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CHAPTER 35:
Female, Child, and Elderly Athletes

A woman's, child's, or senior's sports injuries are basically the same as a young man's. But there are some peculiarities due to differences in anatomy, including problems related to the menstrual cycle, growth spurts, and aging bones. The female, child, or elderly athlete also has certain nutritional needs that a young man doesn't.

THE FEMALE ATHLETE

RUNNER'S KNEE

Runner's knee is much more common among women than men because a woman's pelvis is wider, making the angle between the thigh and the calf sharper. This increases the tendency for the kneecap to pull out of line and rub on the side of its groove, causing knee pain.

DISLOCATED KNEECAP

Dislocated kneecaps are also more common. The groove that the kneecap rides in is much shallower in women than in men. The kneecap therefore has less lateral stability.

TENNIS ELBOW

Tennis elbow is usually associated with lack of forearm strength. I see it particularly among women who play mixed doubles. When the ball comes at a woman with more force than she is used to, the shock of the ball hitting the racquet is transmitted up through her forearm. Since the ball is coming so fast, her weight is typically back and she is late getting her racquet head around. On the backhand, if the ball hits the racquet while the elbow is still bent, the shock is transmitted to the outer area of the elbow, causing elbow pain.

INCONTINENCE

Women athletes also have more problems with incontinence. About one-third of women experience leaking of urine from the bladder during running or high-impact aerobics. The jarring shakes urine out of the bladder.

      The leaking can usually be brought under control with exercises that tone the pelvic muscles, which tend to stretch and loosen from childbirth. Contract the muscles in your pelvis for 10 seconds. It should feel as if you are trying to stop the flow of urine. Rest for 10 seconds. Repeat the exercise several times every day for several weeks.

      A vaginal tampon or diaphragm may eliminate the problem. If the leaking usually occurs late during a long run, stop to urinate at some point. If need be, you can switch to swimming or cycling, which are not as strongly associated with incontinence. There also are medications available to help control incontinence.

MENSTRUAL IRREGULARITIES

A major problem among women who are ultraslim and who exercise heavily is amenorrhea, or disruption of the normal menstrual cycle. I see this particularly among long-distance runners and triathletes.

      Intensive physical activity before puberty can delay a girl's first period by a year or more and lead to an irregular menstrual cycle. Numerous theories have been advanced to explain the relationship between exercise and amenorrhea. There seems to be a change in the control of the pituitary and the ovaries, resulting in a dramatic fall in estrogen levels.

      A very thin woman with little body fat may experience a hormone imbalance. To maintain the natural rise and fall of hormones during the menstrual cycle, a woman must maintain a body fat content of about 22 percent. Too much exercise along with a rigorous diet may reduce a woman's body fat and cause ovulation problems. Women runners with a body fat content of 17 percent or less will not menstruate.

      The good news is that this exercise-induced fertility problem appears to be reversible. As soon as you cut down on exercise and gain a few pounds, your body fat will build up again and your period will return to normal. If it doesn't, you should see a gynecologist. You may have other medical problems that need attention.

BONE LOSS AND STRESS FRACTURES

A menstrual disturbance in a young female athlete can increase her risk of bone loss and stress fractures. Amenorrhea in a young athlete usually leads to insufficient bone mineral density. With aging, she will lose bone tissue and be vulnerable to osteoporosis, a bone wasting disease. In the short term, she will be vulnerable to stress fractures. Fifty percent of competitive runners with irregular periods sustain stress fractures, compared to 30 percent of runners with normal periods. These runners have a bone mineral content comparable to that of postmenopausal women more than twice their age.

      It is thought that postmenopausal women are the most commonly affected by osteoporosis because their ovaries no longer produce estrogen. Estrogen is vital to proper bone growth because it allows calcium to be absorbed from the intestines, and calcium is a necessary ingredient in building the skeleton. I recommend that every amenorrheic athlete raise her daily calcium consumption to 1.5 grams to maintain a normal calcium balance.

      Along with estrogen and calcium supplements, exercise helps to optimize bone mass. Weightbearing exercises, such as walking, dancing, and jogging, are particularly valuable in reducing bone loss in middle-aged and postmenopausal women, and may help to prevent osteoporosis.

SPECIAL PROTECTION AND PRECAUTIONS

Upper-Body Strength

Women can build their legs to be extremely strong, but they cannot, in general, develop their upper-body strength as much as men because of basic physiologic differences. The human male has an innate potential to develop bigger shoulders, chest, and arms than the human female.

