I retitled what we're going to talk about, I'm really talking about how many master's athletes there are and how we can take care of them, but if you're like me, sometimes you have people come into your office and they're talking about a variety of things and all of a sudden it's four or five things. And then they say, oh my God, I think I'm falling apart. And the truth of the matter is, they're not falling apart. Many of them, all of them with ovaries, and I'm going to talk specifically about 51% of the population today who has ovaries, they're not falling apart. Their estrogen has walked out the door and it has profound musculoskeletal implications that we can use as orthopedic surgeons to prevent things that we take care of every day like fracture and osteoporosis and arthritis, believe it or not. So I have, these are my conflicts of interest. I have no, nothing that's relevant to this. So with, there's a big, the zeitgeist in this country right now is on, if you haven't heard of it, just read any newspaper, on longevity and active aging. This country has finally gotten the message that if we pay attention to the lifestyle factors that are in control, we can make a big impact on our longevity. And so these are some of the athletes I take care of and right now the life expectancy in this country for men is about 79 years and for women is 81 years. And if you live in Japan, it's closer to 85. So with that comes the mandate that we stay active longer so that we don't be overtaken by the ravages of chronic disease. So if we're asking, if we're living longer and we're asking people to stay active longer and even using sport as a way to save society from chronic disease, I hope that by the end of this talk and the four talks that follow, you'll have a new perspective on how aggressive we need to be in taking care of people. So I'm going to answer some questions. How many aging athletes are there? How many aging athletes are injured or need surgery? Why do we even need to care? And what do hormones have to do with it? So there's not a lot of big data. We can name every youth sport injury rate. We know how many kids play sports. When it comes to aging athletes, we have to extrapolate. So this is how I've done it and it's a rough estimate. There are 141 million people in the United States that are 35 years and older. Roughly 37% of them spend any time in high calorie or very, very active. So 37% of 141 million. Injury data shows that in the age demographic we're talking about, there are 3.2 million ED visits just for sporting people show up to the ED. And when you look at these graph lines by sport, it's interesting that some of the longest lines are in the master's age categories and not the children. When you pull out different populations, I've put up the Ironman athlete data because Dr. Sutton is going to be talking to us about her Ironman experiences and how to prevent injury. We see that the mean age of an Ironman, the median age is 44, right. So right along the time when hormones are fluctuating wildly and performance changes dramatically with that for both men and women and the incidence of injury increases. But Dr. Spindler has just worked on a project like this where this is the latest example of the exploding sport. Pickleball is exploding in this country up to 22 million people this year. So if you're not on the pickle bandwagon, we probably all should be. Data show that 67,000 ED visits were attributed to pickleball. Almost 400,000 outpatient visits with 9,000 surgeries because pickleball players, the highest percentage are between 18 and 34. But where I live in Orlando, everybody is playing pickleball and everybody is retired. So it's something we should all be interested in. So how many aging athletes are there? Well, if you believe my math, 141 million people over 35 times 37% activity rate leaves us a potential of 52. million hurt people. How many of them are injured or surgeries? Again, there are not good data on master's age athletes. So I found what I could, 50% of all senior Olympians, meaning 50 years and older, have injuries. I found a little more data on that upcoming, 25% of all triathletes and about 12% of them need surgery. And why do we need to care about that? Well, I think it's obvious to me, but before I answer that question, I want to go a little deeper because 51% of the people in the world have ovaries. All of them will go through menopause starting anywhere from 35 and going through 55 when symptoms get less. But after menopause, the day, 366 days after your last period, you are post-menopausal the rest of your life. So this is a full third of a person with ovaries life, right? And so often, I'm going to show you what happens with the existing data, but it's estimated that 1.3 million women a year enter this transition. And it's a huge market if you're interested in the finances of this, meaning that there is plenty of room for us to produce products that diminish the suffering. Plus, with 50 years of Title IX, we have a tidal wave of female athletes now entering the menopause transition and how do we keep them at peak performance is an important question. But here's the thing, and very little known, you know, it's talking about hormonal changes and menopause is all over the news right now, but probably everything you've heard is about brain fog and night sweats and a variety of symptoms like that. But a full 80% of all women in the menopause transition will have musculoskeletal symptoms and 25% are so devastated that they cannot work. Let me talk to you about how those manifest. When estrogen walks out the door, these are the things I'm claiming in the MSK pipeline that we need to be interested in. There is a huge increase in inflammation. Why do these women walk in our office and say, all of a sudden, everything hurts and I think I'm going crazy? It's not because they fell off a bridge, it's because their hormones are changing. Estrogen is a huge anti-inflammatory. We decrease the production of satellite cells, which are muscle-derived stem cells. We lose muscle mass and strength at a rate of 