Abstract
Background
The elderly US population is growing quickly and staying active longer. However, there is limited information on sports-related injuries in older adults.
Hypotheses
(1) National estimate and incidence of sports-related orthopaedic injuries in the US elderly population have increased over the last 10 years, (2) types and causes of sports-related injuries in the elderly have changed, and (3) elderly sports-related injuries will increase more than the number of treating physicians by 2040.
Study Design
Descriptive epidemiology study.
Level of Evidence
Level 4.
Methods:
The National Electronic Injury Surveillance System database was used to identify all patients aged ≥65 years with sports-related orthopaedic injuries in US emergency departments from 2012 to 2021. Surgeon and physician estimates were calculated using the Physician Compare database. Population data were obtained from US Census estimates and used to calculate annual incidence rates of injuries and to project total injuries through 2040. Injury characteristics were analyzed using Wilcoxon Rank-Sum tests and Chi-square or Fisher exact tests.
Results
An estimated 444,078 sports-related orthopaedic injuries occurred in the elderly from 2012 to 2021. There were significant increases in injuries (from 32,573 in 2012 to 50,909 in 2021; P < 0.01) and in the national incidence of injuries (from 78 per 100,000 in 2012 to 91 per 100,000 in 2021; P = 0.01). The number of sports-related injuries in the elderly is projected to reach 111,245 by 2040, an increase of 119% from 2021. The number of orthopaedic surgeons and sports medicine physicians is projected to increase by only 19.7% over the same timeperiod.
Conclusion:
Sports-related orthopaedic injuries in the elderly are increasing in both number and incidence.
Clinical Relevance
Orthopaedic surgeons and other practitioners should be prepared to treat an increasing number of active elderly patients.
Keywords: elderly, epidemiology, injuries, sports
The United States (US) population is getting older and will continue to age for many decades to come. Aging of the US population is fueled by the baby boomer cohort, or those born from 1946 to 1964, that began turning 65 years old in 2011. 12 According to the US Census Bureau, after the 1990s, the growth of the population aged ≥65 years surpassed that of the total population and the population <65 years old. 26 By 2040, there are projected to be over 80.8 million people aged ≥65 years in the US, up from 41.5 million in 2012. 30
This growth has the potential to impact the structure of many healthcare practices moving forward. The field of orthopaedics is no exception, as over 50% of orthopaedic surgical procedures are performed on patients aged ≥65 years. 9 The ≥65-year-old population is the fastest-growing group at trauma centers. 28 In 2013 to 2014, adults aged ≥65 years made up about 20% of orthopaedic patients in the emergency department and about 56% of inpatient orthopaedic patients. 15 Elderly patients currently make up > 60% of patients undergoing hip and knee replacements. 33 The aging population will undoubtedly have an impact on orthopaedic surgery, as such a large proportion of orthopaedic care is centered around the elderly.
Further, there are shifting dynamics in the elderly population. Over the last 40 years, life expectancy has increased, especially life expectancy at age 65.20,37 Importantly, at age 65, there has been a greater increase in disability-free life expectancy than disabled-life expectancy. 6 Moreover, the elderly population has been spending significantly more time being physically active than in the past. 18 The combination of increased disability-free life expectancy with increased physical activity opens the possibility for additional sports- and activity-related injuries.
Whereas common sports-related injuries in the elderly have been explored in the literature,16,17,24 no study has examined incidence at a national level in the US, particularly with the changing demographics that exist in the US today. The purpose of this study was to determine the estimate, incidence, and etiologies of sports-related orthopaedic injuries in the elderly from 2012 to 2021. Further, we sought to investigate any trends in orthopaedic sports-related injuries during this timeperiod. In addition, we sought to predict the future number of orthopaedic sports injuries in the elderly and the number of orthopaedic surgeons and sports medicine physicians through 2040. We hypothesized that the total number and incidence of sports-related injuries in the elderly would increase during this timeperiod.
