JOURNAL OF BONE AND MINERAL RESEARCH

Volume 16, Number 2, 2001

© 2001 American Society for Bone and Mineral Research

Good Maintenance of Exercise-Induced Bone Gain with

Decreased Training of Female Tennis and Squash Players:
A Prospective 5-Year Follow-Up Study of Young and Old
Starters and Controls
SAIJA KONTULAINEN, PEKKA KANNUS, HEIDI HAAPASALO, HARRI SIEVÄNEN, MATTI PASANEN,
ARI HEINONEN, PEKKA OJA, and ILKKA VUORI

ABSTRACT

This prospective 5-year follow-up study of 64 adult female racquet sports players and 27 controls assessed the
changes in the playing-to-nonplaying arm bone mineral content (BMC) differences to answer three questions:
(1) Are training-induced bone gains lost with decreased training? (2) Is the bone response to decreased
training different if the playing career has been started before or at puberty rather than after it? (3) Are the
possible bone changes related to the changes in training? The players were divided into two groups according
to the starting age of their tennis or squash playing. The mean starting age was 10.5 years (SD, 2.2) among the
players who had started training before or at menarche (young starters; n ⴝ 36) while 26.4 years (SD, 8.0)
among those players who had begun training a minimum of 1 year after menarche (old starters; n ⴝ 28). At
baseline of the 5-year follow-up, the mean age of the young starters was 21.6 years (SD, 7.6) and that of old
starters was 39.4 years (SD, 10.5). During the follow-up, the young starters had reduced the average training
frequency from 4.7 times a week (2.7) to 1.4 times a week (1.3) and the old starters from 4.0 times a week (1.4)
to 2.0 times a week (1.4), respectively. The 5-year follow-up revealed that despite reduced training the
exercise-induced bone gain was well maintained in both groups of players regardless of their clearly different
starting age of activity and different amount of exercise-induced bone gain. The gain was still 1.3–2.2 times
greater in favor of the young starters (at the follow-up, the dominant-to-nondominant arm BMC difference
was 22% [8.4] in the humeral shaft of the young starters versus 10% [3.8] in the old starters, and 3.5% [2.4]
in controls). In the players, changes in training were only weakly related to changes in the side-to-side BMC
difference (rs ⴝ 0.05– 0.34, all NS), and this was true even among the players who had stopped training
completely a minimum 1 year before the follow-up. In conclusion, if controlled interventions will confirm our
findings that an exercise-induced bone gain can be well maintained with decreased activity and that the
maintenance of the bone gain is independent of the starting age of activity, exercise can be recommended for
preventing osteoporosis and related fractures. (J Bone Miner Res 2001;16:195–201)

Key words: detraining, bone mineral content, tennis, exercise, osteoporosis

INTRODUCTION nonplaying arm comparison eliminates the confounding ef-

fects of genetic, hormonal, and nutritional factors, which are
squash players are an interesting target group encountered in the cross-sectional comparisons between
T ENNIS AND
when studying the long-term influences of physical ac-
tivity on bone. A study design based on a playing-to-
athletes and their controls. The previous studies on tennis
players have given evidence that bone tissue on the playing

The Bone Research Group, UKK Institute for Health Promotion Research, Tampere, Finland.

