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Age Related Issues in Sports Medicine

Original Editor - Josh Williams, Top Contributors - Purnima Raikwar, Adrienne Williams, Wanda van Niekerk, Natalie Johnston, Trent Harvick, Robert Morris, Evan Thomas, Josh Williams, Alexandra Stead, 127.0.0.1, Vidya Acharya, Mahbubur Rahman, Kim Jackson, Lucinda hampton, Jess Bell, Nupur Smit Shah and Carina Therese Magtibay  


Introduction

Sports medicine encompasses a broad spectrum of age-related considerations, from the growing musculoskeletal system of a child to the degenerative changes observed in older adults.[1] Age is one of the most significant determinants of injury type, severity, recovery capacity, and physiological response to training.[2] Understanding how the human body changes across the lifespan is essential for clinicians, coaches, and allied health professionals involved in sport and exercise medicine.[3]

In paediatric athletes, skeletal immaturity, physeal vulnerability, and ongoing growth create unique injury patterns that differ substantially from adult populations.[4] Adolescence introduces further complexity through rapid growth spurts, hormonal changes, and increasing sport specialisation.[5] In contrast, middle-aged and older athletes face challenges related to declining muscle mass, reduced bone density, altered metabolic function, and the sequelae of joint degeneration.[6]

Physiotherapists play a central role across all age groups in the prevention, assessment, and rehabilitation of sport-related injuries. An understanding of age-specific physiological changes enables physiotherapists to design appropriate exercise programmes, guide safe return to sport, and support long-term athletic participation throughout the lifespan.[7]

Paediatric Athletes (Age 5-12 years)

Preparticipation Screening (5-12 years)

Preparticipation physical examination (PPE) is a cornerstone of sports medicine practice and serves as the primary gateway to safe sport participation at every life stage. The goals, content, and tools of the PPE differ markedly depending on the age of the athlete.[8]

The Preparticipation Physical Evaluation monograph, produced collaboratively by the American Academy of Paediatrics (AAP) and other professional bodies, provides a validated framework for this assessment.[8]

The PPE in children and young adolescents should include assessment of growth and maturation status, physeal health, prior injury history, cardiovascular screening (including family history of sudden cardiac death and hypertrophic cardiomyopathy), musculoskeletal development, and nutritional status.[8]


Epidemiology and Injury Pattern (5-12 years)

Sport participation among children and adolescents is widespread globally.[9] In the United States alone, an estimated 2.6 to 3.5 million sport-related injuries occur annually,[10] making sports injuries a leading cause of paediatric primary care consultation, and accounting for approximately one in five paediatric emergency department visits.[11]

According to data from the Centers for Disease Control and Prevention (CDC), the highest rates of paediatric sports injuries occur in males aged 10-14 years.[10] Male athletes sustain more injuries during team sport participation, whereas female athletes experience a higher proportion of overuse injuries.[12] Female athletes are also disproportionately affected by anterior cruciate ligament (ACL) injuries, particularly in basketball and soccer.[13][9]

Due to skeletal immaturity, physeal plates remain vulnerable throughout childhood and adolescence, with physeal damage accounting for up to 10% of paediatric sport injuries.[14] During adolescence, rapid skeletal growth can contribute to reduced bone strength and decreased muscular flexibility, increasing the risk of fractures.[15]

Table 1: Most Frequent Injury Types by Age Group[13]
Age Group Injury Type
5-12 years Traumatic injuries, upper extremity injuries and fractures

Sport-Specific Injury Patterns (5-12 years)

Lower extremity injuries are the most common overall in paediatric sport.[13] Fractures are the most frequent upper extremity injury, with the hand being the most common fracture site.[13] Elbow injuries account for approximately 5% of paediatric sports injuries.[16] Heat illness and dehydration are significant concerns, particularly in football.[11] Approximately 20% of head injuries in the United States occur during sport.[17] Spinal cord injuries occur most frequently in football and cheerleading.[3] Cardiovascular events, including sudden cardiac death, are among the most serious paediatric sports injuries. Common causes include [cardiomyopathy] and anomalous coronary arteries, with rarer causes being Commotio cordis and Brugada syndrome.[18]