      Through weight training, women can increase their upper body strength markedly without bulking up as men do. This is because women have little circulating male hormone, which is a required for bulking up. The huge upper bodies you see on female weight trainers are due to steroid use. As long as a female athlete has a normal level of circulating female hormones and doesn't take any artificial male hormones, she will increase her strength and not her bulk through weight training.

Good Nutrition

Women may need to supplement their diets for peak athletic performance. Most women need a high calcium intake. Dairy foods such as lowfat milk, calcium pills, or even a few Tums® (which have a high calcium content) a day should provide the calcium a woman needs.

      A female needs a higher concentration of iron in her diet than a male, and this is especially true for athletes. A heavily exercising female athlete breaks down blood cells at a higher rate than a sedentary woman. This, combined with loss of blood during the menstrual cycle, requires increased intake of iron. I recommend that female athletes take in 15 milligrams of iron per day, either through the diet or supplements.

      Some women are still resistant to a high-carbohydrate diet. The idea that a high-starch diet can be nonfattening is hard for some women to comprehend. Traditionally, when women attempted to diet, they gave up bread, potatoes, and rice. These old dietary prejudices may be hard to overcome.

Protecting the Breasts

Any woman must be concerned with protecting her breasts during sports. Sports bras now provide much-needed breast support. The first sports bra was made in the mid-1970s by sewing two jock straps together. Since then, the market has been flooded with sports bras of different shapes and sizes.

      Sports bras are designed to minimize breast motion. They press the breasts against the chest, and they cradle and restrain each breast separately within a cup. A good sports bra is sturdy but not constricting and allows a full range of motion. Most are made of nonabrasive, breathable materials.

      Since there are so many sports bras available, evaluate each one before you make a purchase. When trying on a bra, run in place or do jumping jacks. You want to make sure you get all the support you need.

Pregnancy Care

Most women can continue to exercise while pregnant. Several world-class athletes, such as runners Mary Decker-Slaney and Joan Benoit-Samuelson, have given birth to healthy babies and gone right back to competing. A pregnant athlete simply needs to consult her doctor, follow some simple guidelines, and pay attention to her body for signs of fatigue.

      In 1985 the American College of Obstetrics and Gynecology (ACOG) developed a set of guidelines for women who plan to exercise during pregnancy. These guidelines recommend a target heart rate during pregnancy that is 25 to 30 percent lower than the nonpregnant target. You need to find your own comfortable exercise level. For a fit woman, 30 minutes is probably safe because the blood flow to the uterus is not significantly reduced within this time.

      Keeping fit and maintaining good muscle tone is an important part of health care during pregnancy. Exercise prepares the body for labor, promotes good bowel function, aids in sleep, and makes a woman feel better in general. Women who exercise regularly during pregnancy have fewer cesarean births, less pain during delivery, shorter hospital stays, and slightly heavier babies compared with nonexercising women. Studies show that women who continue to run or participate in aerobic dance programs at intensities between 50 percent and 85 percent of maximum aerobic capacity do not increase their risk of early birth.

      Strengthening muscles will help a woman deal with the low-back pain and other problems encountered during pregnancy due to weight gain and an altered center of gravity. There's no reason for a pregnant woman to avoid lifting heavy objects. That old myth should be put to rest.

      Women who are in a regular exercise program certainly shouldn't take nine months off. If a woman is planning a pregnancy, she should exercise to get in shape before she becomes pregnant and then maintain her fitness during pregnancy.

      Most prenatal classes, in addition to offering a selection of aerobically based exercises, have mothers-to-be work on specific muscle groups. These include three major areas: the shoulders and back, the abdominals, and the muscles at the base of the pelvis.

      The safest sports during pregnancy are those that offer smooth, continuous activity as well as conditioning. Walking, swimming, cross-country skiing, and cycling are all excellent.

Exercising after Birth

Fit women tend to rebound quickly from childbirth. Most postpartum classes offer strength-training routines and exercises similar to those of prenatal classes. These classes help women build strength in the abdominal, back, and shoulder muscles, which is necessary for hoisting a baby around. An aerobic activity can help a woman shed the extra pounds gained during pregnancy. Within a month of giving birth, a woman should be able to see improvements in her aerobic capacity.

      Many women who breast-feed are fearful that exercise may hinder their milk supply. But active women actually produce more milk than inactive women.

