Implications for Training in Youth: Is Specialization Benefiting Kids?

Abstract

Early sports specialization has been a controversial topic in the field of sports medicine, training, and conditioning. Recent studies report increased sportsrelated injuries in singlesport specialized athletes compared with multisport specialized athletes. Two studies demonstrate the proportions of athletes who focused on a single sport in early ages and advanced to elite level in their later careers are ,1%. Furthermore, performing multiple sports was identified as an indicator for greater future athletic success. Synthesizing available evidence, participating in multiple sports seems more beneficial than focusing on a single sport. It is important to provide adequate recovery time for pediatric and adolescent athletes because they are in a growth spurt process. Finally, because a history of previous injury is evidenced as a risk factor for future sports-related injuries, preventive approaches such as resistance training need to be implemented within a training regimen for youth.

Full text

Implications for Training
in Youth: Is Specialization
Benefiting Kids?
Dai Sugimoto, PhD, ATC, CSCS,
1,2,3
Andrea Stracciolini, MD,
1,2,3
Corey I. Dawkins, MS, ATC,
1,2
William P. Meehan, III, MD,
1,2,3
and Lyle J. Micheli, MD
1,2,3
1
The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts;
2
Division of Sports Medicine, Department
of Orthopedics, Boston Children’s Hospital, Boston, Massachusetts; and
3
Harvard Medical School, Boston,
Massachusetts
ABSTRACT
EARLY SPORTS SPECIALIZATION
HAS BEEN A CONTROVERSIAL
TOPIC IN THE FIELD OF SPORTS
MEDICINE, TRAINING, AND CONDI-
TIONING. RECENT STUDIES
REPORT INCREASED SPORTS-
RELATED INJURIES IN SINGLE-
SPORT SPECIALIZED ATHLETES
COMPARED WITH MULTISPORT
SPECIALIZED ATHLETES. TWO
STUDIES DEMONSTRATE THE
PROPORTIONS OF ATHLETES
WHO FOCUSED ON A SINGLE
SPORT IN EARLY AGES AND
ADVANCED TO ELITE LEVEL IN
THEIR LATER CAREERS ARE ,1%.
FURTHERMORE, PERFORMING
MULTIPLE SPORTS WAS IDENTI-
FIED AS AN INDICATOR FOR
GREATER FUTURE ATHLETIC SUC-
CESS. SYNTHESIZING AVAILABLE
EVIDENCE, PARTICIPATING IN
MULTIPLE SPORTS SEEMS MORE
BENEFICIAL THAN FOCUSING ON
A SINGLE SPORT. IT IS IMPORTANT
TO PROVIDE ADEQUATE RECOV-
ERY TIME FOR PEDIATRIC AND
ADOLESCENT ATHLETES
BECAUSE THEY ARE IN A GROWTH
SPURT PROCESS. FINALLY,
BECAUSE A HISTORY OF PREVI-
OUS INJURY IS EVIDENCED AS A
RISK FACTOR FOR FUTURE
SPORTS-RELATED INJURIES, PRE-
VENTIVE APPROACHES SUCH AS
RESISTANCE TRAINING NEED TO
BE IMPLEMENTED WITHIN A
TRAINING REGIMEN FOR YOUTH.
INTRODUCTION
The decision by young athletes to
focus on a single sport early in
their athletic careers is currently
debated among those involved within
sports medicine, training, and condi-
tioning. Some believe that year-round,
high-intensity training specialized to
a single sport at an early age promotes
superior skill sets and leads young ath-
letes to successful future athletic ca-
reers. This notion is often offered to
parents and legal guardians from coach-
ing staffs as an opportunity to move to
a more advanced class/team such as an
elite-level class and traveling team
squad. The promotion to the more
advanced level and team usually entails
even greater time commitments for
young athletes. Increasing off-field time
commitments by both athletes and
their care givers, who often are involved
in transportation, may factor into deci-
sions to focus on one sport and drop
out of other sports. Another potential
factor may stem from friendships culti-
vated among young athletes. They
likely enjoy spending significant
amount of time through practices and
competitions and develop cohesiveness
among friends in a particular sport,
which may play a key role. For excep-
tional athletes, demonstrating superior
athletic abilities relative to their peers
at middle school– and high school–
level competitions often gains atten-
tion from college coaches and scouts.
