Changes in physical performance with aging in master athletes and in the general population: an update

One of the fundamental biological processes underlying aging is the decline in physical performance. Sarcopenia, dynapenia, chronic inflammation, and other factors including the loss of motor units largely account for this decline. Master athletes—individuals who train and compete well beyond early adulthood—represent a valuable model for studying healthy aging. In the general population, physical performance follows a characteristic lifespan trajectory, increasing from childhood to a peak in early adulthood and progressively declining with aging due to a reduction in muscle mass and quality, and in multisystem physiological functions. The seminal studies by Gava and colleagues on master athletes indicate that, under ideal conditions of being disease-free or injury-free, performance loss of these athletes follows an attenuated, linear fashion from early adulthood into advanced age. While lifelong training cannot halt age-related physiological deterioration, it can attenuate the rate of functional decline in cardiovascular, neurocognitive, and musculoskeletal functions. From a sex-based perspective, males demonstrate an absolute advantage in power and strength compared to females, whereas differences in endurance performance are smaller. With age, the physical performance gap between the two sexes tends to narrow, particularly in endurance disciplines. Overall, the master athlete model supports the concept that aging-related performance decay follows predictable biological rules, while its rate remains highly modifiable through sustained physical activity. These insights have important implications for exercise prescription, preventive strategies, and healthy aging.

1. Carraro U, Kern H, Albertin G. Paolo Gava, a professional engineer, who has become a Master athlete, an amateur scientist and a lifelong friend. Eur J Transl Myol 2021;31:10260. DOI: https://doi.org/10.4081/ejtm.2021.10260

2. Gava P, Ravara B. Master World Records show minor gender differences of performance decline with aging. Eur J Transl Myol 2019;29:8327. DOI: https://doi.org/10.4081/ejtm.2019.8327

3. Gava P, Giuriati W, Ravara B. Gender difference of aging performance decay rate in normalized Masters World Records of Athletics: much less than expected. Eur J Transl Myol 2020;30:8869. DOI: https://doi.org/10.4081/ejtm.2019.8869

4. Ganse B, Ganse U, Dahl J, Degens H. Linear Decrease in Athletic Performance During the Human Life Span. Front Physiol 2018;9:1100. DOI: https://doi.org/10.3389/fphys.2018.01100

5. Gava P, Kern H, Carraro U. Age-associated power decline from running, jumping, and throwing male masters world records. Exp Aging Res 2015;41:115–35. DOI: https://doi.org/10.1080/0361073X.2015.1001648

6. Guo J, Huang X, Dou L, et al. Aging and aging-related diseases: from molecular mechanisms to interventions and treatments. Signal Transduct Target Ther 2022;7:391. DOI: https://doi.org/10.1038/s41392-022-01251-0

7. Moskalev A, Guvatova Z, Lopes IDA, et al. Targeting aging mechanisms: pharmacological perspectives. Trends Endocrinol Metab 2022;33:266–80. DOI: https://doi.org/10.1016/j.tem.2022.01.007

8. Vakka A, Warren JS, Drosatos K. Cardiovascular aging: from cellular and molecular changes to therapeutic interventions. J Cardiovasc Aging 2023;3:23. DOI: https://doi.org/10.20517/jca.2023.09

9. Vandervoort AA. Aging of the human neuromuscular system. Muscle Nerve 2002;25:17–25. DOI: https://doi.org/10.1002/mus.1215

10. Hunter SK. Motor performance and aging in males and females. J Electromyogr Kinesiol 2025;85:103066. DOI: https://doi.org/10.1016/j.jelekin.2025.103066

11. Suetta C, Frandsen U, Mackey AL, et al. Ageing is associated with diminished muscle re-growth and myogenic precursor cell expansion early after immobility-induced atrophy in human skeletal muscle. J Physiol 2013;591:3789–804. DOI: https://doi.org/10.1113/jphysiol.2013.257121

