Developing Physically Active and Sporty Kids - Overuse Injuries and Burnout

Original Editor - Jess Bell based on the course by Tracy Prowse
Top Contributors - Jess Bell, Kim Jackson and Naomi O'Reilly

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (7/11/2021)

Introduction

A large number of children participate in organised sports every year. In the US alone, more than 46.5 million children play sports. While the benefits of physical activity are clear, involvement in organised sport can also lead to injuries and burnout. There were, for instance, 1.2 million injuries recorded for high school athletes in the US in 2015 to 2-16.

Each year, more than 10 percent of children aged under 14 are treated for sports injuries in the US. Half of all sports injuries in children aged over 10 years are overuse injuries.

However, despite these high rates, 70 percent of children who participate in sports will drop out by the age of 13. The reasons for this are explored here, but they may be partly due to the influence of pushy parents and coaches.

Growing Need For Intervention

Children may be at more risk of injury for several reasons. These are discussed in more detail here LINK, but the following factors should be considered:

• Immature bones
• Insufficient rest after an injury
• Poor training or conditioning / muscle strength
• Specialisation in just one sport
  • Young athletes are specialising in sports (and positions) at earlier ages, which is known to increase injury risk
  • It has been found that diversified sports training during early and middle adolescence may be more effective in developing elite-level skills
  • Specialisation can be delayed until late adolescence
• Year-round participation
  • Training schedules are often regimented and repetitive, which has increased the number of overuse injuries in children
• Changes in society
  • Shrinking backyard
  • Perceived danger
  • Technology
  • Less play time, more drill time

Overuse Injury and Burnout Prevention

A child’s history of injury is:

• A risk factor for future injury (during both adolescence and adulthood)
• A contributor to long-term degenerative diseases, such as osteoarthritis

As shown in Table 1, which is based on the work of DiFiori and colleagues, risk factors can be divided into intrinsic and extrinsic risk factors.

Table 1. Intrinsice and extrinsic risk factors. Key: +++ = strong predictor of future injury / burnout; ++ = moderate predictor; + = mild predictor; 0 = poor evidence, not considered a predictor of injury

Intrinsic Risk Factors	Extrinsic Risk Factors
Prior injury +++	Higher training volumes ++
Growth spurt +++	Overscheduling+ (recovery time ++)
History of amenorrhea +++	Poor-fitting equipment +
Joint hypermobility + (especially during adolescence)	Sport specialisation +
Readiness + (physical and psycho-social, not age)
Anatomic malalignment, flexibility, functional control of movement 0
Sufficient strength to withstand forces and range of motion +

Jayanthi and colleagues found that the following factors had an increased odds of serious overuse injury:

• Young athletes participating in more hours of sports per week than their age in years (i.e. > 9 hours for 9 years)
• Young athletes whose ratio of organised sport to free play was >2:1 hours per week

Recommendations for Interventions

An intervention programme for overuse injuries should:

• Focus on preventable risk factors first (education and communication)
• Aim for proper technique / basic skills
• Strength and ability training should be part of the child’s part routine
• 10 percent rule:
  • Children should not increase their training volume by more than 10 percent a week
• Training workload and growth rates during growth spurts should be monitored, especially during early adolescence

For acute injuries, intervention programmes should include:

• One or two strength-training sessions a week, perhaps at the end of practice sessions
  • Children should exercise their whole body, including core work and specific muscles
• Include agility and proprioception exercises twice a week
• Make sure to include an adequate warm-up:
  • Prepare the neuromuscular system for competition
• Specific joint and muscle strengthening (particularly for hypermobility / low connective tissue tone)

The rest of this page focuses on specific components of a warm-up, cool-down and strengthening programme.

Warm-Up

Warm-up sessions should include:

• Half to three-quarter speed jogging and backwards jogging
• Mild jog with high knees, skipping, butt kicks and toe reaching
• Crawling calf stretch
• Lunges with twist and walking quadriceps stretch
• Warm-up with active, dynamic mobility exercises
  • Move through the range of motion necessary for a specific sport
  • If the athlete’s sport requires a range that they are yet to achieve, it is important to stretch (in the cool-down or at home)
• Three-quarter speed sport-specific coordination training
  • This includes any activity that challenges balance, stability and agility, such as:
    • Bounding
    • Hopping
    • Diagonal cutting
• Include a few strengthening exercises for muscles that tend to become strained in the relevant sport (often the hamstrings and groin muscles)

NB: The cool-down should include static stretches, and time should be given to drink fluid.

Conditioning

Physical conditioning usually has multiple components including:

• Power
• Strength
• Speed
• Balance
• Agility
• Coordination
• Endurance

To improve fitness and sports performance, physical conditioning is often included in athletic sports and exercise training. Conditioning programmes might also include cross-training - i.e. using different sports / exercises to enhance performance. When cross-training, different physical stresses are applied rather than the stresses applied during the child’s usual routine. This helps to improve the child’s performance generally and reduces the chance of them experiencing an overuse injury.

Risks of a Conditioning Programme

However, acute and overuse injuries can be associated with conditioning programmes.

Acute musculoskeletal injuries (i.e. muscle strains, fractures, and dislocations) usually occur during a traumatic event. Overuse injuries, however, tend to occur when an athlete increases the frequency, duration, intensity and resistance too quickly, which places too much stress on the body.

Training programmes must, therefore, be designed with a specific end goal. Attempting to achieve a goal too quickly can increase the risk of an overuse injury (e.g. stress fracture / shin splints).

