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Brian Schiff’s Blog

Injury Prevention, Sports Rehab & Performance Training Expert

Tag: overuse injuries

carter-runAs a father, coach and physical therapist working in a sports medicine environment, I am all too familiar with youth injuries. While we can not prevent every injury, I do believe we need to do everything possible to keep our young athletes out of harm’s way. In today’s ultra competitive society, parents are faced with pressure to “keep up” or fall behind.

Contrary to what research and real life has to say about it, organizations and coaches who want to win now tell parents and players you need to choose one sport at an early age if you want to be the best.  I see the club fees that organizations charge, the emotional heartbreak of not making the top tier teams and the grind of all the “extra” training sessions for skill work, speed training, etc. that athletes endure.

Gone are the days where just playing for your school team is enough to garner attention at the next level.  It seems as if athletes must play in AAU, clubs, travel teams or showcase opportunities to stand out.  It is apparent to me as if we have become hyper focused on training our children to obtain a scholarship at such an early age.  Some of the things I hear parents say illustrate to me their are pushing their children very hard to meet these expectations.  The idea that sports should be fun for young kids seems to be lost on the coaches and parents in many cases.

My 9 y/o son (picture above running the ball) told me one reason he does not want to play Pop Warner football next Fall is because of all the practice time required.  We practiced 5 days per week in August, followed by two hour practices 3 nights per week and a Saturday game during the regular season.  He loves the game and was one of the best players on his team, but the time and exhaustive training simply wore him out.  So, he says he wants to play soccer next Fall instead.  I told him this was fine as he needs to be the one that wants to play - not me telling him to play.  He also plays basketball in the Winter and soccer in the Spring.

As a parent, I want to encourage others to listen to their kids and put their own goals and interests aside.  We should not try to live vicariously through our kids on the court or field.  Sports should not be work for young people, and adults should not care more about the game than the participants at a young age.  As coaches and medical professionals, we need to do everything in our power to promote health and  life balance for young people.


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So, one of my biggest pet peeves as a PT is seeing athletes hurt as a result of poor coaching and training.  Overuse injuries provide lots of clients for my practice.  While this is good for business, I would really like to help prevent these injuries.  I need your help.  It all starts with education and a willingness on the part of health and fitness professionals to advocate strongly for our young athletes.

Consider the following scenario: a 14 y/o freshman left-handed pitcher presents for rehab to recover from Little League Shoulder. He was hurt on the second day of his high school’s fall conditioning program.  He was being forced to throw in excess of 200 feet.  His exact words were, “I was sore after day one, but I felt my shoulder explode on the second day of the program.”  Think this is a coincidence?  Hardly.

Another player from the same school (a sophomore right hander) is also in my clinic recovering from an avulsion fracture of his medial epicondyle that he too suffered on the second day of the same throwing workout.  I emailed the left-handed pitcher’s father with details about throwing biomechanics and how they decline with long distance throwing.  I also expressed my concern over the coach’s aggressive throwing program.  The father emailed back and said he too disagreed with the throwing program.  However, the coach simply told him his son had “not been properly coached” prior to getting to his program.  Are you kidding me?  Look at the images below to appreciate the type of damage done by overzealous throwing programs.

Coaches need to be more accountable to their training programs and philosophies.  Both of these players are missing no less than 3 months of baseball because the coach is clueless about the impact of aggressive long toss and how it may actually be detrimental to his players as opposed to actually improving their throwing technique/performance.

Click here for an article summary in JOSPT related to throwing biomechanics

So, how do we make a positive impact and prevent unnecessary injuries like the ones I have discussed?  I feel we need to look at the following strategies:

  1. Educate parents and coaches through talks and seminars
  2. Network with high school athletic trainers to ensure they have some feedback/input with respect to preventive training philosophies as well as a direct pipeline to coaches
  3. Reach the athletes directly through arm care screenings, FMS evals and professionally directed throwing programs
  4. Team with high profile baseball players or coaches who understand the game at the highest level and will spread the message in a positive and constructive manner
  5. Participate in CEU course for coaches and present on throwing programs, shoulder strengthening and mobility training

Based on these two cases, I am brainstorming ways I can become more of a “voice” in the baseball community in my area.  It is tough to convince pushy parents and misguided coaches that young kids don’t need to throw curveballs or that pitchers should probably not be forced to throw over 200 feet in hopes of increasing arm velocity.  But, we need to step up and make a difference or more young kids will be suffering from tendinitis, Little League Elbow/Shoulder, labral tears or other overuse injuries.

Click here for an abstract reference with respect injury risk and innings pitched per year

As a father, coach, educator and physical therapist, my personal mission is to make a difference in the lives of those around me. I know many may simply be unaware that there is a better or safer way.  As the emphasis on early specialization continues to grow in our country, now is the time to take action and help stop many of these injuries.