12. Berthelot G, Johnson S, Noirez P, et al. The age-performance relationship in the general population and strategies to delay age related decline in performance. Arch Public Health 2019;77:51. DOI: https://doi.org/10.1186/s13690-019-0375-8

13. Letnes JM, Nes BM, Wisløff U. Age-related decline in peak oxygen uptake: Cross-sectional vs. longitudinal findings. A review. Int J Cardiol Cardiovasc Risk Prev 2023;16:200171. DOI: https://doi.org/10.1016/j.ijcrp.2023.200171

14. Ganse B, Kleerekoper A, Knobe M, et al. Longitudinal trends in master track and field performance throughout the aging process: 83,209 results from Sweden in 16 athletics disciplines. GeroScience 2020;42:1609–20. DOI: https://doi.org/10.1007/s11357-020-00275-0

15. Shen X, Wang C, Zhou X, et al. Nonlinear dynamics of multi-omics profiles during human aging. Nat Aging 2024;4:1619–34. DOI: https://doi.org/10.1038/s43587-024-00692-2

16. Larsson L, Degens H, Li M, et al. Sarcopenia: aging-related loss of muscle mass and function. Physiol Rev 2019;99:427–511. DOI: https://doi.org/10.1152/physrev.00061.2017

17. Damanti S, Senini E, De Lorenzo R, et al. Molecular constraints of sarcopenia in the ageing muscle. Front Aging 2025;6:1588014. DOI: https://doi.org/10.3389/fragi.2025.1588014

18. Naranjo JD, Dziki JL, Badylak SF. Regenerative medicine approaches for age-related muscle loss and sarcopenia: a mini-review. Gerontology 2017;63:580–9. DOI: https://doi.org/10.1159/000479278

19. Tieland M, Trouwborst I, Clark BC. Skeletal muscle performance and ageing. J Cachexia Sarcopenia Muscle 2018;9:3–19.

20. Gschwind YJ, Kressig RW, Lacroix A, et al. A best practice fall prevention exercise program to improve balance, strength/power, and psychosocial health in older adults: study protocol for a randomized controlled trial. BMC Geriatr 2013;13:105. DOI: https://doi.org/10.1186/1471-2318-13-105

21. Beck BR, Daly RM, Singh MAF, Taaffe DR. Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. J Sci Med Sport 2017;20:438–45. DOI: https://doi.org/10.1016/j.jsams.2016.10.001

22. Izquierdo M, Duque G, Morley JE. Physical activity guidelines for older people: knowledge gaps and future directions. Lancet Healthy Longev 2021;2:e380–3. DOI: https://doi.org/10.1016/S2666-7568(21)00079-9

23. Balachandran AT, Steele J, Angielczyk D, et al. Comparison of Power training vs traditional strength training on physical function in older adults: a systematic review and meta-analysis. JAMA Netw Open 2022;5:e2211623. DOI: https://doi.org/10.1001/jamanetworkopen.2022.11623

24. Ai M, Tinney EM, España-Irla G, et al. Brain resting-state functional connectivity mediates the age-associated decline in physical activity engagement. J Gerontol A Biol Sci Med Sci 2025;80:glaf075. DOI: https://doi.org/10.1093/gerona/glaf075

25. Milanović Z, Pantelić S, Trajković N, et al. Age-related decrease in physical activity and functional fitness among elderly men and women. Clin Interv Aging 2013;8:549–56. DOI: https://doi.org/10.2147/CIA.S44112

26. Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019;48:16–31. DOI: https://doi.org/10.1093/ageing/afy169

27. Coletti C, Acosta GF, Keslacy S, Coletti D. Exercise-mediated reinnervation of skeletal muscle in elderly people: An update. Eur J Transl Myol 2022;32:10416. DOI: https://doi.org/10.4081/ejtm.2022.10416

28. Manini TM, Clark BC. Dynapenia and aging: an update. J Gerontol A Biol Sci Med Sci 2012;67A:28–40.

29. Reid KF, Fielding RA. Skeletal muscle power: a critical determinant of physical functioning in older adults. Exerc Sport Sci Rev 2012;40:4–12. DOI: https://doi.org/10.1097/JES.0b013e31823b5f13

