The Active Female: Health Issues Throughout the Lifespan 2008th Edition

18. Prevention and Management of Common Musculoskeletal Injuries in the Aging Female Athlete

Mimi Zumwalt  and Brittany Dowling 


Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79430-9436, USA


Department of Health, Exercise, and Sports Sciences, Texas Tech University, 1545 Shadowtree Court, Colorado Springs, 80921, CO, USA

Mimi Zumwalt (Corresponding author)


Brittany Dowling



The onset of menopause causes numerous changes in the female athlete’s body. The alteration in hormones, particularly a decrease in estrogen, affects both bone quality AND quantity. This mature life stage herald by the occurrence of menopause is associated with a 3 % increase in bone loss per year. Thus one of the greatest threats to the aging female athlete is decreased bone density with the eventual development of osteoporosis. The reduction in estrogen levels also causes a decline of muscular strength in women. However, with the proper physical training regime, particularly weight bearing plus resistance exercises, bone mass and muscular degeneration can be combated. Aging also exposes the female athlete to certain injuries along with increasing the time to recovery once injured. Prevention of musculoskeletal trauma is the best method to ensure that the aging female athlete will maintain an active lifestyle. Appropriate conditioning programs incorporating strength, flexibility, and mobility, as well as proper nutrition, are crucial in keeping the older female population healthy and active to enhance their life in later years.


MenopauseEstrogen3 % increase in bone lossOsteoporosisWeight bearingResistance exercisesStrengthFlexibilityMobilityNutrition

18.1 Learning Objectives

After completion of this chapter, you should have an understanding of:

·               The hormonal, physiological, and anatomical/musculoskeletal changes in female athletes as they transition from young adulthood into the middle age and beyond

·               The differences and similarities between older males and females in terms of their body composition, musculoskeletal components, and athletic performance

·               Various musculoskeletal injuries and orthopaedic conditions more common to aging and fairly unique to older female athletes

·               Several measures of prevention to keep musculoskeletal injuries in older active females from occurring

·               Different methods of treatment for orthopaedic conditions incurred in aging female athletes to include exercise prescription as recommended by various nationally recognized organizations

18.2 Introduction

Throughout the lifespan of females, they undergo a multitude of changes to include structural, hormonal, physiological, neurological, and musculoskeletal. In a woman’s lifetime, there are two most dramatic stages. One occurs early—pubescence during the teen years, and one happens several decades later—senescence after menopause. It appears that certain aspects of a woman’s body come around full circle to the point where she started after birth; she then eventually ends up in a similar state ultimately near the end of life. In particular, the endocrine alterations which affect the quality of bones, making the skeleton so fragile that even the slightest trauma could result in osteoporotic or fragility fractures, and if not addressed promptly and appropriately, could eventually result in dangerous demise. However, it is possible for an older woman to effectively combat some of the negative effects of aging with several positive actions. The primary combatant to aging involves keeping the main muscular components strong in order to protect the skeletal system. The aging female must remain relatively active physically to guard herself from harm. However, this may open her up for incurring potential orthopaedic trauma to her body. Exercise does not necessarily reverse the effects of time, but hopefully will slow it down to the point of allowing an older woman to more effectively cope with the inevitable changes of life.

This chapter will address different issues of biological alterations within a woman’s body as she ages, as well as various musculoskeletal/orthopaedic injuries more common in the master female athlete, along with strategies for prevention and management of these acute and chronic traumatic conditions.

18.3 Research Findings and Contemporary Understanding of the Issues

18.3.1 The Hormonal, Physiological, Anatomical/Musculoskeletal Changes in Female Athletes as They Transition from Young Adulthood into the Middle Age and Beyond

In the past century, the number of elderly adults has increased from 1 to 28 %. In the USA alone, the number of persons 65 years or older was estimated at 39.6 million in 2009. This value translates to 12.9 % of the US population or one in every eight Americans [1]. Advances in health, medicine, and standard of living have greatly contributed to this rise in life expectancy. Most Americans maintain a healthy lifestyle for 85 % of their lifespan; however, the final 15 % of their final years older people are limited significantly with degenerative diseases along with impaired mobility. However, the leading causes of death related to lifestyle can often be preventable. Exercise has been shown to help enhance and even prolong the life cycle. Elderly people are adaptable, thus will respond to endurance and strength training. Endurance training helps to maintain cardiovascular function, enhances exercise capacity, and reduces risk factors for certain diseases. Strength training aids in prevention of loss of muscle mass and strength associated with aging [2].