Complementary comments received
from college coaches and scouts tend to
promote interests in pursuing further
athletic success, and some may be
looking for athletic scholarship oppor-
tunities. This phenomenon is often
referred as “early sports specializa-
tion” (8,22,29).
Serious sport-related injuries, especially
overuse injuries, are currently more
prevalent in this age group than they
were several decades ago (1,6,12). As
a result, there is concern that this trend
toward early sports specialization may
be a contributing factor for the increase
in overuse injuries in young athletes.
The American Medical Society for
Sports Medicine published a position
statement on overuse injuries and burn-
out in youth sports in 2013 (4), which
stated that “early sport specialization
may not lead to long-term success in
sports and may increase risk for overuse
injury and burnout” (4). The American
Address correspondence to Dr. Dai Sugimoto,
dai.sugimoto@childrens.harvard.edu.
KEY WORDS:
training strategies; pediatric and
adolescent athletes; early sports
specialization
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Academy of Pediatrics also highlighted
the potential risk of focusing on a single
sport in early ages from physical, phys-
iological, and psychological standpoints
(14). The American College of Sports
Medicine further recommended a well-
rounded general fitness program to pre-
vent sports-related injuries (2). The
American Orthopedic Society for
Sports Medicine recently suggested
the importance of developing a sound
environment for the long-term health of
the physically active youth with support
of parents, clinicians, and coaches in
their consensus statement (17). In short,
some sports medicine organizations
have announced their concerns for
sports specialization through their state-
ments. Scientific studies that focus on
early sports specialization are limited.
However, several recently published
studies offer valuable insights in regards
to the effects of sports specialization on
athletic injuries and long-term athletic
success. Thus, this article is focused on
synthesizing scientific evidence of early
sports specialization on musculoskeletal
injury and future athleticism develop-
ment in the youth population.
EARLY SPORT SPECIALIZATION
AND MUSCULOSKELETAL
INJURIES
Several studies have identified an effect
of early sports specialization on the
prevalence and incidence of sport-
related injuries. A retrospective cohort
study conducted by Hall et al.(11) re-
ported a 1.5-fold increase in relative risk
of patellofemoral pain in single-sport
specialized female athletes compared
with multisport female athletes. In addi-
tion, single-sport female athletes had 4
times greater risk of Sinding-Larsen–
Johansson disease/patellar tendinop-
athy and Osgood–Schlatter disease than
multisport female athletes (11). Another
study by Jayanthi et al.(15) analyzed
approximately 500 teenage tennis
players for 1 year and found a higher
likelihood of reporting musculoskeletal
injuries among young tennis players
who solely participated in tennis.
Another investigation of 1,200 young
athletes conducted by Jayanthi et al.(16)
reported that total time spent in training
per week and sports specialization was
an independent risk factor for serious
overuse injuries such as spondylolysis,
osteochondritis dissecans, and stress
fractures among young athletes who
participate in a single sport. Further-
more, a recent clinical review high-
lighted a positive linear association
between risk of serious overuse injuries
and the level ofsport specialization such
as number of sports participations, .8
months per year training, and dropping
out of other sports (23). Two other
studies also indicated increased sports-
related injury incidences in young ath-
letes who participate in a single sport
compared with multiple sports (11,15).
Based on the reported evidence, experts
in this field recommended participating
in a variety of athletic activities to
enhance motor skill developments and
to promote ideal growth in young ath-
letes (24).
AGE EFFECT ON FUTURE
ATHLETIC SUCCESS
In regard to age, a cross-sectional
study examining the starting ages of
2004 Olympians reported that the
mean age of initial sports participation
was 11.5 years (34). Although this
study did not examine age of sports
specialization and injury data, it is
intriguing that the mean age of sports
participation in Olympic athletes is
approximately 11–12 years old, which
seems remarkably later than many pa-
rents and coaches believe. However,
another study supports this finding.
To investigate optimum time to
enhance athletic development, Danish
scientists analyzed approximately 200
elite cyclists, rowers, weightlifters,
swimmers, and track and field compet-
itors (21). The conclusion was that the
period of middle teens is vital to facil-
itate international level of athletic suc-
cess (21). Based on this evidence, the
age of athletic participation to deter-
mine future athletic success does not
have to be below 10 years.
