MINIMIZING INJURY RISK IN YOUNG
ATHLETES
Neeru Jayanthi, M.D.
Emory University Sports
Medicine Center
President International
Society for Tennis Medicine
and Science
EMORY SPORTS MEDICINE-ATLANTA
LOYOLA UNIVERSITY CHICAGO
“EMORY TENNIS MEDICINE”
YOUTH SPORTS BACKGROUND
Overuse injuries in Young Athletes AMSSM
Panel/Writing Group
 Collaborative Research with Lurie
Children’s (multiple grants)
 Consultant (Unpaid):
 American Academy Pediatrics (AAP)
Council of Sports Medicine Fitness
(COSMF)
 Aspen Institute (Project Play)
 Mom’sTeam Institute
 WTA medical advisory board (Age
Eligibility Rule)

DISCLOSURE

I have been flying around the country and world
for my work with WTA and the Society for Tennis
and Medicine Science, and AMSSM and I have
had to leave my pregnant wife at home
Palm Springs, CA
 Miami, FL
 Rome, Italy
 Sioux Falls, South Dakota

DISCLOSURE (INCLUDE MILLAN
PICTURE)
OBJECTIVES
To understand how to utilize the evidence
to identify at risk training patterns in
youth sports
 To understand the potential successes and
risks of sports specialized training
 To understand how to counsel a young
athlete on appropriate training
recommendations that may reduce their
risk of serious overuse injuries

COUNSELING?
USA TODAY-SAFE KIDS
1.35 MILLION ER VISITS

Overuse injuries occur due to repetitive
submaximal loading of the
musculoskeletal system when rest is not
adequate to allow for structural
adaptation to take place.
BACKGROUND-OVERUSE INJURIES
American Medical Society of Sports
Medicine (AMSSM)
 Aspen Institute
 American Academy of Pediatrics (AAP)
 National Athletic Training Association (NATA)
 American College of Sports Medicine (ACSM)
 American Orthopaedic Society for Sports
Medicine (AOSSM) STOP campaign
 USA Youth Baseball
 Safe Kids Campaign
 Mom’s Team

“MESSAGING” OVERUSE INJURIES
WHAT HAPPENED TO YOUTH SPORTS?

FACES OF YOUTH SPORTS TODAY
(INDIVIDUAL STORIES)
ORGANIZATIONAL AND COMMUNITY
EFFORTS
Sports specific National Governing Bodies
 Youth sports leagues

DO WE PRACTICE WHAT WE PREACH?
INJURY MODEL
Injury Model
Predisposed
Susceptible
Athlete
Athlete
Intrinsic factors
Extrinsic factors
Age
Inflexibility
Previous injury
(Meeuwisse 1994)
Demands of sport
Equipment
Conditions
Injured
Athlete
Inciting event
Acute injury
Change in volume
Change in mechanics
SPECTRUM OF INJURY
Full Participation
• Optimum performance
Performance affected
• Biomechanical problem
• Training load
Time Loss Injury
• Training errors
• Low/Intermediate risk injuries
High Risk Injury
Prolonged absence/surgery
Long-term implications
Picture: http://i257.photobucket.com/albums/hh207/doodmiguel/SumoWrestler.jpg
EVALUATE RISK

