Treating Injuries in Active Seniors

Warren A. Scott, MD with Gerald Secor Couzens

In Brief: A physician who treats many masters athletes in his practice suggests an approach to managing active seniors' injuries that avoids ageism: Don't treat them any differently than younger patients. Overuse injuries are the most common sports injuries among older patients. The emphasis of rehabilitation and injury prevention strategies is on improving strength and flexibility. Preparticipation exam strategies that evaluate age-related declines and chronic medical conditions help physicians keep patients safe during activity. Arthritis obstacles can be overcome with medication, stretching, strength training, and physician encouragement.

With one out of eight Americans now age 65 or older, there's a "senior boom" going on in this country. Many elders have taken the message to heart about keeping active and exercising regularly—some for reasons of health, quality of life, rehabilitation from injury, illness, or surgery, and others for love of sport, or the fear of ever-expanding waistlines. Inspection of 1992 data from the Healthy People 2000 report (1) shows that the number of adults 65 and older who engage in leisure-time physical activity is now estimated to be more than 60%.

Many of these seniors take a vigorous approach to working out, and they are quick to tell you that, thanks to exercise, age is more surely defined by attitude, not by years (see "Inspiring Case Studies."). Still, this particular patient population is getting on in years, and those who get injured while exercising share injury profiles similar to those of younger groups.

What common injuries do you find in the older (50- to 80-year-old) population?

Basically, overuse injuries compounded by arthritis of the knee, hip, thumb, wrist, and spine (neck and low back). Bursitis of the hip and shoulder are common, as are tendon problems such as lateral epicondylitis, Achilles tendinitis, and rotator cuff tendinitis.

The key to keeping older patients active is to enable them to work out as painlessly as possible. I find that many musculoskeletal problems suffered by seniors are due in part to work- or sports-related overuse. Then, there is an age-related loss of water in the cartilage. As the cartilage becomes more brittle, it cracks and abrades more easily. While a younger person with "rubbery" cartilage needs a strong force to tear cartilage, an older exerciser needs much less. Having said this, I don't discourage my older patients with osteoarthritis from any form of pain-free exercise, because it's regular movement that speeds the rate of cartilage replacement, thereby making it stronger.

If the patient carries over an injury from years past, you have to decide if this is something that needs to be corrected and, more important, if it is something the patient wants fixed. If so, the patient needs to be given a reasonable recovery time and understand that the surgery or rehabilitation could significantly affect his or her exercise routine or sport during recovery. After you have presented all of the pertinent facts, it's the patient's decision.

Is the treatment of an older patient's musculoskeletal injury any different from that of a younger person with a similar injury?

Though there is a fair amount of benign neglect and ageism on the part of the medical community when it comes to treating senior exercisers and athletes, I treat my seniors the same as I do younger patients.

You would think older exercisers would take longer to heal because of their age, but I have seen many of my patients recover just as quickly as a younger patient when following the same treatment and rehabilitation protocols. Adolescents and teenagers heal the fastest, but when it comes to adults, the tissue repair mechanism works fine whether you are 20, 40, 70, or 80 years old.

Though older people do heal well, I think some elderly patients believe an acute or chronic injury will set them back for a long time and think "I'm old, therefore I've got to take it easy." Ten years ago I would have thought the same, but in the intervening years I have come to treat hundreds of older patients in my sports medicine clinic, and I know this is just a myth.

How effective is rehabilitation for the older exerciser?

Very effective. A key point is to lay out the rehabilitation program and give a realistic time period that you think they will complete it in. Some injuries, such as a knee sprain or hip contusion in a 70-year-old, can take up to 18 months to rehabilitate.

Sports play needs to be curtailed and performed below soreness thresholds. It's important that you determine how much your patients really want to continue with the sport or exercise routine that caused the injury. If they are totally committed to the activity, I give them an honest assessment of when I think they'll be able to participate again. Once they know they won't have to give up their sport, compliance with rehabilitation is extremely high.

Are there distinctive rehabilitation differences between older and younger patients?

After an injury, the big difference I see between older and younger patients is that seniors simply have more time and they will follow through with the rehabilitation protocol, generally without taking any shortcuts. Be mindful throughout rehabilitation that sometimes a family member will try to undermine the older patient's desire to rehabilitate and resume exercise or sport. This stems from a misguided notion that an older person will be injuring weak muscles and hurting an already frail body. Family members often feel that the patient should be spending more time at home in the rocking chair than at the gym.

