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It is absolutely imperative that we fitness industry folks understand that degeneration is a normal aspect of aging. If we told everyone with degeneration not to exercise, everyone would suddenly be sedentary, and a host of greater problems would rapidly arise.

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If you don’t have some signs of degeneration, then you’d be “abnormal.” I’m fairly certain that if all of the people reading this post were to obtain full body MRI’s, evidence of degeneration would show up in multiple regions of the body in 100% of individuals. Want some evidence?

First, let’s talk about spinal intervertebral discs. Around 20% of teens have mild disc degeneration, and 60% of discs of 70-year olds are severely degenerated (Urban and Roberts 2003). If you’re looking at the L5-S1 disc of 70-year olds, over 90% of them will be degenerated (Hagiwara et al. 2014).

Looking at people with zero back pain, 64% have abnormal discs (52% had bulges, 27% protrusions, and 1% extrusions), with 38% of the individuals having abnormalities in multiple discs (Jensen et al. 1994). According to a systematic literature review by Brinjinkji et al. 2015, “The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age.”

When looking at arthritis, around 7% of 18-44 year olds have it, and in persons 65 or older, this percentage rises to 50% (2010-2012 NHIS).

If we hone in on the knee joints, 20% of persons under 65 have knee osteoarthrits, whereas 50% of persons over 65 have it (Bhatia et al. 2013). Even 50-90% of athletes with no pain have serious knee abnormalities under MRI (Brunner et al. 1989, Mayor & Helms 2002, Kaplan et al. 2005, Walczak et al. 2008). Regarding meniscal tears, here’s what Dr. Felson had to say: “The rule is, as you get older, you will get a meniscal tear. It’s a function of aging and disease. If you are a 60-year-old guy, the chance that you have a meniscal tear is 40 percent.”

At the hip, 100% of persons older than 60 have acetabular rim degeneration (Leunig et al. 2003), and 63% of gymnasts have signs of ischiofemoral impingment (Papavasiliou et al. 2014).

If we examine the shoulder joints, we’ll see that 31% of persons older than 60 have shoulder osteoarthritis (Chillemi & Franceschini 2013). In 40-70 year old males, 96% have abnormal ultrasound scans – ranging from subacrominal-subdeltoid bursa thickening (78%), acromioclavicular joint osteoarthritis (65%), suprispinatus tendinosis (39%), subscapularis tendinosis (25%), partial-thickness tear of the bursal side of the supraspinatus tendon (22%), posterior glenoid labral abnormality (14%), amongst other abnormalities (Girish et al. 2011). Dr. Andrews found that in healthy professional baseball pitchers, 90% had abnormal shoulder cartilage and 87% had abnormal rotator cuff tendons. For this reason, he stated, “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI.”

As you can see, degeneration is not abnormal – it’s a normal process of aging and it shouldn’t be thought of as a reason to stop moving and exercising. Every single one of us have degeneration, yet we still find ways to exercise. Strength & conditioning and sports medicine professionals must embrace this phenomenon and provide recommendations as to how individuals with varying signs of aged joints can continue being active, employ resistance training, and participate in sports in the most optimal manner possible. This requires consideration of total health & wellness, since sedentarism can lead to weight gain and obesity, metabolic syndrome, frailty and sarcopenia,  and depression (for a comprehensive list of reasons why exercise is beneficial, click HERE).

Focusing on people’s degeneration can provide a nocebo effect which is counterproductive and can lead to pain or increased pain. Instead, we should focus on what people can do (not what they can’t), and augment the way we talk about “degeneration” by assuring people that it’s normal and part of getting older. Activities and exercises can be modified so that individuals can well-tolerate them. Knowledge of proper progressions and regressions (I refer to this as, “Movement Pattern Continuums“) in resistance training goes a long way in keeping people strong and healthy.

Props to The Sports Physio Adam Meakins for providing me with the idea for this blogpost.

 

30 Comments

  • greg says:

    I’ve been looking around for a sports-medicine physician. So many of them also work in pediatrics :-/
    It’s about time for a new speciality: geriatric sports medicine.