As mentioned in Chap.​ 7, after peak bone mass is reached in the mid-twenties, the quantity of bone in the skeleton starts to gradually decline at a rate of 0.3–2 % per year until the fourth decade. After menopause, bone loss is accelerated to over 3 % yearly for 5–10 years. This increased rate of bone loss places elderly women at increased risk for osteoporosis [38] (Fig. 18.1).


Fig. 18.1

Rate of bone loss through a women’s lifetime

This skeletal manifestation is due to a precipitous drop in the female sex hormone levels, namely, estrogen, which had been previously protective in terms of bone building earlier in life [8].

As a female athlete ages, endurance performance, aerobic capacity, and cardiorespiratory functions all deteriorate, whether due to reduction in relative physical activity or to the natural resultant effects of aging [3910]. No matter how well a female athlete takes care of herself, all bodily processes are affected with age. However, the extent of physiological deterioration varies between individuals. Genetic factors have a great influence on the length and quality of life. For example, in females, maximum oxygen uptake tends to decrease approximately 10 % per decade starting in the mid-twenties [11]. However, if training intensity and volume are maintained as compared to their younger counterparts, female master athletes will only lose 1–2 % of their previous aerobic capacity yearly until 50 years of age [3410].

Although body weight gradually increases with age from 20 to 70 years old, during 5–10 years prior to menopause, the amount of fat-free mass undergoes a drastic reduction while the percentage of body fat rises (5–10 kg in the mid-thirties to mid-forties). The increase in extent of body fat is greater in more sedentary women [3910]. For example, in highly trained female runners around their mid-forties, body fat percentage is about 18 %, as compared to 26 % in their sedentary counterparts. Similarly, women swimmers also remain slimmer, although not as marked as in runners, with body fat staying around 23 %, which is still lower than inactive age-matched females. The average woman’s body fat in her youth is approximately 25 %, which rises to over 35 % by age 50. The reasoning behind the increase of body fat is threefold: more dietary intake, less physical activity, and decreased ability to mobilize adipose tissue [1012].

In terms of muscular strength, the absolute level required to perform activities of daily living stays the same throughout one’s lifetime. On the other hand, the maximal level of muscular strength declines at a steady rate from young adulthood (highest level achieved between age 25 and 35) proceeding onto later years [3491012].

If physical activity declines or is absent in later years, the loss of muscular strength starts to occur gradually after the third decade, then up to 15 % per decade between the fifth and seventh decades, progressing more quickly in subsequent years, at a rate of up to 30 % per decade [4]. About 25 % of peak force is lost by the time a woman is in her mid-sixties. This age-related loss in strength stems from reduced mass of primarily skeletal muscle (sarcopenia), which in turn affects the basal metabolic rate (10–20 % decline from early adulthood to beyond middle age), and/or restricted physical activity levels [35810]. The latter functional disuse condition, hypokinesia, accounts for 50 % of the physiological weakness of muscles and bones [7]. This decline in muscular strength seems to affect the lower extremity to a greater extent than the upper extremity [3]. After peaking in the third to fourth decade, the loss of lean muscle mass is attributed to both a reduction in size and number of muscle fibers [391012]. After the fifth decade of life, about 1 % of the total number of muscle fibers are lost per year from atrophic (wasting) changes [10]. Beyond the sixth decade, approximately 15 % of muscle strength is lost every 10 years [5]. In fact, midlife adults not involved in strength training lose about 5–7 lb of muscle every 10 years [9]. In addition, the nervous system’s ability to process information and activate the musculoskeletal system is altered, resulting in slower response times with both complex and simple movements [10]. Resistance training can, however, counteract and partially offset ongoing biological muscular weakness by increasing both muscle size and strength [510].

Furthermore, as previously mentioned, older adults who are more sedentary also gain a substantial amount of fat in their subcutaneous tissue, contributing to the natural decline in function associated with aging [10]. As a corollary, the skeletal system in an older female gradually becomes quite frail as well, leading to thinning bones and increased risk of osteoporosis [57] (Fig. 18.2).


Fig. 18.2

Normal versus osteoporotic bone

However, mechanical loading of the skeleton, especially exercising while weight bearing (standing upright) will also help to build bone according to Wolff’s law, thus counteracting the continuing bone loss due to inactivity and aging [7813]. Even though age-related decline is inevitable, by participating in regular workouts and exercise, older females can fend off some of the inevitable decrements in musculoskeletal strength, power, and endurance [510].