195
196
arm clearly benefits from mechanical loading, the playing-
to-nonplaying arm differences being over 20% in favor of
the playing arm, as compared with less than 5% dominant-
to-nondominant arm differences in nonplayers.(1–10) Con-
trolled racquet sports studies also have given the most
convincing clinical evidence that the majority of the
playing-induced bone gain is obtained already before the
end of the longitudinal growth, and that if the playing
activity is started after the pubescent years, the bone gain is
clearly smaller.(1,2,4)
Although the effects of mechanical loading on the puber-
tal skeleton can be considerable, little is known whether this
additional bone mass is maintained into adulthood despite
decreased activity. Retrospective cross-sectional studies on
former athletes and their controls have given preliminary
evidence that at least some residual benefits appear to be
maintained into adulthood.(11–17) However, these studies
have many confounding factors that may obscure the con-
clusion. First, in retrospective cross-sectional studies the
amount of bone gained by exercise before cessation of the
training is not known. Thus, the likelihood of pure selection
bias when comparing former athletes and their controls
cannot be excluded. Second, the results of the cross-
sectional studies can be biased because the quantity and
quality of the physical activity of the former athletes and
their controls during childhood or adolescence are difficult
to evaluate retrospectively—not to speak about their other
bones—affecting living habits in that time. Third, although
the athletes of these studies have ceased their active career,
it is possible that they are still more active than the seden-
tary controls, and this obscures the conclusion further.
Our preliminary prospective study (a 4-year follow-up
study of male tennis players) evaluating the effects of de-
creased training on bone indicated rather good maintenance
of exercise-induced bone gain despite decreased playing
activity.(18) To confirm these results and especially to eval-
uate whether the bone response to decreased training is
different when the exercise-induced bone gain has been
acquired during the growing years rather than in adulthood,
a prospective 5-year follow-up of female tennis and squash
players was conducted. The purpose of this study was to
compare the changes in the playing-to-nonplaying arm dif-
ference in the bone mineral content (BMC) of the players
and their controls to answer three questions:
(1) Are training-induced bone gains lost with decreased
training?
(2) Is the bone response to decreased training different if
the playing career has been started before or at puberty
rather than after it?
(3) Are the possible changes in side-to-side BMC differ-
ence related to the changes in training?
MATERIALS AND METHODS
Subjects
In 1993 we examined the bones of both upper extremities
of nationally ranked adult female tennis and squash players
(n ⫽ 105) and their age-, height-, and weight-matched
KONTULAINEN ET AL.
controls (n ⫽ 50) and showed that the BMC of the playing
arm was about two times greater if the playing career had
been started before or at menarche rather than after it.(1) The
5-year follow-up measurements could be done on 64 of
these players and 27 controls. The nonattending persons
were either living too far or could not find enough time to
attend. Of note, their baseline BMC values did not differ
from those of the attending persons. The attending players
were divided into two groups according to the starting age
of their tennis or squash training (either before or after
menarche) to examine the possible difference in the main-
tenance of the loading-induced BMC benefit.
The mean starting age of tennis or squash was 10.5 years
(SD, 2.2) among those players who had started their training
before or at menarche (young starters, n ⫽ 36) and 26.4
years (SD, 8.0) among those players who had begun training
a minimum 1 year after menarche (old starters, n ⫽ 28).
During the follow-up, the young starters had reduced the
average training frequency from 4.7 times a week (2.7) to
1.4 times a week (1.3) and the old starters from 4.0 times a
week (1.4) to 2.0 times a week (1.4), respectively (Table 1).
The study groups were clinically healthy, and they did not
have past upper extremity fractures. None of the controls
had been involved in physical activity or work affecting the
dominant extremity only. All subjects were informed of the
study procedure, purposes, and known risks, and all gave
their informed consent.
Study protocol
Interview: A detailed training and medical history of each
subject was obtained in 1993 and 1998, the latter interview
concentrating on the possible changes between the initial
and follow-up measurements. The interview included data
on starting age and years of active playing, training sessions
per week, duration of each session, other physical activities,
possible injuries, menstrual cycle, medication, diet, con-
sumption of alcohol, smoking, and known diseases. The
onset of menses was asked in 1993 and the possible irreg-
ularities of menstrual pattern during the measurement years
were examined at the follow-up.
Anthropometric and isometric strength measurements:
Height (cm) and weight (kg), and circumference of upper
extremities, elbow extension and flexion forces, and grip
strength were measured using the procedure described in
detail elsewhere.(1,19)
Bone mineral measurements: BMC (g) was measured
with a dual-energy X-ray absorptiometric (DXA) scanner
(XR-26; Norland, Inc., Fort Atkinson, WI, U.S.A) at the
proximal humerus, humeral shaft, and distal radius.
All baseline and follow-up DXA measurements were
performed using the standard bone measurement procedure
of our laboratory. The in vivo precision of the BMC mea-
surements has been shown to be 1–2%.(20) The scanner
performance was monitored by our quality assurance pro-
gram(21) and no scanner drift was observed during the
follow-up.
EXERCISE-INDUCED BONE GAIN AND DECREASED ACTIVITY 197