There is not enough data correlating training and risk
of development of a higher risk overuse injuries
Volume
Sports
Specialization
Age and
Growth rate
Prior Injury
EXPOSURE RISK
RISK FACTORS FOR MEDICAL
WITHDRAWALS IN USTA JUNIOR
NATIONAL TENNIS TOURNAMENTS
AGE & MEDICAL WITHDRAWAL INCIDENCE (JAYANTHI N,
O’BOYLE J)
Medical Withdrawal/ 1000 Match Exposures
24
22.7
20
20.6
16
12
8
11.7
7.4
4
0
12's
14's
16's
AGE
18's
LEVEL
OF RISK
RISK OF ATHLETE
RISK OF
INJURY
Q
UANTIFYING INJURY RISK
HIGH
HIGHLY SPECIALIZED SPONDYLOL
SPORTS
PARTICIPATI
ON
RESTRICT
HIGH VOLUME >16
hrs/wk
HIGH COMPETITION
>8 months/year
HRS/WK > AGE
TRAINING RATIO >2:1
PRIOR INJURY (back)
RAPID GROWTH
YSIS
STRESS
FRACTURES
GROWTH
PLATE
OCD
INTERME
DIATE
MOD SPECIALIZE
INTERMEDIATE
GROWTH
INTERMED VOL. <16
hrs/wk
6-8 months/year
HRS/WK = AGE
TRAINING RATIO 2:1
APOPHYSITIS TEMPORARY
APOPHYSEAL RESTRICTIONS
AVULSIONS
OR REDUCE
INSTABILITY
LOW
MULTIPLE SPORTS
RECREATIONAL
PATELLOFE
MORAL
MINIMAL
RESTRICTIONS,
SPECTRUM OF RISK

Where on the spectrum is your athlete?
Low
•Diversified
•Low volumes
Int.
•More
specialized
•Moderate
volumes
High
•Highly
specialized
•High volumes
SPECIFIC ADVISE TO REDUCE RISK?

PREVENTION

Are overuse injuries more preventable?








Volume related
Sports specialization (young athletes)
Age related
Sports specificity
Biomechanical load
Prior injury
Sports specialization
TRACK research (interventional counseling)
NCAA DATA

A more recent NCAA study describes 30% to be
overuse and 70% to be acute/traumatic.
Football was 8 times more likely to be acute
 Females twice as likely to be overuse



Yang et al 2012
Sampling problem of the 16 sports (biased towards
more traumatic sports)
BONE STRESS INJURIES


29% of track and field athletes had MRI
documented bone stress injury over 5 years
10.8% of all female athletes (mean age 18) had
bone stress injuries

Significantly increases with FAT risk factors

Nattiv, UCLA
HIGH SCHOOL DATA
RESULTS:
 A total of 2834 overuse injuries were reported
during 18 889 141 athletic exposures (15.0 per
100 000 athletic exposures).
 Girls had greater rates of overuse injury (18.8)
than boys (12.6)
 Overuse injuries represented 7.7% of all
injuries,
 The most frequent site of injury was the lower leg
(21.8%).
 Injuries most frequently resulted in time loss of
less than 1 week (50.0%), with only 7.6%
resulting in time loss greater than 3 weeks.

AMSSM POSITION STATEMENT

Approximately 49-53% of injuries in
young athletes are overuse rather then
acute.

2133 charts retrospectively reviewed





53% overuse
Female >male (overuse)
Female 3 x more PFPS
Female 90% hip/thigh overuse
Males more contact/collision sports
YOUNG FEMALE ATHLETESS

Patellofemoral pain


Point prevalence 16.3/100 young female athletes
Young female athletes more likely to develop
patellofemoral pain if specialized

Myer et al.
SPORTS SPECIALIZED TRAINING

What information would we
provide non medical sports
community to change this
“perceived succcess by
specialization”?