Table 2: Body Part Injuries by Sport Type[3]
Body Region Associated Sports
Foot and toes Taekwondo
Ankle Volleyball, track and field, basketball, soccer, cheerleading, lacrosse
Upper extremity Throwing sports, gymnastics, snowboarding, judo, baseball
Facial Martial arts, hockey
Cervical and spinal Contact sports, wrestling, football

Growth and Metabolic Changes (5-12 years)

Various metabolic changes occur across the human lifespan. As an individual ages from infancy to young adulthood, muscle fibre size increases approximately twenty-fold.[19] Type I muscle fibres decrease proportionally, while glycogen stores and phosphocreatine levels increase.[20] Oxidative enzymes are present at higher concentrations in children, whereas anaerobic enzyme activity is higher in adults. Blood lactate levels and glycogen depletion rates also increase with age.[7][20]

Children rely more heavily on oxidative metabolism for intense exercise activities compared to young adults and also demonstrate faster recovery from high-intensity exercise.[19] Mitochondrial activity and function are generally higher in children and young adults, while insulin and glucose levels are comparatively lower than in older adults.[7] Thermoregulatory capacity continues to develop through puberty, and resting metabolic rate decreases significantly between childhood and adulthood.[20]

Sport Concussion (5-12 years)

Sport-related concussion in paediatrics is a significant public health concern.[21] A large prospective study across 12 high school sports reported a concussion incidence of 0.24 per 1,000 athletic exposures, with boys' football (0.60 per 1,000) and girls' soccer (0.35 per 1,000) showing the highest rates.[22] Concerningly, concussion rates increased 4.2-fold over an 11-year observation period, suggesting growing incidence over time.[22]

Some research indicates that only 47.3% of concussions sustained by high school football players are reported to medical staff.[23] The primary reasons cited for not reporting include not believing the injury was serious enough to warrant medical attention (66.4%), desire to continue competing (36.1%), and lack of awareness that a concussion may have occurred.[23]

Risk Factors (5-12 years)

Experiencing a concussion makes an athlete approximately three times more likely to sustain a subsequent concussion in the same season.[24] Athletes who experience loss of consciousness during a concussion are four times more likely to sustain a future concussion involving loss of consciousness.[25] Athletes with three or more prior concussions are 6.7 times more likely to experience loss of consciousness.[24]

Assessment (5-12 years)

Assessment of sport concussion should include evaluation of loss of consciousness, post-traumatic amnesia, seizures, cognitive function, sleep disturbance, and emotional symptoms.[21] The Acute Concussion Evaluation (ACE), developed by the Centers for Disease Control and Prevention, provides a validated framework for acute assessment and follow-up planning.[26] The Sport Concussion Assessment Tool (SCAT6) is the most widely used side-line assessment instrument and is validated for use in athletes aged 13 years and over, with the Child-SCAT6 available for those aged 8-12 years.[27]

[10]

Return to Sports (5-12 years)

Current international consensus (Amsterdam 2022 consensus "Concussion in Sport Group guidelines") recommends that return to learn should be achieved before return to sport in paediatric athletes.[21] An appropriate stepwise return to sport protocol is recommended, requiring the athlete to be asymptomatic at each stage before progression. Return to sport should follow an individualised, gradual progression, with advancement only if symptoms do not worsen during or after each stage. If symptoms persist beyond three months, a full neuropsychological evaluation is indicated.[21] Physiotherapists have an important role in vestibular rehabilitation, cervicogenic symptom management, and graduated exercise therapy during concussion recovery.[28]

Injury Prevention Programme (5-12 years)

Injury prevention is a key physiotherapy skill in sports medicine. Prevention strategies and programmes are most effective when tailored to the athlete’s age and stage of development.[29]

A 2024 systematic review and network meta-analysis of exercise-based IPPs in youth team sport athletes (aged <19 years) demonstrated that such programmes reduce overall injury incidence rates by approximately 35%.[30] Interventions comprising strength and flexibility training, as well as those including stability exercises, were found to be the most effective components for reducing injuries in youth team sports.[31] Structured warm-up programmes (the FIFA 11+ Kids) are evidence-based, cost-effective tools that can be readily implemented by physiotherapists and sports scientific staff working in youth sport settings.[32]