As a parent, coach and sports physical therapist, this is a topic I am both passionate about and often confronted with.  I remember growing up in a small town where I played a different sport every season.  No one played year round soccer, baseball or AAU basketball - it was not even an option for those around me.

Now, I live and work in a competitive sports-minded environment where I see 13 y/o baseball pitchers with elbow and shoulder pain, 13 y/o female soccer players with ACL reconstructions, and too many adolescents suffering from overuse injuries like anterior knee pain and tendonitis.  I witness coaches teaching 10 and 11 year olds to throw curve balls, hear athletes tell stories about how they are strongly encouraged or pressured to play only one sport if they want to excel and make a team, and parents who are pushing their kids hard at an early age in pursuit of college scholarships.

Is it all worth it?  In a short answer - NO.  In a recent article in the May/June 2013 issue of Sports Health, Jayanthi et al. performed a comprehensive search of PubMed and OVID from 1990-2011, gathering articles discussing sports specialization, expert athletes, or elite versus novice athletes including original research articles, consensus opinions, and position statements.

Click here to read the abstract

My own personal bias and opinion is that we should encourage youth to participate in multiple sports/activities and not pursue one sport or activity until they reach high school.  I believe there is so much to be gained in terms of coordination, neuromuscular training, recovery and building general athleticism that gets lost with early specialization.  However, I see many young athletes swept into early development programs and travel/AAU teams that naturally discourages or eliminates time/opportunities for other activities.

With that said, I will readily acknowledge that certain sports/activities (gymnastics and playing an musical instrument for example) do require an early commitment in terms of practice and skill mastery if one is to reach elite status.  So, what should we as health and fitness professionals be telling our clients?  How intensely do they need to train and at what age is it okay to focus on one sport?

I think we need to know what the evidence we have says and how we can best use knowledge to make meaningful change in society.  In addition, we need to evaluate the mental and physical injuries that are occurring with the choice to specialize at a very young age.  Consider that participation at age 6 and under has increased from 9 to 12% from 1997 to 2008.

So, for us to make a difference we need to investigate and scrutinize how we coach and train young athletes and become an advocate for their long term health as well as short term success.

Here are the key bullet points from the article I referenced above:

  • Coaches are the most influential in beginning intense training and the decision to specialize
  • Less than 1% of athletes 6-17 years old achieve elite status in basketball, soccer, baseball, softball or football
  • Early diversification is more likely to lead to success based on multiple studies and may lead to more enjoyment, fewer injuries and longer participation
  • Early diversification is more likely to lead to success based on multiple studies and may lead to more enjoyment, fewer injuries and longer participation
  • Data currently suggests enjoyment of sport and intrinsic motivation predicts attainment
  • Exposure is the most important risk factor for injury and there is a significantly increased risk for injury when participating > 16 hours/week
  • Cumulative match exposure also carries a significant injury risk
  • Prospective 10 year analysis of 481 youth baseball pitchers reveals a 3.5x increased risk for injury when pitching more than 100 innings per year

What about burnout?  Consider the following:

  • Swimmers who specialized early spent less time on the National team and retired sooner
  • Minor league hockey players (boys) who dropped out started earlier and spent more time in off-ice training than those who continued to compete
  • One retrospective review revealed that 1 out of 5 elite athletes reported injury as the reason for quitting
  • In the end, the authors conclude that some specialization is necessary to attain elite skill, but the exclusion of other activities should be delayed until late adolescence.

To foster diversification, we must do a few things in sports medicine:

  1. Educate parents, coaches and athletes on the injury risk and facts about the impact of early specialization
  2. Promote the benefits of diversification in terms of joy, diminished  stress to excel, athletic development and physical recovery
  3. Remind everyone involved not to take sports too seriously as only a very select few will move on to elite status, and instead encourage them to enjoy competing, learn to be a good teammate and reap the other rewards in sports (discipline, sportsmanship, learning to overcome adversity, working hard to achieve a goal, etc) that last well beyond a trophy presentation or game

I was just asked a few days ago by the parent of a 9 year old baseball player if I thought it was good for him to play multiple sports since he is pretty good in baseball.  I encouraged this mother to have him do as many sports as he can for the next several years.  Why put so much pressure on kids and expose them to increased injury risk?  Every family and athlete needs to make their own personal decision, but for those who do opt for early specialization, I want to make sure I can help educate them on cross training, rest and recovery to minimize the risk for burnout and injury.

In my practice, I take care of many athletes ranging in age from 10 and up. Many of the injuries I see are related to over training and overuse. Common things I see in the clinic on a daily basis include but are not limited to:

  • Tendonitis
  • Shin splints
  • IT Band Syndrome
  • Patellofemoral pain
  • AC joint pain/arthritis

The list can go on and on.  There are many factors (inherent and training related) that contribute to such problems.  I personally believe many problems can be prevented with better education, smarter training, coaching predicated on individuality and physical response, and of course adding in more recovery.  Cross training is also a must - just look at what sport specialization at an early age has done to current injury rates.