Do we have evidence about
successes and risks?
TIGER WOODS
Study
Sport(s)
Athletes
Evidence for (+):
Begin intense
training before
age 12
Hume 199426
Rhythmic
gymnastics
106 across all levels
+
Law 200731
Rhythmic
gymnastics
6 elite
6 sub-elite
+
Helsen
199823
Hodges
199625
Men’s' soccer,
Men’s' field hockey
Wrestling
Specialize
before age 12
Begin intense
training after
age 12
Study conclusions
Diversify early,
specialize after
age 12
+
Elites and sub-elites began intense training at similar ages, but elites were involved in fewer other
activities from age 4-16, and accumulated more hours training by age 16.
+
33 international
39 national
52 provincial
Amount of gymnastic training during development is related to level of attainment. All gymnasts
participated in other sports, with no difference between elites and sub-elites. Enjoyment of gymnastics
was strong predictor of attainment.
+
Soccer began practicing at age 5, field hockey at age 9. Hours spent in practice were similar among levels
until age 12. After age 12, international players spent more time in practice than national players, and
national players spent more than provincial players.
21 elite
21 club-level
+
Elite wrestlers spent more time training after age 16 compared to club-level wrestlers. However, since all
subjects began intense training at 13.2 + 0.6 yrs, comparison to early intense training (before age 12) not
possible.
4 elite
+
+
Elite players intensified their deliberate hockey training in late adolescence and played other sports
during developmental years
Soberlak 200344
Men’s' ice hockey
Carlson 198813
Men's and women's
tennis
10 elite
10 near-elite
+
+
Elite players began intense training and specialized later (after age 13-15) than near-elites (age 11).
Lidor 200232
Various men’s' and
women’s' sports
63 elite
78 near-elite
+
+
Elite more likely than near-elite athletes to begin intense training after age 12 and to have played >1
sport during developmental years.
1558 German athletes
from Olympic
promotion programs
+
+
Elite athletes began intense training and competition in their sport later than near-elites (11.4 yrs vs
10.2yrs and 13.1 vs 12.0). More elites participated in >1 sport from age 11 than near-elites (64% vs 50%).
Gullich 200622
Olympic sports
Moesch et al.
201139
Sports measured in
cms, gms or secs*
148 elite
95 near-elite
Men's and women's
field hockey,
Men's basketball,
Women's netball
15 elite
13 near-elite
Men's and women's
swimming
Elite Russian swimmers
(number not reported)
Boys' ice hockey
Parents of 8 minor
league players (mean
age 13.9 yrs)
and 4 ex-minor league
players (mean age 14.5
yrs)
Baker et al.
20035
Barynina 19926
Wall
200747
*Canoeing/kayak, cycling, orienteering, rowing, sailing, skiing, swimming, track and field, triathalon, weightlifting
+
Elite athletes began intense training at a later age compared to near-elites. Near-elites accumulated more
hours of training by age 9, 12 and 15 than elites, while elites accumulated more training by age 21 than
near-elites.
+
+
Elites accumulated more hours of sport-specific practice from age 12 years onwards. However, all
subjects began intense training at about age 12, so unable to compare to an early intense training group.
Elites had broader range of sports experiences throughout their careers compared to near-elites.
+
Swimmers who began specializing before 11 yrs of age spent less time on national team and retired
earlier than later specializers.
+
Dropouts began off-ice training earlier than non-dropouts (11.75 vs 13.8 yrs of age) and spent more hours
in off-ice training (107 vs 6.8 per year). Both groups participated in a similar number of other sports
(4.75) from 6-13 yrs of age.
IS 12 THE MAGIC NUMBER?

Higher proportion of injuries in those who quit all
other sports before 12

Jayanthi et al.
WHO SPECIALIZES?

High level goals
College?
 Professional?


Specialized training in
higher median incomes
>70,000 dollars and with
private insurance
 Jayanthi et al.


Technical, individual sports
NCAA STUDIES
Di-Fiori, et al.
296 student athletes vs 164 students
Similar age of specialization (14-17 y/o)
Parent or sibling in competitive sports (p<0.001)
Unpublished
Malina et al.
376 Div 1 Female athletes
17% specialized (highest rates in individual sports)
Jayanthi, et al.
318 student athletes
Many chose their Univ sport as main sport in elem school
Many played multiple sports in high school without year round
training
Unpublished
“TRAINING AND SPORTS SPECIALIZATION
RISKS IN JUNIOR ELITE TENNIS PLAYERS,”
JAYANTHI, DECHERT, LUKE ET AL.
100%
95%
90%
79%
80%
Percent Specializing
88%
84%
71%
70%
60%
63%
58%
61%
55%
50%
40%
30%
20%
10%
0%
<10
11
12
13
14
Age
15
16
17
18
“TRAINING AND SPORTS SPECIALIZATION
RISKS IN JUNIOR ELITE TENNIS PLAYERS,”
JAYANTHI, DECHERT, LUKE ET AL.
•
Relationship to injury
•
•
•
If player specialized, 1.5 x more
likely to have reported an injury
(p<0.05)
We do not know true
specialization risks in all
sports
Can we separate sports
specialization from the
volume of training?
SPORTS
PHYSICALS
(UNINJURED)
SPORTS INJURY
(INJURED)
AMSSM FOUNDATION GRANTS
AMSSM (American Medical Society for Sports
Medicine) (two time recipient)
Foundation Grant to continue this study in
Collaboration with Lurie Children’s Memorial
Hospital, Chicago, IL
LONGITIDUNAL COMPONENT
PHASE 1:
Ht/wt
PHASE 2: 2-3 year longitudinal phase
UNINJURED
UNINJURED
INJURED
INJURED
UNINJURED
INJURED
DEFINING SPORTS SPECIALIZATION