18.3.2 The Differences and Similarities Between Older Males and Females in Terms of Their Body Composition, Musculoskeletal Components, and Athletic Performance

The aging process in both men and women is associated with a decline in muscle mass and strength, resulting in a loss of physical function. Sarcopenia (previously described) is a term coined to describe such changes. Sarcopenia results in decreased mobility, increased fatigue, and higher risk for falling [14]. It is estimated that humans lose 20–40 % of skeletal muscle mass and strength from age 20 to 80. A decline in muscle mass is related to weakness, decreased performance, functional impairment, falls, and physical disability [15]. Sarcopenia is also associated with a relative increase in body fat along with a decrease in proprioception, coordination, strength (both muscular and skeletal), power, flexibility (pliability of soft tissues such as joint capsules, articular cartilage, tendons, and ligaments), speed of reaction, and aerobic capacity [4101617].

Between the second and seventh decades of life, muscular strength decreases about 30 %, along with an approximate 40 % decline in muscle mass. The loss in muscular strength associated with aging is primarily attributed to this great decline of muscle mass. Studies show that with age, there is a decrease in the number of alpha motor neurons, total nerve fibers, and neuromuscular junctions in skeletal muscle [14]. Various studies which have been conducted on both animals and humans find similar results as well. After the age of 60, there is a decrease of up to 50 % of motor neurons in these older individuals as compared to younger populations [18]. Thomlinson and Irving calculated the total number of motor neurons in the spinal cord of the lumbosacral region in 47 subjects ages 13–95. They determined that after age 60, there was a decline of motor neurons, with some subjects having 50 % less than in younger counterparts. Similar results have been found in a study on the biceps brachii where subjects over age 60 have 50 % less motor neurons as compared to those in younger age groups [1920].

Evidence shows that with aging there is a loss of motor neurons for both slow and fast twitch muscles, with a greater loss in fast motor units [14]. However, most fibers are reinnervated by other motor neurons, thus affecting a greater loss of muscle fibers within a motor unit. Studies conducted on human and animal subjects have shown that the muscle fibers are reinnervated with different motor neurons [21]. Hashizume and Kanda used a rat model to show a decline in motor neurons as well as a decrease in Type II fibers in the hind limb muscles of older rats [22]. Pettigrew and Gardiner found an increase in Type I muscle fibers in the plantaris muscle of aged rats [23]. Lochynski, Krutki, and Celichowski also used rats to demonstrate a 22 % decline in Type II motor neurons and a 15 % increase in Type I motor units in the medial gastrocnemius of older rats as compared to younger rats [24]. As aging occurs, there is a greater tendency to lose motor neurons innervating Type II fibers, thus reinnervation tends to be by Type I motor neurons. There is a general shift in the type of muscle from fast twitch to slow twitch as an animal ages [14].

Other studies have found that with age, there is little change in the average cross-sectional area (CSA) of Type I fiber. However, the total muscle CSA innervated by Type I increases with aging, and the total CSA for Type II plus power declines rapidly with age. As the innervation for fast motor units decreases the concentration of muscle work switches over to existing slower motor units [14]. It has also been found that there is an increased density of muscle fibers belonging to a motor neuron with age [25]. A decrease in Type II fibers causes a decline in the muscle’s capacity for power (14.). A major contributor to muscle weakness is the decrease in CSA of active muscle tissue. Sugiura and Kanda found as rats increase in age, there is a subsequent decline in CSA and Type II muscles fibers [21]. They also found that with aging, there was a decrease in tension produced in the medial gastrocnemius of the older rats. As a corollary, in humans, the decline in power can be attributed to the loss of Type II fibers, which is reflected in actions such as rising from a chair, climbing stairs, or regaining balance after a gait disturbance [14]. Kostka found velocity at maximal power decreased by roughly 18 % between ages 20–29 and 50–59, with a further 20 % decline in subjects aged 60–69 and 80–89 [26].

