In this article, we hear from Hannah Anderson, a senior physio practicing in Auckland. As a physio, Hannah is placed right at the bottom of the cliff, helping to mend young athletes whose bodies have succumbed to the pressures of early specialisation, overuse injury and overtraining.
What is early specialisation?
The Australasian College of Sport and Exercise Physicians (ACESP) defines early sports specialisation as:
- “A ‘young athlete’ is defined as an athlete 18 years old or younger” 
- “Sport specialisation is defined as the intensive, year-round training in a single sport at the exclusion of other sports” 
- “‘Early’ specialisation is defined as sport specialisation occurring before the age of 12” 
The current recommendation held by the ACESP is that children only participate in sports training and games relative to their age, and this should then be balanced out with free play with a ratio of 2:1 .
What is overuse injury?
Overuse injuries are the results of repetitive stress to the musculoskeletal system without enough time for recover.
Signs of overuse injury include:
- Gradual onset of pain
- Pain presenting as an ache
- Stiffness or aching during or after training/competition
- Pain persisting for gradually longer periods
- Point tenderness, especially when palpated
- Missed session(s) due to pain/injury
- Recurring injury problem
What is overtraining syndrome and its signs?
Overtraining syndrome, as it sounds, is simply doing more than the body can recover from – often to the point of declining performance and potentially injury. Overtraining can also negatively affect the biological, hormonal and neurological systems in the body.
A rough rule of thumb is that a young person is overtraining if the number of hours they spend doing training and competing in a given week is more than their age. Other signs include:
- Decreased performance in sport or/and school
- Chronic muscle or joint pain
- Rapid weight loss
- Mood swings
- Lack of enthusiasm or change in motivation to be involved in a sport
- Sleep change
- Decreased appetite
- Increased injuries, illness or infections
For females, its also important that athletes, parents and coaches learn about Relative Energy Deficiency Syndrome (RED-S).
What is the relationship between early sport specialisation, overtraining and overuse injury?
While overtraining and overuse injury can occur without early sport specialisation, as the combination of volume and intensity is the main underlying issue, early sport specialisation environments are likely to predispose young people to doing excessive training and competition volumes and intensity with not enough emphasis on rest and recover. In addition, early sport specialisation environments promote the repetition of the same activities, particularly movement patters, which too can contribute to overuse injury and overtraining.
As a physio what are your thoughts on overtraining and early specialisation in youth sport?
I have seen first-hand the consequences of young athletes who overtrain and subsequently develop overuse injuries. Notably, I’ve observed that children who overtrain, also tend to have specialised in a sport, or are showing signs of beginning to specialise in a sport.
It is worrying to note that I often see injured young athletes who will continue to train as normal, despite having prescribed them with training restrictions. It makes me wonder about the pressures and dilemmas they must face playing their sport. Do these young people contravene my advice because they don’t fully comprehend the consequences of further overtraining? It doesn’t help when coaches don’t, or don’t know how to accommodate for athletes who are placed on a training restriction. Likewise, parents who continue to pressure their child to participate (even, as I have seen at times, when the athlete themselves tries to resist this pressure). I recall one sad story where, despite my best efforts to restrict the amount of training a young person was doing, the countering pressure from their coach and parent (under the guise that following their advice would mean better athlete success) saw the athlete sustain a stress fracture. When you weigh these kinds of dilemmas up, you wonder if adults hold the best long-term interests of young athletes at the centre of their decision making and thinking when it comes to youth sport?
Are coaches and parents to blame?
I’m not trying to lay the blame solely at coaches and parents. It’s bigger than that. Sport competitions and structures (tournaments, selection pathways, etc) are set up to incentivise a lot of the behaviours we see from young people, parents and coaches that lead to overuse injury and overtraining.
But it’s even bigger than that – just think of the stories we tell throughout society about training longer and harder. It’s likely you have heard a coach talk about the 10,000 hours rule – that is it takes 10,000 hours of deliberate practice to become an expert. In reality, this “rule”, has been debunked as a myth.
