Orthopedics and Athletes
Bone and joint issues are the leading cause of disability in Americans, as well as the cause of more than half of all chronic conditions in people over age 50. The American Academy of Orthopaedic Surgeons (AAOS) estimates that such problems cost Americans $849 billion in medical fees and lost wages in 2004 (the most recent year cited), an amount equal to 7.7 percent of the gross domestic product.
The problem is expected to escalate markedly over the next two decades, something the AAOS attributes to two competing factors: an ongoing problem with sedentary lifestyle and an increasing number of people who are pursuing athletics well into their golden years.
Dr. Terrence Philbin of the Orthopedic Foot and Ankle Center says older athletes have special concerns when it comes to exercise. High on the list is osteoarthritis, where cartilage loss causes the ends of bones to rub together. It can result in pain, swelling and even loss of motion in the joint. The condition can be the result of one traumatic incident or a series of injuries over time, Philbin says. “Patients sometimes tell me they injured their ankles repeatedly in high school, and now it’s finally caught up with them,” he says.
If the arthritic response is minimal, a patient may be able to manage the condition with over-the-counter pain relievers and a brace. Worst-case scenarios may call for surgery, during which the doctor cleans debris out of the joint.
Regardless of their age, athletes should be respectful of their joints to avoid complications down the road. “At this point, nothing has been medically proven to restore that lost cartilage,” Philbin says.
Activity modification is certainly in order when an injury occurs. Philbin cites one of his patients, a 62-year-old lifelong runner who is now experiencing pain when he runs. He’s also suffering from frustration, since something that once came easily has now become difficult.
When such situations occur, a willingness to be flexible and alter one’s usual routine is helpful. “Fortunately, he liked the idea of cross-training, and maybe doing some biking or swimming,” Philbin says. “He can continue working out and getting the benefits, but his body won’t take as much of a pounding as it would from running.”
It’s not just older Americans who are finding themselves victims of unexpected injury and overuse. With increasing participation in events such as the Ironman, Warrior Dash, Tough Mudder, triathlons and marathons, people of all ages are finding themselves on the orthopedist’s table. Doctors say they have noticed a years-long trend toward more ambitious athletic endeavors—and a resulting uptick in joint injuries.
“As more people participate in endurance events and push themselves to higher levels of performance, we do see more injuries as a result,” says Dr. Christopher Kaeding, co-director of the Ohio State University Sports Medicine Center.
Dr. Joseph Wilcox of the Cardinal Orthopaedic Institute has been practicing sports medicine in Columbus for 11 years, and he sees a spike in injuries every spring and fall as runners prepare for athletic events. “We always see a period of increase right before the big marathon seasons,” he says. “Over the years, we’ve seen a drastic increase in the number of people who come in with injuries, because more and more people are enjoying long-distance running.”
The 2011 Columbus Marathon (which also includes a half-marathon) had 17,000 registered participants, up from 15,000 the previous year. The 32nd annual race attracted people from around the country and around the world.
For those who’ve caught the marathon bug, a gradual increase in physical conditioning is the safest way to go. Enthusiasm will only take you so far. Dr. Greg Bellisari of the Ohio Orthopedic Center of Excellence says that’s true of any new athletic endeavor. “I think it is always wise to gradually adopt any physical activity and progress to a comfortable level,” he says. “I would not endorse intense workouts such as boot camp or CrossFit to any athlete who has been sedentary for a while.”
“I would also include as much variation into your healthy lifestyle that you can fit,” Bellisari says. “For example, running on the pavement six days a week would not be advised for any joint with joint pain or early arthritis. Cross-training to include other low-impact activities such as swimming, biking and elliptical machines would be a safer way to continue working hard without wearing out your joints.”
Don’t take the threat of injury as an excuse to settle into the couch, though. “Maintaining a workout routine is beneficial for reversing muscle loss and keeping good balance and mental health,” Bellisari says.
Heeding the Warnings
Kaeding says orthopedic sports injuries fall into two broad categories. Some, such as ligament tears, are categorized as acute structural failures and occur without much warning. Others, such as stress fractures, build up over time and can be a result of athletes not listening to their bodies.
Philbin says he sees a lot of the latter in the form of strains, sprains and tendonitis. “In many of these cases, it’s either a case of overuse, or of ramping up too quickly and not letting the body adapt,” Philbin says. “It’s a universal theme I see among athletes these days. Even in high school, they never get a rest. They are in sports year-round.”
Dr. Jim Latshaw of the Ohio Orthopedic Center of Excellence has observed the same thing among avid athletes he knows. “This is the most difficult recommendation for an athlete training for a marathon to hear: that they must stop running to allow injuries to heal,” he says. “I have seen marathon runners train through pain only to have a stress fracture propagate through the bone.”
Weight-bearing exercise is beneficial to bones, strengthening them and preventing debilitating conditions such as osteoporosis. But it is possible to have too much of a good thing. Wilcox says excessive running can result in an unfavorable stress response. Instead of growing stronger, a bone may swell and develop tiny microfractures. “The X-rays look fine and there is no frank fracture line, but the tiny fractures may coalesce into a true fracture,” Wilcox says.