Do you recommend physical therapy?

In some instances, physical therapy may be a useful adjunct in the overall recovery plan, especially for people who I feel can't rehabilitate on their own. For the others who have access to a training facility and the proper equipment, I simply prescribe a rehabilitation program. For the most part, these patients are long-time exercisers and active competitors. They have a good understanding of general exercise and rehabilitation, and their compliance with a rehabilitation program is generally excellent.

I generally recommend cross-training activities during rehabilitation to maintain aerobic conditioning and muscle strength while the patient heals: walking, bicycling, swimming, water and traditional aerobics, cross-country skiing, and strength training.

Can patients continue to play their favorite sport while injured?

I differ from the average physician who typically will say, "If it hurts, don't play your sport." Whenever possible, I encourage my patients to continue their sport, though I often have them modify their sport. For example, I would advise tennis players who have supraspinatus tendinitis to play doubles instead of singles. They can hit ground strokes and serve underhand. With changes like these I'm able to keep patients in their sport, even if it's in a greatly reduced capacity. Still, it's a win-win situation because they don't lose too much strength and coordination, which allows them to pick up where they left off when they get the green light from me to resume their sport at full strength.

Is your preparticipation examination of the older patient any different from that for your younger patient?

When examining senior patients, it's important to evaluate the extent of their coordination and fine-motor function. I emphasize this because if someone wants to ride a bike outside on the roadway or go hiking in the mountains, they need a high level of proficiency to perform the activity safely. I also make a point of checking patients' nutrition status by determining if they are eating enough, what their food source is, and who prepares their meals. I have found that too many seniors undereat because they believe they don't need as much food as they did when they were younger. Exercising, of course, dramatically increases their calorie requirements, and active seniors who aren't eating sufficiently may experience muscle glycogen depletion.

In addition to checking vision and hearing, I also ask what medications they are taking. Medications for diabetes, blood pressure, the heart and stomach, as well as sedatives, antihistamines, and different cold medications may have side effects that influence exercise safety. Thermal regulation—the ability to perspire and dissipate heat—will be affected by many drugs. Some cardiac drugs may produce postural hypotension, and other drugs may also affect balance and coordination. Antihypertensive medications can contribute to dehydration during activity, while other medications may cause blurred vision.

The good news for patients is that they don't have to stop exercise when taking medication. Most medications can be adjusted or can be replaced with a substitute. Sometimes when patients begin exercising regularly, dosages can be reduced—this is especially true for diabetes and blood pressure medication.

What is the best exercise for the senior patient?

I find that the best exercise is the one that your patient wants to do on a regular basis. The key, then, for the physician is to find out what patients like. Listen carefully, however, because you also have to take into account their age-related disabilities and may need to suggest alternatives. For example, are your patients interested in continuing their bicycling now that their hearing is diminished and they have trouble hearing oncoming cars? Do they really want to play tennis anymore, when their hip or knee arthritis pain causes them to rely on daily medication?

Some will tell you they'd rather cross-train, picking and choosing from a variety of sports or exercise routines that won't cause them pain or put them at risk of injury. Sometimes, it's you who should suggest and gently prod the patient to try these other, safer activities.

How do you keep patients who have chronic medical conditions active?

When dealing with a patient who has a chronic medical condition, the key is to individualize your treatment prescription. Osteoarthritis comes quickly to mind (see "How I Manage Arthritis.") What's needed is a judicious balance of rest and exercise, not emphasizing too much of either. Then too, you have to steer patients to the best possible form of exercise, based on their interests and physical abilities.

Some people who have arthritis, for example, may not be suited to a running program because it's too painful. However, other activities such as resistance training, water running or aerobics in a pool, bicycling, or cross-country skiing may be better and should be recommended. Again, it's up to the physician to point out the benefits of each exercise and sport and encourage the patient to participate.

Are there any injury-prevention strategies you recommend for this age-group?

I stress moderation in everything for my older patients and that they listen to their body signals as they exercise. If they go too hard for too long, their body will tell them so. Even if there are no specific pains, sometimes they will start to feel lethargic after an exercise session—a sign that they need to cut back and take a rest.