  • jay says:

    Wait a second Bret, So I could cherry pick most normal people’s Imaging study’s, find something wrong and recommend them for some sort of elective surgery :P. I guess that is another can of worms.

  • Pete says:

    I’m 42, and I was so crushed when I finally accepted that knee arthritis would prevent me from ever again doing squats without severe pain. But I can still do hip thrusts and deadlifts without pain, so that’s where I’ll focus my efforts.

  • Jim says:

    I apologize but I have to disagree with this post. It is true that degeneration is present in the population but we should fix it not work around it. I’ll give the recent example of a segment on npr discussing the lack of back problems and degeneration in “primitive” cultures. These people’s spine assumes a “j” curve instead of the “s”curve spine so common in the “developed” world. They have no back problems well into old age because of the position their spine is held in – the spine, held by muscles which are controlled by the nervous system.

    The problem isnt that people simply fall apart at a certain age or even begin to. The problem is our cns is sending the wrong commands to stabilize joints and properly absorb internal an external forces thus creating inflammation which causes degeneration and a shut down of nervous function particularly with respect to support mechanisms like hormonal secretion, digestion and immune function to name a few. If this is the case, and I believe it is, it is obvious that there will be a rapid decline in physical ability and bodily function as we age. If you drive a car in poor alignment with no shocks the car breaks down very fast. Same thing for the human body. The key then is to communicate to the cns the ideal and desired pattern of motor activity to maintain the proper bodily position and to avoid degeneration. Actually it should be the exact opposite of your assertion if training is sound. Connective tissue should thicken, bone density should increase and organ and immune function should improve through the process of training.
    Respectfully,
    J

    • nell says:

      Although the histological mechanisms underlying tendinopathy are still not well understood, what people mistakenly call “tendonitis” is not now thought to relate to inflammatory processes. Better posture is not going to prevent or cure failed collagen healing. Also, it takes a long time for tendinosis to improve – that’s if it ever does (because in some people, it just *doesn’t* improve). You learn to live and work around it, that’s it. Same for osteoarthritis.

      There is still debate over tendinopathy in the medical and rehab community. Some still believe it’s related inflammation, and want to give you cortisone shots and anti-inflammatories. Finding a knowledgeable practitioner is pure luck. By the time you learn enough to ask the right questions to find someone good, an acute injury may well already be chronic, and then you’re really out of luck.

      I appreciate this post, Bret. It’s frustrating to feel cut off from the activities you see other people your age enjoying, especially if you’re under 40. You *do* feel alone, and old before your time. Thank you for normalizing the experience.

      One issue with working out once you’ve been injured is not knowing how to interpret pain signals, which might mean something different than they did in your 20s. A little pain during exercise can mean nothing at all, and you can just ignore it (the way you did in your 20s). Or, it can be the start of a lifelong impairment, if you don’t watch it. With tendon issues, often, by the time you even feel the pain, the damage to tissue has already set in. Also, lots of people don’t want to accept that they’re vulnerable, or feel like they’re not really working out unless they’re pushing themselves. Or, they’re impatient with the lengthy healing process. Figuring out how to work smart, instead of hard, is definitely a learning process.

    • Chris says:

      The intention of the article, and the author or Bret may correct me if im wrong, was exactly the opposite of what you thought it would be: it is an appeal to stay/get fit and healthy, to continue training and improving your capabilities even if that means working around some things in some circumstances. It is placed as a caveat that even when documenting abnormalities or degeneration – be it due to an unhealthy lifestyle as youre stressing which is certainly right in many cases, or due to simple ageing (you just cant deny this, give me a 90 year-old “primitive culture member” and youll see that he probably isnt as fit as a 30 year old) – you should go on. And not let you discourage by catastrophic-sounding diagnoses because these findings wont prevent you from training in some individually adequate way.

      • nell says:

        I absolutely do work out, as best I can! I do bodyweight exercises, and use the cable machine or bands, and I rotate between cardio machines for CV health. It’s just extremely frustrating not to be able to run, or skate, or swim, or lift the heavy weights I’d like to lift – just to have to be cautious in the ways I do, all the time, even with ordinary things like going grocery shopping. You can’t help but look over your shoulder at people doing amazing things with their bodies and having a ball with their physicality. So it helps to know you’re not alone.