      Before a woman starts any postpartum workout, the ACOG recommends that she check with her doctor.

Relieving Menstrual Woes

A regular, moderate exercise program can help relieve the painful, disabling symptoms of premenstrual syndrome as well as those of menopause. Exercise causes the pituitary gland to release endorphins, a group of substances chemically similar to morphine and thought to be the source of the elusive runner's high. Studies show that exercise can help ameliorate the aches and abdominal cramps associated with menstrual changes.

THE CHILD ATHLETE

The biggest problem I see with children is lack of exercise and conditioning. In an age when adults have become more involved in fitness, today's children are more obese and less physically fit than their older brothers and sisters, as well as their parents.

      One reason for this is that watching television or playing computer games has replaced after-school play. Children will sit for hours amusing themselves in front of a television. Studies have shown that the more television children watch, the more likely they are to be overweight.

      Another reason many children are in sorry shape is that physical education classes are no longer mandatory in most states. New Jersey is one of the few states that still requires mandatory gym classes. Yet even in New Jersey, one quarter of the gym class time is taken up by driver's education and one quarter by health education, so students really only get two quarters of physical education each year.

      The whole concept of physical education in schools is due for an overhaul. Even in those areas where physical education is mandatory, children don't get enough uninterrupted class time to do much good. After they change clothes and have attendance taken, there probably is only about 20 minutes for actual exercise before they have to take a shower and change back to their street clothes. They exercise within the training range for only about 6 or 7 minutes of the available class time.

      Even methods of punishment need to be rethought. If a child misbehaves in physical education class, the teacher usually makes him run laps. The child's punishment should be that he can't run or play at all.

      The goal of physical education classes should be to teach children about the value of exercise and fitness so that they will continue to exercise on their own after they graduate. It would be much more beneficial to get students into cardiovascular conditioning and weight-training programs in high school and to give them instruction in lifestyle and life sports, such as tennis and golf.

      Whether it's individualized weight training or team sports, it's important that children do something physical. Numerous studies show a correlation between academic performance and participation in high school sports and achievement in extracurricular activities. Children learn tremendous lessons concerning teamwork, sportsmanship, and social interactions, as well as the discipline of being coached and following instructions, lessons that will help them in later life.

GROWTH PLATE INJURIES

Despite rumors to the contrary, too much exercise does not stunt growth. In fact, exercise enhances growth. Problems arise only when young athletes push themselves to the point of overuse injuries.

      The trauma of long-term training can damage joints that aren't completely developed. Before age 13, any activity that requires repetitive jumping, falling, or high-intensity training can affect a child's physical development by putting stress on the growth plates, the growing areas at the ends of bones at the joints. This is less of a problem among older teens, who have gone through most of their growth spurts.

      The most common growth plate injury is Osgood-Schlatter disease, which causes swelling and marked tenderness in a lump of bone just below the knee. This piece of bone is the tibial tubercle, the area where the tendon from the kneecap attaches to the shin bone. It contains a growth center that controls the growth of the tubercle itself, not the whole leg. As the child gets bigger and heavier, the knob has to become bigger for the attachment of the tendon. In some children, the repetitive yanking of the kneecap tendon as they flex and extend the knee while running causes the growth center in the tubercle to become irritated. When a growth center is irritated, it becomes painful and is stimulated to overgrow.

      Osgood-Schlatter disease, like most growth plate injuries, is self-limiting; that is, it always goes away by itself. By the time the child reaches age 17, the growth center closes, and the tendon is then pulling on a solid knob of bone. The pain disappears, but the lump under the knee does not. It is a permanent fixture in the child's bone.

      This disease is self-limiting also because the more it hurts, the harder it is for the child to play. In the past, doctors limited what kids could do, and some kids sat out as much as two years waiting for the growth center to close. There is absolutely no reason for this, and we now allow a child to do whatever he or she can.

      Only when the child says, "I can't play any more. It hurts too much," do I prescribe a knee immobilizer. The immobilizer keeps the knee straight and prevents the tendon from yanking on the growth center, which relieves the pain. This also prevents the child from running around, so the pain doesn't recur. The immobilizer is taken off every night to allow the child to shower and to test the tibial tubercle. When the bump under the knee is no longer tender to the touch, the child can return to activity.

      Ice and aspirin or anti-inflammatory agents are also used to relieve any pain. Virtually all children can continue to play through this disability I also recommend that the youngster wear a good pair of basketball or wrestling knee pads over the bump. Hitting the bump on the floor not only hurts tremendously but further irritates the condition.