30. Borges N, Reaburn P, Driller M, Argus C. Age-related changes in performance and recovery kinetics in masters athletes: a narrative review. J Aging Phys Act 2016;24:149–57. DOI: https://doi.org/10.1123/japa.2015-0021

31. Trombetti A, Reid KF, Hars M, et al. Age-associated declines in muscle mass, strength, power, and physical performance: impact on fear of falling and quality of life. Osteoporos Int J Establ Result Coop Eur Found Osteoporos Natl Osteoporos Found USA 2016;27:463–71. DOI: https://doi.org/10.1007/s00198-015-3236-5

32. Hunter SK, Pereira HM, Keenan KG. The aging neuromuscular system and motor performance. J Appl Physiol 2016;121:982–95. DOI: https://doi.org/10.1152/japplphysiol.00475.2016

33. Piasecki J, Inns TB, Bass JJ, et al. Influence of sex on the age-related adaptations of neuromuscular function and motor unit properties in elite masters athletes. J Physiol 2021;599:193–205. DOI: https://doi.org/10.1113/JP280679

34. Della Peruta C, Lozanoska-Ochser B, Renzini A, et al. Sex differences in inflammation and muscle wasting in aging and disease. Int J Mol Sci 2023;24:4651. DOI: https://doi.org/10.3390/ijms24054651

35. Gleeson M, Bishop NC, Stensel DJ, et al. The anti-inflammatory effects of exercise: mechanisms and implications for the prevention and treatment of disease. Nat Rev Immunol 2011;11:607–15. DOI: https://doi.org/10.1038/nri3041

36. Halter JB, Musi N, McFarland Horne F, et al. Diabetes and cardiovascular disease in older adults: current status and future directions. Diabetes 2014;63:2578–89. DOI: https://doi.org/10.2337/db14-0020

37. Laddu DR, Kim H, Cawthon PM, et al. Physical performance changes as clues to late-life blood pressure changes with advanced age: the osteoporotic fractures in men study. J Nutr Health Aging 2024;28:100317. DOI: https://doi.org/10.1016/j.jnha.2024.100317

38. Tanaka H, Seals DR. Endurance exercise performance in Masters athletes: age-associated changes and underlying physiological mechanisms. J Physiol 2008;586:55–63.

39. Tayrose GA, Beutel BG, Cardone DA, Sherman OH. The masters athlete. Sports Health 2015;7:270–6. DOI: https://doi.org/10.1177/1941738114548999

40. Geard D, Reaburn PRJ, Rebar AL, Dionigi RA. Masters athletes: exemplars of successful aging? J Aging Phys Act 2017;25:490–500. DOI: https://doi.org/10.1123/japa.2016-0050

41. Pollock ML, Mengelkoch LJ, Graves JE, et al. Twenty-year follow-up of aerobic power and body composition of older track athletes. J Appl Physiol Bethesda Md 1985 1997;82:1508–16. DOI: https://doi.org/10.1152/jappl.1997.82.5.1508

42. Hawkins SA, Wiswell RA, Marcell TJ. Exercise and the master athlete—a model of successful aging? J Gerontol Ser A 2003;58:M1009–11. DOI: https://doi.org/10.1093/gerona/58.11.M1009

43. Ireland A, Mittag U, Degens H, et al. Age-Related declines in lower limb muscle function are similar in power and endurance athletes of both sexes: a longitudinal study of master athletes. Calcif Tissue Int 2022;110:196–203. DOI: https://doi.org/10.1007/s00223-021-00907-3

44. Suominen TH, Alén M, Törmäkangas T, et al. Regular strength and sprint training counteracts bone aging: a 10-year follow-up in male masters athletes. JBMR Plus 2021;5:e10513. DOI: https://doi.org/10.1002/jbm4.10513

