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Sports and Fitness Activities: The Negative Consequences James G. Garrick, MD, and Ralph K. Requa, MPH Abstract Since the publication more than 40 years ago of O’Donoghue’s Treat- ment of Injuries to Athletes, 1 the diagnosis and management of injuries associated with sports participation have beenrecognized as a major component of orthopaedic practice. The number of participants in sports and fitness activitiesincreases inthe Unit- ed States every year. Participation in soccer grew at nearly ten times the rate of population growth (60% vs 6.9%) between1988 and 1996. 2,3 Wom- en’s basketball had 65% more participants in 1996 than in 1988. Exercise walking increased by nearly 62% and running/jogging by 27% among those older than 55 years between 1988 and 1996. 2,3 There is little evidence that the rate of occurrence of injuries associated with participation in sports and fitness activities has changed. Although injuries such as those of the meniscus and the anterior cruciate ligament (ACL) do not occur exclusively in those engaged in such activities, the increased number of such participants has resulted in sports injuries becoming a growing segment of orthopaedic practice. In addition to diagnosis and initial management, the primary goal in managing sports injuries used to be return to participation. Return to play was the most important—often the only—outcome measure of management. Many of the injuries occurred because of participation in team sports, such as those available primarily during high school and college. Thus, the ability to finish a high school or college athletic career after an injury was considered a successful outcome. However, although returning an injured athlete to participation remains a laudable goal, it is no longer a suf- ficient measure of management success. The capability of continuing an active lifestyle, often enhanced by athletics, is deemed an increasingly important component of a longer and meaningful life. Consideration of the long-term consequences of sports participation is of concern. Effective management of common problems of adulthood, such as obesity, cardiovascular disease, diabetes, osteoporosis, and depression, may be aided by participation in sports or fitness activities. Such participation often requires that the extremities and spine be relatively free of disabling musculoskeletal conditions. However, this may be less likely in individuals with an appreciable history of sports participation. Active older individuals must overcome the residual effects of previous sports injuries as well as cope with any injuries resulting from continuing fitness activities. Dr. Garrick is Director, Centers for Sports Med- icine, Saint Francis Memorial Hospital, San Fran- cisco, CA. Mr. Requa is Research Director, Cen- ters for Sports Medicine, Saint Francis Memorial Hospital. None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial com- pany or institution related directly or indirectly to the subject of this article: Dr. Garrick and Mr. Requa. Reprint requests: Dr. Garrick, Saint Francis Me- morial Hospital, 900 Hyde Street, San Francisco, CA 94109-4806. Copyright 2003 by the American Academy of Orthopaedic Surgeons. Participation in sports and fitness activities offers potential health benefits for individuals of all ages, such as combating obesity and osteoporosis, as well as enhancing cardiovascular fitness. Negative consequences of musculoskeletal injuries sustained during sports participation in childhood and adolescence may compromise function in later life, limiting the ability to experience pain-free mobility and en- gage in fitness-enhancing activity. Increasingly successful management of sports- related injuries has allowed more athletes to return to participation. However, even effective early management of meniscal or anterior cruciate ligament injury does not minimize or preclude the increased likelihood of developing subsequent osteoarthritis. In addition, even in the absence of injury, vigorous participation in sports and fitness activities during childhood and adolescence increases the likelihood of developing osteoarthritis. It is ironic that return to vigorous sports participation has been adopted as an important measure of success of treatment, yet few efforts have been made to document long-term consequences of continued participation. Awareness of the long-term consequences of intensive sport and fitness activities allows the physician to help patients make informed decisions about the types and levels of activity they choose. J Am Acad Orthop Surg 2003;11:439-443 Vol 11, No 6, November/December 2003 439 Sports Injuries Intuitively, it would seem that the se- verity of a sports injury should relate directly to its documented long-term