LITTLE LEAGUE ELBOW

A young pitcher who throws the ball too often or too hard may feel pain on the inner side of the elbow. The elbow may swell and be tender to the touch. The muscles that flex the wrist attach to a growth center on the inner side of the elbow. Throwing too much irritates this growth center, causing the area to overgrow and become painful.

      The treatment is to rest the elbow by not throwing. If the pain is not severe, icing the elbow and taking anti-inflammatory agents will allow the pitcher to continue to play, but at a position where he doesn't have to throw very often, such as first base.

      If the pain becomes severe, the child must cease activity entirely. Some young pitchers throw so hard that they tear the knob of bone off the elbow. The bone must then be reattached surgically and the elbow allowed to heal, and the child must refrain from throwing altogether.

SLIPPED CAPITAL EPIPHYSIS

The growth plate in the neck of the thigh bone where it attaches to the hip can slip from overactivity. This disease, called slipped capital epiphysis, causes pain in the hip and sometimes in the knee as well. It also requires surgical repair. The pain prevents the child from doing any running at all. I tend to see this more often in very heavy children. The growth center is at an angle and is subjected to a shearing force when excessive weight is placed upon it.

SEVER'S DISEASE

Many children come to me with heel pain from running. I see it particularly in the spring and fall, when they begin running in cleats for football, soccer, or track. Many doctors diagnose this as an inflammation of the epiphyseal plate in the heel, which is known as Sever's disease. Pounding against the growth plate in the heel bone causes inflammation.

      However, Sever's disease is extremely rare, and 99 percent of children with heel pain from running simply pronate their ankles too far. The ankle rolls to the inside, which leads to pounding on the heel. The stress of the heel hitting the ground is transmitted up through the thinner, inner portion of the heel bone, rather than the stronger middle portion, which causes pain.

      Children who wear cleats are more susceptible to pronation because the points of the cleats have less contact with the ground than the wide, flat base of a sneaker. Put a pronator in cleats, and the shoe rolls even more to the inside.

      If the child puts an arch support inside the shoe to prevent pronation, the heel pain usually goes away within two or three days, and the child is able to continue running. There is no way the pain could disappear so quickly if the growth center were inflamed from Sever's disease. Sometimes, I suggest that a youngster practice in sneakers and use cleats only during games.

PELVIC PAIN

Young runners may experience severe pain in the upper rim of the pelvis. This area becomes tender to the touch because the upper rim of the pelvis is partially pulled away from the lower rim right at the site of the growth center in the hip.

      This hip problem requires rest for six to eight weeks, and the child must stop running. Once the growth center is back to normal, the child can run again. Normally, this growth center closes at about age 15, and the child is no longer at risk of this problem.

CHILDHOOD ASTHMA

Asthma should not in any way restrict a child's ability to exercise and compete. An asthmatic child should be allowed to exercise at any level he or she is capable of, as long as he or she follows a physician's advice. If respiratory problems are severe, bronchodilating medications in pill form or administered through inhalers can increase a child's capacity to breathe normally and to compete.

      There is one caveat: Asthma medications may affect performance, so I tell my patients with childhood asthma to use medications during practice or playtime before they use them during competition. Only then will the child know how he or she responds to the medications while exercising. Also, the use of some asthma medications is banned from higher levels of competition, so the athlete must know what he or she can use effectively. Then, along with a physician, the asthmatic athlete can make appropriate adjustments in the amount and type of medication.

Exercise-Induced Asthma

Asthma attacks usually result from exposure to environmental factors, but they may be induced by exercise. This condition, which I see fairly often among children, is called exercise-induced asthma. Mild symptoms can be managed by reducing the intensity of the exercise or with the help of an inhaler. To prevent an attack, I recommend a slow, prolonged warmup and a longer, but slightly less vigorous, aerobic activity period. An inhaler can be used before exercise, if necessary.

      If you are participating in an organized sport or activity, let the coach or instructor know of this condition. Also make sure someone knows the location of the inhaler and whom to call in case of an emergency.

      Children and others who are susceptible to exercise-induced asthma are unable to warm and moisten large amounts of air inhaled during exercise. The condition is worse in cold weather, and often bothersome only at low temperatures. Many people who experience exercise-induced asthma during the winter can exercise indoors without any symptoms. Indoor swimming is particularly helpful because of the warm, moist air surrounding the pool.

