Youth sport superspecialization: A path to injuries, burnout
Weekly hours spent in sports activity should not exceed young athletes' age.
When it comes to youth sports, often it is all about “keeping up with the Joneses.” Young athletes are specializing in a single sport at earlier ages with the belief that more hours focused on one sport will result in them becoming a better athlete. However, research has shown this may not be the case and putting more hours into a sport at a young age may have such consequences as burnout and overuse injuries.
“One of the most interesting things is there are no good data to show that specializing in a single sport at an early age increases the likelihood of you being successful,” Mininder S. Kocher, MD, MPH, professor of orthopedic surgery at Harvard Medical School and associate director of the division of sports medicine at Boston Children’s Hospital, told Orthopedics Today. “In fact, there are some data showing that in college and professional athletes, the ones who are multi-sport athletes are more likely to succeed and play at those levels than the ones who focused on a single sport.”
By participating in multiple sports at a young age, athletes cross-train and stretch different muscles and joints, according to Shital N. Parikh, MD, professor of orthopedic surgery at Cincinnati Children’s Hospital Medical Center, who said this occurs when pediatric and adolescent athletes perform varied balancing and coordination skills, build core stability and do overall conditioning exercises.
Single-sport specialization, he said, may cause acute and overuse injuries due to the “repetitive microtrauma” of particular joints and muscles during a period of time.
Effect on boys vs girls
The type and frequency of injuries from superspecialization in sports differs among boy and girl athletes, with girl athletes being “as much as seven-times more likely to get an ACL injury,” Brandon D. Bushnell, MD, MBA, chairman of orthopedics and sports medicine at Harbin Clinic LLC in Rome, Georgia, told Orthopedics Today.
However, according to Parikh, gender differences among athletes may not be seen until puberty when girls begin to show a greater rate of injuries compared with boys. This phenomenon can be due to anatomic and hormonal differences, as well as differences in neuromuscular performance, he said.
“After puberty, girls’ injury rates are higher than boys. It is also related to the sports that they play,” Parikh, who is an Orthopedics Today Editorial Board Member, said.
Overhead sports, such as baseball, are one of the biggest culprits and most studied overuse injuries among boy athletes, but girl athletes have a greater risk of overuse injuries in volleyball, soccer, softball, field hockey and swimming, Eric C. Makhni, MD, MBA, told Orthopedics Today.
“Much of our research on overuse injuries is in male athletes. So we have a way to go in studying these injuries in youth female athletes,” he said.
Soccer has an increased risk of overuse injury among both boy and girl athletes, according to Jeremy A. Alland, MD, of Midwest Orthopaedics at Rush in Chicago.
“The most common overuse injuries a lot of times are in girls track, girls field hockey. Lacrosse also had high [overuse injury] rates in a pediatric study done on high school athletes,” Alland, said. “We see them a lot in gymnastics and dance.”
Hours at play matter
Research by Kocher and colleagues presented at the American Academy of Orthopaedic Surgeons Annual Meeting showed the total hours a child or adolescent participates in sports per week plays a big role in overuse injuries.
“What we found was specialization was associated with an increased risk of injury in multiple sports, but when you controlled for the number of hours participating in vigorous sports activity a lot of those effects went away,” Kocher, who is an Orthopedics Today Editorial Board Member, said.
Boys who participated in baseball and gymnastics had an increased risk of injury despite whether the researchers in that study controlled for total number of hours. However, Kocher said girls who participated in soccer, gymnastics, running, volleyball and basketball had an increased risk of injury, but when he and his colleagues controlled for the total number of hours of vigorous sports activity, that risk went away.
“The most important things are recognizing there is a risk, recognizing that sport specialization plays a role in that risk, but also it is the total number of hours that is probably the more important factor,” Kocher said. “All hours are not equal and so I think we also need to think about whether they are in games or in practice.”
One rule of thumb young athletes should follow, according to Kocher, is not doing more hours of vigorous sports activity per week than their age.
“That is, if you are 12 or 13 [years old], you should not be doing more than 12 or 13 hours of vigorous sports activity per week,” he said.
Strong, overall core strength can help prevent overuse injuries in youth athletes. Furthermore, participating in strength and conditioning programs may help reduce instability in youth athletes, according to Alland.
However, Bushnell said there is a stigma regarding girls lifting weights.
“[Female athletes] often do not want to have that kind of manly bulk to them, but what we know is strength training is just as important if you are female, maybe even more important,” Bushnell said.
In addition, muscle fatigue may factor into overuse injuries. Research into youth baseball pitchers showed a decrease in velocity and increase in torque at the elbow when pitchers become more fatigued, Makhni said.
“There is definitely a notion that if you do not have proper mechanics or do not have proper strength and balance and control in the rest of the kinetic chain — particularly your core, your legs and your back — you are going to be overstressing the shoulder and elbow, leading to injury,” Makhni said.
By parents and coaches screening and identifying at-risk athletes, young athletes can then undergo specific training on how to properly run, pivot, jump and land in a way that prevents current and future injuries, according to Parikh.