Methods
This retrospective cross-sectional epidemiological study utilized cases of sports-related orthopaedic injuries in the US Consumer Product Safety Commission’s National Electronic Injury Surveillance System (NEISS) database. The NEISS database uses collected product-related injury data to estimate nationwide injuries in all US emergency departments. The NEISS sample includes about 100 hospitals that act as a nationally representative probability sample of all US hospitals with emergency departments. The NEISS database has been used previously to investigate the epidemiology of many orthopaedic conditions.1,7,19,22,25,36 Data were gathered on all emergency department visits involving patients aged ≥65 years in the NEISS database between 2012 and 2021, with each datapoint assigned a national weight. 35 Data were included only if the visit involved a sports-related activity and an orthopaedic injury defined by body location and type of injury. Sports-related activities included generic exercise, biking, golf, swimming, tennis, weightlifting, basketball, and more. A full list of sports-related activities and their associated NEISS codes can be found in Appendix Table 1, available in the online version of this article. Orthopaedic injuries were defined by anatomic location and included finger, hand, wrist, lower arm, elbow, upper arm, shoulder, toe, foot, ankle, lower leg, knee, upper leg, and spine. Spine was a combination of NEISS defined neck injuries and injuries to the lumbar and thoracic spine identified by a previously described method to isolate lumbar spinal injuries in NEISS data. 36 Orthopaedic types of injury were narrowed down to amputation, crush, dislocation, foreign body, fracture, nerve, strain/sprain, and avulsion injuries. The following variables were collected from the NEISS data: age, sex, race/ethnicity, year, consumer product codes (representing the sport/activity), body part, diagnosis, and a narrative.
Population estimates and projections were obtained from the US Census Bureau. 30 Projections were collected through 2040, as the youngest baby boomers will be >75 years old by then. To estimate the total number of orthopaedic surgeons and sports medicine physicians in the US, we utilized the Physician Compare database. 4 Of note, physicians are included in this dataset only if they have been registered into the Medicare Provider Enrollment, Chain, and Ownership System in the past 6 months or have billed Medicare for ≥1 fee-for-service reimbursement in the past 12 months. Physicians were identified by unique National Provider Identifier number and were included if their primary specialty was orthopaedic surgery or sports medicine. Orthopaedic surgeons with <6 years and sports medicine physicians with <4 years from their medical school graduation date were excluded from analysis as they were presumed to still be in training.
Statistical Analysis
National injury estimates were calculated as the sum of the provided NEISS weights, which are representative of the US population. An algorithm provided by NEISS was used to calculate the 95% confidence intervals (CIs) of the national estimate. 35 Population estimates of the US population aged ≥65 years were obtained from annual US Census estimates and used to calculate annual incidence rates of sports-related injuries per 100,000 people.
Orthopaedic-related sports injuries were projected through 2040 using incidence data and population projections using 2 different methodologies. The first was using the mean orthopaedic-related sports injury incidence over the last 5 years. The second utilized linear regression on orthopaedic-related sports injury incidence over the entire study timeperiod.
When comparing yearly injury characteristics, continuous variables were assessed using the Wilcoxon Rank-Sum test. Categorical variables were analyzed with the Chi-square or Fisher exact test, where appropriate. Age distributions were analyzed using the Kolmogorov-Smirnov test. Post hoc proportion analysis with Bonferroni adjustment was used to analyze differences in injury characteristics year over year. Univariate linear regression modeling was performed to assess significant growth trends and to predict future growth in surgeon volume. All statistical analysis was conducted using Python software (Version 3.7). Two-sided P values <0.05 were considered statistically significant.
Results
Between 2012 and 2021, there were 8710 sample sports-related orthopaedic injuries in adults aged ≥65 years isolated from the NEISS database. Utilizing the NEISS algorithm, there were an estimated 444,078 (95% CI: 404,331-483,824) total sports-related orthopaedic injuries in the elderly during this timeperiod. The mean age was 72.7 years and 49.4% of patients with sports-related orthopaedic injuries were female. The age distribution of injuries can be found in Table 1.
Table 1.