A major part in injury prevention is recognizing pain. Your patient needs to be able to differentiate between "good" and "bad" pain. Good pain is muscle soreness that typically develops shortly after starting a new exercise program or after increasing the intensity or duration of a current exercise or sports program. This soreness is never severe, does not involve a joint, and lasts about 2 weeks or less.

"Bad" pain is felt in a joint or tendon and typically stems from overload of the injured tissues. The patient has to understand that he or she cannot continue to exercise in the same fashion with this type of pain. This does not mean that exercise comes to a complete halt, but that the patient must instead find an alternate activity during recovery that will not further the pain. In querying your patient about pain, ask when it occurs: during, right after, or the day after exercise. During rehabilitation, ask the patient how he or she feels the day after a rehab session. Pain that diminishes in subsequent days is an excellent sign that exercise is not furthering the injury.

Do you stress flexibility exercises with your seniors?

Being flexible is an essential part of physical fitness. A regular stretching program promotes flexibility and allows the patient to use muscles and joints through the full range of motion. Good muscle elasticity will also help cut down injuries to muscles, tendons, and ligaments.

What is the importance of resistance training for seniors?

Resistance training can help slow down many of the physical declines typically associated with aging. Maintaining overall muscle strength not only increases stamina, but also self-confidence. Resistance training increases bone density, which can delay or minimize the onset of osteoporosis, and improves overall muscle strength, which helps correct joint instability or imbalance that can lead to injury.

Most of all, I encourage resistance work to give my patients the strength they need to remain self-sufficient. It is now estimated that one of every four people over age 65 and half of those over age 85 can't bathe, dress, eat, or get out of bed without help. In many cases, a regular resistance training program can help prevent this. Some patients train in a pool with water for resistance, while others use machines or free weights.

I always make it a point to explain to my patients that the frailty typically associated with old age is due to lack of exercise more than age. Strength, muscle mass, and bone density can all be increased by exercising regularly, lifting weights, and stretching. The simple message I give to my patients is one I think you could pass on to your own elderly patients: You're not getting older, you're getting better.

Inspiring Case Studies My active senior patients are an inspiration. It gives me great pleasure to share some of their medical experiences. Patient 1. I have treated this 73-year-old woman-a race walker, world traveler, hiker, and nature guide—for several years. Her most recent visit to my office was for several broken ribs, a clavicle fracture, and a lumbar sprain that she sustained in a car accident. The accident occurred right before a boat trip to Antarctica. Aside from persistent sciatic nerve pain, her recovery went so well that she made the trip as planned. When her shipmates became seasick during hurricane-force winds and 60-ft waves, patient 1 didn't miss a meal. She demands to get well and stay well because there's a lot she wants to do. Patient 2. Over the years, patient 2, a female 78-year-old yoga instructor, has sought treatment for a variety of minor overuse injuries. Each of her injuries quickly responded to my sports medicine rehabilitation programs. Patient 2 recently had an accident and fractured several bones and sustained hip and back contusions. She is recovering from these significant injuries. A couple years ago, patient 2 was featured on the cover a local publication in her leotard demonstrating a yoga pose. She is living proof that high levels of flexibility can be achieved well into old age. The old adage "use it or lose it" seems to apply in this instance. Her 81-year-old husband maintained an active lifestyle until 6 months ago when he developed rheumatoid arthritis in multiple joints. He is recovering nicely with short-course prednisone treatment. Patient 3. One of my most amazing patients is a 78-year-old man, a world-class sprinter. On occasion, he competes in the javelin event. His over-70 record in the 100-m is 16.5 seconds. He travels all over the world participating in masters track and field events and sends me postcards from his events. He has recovered from multiple injuries that seem like they should not heal in a person over age 70. On some days his training sessions—running, weight lifting, and biking—last 2 to 3 hours. Patient 4. At age 78, patient 4 is a world-class male tennis player. I treated him for a shoulder problem several years ago. He recently underwent surgery for a meniscal tear in his knee and release of a Dupuytren contracture in his tennis hand. Two months later, he successfully resumed tournament play. Warren A. Scott, MD (Back to article)

