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doi: 10.1136/bjsm.2009.068098
2009
2010 44: 56-63 originally published online November 27,Br J Sports Med
A D Faigenbaum and G D Myer
safety, efficacy and injury prevention effects
Resistance training among young athletes:
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Resistance training among young athletes: safety,
efficacy and injury prevention effects
A D Faigenbaum,
1
G D Myer
2,3,4
1
Department of Health and
Exercise Science, The College of
New Jersey, Ewing, New
Jersey, USA;
2
Cincinnati
Children’s Hospital Medical
Center, Cincinnati, Ohio, USA;
3
Sports Medicine Biodynamics
Center and Human Performance
Laboratory, Cincinnati, Ohio,
USA;
4
Rocky Mountain
University of Health Professions,
Provo, Utah, USA
Correspondence to:
Dr A D Faigenbaum, Department
of Health and Exercise Science,
The College of New Jersey,
2000 Pennington Road, Ewing,
NJ 08628, USA; faigenba@tcnj.
edu
Accepted 10 October 2009
Published Online First
27 November 2009
ABSTRACT
A literature review was employed to evaluate the current
epidemiology of injury related to the safety and efficacy of
youth resistance training. Several case study reports and
retrospective questionnaires regarding resistance exercise
and the competitive sports of weightlifting and power-
lifting reveal that injuries have occurred in young lifters,
although a majority can be classified as accidental. Lack
of qualified instruction that underlies poor exercise
technique and inappropriate training loads could explain,
at least partly, some of the reported injuries. Current
research indicates that resistance training can be a safe,
effective and worthwhile activity for children and
adolescents provided that qualified professionals super-
vise all training sessions and provide age-appropriate
instruction on proper lifting procedures and safe training
guidelines. Regular participation in a multifaceted
resistance training programme that begins during the
preseason and includes instruction on movement biome-
chanics may reduce the risk of sports-related injuries in
young athletes. Strategies for enhancing the safety of
youth resistance training are discussed.
There is a growing number of young athletes
participating in resistance training programmes in
school-based programmes, fitness facilities and
sport training centres to enhance their athletic
performance and reduce their risk of injury during
practice and sport competition (fig 1).
1
Although
some clinicians once considered resistance training
unsafe and potentially injurious to the developing
musculoskeletal system,
2
evidence related to the
safety and efficacy of resistance exercise for
children and adolescents has increased over the
past decade.
3–7
The qualified acceptance of super-
vised and well-designed youth resistance training
by medical, fitness and sport organisations is now
becoming universal.
8–13
Current public health initiatives now aim to
increase the number of youth who participate
regularly in ‘‘muscle strengthening’’ activities,
14
and contemporary physical education programmes
include resistance training as part of a health-
enhancing approach to fitness education.
15 16
In
addition, some fitness facilities and sport centres
serve the youth fitness market by providing
programmes for children and adolescents that
enhance musculoskeletal strength, improve motor
skill performance and reduce the risk of sports-
related injuries.
5711
On the other hand, there is substantial interest
and concern from the general public, medical
societies and the scientific community regarding
the safety and appropriateness of resistance train-
ing for young athletes. Boys and girls as young as
6–8 years of age participate in resistance training
activities and the weekly training volume (com-
bined sports practice, sports competition and
resistance training) of some teenage athletes rivals
that of adults.
17 18
Moreover, advanced training
programmes that include weightlifting movements
and plyometrics are now recommended as part of
performance-enhancing and injury-reducing youth
programmes.
19–22
The growing popularity of youth
resistance training and the complex nature of
youth sport participation raise new questions and
concerns about the safety of youth resistance
training, the risk factors associated with resistance
training-related injuries in youth and the effective-
ness of preventive measures. Our purpose is to
review the current epidemiology of injury related
to the safety and efficacy of resistance training
among youth and to provide age-appropriate
training recommendations for children and adoles-
cents.
