Musculoskeletal Problems

Summary

Musculoskeletal deterioration is a major cause of loss of function as we age. From 50 onwards loss of muscle, bone mass and collagen lead to reduced strength, susceptibility to fracture, and problems with joints. When somebody is 70 and these problems have been going on for 20 years, they frequently are frail. Frailty is a specific term for a tragic inability to perform daily acts of living and consequently reduced independence. When we say ‘so and so is looking old …’ what we mean is they are looking frail.

What exactly is the problem?

Age itself does no harm but various underlying processes Lead to loss of functionality; recognizing and reversing these is our purpose.

The diagram shows the contributing factors.

The predominant cause of loss of tissue and loss of function is the long-term reduction in sex hormone output in later life, compounded by an unnatural habit in the first world to do less and less physical activity. Growth hormone does decline to some extent with age but is not the principal driver, and is not a part of the therapeutic approach, currently.

Women lose testosterone and other androgens progressively from their mid 30’s, in a gradual linear fashion and oestrogen dramatically with the ovarian failure that triggers the menopause. Men lose testosterone gradually from their late 40s but not all are affected to the same degree. Around 40% of 65-year-old men are testosterone deficient and around 80% of 80 year old’s [check this].

For men, oestrogen is derived from testosterone conversion in the tissues that need it.. This is detailed in the chapter on sex hormones.

In terms of bone, collagen and muscle both oestrogens and androgens are biologically active. So in muscle, oestrogen slows muscle cell loss and testosterone stimulates muscle replacement; in bone the driver of bone density is oestrogen [in both sexes] with testosterone being responsible for preserving bone microarchitecture. Both hormones act in connective tissue such as ligaments and joints.

For all the structural tissues, being under physical stress by exercise or weightbearing is a trigger to tissue growth and repair mechanisms.

KEY message

Maintain structural integrity of muscle, collagen, and bone by:

  1. Regular resistance based and weight bearing exercise throughout life.

  2. Adequate protein intake. This means a supplement for over 60s as absorption reduces with age

  3. Sex hormone replacement for both sexes.

For women conventional HRT from menopause onwards and for many, testosterone supplementation for optimum effect.

For men testosterone measurement from 60 onwards, or sooner if there is erectile dysfunction, identifies those who need capital TRT. 

Understanding - what the science says

Osteoporosis means bones with holes in them. Bone strength Comes both from the rigid outer skin of the bone or cortex and from the Spongy bone in the center which functions in the same way as reinforced concrete. Bone is constantly being remodeled with specialized cells cold osteoclasts removing old bone and osteoblasts renewing the structure. It is intense osteoblastic activity which helps us repair fractures but both processes go on side by side continuously.

When estrogen drops at the menopause this process gets out of balance and bone absorption exceeds bone repair, hence thinner bones. In men bone density is also controlled mainly by estrogen, derived by conversion of testosterone in the tissues. As indicated above an increasing proportion of men become low in testosterone from around 60 onwards. This means that men are equally at risk of fracture but problems occur around a decade later than they do in women. Essentially one woman in three and one man in 10 will experience an osteoporotic fracture in their lifetime.

These fractures are entirely preventable.