You need not look any further than the declining age of patients walking through the door with what I term “repetitive microtrauma” injuries.  I saw a 14 year old cross country female runner a few weeks ago who had her second stress reaction injury inside of 12 months.  In addition, the rise in the number of Tommy John surgeries performed in the past decade with respect to those having them at an earlier age may serve as a harsh warning sign about doing too much too soon or doing too much of the same thing year round.

I say all this simply to say we must not be oblivious to the rise in these types of mechanical injuries.  Throwing, swimming, and running are all activities that become dangerous if done in excess, and they also produce predictable injury patterns.   So, if you are curious about some risk factors and how to better balance your training and manage these types of injuries, then check out a webinar I just did for Raleigh Orthopaedic Clinic last week (click on the screen shot below to view the webinar)

screen-shot-overuse-injuries

This presentation is ideal for athletes, parents, weekend warriors and sports coaches looking for practical, straightforward information on this topic with some foundational guidelines that can be applied objectively and immediately to injury management and recovery.  If this information helps just one person avoid an injury or accelerate their recovery then I will be thrilled!  Please feel free to forward this post to friends, share it on FB or tweet it!

The News and Observer (our local paper here in the Triangle) recently ran a great story on overuse injuries in young athletes.  I firmly believe this is one of the fastest growing injuries I see in the clinic and in many cases it is preventable.  One of the biggest issues now is this commonplace idea that gifted athletes should play the same sport year-round to get ahead.

I remember growing up as a kid and playing football, basketball and baseball in the fall, winter and spring.  While AAU basketball and Legion ball existed, most kids were still playing multiple sports.  Over my 15 years as a physical therapist I have witnessed several of these one sport stars see their playing time and bodies take a hit due to injury.

The American Orthopedic Society for Sports Medicine (AOSSM) and the American Academy of Orthopedic Surgeons (AAOS) state that overuse injuries account for nearly half of the 2 million injuries seen among high school athletes each year.  While soccer and swimming seem to send many athletes into PT, any repetitive throwing or overhead activity bears considerable risk for an eventual shoulder or elbow problem as well.  Some of the common injuries I typically see are:

  • Patellofemoral pain
  • Shin splints
  • Rotator cuff injury
  • Bursitis
  • Shoulder instability
  • Little League elbow

Little League Elbow (medial epicondylar apophysitis)

Little League Elbow (medial epicondylar apophysitis)

These injuries are just some of the most common ones I see.  In the article, the reporter focused on baseball and throwing.  With that in mind, consider research published in the American Journal of Sports Medicine this past February from renowned surgeon James Andrews that revealed players who pitch more than 100 innings in a calendar year are 3.5 times more likely to be injured.

He goes on to say that “these injuries are the result of a system that prepares genetically gifted athletes to play at the highest levels, but eliminates most players because their bodies cannot withstand such intense activity at such an early age.”  Sadly, he told the reporter that in 1998 he performed the Tommy John procedure on 5 kids high school age or younger, while in 2008 he did the same procedure on 28 children in the same age range.  This injury is usually caused by throwing too much too soon.

Consider the following data on suggested pitch counts per game (source James Andrews, MD & Glenn Fleisig, MD):

  • 8-10 y/o = 52 plus/minus 15 pitches
  • 11-12 y/o = 68 plus/minus 18
  • 13-14 y/o = 76 plus/minus 16
  • 15-16 y/o = 91 plus/minus 16
  • 17-18 y/o = 106 plus/minus 16

Unfortunately, I can personally relate to this blog post and story.  I was a promising young pitcher up until the point I threw my arm out in travel baseball at age 13.  The pain got so bad in my arm I could barely throw a ball 10 feet.  I remember the orthopedic surgeon telling me that I could not throw again the rest of the summer.  The pain (and memory of it) was so bad I elected to focus on position play and not to pitch again until my senior year of high school.  At that point, my arm was no longer the same as I had missed three years of practice and development.  Now, I too had become one of those kids whose body was never the same.

So, as a rehab and strength & conditioning professional, I want to help educate and promote better awareness to athletes, parents, coaches, trainers, AD’s, ATC’s and anyone who is involved in the care and training of young athletes.  Fortunately, people are taking positive steps to reduce overuse injuries.  One great initiative is STOP - Sports Trauma Overuse Prevention and you can learn more by clicking here to visit their website.

In the end, we must continue to educate everyone that the old motto of “No Pain, No Gain” is NOT the way to handle overuse injuries as this mentality may ruin the careers of young athletes or lead to an otherwise preventable injury and/or premature musculo-skeletal damage.  Pain truly is a warning signal the body gives us to detect mechanical problems and make changes in our training/activity level until we sort out the cause and solution.  I hope you will join me in supporting this mission and working hard at making sports fun, safe and free of overuse injuries for young athletes of all ages in the years to come.

References - The News & Observer - May 15, 2011