TABLE 1. CHARACTERISTICS OF THE SUBJECTS (MEAN ⫾ SD)

Players (N ⫽ 64)
Young Starters ( N ⫽ 36) Old Starters ( N ⫽ 28) Controls ( N ⫽ 27)
1993 1998 1993 1998 1993 1998

Age (yr) 21.6 ⫾ 7.6 26.5 ⫾ 7.7 39.4 ⫾ 10.5 44.4 ⫾ 10.5 28.6 ⫾ 10.0 33.6 ⫾ 10.0
Height (cm) 168.7 ⫾ 4.9 168.7 ⫾ 5.1 165.0 ⫾ 5.8 164.7 ⫾ 5.4 166.6 ⫾ 4.7 167.0 ⫾ 4.9
Weight (kg) 60.8 ⫾ 6.1 62.5 ⫾ 6.5 62.6 ⫾ 6.9 65.3 ⫾ 10.3 63.0 ⫾ 9.6 65.0 ⫾ 9.9
Body-mass index* 21.4 ⫾ 2.0 21.9 ⫾ 1.9 23.0 ⫾ 2.2 24.0 ⫾ 3.3 22.7 ⫾ 3.2 23.3 ⫾ 3.2
Starting age of playing 10.5 ⫾ 2.2 26.4 ⫾ 8.0
Years of training 9.8 ⫾ 7.8 14.4 ⫾ 8.2 12.1 ⫾ 8.0 16.8 ⫾ 6.1
Number of training sessions per week 4.7 ⫾ 2.7 1.4 ⫾ 1.3 4.0 ⫾ 1.4 2.0 ⫾ 1.4
Duration of each session (min) 80 ⫾ 19 57 ⫾ 31 79 ⫾ 15 54 ⫾ 26
Total number of tennis of squash training 338 ⫾ 236 101 ⫾ 101 266 ⫾ 93 133 ⫾ 90
hours during the year preceding the
measurement
Other physical activities (number of 2.1 ⫾ 1.1 2.8 ⫾ 1.5 2.2 ⫾ 1.3 1.7 ⫾ 1.0 2.7 ⫾ 1.6 3.4 ⫾ 4.9
sessions per week)#

* Weight in kilograms divided by the square of the height in meters.

#
Physical activities such as aerobics, weight training, jogging, and cross-country skiing.

Statistical analysis
The data were analyzed using the SPSS statistical package
(SPSS, Inc., Chicago, IL, USA). The relative side-to-side dif-
ference was calculated by dividing the dominant-to-
nondominant side difference by the nondominant side value
and then multiplying the absolute value of the outcome by 100.
In players and controls, the changes in side-to-side dif-
ference in arm circumference, muscle strength, and BMC
between 1993 and 1998 were determined with the matched,
paired t-test. The change in the relative side-to-side BMC
difference across the three study groups (young starters, old
starters, and controls) was analyzed using the analysis of
variance (ANOVA) with repeated measurements (the
within-subject factors were limb and time, and the between-
group factor was the study group). The post hoc group
comparisons with corresponding the 95% CIs (adjusted for
multiple comparisons) were done by the Scheffè’s method.
The associations between the changes in the training vari-
ables of the players and the changes in their relative side-
to-side BMC differences were determined with the nonpara-
metric Spearman rank correlation coefficients.
The results are expressed as the mean ⫾ SD and the 95%
CI. The given significance levels refer to two-tailed tests.
An ␣ of less than 5% (p ⬍ 0.05) was considered statistically
significant.
and controls and slightly decreased among the old starters
(Table 1).
There were no severe injuries during the follow-up pe-
riod, and no one used bone-affecting medication. No men-
strual irregularities were reported in the player groups but
two controls reported oligomenorrhea in both interviews. In
the player groups, the number of oral contraceptive users
increased from 16 in 1993 to 28 in 1998. In the control
group, there were 11 users in 1993 and 12 users in 1998.
Two players and three controls had given birth during the
follow-up. At the follow-up, five players (old starters) and
three controls reported that menopausal symptoms had
started, and all of them except one player used estrogen
replacement therapy.
Changes in arm circumference and muscle strength
The average arm circumferences and the results of the
strength and bone measurements in 1993 and 1998 are listed
in Table 2, the significance of the change by time given as
the 95% CI.
Among the young starters, a statistically significant de-
crease by time was seen in elbow flexion (⫺7%) and grip
strength (⫺9%) while in the old starters the change in the
elbow extension was the only statistically significant change
(⫺7%) (Table 2).

