Brian Schiff’s Blog

One of the biggest issues I see today in youth sports is an abundance of overuse and preventable musculoskeletal injuries due to improper conditioning, lack of recovery or both. In the current era of sports specialization and the hyper-competitive pursuit of college scholarships, an athlete can unknowingly be placed in a comprising position with respect to his/her physical and mental health. Coaches and parents may push a player to participate in a weakened or vulnerable state.

Now, more than ever, athletes who do focus in on a singular sport need a year-round training plan to match their year-round sport demands. In order to stave off injury and avoid burnout, a successful plan must accomplish the following:

1. Implement de-loading periods along with scheduled rest in the training and competitive cycles
2. Periodize the training to peak at the desired times
3. Allow for adequate time to ramp up training and sport specific activity in order to condition the body for the high demands of the sport and safely move from the athlete’s “floor” to the “ceiling”

A surefire recipe for injury and soft tissue failure is progressing training loads too fast, where the athlete often endures too much acute workload without enough time to build up an adequate amount of loading tolerance or chronic workload. I see this frequently in baseball pitchers (shoulder and elbow pain), female soccer and basketball players (patellofemoral pain), along with many athletes who suffer soft tissue strains including hamstring, hip flexor and groin injuries.

Tim Gabbett, published an excellent clinical commentary in the October edition of JOSPT (1) that highlights the importance progressing training loads to minimize injury risk and optimize performance. Specifically, he discusses the concepts of “floor”, “ceiling” and “time” as it relates to developing rehab and performance plans.

Floor – the athlete’s current level of capacity

Ceiling – the capacity needed to perform the specific acuities of their sport

Time – an athlete can safely progress from the floor to the ceiling when afforded enough time

Further, Tim discusses how an injured athlete can actually fall behind in conditioning and end up in the “basement” in terms of training capacity. This presents additional challenges in getting the injured athlete back safely, particularly if it is in-seasonwith a shorter time window. He presents an option of raising the floor when an athlete enters rehab or if he/she will be on an extended break from training to ensure the loading capacity not drop below the floor to the basement, but rather increase the height of the floor, perhaps allowing the athlete to eventually reach a higher ceiling (greater loading capacity) later on.

According to Gabbett, there are 5 key ways to ensure athletes are prepared for competition:

1. Maintain adequate training load during the offseason and while injured.
2. Identify the ceiling and make sure the training load is in line with the sport’s demands.
3. Assess individual differences in training tolerance. We need to consider young versus older athletes, injuries, training history, aerobic fitness and physical deficiencies to do this properly.
4. Identify and prepare for the most demanding parts of competition.
5. Coaches need to plan enough time to move from the floor to the ceiling considering the physical demands of the sport, capacity needed to perform these activities, and individual limiting factors that may impede the ability to meet these demands.

Having spent a considerable amount of my career working with high level amateur and professional athletes, I am well aware of the narrow windows of time to compete and recover with weekend tournaments and professional schedules. It takes a lot more time to get in elite shape and only a few days to begin detraining. Cross training, smart and progressive rehab and clear communication with coaches, training staff and the athlete is essential in managing an injury for a high level athlete.

In addition, I always tell my athletes the only thing worse than not competing at all is going out and performing poorly. Without proper training and rehab plans, athletes will eventually fail mechanically. I often encourage the athlete to communicate clearly in terms of pain response on a scale of 1-10 during, immediately after and for the 24 hour period following rehab to assess the body’s response to loading. Using these concepts and the floor, ceiling and time as discussed by Tim Gabbett, strength coaches, sport coaches and rehab professionals can all refine their methods to put the athlete in the best position to succeed and reduce injury risk.

References:

1. Gabbett TJ. How much? How fast? How soon? Three simple concepts for progressing training loads to minimize injury risk and enhance performance. J Orthop Sports Phys Ther. 2020 Oct;50(10):570-573.

As 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)

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!