      Athletes with exercise-induced asthma can exercise safely by using the same bronchodilating drugs prescribed for asthmas of other origins.

SPECIAL CONCERNS AND PRECAUTIONS

Pressure to Perform

From Little League age on up, children are pressured to participate in organized, competitive athletics. Everything today seems to be organized, with weekly games and rigidly scheduled leagues. Yet sports competition should be no more or less stressful than performing in the school play or playing in the school band.

      The pressures of organized leagues can be difficult for children. It's not that they don't want to have fun, but that the parents and coaches take the fun out of the game for them. With so much pressure on them to win, they tend to burn out at an early age. I see children over and over again who don't want to play a particular sport any more. They come into my office with symptoms of injuries or overuse syndromes. They are afraid to tell the coach or their parents that they don't want to play, so they hide behind recurrent injuries. Parents need to be sensitive to the hidden language behind the excuses children use to avoid practice or competition.

      Sports are supposed to be fun. According to a study of 10,000 students of ages 10 to 18 concerning their feelings about sports, "fun" is the critical factor in the decision to play or to drop out of a sport. For those who play, "fun" means improving skills, staying in shape, taking satisfaction in individual performance, and competing against others. Even among the most dedicated athletes, winning takes a back seat to "having fun," self-improvement, and the excitement of competition.

      For those who drop out, the aspect of sports that is "not fun" is pressure--pressure to perform, to win, and to practice too much. There is no sense of play left.

      An experiment from the 1970s shows the beneficial effects of fun. Philadelphia had two rival baseball leagues, one run by the Little League and the other run by the Police Athletic League (PAL). The Little League drafted players for teams and had playoffs for a championship. The PAL also drafted players, but every two weeks they broke up the teams and redrafted players so that everyone had different teammates and different coaches. There was no real pressure to win since teams changed character every two weeks.

      When these children entered high school, their baseball skills were judged to be equal. Without pressure to perform, the PAL players had learned just as much. And they had half as many injuries as the Little Leaguers had.

      Another prevalent problem involving pressure on young athletes concerns distance running. Young runners may begin by jogging with their parents. Then they start running races. It's not uncommon to see five-year-olds running 10-kilometer races.

      No one knows the effect of long-distance running on children, but I suspect it is not good for them. Most children run until they are tired, flop down, rest, and then get up and run again. They listen to their bodies. We don't yet know all the ramifications of putting children into a training regimen so that they can compete in long races. What does the continuous pounding do to their growth plates? Running around on soft grass is not the same as running a 10-kilometer race on a hard road. Long-distance running can subject a growing body to unrelenting stresses and strains. Run a child long and hard enough, and eventually he or she will develop stress fractures, back strain, knee injuries, and chronic tendinitis. If you do run with your child, which can be fun for both of you, let the child set the pace and intensity.

Fatigue

Fatigue is a common problem among young athletes. Teens need sleep to help their bodies grow. They also need extra energy to help their bodies grow, and this comes from a good, healthy diet.

      Some teens lack sufficient iron in their bodies. Even though their iron deficiency may not be severe enough to produce anemia, it can slow their growth, deplete their energy supply, and lead to poor sports performance. Although iron deficiency is usually associated with girls, boys also lose iron during strenuous exercise.

      In general, I don't think vitamin supplements are appropriate for young athletes. Most of them eat a lot, and as long as they eat a balanced diet, they don't need vitamin supplements. For a picky eater, supplements may be beneficial.

      Children cannot be regarded as little adults. The American Academy of Orthopedic Surgeons has outlined some physiologic distinctions. Children must sustain higher heart and breathing rates than adults, so they burn more calories and tire faster. Children are less efficient at using the muscle fuel glycogen, so, even taking into account the size difference, they cannot produce as much muscle power as adults.

Sensitivity to Temperature

Children take longer to adjust to abrupt increases in heat and humidity and therefore have an increased risk of dehydration in hot weather. Children also don't generate as much heat in the winter, so they should dress warmly in extremely cold weather.

Fears about Football

I am often asked about the safety of Pop Warner football. It is supposedly dangerous because of the risk of blows to the extremities, which can cause growth plate injuries. But I really see few injuries among these youngest football players. These children don't weigh very much or run very fast; consequently, they don't run into each other hard enough to hurt themselves much. I applaud the use of equipment and the supervision these players get. Their games are much safer than the sandlot games that are played without proper equipment and supervision, where anything goes.