consequences. More severe injuries usually require contact with the medical community, so formal medical records exist and, because of our in- terest in establishing efficacy of treatment, those records should include some evaluation ofoutcome. Howev- er, outcome concerning sports injuries is usually considered primarily in the context of the sport related to the injury. For example, the ability to return to playing soccer at a preinjury level is deemed a successful outcome, whereas compromise of activities after the soccer career is rarely inves- tigated. The examination of true long- term consequences, if undertaken at all, usually involves veteran players with decades of participation, not those who played only in high school or college. 4 One reason for this lack of long- term follow-up information is that athletes become more difficult to track after they end their team affiliations. While participating as team members, individuals are easily identified, their injuries documented, and their medical records available for follow-up studies. However, few athletic train- ers or team physicians maintain contact with their patientsbeyond 5 years and certainly not for decades. When return to participation is used as the primary indicator of success, most injured athletes are considered to be successfully treated. Only recently has the level of play to which they return been examined; rarely has the tenure of return been documented. Andrews and Timmerman 5 documented both of these factors in their study on the outcome of elbow surgery in professional baseball players. They reported that 47 of the 59 patients “returned to playing professional baseball” and notedthat 4 com- peted at a lower level than before the surgery but 43 returned to the same level or a higher level of play. In addition to the abbreviated temporal aspects of follow-up studies, compromise of activities beyond the sport in question is rarely assessed. Knee injuries involving the ACL and/or the meniscus are an exception to these generalities. The long-term effect of meniscectomy was reported by Tapper and Hoover 6 in 1969 in a study of 213 patients 10 to 30 years after undergoing either partial or total meniscectomy for isolated meniscal tears. Radiographic changes were evident in 85% of patients on the side of the meniscectomy. Although 68% had satisfactory clinical results, only 45% of men and 10% of women had symptom-free knees. In addition, those who underwent meniscectomy before age 20 years had statistically significantly fewer good or excellent results (P < 0.01) than those age 21 years and older. Higuchi et al 7 reported on a similar group of 67 patients with isolated arthroscopic partial meniscectomy at a mean follow-up of 12.2 years. Seventy-nine percent had satisfactory functional outcome, but 48% had radiologic evidence of mild osteoarthritic degeneration. Faunø and Nielsen 8 examined 136 patients who had undergone arthroscopic resection of isolated meniscal tears at a mean follow-up of 8.5 years. Fifty-three percent of the patients exhibited at least one of the Fairbanks changes in the operated knee compared with 22% in the unoperated knee. Accurately determining the prev- alence of arthrosis after meniscectomy is difficult for many reasons. Pre- dominantly, the patients in thestudies with the longest follow-ups had open total meniscectomies, a technique no longer used. Also, a variety of clas- sification systems has been used to describe radiographic evidence of joint deterioration. However, by 10 years after meniscectomy, at least half of patients show some evidence of joint deterioration on radiographic examination. The concurrent incidence of meniscal injury also complicates the deter- mination of theroleACLinjuries play in causing arthrosis. In a comprehen- sive review of the consequences of ACL injuries, Gillquist and Messner 9 found that “in a 10- to 20-year per- spective, about 70% of all ACL- deficient knees have radiological signs of arthrosis” and that “it has not been shown that ACL reconstruction can diminish the rate of osteoarthrosis.” They also noted that gonarthrosis is more common in the presence of associated injuries, especially meniscal and other ligament ruptures, a conclusion similar to that reached by Daniel et al 10 in their study of 292 patients with a mean 64-month follow- up. Similar to virtually every other study reporting long-term results of both meniscal and ACL injuries, the authors noted that the incidence of clinical symptoms or decreased function is usually lower than that of radiographic changes. Although most studies are sport- specific, Gelber et al 11 examined the long-term consequences of knee and hip injuries from all etiologies in young adults.Atotal of 1,321 individuals (initial mean age, 22 years) were followed up at a median of 36 