RESULTS Changes in bone

Changes in lifestyle and medical history
Diet, Ca-intake, consumption of alcohol, and smoking at
baseline have been reported previously.(1) In these variables,
no major changes occurred during the 5-year follow-up.
Number of sessions per week in physical activities other
than racquet sports had slightly increased in young starters
Change in the side-to-side BMC difference from 1993 to
1998: In the young starters, a 2.7% decrease (95% CI,
⫺4.6% to ⫺0.7%, and p ⫽ 0.009) in the relative side-to-
side BMC difference was seen at the proximal humerus
(Table 2; Fig. 1). At the humeral shaft, there was no sig-
nificant change, whereas at the distal radius a 2.1% decrease
198 KONTULAINEN ET AL.

TABLE 2. DOMINANT VERSUS NONDOMINANT ARM COMPARISONS (MEAN ⫾ SD)

1993 1998

Mean % Mean % Mean

Dominant Nondominant differencea Dominant Nondominant differencea ⌬-% diff.b 95% CIc

Young Starters (N ⫽ 36)

Circumference (cm)
Upper arm 25.6 ⫾ 2.2 24.8 ⫾ 2.0 3.5 27.5 ⫾ 2.4 26.5 ⫾ 2.4 3.8 0.3 ⫺1.9 to 2.5
Forearm 21.6 ⫾ 1.2 20.6 ⫾ 1.7 5.5 22.2 ⫾ 1.7 20.8 ⫾ 1.2 6.7 1.2 ⫺1.3 to 3.7
Strength measurements (kg)
Elbow extension 10.3 ⫾ 2.6 9.3 ⫾ 1.9 9.9 11.6 ⫾ 2.5 11.1 ⫾ 2.3 5.8 ⫺3.9 ⫺8.8 to 1.1
Elbow flexion 16.8 ⫾ 3.1 14.3 ⫾ 2.7 18.2 19.1 ⫾ 3.9 17.1 ⫾ 3.3 11.3 ⫺6.6 ⫺10.1 to ⫺3.1
Grip strength 23.0 ⫾ 4.3 18.9 ⫾ 3.6 22.7 24.9 ⫾ 3.9 21.9 ⫾ 3.3 14.3 ⫺8.5 ⫺15.0 to ⫺2.0
BMC (g)
Proximal humerus 11.03 ⫾ 1.53 9.21 ⫾ 1.13 19.8 10.91 ⫾ 1.52 9.31 ⫾ 1.18 17.2 ⫺2.7 ⫺4.6 to ⫺0.7
Humeral shaft 20.49 ⫾ 2.51 16.91 ⫾ 1.88 21.3 21.22 ⫾ 2.62 17.45 ⫾ 1.87 21.6 0.3 ⫺1.4 to 2.0
Distal radius 2.98 ⫾ 0.35 2.60 ⫾ 0.33 15.1 2.99 ⫾ 0.35 2.66 ⫾ 0.33 12.3 ⫺2.1 ⫺4.2 to ⫺0.1