Definitions
By definition, the term ‘‘resistance training’’ refers
to a specialised method of physical conditioning
that involves the progressive use of a wide range of
resistive loads, different movement velocities and a
variety of training modalities including weight
machines, free weights (barbells and dumbbells),
elastic bands, medicine balls and plyometrics. The
term ‘‘resistance training’’ should be distinguished
from the sports of weightlifting and powerlifting
in which individuals periodically train with heavy
loads and attempt to lift maximal amounts of
weight in competition. Resistance training should
also be distinguished from the sport of body-
building in which the goal is muscle size, symme-
try and definition. In this review, the term
‘‘youth’’ refers to both children and adolescents.
INCIDENCE AND DISTRIBUTION OF YOUTH
RESISTANCE TRAINING INJURIES: REPLACING
DOGMA WITH DATA
Incidence of injury
Current research findings indicate a relatively low
risk of injury in children and adolescents who
follow age-appropriate resistance training guide-
lines, which include qualified supervision and
instruction.
42324
A wide variety of resistance
training programmes from single-set sessions on
child-size weight machines to multi-set protocols
using different types of equipment have proved to
be safe and efficacious.
17 25–49
Of note, significant
gains in strength without any report of injury have
been reported in prospective studies in which
weightlifting movements (including modified
cleans, pulls and presses) were incorporated into
Review
56 Br J Sports Med 2010;44:56–63. doi:10.1136/bjsm.2009.068098
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youth resistance training programmes.
44 46 47 49
These findings
are supported by others who found that the sport of
weightlifting can be safe for youth provided that well-informed
coaches supervise all training sessions and competitions in order
carefully to prescribe the weight lifted.
50 51
In the vast majority
of resistance training intervention studies summarised in
table 1,
17 25–49
the injury occurrence in children and adolescents
was either very low or nil and the resistance training stimulus
was well tolerated by the young subjects.
Three prospective research studies have reported training-
related injuries in youth that required cessation from training or
time away from a training session.
28 35 37
Namely, anterior
shoulder pain that resolved within one week of rest,
28
a strain of
a shoulder muscle that resulted in one missed training session
35
and non-specific anterior thigh pain that resolved with
5 minutes of rest.
37
A review of these findings revealed
estimated injury rates of 0.176, 0.053 and 0.055 per 100
participant hours, respectively, which suggest that supervised
resistance training protocols are relatively safe for youth.
28 35 37
Furthermore, Rians and colleagues
28
found no evidence of either
musculoskeletal injury (measured by biphasic scintigraphy) or
muscle necrosis (determined by creatine phosphokinase levels)
in children after 14 weeks of progressive resistance training on
hydraulic resistance machines.
The evaluation of maximal muscle strength has also proved
to be relatively safe for children and adolescents. Faigenbaum et
al
52
evaluated the safety and efficacy of 1 repetition maximum
(RM) testing in 96 children (6–12 years) and reported that
healthy boys and girls can safely perform maximal effort
strength tests on weight machines provided that appropriate
testing procedures are followed. In other reports, children and
adolescents safely performed 1 RM strength tests using free
weights.
36 37 53–55
These data suggest that children and adoles-
cents can safely engage in this type of strength testing provided
that appropriate loads are used, established guidelines are
followed and qualified professionals are present. Although
some observers are opposed to the use of 1 RM testing in
children,
12
it is important to realise that many of the forces
that youth are exposed to in sports and recreational activities
(eg, gymnastics, rugby and running) are likely to be greater
both in duration and magnitude than properly performed
maximal strength tests.
A summary of descriptive and observational studies that
reported on the frequency or incidence of injury in youth from
resistance training, weightlifting or powerlifting are presented
in table 2.
23 51 56 57
In one retrospective evaluation of injury rates
in adolescents it was noted that resistance training and
weightlifting were markedly safer than many other sports and
activities.
23
In that study, the overall injury rate per 100
participant hours was 0.8000 for rugby and 0.0035 and 0.0017
for resistance training and weightlifting, respectively.
23
In
support of these findings, Pierce and colleagues
51
followed 70
competitive weightlifters (7–16 years) over a one-year period
(1224 lifts were performed in competition) and reported no
injuries that limited training or required medical attention.
A retrospective survey of resistance training injuries in 354
adolescent American football players found 27 injuries (causing
more than 7 days of missed participation), which resulted in
estimated injury rates in junior high school athletes (mean age
13.3 years), high school freshman/junior varsity athletes (mean
age 15.6 years) and high school varsity athletes (mean age
17.2 years) of 0.11, 0.091 and 0.51, respectively, per person-
year.