Intense Year Round Training in a Single
Sport at the exclusion of other sports

Jayanthi et al., DiFiori et al.
Year round
training/competition> 8
months)
Choose a main sport
Quit all other sports to
focus on one sport
RATES AND DEGREES OF SPECIALIZATION
38%
34%
Jayanthi, et al.
SPORTS SPECIALIZATION RATES
Highly
specialized
baseball
15.42%
basketball
20.51%
cheerleading
28.30%
cross country
27.62%
dance
25%
diving
38.46%
football
12.32%
gymnastics
32.97%
lacrosse
26%
soccer
26.56%
softball
22.89%
swimming
21.50%
tennis
47.95%
track & field
21.84%
volleyball
24.18%
wrestling
12.20%
Low
specialization
baseball
50.25%
basketball
47.34%
cheerleading
41.51%
cross country
43.81%
dance
34.72%
diving
30.77%
football
50.74%
gymnastics
21.98%
lacrosse
42%
soccer
39.06%
softball
45.78%
swimming
45.79%
tennis
20.55%
track & field
44.83%
volleyball
43.79%
wrestling
48.78%
1191 athletes (Male 50.7%)
 Total of 1880 evaluations (35% are
follow up)
 Baseline

Uninjured 360 (30.1%)
 Injured 837 (69.9%)


Injury type:
Overuse: 564 injuries
(66.4%)
 Serious overuse
(139/564) or (24.6%)
 Traumatic: 286
(33.6%)

CLINICAL DIAGNOSIS

Injury causes/type
(Clinical diagnoses) (confirmed through
EMR)

Acute

Overuse

Serious Overuse




Stress fractures
Spondylolysis/Stress Fracture
OCD
Elbow ucl, etc.
INJURY LOCATIONS
APOPHYSITIS/AI (96 CASES)
O Growth rates higher
O Training volumes
similar
O Developmental issue
SERIOUS OVERUSE INJURY RISK
DEGREE OF SPECIALIZATION
Overuse and Serious Overuse injuries more likely
with increased specialization
 Acute injuries less likely with increased
specialization

TRAINING RULES

Age vs hours
Train less hours week then
your age
 i.e. if 12 year old, train less
then 12 hours week (all
physical activity, or just
your sport)
 16 year old….<16


SPORTS TRAINING RATIO

Do not exceed 2:1 ratio of organized sports to free
play

12 year old
<12 hours/week total
 <8 hours/week organized sports
 >4 hours/week free play

AGE OF SPECIALIZATION


Higher proportion of injured athletes who
specialized <12 years old vs > 12 years old
Higher proportion of serious overuse injuries in
athletes who specialized <12 years old vs >12
years old.