Old Starters (N ⫽ 28)
Circumference (cm)
Upper arm 26.7 ⫾ 1.7 25.8 ⫾ 1.7 3.6 28.9 ⫾ 3.0 27.8 ⫾ 3.3 4.6 1.0 ⫺2.1 to 4.1
Forearm 22.3 ⫾ 1.4 21.2 ⫾ 1.1 5.3 23.2 ⫾ 2.2 21.6 ⫾ 1.5 7.7 2.4 ⫺0.1 to 5.6
Strength measurements (kg)
Elbow extension 10.9 ⫾ 2.0 9.8 ⫾ 1.8 12.7 12.0 ⫾ 2 11.5 ⫾ 2 5.5 ⫺7.3 ⫺13.1 to ⫺1.5
Elbow flexion 16.0 ⫾ 3.9 14.9 ⫾ 4.0 8.1 17.3 ⫾ 3.8 16.8 ⫾ 3.7 4.3 ⫺3.9 ⫺10.1 to 2.3
Grip strength 23.8 ⫾ 5.0 19.2 ⫾ 4.1 25.8 25.0 ⫾ 4.3 21.7 ⫾ 4.0 18.2 ⫺8.2 ⫺19.7 to 3.2
BMC (g)
Proximal humerus 10.27 ⫾ 0.98 9.25 ⫾ 0.86 11.0 10.28 ⫾ 1.11 9.09 ⫾ 0.90 13.3 2.3 0.1 to 4.5
Humeral shaft 20.06 ⫾ 1.21 18.50 ⫾ 1.29 8.6 20.41 ⫾ 1.39 18.59 ⫾ 1.40 9.9 1.3 0.3 to 2.3
Distal radius 3.10 ⫾ 0.35 2.82 ⫾ 0.33 10.2 3.17 ⫾ 0.47 2.89 ⫾ 0.41 9.8 ⫺0.4 ⫺2.5 to 1.8
Controls (N ⫽ 27)
Circumference (cm)
Upper arm 27.4 ⫾ 2.5 27.3 ⫾ 2.8 0.6 28.5 ⫾ 3.3 28.2 ⫾ 3.4 1.0 0.4 ⫺0.7 to 1.5
Forearm 21.8 ⫾ 1.5 21.6 ⫾ 1.5 1.1 22.4 ⫾ 1.5 21.7 ⫾ 1.4 3.5 2.4 0.7 to 4.0
Strength measurements (kg)
Elbow extension 10.9 ⫾ 3.7 10.7 ⫾ 3.4 2.2 11.9 ⫾ 2.9 11.9 ⫾ 3.2 0.1 ⫺2.1 ⫺6.7 to 2.5
Elbow flexion 18.0 ⫾ 4.3 16.6 ⫾ 4.6 9.3 19.5 ⫾ 4.1 19.0 ⫾ 5.3 4.5 ⫺4.8 ⫺11.3 to 1.7
Grip strength 23.4 ⫾ 4.0 20.3 ⫾ 3.5 16.2 25.2 ⫾ 4.2 22.6 ⫾ 3.6 11.5 ⫺4.7 ⫺11.4 to 1.9
BMC (g)
Proximal humerus 9.78 ⫾ 1.27 9.30 ⫾ 1.17 5.3 9.79 ⫾ 1.33 9.14 ⫾ 1.04 7.0 1.7 ⫺0.1 to 3.5
Humeral shaft 18.48 ⫾ 2.04 17.92 ⫾ 1.99 3.2 18.81 ⫾ 2.05 18.17 ⫾ 1.98 3.5 0.3 ⫺0.8 to 1.5
Distal radius 2.84 ⫾ 0.34 2.75 ⫾ 0.35 3.8 2.76 ⫾ 0.31 2.65 ⫾ 0.33 4.4 0.7 ⫺1.9 to 3.2
a
% difference ⫽ (dominant arm ⫺ nondominant arm)/nondominant arm ⴱ 100.
b
⌬-% diff. ⫽ % difference ’98 ⫺ % difference ’93.
c
95% CI ⫽ 95% Confidence interval of the mean ⌬-% difference.