In 2016, Macnamara, Moreau and Hambrick’s published a meta-analysis of the relationship between deliberate practice and performance in sport , which found that:
Overall, deliberate practice accounted for 18% of the variance in sports performance. However, the contribution differed depending on skill level. Most important, deliberate practice accounted for only 1% of the variance in performance among elite-level performers. This finding is inconsistent with the claim that deliberate practice accounts for performance differences even among elite performers.
Unfortunately, the 10,000 hour myth has propelled the thinking that share quantity of practice is the secret to elite performance.
Then couple this with the stories we tell about what successful athlete development looks like, where we pedestal the athlete journeys of the likes of Tiger Woods and Serena Williams, who went all in early. You start to see where the preoccupation with doing more and sooner starts to come from.
By the way, I’m not trying to say athletes shouldn’t work and train hard. And yes, a work ethic is definitely important when it comes to becoming successful athlete. But young athletes are at risk, when coaches and parents translate the ‘work hard message’ into more volume and higher intensity, without balancing this with rest and recovery, as well as providing opportunities for these young athletes to experience a variety of movement patters, and a variety of environments that will support better psychological and social development.
And on Tiger and Serena? Well yes, the early specialisation path is one that can lead to success. The issue with the pedestalling of this path is we often don’t talk about the fact that:
- Few athletes ever become elite, regardless of what path they take.
- The early specialisation path carries significant more risks for young people (look up Todd Marinovich and watch the Marinovich Project for a graphic insight into the pitfalls of early specialisation)
- Alternative models of talent development that encourage young people to sample lots of sports at a young age:
- Lessens the risks of injury and burnout
- Increases factors for success in sport, such as increasing skill due to being exposed to a wider arrange of motor learning experiences; and increased likelihood to succeed due to having more opportunity to ‘pick a sport’ that you are biologically and psychologically suited for, especially post-puberty.
So wider societal norms and beliefs underpin the issues we see in youth sport leading to young people being injured?
Whether it is the parents, coaches or the children themselves being the driving force, the increased prevalence of early sports specialisation is emblematic of the (mis)beliefs we have about youth sport in society today, such as:
- early childhood success in sport is a predictor of adult success;
- and that all high-performance sport behaviours and practices should be adopted into the youth sport context.
From a physio’s perspective, when you then layer in our historically complacent attitudes towards sports injury, where we often see coaches, parents and players react to an injury with one or a combination of: “toughen up” or “she’ll be right”; and society and media at large mythologizing and glorifying athletes who play through injury. The context surrounding increased prevalence in overuse injuries in young people quickly becomes apparent.
Notably, in one recent study on coach and player attitudes to injury in youth sport , researchers found that 87% of players surveyed reported hiding an injury to play on. 87% of players and 91% of coaches had witnessed injured players play on and approximately 50% of players and coaches had seen players put under pressure to play on when injured.
While the literature is expanding on the importance for young athletes to not specialise early, if the information is not trickling down to the influential figures of the young athletes, I wonder how long it will take for this culture to change?
What are some of the biological factors affecting teenagers that puts them at further risk of injury if specialising and overtraining?
As mentioned earlier, specialising in a sport comes with increased training and competition load and volume, and therefore increased risks of the body succumbing to overtraining, i.e. greater risk of acute and chronic injury. One only has to look at the proliferation of ‘load-management’ in professional sport over the past decade to see the general acceptance of this within sport and exercise science communities.
But overtraining is even more vexing for young people! This is because as young people go through puberty, their bodies are even further predisposed to injury risk – thus compounding the risks of specialisation – or in instances early specialisation.
Key biological factors putting young people at further injury risk include:
- Compared with adults, children have an immature skeleton with anatomical differences such as the presence of epiphyseal growth plates, which makes them more susceptible to bone and soft tissue injuries .
- Young people going through puberty have reduced motor control in periods of growth as there are imbalances between the strength and length of their limb which is also thought to increase the risk of both acute and gradual onset injuries .