Unpublished, Jayanthi et al. 2015
SOCIOECONOMIC FACTORS FOR
SPORTS SPECIALIZATION AND
INJURY IN YOUNG ATHLETES:
A CLINICAL STUDY
Daniel B. Holt, B.S.1, Neeru Jayanthi, M.D.1, Alex Austin,
M.D.2, Pasulka Jacqueline, B.A.3, Cynthia LaBella, M.D.3
and Lara Dugas, Ph.D.1,
1. Loyola University Chicago – Stritch School of Medicine, Maywood, IL
2. Cook County-Loyola-Provident Family Medicine Residency Program,
Chicago, IL
3. Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
SOCIOECONOMIC STATUS AND SPORTS
PARTICIPATION
Percent of Students Playing Sports
40
35
30
25
20
15
10
5
0
Low SES Schools
Middle SES Schools
(Colabianchi N, Johnston L, and O’Malley PM, 2012)
High SES Schools
SPECIFIC OBJECTIVE

To determine whether the following factors are associated
with a risk of serious overuse injury in a diverse clinical
population of young athletes.
Insurance status
 Financial class



Median Income
Race
METHODS

Design:


Clinical Cohort Study
Population:

Multi-Center (Loyola - Chicago and Lurie Children’s)

Sports Medicine and Primary Care Clinics
 7-18 year-old young
athletes
 Injured and Uninjured
METHODS
 Demographic information was collected and analyzed:
 Public Assistance vs. Private
Insurance
 Public Assistance < $31,716/year
 Low, Medium, High
Socioeconomic Status
 Divided into tertiles based on
median household income by zip
code
 US Census Bureau: 2007-2011
American Community Survey
RESULTS

Athletes included in study = 1,121

94% of young athletes who initially completed the survey were
included
Public Assistance = 19%
 33% in Low, Medium, and High SES tertiles


$111,499, $71,440, and $48,895
RESULTS
Type of Play vs. SES and
Insurance
12
10.69
10.35
Hours/Week
10
8
6
11.27
10.55
10.00
Public Assistance
7.13
6.00
5.23
5.53
Private Insurance
5.25
Low SES
Medium SES
4
High SES
2
0
Free Play
Organized Sports
RESULTS
Organized Play:Free Play
Sports Training Ratio
2.50
2.00
1.50
2.15
2.04
1.91
1.67
1.45
1.00
0.50
0.00
Public
Private
Assistance Insurance
Low SES
Medium
SES
High SES
RESULTS
Months/year competing main
sport
Months/year competing Main
Sport
8.9
7.8
Public
Private
Assistance Insurance
7.6
Low SES
8.6
Medium
SES
9.7
High SES
RESULTS
Rate (%)
Effect of SES and Insurance on
Specialization Rate and Serious Overuse
Injury
45.00
40.00
35.00
30.00
25.00
20.00
15.00
10.00
5.00
0.00
41.81
30.22
Public Assistance
Private Insurance
24.00
18.18
18.37
19.7819.86
16.99
Medium SES
11.11
7.84
Specialization Rate
Low SES
Serious Overuse Injury
High SES
CONCLUSIONS

Young athletes on public assistance may be protected
from serious overuse injury due to:


A greater amount of free play and lower sports training ratio
Young athletes on public assistance and of lower
socioeconomic status may be protected from serious
overuse injury due:

Lower sports specialization rates
SPORTS SPECIALIZED TRAINING: 2+ YEAR
FOLLOW UP: PRELIMINARY RESULTS
RE-INJURY, REPEAT INJURY
GOOD NEWS!! GREAT FOR BUSINESS!!
Re-injury
Repeat
Injuries
Total
Injuries
Responses
6 month
60
38
110
256
12 month
34
27
72
160
18 month
28
31
59
120
24 month
22
15
40
83
REINJURY

Recurrence: Any type of injury following a
previous injury.

Repeat: Same type of injury

45% recurrent/repeat injuries

Jayanthi et al. 2+ year follow up
HOW DO WE MINIMIZE INJURY RISK?