Strength gains of more than 100 % can be made in men (60–72 years of age) after lifting weights for about 3 months. Similar studies in both males and females demonstrate that those older than 90 or even 100 years of age participating in strength training could also become physically stronger (~125 %), with a concomitant increase in lean muscle mass (10 %) [16]. One study has shown that an 8-week resistance program in men and women ranging in age between 89 and 92 years old effected an increase in quadriceps strength of 175 % [317]. Likewise, a similar study in women ages 87–96 years old demonstrated an increase of strength three times over baseline values, along with a 10 % gain in muscle size [9]. This rise in muscular strength has been shown to translate into enhancing physical function, decreasing limitations, and increasing mobility, such as speed of gait and stair climbing [1316]. Although relative strength gains are comparable for men and women engaged in the same sort of conditioning program, the absolute rise in females is only 50 % that of males [316]. Muscular weakness also occurs earlier in females; thus it is very important to implement and continue a regular resistance training regimen throughout a woman’s life [3].

Older adults can make great gains in their capacity to generate force by participating in a regular weight-lifting program. In fact, even as late as the eighth decade of life, intensive muscular training can minimize or even reverse the age-related effects of ongoing weakness [4516]. However, improvements made in muscular strength far exceed the enhancement in the quantity of lean muscle mass, meaning that neural activation is responsible for the strength increase [16]. The exception lies in the quality of muscular integrity in men and the ability of their skeletal muscle to retain the capacity for endurance training. Despite the loss of muscle mass over time in males, the remaining muscle still retains 85–90 % of the enzymatic activities required for aerobic type sports [10]. Unfortunately, the amount of strength gains needed to effect a meaningful change in athletic performance is still unknown. What has been shown, however, is the fact that muscular strength appears to improve physical function qualitatively and partially offset age-related bone loss [71316]. Therefore, having more muscle mass tends to positively affect bone mineral density in later years [7].

Physical and physiological aspects in the body such as range of motion, coordination, reaction time, and cardiorespiratory fitness can also be improved with exercises specifically aimed at enhancing these parameters. For example, men and women in their sixties and early seventies can improve their aerobic capacity by over 20 % after engaging in 9 months of endurance training [16]. Similarly, another study found that older subjects 65–90 years of age can also effectively increase flexibility of several large joints after participation in a 12-week program of dancing plus stretching exercises [17].

As one ages, the decrease in muscle mass is accompanied by an increase in adipose tissue [18]. The percentage of fat in women on average changes from about 35 % at 17 years old to approximately 39 % at 60 years of age [2]. However, this change is highly variable and is much less evident in active females. There are a few possible mechanisms that can contribute to this alteration in soft tissue composition. It is thought that due to the loss of muscle mass and strength, there is a subsequent decrease in VO2max, which affects the physical activity levels in the elderly. This decline in activity will cause a decrease in daily energy expenditure, which in turn causes an increase in adipose tissue in visceral organs and muscle tissue, as well as total body fat [27]. An increase of fat content in muscles that occurs with aging is associated with a decrease in muscle strength [28]. The age-related increase in muscle weakness translates to a decrease of almost 50 % in isometric knee extension torque strength from age 30 to 80. Even when correcting for decreased muscle mass, there is a decrease in peak torque, indicating a decline in quality of the muscle or reduction in the efficiency of muscle strength with increase in age [18].

As aging occurs, in spite of being able to keep the percentage of body fat low, athletic performance of events comprising endurance plus strength in both males and females inevitably experiences a decline at about 1–2 % per year after the third decade. A study of over 500 subjects (men and women) between the ages of 30 and 70 years old shows that maximal running velocity gradually decreases approximately 8.5 % per decade which is independent of distance. Similarly for cycling performance, speed for both male and female cyclists between 20 and 65 years of age undergoes a gradual drop of about 0.7 % per year. There are some exceptions in sports dependent on athletic skill for successful completion such as golf, equestrian and swimming performance, which continues to improve after years of experience, along with strength and endurance. Thus, the former two types of athletes max out in the third decade, but master swimmers may peak and perform their best as late as 45–50 years of age [310]. In contrast, gymnasts usually peak very early in their teens as far as athletic performance, since flexibility is of paramount importance for this type of sport which tends to decline over time [3].