The following should be considered prior to starting a conditioning programme:

• Before starting an exercise programme, trainers should consult with the child’s doctor, sports medicine physician or physiotherapist
  • Some teams may have pre-participation physicals / screening to identify any issues
  • If a child has experienced an injury or had surgery, their doctor / physiotherapist should be consulted to ensure they are able to return to sports safely
  • Children should be encouraged to see a medical professional if they have aches and pain. Untreated injuries may get worse or cause further complications
• It can be beneficial for coaches to include a variety of exercises or resistance training that are different from the team's usual training

Strengthening

Strength and agility training should be promoted in school sport:

• Use a variety of strengthening techniques
  • Therabands
  • Weights
  • Medicine balls
  • Swiss balls
  • Bodyweight
  • Gravity
• Agility and proprioception exercises should be sport-specific
• It is important that student athletes connect with a health professional to determine which muscles they should focus on.

Strength Training in Children

Strength training is a specialised approach to conditioning. It includes a range of activities / exercises that usually require specific pieces of equipment, including:

• Dumbbells
• Elastic bands
• Strap-on weights
• Weight machines
• Medicine balls

It also includes body-weight exercises that are specifically designed to enhance or maintain muscular fitness and core exercises.

There is no minimum age to start a strengthening programme, but it is important to remember that children and adolescents are not mini-adults. The following points should be considered before starting any programme:

• The child must have the emotional maturity to follow instructions
  • As a general rule, children who are ready to participate in a sports activity (usually around the age of 7 or 8) may be ready to begin strength training
• Children must be fit enough to successfully participate in a programme and should not have any pre-existing conditions which could increase their risk of injury
• Children / adolescents should not attempt a strength training programme on their own
  • Qualified professionals should provide guidance in order to create a programme that is suitable for the child - i.e. one that considers the child’s needs, interests and ability
  • Close supervision, age-appropriate instruction, suitable equipment and a safe environment are all essential
• Children should initially try an exercise with no load - as their skill increases, load can gradually be increased

Components of a Strengthening Programme

Key components of a strengthening programme include:

• Adequate warm-up (5 to 10 minutes)
• Aim for 60% of 1 RPM for the average child for the average sport
• Initially no load
• Aim for 3 sets of +/- 15 repetitions (no cheating)
• Strength train 2 to 3 times per week on non-consecutive days
• When progressing, remember the 10 percent rule (i.e. do not increase load by more than 10 percent each week)
• The child should aim for three sets at 7/10 fatigue
  • Strengthen to fatigue, rest and repeat
• Use a variety of strengthening techniques
• Close supervision, individual effort and levels

NB: to achieve pure strength, work at 75-90% 1 RM (Repetition maximum) for 5-10 reps (aim for 10). To achieve muscular endurance, work at <60% 1RM  15-20 reps.

A strengthening programme should be general - i.e. aim for “comprehensive capacity”. Sports-specific skills can be added in later if required. Balance, coordination and plyometric exercises should also be included. It is important that the programme is challenging and does not get boring for the child. This can be achieved by systematically reviewing / varying the training programme.

Children and adolescents should not participate in powerlifting, bodybuilding and any maximal lifts (due to physical and skeletal immaturity) - i.e. they should avoid explosive, rapid weight lifting.

Another important consideration is the structure of the strengthening class. Children should have access to fluids and proper nutrition. Moreover, illness or injury must be considered:

• Aim for a 10 to 15 minute dynamic warm-up (see above)
• Focus on proper exercise technique and learning fundamental training principles
• The cool-down should include less intense activities and stretching, mobility or yoga

NB: The AAP advises that instructors or teachers be certified to provide specific paediatric strength training. It is also essential to obtain medical and parental consent before commencing any programme.

Core Training in Children

It is useful to consider how important the core is in children:

• More emphasis should be placed on general strength training than just core strengthening
• Many basic strength training exercises will also train the core
• Basic sport / exercise provides the stimulus for endurance adaptations in the core, just like in other systems
• To train at true comprehensive capacity and be well-rounded, a core workout should also address strength and power, not just endurance and speed-endurance

Benefits of Strength Training in Children

Potential benefits of paediatric resistance training include:

• Greater muscle strength, power and endurance
• Improved motor skill performance
• Increased bone mineral density
• Enhanced body composition
• Improved insulin sensitivity and blood lipid profile
• Decreased risk of sports injuries
• Improved sports performance
• Helps create a more positive attitude to physical activity throughout the lifespan

Monitoring Effectiveness

It is beneficial to consider the child's aims when monitoring the effectiveness of an intervention:

• To assess if physical activity, physical literacy and physical fitness are increasing:
  • PANIC Physical Activity Questionnaire
  • PACER Shuttle Run
  • CAPL Canadian Assessment for Physical Literacy
• Motor coordination skills (i.e. for DCD) can be measured using the mABC and BOT2
• Injury prevention - monitoring numbers
• Specific muscle testing or quick specific tests (see below)

There are a number of quick specific tests that can be used to measure balance, strength and activity. The normal ranges for these tests are provided here.

• Standing on one leg (in seconds)
• Walking heel-to-toe on a line (max of 6 steps)
• Plank assessment of torso strength (for 8 to 12 year olds)
• Kneeling press up (BOT2 for 4 to 7 year olds)
• Daily step count using a pedometer

Motivating Children

A child needs a sense of self-efficacy to engage in challenging tasks. Intrinsic motivation is an essential component of strength training. It can be enhanced by:

• Setting a SMART goal for the child
• Choosing praise carefully, rewarding effort and being specific with praise
• Trying to find other “similar” children who can lead the way
• Acknowledging and explaining discomfort