      High school players suffer more injuries, often because bigger players go up against smaller players of the same age. About one-third of the nation's one million high school football players are sidelined by an injury at least once, but the majority of injuries are not serious. About half are sprains and strains, and about one-third are cuts and bruises. Less than 10 percent are major injuries that require the athlete to miss a few weeks of action. Two out of three injuries are suffered during practice, when there usually are no trainers available, and the remainder occur during games, which are supervised by trainers and emergency medical personnel.

      In contrast, high school track and field athletes are more likely to suffer a serious injury, such as a broken bone, and will be sidelined longer. On average, an injured football player is out for about a week, whereas a track athlete stays out for three or four weeks.

Sudden Death

Despite the attention it receives in the media, sudden death is a rare occurrence among young athletes. Only 1 or 2 out of 200,000 athletes under age 30 dies suddenly each year. About 5 in every 100,000 young athletes have a heart condition that places them at risk for sudden death, and only 1 in 10 of them dies suddenly.

Safeguards for Playing

Each year more than 20 million boys and girls in the United States participate in nonschool recreational and competitive sports. Yet most volunteer coaches are unaware of a young athlete's vulnerability to injury, especially overuse injury. The coaches that supervise community sports programs are usually less experienced and knowledgeable than school phys ed instructors. Parents should assess the qualifications and techniques of their children's coaches and sports teachers.

      Every youth sports program should require a child to have a physical exam before he or she can play. This provides a pediatrician the opportunity to check for problems associated with specific sports and to assess a child's overall health. Facilities and equipment should be well maintained. Policies should be established for first aid, referral, and treatment of injured players. Ideally, a certified athletic trainer should be on hand for games, although this is not generally feasible. Every athlete should go through warmup and warmdown exercises before and after practices and games.

The Dangers of Steroids

An increasing concern among parents is the popularity of anabolic steroids and other performance enhancers. The medical issues surrounding the use of these insidious drugs don't seem to concern young athletes. Very few side effects of steroid use are immediately apparent, so young athletes are more likely to continue using steroids, ignoring the serious long-term medical implications. For more about steroids and their effects, see Chapter 3.

      Influencing adolescent athletes' attitudes toward steroids requires more than merely presenting information about the medical consequences of their use. Providing alternatives to performance-enhancing drugs, such as advice about good nutrition and strength-training techniques, may be more effective in discouraging steroid use. Approaches that enhance self-esteem, similar to those used in substance abuse programs, may help to keep adolescent athletes off steroids.

      Fortunately, steroid use is not difficult to detect. If your teenage son has undergone an aggressive personality change, has put on 30 pounds of solid muscle in the past year, and has developed severe acne on his upper body, chances are he hasn't just been eating his Wheaties. These are clear signs of steroid abuse. Other physical signs of steroid use in a teenage boy are hair loss, breast growth, and smaller testicles, which may lead to impotence.

Infant Exercise

Infant exercise programs are all the rage today, but I see no reason for them. Infants move as much as they are capable of, and toddlers never seem to stop. I'd like to see a fit adult try to keep up with a toddler. He'd poop out in half a day.

      There is no evidence that gym and swim classes will speed a baby's development of strength and balance, according to the American Academy of Pediatrics. Children develop skills in crawling, walking, jumping, and running through normal play. Each child is different and will progress at his or her own rate.

      What's more, very young children could sustain injuries from overly strenuous exercise. Broken bones, muscle strains, and dislocated limbs have resulted from infant exercise programs.

      Like any other child who grew up in the cold part of the country, I learned to ice-skate at age 3. My parents gave me an old kitchen chair to push around the ice until I was able to let go and not fall down. In the summer, we all splashed around in the water until someone began to move, and then we all did what he did. That's how I learned to swim. I firmly believe that the best sports training for infants or young children is simply to allow them to do what comes naturally.

THE OLDER ATHLETE

Molly, an 83-year-old tennis player, came to me because her elbow was bothering her. She played tennis every afternoon with her girlfriends, and she had begun to feel pain right after playing. I put Molly on a light weight-training program using dumbbells and stretching, and I told her to come back in a few weeks. When she returned, she said her elbow hurt even more. So I sat her down and had her describe her rehabilitation program to find out exactly what she was doing. Rather than doing 50 repetitions of the exercises I had given her, she was doing 500. No wonder her elbow pain was worse! I found it hard to yell at a well-meaning Jewish grandmother, so I asked her granddaughter to make sure Molly did only as much as she was supposed to do, not 10 times more. Within a few months, Molly was again frolicking pain-free on the tennis court.