57
In the aforementioned study,
57
only 36% of the training
sessions performed by junior high school athletes were
supervised by a coach. Brown and Kimball
56
estimated an injury
rate of 0.29/100 participant hours in adolescent powerlifters
who presumably trained with heavy loads on the bench press,
deadlift and back squat exercises.
Although discussions of resistance training-related injuries
typically include muscle strains and lower back pain, if safety
standards for youth resistance training are not followed there is
the potential for a catastrophic injury. In one case report, a 9-
year-old boy died at home when a barbell rolled off the bench
press support and fell on his chest while he was ‘‘playing’’ with
his older brother’s weights.
58
Serious accidents have also been
reported in adults who resistance train for recreation and
sport.
59
Location and type of injuries
The potential for soft tissue injuries from repetitive use is an
important consideration related to resistance training. In a
recent evaluation of ‘‘weightlifting’’ injuries (ie, resistance
training injuries), presenting to US emergency rooms,
Quatman and colleagues
1
reported that the trunk was the most
Figure 1 Reported high school
‘‘weightlifting’’ (ie, resistance training)
participants after the induction of Title IX
(school years 1973–2005) based on the
participation estimates from the High
School Athletics Participation Survey
conducted by the National Federation of
State High School Associations.
Reprinted from Quatman et al.
1
Reproduced by permission of the National
Strength and Conditioning Association,
Colorado Springs, Colorado, USA.
Review
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commonly injured body part for both men (36.9%) and women
(27.4%) between the ages of 14 and 30 years. Others reported that
the lower back region was the most frequent site of injury site in
adolescent athletes who participated in a resistance training
programme.
56 57 60
In a retrospective study involving adolescent
powerlifters, 50% of reported injuries were to the lower back.
56
Of
potential relevance, the average powerlifter in that report trained
4.1 times per week (99 minutes per training session) and a
majority of the training sessions were performed without super-
vision from a ‘‘trained coach’’.
56
In contrast, Myer and colleagues
24
reported that injuries to the trunk constituted only 12% of
reported injuries in youth aged 8–13 years. While the potential for
injury to the lower back is a concern, many modifiable and
controllable factors need to be considered when evaluating these
data (eg, quality of supervision and instruction, exercise technique,
progression of training loads and weekly training volume).
Table 1 Intervention studies of resistance training in youth
Reference Participants Intervention Injury outcome
Vrijens, 1978
25
M, ages 10–16 years E = 28 Eight ‘‘isotonic’’exercises, 1 set/8–12 reps, 3 6/week, 8 weeks No injuries
Sewall and Micheli, 1986
26
MF, ages 10–11 years 10E, 8C Weight machine, 3 sets/10 reps, 25–30 minutes, 3 6/week, 9 weeks No injuries
Funato et al, 1987
27
MF, ages 6–11 years 52E, 47C Maximum isometric elbow flexion, 2 6/day, 3 6/week, 12 weeks No injuries
Rians et al, 1987
28
M, ages 6–11 years 18E, 10C Hydraulic machine circuit, 45 minutes/session,36/week, 14 weeks,
shoulder pain