With advancing age, bone loss causes a decrease in bone density and tensile strength, thus resulting in osteoporosis [2]. Osteoporosis increases the risk of bone fracture. Skeletal bone loss is a serious problem in the aging population, affecting women earlier and more so than men. Osteoporotic changes affect both males and females. However, women are affected at a younger age (females start to lose bone mass at age 30 versus males at age 50), while fewer men (only 20 % compared to 80 % of women) are affected; and even then, men tend to experience a lesser degree of total bone loss than women. After the fourth decade, males lose bone mass at a rate of 0.5–0.75 % per year, while the bone density decline in women is twice that rate—1.5–2 % per year, increasing to at least 3 % per year after menopause. It is not until after the sixth decade that the rate of bone loss in men begins to parallel that of women [3568121729]. Postmenopausal females lose bone density more rapidly in the vertebrae, pelvis, and distal radius [30]. After menopause there is less cortical bone loss in the long bones [30]. Riggs et al. conducted a cross-sectional study of women aged 20–97 years and found large decreases in lumbar spine bone density. The decrease in density was due to loss of vertebral trabecular bone (spongy bone with higher surface area, but less dense) starting in the third decade, whereas cortical bone loss did not begin until middle age [31]. Another sign of normal aging in women is an increase in the cross-sectional area of the femoral neck in the hip and distal radius of the wrist due to formation of trabecular bone in those areas [30].

The age-related changes in bone density are associated with an increased risk of osteoporotic fractures in women. According to the World Health Organization (WHO), in the USA approximately 15 % of postmenopausal Caucasian women and 30–35 % of females older than 65 are affected by osteoporosis [632]. Studies have shown that the incidence of Colles’ fracture (distal radius) increases in postmenopausal women [30]. Epidemiology also demonstrates that, after the fifth decade of life, about 40–60 % of Caucasian females and 13 % of Caucasian males will suffer one or more clinically significant osteoporotic-related fractures in their lifetime, with 7 % of them experiencing permanent disability [672932].


Fig. 18.3

Osteoporotic fracture rate verses age

Nine out of ten elderly individuals who sustain a hip fracture are 70 years of age or older [5] (Fig. 18.3). Alarmingly, if an osteoporotic fracture occurs between the ages of 20 and 50, then the risk for another fragility fracture increases to almost 75 % [33].

However, it has been shown that men and women older than 65 who are involved in 10–12 weeks of physical activity such as T’ai Chi (Chinese exercise program consisting of repetitive, rhythmic body movements) or other low-intensity workouts can enhance athletic performance, improve physical balance, and decrease the chance of falling [516] (Fig. 18.4).


Fig. 18.4

T’ai Chi

Another study has demonstrated that this martial arts form, if practiced for at least a few months, can be very effective in reducing the risk of falls by almost 50 % [67].

18.3.3 Various Musculoskeletal Injuries and Orthopaedic Conditions More Common to Aging and Fairly Unique in Older Female Athletes

Because the average life expectancy has increased by more than 30 years within the past century, elderly people, especially women, currently are more involved in all sorts of athletic endeavors. Along with this increased participation in physical activity has surfaced different types of musculoskeletal issues, some of which are due to the hormonal changes associated with the female sex, while others occur as a result of the natural aging process [49].

The collagen in ligaments and tendons gradually become less elastic with aging due to loss of water content among other ultrastructural alterations, contributing to increased stiffness. As a result, this type of connective tissue is less able to adapt to mechanical “wear and tear,” making it more susceptible to injury along with having less capability for healing. A similar phenomenon happens in cartilaginous tissue, such as the menisci within the knee joint or articular cartilage surrounding bone ends. These connective tissues are unable to distribute force efficiently over time, especially when subjected to repetitive high impact loading. The resultant cumulative microtrauma has an additive effect of joint destruction and cartilaginous degeneration, leading to progressive osteoarthritis and resultant disability. This type of mechanical breakdown is more marked in large weight-bearing joints such as the hip and knee. In fact, middle-aged athletes participating in intense physical loads are more than eight times as likely to develop degenerative arthrosis of their hips. The effects of arthritis are accelerated and exacerbated by previous episodes of injury and/or surgical removal of certain intra-articular structures, such as anterior cruciate ligament tear or partial meniscectomy in the knee, respectively, resulting in posttraumatic arthropathy. Fortunately, unlike the aforementioned soft tissues where one must succumb to natural progressive deterioration, the physiological decline in muscle function due to sarcopenia can be counteracted somewhat by engaging in an intense resistance training program. This is possible since muscular contractility is not influenced to the same extent as loss of muscle mass with aging, enabling maintenance of muscular strength through exercising [14].

As discussed in Chaps. 1517, the most noted orthopaedic injury occurring in sports participants is the overuse type of microtrauma, such as tendinosis/bursitis/tendonitis affecting the shoulder (rotator cuff disorder/impingement syndrome) and elbow (lateral and medial epicondylitis/tendinosis), and foot (Achilles tendonitis). This type of condition, resulting from chronic, repetitive trauma, accounts for 70 % of veteran athletes beyond the sixth decade versus only ~40 % of younger athletes in their twenties. In addition, 20 % of these overuse injuries can last much longer in older athletes (up to 2 years), affecting their ability to train and/or compete in sports [4].