years. Osteoar- thritis (OA) by age 65 years was more than twice as likely in those who sustained a knee injury during adolescence compared with those without injury (13.9% versus 6.0%). Among those who sustained a knee or hip injury during the study, the relative risk of OAof the knee was 5.17 compared with those without knee injuries and, for the hip, was 3.50 compared with those without hip injuries. Regardless of the long-term results, the public health consequences of these injuries are based on the frequency with which they occur. Es- timates of frequency of occurrence generally are based on data from relatively small studies and reflect the experience of a single surgeon or clin- ic. Global projections are then made from these data. For example, the fre- Sports and Fitness Activities: The Negative Consequences 440 Journal of the American Academy of Orthopaedic Surgeons quency of meniscus surgery has been reported to be approximately 61 pro- cedures per 100,000 population, or approximately 163,000 cases annually in the United States. 12 ACL injuries are estimated to occur at a rate of 33 per 100,000 in the United States, 13 resulting in approximately 86,000 injuries annually, for an aggregate total of both conditions of nearly 250,000 per year. TheACL injury rate in Den- mark is 31 per 100,000 per year. 14 In addition to the annual incidence of these injuries, the occurrence of other, subsequent injuries also should be of concern. Shelbourne and Gray 15 reported that 2.6% of patients (27/1,057) with reconstructed ligaments had traumatically torn thegraft at a mean follow-up of 2.5 years, for an annual average incidence of 1.0%. Jomha et al 16 noted three retears after injury among 59 patients followed for 7 years (average annual incidence, 0.7%) as well as five ACL ruptures of the opposite knee (annual incidence, 1.2%). Oates et al 17 reported a recur- rence rate of 6.6% in a group of ski- ers with reconstructed ACL versus 2.1% in those with uninjured knees, at a mean follow-up of 3 years. Despite differences among the var- ious reports, once a patient has had an ACL tear, the likelihood of sustain- ing another ACL injury (previously reconstructed or on the contralateral side) increases substantially, from 1 in 3,000 to 1 in 50 annually. 13,15,16 In- terestingly, the 1 in 50 rate is similar to that observed in women participating in sports such as basketball and soccer, which have the highest ACL injury rates. The effect of lower extremity injuries is easier to assess than that of up- per extremity injuries because resulting joint deterioration in the lower extremity is more likely to compromise fitness activities. Because meniscal and ACL injuries frequently result in surgical intervention, their long- term consequences are more likely to be studied than those of injuries treated nonsurgically. Injuries such as an- kle sprains or fractures and problems involving other knee ligaments are important, but their rate ofoccurrence is not as well-defined, and the long- term outcomes associated with them have not been reported. Sports Participation Less obvious than the consequences of injuries are the consequences of simply participating in sports or fitness activities. Overuse or gradual- onset injuries abound in most fitness and athletic activities, yet almost nothing has been reported on the long-term effects of such conditions as patellofemoral dysfunction, tibial stress syndrome, shoulder impinge- ment, and Achilles tendinitis. Even more obscure are the consequences of repetitive loading of joints in the absence of symptoms or injuries. Buckwalter and Lane 18 reviewed the relationship between athletics and OA and found that, although many who participate in sports lack a clear history of joint injuries, such injuries may go unrecognized because they do not cause persistent pain or they lack discrete findings on physical and radiographic examinations. Just as some activities might be more haz- ardous because they produce higher impact and torsional loads, some individuals might be more susceptible to joint degeneration because of joint configuration, congruence, stability, muscle strength, and a host of other poorly correlated variables. Unfortu- nately, these same variables also might influence one’s choice of sports or fitness activities, resulting in selec- tion bias when examining the consequences of long-term participation in activities. Studies of the musculoskeletal consequences of participation in sports or fitness activities are generally of two types: those in which a group of participants in a particular activity (usually running) are followed prospec- tively, and those in which the previous activities of subjects with evidence of OA are compared with the activities of those without obvious predispos- ing factors. In studies of running