45. Zange J, Endres J, Clemen CS, Rittweger J. Leg and hip muscles show muscle‐specific effects of ageing and sport on muscle volume and fat fraction in male Masters athletes. J Physiol 2026;604:917–35. DOI: https://doi.org/10.1113/JP285665

46. McElroy CL, Wang B, Zhang H, Jin K. Cerebellum and aging: update and challenges. Aging Dis 2024;15:2345–60.

47. Ahlskog JE, Geda YE, Graff-Radford NR, Petersen RC. Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging. Mayo Clin Proc 2011;86:876–84. DOI: https://doi.org/10.4065/mcp.2011.0252

48. Tseng BY, Uh J, Rossetti HC, et al. Masters athletes exhibit larger regional brain volume and better cognitive performance than sedentary older adults. J Magn Reson Imaging JMRI 2013;38:1169–76. DOI: https://doi.org/10.1002/jmri.24085

49. Koblinsky ND, Meusel LAC, Greenwood CE, Anderson ND. Household physical activity is positively associated with gray matter volume in older adults. BMC Geriatr 2021;21:104. DOI: https://doi.org/10.1186/s12877-021-02054-8

50. Guiney H, Machado L. Benefits of regular aerobic exercise for executive functioning in healthy populations. Psychon Bull Rev 2013;20:73–86. DOI: https://doi.org/10.3758/s13423-012-0345-4

51. Thomas BP, Yezhuvath US, Tseng BY, et al. Life-long aerobic exercise preserved baseline cerebral blood flow but reduced vascular reactivity to CO2. J Magn Reson Imaging JMRI 2013;38:24090. DOI: https://doi.org/10.1002/jmri.24090

52. Omole JG, Okon IA, Udom GJ, et al. Neurophysiological mechanisms underlying cardiovascular adaptations to exercise: A narrative review. Physiol Rep 2025;13:e70439. DOI: https://doi.org/10.14814/phy2.70439

53. Clark BC, Manini TM. What is dynapenia? Nutr Burbank Los Angel Cty Calif 2012;28:495–503. DOI: https://doi.org/10.1016/j.nut.2011.12.002

54. Tieland M, Trouwborst I, Clark BC. Skeletal muscle performance and ageing. J Cachexia Sarcopenia Muscle 2018;9:3–19. DOI: https://doi.org/10.1002/jcsm.12238

55. Kobayashi K, Imagama S, Ando K, et al. Dynapenia and physical performance in community-dwelling elderly people in Japan. Nagoya J Med Sci 2020;82:415–24.

56. Manini TM, Clark BC. Dynapenia and aging: an update. J Gerontol A Biol Sci Med Sci 2012;67:28–40. DOI: https://doi.org/10.1093/gerona/glr010

57. Janssen TAH, Lowisz CV, Phillips S. From molecular to physical function: The aging trajectory. Curr Res Physiol 2025;8:100138. DOI: https://doi.org/10.1016/j.crphys.2024.100138

58. Cesare MM, Felice F, Santini V, Di Stefano R. Antioxidants in sport sarcopenia. Nutrients 2020;12:2869. DOI: https://doi.org/10.3390/nu12092869

59. Rosa TS, Neves RVP, Deus LA, et al. Sprint and endurance training in relation to redox balance, inflammatory status and biomarkers of aging in master athletes. Nitric Oxide 2020;102:42–51. DOI: https://doi.org/10.1016/j.niox.2020.05.004

60. Piasecki M, Ireland A, Stashuk D, et al. Age‐related neuromuscular changes affecting human vastus lateralis. J Physiol 2016;594:4525–36. DOI: https://doi.org/10.1113/JP271087

61. Hepple RT, Rice CL. Innervation and neuromuscular control in ageing skeletal muscle. J Physiol 2016;594:1965–78. DOI: https://doi.org/10.1113/JP270561

62. Orssatto LBR, Borg DN, Pendrith L, et al. Do motoneuron discharge rates slow with aging? A systematic review and meta-analysis. Mech Ageing Dev 2022;203:111647. DOI: https://doi.org/10.1016/j.mad.2022.111647