Another frequent injury which tends to occur in older athletes is muscular strain even with only moderate exercise, an example being performing an eccentric muscle contraction. This is can be related to the fact that the musculotendinous unit is not as flexible as in younger age groups, when much more force is needed to inflict trauma [17]. However, the musculotendinous junction can be affected in a similar manner when compared to other types of connective tissues in terms of relative inflexibility; thus, it is important to also incorporate a stretching routine into the workout regimen in order to decrease risk of injury [417].

Kyphosis, known in layman’s terms as “dowager’s hump,” is a sagittal plane deformity which is characterized by excessive forward spinal flexion, generally in the thoracic region. As opposed to an orthopaedic injury, this is a naturally occurring condition that tends to be especially prominent in women of advancing age. Specifically, postmenopausal women are at greater risk for this type of spinal deformity because of the association between kyphosis and osteoporosis. Supporting evidence was determined by Granito et al., who showed that there is a higher degree of kyphosis in osteoporotic elderly women. They also found a negative correlation between BMD and degree of kyphotic deformity. On the other hand, it was noted that women who participate in a regular exercise regime have lower incidences of thoracic kyphosis [34] (Fig. 18.5).


Fig. 18.5

“Dowager’s hump”

The most common joint disorder in the aging population is osteoarthritis (OA), also known as osteoarthrosis or degenerative joint disease (DJD). A common misconception is that OA is an arthritic disease. On the contrary, because it is not manifested as an inflammatory condition, it is considered more of a degenerative entity. Osteoarthritis begins with the softening of articular cartilage due to a decrease in matrix proteoglycan content. The cartilage thins out, becoming rougher with ulceration, pitting, and fissuring. Continued degeneration is manifested by subchondral bone necrosis and osteophyte formation at the joint margin. The severity of OA is generally classified by the degree of joint space narrowing, osteophyte formation, sclerosis, and bony deformity [35]. The initial presentation of OA varies at different joint sites and generally is first manifested at the metatarsophalangeal joints, followed by the wrist and spine, next in the interphalangeal articulation, carpometacarpal joints, then in tibiofemoral, and lastly seen in the hip joint [672935].

The most prevalent type of musculoskeletal trauma occurring in the geriatric female is a fragility fracture due to osteoporosis from excessive bone thinning. The amount of bone loss can be quantified by obtaining a bone density study, with DEXA being the current gold standard. Alarmingly, once osteoporosis sets in, even minimal amounts of force inherent in activities of daily living such as bending over and lifting objects can subject osteopenic bone to potentially injurious loads [6729].

Osteoporotic bone is more porous and thus weaker structurally, which can increase the likelihood for a fragility fracture. Compared to younger people, the femur of an older person is only half as strong and has merely a third of the energy absorbing capability before failure [6]. Dynamic models have found that falls create peak hip trochanteric forces ranging from 2.9 to 9.99 kN, which are sufficient to cause a fracture even in healthy bone [36]. Over 90 % of hip fractures occur in older adults beyond the seventh decade [5]. Osteoporosis is a contributing factor to hip fractures; however, other sources need to be considered such as bone quality, muscular strength, soft tissue characteristics, and neuromuscular coordination. Hip fracture generally occurs due to direct impact such as striking the ground after a fall or during car accidents. While rare in younger populations, proximal hip fractures, usually incurred from more violent forces, increase in frequency with age. In fact, 90 % can occur just by falling from only a standing height [3536].

More recent longitudinal studies have found a decrease in hip fractures for both men and women from 1990 to 2006, but the factors for this decline are largely unknown [37]. However, women are still three times more likely to suffer from a hip fracture than men. Interestingly, hip fracture rates are lower in people with higher body mass index (BMI weight/height2) [35]. Along the same line, vertebral fractures become more of a concern in the elderly population as well. If an older woman has a height loss of more than 2 in., then this should raise the suspicion for one or more spinal compression fractures resulting from osteoporotic bone [6].

Similarly, wrist fractures herald the early onset of osteoporosis and tend to occur much more often in women between the ages of 50 and 65. If they occur after this age, then the risk of other types of osteoporotic fracture tends to increase in the future [29]. Fortunately, the incidence of acute orthopaedic trauma in the master athlete is much lower. Only about 1 % of those athletic women hospitalized for sports-related injuries are over 55 years of age [4]. However, the development of OA and site affected varies between each individual based on genetics, joint structure, patterns of mechanical loading, and injury [37].