Distribution of sports-related orthopaedic injuries by age
| Age, y | Sports-Related Orthopaedic Injuries, % |
|---|---|
| 65-69 | 40.6 |
| 70-74 | 27.1 |
| 75-79 | 16.3 |
| 80-84 | 8.9 |
| ≥85 | 7.2 |
There was a significant increase in the national estimates from 32,573 (95% CI: 22,602-42,544) in 2012 to 50,909 (95% CI: 39,654-62,164) in 2021 (P < 0.01). Similarly, there was a significant increase in the national incidence of sports-related orthopaedic injuries from 78.5 per 100,000 people (95%: 54.5-103) in 2012 to 91.2 per 100,000 people (95%: 71.0-111) in 2021 (P = 0.01) (Table 2).
Table 2.
Annual estimate and incidence of sports-related orthopaedic injuries in the elderly
| Year | Yearly Estimate (95% CI) a | Yearly Incidence per 100,000 (95% CI) a |
|---|---|---|
| 2012 | 32,573 (22,602-42,544) | 78.5 (54.5-103) |
| 2013 | 31,957 (20,908-43,006) | 73.8 (48.3-99.4) |
| 2014 | 37,159 (24,438-49,879) | 83.5 (54.9-112) |
| 2015 | 42,436 (28,458-56,413) | 92.3 (61.9-123) |
| 2016 | 44,122 (29,426-58,818) | 92.8 (61.9-124) |
| 2017 | 45,036 (32,683-57,390) | 91.4 (66.3-116) |
| 2018 | 51,487 (39,284-63,690) | 101 (76.9-125) |
| 2019 | 56,675 (42,876-70,473) | 107 (81.2-134) |
| 2020 | 51,724 (39,174-64,274) | 94.7 (71.7-118) |
| 2021 | 50,909 (39,654-62,164) | 91.2 (71.0-111) |
Represents significant growth trend determined by linear regression P value <0.05.
The mean incidence from 2016 to 2021 was 97.1 injuries per 100,000 elderly. At this incidence level, the total number of sports-related orthopaedic injuries in the elderly is projected to reach 78,467 (95% CI: 59,355-97,579) by 2040. During our study timeperiod, the incidence increased at a rate of 2.4 injuries per 100,000 per year (P = 0.01). At this rate, the projected total number of sports-related orthopaedic injuries in the elderly is projected to reach 111,245 (95% CI: 83,846-138,640) by 2040, an increase of 119% from 2021 (Figure 1). By 2040, the population of adults aged ≥65 years in the US is expected to reach 80.8 million, a 44.8% increase from 2021. 30
Figure 1.
Yearly sports-related orthopaedic injury projections in the elderly through 2040 (confidence interval is shaded).
According to the Physician Compare database, the number of orthopaedic surgeons increased from 21,419 in 2016 to 22,206 in 2023, a 3.7% increase or an annual growth rate of 78 orthopaedic surgeons per year (95% CI: 10.5-145; P = 0.03). At this rate, there are projected to be 23,527 (95% CI: 22,384-24,670) orthopaedic surgeons in 2040 (Figure 2). In addition, the number of sports medicine physicians increased from 1150 to 1762 over the same timeperiod. This equated to an increase of 102 physicians per year (95% CI: 84.4-119; P < 0.01). At this rate, there are projected to be 3490 (95% CI: 3,197-3,782) sports medicine physicians in 2040 (Figure 2). In total, there is projected to be an increase of 19.7% in orthopaedic surgeons and sports medicine physicians from 2021 to 2040.
Figure 2.
Yearly orthopaedic surgeon and sports medicine physician projections through 2040 (confidence intervals are shaded).
In an effort to understand changing dynamics in sports-related injuries in the elderly, injuries occurring in 2012 were compared with those occurring in 2021. There was no difference in age distribution of sports-related injuries in the elderly between 2012 and 2021 (P = 0.41). There were significant differences in the activity, type of injury, and location of injury between 2012 and 2021 (all P < 0.01). There was a significantly higher proportion of injuries associated with biking (P < 0.01) and scooters (P = 0.02), and there were less associated with dancing (P < 0.01) and skiing (P < 0.01) in 2021 than in 2012. In terms of injury location, there was a higher proportion of sports-related injuries to the elbow (P < 0.01), lower arm (P = 0.05), and upper leg (P < 0.01) in 2021 than in 2012 (Table 3). Fractures, nerve injuries, and avulsions were more common injuries in 2021 than 2012, while strains/sprains were less common (Table 4). Detailed injury data by injury type and location can be found in Table 5.