63. Alvero-Cruz JR, Brikis M, Chilibeck P, et al. Age-related decline in vertical jumping performance in masters track and field athletes: concomitant influence of body composition. Front Physiol 2021;12:643649. DOI: https://doi.org/10.3389/fphys.2021.643649

64. Appleyard M, Lund H, Stockmarr A. Isokinetic and isometric muscle strength in a healthy population with special reference to age and gender. Acta Physiol (Oxf) 2009;197:1-68. DOI: https://doi.org/10.1111/j.1748-1716.2009.02022.x

65. Caserotti P, Aagaard P, Puggaard L. Changes in power and force generation during coupled eccentric-concentric versus concentric muscle contraction with training and aging. Eur J Appl Physiol 2008;103:151–61. DOI: https://doi.org/10.1007/s00421-008-0678-x

66. Tanaka H, Seals DR. Endurance exercise performance in Masters athletes: age-associated changes and underlying physiological mechanisms. J Physiol 2008;586:55–63. DOI: https://doi.org/10.1113/jphysiol.2007.141879

67. Lazarus NR, Harridge SDR. Declining performance of master athletes: silhouettes of the trajectory of healthy human ageing? J Physiol 2017;595:2941–8. DOI: https://doi.org/10.1113/JP272443

68. Aagaard P, Suetta C, Caserotti P, et al. Role of the nervous system in sarcopenia and muscle atrophy with aging: strength training as a countermeasure. Scand J Med Sci Sports 2010;20:49–64. DOI: https://doi.org/10.1111/j.1600-0838.2009.01084.x

69. Wroblewski AP, Amati F, Smiley MA, et al. Chronic exercise preserves lean muscle mass in masters athletes. Phys Sportsmed 2011;39:172–8. DOI: https://doi.org/10.3810/psm.2011.09.1933

70. Dinenno FA, Jones PP, Seals DR, Tanaka H. Limb blood flow and vascular conductance are reduced with age in healthy humans: relation to elevations in sympathetic nerve activity and declines in oxygen demand. Circulation 1999;100:164–70. DOI: https://doi.org/10.1161/01.CIR.100.2.164

71. Donato AJ, Machin DR, Lesniewski LA. Mechanisms of dysfunction in the aging vasculature and role in age-related disease. Circ Res. 2018;123:825–48. DOI: https://doi.org/10.1161/CIRCRESAHA.118.312563

72. Tracy E, Rowe G, LeBlanc AJ. Cardiac tissue remodeling in healthy aging: the road to pathology. Am J Physiol - Cell Physiol 2020;319:C166–82. DOI: https://doi.org/10.1152/ajpcell.00021.2020

73. Mazzotti AL, Hassani M, Li Z, et al. Cardiac wasting is not cardiac cachexia: the problem of the subjective/objective genitive in matters of the heart. Eur J Transl Myol 2025;35:14147. DOI: https://doi.org/10.4081/ejtm.2025.14147

74. Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol 2001;37:153–6. DOI: https://doi.org/10.1016/S0735-1097(00)01054-8

75. Tanaka H, Seals DR, Monahan KD, et al. Regular aerobic exercise and the age-related increase in carotid artery intima-media thickness in healthy men. J Appl Physiol 2002;92:1458–64. DOI: https://doi.org/10.1152/japplphysiol.00824.2001

76. Seals DR, DeSouza CA, Donato AJ, Tanaka H. Habitual exercise and arterial aging. J Appl Physiol 2008;105:1323–32. DOI: https://doi.org/10.1152/japplphysiol.90553.2008

77. Merghani A, Maestrini V, Rosmini S, et al. Prevalence of subclinical coronary artery disease in masters endurance athletes with a low atherosclerotic risk profile. Circulation. 2017;136:126–37. DOI: https://doi.org/10.1161/CIRCULATIONAHA.116.026964

78. Eijsvogels TMH, Molossi S, Lee DC, et al. Exercise at the extremes: the amount of exercise to reduce cardiovascular events. J Am Coll Cardiol 2016;67:316–29. DOI: https://doi.org/10.1016/j.jacc.2015.11.034

79. Tanaka H, Tarumi T, Rittweger J. Aging and physiological lessons from master athletes. Compr Physiol 2019;10:261–96. DOI: https://doi.org/10.1002/cphy.c180041

80. Demontiero O, Vidal C, Duque G. Aging and bone loss: new insights for the clinician. Ther Adv Musculoskelet Dis 2012;4:61–76.