[33]

Physiotherapy Management (5-12 years)

Physiotherapists are integral members of the sports medicine team across all age groups. The specific focus of physiotherapy management varies according to the developmental stage and clinical needs of the athlete.[34]

Priorities: Growth plate injury, Fractures, Heat illness prevention.[5]

Key role: Physeal injury assessment and rehabilitation, overuse injury management, Education of parents and coaches.

Adolescent Athletes (13-17 years)

Preparticipation Screening (13-17 years)

Screening for adolescent athletes should additionally include assessment for early sport specialisation risk, relative energy deficiency in sport (REDs), psychological wellbeing (including burnout risk), and musculoskeletal asymmetries associated with rapid skeletal growth.[35]

Table 3: Most Frequent Injury Types by Age Group[13]
Age Group Injury Type
13-17 years Pelvis, spine and chest injuries

Female athletes are disproportionately affected by anterior cruciate ligament (ACL) injuries, particularly in basketball and soccer. During adolescence, rapid skeletal growth can contribute to reduced bone strength and decreased muscular flexibility, increasing the risk of fractures.

Early Sports Specialisation in Adolescents (13-17 years)

Early sport specialisation (ESS) is defined as year-round participation in a single sport, typically before the age of 12 years, with the cessation of all other sports.[36] While ESS is common in modern youth sport, with prevalence rates of 17-41% reported in youth athletes, growing evidence highlights significant risks associated with this practice.[37]

Risk factors for injury in young athletes who specialise include:[36]

  • Year-round single-sport training
  • Increased volume of competition
  • Decreased age-appropriate free play
  • Involvement in individual sports requiring early technical skill development
  • Parental and coaching pressure towards specialisation

Early sport specialisation is associated with hindrance of overall motor development, increased risk of overuse injuries in the short term, risk of severe injuries over an athlete's career, and higher rates of burnout and early retirement from sport.[5] The degree of specialisation is positively correlated with increased serious overuse injury risk.[38]

Psychological Aspect (13-17 years)

Psychological consequences are also significant. Early sport specialisation is associated with high psychological burden, including increased risk of athlete burnout, performance anxiety, and sport-related identity issues in adolescent athletes. [39][5] A 2024 longitudinal study confirmed that specialisation and burnout increase progressively from junior high to high school, while overall sports participation decreases.[40] Physiotherapists should routinely screen for psychological wellbeing and refer to sports psychology services when indicated.[41]


Relative Energy Deficiency in Sports (REDs) (13-17 years)

Relative Energy Deficiency in Sport (REDs) is a syndrome characterised by low energy availability (LEA) and its multisystemic consequences on health and performance.[35] It reflects an evolution of the earlier concept of the Female Athlete Triad, which described the interrelationship between low energy availability (with or without disordered eating), menstrual dysfunction, and low bone mineral density.[42]

The 2023 International Olympic Committee (IOC) consensus statement on REDs broadened the conceptual framework to include male athletes and recognise the extensive physiological impact of LEA beyond the three components of the original Triad.[35]

Athletes most at risk for REDs include those participating in:[43]

  • Aesthetic and leanness sports (gymnastics, ballet, figure skating)
  • Weight-category sports (boxing, wrestling, martial arts)
  • Gravitational endurance sports (cycling, distance running)
  • Adolescent female athletes with high training volumes

The physiological consequences of REDs include impaired bone health (including stress fractures), menstrual dysfunction, impaired immune function, reduced muscle protein synthesis, impaired cardiovascular function, and impaired psychological wellbeing.[35] Low bone mineral density resulting from REDs is of particular relevance in the adolescent athlete, where peak bone mass accrual is a critical developmental process.[35]

Injury Prevention Programme (13-17 years)

Physiotherapists working with adolescent athletes should routinely screen for overuse injury patterns associated with early specialisation, including apophyseal injuries (Osgood-Schlatter disease, Sever's disease), stress fractures, and joint-specific overuse syndromes.[5] Education directed at athletes, families, and coaches regarding the benefits of multi-sport participation during childhood is an important component of the physiotherapist's preventive role.[36] As with younger children, exercise-based IPPs (strength, flexibility, and stability training) reduce injury incidence by approximately 35% in youth team sport athletes under 19. Structured warm-up programmes such as FIFA 11+ remain relevant tools in adolescent sport settings.