Table 3.
Injury location of sports-related orthopaedic injuries in the elderly by year
| 2012, % | 2021, % | P value | |
|---|---|---|---|
| Injury location | <0.01 | ||
| Spine | 14.73 | 15.51 | 0.65 |
| Shoulder | 14.59 | 13.94 | 0.70 |
| Knee | 14.16 | 7.11 | <0.01 |
| Wrist | 13.17 | 12.47 | 0.66 |
| Ankle | 9.21 | 8.68 | 0.70 |
| Lower leg | 6.66 | 8.59 | 0.14 |
| Finger | 5.10 | 4.34 | 0.46 |
| Upper arm | 4.96 | 6.00 | 0.35 |
| Foot | 4.39 | 2.86 | 0.09 |
| Lower arm | 4.11 | 6.28 | 0.05 |
| Elbow | 2.83 | 6.09 | <0.01 |
| Hand | 2.55 | 1.66 | 0.19 |
| Upper leg | 1.84 | 4.80 | <0.01 |
| Toe | 1.70 | 1.66 | 0.95 |
Table 4.
Type of sports-related orthopaedic injuries in the elderly by year
| 2012, % | 2021, % | P value | |
|---|---|---|---|
| Type of injury | <0.01 | ||
| Strain/sprain | 51.1 | 30.2 | <0.01 |
| Fracture | 39.9 | 57.3 | <0.01 |
| Dislocation | 5.0 | 4.6 | 0.74 |
| Nerve injury | 1.8 | 3.4 | 0.05 |
| Avulsion | 1.3 | 3.8 | <0.01 |
| Foreign body | 0.4 | 0.4 | >0.99 |
| Crush | 0.3 | 0.0 | 0.16 |
| Amputation | 0.1 | 0.3 | >0.99 |
Table 5.
Detailed types of sports-related orthopaedic injuries in the elderly by year. Reported as percentage of injury type by body part
| Injury | 2012, % | 2021, % |
|---|---|---|
| Amputation | ||
| Finger | 100 | 100 |
| Crush | ||
| Foot | 50 | 0.00 |
| Toe | 50 | 0.00 |
| Dislocation | ||
| Shoulder | 37.1 | 64.0 |
| Finger | 25.7 | 22.0 |
| Knee | 25.7 | 4.00 |
| Elbow | 8.57 | 4.00 |
| Toe | 2.86 | 2.00 |
| Ankle | 0.00 | 2.00 |
| Wrist | 0.00 | 2.00 |
| Foreign body | ||
| Finger | 33.3 | 50.0 |
| Knee | 33.3 | 0.00 |
| Hand | 33.3 | 0.00 |
| Toe | 0.00 | 25.0 |
| Lower arm | 0.00 | 25.0 |
| Fracture | ||
| Wrist | 22.0 | 16.9 |
| Upper arm | 11.0 | 9.17 |
| Ankle | 9.22 | 8.05 |
| Finger | 5.67 | 3.70 |
| Shoulder | 8.87 | 10.6 |
| Lower arm | 8.87 | 9.18 |
| Spine | 7.45 | 10.1 |
| Lower leg | 7.09 | 7.89 |
| Hand | 4.61 | 2.25 |
| Elbow | 3.90 | 6.92 |
| Toe | 3.55 | 2.42 |
| Foot | 3.19 | 2.90 |
| Knee | 2.48 | 3.54 |
| Upper leg | 2.13 | 6.28 |
| Nerve injury | ||
| Spine | 76.9 | 83.8 |
| Finger | 15.4 | 0.00 |
| Knee | 7.69 | 0.00 |
| Lower leg | 0.00 | 5.41 |
| Hand | 0.00 | 2.70 |
| Wrist | 0.00 | 2.70 |
| Lower arm | 0.00 | 2.70 |
| Upper leg | 0.00 | 2.70 |
| Strain/sprain | ||
| Knee | 22.7 | 16.2 |
| Spine | 20.2 | 22.6 |
| Shoulder | 18.0 | 16.2 |
| Ankle | 10.8 | 13.1 |
| Wrist | 8.31 | 8.56 |
| Lower leg | 6.37 | 8.87 |
| Foot | 5.82 | 3.98 |
| Upper leg | 1.94 | 3.67 |
| Finger | 1.94 | 1.22 |
| Upper arm | 1.11 | 2.14 |
| Elbow | 1.11 | 2.14 |
| Hand | 1.11 | 0.31 |
| Lower arm | 0.55 | 0.61 |
| Toe | 0.00 | 0.31 |
| Avulsion | ||
| Lower leg | 44.4 | 31.7 |
| Elbow | 22.2 | 34.1 |
| Lower Arm | 22.2 | 17.1 |
| Wrist | 11.1 | 0.00 |
| Finger | 0.00 | 9.76 |
| Hand | 0.00 | 4.88 |
| Upper arm | 0.00 | 2.44 |
To eliminate the impact that the COVID-19 pandemic had on sports-related activity, 2012 was also compared with the last year before the pandemic, 2019. In 2019, there were proportionally fewer skiing-related injuries (P < 0.01), and more upper leg (P < 0.01) injuries than in 2012. In addition, in 2019, strains/sprains (P < 0.01) were less common than in 2012, and fractures (P < 0.01) were more common.