1 injury
Siegal et al, 1989
29
E = 26M, 24F, 8.4 years C = 30M, 16F,
8.6 years
Free weights, tubing, body weight, 30 minutes, 3 6/week, 12 weeks No injuries
Ramsay et al, 1990
30
26M, 9–11 years 13E, 13C Free weights and weight machines, 3–5 sets/5–12 reps, 3 6/week,
20 weeks
No injuries
Faigenbaum et al, 1993
31
MF ages 8–12 years 14E, 9C Weight machines, 7 exercises, 3 sets/10–15 reps, 2 6/week, 8 weeks No injuries
Ozmun et al, 1994
32
MF, ages 9–12 years 8E, 8C Dumbbell elbow flexion, 3 sets/7–11 reps, 3 6/week, 8 weeks No injuries
Faigenbaum et al, 1996
33
MF ages 7–12 years 15E, 9C Weight machines, 7 exercises, 3 sets/6–10 reps, 2 6/week, 8 weeks No injuries
Falk and Mor, 1996
34
M ages 6–8 years 14E, 15C Body weight, 3 sets/1–15 reps, 40 minutes, 2 6/week, 8 weeks No injuries
Lillegard et al, 1997
35
MF ages 9–15 years 52E, 39C Free weights and machines, 6 exercises, 3 sets/10 reps shoulder strain,
1 h/session, 3 6/week, 12 weeks
1 injury
Hetzler et al, 1997
36
E = 20M, 12–15 years C = 10M Free weight and machines, 17 exercises, 1–3 sets/10–12 reps, 3 6/
week, 12 weeks
No injuries
Faigenbaum et al, 1999
17
E = 22M, 9F, 5–11 years C = 9M, 3F Weight machines, 11 exercises, 1 set/6–15 reps, 2 6/week, 8 weeks No injuries
Sadres et al, 2001
37
E = 27M, 9–10 years C = 22M Free weights, 1–4 sets/5–30 reps, 3–6 exercises, 2 6/week, thigh pain,
21 months
1 injury
Pikosky et al, 2002
38
E = 7M, 4F, 8.6 years Weight machines and body weight, 9 exercises, 1–2 sets/10–15 reps,
2 6/week, 6 weeks
No injuries
Siegal et al, 1989
29
E = 26M, 24F, 8.4 years C = 30M, 16F,
8.6 years
Free weights, tubing, body weight, 30 minutes, 3 6/week, 12 weeks No injuries
Flanagan et al, 2002
39
MF, 8–9 years 38E, 20C Weight machines, body weight 1–3 sets/8–15 reps, 2 6/week, 8
exercises, 40 minutes, 10 weeks
No injuries
Faigenbaum et al, 2002
40
E = 34M, 21F, 7–12 years C = 8M, 5F,
9.3 years
Weight machines, 12 exercises, 1 set/10–15 reps, 1–2 6/week,
8 weeks
No injuries
Tsolakis et al, 2004
41
19M, 11–13 years 9E, 10C Weight machines, 3 sets, 6 exercises, 2 6/week, 8 weeks No injuries
Coutts et al, 2004
42
42M, 16.7 years 21E, 21C Free weights, 4–16 reps/set 7–8 exercises, 3 6/week, 12 weeks No injuries
Faigenbaum et al, 2005
43
22M, 19F, 8–12 years C = 9M, 3F Weight machines, 9 exercises, 1 set/6–20 reps,26/week, 8 weeks No injuries
Gonzalez-Badillo et al, 2005
44
E1 = 16M, 16.4 years E2 = 17M,
16.5 years E3 = 18M, 16.8 years
Free weights, 1–6 reps/1–3 sets, 4–5 6/week, 10 weeks No injuries
Faigenbaum and Mediate, 2006
45
E = 42M, 27F, 15–16 years C = 35M,
14F
Medicine ball, 1–3 sets/5–15 reps, 15–40 exercises, 2 6/week, 6 weeks No injuries
Faigenbaum et al, 2007
46
E1 = 14M, 12–15 years E2 = 13M Free weights, body weight 4–12 reps/1–3 sets, 6–18 exercises, 2 6/
week, 6 weeks
No injuries
Faigenbaum et al, 2007
47
E = 22M, 13.9 years Free weights, 3 sets, 1–15 reps 9–10 exercises, 2 6/week, 8 weeks No injuries
Szymanski et al, 2007
48
E2 = 25M, 14–18 years E1 = 24M,
14–18 years
Free weights and medicine ball, 9–15 exercises, 2–3 sets/6–10 reps, 2–
3 6/week, 12 weeks
No injuries
Channell et al, 2008
49
E1 = 11M, 16.4 years E2 = 10M,
16.5 years C = 6M, 16.8 years
Free weights and body weight, 3–20 reps/3–5 sets, 8 weeks No injuries
C, control group; E, experimental group; F, female; M, male; reps, repetitions.