Physiotherapy Role and Management (13-17 years)

Physiotherapists are well positioned to identify REDs in athletes presenting with stress fractures, recurrent - musculoskeletal injury, or unexplained fatigue. One US study found that fewer than 50% of physicians, coaches, physiotherapists, and athletic trainers can correctly identify all components of the Triad and REDs, highlighting the importance of ongoing education. Early identification and onward referral to a multidisciplinary team (including a sports physician, dietitian, and psychologist) is essential for management.[44]

Priorities: ACL injury prevention, concussion, overuse injuries, burnout.

Key roles: Load monitoring, REDs screening and referral, concussion rehabilitation (vestibular rehab), safe return to sport, injury prevention programmes.

Young Adults (18-34 years)

Table 4: Most Frequent Injury Types by Age Group[13][45]
Age Group Injury Type
18-34 years Sprains and Strains

Injury Prevention Programme (18-34 years)

A 2024 systematic review of exercise-based injury prevention programmes in adult recreational athletes (aged >16 years) found evidence of injury risk reduction across a range of exercise modalities, though heterogeneity between studies was noted. [46] Neuromuscular training components demonstrated the most consistent injury risk reduction benefits.[31]

Physiotherapy Management (18-34 years)

Priorities: Ligamentous Injuries, Overuse, Sports-specific injury.[47] Key role: Sports injury rehabilitation, injury prevention programme, return to sports planning, performance optimisation.

Middle-Aged Athletes (35-59 years)

Pre-participation Screening (35-59 years)

In adult and masters athletes (aged 35 years and over), cardiovascular risk stratification becomes the priority. Pre-participation Screening should assess a variety of medical comorbidities, with particular emphasis on cardiovascular health in high-risk individuals.[7] Questionnaires such as the Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) provide a validated, age-appropriate starting point for screening adult athletes prior to sport participation.[7]

Metabolic and Musculoskeletal Changes (35-59 years)

From approximately the fourth decade of life, muscle density and bone mass begin to decline. This decline progresses with advancing age, eventually leading to sarcopenia and osteoporosis if not addressed through physical activity and nutrition. Body fat is redistributed centrally and can infiltrate muscle and visceral organs, particularly in sedentary individuals.[48]

Osteoporosis onset is accelerated in post-menopausal women from approximately the fifth decade. It is characterised by decreased bone mass and increased risk of bone fractures, disability, and mortality.[1] Sarcopenia - the progressive loss of skeletal muscle mass and function- is a normal part of the ageing process. Muscle strength in the back, legs, and arms can decrease by as much as 20 to 40% by the age of 80.[2] A longitudinal study of adults aged 65-75 years demonstrated a 2.5% per year reduction in both knee extensor and knee flexor strength.[49]

Normal ageing losses are compounded by sedentary behaviour, which hastens the onset and severity of both sarcopenia and metabolic decline. The American College of Sports Medicine (ACSM) recommends that exercise and appropriate nutrition are both effective strategies for slowing sarcopenia and maintaining adequate bone mass in older adults.[50]

Psychological Aspect (35-59 years)

Middle-aged athletes may face psychological challenges related to accepting declining physical performance, adjusting training expectations following injury, and managing motivational shifts across their athletic career.[51] Psychological readiness is a validated predictor of successful return to sport following injury and should be formally assessed during rehabilitation.[47]

Total Joint Replacements and Sport

Total Joint Replacement (TJR) is a surgical procedure which is increasingly performed in older adults with end-stage joint degeneration, most commonly due to osteoarthritis. The damaged joint is replaced with a prosthetic implant.[52] The most frequently performed procedures are:[53]