(95% CI, ⫺4.2% to ⫺0.1%, and p ⫽ 0.040) was seen.
Among the old starters, in turn, the relative side-to-side
BMC difference increased 2.3% (95% CI, 0.1% to 4.5%,
p ⫽ 0.044) at the proximal humerus and 1.3% (95% CI,
0.3%– 02.3%, and p ⫽ 0.016) at the humeral shaft whereas
no change was seen at their distal radius (Fig. 1). There
were no statistically significant side-to-side BMC changes
in the control group.
The noted decrease in the young starters’ relative side-
to-side BMC difference at the proximal humerus was
caused by a slight increase (1.1%) in the absolute BMC
value of the nonplaying arm and simultaneous decrease
(⫺1.1%) in that of the playing arm, while among the old
starters the absolute BMC of this nonplaying arm site de-
creased (⫺1.7%) and that of the playing arm remained at the
1993 level (0.1%) leading thus to the previously noted
increase in the relative side-to-side BMC difference (Table
2; Fig. 1).
Change in the relative side-to-side BMC difference
across the study groups: In the ANOVA, the only statisti-
cally significant between-group difference in the change of
the relative BMC was seen at the proximal humerus (p ⫽
0.001; Fig. 1). At this site, the post hoc analysis revealed a
4.1% (95% CI, 1.1–7.2%, and p ⬍ 0.001) decrease in the
relative side-to-side BMC difference between the young and
old starters, and this was caused by the previously noted
opposite changes in the relative BMC differences between
the young and old starters.
In controls, the changes in the absolute BMC values of
the proximal humerus were similar to those of the old
starters, resulting, in the posthoc analysis, in a 3.8% (95%
CI, 0.8 –7.0%; p ⫽ 0.002) decrease in the relative side-to-
EXERCISE-INDUCED BONE GAIN AND DECREASED ACTIVITY
FIG. 1. Comparison of the players’ (young and old starters) and
controls’ side-to-side BMC differences (%) between 1993 and 1998
(mean, 95% CI).
side BMC difference between the young starters and con-
trols, and this explained the unchanged relative BMC dif-
ference between the old starters and controls (0.3%; 95%
CI, 2.8 –3.5%).
The ANOVA showed no statistically significant between-
group differences in the change of the relative side-to-side
BMC difference at the humeral shaft (p ⫽ 0.47) or distal
radius (p ⫽ 0.26; Fig. 1).
Players’ side-to-side BMC difference in relation to
change in training: In both player groups, the Spearman’s
rank correlation coefficients between the change in the
relative side-to-side BMC difference and the change in the
199
training variables (number of training session per week, and
the number of the training hours during the year preceding
the measurement) varied from 0.05 to 0.36, showing thus a
weak, but an insignificant relationship in every comparison.
The individual side-to-side BMC changes also were an-
alyzed separately among the 10 players who had completely
stopped their tennis or squash training at least 1 year before
the follow-up measurement; however, no clear and system-
atically decreasing trend was found in these players’ relative
side-to-side BMC difference and this concerned both the
young starters and the old starters.
DISCUSSION
Retrospective cross-sectional studies on former athletes
and their controls have given preliminary evidence that at
least a part of the exercise-induced bone gain that is ob-
tained during the years of growth may persist despite de-
creased physical activity.(11–17,22,23) This 5-year prospective
follow-up study of female racquet sports players showed a
good maintenance of the side-to-side BMC difference be-
tween the playing and nonplaying extremity during the
follow-up, although the mean training frequency and the
mean hours of training were decreased clearly, thus sup-
porting the results of the previously noted cross-sectional
studies. This result was also in line with that of our recent
investigation in male tennis players.(18)
Our initial investigation of female players provided
strong evidence that the effect of unilateral loading on the
playing arm BMC is about two times greater if the playing
is started before or at puberty rather than after it.(1) The
current study, in turn, indicated that the exercise-induced
bone gain was well maintained in both groups of players
regardless of the clearly different starting age of activity and
the magnitude of the exercise-induced bone gain. Thus, our
results did not give direct support to the notion that the
exercise-induced bone gain that is obtained during the
growth may better withstand the effects of decreased train-
ing than the bone gain obtained in adulthood.(24) At the
proximal humerus, the old starters even slightly increased
their relative side-to-side BMC difference compared with
the reverse change among the young starters. These changes
were caused by the opposite changes in the absolute BMC
values of the dominant and nondominant sides of these two
groups. However, because all these absolute BMC changes
were generally small and within the 1–2% precision error of
the measurement,(20) we should not emphasize these find-
ings too much.
One limitation of our study is that a longer than 5-year
follow-up period may be needed to see greater changes
(reductions) in players’ side-to-side BMC difference, at
least to get more players with complete cessation of the
activity. In other words, the lack of negative bone response
to reduced training in this study may have been partly
because of the fact that most of the players were still active