Although microfractures aren’t visible on X-rays or MRIs, they can cause significant pain. Wilcox says many athletes ignore the discomfort to their own detriment. “Pain is a built-in security system that too many people have been taught to ignore,” he says.
Wilcox says mantras that encourage people to push through the pain aren’t healthy for most individuals. “That’s something that originated in the military,” he says. “It has trickled down into the general population, and so have the injuries.”
Bellisari says paying attention to the body’s signals is an essential component of detecting potential trouble. “Any intense pain or weakness that does not resolve with appropriate rest is always worrisome,” he says. “Severe stiffness or swelling of any joint for more than a couple of days is also a sign that damage may be occurring.”
Kaeding says other warning signs include loss of motion of a joint, or mechanical symptoms of a joint locking, catching or giving way.
Philbin, who specializes in foot and ankle ailments, sees a lot of aggravated and overtaxed tendons, particularly the Achilles tendon. He says catching a problem early involves a relatively simple course of treatment: If the tendon is a little inflamed but the patient can still walk, a simple course of rest, icing, stretching and over-the-counter anti-inflammatory drugs is likely to resolve the issue. “If they are limping, and not just unable to run but unable to walk normally, it may require a little more attention,” Philbin says. Immobilizing the ankle in a cast or boot may be necessary. If that doesn’t help, physical therapy or surgery may be recommended.
Wilcox says people should also take into consideration that maybe they just aren’t cut out to be a championship endurance athlete. “Not everyone’s bodies are made to run those distances,” he says. “Any biomechanical problem we may have, whether it’s an alignment problem or weakness in the muscles, can predispose us to a stress fracture.” Any new activity is potentially detrimental if not approached properly, and talking to your physician first is a wise choice. “In some activities, everyone is sort of put into the same category no matter what their biomechanics, age or fitness level. They may push themselves into a program without any real forethought into whether they are ready,” Wilcox says.
While sports can result in a wide variety of injuries, joints are particularly susceptible. The AAOS reports that in 2007, the most recent data available, 24,000 Americans went to the emergency room for sports-related ankle injuries and another 20,000 suffered knee injuries. One of those was Kristen McMahon, a former collegiate soccer player who suffered an unexpected knee injury.
“It was the first day of pre-season, and I turned my body but my knee did not follow,” she says. McMahon, 24, underwent surgery at OSU Medical Center about a month after her injury in order to repair torn anterior cruciate and medial collateral ligaments and a damaged meniscus.
Although McMahon was a trained athlete who had run consistently since age 8, that one unfortunate move was enough to cause significant damage. Following surgery, she was out for the season. “I was on crutches for four weeks and had physical therapy for six months,” she says. “It probably took my body a year to get back to full contact in soccer and full running strength.”
Experts say that regardless of the age of the athlete, preparation is key. Wilcox recommends quality athletic shoes above all else. “Make sure you have supportive shoe wear, and get it from one of the running stores in town,” he says. “There are people there who can help you find exactly the right shoe.” Athletic shoes found at typical shoe stores, no matter how sleek or high-tech they may look, don’t protect the way high-quality gear will. “Shoes that cost less are not going to support you, and you are going to end up with real problems, real quick,” Wilcox says. “Invest the money in shoes from a store that specializes in running, and it will pay off.”
Next, get your body prepared. Aside from ramping up slowly to meet long-term goals, athletes should invest significant warm-up time each and every day they exercise. “Stretching takes a good 10 or 15 minutes, and that’s not just the standing or sitting static stretches, but also dynamic stretches,” Wilcox says. “A short, easy run and maybe some high kicks—what we sometimes call goose step kicks—will tell the muscles to get ready. Warming up will help you gain some flexibility, and you won’t be so apt to strain a muscle.”
Another key is education, and the most effective form may be a professional assessment of an athlete’s strengths and shortcomings. “If you start having problems, it’s always good to talk to a physical therapist or to your physician, who may prescribe a short course of physical therapy,” Wilcox says. A therapist can assess a person’s gait, core strength and body posture and detect any potential problems with alignment or biomechanics.
Getting Back in the Game
Orthopedic doctors almost always opt for the least-invasive method of treatment first when a patient suffers an injury. But even in cases where surgery is necessary, athletes can be back on the road to recovery quickly. An injury—even a major one—doesn’t have to mean a permanent end to athletic endeavors.
Philbin says patients who undergo surgery may have to keep weight off the recuperating body part for three to six weeks and then undergo a course of physical therapy, both to regain strength and to learn new ways of using the limb or joint to prevent re-injury.
“Athletes may start back to their sport in as little as three months,” Philbin says. “It depends on the scenario and the age of the athlete, but in many cases, they can go back to whatever sport they want.” Doctors may encourage athletes to opt for activities that are gentler on the joints and tendons, such as basketball or an elliptical machine, rather than high-impact sports such as running.
In some cases, surgery isn’t just a repair, but a jumping off point for even greater athletic achievement. McMahon was forced to give up soccer for a season and to modify her activities for about a year, but has since taken up marathoning. “Since the year mark, I have gone above my athletic capacity before my surgery,” she says. “I ran my first marathon this past October, which is something I never did prior to my surgery.”
Kristin Campbell is a freelance writer.
Reprinted from the March 2012 issue of Columbus C.E.O. Copyright © Columbus C.E.O.