    • Bret says:

      Jim, of course we should use good form and try to minimize degeneration throughout life. But thinking you can prevent it is wishful thinking. Several studies show a sweet spot with loading/physical activity and degeneration/arthritis/etc. Too little or too much isn’t ideal, with just the right amount in the middle. Even then, you’re going to break down a bit. For example, look at the hips in the elderly – even if you did everything right and used great form, your going to have acetabular rim degeneration, it’s just a rule of life. We shouldn’t pussy foot around this.

  • Jack says:

    Jim is right. I’ve even used weight training, stretching, swimming, and jogging to stop degeneration and correct degeneration when very expensive doctors, hospitals, and chiropractors failed. Now as I age degeneration should only be a worry for overusing in physical activities not misusing our bodies with too much sitting.

    Industrial cultures are abusive in their expectations with how our bodies are expected to spend so much time every day sitting in chairs. We should have 8 hour work days divided into two 3 hour segments and 2 hours to eat lunch and exercise with the exercise being at a facility on-site or within 10 minutes walk or drive from the work place. Schools likewise not to change with 2 hours for physical activity (hint: not shopping, TV, or video games although dancing would be OK) and lunch. I believe with the lifestyles we lead weigh lighting and stretching are musts to remedy the deficit. I’m not talking Mr Universe bodies as a goal but physical fitness.

    The horrid statistics you cite to back your case are biased toward those that are injured and do have degeneration and severe enough to ask for help in alleviating problems from the degeneration.

    That’s not to say that we all don’t suffer from the degeneration but those that are more physically active tend to avoid injuries and debilitating degeneration more that those that are inactive.

    One of the more important things I found out personally as having both started weight lifting and stretching to remedy a pinched shoulder and upper vertebra not quite lining up correctly and having stopped weight lifting and stretching is the weight lifting and stretching just as importantly remedy and correct poor posture, weak muscles and the do a lot to prevent the degeneration in the joints, tendons, and bones that the poor posture and weak muscles are causing.

    I was in an auto accident and thrown from a horse and those accidents combined to stretch the ligaments binding my hips in the center such that one hip / leg is higher than the other and for about 10 years occasionally from the pain in the center of my hips becoming so intense I would blackout. There was also much bone rubbing in the ball and socket joints of the hips as well. I visited several experts but that were powerless against the type of injury I had. What finally stopped that was me developing the muscles in my hips such that they could support my skeleton in the new (mis)alignment with stronger muscles to protect the bones, ligaments, tendons, and such.

    • Bret says:

      Jack – did you see the studies I quoted above with NBA and NFL players? They’re more jacked up than normal people. There’s a classic study by Videman on the spine (Brad and I quoted it in our “To Crunch or Not to Crunch” article for SCJ) – shows that too much or too little activity and loading was not beneficial for the spine, with a sweet spot in the middle. There’s another showing the same thing with arthritis.

      I definitely agree that we can combat and minimize degeneration through some of the things you suggested (using good form, stretching, staying strong, having a good program design that allows for optimal recovery, listening to our bodies and autoregulating, changing posture regularly, etc.), but we definitely can’t prevent it from happening altogether. Thinking otherwise would be foolish. And there’s also a strong genetic component to degeneration (Battie, a prominent spinal researcher, estimates something like 70% of disc degeneration is genetic, which is crazy!).

  • Jim says:

    Chronic inflammation is highly associated with poor diet, toxic exposure, poor vagal tone, and/or poor bodily posture. Though it may be normal it is not healthy and there is a way out. For example there are studies which show that fasting can decrease systematic inflammation and reverse rheumatoid arthritis https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.nutritionalresearch.org/sites/ntr.civicactions.net/files/research/autoimmune-waterfasting.pdf&ved=0CCwQFjAEahUKEwjR0OrhvpDGAhUEmogKHYqNADY&usg=AFQjCNHC-_p1KtXeK4mY-PM6Tj4gH7YjEA&sig2=pm-X8DOf748JUKoHsOAsWA Whatever the limitation you must eliminate the unhealthy stressor first before healing can occur. In the case of most people there is a constant inflammatory load from the way we move. Not a big suprise after spending most of our lives in a seated posture, hence the big emphasis on this site to just turn on a persons glutes.