  • Total Knee Replacement (TKR)
  • Total Hip Replacement (THR)

TJR is primarily indicated for pain relief and restoration of quality of life. With increasing life expectancy and higher expectations for maintaining an active lifestyle many individuals undergoing TJR wish to return to recreational or competitive sport following surgery.[53]

Current evidence regarding sport participation following TJR is conflicting, with concerns that high-impact sport may increase the risk of prosthetic loosening or component wear, necessitating revision surgery.[54] An active lifestyle increases an individual’s muscular strength, endurance, proprioception, cardiovascular health, balance, and coordination, decreasing the likelihood of injury and falls. Studies found that patients with a TJR also benefit from physical activity, but the level of activity is controversial.[54]

Low-impact sports like walking, water aerobics, cycling, swimming, and cross-country skiing are healthy and recommended by most surgeons which decreases the risk of revision, when compared to more sedentary individuals.[55] An increase in low-impact sports participation was reported in individuals who received a total hip arthroplasty.[56] Moderate-level sports activity like doubles tennis, hiking, and light resistance training generally require individualised assessment. Some studies suggest that high-impact sports exercises (e.g. running or basketball) may:[54]

  • Increase stress on the prosthesis.
  • Cause wear of the implant.
  • Lead to loosening of the implant from bone.
  • Eventually require revision surgery, which replaces or repairs the artificial joint.

Physiotherapy Role and Management (35-59 years)

Regardless of the sport an individual wishes to return to following TJR, it is recommended that they discuss their activity goals with their surgeon prior to or at the time of surgery, to allow selection of the most appropriate implant type and surgical approach. Physiotherapists play a key role in postoperative rehabilitation, progressive loading, proprioceptive retraining, and safe return to sport planning for persons following TJR.[34]

Priorities: Joint Degeneration, Body composition, Cardiac health.[2][57]

Key role: Osteoarthritis management, sarcopenia- delaying exercise prescription, post TJR - rehabilitation, cardiovascular risk awareness.

Senior and Masters Athletes (60+ years)

Masters athletes should follow regular, structured training regimens to maximise performance potential whilst minimising injury risk.[48] A multidisciplinary approach to care encompassing physiotherapy, sports medicine, and nutrition is recommended, with attention to recovery requirements between training sessions, which may be prolonged compared to younger athletes.[58] Falls prevention exercise programmes like Otago (Otago Exercise Programme), balance-based resistance training, have strong evidence for reducing injury risk in those aged 65 years and over.[59]

Psychological and Social Aspects (60+ years)

Psychological factors are integral to sports participation and injury risk at every age.[60] Physiotherapists should be aware of age-specific psychological considerations when assessing and managing athletes.[41]

Participation in masters sport is associated with significant psychological and social benefits.[61] Qualitative research with masters athletes aged 50-79 years found that all participants experienced social and psychological benefits from sport engagement, including improved sense of purpose, social connection, and wellbeing.[62] These findings have important implications for physiotherapists advocating for continued sport participation in older adults.[63]

Sport Training in Masters and Senior Athletes (60+ years)

Masters athletes (typically defined as competitive athletes aged 35 years and over) represent a growing and clinically important population in sports medicine. Adults aged over 80 years represent the fastest-growing demographic globally, and evidence consistently demonstrates that the benefits of physical activity and sport training in this population are substantial.[50]

Benefits of regular physical activity and sport training in senior athletes include:[64]

  • Reduced incidence of injurious falls
  • Improved muscular strength and endurance
  • Decreased incidence of coronary artery disease
  • Lower risk of cardiovascular-related mortality
  • Maintained muscle mass and reduced risk of sarcopenia
  • Improved balance, proprioception, and coordination
  • Psychological and social wellbeing benefits

Research comparing masters athletes to sedentary age-matched peers demonstrates substantially better anthropometric, physical function, and general health characteristics in the active group. In one cross-sectional study, no masters athletes were classified as sarcopenic, despite significant age-related reductions in handgrip strength and an increasing number of chronic conditions in the oldest participants.[64]

ACSM Training Guidelines (60+ years)