      There is a common misconception that older people should remain sedentary because exercise could cause injuries and place undue strain on the heart. However, research now shows that much of what doctors have ascribed to aging is actually due to inactivity. Time and time again, I am visited by an elderly patient who complains that her doctor said she shouldn't exercise because she is too old, that exercise is not good for her. This is a trap many doctors fall into. Exercise is good for people regardless of their age.

      If your doctor takes the easy way out and says, "Don't exercise," you may be better off finding a new doctor. Most doctors can carefully determine what you can do physically and design a safe exercise program for you.

      Some doctors flatly state that anyone over 35 or 40 should check with a doctor before beginning a new exercise program. I don't agree. If you have been exercising regularly for many years, you probably can continue to exercise quite safely without a doctor's prescription. Only those people with known chronic diseases, such as high blood pressure, heart disease, lung disease, and diabetes, need to consult a doctor first.

      Someone who decides late in life to take up exercise needs to avoid undue stress on the heart. A sedentary older person who decides to start exercising regularly should have a complete, thorough checkup, particularly to ascertain the status of the heart.

      This does not mean that if you have heart disease you can't exercise. Exercise will benefit someone with mild to moderate heart disease by strengthening the entire cardiovascular system. Your doctor can set limits and outline appropriate levels of exercise. You should start your exercise program at a low level and advance very slowly so that you don't overstress your body.

MIDDLE-AGED ATHLETES

Athletes in their forties and fifties should continue to exercise at whatever level they are capable of. They should not feel that because they are over 40 they have to cut back.

      If an athlete is exercising at competitive level at age 39 or 49, the change in the level of exercise at age 40 or 50 should be totally insignificant. Keep doing what you have been doing until, for some reason, you can't do it any more. However, with increasing age, it becomes more and more important to listen to your body. It will tell when you are abusing it and when you should begin to back off. Injury or sickness can also cause an athlete to reduce his or her exercise level.

      Pitcher Nolan Ryan and boxer George Foreman have shown that athletes in their forties can compete with men half their age. But Nolan and George are anomalies. Emulating them may lead to injury and frustration, which the aging athlete certainly doesn't need.

ELDERLY ATHLETES

Elderly athletes are capable of participating in virtually all of the sports young people do. But they do need to take care to warm up properly. The warmup and warmdown periods should be almost as long as the exercise session itself. Take 10 to 20 minutes to warm up, then exercise for 20 to 30 minutes, and take another 10 to 20 minutes to warm down.

      An older athlete's injuries may take longer to heal, so be careful to rehabilitate yourself fully, and slowly, before returning to activity.

      Also, the elderly are much more likely to suffer from heat stress and dehydration than younger people. So make sure to drink plenty of liquids before and during exercise.

THE BENEFITS OF EXERCISE

We have to get away from the idea that if you can't run a marathon, you aren't fit. An elderly person needs only take a few brisk walks each week to increase his or her odds of living a long, healthy life. Almost any daily activity can increase the workload on the muscles and raise the heart rate. The elderly can keep fit by doing ordinary, useful activities such as mowing the lawn, cleaning the bathroom, and working in the yard.

      Exercise strengthens the heart and lungs, lowers blood pressure and cholesterol, thickens bones, tones muscles, and may improve memory. Moderate exercise also seems to boost the immune system and improve the reflexes of elderly athletes. Because of these benefits, elderly people who exercise tend to outlive their inactive contemporaries by two or three years. Even if they don't live longer, they will probably live better and remain independent longer. Thus, exercise improves the quality as well as the quantity of life.

Weight Loss

Weight loss is very important for the elderly. Everyone tends to put on weight with age, and it becomes more difficult to lose weight with the advancing years. New data out of the Framingham Heart Study reveal that being overweight at age 65 is accompanied by a significant increase in mortality.

      Exercise is still the best way to lose weight. A regular exercise program combined with a good, healthy diet will help you to keep your weight down.

      It doesn't matter what you do as long as you burn calories. Walking is just as good as running. The only difference is that it takes a little longer to burn calories through walking.

      A good diet is an essential part of any exercise program. Elderly people who successfully strengthen their muscles usually also eat well. Food provides the basic building blocks for muscle.