Table 2 Descriptive and observation studies on the frequency or incidence of injury in youth from resistance
training, weightlifting or powerlifting
Study Exercise activity Sample Injury incidence
Brown and Kimball, 1983
56
Powerlifting M, 14–19 years, N = 71 0.29 per 100 h
Risser et al, 1990
57
Resistance training M, 13.3 years (SD 0.08), N = 98 0.11 per person-year
Resistance training M, 15.6 years (SD 0.05), N = 159 0.091 per person-year
Resistance training M, 17.2 years (SD 0.04), N = 97 0.051 per person-year
Hamill, 1994
23
Weightlifting M, ,13–16 years, N = 1634+ 0.0017 per 100 h
Resistance training M, ,13–16 years, N = 4040+ 0.0035 per 100 h
Pierce et al, 1999
51
Weightlifting M, F, 7–16 years, N = 70 0.000
F, female; M, male.
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Growth plate injuries
Another concern associated with youth resistance training is the
potential for injury to the physis or growth plate in a young
lifter’s body. The growth plate can be three to five times weaker
than surrounding connective tissue and it may be less resistant
to shear and tension forces.
61
Injury to this section of bone could
result in time lost from training, significant discomfort and
growth disturbance.
62
A summary of case reports of resistance
training-related physeal injuries in youth is provided in table 3.
63–68
Although a few retrospective case reports noted injury to the
growth cartilage in youth,
63–68
most of these injuries were caused
by improper lifting techniques, poorly chosen training loads or
lack of qualified adult supervision. For example, in one case
report a 13-year-old boy had bilateral fracture separations of the
distal radial epiphyses when he lost control of a barbell as he
attempted to press a 30 kg weight overhead while exercising
alone in a ‘‘makeshift gymnasium’’ at home.
66
It is unclear from
this report if this adolescent received instruction on proper
resistance training procedures or if he was involved in an
activity that could be characterised as ‘‘horse play’’.
Of note, injury to the growth cartilage has not been reported
in any prospective youth resistance training study that provided
professional guidance and instruction.
17 25–49
Furthermore, there
is no evidence that resistance training will negatively impact
growth in height during childhood and adolescence.
34
The risk
of growth plate injury may be greater when young athletes
perform jumping and landing activities during competitive sport
play that induces ground reaction forces of up to five to seven
times body mass.
69 70
RELATIVE SAFETY OF YOUTH RESISTANCE TRAINING
Although youth resistance training does involve some degree of
inherent risk of musculoskeletal injury, this risk does not appear
to be any greater than other sports and recreational activities in
which children and adolescents regularly participate.
23 71
Zaricznyj and colleagues
71
evaluated the incidence of sports-
related injuries (based on accident reports) in school-age youth
over a one-year period and found that resistance training
resulted in 0.7% of 1576 injuries, whereas American football
resulted in 19% of all injuries. When the data were evaluated in
terms of injury to participant ratio in school team sports,
American football (28%), wrestling (16%) and gymnastics (13%)
were at the top of the list.
71
In support of these observations,
more recent data indicate that American football had the
highest injury rate (4.36 injuries per 1000 athlete exposures) for
nine sports studied.
72
A related concern regards the performance of plyometric
exercises (also called stretch-shortening cycle exercise) for
children and adolescents. Although some observers suggested
that a predetermined baseline level of strength (eg, 1 RM squat
should be 1.5 times body weight) should be a prerequisite for
lower body plyometric training,
73
this contention is not
supported by current research and clinical observations.
19 46 74–77
Plyometric training can be a relatively safe and effective method
of conditioning for children and adolescents if appropriately
prescribed and sensibly progressed over time.
11 19
Nonetheless, the addition of any type of resistance training to
the total exercise dose of young athletes (ie, sports practice,
sports competition and free play) should be carefully considered
as this type of training may add to the chronic repetitive stress
placed on developing musculoskeletal systems. Injury or illness
can result if the intensity, volume or frequency of training
exceeds the ability of the participants to perform technically
sound movements or to recover from earlier training bouts. For
example, a 12-year-old boy developed exertional rhabdomyo-
lysis after he was instructed to perform excessive (.250)
repetitive squat jumps in a physical education class.
78
RISK FACTORS
By addressing the risk factors associated with resistance
training-related injuries it is possible to reduce the risk of injury
and enhance the training experience for young athletes.
Although additional research is warranted, common risk factors
that have been associated with sports-related injuries in youth
include: the adolescent growth spurt; age; biological maturity;
body size; poor coaching; fitness and previous injury.