EARLY RECOGNITION
EARLY INTERVENTION
Rehabilitative
 Training volumes/Cessation of sport
 Biomechanical flaws
 Identification of high risk overuse
injuries/imaging
 Late stage lesions

LATE STAGE LESIONS

Pars Interarticularis


OCD


0% healing
Fragmentation/instability
Apophysitis
Late stage
 Chronic Ossicles

SPORTS-RELATED LOW BACK PAIN



Initial Plain xray
48.5% xray negative low
back problems were found to
have spondylolysis
Physical exam not
helpful



Kobayashi et al, AJSM 2012
MRI
MRI with pars sequencing
(lumbar spine)
PARS STRESS INJURIES
Healing rates vary
considerably by stage of
spondylolysis
 Late stage spondylolysis
may have close to 0% bony
healing rates
 Need early recognition (by
patients/parents/coaches/A
TPT) in addition to sports
medicine physician

REINJURY

Some successful programs to prevent primary
injury

ACL
Myer
 Silvers
 LaBella


The most success is in the previously injured
(effect on risk reduction).

Hamstring


Bahr
Serious overuse injuries?
REHABILITATIVE

DEFICITS
Young females with PFPS may predict future
ACL risk

Myer et al.
TRAINING RULES
Age vs hrs
 Sports training ratio
 Year round (8 months)
 Sports specialized training

SPORTS SPECIFIC RECOMMENDATIONS
Pitch volumes
 Tennis tournament training guidelines

SPORTS MEDICINE

If we really want to get more business, we should
tell young athletes:







Play more hours/week then age
Play >2:1 sports training ratio
Start specialization before the age of 12
Play an individual sport
Be a female?
Have a prior injury
…we know you will probably need to see us!
BIOMECHANICAL ASSESSMENTS



Courtesy of
Sergio
GomezCuesta MSs
(App
Biomech)
Head of
Physiotherapy
and
Biomechanical
Analysis
LTA
International
High
Performance
Centre,
Gosling Sports
Park, UK
TRAINING, RISK ASSESSMENT, AND
COUNSELING IN KIDS (T.R.A.C.K)

May Lower Risk of Serious
Overuse Injury By
Being less specialized in sports
 Doing less hours of sports in a week
than your age
 Increasing Free Play so your Sports
Ratio is NOT >2:1.

Having at least 3 months off a year
 Having at least 1 day off a week

ONGOING RESEARCH
TRACK (Training Risk
Assessment and Counseling in
Kids)
CONTROL N=252
One time counseling and
serial risk assessment
INTERVENTION
N=252
Serial counseling
Risk Assessment
Risk Assessment
SPORT Counseling
Risk Assessment
Risk Assessment
SPORT Counseling
Risk Assessment
Risk Assessment
SPORT Counseling
 What
age did you start using the Kick (topspin)
serve?
 How many tournaments per month?
 How many matches in last 3 months?
 Any medical withdrawals in last 3 months?
During last 3 months,
have you continued to
throw or pitch with arm
pain/fatigue during a
practice, game or
tournament?
 How many pitches do
you throw in a typical
game?
 How many months off
from pitching?
 At what age did you start
throwing a breaking ball
(curve or slider)?

http://photos2.demandstudios.com/dmresize/photos.demandstudios.com%2F116%2F16%2Ffotolia_175752_XS.jpg?w=391&h=10000
&keep_ratio=1



During last 3 months, have you
been involved in an ACL injury
prevention program or training
program aimed at injury
prevention?
During the last 3 months, have
you continued to play through a
practice or competition after
suffering a head injury and/or
feeling symptoms of lightheadedness, dizziness, and/or
headaches?
Is your equipment checked by a
qualified coach or athletic
trainer before each season?
http://www.politicspa.com/wp-content/uploads/2011/08/peewee-football-300x239.jpg
TRACK-PRELIMINARY DATA

Nearly 400 athletes (2 institutions):
Intervention group: 27.7% injured
 Control group: 45% injured

MESSAGING FOR OVERUSE INJURIES
JUST DON’T
OVER DO IT.
Don’t give
110%...
you can
stop at
100!

No! Actually, it is more likely from
extrinsic modifiable causes such as
excess training volume or sports
specialization or neuromuscular training.
THANK YOU!