SPORT SPECIALIZATION AND
FUTURE ATHLETIC SUCCESS
Although mass media tends to high-
light successful stories of high profile
athletes who started participating in
a certain sport at an early age, studies
indicate that a relatively low propor-
tion of young athletes who specialize
in a single sport become international-
level athletes later in their careers.
According to a longitudinal study con-
ducted in Germany, only 0.3% of
young athletes who specialized in a sin-
gle sport became international-level
athletes (10). Similarly, another study
conducted in Russia followed approx-
imately 35,000 young athletes who
were selected to train at a high-level
training institution and found that only
0.14% became elite athletes (20). Find-
ings from both studies implied that
a chance to be an elite-level athlete is
a low fraction, even if one is specialized
to a single sport.
EFFECT OF PARTICIPATING IN
MULTIPLE SPORTS
To determine a link between early
sports specialization and future athletic
successes, German researchers con-
ducted a retrospective study of 1,558
German national-level athletes who
were classified either as world class ath-
letes (those who finished in the top 10
places at the Olympic competitions
and/or senior world championships)
or national-level athletes (those who
were ranked in the top 10 at national
senior championships, but not at inter-
national competitions) (10). The results
indicated that single-sport athletes who
started their athletic careers early dem-
onstrated successful competition out-
comes during the middle teenage
period (,14 years old) (10); however,
a later age of specialization was associ-
ated with senior world class success. In
addition, more world class athletes not
only participated in additional sports
compared with the national-level ath-
letes, but practiced additional sports
for longer periods of time compared
with the national-level competitors
(10). Interestingly, when the world class
athletes were categorized by the num-
ber of additional sports they partici-
pated in, the proportions of the world
class athletes showed an increase. The
proportions in number of participated
sports among the world class athletes
Training, Youth, Specialization, Kids
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78
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were as follows: zero: 56%, 1 additional
sport: 67%, 2 additional sports: 69%, and
3 or more additional sports: 76% (10).
The overall training volumes were not
different between the world class ath-
letes and national-level athletes. How-
ever, the training volume for additional
sport(s) was significantly greater in the
world class athletes than that of the
national-level athletes until the age of
10 years. Furthermore, the world class
athletesfocused on a single sport later in
their careers compared with the
national-level athletes (10). The authors
of this study concluded that performing
additional sport(s) is a predictor for
greater athletic successes later in ath-
letes’ careers.
TRAINING CONSIDERATIONS FOR
YOUNG ATHLETES
According to the study by German re-
searchers (10), early sports specializa-
tion may result in early athletic
successes, but it is less likely to result
in longer, senior-level success. Con-
versely, the evidence suggests that per-
forming multiple sports at early ages is
more beneficial for young athletes and
more likely to generate greater suc-
cesses later in their careers. Participat-
ing in different sports activities likely
facilitates the development of better-
rounded motor skill sets. According
to Myer et al.(24), this approach helps
develop the positive implications of
skill transfer with sport diversification
in youth. The transfer of skills from
sport to sport as well as training of
opposing muscle groups and flexibility
patterns may promote and contribute
to the development of superior overall
athletic capability, which may more
positively influence young athletes’
well-rounded athleticism later in their
careers. It is critical to keep in mind
that young athletes are still in the pro-
cess of growing. Among teenage
athletes, especially prepubescent and
pubescent athletes, adequate recovery
time is necessary to promote appropri-
ate growth. Jayanthi et al.(16) offer
a simple and practical ratio: once the
time spent for organized athletic activ-
ities exceeds twice that of free play
time, the odds of sustaining serious
overuse injuries increase significantly.
Several studies also indicate that par-
ticipating in athletic activities more
than 16 hours per week may increase
risk of athletic injuries (15,19,27).
Therefore, providing an environment
in which young athletes can engage
in multiple sports with proper recovery
time would be ideal to enhance their
athletic activities and success later in
their lives.