20% during the menopause transition if we don't do something about it, including lifting heavy weights. We lose bone density. I don't have to tell you this, you're orthopedic surgeons, we can lose 20% right around menopause. And so when finally insurance will pay for a DEXA scan at 65, many women have already been decimated by the loss of their bone density. So I would love all of us to order DEXA scans on our women starting at 35 or 40. Because you've all had the 28-year-old or 30-year-old, like I did, who broke her hip doing just normal activities, right? And then finally, with estrogen fluctuations, we gain visceral fat, which is metabolically diabolical. So of all the things you hear in the news that happens when estrogen walks out the door, only the MSK symptoms are life-changing, devastating, and can result in severe disability with bone loss and fracture, lean muscle mass and sarcopenia, weakness, fragility, metabolic dysfunction, so that when we put a total knee in someone and they have a BMI like this, that has orthopedic consequences. So I'm trying to answer for you, why should I care about estrogen walking out the door? Well, in our patients, it is a huge problem. But who are these people? I just want to give you real people. Maybe the 51-year-old triathlete who comes in in pain she can't explain, not sleeping, feeling anxious, but there's nothing on exam. I mean, what are you going to do with them? Many women who come to your office are then told, nothing's wrong with you. I don't know what's wrong with you. The X-ray shows nothing. It doesn't mean it's not real. Or maybe it's a mere mortal woman like me who just comes in with shoulder pain and you diagnose her with adhesive capsulitis. That is one of the most common presentations for estrogen walking out the door. And so we do what we do. We inject them. We send them to therapy. But that is not the end of the conversation if you want them to feel better. Or maybe you've got true elite women who are trying to maintain their place on the podium and cannot squeeze the juice out of their performance anymore. How are we going to help them? Well, there's some good news and some bad news. Jocelyn has published this abstract. It's here at this meeting. The first research on the role of hormone replacement and adhesive capsulitis. Okay, here's another piece of good news. So go read her poster. Another piece of good news. Oh yes, there's another study on rotator cuff repair with hormone fluctuations. I know Johannafin is producing one that's about to be published. I'm producing two reviews. That's about it. There's so much work to do. So much opportunity for us to figure this out. If you're interested in what I've had to say, then maybe just take a picture of this. This is all the things that estradiol does for us. Bone, muscle, myosin fibers, cartilage, I'm going to show you that data. Ligaments and tendons, mitochondrial support, the heart of our metabolic health. Because when we go metabolically awry, when we get too much visceral fat, right, then our mitochondria do not function. We get diabetes and then we get Alzheimer's, right? Do you see the pattern of why mobility is so important for us to not drop the ball on this? So I'm going to run through this. I don't really have any time left, but if you're interested in this topic, these are all areas that need research. When estrogen runs out the door, 71% of people will experience musculoskeletal pain. 41% of the time, they will be worked up and there will be nothing structural going on. And that can't be the end of the story. So what is the role of estrogen in cartilage? There are some studies. Cartilage contains estrogen receptor alpha, estrogen receptor beta. When estrogen is no longer available, those receptors are empty and the matrix breaks down because estrogen is very important for the microenvironment of chondrocytes. Estrogen depletion results in increased damage to the articular cartilage and abnormal subchondral bone remodeling leading to OA. It is not a wonderment why before age 50, men have more osteoarthritis. And after age 50, when women lose their estrogen, they have a rapid increase in their progression of arthritis such that 75 years ago, Cecil and Archer described the arthritis of menopause trying to figure out why once you lose estrogen, women have so much more arthritis. There's so much work that can be done here. And finally, loss of lean muscle mass. Our muscle fibers atrophy. We have decreased numbers of motor units. We have increased intramuscular adipose tissue. We just become metabolically unhealthy and we lose our muscle mass. The muscle is the organ of longevity, if you will. It's so metabolically important and it falls in our venue. And then I don't have to tell you about osteoporosis. You know, women do lose 20% of their bone density around this time leading to hip fracture, 50% loss of the lifestyle they had before, and 30% death. That's why I think we should all be screening early and intervening early. Not waiting until 65 when it's late. So we're going to transition now. We're going to have several talks about injury. We're going to have talks about biologics and we're going to have a talk about the experience of preventing injury from an elite master's athlete. We began studying injury patterns in master's athletes in 2004 at the University of Pittsburgh where I was for 20 years. And we studied 3,000 athletes at the National Senior Games at that time and found, just as an introduction to the next two talks, that 89% had at least one musculoskeletal injury. Most of those happened during competition with a third of them in practice. Many were overuse and the rest were trauma. So as we progress now to our next speaker who is Catherine Burns talking about upper extremity injury treatment and return to sport, I want you to keep all this enthusiasm you see in mind to develop research questions and really progress this field. It affects 51% of everybody you take care of. So Catherine. Thank you.

aging athletes

estrogen depletion

women with ovaries

chronic diseases

musculoskeletal implications