“[The training] has a temporary effect, but almost all the studies have shown that prevention efforts are effective,” he said.
Female athletes at risk
Among female athletes, there is the risk of performance body image issues known as the female athlete triad, which can lead to eating disorders, an increase in burnout and low bone mineral density, according to Kocher.
At the 2018 Arthroscopy Association of North America Annual Meeting, Elizabeth G. Matzkin, MD, of Brigham and Women’s Hospital, said the driving force behind injuries among female athletes is relative energy deficiency or low energy availability.
“If you do not put enough energy into your system for the amount of activity you are going to perform, then you are going to affect your system in many ways, with one of the first being menstrual dysfunction which then is going to result in low bone mineral density,” Matzkin said.
With previously published studies showing 30% to 70% of female athletes struggle with a low energy availability, athletes who present with a stress fracture should be questioned about their nutrition, she said.
“When you ask about their nutrition, usually the first response is ‘I eat great,’ and then you ask a little further and sometimes they are vegan or sometimes they eat one meal a day or think diet Coke is lunch,” Matzkin said. “So, you have to sometimes probe it further to see where they are at.”
Sports on the mind
Single-sport specialization may also affect an athlete’s mental health and cause burnout, according to Parikh, who said studies have shown athletes who start to specialize at an earlier age are more likely to quit sports altogether than those who start at later ages of about 15 to 16 years old.
In a study in Orthopedic Clinics of North America, Parikh and colleagues noted early sport specialization may lead to social isolation, over-dependence and dropping out of sports.
“There are high rates of depression seen in young athletes when they grow up,” Parikh said. “So, there are adult consequences of superspecialization at an early age.”
Girls also may be more affected by coping with their injury and fear of reinjury than boys, according to research Kocher cited.
“You can only imagine that if an athlete ties his or her identity to a particular sport, then any injuries or any time missed may adversely impact their mental health,” Makhni said. “A lot of these athletes have routines that center on their sport. Disrupting these routines can affect not only their health, but also their social and mental health. Everything gets off balance.”
Regulations for kids
Although there are guidelines and consensus statements in place to prevent overuse injuries, much research in this area focuses primarily on baseball and pitchers, according to Makhni, including creating pitch count guidelines by age, as well as developing guidelines on “how often a player can pitch, how much rest they are getting and general guidelines on not being on multiple teams in the same season, not playing year-round and so forth.”
Makhni said the focus on baseball may be due to the fact that it is known as “America’s sport.”
A reason that guidelines are lacking in such sports as swimming, gymnastics and girls track may be because “we do not know how much is too much,” Bushnell said.
“We know that if you never run, you are never going to be fast, and in baseball, to a certain extent, the prevailing thought is similar, that if you never pitch, you are never going to be any good,” he said.
Education is key
The Sports Trauma and Overuse Prevention (STOP) Sports Injuries and other programs were established to investigate and address the activities associated with an increase in overuse injuries. According to Parikh, STOP Sports Injuries, Pitch Smart and similar programs are resources that can be used to educate athletes, parents and coaches on the risks of single-sport specialization and overuse injuries.
With 1,100 organizations, including sports medicine practices, hospitals and sporting organizations, collaborating with STOP Sports Injuries, James R. Andrews, MD, medical director for Andrews Institute for Orthopedics & Sports Medicine in Gulf Breeze, Florida and co-campaign chair for STOP Sports Injuries, believes the information this program provides has reduced overuse injuries.
Although it has been a challenge to directly track the impact of information from STOP Sports Injuries, Andrews told Orthopedics Today, “I know now there is a lot more information [about prevention] out there and a lot more media attention and talk about specialization.”
Another resource for related education are sports medicine facilities like the Children’s Health Andrews Institute in Dallas. The facility has a performance center dedicated to caring for youth athletes up to the age of 22 years with the help of EXOS, which is a performance training company focused on athletes.
“It is unbelievable how many kids are out [in the Dallas metropolitan area] participating in sports, which is what we want, but also they are being injured,” Andrews said. “We thought [a performance center] would be a great thing to have in the Dallas area to try to get parents involved and kids involved in performance preventative programs, and also in the care of these young kids.”
Enforcement of recommendations
Although education is key, there is nothing in place to enforce these recommendations, Parikh said.
“There is no regulation. There are only guidelines, so you can only educate them. There is nothing that you can force them [to do],” he told Orthopedics Today. “But, if you are looking out for kids and if that is what our purpose is, then maybe some regulations or having someone supervise what the parents are pushing their kids to do might be a worthwhile step in the future if education alone does not work.”
An example of state government legislation focusing on sport specialization and overuse injuries in young athletes can be found in Alabama, which recently passed a mandate and state law for all paid and unpaid youth coaches to receive accreditation to coach youth athletes, Andrews said.
Coaches of youth athletes in Alabama now use the Coach Safely program, he said.