79
Other
hypothesised but untested factors include: poor conditioning;
muscle imbalances; inadequate nutrition; improper equipment;
hazardous playing conditions; poor exercise technique; training
errors and lack of coaching education.
79 80
Myer and colleagues
24
recently examined data from the
United States Consumer Product Safety Commission in order
to evaluate resistance training-related injuries from patients
presenting to US emergency rooms (fig 2). They found that as
the age group increased (8–13, 14–18, 19–22 and 23–30 years)
the number of accidental injuries decreased significantly for
each successive age group. Of potential relevance, they noted
that two-thirds of the injuries sustained by 8–13-year-old
patients were to the hand and foot and were most often related
to ‘‘dropping’’ and ‘‘pinching’’ in the injury descriptions (fig 3).
Conversely, the number of joint sprains and muscle strains was
higher in the older age groups.
Although supervised and age-appropriate resistance training
is currently recognised by medical and fitness organisations to
be a safe and effective method of exercise for children and
adolescents,
8–11
teachers and coaches need to be aware of proper
resistance training procedures because the aggressive progres-
sion of training loads and the improper performance of free
weight lifts can be injurious.
56 60
A recurring theme in most
youth resistance training-related injuries is the lack of qualified
adult supervision and instruction. Without guidance from
professionals knowledgeable in youth resistance training proce-
dures, children and adolescents who use exercise equipment are
more likely to have an injury as a result of unsafe behaviour,
equipment malfunction and lack of proper supervision.
24 81 82
Table 3 Summary of case reports of resistance training-related physeal injury in youth
Reference Age (years) Injury location Exercise action, load
Ryan and Salciccioli, 1976
64
14–17 Distal radius Overhead press, 34–81 kg
Benton, 1982
63
3–18 Distal radius Not reported
Gumbs et al, 1982
65
12, 14 Distal radius and ulna Overhead press, 40–68 kg
Jenkins and Mintowt-Czyz, 1986
66
13 Distal radius Overhead press, 30 kg
Weiss and Sponseller, 1989
67
16 Distal radius Bench press, 48 kg
Browne et al., 1990
68
16 Lumbar ring apophysis Bench press, deadlift, ‘‘power
clings’’, 73–160 kg
Review
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PREVENTION
Resistance training to prevent other sport injuries
In addition to enhancing strength and power, regular participa-
tion in a preseason conditioning programme that includes
resistance training may facilitate injury risk reduction during
sports participation. Comprehensive resistance training pro-
grammes that included plyometric exercises (and instruction on
jumping and landing techniques) have been found to enhance
movement biomechanics, improve functional abilities and
reduce the number of sport-related injuries in young ath-
letes.
83–86
Indeed, most multifaceted conditioning programmes
that included progressive resistance exercise have proved to be
an effective strategy for reducing sports-related injuries in
adolescent athletes.
83–85 87–90
However, one limitation of inter-
vention trials that use multiple interventions in a trial arm is
that it is difficult to characterise the contribution of each aspect
of the intervention to the decrease in injury.
Prevention of resistance training injuries
Research findings suggest that a majority of resistance training-
related injuries in children and adolescents are the result of
accidents, improper exercise technique or lack of qualified
supervision.
24 82 91
Attention to weight room etiquette, safe use
of equipment, age-appropriate training and proper handling of
heavy objects may limit the risk of accidental injuries among
young lifters. Of note, qualified professionals who have an
understanding of youth resistance training guidelines and who
are knowledgeable of the physiological and psychosocial
uniqueness of children and adolescents should provide super-
vision and instruction (eg, UK Strength and Conditioning
Association level 1 strength and conditioning coach or National
Strength and Conditioning Association certified strength and
conditioning specialist). Although there have been no preventive
trials that have focused specifically on measures to prevent
resistance training injuries in children and adolescents, the
Figure 2 Estimated number of
‘‘weightlifting’’ (ie, resistance training)
injuries presenting in US emergency
rooms between the years 2002 and 2005.
Reprinted from Myer et al.
24
Reproduced
by permission of the National Strength
and Conditioning Association, Colorado
Springs, Colorado, USA.
