensus statement" [Med Sci Sports Exerc. 2004;36(11):2004-8] for equipment and medical supplies related to arrhythmias and managing individuals presenting with sudden cardiac arrest. Atherosclerotic CAD The most common cardiac disease in this age group and major risk factor for angina, myocardial infarction, and arrhythmia. Acute myocardial infarction occurs in individuals even with minimal coronary artery stenosis. Treatment Individuals with documented CAD (>50% narrowing if angiography has been performed) should not participate in high-intensity sports/activities without further consultation because of increased risk of myocardial infarction and sudden cardiac death. Hypertension Prehypertension (120-139/80-89 mm Hg) Stage 1 hypertension (140-159/90-99 mm Hg) Stage 2 hypertension (>160/>100 mm Hg) Incidence increases with age Treatment Athletes with prehypertension and stage 1 hypertension in the absence of target organ damage should not be restricted from participation in master activities. Athletes with stage 2 hypertension should be restricted from static high-resistance sports (e.g., weight training) and should likely be restricted from high-intensity sports until their blood pressure is normalized. Congenital and valvular heart disease conditions HCM ○See page 2062, "Selected issues in injury and illness prevention and the team physician: a consensus statement" [Med Sci Sports Exerc. 2007;39(11):2058-68]. ○Heterogeneous disorder, in which there is an imprecise means of stratifying risk. Dilated cardiomyopathy or arrhythmogenic right ventricular dysplasia Mitral valve prolapse (MVP) Treatment Athletes with definitive diagnosis of HCM should be advised to avoid participation in high-intensity sports. Individuals with dilated cardiomyopathy or arrhythmogenic right ventricular dysplasia should be restricted from high-intensity sports. Most athletes with MVP can participate on an unrestricted basis. ○Individuals with the following criteria should be restricted to low-intensity sport ▪History of syncope likely secondary to arrhythmia related to MVP ▪Family history of sudden death due to MVP ▪Exercise-induced repetitive supraventricular or complex ventricular arrhythmias ▪Moderate to severe mitral regurgitation Arrhythmias Supraventricular ○Atrial fibrillation is the most common arrhythmia. ○Vigorous exertion and endurance training have been reported to increase atrial fibrillation. Ventricular arrhythmia is the most common cause of death in those with HCM. Treatment Individuals with controlled atrial fibrillation can participate in sport or activity. Evaluation Refer to Table 1. Moderate- to high-risk profiles for CAD include men older than 40 yr and women older than 50 yr or postmenopausal with one or more independent coronary risk factors (hyperlipidemia or dyslipidemia, systemic hypertension, cigarette smoking, diabetes mellitus, family history of premature CAD). Both should have symptom-limited ECG exercise testing. TABLE 1: AHA 12 element recommendations for preparticipation cardiovascular screening of competitive athletes.It is essential that the team physician understand: The most common cause for sudden death in master athletes is atherosclerotic CAD. The indications for exercise ECG testing. The effects and adverse effects of cardiovascular medications on health and performance. When to restrict activity or participation among master athletes with cardiovascular issues. Automatic external should be at with in cardiopulmonary It is desirable that the team physician understand: to medications in the master athlete with cardiovascular disease. Age-related cardiovascular of exercise such that may be given for exercise Evaluation General considerations should be for the athlete who is in a vigorous The should the and and be specific to the athlete and sport or activities. The goal is to patients at risk for cardiovascular of exercise, with disease. Other include athletes who have and further or The team physician should on of Cardiovascular evaluation exercise Cardiovascular to exercise and/or exercise are given in Table TABLE to exercise and/or exercise of the medical history and of of or from sports or activity Medications Cardiovascular issues issues injury loss, and treatment of or conditions injury or or issues in and/or General (e.g., and Other medical issues and issues issues athlete issues; athlete issues for the team physician: a consensus statement" [Med Sci Sports Exerc. physical with on and musculoskeletal or as by history Cardiovascular and as by and and lower and to on history and physical issues without further or evaluation with (e.g., vigorous for participation issues team physician and a consensus statement" [Med Sci Sports Exerc. the athlete at increased risk for injury or this risk be to it other at risk for injury or illness because of the It is essential that the team physician understand: The purpose of the is to patients at risk for cardiovascular of exercise, with cardiac disease. The should the and and be specific to the athlete and sport or activities. a history and physical that the athlete for participation