Competitive Youth Sports and the Rise of Overuse, Burnout, and Career-Ending Injury

It used to be that children were pushed outside and told simply to play with their friends. The neighborhood kids would dabble in backyard football, pickup basketball, or maybe a game of baseball—picture The Sandlot. They might even have been on a recreational little league team with a fun, no-stress game once a week where everyone got a juice box after the game. That used to be the face of youth sports in America, but not anymore. In 1930, the percentage of U.S. children that were involved in organized sports was practically zero. Today, that number is close to fifty percent. Of these approximately 60 million children, thirty percent of them were predicted to sustain a serious injury in 2015 alone. This statistic increases every year, and soon everyone in the country will feel the repercussions of this injury epidemic. The total cost of treatment for these injuries will be about $1.8 billion. This does not even include the potential long-term medical costs associated with musculoskeletal injury. There is no question about whether this is a worthy issue of investigation and reform (Hawkins and Metheny). But where do we start? I believe that the societal shift to instant game information, competition, and excellence has infiltrated the world of youth sports. No longer are organized youth sports for fun. Youth athletes are urged to push themselves to be exceptional. With this attitude comes intense training and large time commitments. The competitive, high-intensity nature of youth sports has created an atmosphere that functions as a breeding ground for overuse, burnout, and career-ending injuries. I want to discuss injury preventative medicine and apply its practical uses to the most common injuries in competitive youth sports.

It is no cakewalk to be a competitive youth athlete in America today. Young athletes are encouraged to specialize early. The definition of sport specialization is “intensive, year-round training in a single sport at the exclusion of other sports” (Difiori et al.). Sport specialization eliminates the recreational motive of participation and emphasis on fundamental skills, strength, and all-around fitness. Sport specialization increases the likelihood of injury because it increases the required number of hours a youth athlete will practice. Studies have established a linear relationship between hours of sport participation and incidence of injury. The risk of overuse injury is especially increased by this type of training. Overuse injury often occurs when a particular motion or action is repeated far too many times for the body to handle without adequate recovery time. In sport specialization the traditional “seasons” of a sport are ignored and athletes train year-round. Many young athletes’ bodies cannot handle the decreased recovery time and increased training and, thus, overuse injuries occur (Difiori et al.).

The risk factors for burnout, overuse, and career-ending injuries are traditionally grouped into two categories: intrinsic and extrinsic. Intrinsic risk factors are psychological and physical characteristics of the athlete that might put him or her at risk, while extrinsic risk factors refer to risk factors introduced by the sport. The most common intrinsic risk factors are prior injury; stage of growth and development, which encompasses flexibility, potential for strength and conditioning, and skeletal development; and individual body mechanics. Adolescence is a critical time for growth and development. Young athletes are often trained with no regard for development. This can lead to increased stress on bones, ligaments, or other structures that are not completely developed, let alone prepared, to handle vigorous, strenuous activity. Extrinsic risk factors include workload, scheduling, and equipment. Coaches rarely have an understanding of their athlete’s lives outside of their participation on the team and can easily push already exhausted young athletes to their breaking point. If scheduling and intensity of sporting events are not considered carefully, then injury is extremely likely (Difiori et al.).

Youth baseball players and their shoulder and elbow injuries are perfect examples of overuse injury in youth sports. Little league pitchers have long been advised to stay away from curveballs and limit their pitches per game or games pitching per week. The rise of competition in youth baseball has fought against this advice. The dangers of throwing a curveball or pitching too many times have been established over and over again by studies and academic journals. There is a particular ligament in the elbow called the Ulnar Collateral Ligament (UCL). This ligament is the most susceptible to injury through pitching (specifically curveballs). The UCL is worn down by pitching over time. It makes sense that many older major league pitchers experience UCL rupture. However, the increasing incidence of UCL damage in youth players is concerning. The same mechanisms that wear down a pitcher’s elbow in 20 years are doing the same to young pitchers in 2-3 years or less. This implies that gaining a competitive edge is being prioritized over this serious complication (Stenson).

The Tommy John Surgery, named after a famous major league player whose career was ended by the condition, is meant to repair UCL injuries and is a serious, complicated procedure with a tough rehabilitation period. Even with all this intensive work to heal the joint, virtually no victims of this ailment are able to recover and play as well as they once could. However, only recently has the Little League organization enacted pitch count rules for different types of pitches. Even still, travel team leagues are gaining popularity. These leagues are not bound to little league rules and have no regulations protecting the athletes and their developing arms from overuse injury (Caron).

If medical knowledge and studies are out there telling us what is and is not safe for youth athletes, why have we not changed our practices? Similar to professional sports, there is an ever-present conflict between ensuring the best rehab for the athletes on a team and ensuring the athletes are away from play for as little time as possible. In the hypercompetitive youth sports world, time away from play is often seen as simply falling behind. This means that coaches, players, and parents often find themselves more concerned with how much longer the athlete will be in rehab rather than the quality and readiness of the athlete to return to play. Unfortunately, this attitude creates career-ending or recurring injuries that often keep athletes away from play longer than the original injury did (Difiori et al.).

Much of the advancement in sports medicine in the past few decades has been aimed at simplifying surgical procedures that are a result of years of overuse and joint burnout. An example of such an advancement is the development of hip arthroscopy. Arthroscopy is a practice of surgery that is extremely non-invasive. Instead of making a large incision to reveal the entire affected area, surgeons use small cameras and tools that require only a few centimeter-long incisions. The purpose of hip arthroscopy is often to “clean out” the joint by removing scar tissue that has accumulated over time. This practice does not address the most important facet of the entire process: what caused the scar tissue to accumulate in the first place? Although arthroscopy is a rather non-invasive procedure, any surgery poses significant risk to the patient. Research shows that, in a disturbing amount of hip arthroscopy cases, the buildup of scar tissue could have been avoided. What this means is that while surgery advancement is significant and extremely helpful, it is merely repairing preventable damage. This “fix it later” attitude is a main contributor to the youth sports injury epidemic (Brukner et al.).