18.3.4 Several Measures of Prevention to Keep Musculoskeletal Injuries in Older Active Females from Occurring

By the time the female reaches adulthood, the physical condition of her body is a by-product of prior years of living. Lifestyle and activity choices affect the body’s condition in later years. Participation in athletic activities has positive as well as negative consequences in terms of affecting overall physical body condition. While aging is inevitable, the extent it affects the body is highly regulated by the ability to maintain and preserve muscle mass and bone density throughout one’s life [35].

Numerous studies have proven that resistance training exercises have benefits of increasing muscle/bone mass, muscle/bone strength, joint flexibility, balance, and basal metabolic rate [38]. On the other hand, participation in endurance training maximizes cardiorespiratory function [4616]. Any type of weight-bearing workout, such as dancing, playing volleyball, basketball, walking, jogging, and stair climbing, are beneficial for building muscle and bone as well as cardiorespiratory fitness [58]. Other moderate but lower impact exercises, including calisthenics, weight-supported swimming or water aerobics, bicycling, and T’ai Chi, also help in enhancing physical fitness while protecting problematic joints [3578] (Fig. 18.4).

However, certain sporting activities should be avoided by older women athletes. These include skiing and rock climbing, as these sports place the body at higher risk of falling, thus causing damage to the already thinning bones and stiffer connective tissues [17]. Similarly, avoidance of contact team sports involving potential collision with stationary objects or opponents is also prudent and well advised [3].

18.3.5 Different Methods of Treatment for Orthopaedic Conditions Incurred in Aging Female Athletes, to Include Exercise Prescription as Recommended by Various Nationally Recognized Organizations

Injury is not completely avoidable in the female athlete, no matter what age she may be. Once the master female athlete has suffered a musculoskeletal injury, the first step is prompt initiation of PRICE first aid measures: Protect and prevent the damaged area from further harm, Relative rest for the involved limb while maintaining range of motion to counteract stiffness, apply Ice intermittently to the injured extremity to help with inflammation, use Compression to minimize edema, and Elevate above the heart to aid in swelling. These primary first-line measures are implemented to hopefully alleviate painful symptoms [1739]. Administration of medication such as mild analgesics and nonsteroidal anti-inflammatory drugs (NSAIDS) can be used for inflammation and pain. Sports supplements have not been shown conclusively to improve joint condition or enhance athletic performance. In fact, the associated side effects of certain supplements to internal organs far outweighs the touted benefits of any supplement [4]. Oral consumption of glucosamine and chondroitin has been widely debated on its benefits in increasing cartilage components within joints. Numerous studies have shown that a 1,500 mg daily dose of glucosamine sulfate significantly reduces symptoms of osteoarthritis in certain joints of the lower limbs by reducing pain and aiding in functional improvement [40]. However, other studies have shown that glucosamine provides no clinical effect on pain or function [41].

Medications can be administered by a physician for the prevention and treatment of osteoporosis in older women, which helps to slow the rate of bone breakdown. Controversy centers on whether treatment with calcium and vitamin D for bone building is an effective modality in combating osteoporosis. A study conducted in England on over 5,300 men and women over age 70 found that daily supplementation of calcium, vitamin D, or a combination of both did not significantly affect the fracture rate between groups [42]. On the other hand, Meunier studied a group of French women living in a nursing home setting who were given a daily dose of vitamin D and calcium for 12 months. These researchers found a reduction in the number of hip and non-vertebral fractures by 23 % and, by 18 months, increased bone density in the femoral neck of those taking calcium and vitamin D [43]. While there is still debate on the effectiveness of vitamin D and calcium supplementation in elderly women in terms of bone density, there has been no suggestion that it will decrease bone density. Fish oil supplements have been shown to provide anti-inflammatory effects on soft tissues. A study conducted on 45 women, median age 64 years old, found fish oil supplementation combined with a strength-training regime produced greater improvements in muscle strength and functional capacity compared to strength training alone [44].