“They have to be accredited in injury prevention, recognition of heat illness, recognition of basic injuries and basic first aid,” Andrews said, noting the law stipulates coaches must now take and pass an online test to be able to coach. “The curriculum for Coach Safely was developed by Andrews Research & Education Foundation in Gulf Breeze, Florida.”
Andrews is hopeful similar laws will be passed in other states. However, Bushnell noted many questions remain unanswered about implementation of such laws and this increases the probability these laws will not pass easily.
“What does that look like logistically? Who provides that education? Who pays for that education?” Bushnell said. “I think those are some of the questions that result in resistance to passage, but I think we are going to see that in the next few years more states are going to follow Alabama’s example and get involved in requiring education of some kind, regulations of some kind. I do not think that this movement is going away.”
Advocate for athletes
Unless orthopedic surgeons discuss these issues with parents and coaches, or are educated themselves, then the first time they will see these young athletes will be after they are already injured, said Kocher. He said that situation provides a good opportunity to provide educational material on overuse injuries, avoiding reinjury and preventing other injuries.
“Sometimes just some simple education can go a long way but the other thing is just [asking] the basic screening questions for some of those big risk factors,” Bushnell said. “Playing on more than one team, single-sport specialization at a young age, nutrition — those are sometimes easy things to go after.”
According to Makhni, part of the educational challenge is finding out why a young athlete has an overuse injury in the first place.
“Is it an issue that they are throwing too much, too hard, not following guidelines, not training the rest of their body or what?” Makhni said.
He noted orthopedic surgeons should stress how important it is for young athletes to speak up if they are in pain instead of playing through it.
“We had a study in [the American Journal of Sports Medicine] AJSM in 2015 in which we reported almost half of healthy youth baseball players felt encouraged to keep playing despite having an injury. Many kids with pain still play and do not report it because they feel pressure not to report it,” Makhni said. “Education on these injuries may help these athletes, as well as coaches and families, understand that proper rest and recovery after an injury may prevent longer downtimes in the future if those injuries go unchecked, especially with overuse injuries. It is better to rest for 4 to 6 weeks when you start developing elbow pain than to be shut down for a year after a Tommy John surgery.”
Orthopedic surgeons should also look beyond the athlete to parents and coaches, Alland said.
“The guidelines ... have shown [among] the athletes who specialize or superspecialize, the top factors that contribute to [overuse injuries] a lot of times are adults, and specifically parents and coaches,” he said.
Alland advises athletes to be their biggest advocate and speak up when something does not feel right. He tells parents they are their child’s biggest defender and advises them to speak up and advocate for their child if the child is at an increased risk of injury or overtraining. He advises coaches, as well, on the importance of not overtraining the athletes.
“In reality, it is not necessarily being less than 14 years old and training all the time and playing year-round that makes you an elite athlete,” Alland said. “In fact, it leads to more burnout and more injuries.” – by Casey Tingle
About STOP Sports Injuries. Available at: https://www.stopsportsinjuries.org/STOP/About/STOP/About/STOP_Sports_Injuries.aspx?hkey=7404718a-bf38-4936-acb8-a2a146f5045a. Accessed May 4, 2018.
Bergeron MF, et al. Br J Sports Med. 2015;doi:10.1136/bjsports-2015-094962.
Field AE, et al. Poster 895. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 6-10, 2018; New Orleans.
LaPrade RF, et al. Orthop J Sports Med. 2016;doi:10.1177/2325967116644241.
Makhni EC, et al. Am J Sports Med. 2015;doi:10.1177/0363546514555506.
Matzkin EG. Instructional Course 105. Presented at: Arthroscopy Association of North America Annual Meeting; April 26-28, 2018; Chicago.
Smucny M, et al. Orthop Clin N Am. 2015;doi:10.1016/j.ocl.2014.11.004.
Sports performance powered by EXOS. Available at: https://www.childrens.com/specialties-services/specialty-centers-and-programs/orthopedics/orthopedics-plano/programs/sports-performance. Accessed May 17, 2018.
For more information:
Jeremy A. Alland, MD, can be reached at 1611 W. Harrison St., Chicago, IL 60612; email: firstname.lastname@example.org.
James R. Andrews, MD, can be reached at 1040 Gulf Breeze Parkway, #203, Gulf Breeze, FL 32561; email: email@example.com.
Brandon D. Bushnell, MD, MBA, can be reached at 330 Turner McCall Blvd., Rome, GA 30165; email: firstname.lastname@example.org.
Mininder S. Kocher, MD, MPH, can be reached at 319 Longwood Ave., Boston, MA 02115; email: email@example.com.
Eric C. Makhni, MD, MBA, can be reached at Henry Ford Health System, 6777 W. Maple Road, West Bloomfield, MI 48322; email: firstname.lastname@example.org.
Elizabeth G. Matzkin, MD, can be reached at Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115; email: email@example.com.
Shital N. Parikh, MD, can be reached at 3333 Burnet Ave., Cincinnati, OH 45229; email: firstname.lastname@example.org.
Disclosures: Alland, Andrews, Bushnell, Kocher, Makhni, Matzkin and Parikh report no relevant financial disclosures.
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