clubs or of individuals who have been habitual competitive runners, most authors agree that modest levels of running, even over decades, result in no discernable increase in OAof the hip or knee. 19 In some studies, even many years of high levels of running appear to produce no increased risk. 20 How- ever, such studies usually fail to identify participants who might have dropped out because of osteoarthritic problems. They also fail to identify the physical attributes of those who successfully choose running as a habitual activity. Examination of populations with evidence of OA indicates that previous levels of physical activity might play a causative role. In the Framing- ham Study, Felson et al 21 noted that physical activity increased the risk of OA of the knee for those in the highest quartile (odds ratio = 3.3). In a study of 5,818 elderly women, Lane et al 22 noted that both symptomatic hip OA (odds ratio = 2.0) and mod- erate to severe radiographic evidence of hip OA (odds ratio = 1.7) were evident in those who were in the highest quartile for allphysical activityen- gaged in as teenagers. In a study of Swedish men and women who had undergone pros- thetic surgery for OAof the knee, men who were “highly exposed to sports” had a relative risk of 2.9 for requir- ing TKA. 23 The risk was consistent with that reported by Vingård et al, 24 who found the relative risk for OA of the hip in men with high exposure to sports of all types to be 4.5 times higher than in those with a lower exposure. Very few of the men in the lat- ter study had engaged in sports at an elite level; most had participated in sports early in lifeand were more sed- entary at the time of the study. Most authors examining the consequences of sports or fitness activities emphasize positive effects, such James G. Garrick, MD, and Ralph K. Requa, MPH Vol 11, No 6, November/December 2003 441 as weight control, enhanced cardiovascular health, and slowing the pro- gression of osteoporosis. 25 Although some authors deny the existence of negative musculoskeletal sequelae as a result of such participation, virtually none suggest that such activities aid in the prevention of OA. Discussion Although the terms sports and fitness activities are used almost interchange- ably, they are not synonymous. The connotations associated with fitness activities in adults (eg, lowered risk of cardiovascular disease) generally are not applicable to the child or adolescent athlete. Despite the benefits of youthful involvement in sports, physicians should attempt to identify and minimize factors that contrib- ute to the long-term cost of such participation rather than encourage involvement by simply managing injuries to enable return to play. Athletic injuries are managed more successfully now than two or three decades ago. However, there is a dichot- omy between managing the injury and treating the injured. Physicians should consider the appropriateness of recon- structing a tornACL, thereby enabling the injured patient to return to an activity that carries with it a substantially increased likelihood of sustain- ing yet another disabling knee ligament injury. Also, there is an appreciable increased risk of developing OAwith each additional knee injury. Most of these knee injuries occur in individuals during the second and third decades of life; over the succeed- ing four or five decades, they will have both osteoarthritic changes and subsequent symptoms as a result. Most physicians likely would counsel a 45- year-old with radiographic evidence of early degenerative joint disease to either forgo or attenuate impact- loading activities (eg, running, soccer, basketball). Is it appropriate to encourage the postinjury teenager to return to those same activities, knowing that he or she has a >50% likelihood of developing similar radiographic changes before the age of 35? 9 Perhaps physicians should begin to examine the long-term consequences of their advice (ie,to get more exercise) and actions (ie, more aggres- sive management of injuries). Al- though the current effort to prevent these injuries is an important solu- tion, it will, at best, take many years to have a significant impact. Until then, it might be appropriate to focus more on identifying the risk factors associated with both the development of postinjury OA and the arthroses associated with habitual, vigorous physical activity. Summary Although managed more effectively today than previously, most serious lower extremity athletic injuries have the same predictable, long-term skel- etal consequences described decades ago. Of additional concern is that, because of increased participation in the injury-producing activities, these injuries now occur more frequently. Thus, there likely will be both a growing incidence of postinjury OA and an increased incidence of generic OA because of elevated levels of participation. Awareness of such long-term consequences allows the physician to help the child or adolescent and his or her parents make informed decisions about the types and levels of fitness activity to become involved in. References 1. O’Donoghue DH (ed): Treatment of Inju- ries to Athletes. Philadelphia, PA: WB Saunders, 1962. 