Muscle Strength

Stronger muscles enable the elderly to perform daily tasks more easily. Also, increased strength can help prevent falls, the leading cause of injury in older people. Just by lifting one-pound dumbbells and increasing the weight gradually, an elderly person can markedly increase his or her strength. I have found that bedridden people respond well to light weight training, and I recommend that all older athletes incorporate light weight training into their regular activities.

      Exercise all the major muscle groups two or three times a week for 20 to 30 minutes a session. Work on muscles of the chest, back, and trunk as well as the limbs. Light toning exercises are all that's necessary to increase strength.

      Certain people with chronic diseases should be carefully evaluated before they are allowed to begin a strength-training program. These include people with high blood pressure, those with uncontrolled angina, and those who have recently had a heart attack.

      Even very feeble people in their late eighties and nineties can benefit from light weight training. In one study, a group of frail nursing home residents, ages 86 to 96, achieved dramatic gains in strength, muscle mass, and walking speed after an eight-week program of supervised, highresistance leg training. By the end of two months, most participants had achieved a three- to fourfold increase in leg strength.

      Just as younger athletes must "use it or lose it," an ongoing conditioning program proved necessary to maintain these improvements in muscle strength. After a month of inactivity, the nursing home residents' leg strength dropped by one-third.

      These findings show that improvements in muscle strength, size, and mobility from exercise are not restricted to younger athletes. They also challenge the theory that muscle strength must decline with age. As we age, there is an unavoidable, biologically determined decline in muscle size; this is true even for elite athletes over age 40. Muscle strength declines 30 to 40 percent over the average adult's life span. However, an increasingly sedentary lifestyle causes muscles to atrophy more quickly, and older people tend to lose more strength than necessary simply because they decrease their activity level.

Well-Being

Even if you don't reach that peak range known as the exercise "high," a good exercise program can increase your physical and emotional well-being. Healthy older people say that they look better and that they have more energy, endurance, and flexibility. They sleep better, are more satisfied with life, and experience less anxiety.

      In addition to its health benefits, exercise increases your self-esteem. It's a good feeling to know that your body is not deteriorating. You can still do things and be active. You show yourself and others that you are not ready for a wheelchair just yet.

      Even if you are over age 65, you can control your physical and physiological destiny through exercise. Working out regularly can keep you physiologically younger. Exercising slows the various aging processes, such as the deterioration of muscle and connective tissue and the increase of fat. And it's never too late to begin.

      Simple stretching, range-of-motion, and deep-breathing exercises were shown to significantly improve the health and mobility of people in their seventies and beyond who were overweight, who had never exercised regularly, and who had serious chronic ailments, including arthritis, high blood pressure, heart disease, and diabetes.

Sharper Reflexes

Fitness helps to shorten reaction time by improving circulation in the brain. An active person of age 65 can have quicker reflexes than an unfit person 40 years his junior.

      Aerobic exercise can improve short-term memory, reaction time, and mental flexibility. People who exercise regularly process information faster than those who don't. Active people can react quickly enough to break a fall with their hands, whereas inactive people are more likely to fall with full force on their hips, which often results in permanent disability. So keeping the body active helps keep the brain active.

Special Benefits for Exercising Women

Exercise may benefit women even more than men. Walking and running help reduce bone loss and prevent osteoporosis. Bone densities are much higher in exercising women than in those who are sedentary.

      Also, women who exercise regularly starting at a young age are less likely to develop breast cancer. Obesity increases the risks of breast cancer, and exercise helps women remain lean. Researchers have reported lower rates of breast and reproductive system cancer in women who were athletes in college compared to their non-active classmates.

      In addition, elderly women who regularly perform endurance exercises have been found to undergo greater changes in cholesterol level compared with middle-aged women who exercise.

Additional Health Benefits

Many elderly people have stomach and intestinal tract problems. The increase in circulation brought on by exercise increases the tone of the gastrointestinal tract and prevents many of these problems.

      A person who has had a stroke or some muscular dysfunction certainly can benefit from exercise. Individualized exercise programs can help post-stroke patients return to a lifestyle as close to normal as possible.

      There is no evidence that aerobic exercise such as running, swimming, cycling, or walking causes arthritis or joint damage. Exercise, within reasonable limits, is good because it preserves the health of joints and muscles. I have found that people who suffer aches and pains from mild osteoarthritis do well if they keep their joints active.




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