The practice of treating muscle injuries with corticosteroids exemplifies this attitude. Although this practice is primarily used only at the highest level of competition in youth sports, it embodies the conflict between athletes’ health and their athletic performance. Corticosteroids were first developed for treatment of athletic injury in the 1960s. In some cases, corticosteroids are an appropriate treatment. However, they are often used to “freeze up” a muscle that has been strained or pulled so that the athlete can return to the game pre-form. Multiple studies have been published discouraging the use of corticosteroids for treatment of this type of injury. Imagine a large muscle is like a rubber band. The corticosteroid acts as a freezing agent on the “rubber band.” However, it also blocks pain transmitters so the athlete perceives the “rubber band” to be normal. Frozen rubber bands don’t stretch very well; add to this the athlete’s perception of a normal situation and you have a ticking time bomb. Strong correlations between the use of corticosteroids in muscle injuries and major career-ending injuries have been established. Despite this, corticosteroids are still used in this way (Nichols).

The specific practices and attitudes contributing to this injury epidemic are seemingly ingrained in our culture, but this is not an epidemic without a cure. Millions of dollars and hundreds of research teams have been devoted to developing injury preventative medicine. Throughout the past few decades, researchers and sports medicine professionals have settled on a few key practices that could (and have been proven to in studies) drastically reduce the number of overuse, burnout, and career-ending injuries. One of these tools is biomechanical analysis. Biomechanical analysis combines the fields of physics, kinesiology, and anatomy to examine the musculoskeletal system’s response to repetitive or specific forces. This tool is especially helpful because it takes into account the unique qualities and differences in each young athlete’s body (Hawkins and Metheny).

An example of how biomechanical analysis would prevent an injury can be seen in the discovery of why female soccer players are more susceptible to ACL rupture. The male skeleton differs from the female skeleton in many areas. One area of interest in relation to this topic is the Q angle. The Q angle is the angle between the pelvic girdle and the femur. In males, this is almost a right angle because males have narrow hips and less curves in the skeleton. In the female body, the Q angle is acute. Females have wider hips for birthing. This means that when a female bends down (think of a squatting mechanism) their knees are more likely to go inwards rather than straight over their toes. This mechanism is a common cause of ACL injury and thus explains one reason why females are more likely to injure their ACLs (Griffin).

Another general practice is sports readiness evaluation. Sports readiness is determined by the combination of the child’s cognitive, physical development, and their social/emotional development. Because every child matures at a different rate, chronological age is not a good indicator of sports readiness. Sports readiness evaluations often uncover weaknesses from prior injuries or underdeveloped muscles that would be extremely susceptible to injury if left unaddressed. In keeping with my prior example of ACL rupture, sports readiness evaluations can also be used for this purpose. One of the most common injuries in youth sports is a sprained ankle. This seemingly minor injury is easily treated and, in most cases, the athlete can return to play in a matter of weeks. However, the common and seemingly minor nature of this injury often leads people to self-treat. This is not necessarily a bad practice, except that most people are not educated in the most important part of ankle sprain rehabilitation: restoration of range of motion. An athlete can recover from an ankle sprain, feel completely normal, and experience no loss in performance but still have a restriction of motion at the joint. The ankle is built to absorb force from landing from a jump. It has elements that help prevent rolling in or out when absorbing this shock. When the ankle’s motion is restricted, it cannot absorb this force and it is transferred to the next joint up the leg: the knee. The knee does not contain the same kind of structures that prevent inward or outward movement and thus, ACL injury is likely. In a sports readiness evaluation, an old injury like an ankle sprain may be uncovered and treated to prevent an ACL injury from occurring (“American Academy of…”).

In addition to biomechanical analysis and sports readiness evaluations, many training programs specific to certain genders, ages, and sports have been created to explicitly prevent injuries common to that faction of youth athletes (Difiori et al.). Scientists and medical professionals have worked hard to come up with comprehensive training programs aimed at training young female athletes to be more aware of their body mechanics and strengthen certain muscle groups to decrease their chance of ACL injury. Although they cannot change their genetic anatomical predisposition to ACL injury, young girls are encouraged to strengthen muscles, like the glutes and abdominals, that help stabilize and protect the knee joint from injury. Female soccer players are also being screened for persisting injuries that may cause asymmetries or weaknesses that could cause ACL injury. When specific training programs are applied, incidence of injury dramatically decreases. This is not only because of the training. While the girls are training their muscles to physically prevent injury, they, their parents, and coaches are also learning about what is safe, how injuries occur, and how to take care to prevent an injury from ever occurring. This education is a crucial part of the injury prevention programs (“American Academy of…”).

I believe that stronger pathways of communication between sports medicine professionals, athletes, coaches, and parents must be established. I am confident that if the information already published is presented to all parties involved in a clear, easy-to-understand manner, it will prompt a more concentrated focus on the health of these young athletes. I hope to bring about a change in the youth sports realm that stresses the health of the athlete. After all, everyone ultimately wants the same thing: for young athletes to be able to play the sports they love and perform at their best.

The statistics regarding overuse, burnout, and career-ending injuries in youth sports reflect the hypercompetitive environment that has developed over the past few decades. I am not against competitive youth sports. I am against the attitudes present in youth sports that are more concerned with athletes’ performance and competitive edge rather than their health. I have scanned the sports medicine world thoroughly and the findings contained in this report include only the most promising, intriguing aspects of injury prevention in the modern competitive youth sports world.