Figure 3 Percentage of injuries of the
oldest and youngest age categories. Note
that the small prevalence of leg injuries in
the 8–13 years age categories provides
invalidated results and should be
interpreted with caution. Reprinted from
Myer et al.
24
Reproduced by permission of
the National Strength and Conditioning
Association, Colorado Springs, Colorado,
USA.
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following recommendations appear warranted for apparently
healthy youth:
c All youth should have the emotional maturity to accept and
follow coaching instructions.
c All youth should wear comfortable attire that does not
restrict movement patterns and athletic footwear that
provides good traction and support.
c Resistance training sessions should begin with dynamic
warm-up activities.
c Resistance training sessions should include exercises for all
of the major muscle groups including the hips, abdomen and
lower back.
c The focus of youth resistance training programmes should
be on learning proper exercise technique and not on the
amount of weight lifted.
c Qualified professionals who have an understanding of youth
resistance training and paediatric fitness should provide
supervision and instruction.
c Qualified professionals should ensure the training area is
safe, adequately ventilated and free of any potential hazard.
c Qualified professionals should monitor each participant’s
ability to tolerate the exercise stress and should modify the
training programme when appropriate.
c Qualified professionals should systematically vary the
training programme over time in order to minimise the risk
of injury or overtraining.
c Lifestyle factors that influence training adaptations such as
proper nutrition, sufficient hydration and adequate sleep
should be addressed in youth sport programmes.
FURTHER RESEARCH
Well-designed longitudinal epidemiological studies are needed to
understand better the long-term effects of structured resistance
training on youth. This research should ensure the collection of
exposure data (time exposed) to support injury incidence
determination and comparisons with other sports and recrea-
tional activities. Accurate recording of information such as
equipment design and layout, level of supervision, training
experience, quality of instruction and programme design
variables (eg, exercises, sets, repetitions, load and frequency)
may be helpful to the evaluation of possible injury risk factors.
Studies are also needed to determine the effects of injury
prevention strategies (eg, coaching education and preparatory
resistance training) on acute and overuse injuries in young
athletes. Although youngsters as young as 6–8 years of age play
organised sports, no preventive trials have evaluated the effects
of fitness conditioning (including resistance training) on sports-
related injuries in children.
Epidemiological research will also help to provide descriptive
information on the location and type of injuries that are most
prevalent, where the injuries happened, when the injuries
occurred and time loss associated with injury. Descriptive data
on the resistance training protocol of young athletes may
provide additional insight into possible injury mechanisms and
risk factors and how programme design variables may influence
the rate and severity of injury. Cumulatively, these data will aid
in the development and implementation of evidence-based
prevention measures in schools, fitness centres and sports
training facilities that cater to children and adolescents.
Funding: GDM received funding support from the National Institutes of Health grants
R01-AR049735 and R01-AR055563.
Competing interests: None.
Provenance and peer review: Commissioned; externally peer reviewed.
REFERENCES
1. Quatman C, Myer G, Khoury J, et al. Sex differences in ‘‘weightlifting’’ injuries
presenting to United States emergengy rooms. JStrengthCondRes2009;23:2061–7.
2. American Academy of Pediatrics. Weight training and weightlifting: information
for the pediatrician. Phys Sports Med 1983;11:157–61.
3. Falk B, Eliakim A. Resistance training, skeletal muscle and growth. Pediatr Endocrinol
Rev 2003;1:120–7.
4. Malina R. Weight training in youth – growth, maturation and safety: an evidenced
based review. Clin J Sports Med 2006;16:478–87.
5. Myer G, Wall E. Resistance training in the young athlete. Oper Tech Sports Med
2006;14:218–30.
6. Faigenbaum A. Resistance training for children and adolescents: are there health
outcomes? Am J Sports Med 2007;1:190–200.
7. Vaughn JM, Micheli L. Strength training recommendations for the young athlete.
Phys Med Rehabil Clin North Am 2008;19:235–45.
8. American College of Sports Medicine. ACSM’s guidelines for exercise testing
and prescription, 8th edn. Baltimore, MD: Lippincott, Williams and Wilkins,
2010:183–206.
9. British Association of Exercise and Sport Sciences. BASES position statement
on guidelines for resistance exercise in young people. J Sport Sci 2004;22:383–90.