It is often for these reasons that restrictions on specialisation and participation volume are suggested in sport guidelines for children who remain skeletally immature.
What changes are occurring?
The ACSEP recommends that the risks and lack of associated benefits associated with early specialisation should be communicated to sporting bodies, coaches, parents and the athlete . A great example of this is the NetballSmart resources developed by Netball New Zealand . This is an online platform where players, coaches and parents can get resources to enhance the athlete’s performance and well-being. While this resource is not specific to early specialisation and the associated risks, it highlights to both the coaches and parents the importance diversification in youth, as it allows them to gain skills which can be transferable across sports. It promotes the importance of youth aged between 10 to 13 gaining fundamental movement patterns for the sport rather than getting into rep teams. Another resource that can be used within the community is the infographic created by McGowan et al. (2019). The infographic illustrates the importance of playing sport for developmental reasons but also the importance of balancing sport and play to reduce the likelihood of overtraining.
As physiotherapists, education is our best tool for combating the negative consequences associated with early sports specialisation in young athletes. It is important that we advocate for the health and well-being of the young athletes. In order to see more profound change in the culture surrounding early specialisation and overtraining of young people, sporting bodies need to have resources available at a community level to help educate the coaches and parents that young athletes do not have to train excessively to gain sporting success in later years.
What are some tips for parents when it comes to early sport specialisation, overuse injury and overtraining?
- Encourage your child to participate in multiple sport. If they are motivated to begin committing to one sport, encourage them to participate in other types of informal sport and other activities as well.
- Monitor your child’s workload and be aware for symptoms of overtraining and rest. Ensure that your child has a good rest and recovery in the offseason by ensuring that they play or participate in a different physical activity, ideally with much different movement patters.
- If you child has multiple coaches, be proactive in getting them to communicate together so they have all have a collective idea about your child’s workload.
- Adhere to any advice from physio’s, doctors or other medical professionals about athletes needing to rest and recover.
What are some tips for coaches when it comes to early sport specialisation, overuse injury and overtraining?
- Encourage your athletes to have a good offseason, where rest and recovery is promoted, including participating in a different type of physical activity (i.e. different movement patterns).
- Be aware of and monitor your athletes for signs of overuse injury and overtraining and adjust your session plans appropriately. Often adjusting plans will start with changing volume and intensity, but you could also look to mix up the activities so that different movement patters are promoted.
- If you have athletes with multiple coaches, make sure that you connect with those coaches at the start of the season and again every one-to-two months to ensure all coaches have a collective idea on how various training and competition schedules will impact an individual athlete.
- Adhere to any advice from physio’s, doctors or other medical professionals about athletes needing to rest and recover.
 Whatman, C., Walters, S., & Schluter, P. (2018). Coach and player attitudes to injury in youth sport. Physical therapy in sport: official journal of the Association of Chartered Physiotherapists in Sports Medicine, 32, 1–6. https://doi.org/10.1016/j.ptsp.2018.01.011
 Australasian College of Sport and Exercise Physicians. (2019). Australasian college of sport and exercise physicians position statement: Sport specialisation in young athletes. Australasian College of Sport and Exercise Physicians – ACSEP. Retrieved 20th August 2020, from https://www.acsep.org.au/content/Document/Early%20Specialisation%20Position%20Statement.pdf
 McGowan, J., Whatman, C., & Walters, S. (2020). The associations of early specialisation and sport volume with musculoskeletal injury in New Zealand children. Journal of Science and Medicine in Sport, 23(2), 139-144. https://doi.org/10.1016/j.jsams.2019.09.002
 Netball New Zealand. (n.d.). Netball Smart – Official injury prevention programme of Netball New Zealand. https://www.netballsmart.co.nz
 Macnamara, Brooke & Moreau, David & Hambrick,. (2016). The Relationship Between Deliberate Practice and Performance in Sports: A Meta-Analysis. Perspectives on Psychological Science. 10.1177/1745691616635591.