How I Manage Arthritis Osteoarthritis affects almost 16 million Americans, stiffening up knees, hips, spines, and hands. I've found that many people with arthritis who are not athletic or don't exercise use their disabling ailment as a reason not to be active. It seems logical: If it hurts, don't move it. But most patients with arthritis can exercise safely, regularly, and oftentimes vigorously without damaging their joints. I like to point out to my less active patients that my senior athletes tell me that their regular swimming, bicycling, walking, and weight training workouts seem to dramatically improve arthritis symptoms. Relieve Symptoms When it comes to pain relief, I prefer that my patients use a minimum amount of medication—that's because osteoarthritis is a mechanical problem, for the most part. For inflammation I will have them use a nonsteroidal anti-inflammatory drug for 2 to 4 weeks. At the same time, I recommend nonpainful semiweight-bearing, rhythmic exercise to maintain or improve aerobic capacity. I institute a strengthening program to build the muscles around the aggravated joint(s) and a stretching program to get improved motion in the joints and overall flexibility. The additive effect of aerobic conditioning, muscle strengthening, and stretching can reduce the chance of injury. Patients should follow a daily—or at least three-times-a-week-program of static stretching. The patient performs this gentle form of stretching by gradually moving the muscle through its full range and holding the maximum-stretch position for 10 to 30 seconds while breathing slowly. After several seconds of relaxation, the patient repeats the stretch. Patients are instructed to keep their movements relaxed and to avoid straining or bouncing. Before any stretching session, the patient should do a slow, gradual warm-up, such as brisk walking, jogging, bicycling, or calisthenics. This activity increases the temperature of the muscles, ligaments, and tendons and makes stretching easier. Additionally, I recommend weight loss when necessary to help alleviate the pain and swelling that often affects the hips and knees. Encourage Exercise Once you have ascertained that your patient has osteoarthritis and have decided on a treatment plan, you should encourage your patient to continue exercising. Regular workouts help maintain the overall muscle strength needed not only for sport but for activities associated with everyday living. For some active seniors with arthritis, I have to act as coach and counselor to keep them motivated through rehab, instilling the belief that they can heal. Many seniors with arthritis will experience some stiffness in the morning; therefore, afternoon is probably a better time to exercise. If they want to begin their rehabilitation or exercise earlier, I caution them to start off very slowly. You may need to advise some patients to consider a new sport or exercise routine. I urge them to follow the REST concept: Resume Exercise below the Soreness Threshold. This can mean taking their road running workouts into a swimming pool or going from running to bike riding to reduce the stress on painful knees or hips. Warren A. Scott, MD with Gerald Secor Couzens (Back to article)

Reference

1. US Public Health Service: Healthy People 2000: Public Health Service Action. Washington, DC, Dept of Health and Human Services, 1992

Suggested Readings

• Barry HC, Rich BSE, Carlson RT: How exercise can benefit older patients: a practical approach. Phys Sportsmed 1993;21(2):124-140
• Bouchard C, Shepard R, Stephens T, et al: Exercise, Fitness, and Health: a Consensus of Current Knowledge. Champaign, IL, Human Kinetics Publishers, 1990
• Johnson Hipps M, Deving A: Exercise habits of older adults. Melpomene J 1990;9(3):16-22
• Kaneko M, ed: Fitness for the Aged, Disabled, and Industrial Worker. Part I, Health and Fitness of the Aged, Champaign, IL, Human Kinetics Publishers, 1990, pp 1-124
• Paffenbarger R, Hyde RT, Wing AL, et al: Physical activity and all-cause mortality and longevity of college alumni. N Engl J Med 1986;314(10):605-613
• Quinn TQ, Sprague HA, Van Huss WD: Caloric expenditure, life status, and disease in former male athletes and non-athletes. Med Sci Sports Exerc 1990;22(6): 742-750
• Shepard RJ: Economic Benefits of Enhanced Fitness. Champaign, IL, Human Kinetics Publishers, 1986
• Stone JA, Ryan III EJ: Rehabilitating at home: steps for success. Phys Sportsmed 1993;21(1):77-84
• Wilmore J, Costill D: Training for sport and activity, ed 3. Dubuque, IA, Wm C. Brown Publishers, 1988

Dr Scott is chief of sports medicine at Kaiser Permanente in Santa Clara, California. Mr Couzens is a freelance writer in Woodstock, New York. Address correspondence to Warren A. Scott, MD, Permanente Medical Group, 900 Kiely Blvd, Bldg D, Santa Clara, CA 95051.

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