81. Föger-Samwald U, Dovjak P, Azizi-Semrad U, et al. Osteoporosis: Pathophysiology and therapeutic options. EXCLI J 2020;19:1017–37.

82. Rosen CJ. The Epidemiology and Pathogenesis of Osteoporosis. In: Feingold KR, Ahmed SF, Anawalt B, Blackman MR, Boyce A, Chrousos G, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000 [cited 2025 Dec 1]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK279134/ PubMed PMID: 25905357.

83. Carter MI, Hinton PS. Physical Activity and Bone Health. Mo Med 2014;111:59–64.

84. Demontiero O, Vidal C, Duque G. Aging and bone loss: new insights for the clinician. Ther Adv Musculoskelet Dis 2012;4:61–76. DOI: https://doi.org/10.1177/1759720X11430858

85. Chang X, Xu S, Zhang H. Regulation of bone health through physical exercise: Mechanisms and types. Front Endocrinol 2022;13:1029475. DOI: https://doi.org/10.3389/fendo.2022.1029475

86. Ireland A, Degens H, Ganse B, et al. Greater tibial bone strength in male tennis players than controls in the absence of greater muscle output. J Orthop Transl 2015;3:142–51. DOI: https://doi.org/10.1016/j.jot.2015.04.001

87. Ireland A, Mittag U, Degens H, et al. Greater maintenance of bone mineral content in male than female athletes and in sprinting and jumping than endurance athletes: a longitudinal study of bone strength in elite masters athletes. Arch Osteoporos 2020;15:87. DOI: https://doi.org/10.1007/s11657-020-00757-w

88. Troy KL, Mancuso ME, Butler TA, Johnson JE. Exercise early and often: effects of physical activity and exercise on women’s bone health. Int J Environ Res Public Health 2018;15:878. DOI: https://doi.org/10.3390/ijerph15050878

89. Karlsson MK, Rosengren BE. Exercise and peak bone mass. Curr Osteoporos Rep 2020;18:285–90. DOI: https://doi.org/10.1007/s11914-020-00588-1

90. Collins BC, Laakkonen EK, Lowe DA. Aging of the musculoskeletal system: How the loss of estrogen impacts muscle strength. Bone 2019;123:137–44. DOI: https://doi.org/10.1016/j.bone.2019.03.033

91. Hunter SK. The relevance of sex differences in performance fatigability. Med Sci Sports Exerc 2016;48:2247–56. DOI: https://doi.org/10.1249/MSS.0000000000000928

92. Lowe DA, Baltgalvis KA, Greising SM. Mechanisms Behind Estrogen’s Beneficial Effect on Muscle Strength in Females. Exerc Sport Sci Rev 2010;38:61. DOI: https://doi.org/10.1097/JES.0b013e3181d496bc

93. Staron RS, Hagerman FC, Hikida RS, et al. Fiber type composition of the vastus lateralis muscle of young men and women. J Histochem Cytochem Off J Histochem Soc 2000;48:623–9. DOI: https://doi.org/10.1177/002215540004800506

94. Thibault V, Guillaume M, Berthelot G, et al. Women and men in sport performance: the gender gap has not evolved since 1983. J Sports Sci Med 2010;9:214–23.