  • nell says:

    I think we’re talking about two different things, here. I agree that healthy movement throughout the day is valuable for many reasons, including minimizing unnecessary or pathological mechanical stress; I agree that eliminating a stressor is a prerequisite for addressing whatever noxious effects it may have, generally. I can’t say I follow with respect to how improving posture might directly tie in with systematic inflammation of the kind observed in autoimmune disorders.

    The inflammation I was referring to was regarding older theories of tendinopathy, specifically:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1122566/

  • Jim says:

    Nell,
    When you mentioned your physical limitations (with your knee I believe please correct me if I am wrong) The first thing that popped into my mind was – front dominance which is related to pelvic tilt. Interestingly enough Bret wrote an article a few weeks back detailing his thoughts on pelvic tilt. I believe he came to the conclusion that an anterior pelvic tilt was somewhat the norm especially amongst high level athletes and that we should not do much in the way of correctives with respect to the increased lumbar lordosis ( please correct me if I am incorrectly paraphrasing you Bret). That of course would increase lumbar lordosis along with the thoracic kyhphosis and cervical lordosis. Basically it would put your spine in an S curve instead of the J curve you were born with. An s curve increases the torques acting upon the spine as the external load has a greater lever arm to work with. Basically and S curve spine requires more internal force to stabilize and move.

    An anterior pelvic tilt also means the hamstrings are maintained at a longer length. Their tension becomes passive and they cannot act as an efficient stabilizer of the knee. Meaning when you try to fire your quads to jump, sprint, lift a heavy load etc. it is like shooting a cannon from a row boat, there is no stability so inefficiency, injury and degeneration will in-sue. Many often forget that antagonist is just another word for dynamic stabilizer.

    The problem is this, because of some compensation or past injury you lack the ability to properly stabilize your knee or knees. When this occurs inflammation shuts down your nervous system causing afferent or sensory amnesia, your brain stops recognizing that there is muscle there, in the injured site that requires resources like blood flow and so it send none or sends very little not matching the metabolic requirements of use or recovery so the tissue does not heal. It is a NEUROLOGICAL problem not a tissue problem. How do I know this… well I use to work for a company called ARPwave owned by a controversial figure, Jay Schroeder, and I have literally seen people with degenerative arthritis unable to open their hands do so with in minutes after their neurology was properly stimulated with carefully design EMS protocols. He used technology to trick the brain into thinking everything is fine in an area that is damaged and inflamed. Once the brain thinks everything is sunshine and rainbows it resumes normal function delivering blood flow to the area allowing for healthy healing of any degeneration and a return to normal or better than normal function.

    I have another example, there is a therapy known as Prolozone therapy in which the ozone gas and a cocktail of nutrients are injected into damaged tissue the gas diffuses and rapidly degrades into O2 which oxygenates the tissue jump starting the healing process. The solution in both cases, Prolozone, and ARPwave ems technology is to oxygenate and deliver the proper nutrition to the tissue something that could not occur normally because of the inflammatory response. In both cases individuals who were told by multiple doctors that they required joint surgery were able to forgo the surgery and resume or exceed the activity they engaged in before the injury. These things can be achieved without ems or prolozone therapy but you have to understand the limitation present and the desired end goal.

    Nell, with respect to systemic inflammation and posture I would appeal to the concepts of allostasis, allostatic load, and allostatic overload. We want to be in a state of allostatis because in this state we are most able to respond to stress like physical danger, emotional stress, adaptation to training etc. It basically allows us to adapt to whatever life throws at us. It can be thought of as resilience. When we experience stress it manifests in the body as inflammation. Neurological inflammation can be a result toxin exposure or mental stress and elevated cortisol levels which can result in brain atrophy and decreased vagal tone which in and of itself increases systemic inflammation exacerbating the problem. There is also stress from training and movement. The latter is often ignored but can be a large source of allostatic load which lowers our level of resilience or allostasis and increases the chance of allostatic overload ie. Disease, injury, mental breakdown (loss of emotional control, etc.) If posture is poor every movement you make increases allostatic load and decreases allostasis lowering your resilience and ability to adapt to changing situations.