Discussion
This study provides an estimate of sports-related orthopaedic injuries in the elderly with future injury projections. Our findings demonstrate that the total number and the incidence of these injuries in the elderly are increasing. If trends continue at their current rate, we project sports-related orthopaedic injuries in the elderly to reach up to 111,245 injuries in 2040, a 119% increase from 2021. This increase is projected to occur in an elderly population that is expected to grow by 44.8% over the same timeperiod. Meanwhile, we project the number of orthopaedic surgeons and sports medicine physicians to increase by only 19.7% over the same timeperiod. Although the relationship between sports-related injuries and demand for these physicians is not one-to-one, there is clearly potential for a large disparity. This possible future physician shortage has been explored before. A previous study utilized population projections and expected relative value units requirements to determine that there may be up to 12,000 additional orthopaedic surgeons needed in 2040. 27 More recently, the National Center for Health Workforce Analysis projected a more conservative need of over 3000 additional orthopaedic surgeons in 2035. 11 Despite the difference in estimates, there is consensus that there will likely be demand for more orthopaedic surgeons and sports medicine physicians in the future.
Not only did the total number of injuries increase significantly from 2012 to 2021, but the incidence did as well. This indicates that older people are getting injured more frequently during sports, they are participating in more sports and/or they are participating in different sports in which they are more likely to get injured. Previous research has shown that the elderly have increasing disability-free life expectancy. 6 However, there is conflicting evidence whether frailty is increasing or decreasing in older adults.23,38 So, while it is possible that older adults are getting injured more often with the same type and amount of activity, other explanations are more likely. For example, our study found that there was a significantly higher proportion of injuries associated with biking in 2021 than in 2012. Cycling has grown more popular in the US overall, and older adults showed an increasing trend in cycling from 2001 to 2009. 31 Age has also been shown to be the most important risk factor for being injured while cycling, with adults aged ≥65 years being 6.35 times more likely to be severely injured than the 25- to 44-year-old group. 8 So, older adults may be increasingly participating in sports like cycling, in which their risk for injury is high. Finally, there have been studies showing an increasing trend of continued participation in sports and exercise in the older population.18,34
Given these findings, elderly patients are likely to become a more important part of orthopaedic and sports medicine practices, even in specialties that have focused traditionally on younger patients.