95. Hunter SK. Sex differences in human fatigability: mechanisms and insight to physiological responses. Acta Physiol Oxf Engl 2014;210:768–89. DOI: https://doi.org/10.1111/apha.12234

96. Jokl P, Sethi PM, Cooper AJ. Master’s performance in the New York City Marathon 1983–1999. Br J Sports Med 2004;38:408–12. DOI: https://doi.org/10.1136/bjsm.2002.003566

97. Hunter SK, Stevens AA. Sex differences in marathon running with advanced age: physiology or participation? Med Sci Sports Exerc 2013;45:148–56. DOI: https://doi.org/10.1249/MSS.0b013e31826900f6

98. Enns DL, Tiidus PM. The influence of estrogen on skeletal muscle. Sports Med 2010;40:41–58. DOI: https://doi.org/10.2165/11319760-000000000-00000

99. Xu Y, Deng KL, Xing TF, et al. Effect of hormone therapy on muscle strength in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials. Menopause N Y N 2020;27:827–35. DOI: https://doi.org/10.1097/GME.0000000000001538

100. Greising SM, Baltgalvis KA, Lowe DA, Warren GL. Hormone therapy and skeletal muscle strength: a meta-analysis. J Gerontol A Biol Sci Med Sci 2009;64:1071–81. DOI: https://doi.org/10.1093/gerona/glp082

101. Travison TG, Basaria S, Storer TW, Jette AM, Miciek R, Farwell WR, et al. Clinical meaningfulness of the changes in muscle performance and physical function associated with testosterone administration in older men with mobility limitation. J Gerontol A Biol Sci Med Sci. 2011;66:1090–9. doi:10.1093/gerona/glr100 PubMed PMID: 21697501; PubMed Central PMCID: PMC3202898.

102. Storer TW, Basaria S, Traustadottir T, et al. Effects of testosterone supplementation for 3 years on muscle performance and physical function in older men. J Clin Endocrinol Metab 2017;102:583–93. DOI: https://doi.org/10.1210/jc.2016-2771

103. D’Andrea S, Spaggiari G, Barbonetti A, Santi D. Endogenous transient doping: physical exercise acutely increases testosterone levels-results from a meta-analysis. J Endocrinol Invest 2020;43:1349–71. DOI: https://doi.org/10.1007/s40618-020-01251-3

104. Potter NJ, Tomkinson GR, Dufner TJ, et al. Effects of exercise training on resting testosterone concentrations in insufficiently active men: a systematic review and meta-analysis. J Strength Cond Res 2021;35:3521–8. DOI: https://doi.org/10.1519/JSC.0000000000004146

105. Amiri N, Fathei M, Mosaferi Ziaaldini M. Effects of resistance training on muscle strength, insulin-like growth factor-1, and insulin-like growth factor-binding protein-3 in healthy elderly subjects: a systematic review and meta-analysis of randomized controlled trials. Horm Athens Greece 2021;20:247–57. DOI: https://doi.org/10.1007/s42000-020-00250-6

106. Layton JB, Kim Y, Alexander GC, Emery SL. Association between direct-to-consumer advertising and testosterone testing and initiation in the United States, 2009-2013. JAMA 2017;317:1159–66. DOI: https://doi.org/10.1001/jama.2016.21041

107. Bandari J, Ayyash OM, Emery SL, et al. Marketing and testosterone treatment in the USA: A systematic review. Eur Urol Focus 2017;3:395–402. DOI: https://doi.org/10.1016/j.euf.2017.10.016

108. Ding JB, Ng MZ, Huang SS, et al. Anabolic-androgenic steroid misuse: mechanisms, patterns of misuse, user typology, and adverse effects. J Sports Med 2021;2021:7497346. DOI: https://doi.org/10.1155/2021/7497346

109. Baker JS, Graham M, Davies B. Gym users and abuse of prescription drugs. J R Soc Med 2006;99:331–2. DOI: https://doi.org/10.1177/014107680609900703

110. Di Luigi L, Pigozzi F, Sgrò P, et al. The use of prohibited substances for therapeutic reasons in athletes affected by endocrine diseases and disorders: the therapeutic use exemption (TUE) in clinical endocrinology. J Endocrinol Invest 2020;43:563–73. DOI: https://doi.org/10.1007/s40618-019-01145-z