Another important training consider-
ation in youth is to protect young ath-
letes from serious injuries. An example
might include the early specialized
young baseball pitcher. Lack of shoul-
der internal rotation range of motion
called glenohumeral internal rotation
deficit (GIRD) is a particularly alarm-
ing finding among young throwers
(5,25,33) because it remains unknown
whether or not the GIRD is fully
reversible once it develops. To reduce
the number of pitches, guidelines of
less than 75 pitches per game, 600
pitches per season, and 2,000–3,000
pitches per year were proposed for
9–14-year-old athletes (35). In baseball,
pitchers have a substantially greater
number of skilled throws than field
players. To avoid overpitching, it may
be a good alternative to rotate players’
positions frequently instead of focusing
on solely pitching, especially while the
players are still in the growth spurt.
These tactics may not only protect
young athletes from overpitching but
provide all players experience at vari-
ous positions, which may help to foster
more comprehensive baseball skill
development.
REDUCE MUSCULOSKELETAL
INJURIES THROUGH PREVENTIVE
TRAINING
Furthermore, several studies showed
that a previous injury history is a risk
factor for future injury (7,26). A previous
history of traumatic knee injury such as
anterior cruciate ligament (ACL) injury,
increases the risk of subsequent ACL
injury and other knee injuries. More
specifically, athletes who sustained an
ACL injury 1 time have 15 times greater
risk of sustaining a second ACL injury
relative tothose who never had an ACL
injury (26). Furthermore, previous knee
surgery itself can be a risk factor. A
study performed by Rugg et al.(28)
documented that those who underwent
knee surgery before college showed 7–
20 times higher likelihood of sustaining
another knee injury in their college ca-
reers. To decrease the risk of ACL
injury, prophylactic effectiveness of neu-
romuscular training was examined, and
the results demonstrated a 74% risk
reduction for noncontact ACL injury
(31,32). One of the important compo-
nents of neuromuscular training is the
incorporation of strength training (30).
Enhancing muscular strength seemed
to be beneficial to prevent ACL injury
(30). Historically, concerns for young
athletes engaged in resistance training
have been raised, particularly about risk
of injury to growth cartilage. How-
ever, a recent international consensus
statement based on available studies
found no evidence to support this
notion (18), and actually a few studies
documented greater bone mass devel-
opment in young athletes who regu-
larly performed resistance training
(3,9,13). In short, it is key to integrate
preventive exercises to reduce poten-
tial risk of serious injuries among
young athletes, and resistance train-
ing with proper form can be used as
an effective intervention.
CONCLUSION
In summary, there is a growing concern
among clinicians in the field of sports
medicine regarding early sports special-
ization, which was reflected in their
organizational statements (2,4,14,17).
Recent research studies show increased
sport-related injuries, especially overuse
injuries, among young athletes who spe-
cialized in a single sport (11,15,16). In
terms of age of participation, several
studies showed that internationally pro-
lific athletes begin participating in their
sports around 11–12 years old (34), and
themidteensareacriticaltimefortheir
future athletic success (21). Another
study suggested that performing multi-
ple sports is more beneficial than par-
ticipating in a single sport at early ages,
which also demonstrates an association
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with greater athletic success later in their
careers (20).
Based on the documented evidence, it
seems to be more beneficial for young
athletes to perform multiple sports
rather than focusing on a single sport
in early ages, which may potentially
reduce overuse injuries among young
athletes. In addition, adequate recovery
periods need to be programmed into
young athletes’ training regimens while
they are still growing. Avoidance of
sports-related injuries should be one of
the priorities in young athletes’ training
because past studies have shown that
a previous injury history is a predictor
for subsequent injuries (7,26). Preventive
training such as resistance training can
be used as a part of young athletes’
training regiments. Incorporation of
preventive training may potentially
reduce the number of sports-related in-
juries, while further maximizing young
athletes’ future performance.
Conflicts of Interest and Source of Funding:
W. P. Meehan receives royalties from
ABC-Clio publishing for the sale of his
book, Kids, Sports, and Concussion: A
guide for coaches and parents; Springer
International for the book Head and Neck
Injuries in Young Athlete; and Wolters
Kluwer for working as an author for
UpToDate. He is under contract with
ABC-Clio publishing for a future book
entitled, Concussions. His research is
funded, in part, by a grant from the
National Football League Players
Association and by philanthropic support
from the National Hockey League Alumni
Association through the Corey C. Griffin
Pro-Am Tournament. The remaining
authors report no conflicts of interest and
no source of funding.
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