2. US Bureau of the Census: Statistical Ab- stract of the United States: 1990. 110th ed. Washington, DC: US Bureau of the Cen- sus, 1990. 3. US Bureau of the Census: Statistical Ab- stract of the United States: 1998. 118th ed. Washington, DC: US Bureau of the Cen- sus, 1998. 4. Chantraine A: Knee joint in soccer players: Osteoarthritis and axis deviation. Med Sci Sports Exerc 1985;17:434-439. 5. Andrews JR, Timmerman LA: Outcome of elbow surgeryinprofessional baseball players. Am J Sports Med 1995;23:407-413. 6. Tapper EM, Hoover NW: Late results after meniscectomy. J Bone Joint Surg Am 1969;51:517-526. 7. Higuchi H, Kimura M, Shirakura K, Terauchi M, Takagishi K: Factors affect- ing long-term results after arthroscopic partial meniscectomy. Clin Orthop 2000; 377:161-168. 8. Faunø P, Nielsen AB: Arthroscopic partial meniscectomy: A long-term follow- up. Arthroscopy 1992;8:345-349. 9. Gillquist J, Messner K:Anterior cruciate ligament reconstruction and the long- term incidence of gonarthrosis. Sports Med 1999;27:143-156. 10. Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR: Fate of the ACL-injured patient: A pro- spective outcome study. Am J Sports Med 1994;22:632-644. 11. Gelber AC, Hochberg MC, Mead LA, Wang N-Y, Wigley FM, Klag MJ: Joint injury in young adults and risk for subsequent knee and hip osteoarthritis. Ann Intern Med 2000;133:321-328. 12. Baker BE, Peckham AC, Pupparo F, Sanborn JC: Review of meniscal injury and associated sports. Am J Sports Med 1985;13:1-4. 13. Daniel DM, Akeson WH, O’Connor JJ (eds): Knee Ligaments: Structure, Func- tion, Injury, and Repair. New York, NY: Raven Press, 1990. 14. Nielsen AB: Abstract: The epidemiologic aspects of anterior cruciate ligament injuries in athletes. Acta Orthop Scand Suppl 1991;243:13. 15. Shelbourne KD, Gray T: Anterior cruciate ligament reconstruction with autog- enous patellar tendon graft followed by accelerated rehabilitation: A two- to nine-year followup. Am J Sports Med 1997;25:786-795. 16. Jomha NM, Pinczewski LA, Clingelef- fer A, Otto DD: Arthroscopic reconstruction of the anterior cruciate liga- Sports and Fitness Activities: The Negative Consequences 442 Journal of the American Academy of Orthopaedic Surgeons ment with patellar-tendon autograft and interference screw fixation: The results at seven years. J Bone Joint Surg Br 1999;81:775-779. 17. Oates KM, Van Eenenaam DP, Briggs K, Homa K, Sterett WI: Comparative injury rates of uninjured, anterior cruciate ligament-deficient, and reconstructed knees in a skiing population. Am J Sports Med 1999;27:606-610. 18. Buckwalter JA, Lane NE: Athletics and osteoarthritis. Am J Sports Med 1997;25: 873-881. 19. Konradsen L, Hansen EM, Sonder- gaard L: Long distance running and osteoarthritis. Am J Sports Med 1990;18: 379-381. 20. Hubert HB, Fries JF: Predictors of physical disability after age 50: Six-year longitudinal study in a runners club and a university population. Ann Epidemiol 1994;4:285-294. 21. Felson DT, Zhang Y, Hannan MT, et al: Risk factors for incident radiographic knee osteoarthritis in the elderly: The Framingham Study. Arthritis Rheum 1997;40:728-733. 22. Lane NE, Hochberg MC, Pressman A, Scott JC, Nevitt MC: Recreational physical activity and the risk of osteoarthritis of the hip in elderly women. J Rheu- matol 1999;26:849-854. 23. Sandmark H, Vingård E: Sports and risk for severe osteoarthrosis of the knee. Scand J Med Sci Sports 1999;9: 279-284. 24. Vingård E, Alfredsson L, Goldie I, Hogstedt C: Sports and osteoarthrosis of the hip: An epidemiologic study. Am J Sports Med 1993;21:195-200. 25. Lane NE, Bloch DA, Hubert HB, Jones H, Simpson U, Fries JF: Running, osteoarthritis, and bone density: Initial 2-year longitudinal study. Am J Med 1990;88:452-459. James G. Garrick, MD, and Ralph K. Requa, MPH Vol 11, No 6, November/December 2003 443 . play to which they return been examined; rarely has the tenure of return been documented. Andrews and Timmerman 5 documented both of these factors in their study on the outcome of elbow surgery. Injuries Intuitively, it would seem that the se- verity of a sports injury should relate directly to its documented long-term consequences. More severe injuries usually require contact with the medical. affiliations. While participating as team members, individuals are easily identified, their injuries documented, and their medical records available for follow-up studies. However, few athletic train- ers