enough to maintain their exercise-induced bone gain. It may
well be that the decreased but still regularly done tennis or
squash training was able to produce a sufficient stimulus for
the maintenance of the training-induced bone gain.
200
On the other hand, our study allowed us to gather some
information about the effects of completely stopped tennis
or squash training on the exercise-induced bone gain via the
players who had not played for at least a year before the
follow-up measurement. These players’ individual changes
in side-to-side BMC difference showed that players with the
highest side-to-side difference seemed to have lost some of
their exercise-induced bone gain although there also were
such players who had well maintained the side-to-side BMC
difference in the upper and forearm bones despite ceased
tennis activity. Interestingly, both the individual changes of
the detrained players and the mean changes in the young
and old starters’ side-to-side BMC difference seemed to be
greater at the bone sites that contained more trabecular bone
(proximal humerus and distal radius) than cortical bone
(humeral shaft). This was especially clear among the young
starters whose side-to-side difference decreased at the prox-
imal humerus and distal radius but remained unchanged at
the humeral shaft (Fig. 1). It may well be that decreased
loading has a greater influence on trabecular bone sites
where a high surface-to-volume ratio makes the bone more
susceptible to rapid bone mineral turnover.(25)
Some animal studies support the notion of maintenance of
exercise-induced bone gain during at least a short detraining
period.(26 –28) In contrast, some human studies(29 –31) have
shown that even a short detraining period reduces the
exercise-induced bone gain at the trabecular regions to
pretraining values thus suggesting that long-term benefits
are only retained with continuing exercise. As evident in the
current study, the amount of training needed to maintain the
exercise-induced bone alterations clearly can be less than
that needed to achieve the additional bone. To support this,
aerobic classes approximately twice a week turned out to be
an efficient way to maintain premenopausal women’s
exercise-induced bone gain after cessation of an intense
jumping training.(32)
It has been assumed that growing bone responds to exer-
cise through significant additions of new bone at both the
cortical site (periosteal expansion and endosteal enlarge-
ment) and the trabecular site while there is no exercise-
induced endosteal bone accrual in a mature bone.(24,25)
Ashizawa et al.(33) suggested that the mature bone might
have an alternative mechanism to respond to exercise by
increasing it’s volumetric trabecular density. Their mea-
surements, carried out with peripheral quantitative com-
puted tomography (pQCT), revealed that all three of the
tennis players who had not started playing until the age of
16 years seemed to have increased the trabecular density,
not the cross-sectional area, of the distal radius, while the
opposite was the case in players who had started playing
when younger.
Because the majority of the benefits of training on bone
seems to be achieved already during the pubertal years, includ-
ing the adolescent growth spurt when the effect of physical
activity on bone has been shown to be large,(2,34 –38) the
exercise-induced changes in bone mass and geometry(5,33,35)
also might be more permanent if the benefit is obtained during
the growing years rather than later on. However, as noted
before, the current study could not show more permanent bone
preservation with decreased loading in those with whom the
KONTULAINEN ET AL.
bone gain was achieved before or at menarche than in those
who had obtained the bone gain later in adulthood. On the
other hand, in both groups of players only a few subjects had
completely stopped the racquet sports activity and the average
one to two times a week of playing may well have been enough
for the maintenance of the loading-induced bone gain. Conse-
quently, there is a clear need to follow our players for a longer
time, until most of them have ceased the playing completely,
and then analyze again the side-to-side BMC difference in both
groups. In addition, prospective, randomized exercise trials
with children, adolescents, and adults, using precise measure-
ments of the geometry, composition, and volumetric density of
the bone compartments, are needed, and these study subjects
should be followed long enough after the decrease or cessation
of the activity.
Overall, if controlled interventions will confirm our find-
ings that an exercise-induced bone gain can be well main-
tained with decreased activity and that the maintenance of
the bone gain is independent of the starting age of the
activity, exercise can be recommended for preventing os-
teoporosis and related fractures.
ACKNOWLEDGMENTS
We are grateful to Ulla Hakala, Kirsi Martinsen, and
Virpi Koskue for their skillful bone measurements. This
study was financially supported by the Ministry of Educa-
tion, Helsinki, the Emil Aaltonen Foundation, Tampere, and
the Medical Research Fund of the Tampere University
Hospital, Tampere, Finland.
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Address reprint requests to:
Saija Kontulainen, M.Sc.
The Bone Research Group
UKK Institute
Kaupinpuistonkatu 1
FIN-33500 Tampere, Finland
Received in original form January 19, 2000; in revised form April
18, 2000; accepted August 1, 2000.