Once pain from an injury has subsided, an intensive rehabilitation program should be incorporated, along with an exercise regimen designed to maximize recovery and return to pre-injury status [71617]. A structured, balanced workout program should include the following elements: resistive training, cardiovascular endurance activity, flexibility, and balance. Various exercise programs are endorsed by different national organizations, including the American Heart Association (AHA), American College of Sports Medicine (ACSM), and the American Academy of Orthopaedic Surgeons (AAOS) [16]. Specifically speaking, the exercise prescription should involve the following three elements for each workout session: FIT(T)—frequency, intensity, time or duration, and type of physical activity. The ACSM and Center for Disease Control and Prevention (CDC) recommend 20–60 min of moderately intense activity 3–7 days per week [57811]. The mode of exercising is dependent on a woman’s most current physical fitness level and/or associated musculoskeletal problems. In older women with healthy bones, running in place and other weight-bearing type of mechanical loading can be performed with attention paid toward correct form and technique [8]. However, for those who are frail or females who are already inflicted with arthritic joints, low or minimal impact activities should be chosen, such as exercises done in a pool and bicycling in a sitting or recumbent position [3578]. In contrast, to benefit osteoporotic bone, workouts should be done in the standing or erect posture (climbing stairs or walking) to best load the skeleton, especially the spine to optimize bone building [578]. To maximize aerobic fitness, the target heart rate range should be 40–80 % of maximal heart rate of 220 while exercising [58] (see Table 18.1).

Table 18.1

Target heart rate (THR) ranges


THR (bpm)

50 years old


60 years old


70 years old


80 years old


bpm = beats per min

In addition to aerobic conditioning, resistance training needs to be incorporated into the workout routine as well to minimize loss of muscle strength and mass, stabilize joints, and maintain bone density [15717]. The effect of exercise on bone mass is quite specific in terms of skeletal building; therefore, a training program needs to include both lower and upper extremities [78]. When the older female athlete first starts the training program, she should begin with mild resistance/light weights (10–12 repetitions for 1–2 sets), then gradually increase the amount of weight lifted as tolerated. She can then work up to 12–15 reps for 2–3 sets, 3–4 sessions per week, for all major muscle groups, concentrating on trunk extensors and the lower extremity muscles to help with body stability and dynamic balance. To ensure appropriate body alignment, especially on the structural type of exercises using multiple muscle groups, plus to direct force through the hip and spine, she can make use of such exercises as free standing squats, dead lifts, and lunges [8]. Additionally, neighboring joints and surrounding musculature close to the injured one(s) should also be included in the rehabilitation phase [17].

Balance and stability training need to also be a part of the exercise regime. Stretching (several short sessions per day are better than one long episode) has been shown to maintain flexibility, balance, and proprioception [5817]. Static, passive, and active-assisted stretches for major musculotendinous units should be done on most days of the week. Burke et al. studied 50 women age 65 years or older and divided them into three groups: stretching, strengthening, and control. They found that after 8 weeks, both the stretching and strengthening groups had improved posture as compared to the control group [45]. As for balance and stability training, the following drills have been found to be effective: getting up from a chair without arm usage, alternating one-legged stance, walking backward, and negotiating various obstacles set up on a course. In addition, physio-balls can be used for strengthening core muscles, promoting a neutral spine, and improving postural control as well [8].

A regular exercise program for the elderly woman will promote mobility while decreasing falls, which have been shown to be the sixth leading cause of death [7]. In effect, exercising will maximize residual function and even reduce biological age by as much as two decades [3]. If all conservative management strategies fail to heal the injured extremity, radiographs should be ordered and orthopaedic consultation should be sought since invasive procedures may be warranted at this point [417].

18.4 Future Directions and Concluding Remarks

As the active female proceeds from childhood through adolescence into adulthood, she must constantly try to slow down her biological clock as far as the body is concerned in general and the musculoskeletal system in particular. The old adage of “use it or lose it” applies when speaking about maintaining physical fitness in order to continue participating in different athletic activities. However, as time passes, both the muscular and skeletal systems start to gradually decline in terms of strength and integrity. Furthermore, higher risks of potential injuries exist to challenge the master female athlete as well as slower course of recovery after sustaining traumatic episodes. Ideally, the best method of treatment for orthopaedic trauma is of course prevention but certain situations are beyond a woman’s control. In that case, measures to protect the injured extremity are of prime importance so she can rehabilitate and physically recover in a timely fashion. The recovery course might last several days to a couple of weeks but may take as long as a few months depending on the extent of injury. In addition, a regular workout program should be instituted, targeting the affected limb but also incorporating resistance training plus aerobic endurance exercises, along with balance and flexibility elements. This way, the aging female can regain strength, function, and mobility to hopefully return to competitive sports or any other athletic endeavor of her choosing.



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