    Degeneration isn’t a necessary aspect of life though it may appear to be so. There is no law that says once you hit such and such age your bones must start losing calcium and your tendons and ligaments must start losing collogen. There is a reason this occurs. Effects are a product of cause and condition. Before you assume degeneration is necessary component to aging I would appeal to you to investigate the conditions which allow for the effect. Degeneration isn’t caused by aging or even living but aging and living coupled with the condition of living in a western culture (poor diet, stress management, etc), having short hip flexors, in general assuming a poor posture, and not having the knowledge to do otherwise creates the effect ie. Degeneration. Consider that your spine hasn’t been in the proper posture since you were a young child, that like most people in the developed world you are front dominant. Then ask yourself is it reasonable that I struggle with back, knee, ankle, and neck problems. Finally if its reasonable to assume that these conditions contributed to the effect ask yourself what is the way back to health and balance.

    • nell says:

      Hi Jim,

      I’m sorry I missed your reply. Thank you for taking the time to further explain your reasoning. I don’t want to take up too much more space here, but yes it’s true, others have talked about a neurological component playing a role in maintaining chronic pain, and I think there’s no doubt stress causes general inflammation and influences systemic immune responses. I guess the questions I have would be, how *much* of a role does all this play (in a normal population) compared to genetic influence (i.e. tissues) and just the nature of the specific trauma/s, and how direct is that relationship, especially when it comes to a local ortho (not rheumatic) injury? (FWIW, yup it’s knees [2], a shoulder, wrists [2], an ankle, and a hip.)

      Always learning, here 🙂

      • Jim says:

        Hey Nell, in my experience the relationship is huge. I mean huge! Since I have taken the time to deal with these extraneous sources of stress everything training and performance wise has fallen into place. I adapt faster, heal faster, perform better and in general I am more aware and responsive to my bodies needs to maintain a high level of function.

        It is actually my belief that this has a much larger effect on performance and adaptation than genetics do.People always complain about their perceived genetic limitations, ” I will never be, fast, super strong, muscular, etc because I have bad genes.” I’m sorry where did you get your genetic testing and subsequent analysis of your abilities from? Oh yea you pulled it out of your ass because your not adapting/ performing to a level you desire. Bullshit lol. What is really the limitation to adaptation and performance is the nervous system. Luckily it can change and adapt to allow for us to be at our best and continue to adapt towards our ideal. But you have to allow it to work, you have to remove unecessary inflammatory/ stress loads and then take it through a process of being able to deal with ever greater laods, velocities, and volumes to facilitate increased resilience in the face of life stresses.

  • Alan Powrie says:

    What a great article and what great commentary… I may have missed something critical but as an ageing former athlete with a non medical background I saw merit in most of the arguments…. I believe the “sweet spot” will be the arbiter and that will depend on a myriad of factors. Many thanks Brett.

  • Evy says:

    I couldn’t agree more. My asymptomatic lumbar stenosis was diagnosed last fall (I turned down the offered steroid injection for my spine) and recent x-rays of my painful knees show osteoarthritis (turned down the total knee replacement and steroid injection offer). Instead, I’m working on retraining my VMO to do its job and will then start strengthening the rest of the quads, my hamstrings, and my glutes in addition to the rest of my workouts.. I’ll continue to adjust as my body needs to help it heal and stay fit.

    I’m in my early 60’s, never obese or overweight, and live an active lifestyle. I intend on staying that way. Working to keep the body at optimal balance allows for a big part of life’s pleasures.

    • Jim says:

      Evy if you are having knee issues I would look very closely at your hamstrings. They act as dynamic stabilizers of the knee. In my experience knee problems stem from front dominance and that has a lot to do with pelvic tilt.

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