Sports medicine has largely been a subspecialty that focuses on athletes and younger patients. There are up to 200,000 anterior cruciate ligament (ACL) injuries a year in the US with a mean age of 29 years old.10,32 In the past, less than a quarter of adults >40 years old with an ACL injury went on to ACL reconstruction. 5 However, as older adults remain active, there may be an increasing desire and need for procedures that preserve sport-specific function in this patient population. Data reported in the literature suggest that ACL reconstruction can be successful in older patients who want to return to sport and recreational activities. 21 Similarly, treatment for other common injuries, such as proximal humerus fractures, must take the activity level of older adults into consideration. For example, proximal humerus fractures in younger adults may be more likely to be treated with fixation techniques, whereas older adults are often recommended to undergo nonoperative management, even with displaced fractures.2,3 The recommendations for nonoperative treatment in adults aged ≥65 years are based largely on outcome scores related to subjective and objective measures regarding activities of daily living. 2 Healthy older adults who are more active may desire further functionality and benefit from further treatment. So, as sports-related injuries in older adults continue to increase, orthopaedic surgeons should be prepared to discuss and consider both operative and nonoperative treatment.
Our study revealed that, in 2021, strains/sprains represented a smaller proportion of sports-related injuries, whereas fractures, nerve injuries, and avulsions represented a larger proportion than in 2012. This may seem counterintuitive, as one would not expect common sports injuries like sprains and strains to decrease in the elderly if they were participating in more sports and activities. However, it is important to remember that the NEISS database only includes patients presenting to emergency departments. This is consistent with the trend of increasing utilization of nonemergency treatment settings for nonurgent diagnoses. 29 When comparing 2012 with 2019 to eliminate the impact of the COVID-19 pandemic, there was no difference in fractures. The fact that fractures made up a significantly larger proportion of sports-related injuries in 2021 but not in 2019 is likely explained by decreased emergency department visits during the COVID-19 pandemic. Elderly patients with emergent conditions were reluctant to visit the emergency department during the COVID-19 pandemic.13,14 Only visits truly necessitating evaluation made it to the emergency department, potentially explaining why fractures made up a larger proportion of sports-related orthopaedic injury visits in 2021 than in 2012.
Limitations
The NEISS database is a useful tool for epidemiological studies on injuries evaluated at emergency departments in the US but has inherent limitations. First, our estimates of incidence and total number of injuries are subject to sampling bias given their dependence upon a weighted probability sample of emergency department visits. Although this increases the risk of sampling bias, NEISS does attempt to account for these inherent biases in its calculations. Second, since the database only includes patients evaluated in the emergency department, those who did not seek medical care or were evaluated at another location (walk-in clinics, urgent care, specialists, etc) are not represented. A large subset of patients with sports injuries likely presented to these alternative locations of care, and the emergency room visits that comprise this study can only serve as a proxy for the true total number of injuries. In addition, spine injuries were identified with a text search of the narrative variable, which may underestimate the total number of spine injuries in the NEISS database. The Medicare database excludes a limited number of physicians who do not participate in Medicare, so the total number of orthopaedic surgeons and sports medicine physicians in the US is likely underestimated.
Conclusion
Sports-related orthopaedic injuries in the elderly have been increasing in both number and incidence. Recently, sports-related injuries in the elderly were more likely to involve the elbow and upper leg than in the past. By 2040, the total number of sports-related injuries in the elderly may reach up to 111,245, an increase of 119% from 2021. In this same timeperiod, the number of orthopaedic surgeons and sports medicine physicians is projected to increase by only 19.7%.
Supplemental Material
Supplemental material, sj-docx-1-sph-10.1177_19417381251314078 for Orthopaedic Sports Injuries in an Aging Population: Current Trends and Future Projections by Jay M. Zaifman, Martinus Megalla, Zachary Grace, Nareena Imam, John D. Koerner, Eitan Kohan and Francis G. Alberta in Sports Health
Footnotes
The following author declared potential conflicts of interest: F.G.A. has received consulting and speaking fees from Integra Life Sciences, compensation for services other than consulting from Arthrex, and royalties from NewClip USA.
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Supplementary Materials
Supplemental material, sj-docx-1-sph-10.1177_19417381251314078 for Orthopaedic Sports Injuries in an Aging Population: Current Trends and Future Projections by Jay M. Zaifman, Martinus Megalla, Zachary Grace, Nareena Imam, John D. Koerner, Eitan Kohan and Francis G. Alberta in Sports Health