or for further evaluation or It is desirable that the team physician understand: screening for chronic disease in the older a team to care for the master to and cardiovascular disease, major musculoskeletal and issues. CONSIDERATIONS FOR THE MASTER ATHLETE Achilles factors There is a older than yr of increased risk Sudden changes in of which in changes include the following: ○Decreased strength and increased ○Decreased of tendon which in force to muscle There are minimal Achilles Acute of on sudden in ability to to on or to in tendon in the or at the this from muscle tendon of with is of injury and performance in and include with tendon or as as and strength for or in may be in chronic Treatment is for by weight of or are for chronic 2 is chronic with is have similar high of initial tendon rate is in compared with of in reduction of muscle strength, and of the complex and the of the lower and training training strength training Use from to activities. It is essential that the team physician: that are associated with increased risk of tendon the clinical of Achilles tendon to a It is desirable that the team physician The of Achilles tendon The clinical of chronic Achilles tendon The benefits and associated with and The and of a program for the risk factors of Achilles tendon General considerations of cartilage characterized by loss of cartilage and The most common cause of musculoskeletal and factors of dysplasia of the hip, ○Increased risk with and more than 60 and sports can be to ○Increased with weight be to knee to ○Decreased of in diagnosis peripheral and not treatment lateral narrowing and and associated is Treatment loss if to improve for the in to have less than that in knee exercise to be as as at only repetitive as at only is with for for is not of has not been to be if changes history or decreases in strength in and in exercise and sports activity is on activity. who have high levels of performance have a of that usually with TABLE after total Society is essential that the team physician: the clinical of Understand medical management is Understand treatment a history and physical of the It is desirable that the team physician: Understand the of a including activity and weight control if an history and physical to for other of to patients risks and benefits of sports activity after factors injury (e.g., and Muscle and and Muscle may be not For associated Treatment loss if at is with of and should be used may or may repetitive of exercise to training (e.g., to address knee exercise to be as as exercise program in decreased in may be in disease and for be for patients with and not the history of cartilage are specific indications for replacement optimal in for specific issues knee replacement for increased function exercise and sports activity on activity. who have high levels of performance have a of that usually with TABLE is essential that the team physician: the clinical of knee that muscle is a in Understand treatment Understand medical management is a history and physical of the It is desirable that the team physician: a including activity and weight control if to patients risks and benefits of sports activity after is most common it is not necessarily associated with activity. injury of loss of cuff disease rotator cuff with at and of ability to Strength may or may not be decreased not are in and external is for initial it is for Treatment In is is commonly minimal significant the of can be of Athletes with may not and may require more customized and to be in ○Decreased ○Decreased ability to strength loss ○Decreased strength treatment is with for for is not of to increase after rotator cuff strength as of treatment significant (e.g., rotator cuff in the in and for of bone with minimal for increases increases strength, of athletes are to return to with without may be in sports/activities that require It is essential that the team physician: clinical of Understand not is due to Understand treatment a history and physical of the It is desirable that the team physician: a treatment Understand the of and implement activity to participation the of the arthritis. 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Team physician consensus Sci Sports Exerc. American College of Sports Medicine, American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine. for the team physician: a consensus Sci Sports Exerc. American College of Sports Medicine, American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine. The team physician and of athletes for a consensus Sci Sports Exerc. American College of Sports Medicine, American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine. 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American College of Sports Medicine, American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine. and the team physician: a consensus Sci Sports Exerc. American College of Sports Medicine, American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine. issues related to injury in athletes and the team physician: a consensus Sci Sports Exerc. 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