Table 5: ACSM Training Guidelines for Older/Senior Athletes:[7] [65]

Training Components Frequency Intensity/Details
Aerobic Training 3 to 5 days per week 55 to 90% maximum heart rate or 40 to 85% VO2 reserve, 20 - 60 min. continuous or intermittent, activities engaging large muscle groups (walking, cycling, swimming, rowing, stair climbing).
Resistance Training 2 to 3 days per week One set of 10 to 15 repetitions for major muscle groups, progressive loading as tolerated.
Flexibility Training 2 to 3 days per week (minimum) Stretch major muscle groups, hold and relax technique, hold for 30 seconds, with 4 repetitions per muscle group.
Balance Training Daily or as a part of exercise sessions Particularly important for those at risk of falls, static and dynamic balance exercises recommended.


A basic understanding of physiology and age-related changes in muscle composition, cardiovascular function, and performance is essential for any clinician providing care to the masters athlete.[48] Osteoarthritis and joint arthroplasty are not contraindications to exercise in this population, and appropriate analgesia has a role in supporting participation in the context of acute or chronic injury.[66] Masters athletes are best cared for through a multidisciplinary approach, with attention to their specific physiological and psychological needs both during competition and during training periods.[7]

Physiotherapy Management (60+ years)

Priorities: Falls, Sarcopenia, Osteoporosis, Cognitive health, Social Engagement.[50]

Key role: Falls prevention, cardiovascular exercise prescription, balance and proprioception training, multidisciplinary co-management.

Conclusion

Age is one of the most powerful factors shaping how athletes experience injury, respond to training, and recover during rehabilitation. From childhood through older adulthood, physiotherapists must adapt their approach to match the unique needs of each stage of life.

Paediatric and adolescent athletes face challenges linked to growth and development. Their bones and joints are still maturing, which makes growth plates vulnerable to injury. Overuse problems such as stress fractures or tendinopathies are common, especially in those who specialise too early in a single sport. Concussion management and education around Relative Energy Deficiency in Sport (RED‑S) are also critical at this age. Careful screening and age‑appropriate guidance help protect the developing musculoskeletal system and support safe participation.

As athletes move into adulthood, the clinical focus shifts. Cardiovascular risk assessment becomes more important, alongside managing ligament injuries and sport‑specific demands. Physiotherapists play a central role in guiding safe return‑to‑sport decisions, balancing performance goals with long‑term health.

In middle and older age, priorities evolve again. Age‑related changes such as sarcopenia, osteoporosis, and joint degeneration increase the risk of falls and chronic pain. Physiotherapy interventions emphasise strength, balance, and independence, while also recognising the psychosocial benefits of continued sport participation. For those undergoing procedures like total joint replacement, physiotherapists help ensure a safe and meaningful return to activity.

Across all stages of life, physiotherapists provide tailored support: protecting the growing body in youth, guiding performance and recovery in adulthood, and preserving mobility and wellbeing in later years. A deep understanding of age‑specific physiology, injury patterns, and psychological factors allows them to design evidence‑based programmes that keep people active, safe, and engaged in sport throughout their lifespan.

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  49. ↑ Goodpaster BH, Park SW, Harris TB, Kritchevsky SB, Nevitt M, Schwartz AV, et al. The loss of skeletal muscle strength, mass, and quality in older adults: the Health, Aging and Body Composition Study. J Gerontol A Biol Sci Med Sci. 2006;61(10):1059–1064.
  50. ↑ 50.0 50.1 50.2 World Health OrganizationWHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organization; 2020.
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  52. ↑ Katz JN. Total joint replacement in osteoarthritis. Best practice & research Clinical rheumatology. 2006 Feb 1;20(1):145-53.
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  55. ↑ American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty and Surgical Management): Clinical Practice Guideline. Rosemont (IL): AAOS; 2021.
  56. ↑ Chatterji U, Ashworth MJ, Lewis PL, Dobson PJ. Effect of total hip arthroplasty on recreational and sporting activity. ANZ Journal of Surgery. 2004 Jun;74(6):446–9.
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