10. Behm DG, Faigenbaum AD, Falk B, et al. Canadian Society for Exercise Physiology
position paper: resistance training in children and adolescents. Appl Physiol Nutr
Metab 2008;33:547–61.
11. Faigenbaum A, Kraemer W, Blimkie C, et al. Youth resistance training: updated
position statement paper from the National Strength and Conditioning Association.
J Strength Cond Res 2009;23(Suppl 5):S60–79.
12. American Academy of Pediatrics. Strength training by children and adolescent.
Pediatrics 2008;121:835–40.
13. Australian Strength and Conditioning Association. Resistance training for
children and youth: a position stand from the Australian Strength and Conditioning
Association, 2007. www.strengthandconditioning.org (accessed 17 June 2009).
14. United States Department of Health and Human Services. 2008 Physical
activity guidelines for Americans. www.health.gov/paguidelines (accessed 17 June
2009).
15. Lee S, Burgeson C, Fulton J, et al. Physical education and physical activity: results
from the school health policies and programs study 2006. J School Health
2007;77:435–63.
What this paper adds
c This paper suggests that most injuries related to youth
resistance training are a result of inadequate professional
supervision, which underlies poor exercise techniques and
inappropriate training loads.
c The risk of musculoskeletal injury resulting from age-
appropriate resistance training, weightlifting and plyometrics
does not appear to be any greater than other sports and
recreational activities in which children and adolescents
regularly participate.
c Comprehensive conditioning programmes designed and
supervised by qualified professionals who have an
understanding of youth resistance training guidelines as well
as the physical and psychosocial uniqueness of children and
adolescents appear to be an effective strategy for reducing
sports-related injuries in young athletes.
What is already known on this topic
c There is clear evidence that resistance training can be a
worthwhile and beneficial activity for children and
adolescents.
c A growing number of youth are participating in resistance
training programmes in schools, recreation centres and sports
training facilities.
c Little is being done to address the risk factors associated with
resistance training-related injuries in young athletes.
Review
Br J Sports Med 2010;44:56–63. doi:10.1136/bjsm.2009.068098 61
group.bmj.com on January 4, 2010 - Published by bjsm.bmj.comDownloaded from
16. National Association for Sport and Physical Education. Physical education for
lifetime fitness, 2nd edn. Champaign, IL: Human Kinetics, 2005:83–104.
17. Faigenbaum AD, Westcott WL, Loud RL, et al. The effects of different resistance
training protocols on muscular strength and endurance development in children.
Pediatrics 1999;104:e5.
18. Micheli L, Nielson J. Overuse injuries in the young athlete: stress fractures. In:
Hebestreit H, Bar-Or O, eds. The young athlete. Malden, MA: Blackwell Publishing,
2008:151–63.
19. Myer GD, Paterno MV, Ford KR, et al. Neuromuscular training techniques to target
deficits before return to sport after anterior cruciate ligament reconstruction.
J Strength Cond Res 2008;22:987–1014.
20. Hewett TE, Myer GD, Ford KR, et al. Dynamic neuromuscular analysis training for
preventing anterior cruciate ligament injury in female athletes. Instr Course Lect
2007;56:397–406.
21. Faigenbaum A, Westcott W. Youth strength training. Champaign, IL: Human
Kinetics, 2009:139–65.
22. Pierce K, Brewer C, Ramsey M, et al. Youth resistance training. Profess Strength
Cond 2008;10:9–23.
23. Hamill B. Relative safety of weight lifting and weight training. J Strength Cond Res
1994;8:53–7.
24. Myer G, Quatman C, Khoury J, et al. Youth vs adult ‘‘weightlifting’’ injuries presented
to United States emergengy rooms: accidental vs non-accidental injury mechanisms.
J Strength Cond Res 2009;23:2054–60.
25. Vrijens F. Muscle strength development in the pre and post pubescent age. Med
Sport 1978;11:152–8.
26. Sewall L, Micheli LJ. Strength training for children. J Pediatr Orthop 1986;6:143–6.
27. Funato K, Fukunaga T, Asami T, et al. Strength training for prepubescent boys and
girls. Proc Dept Sport Sci University of Tokyo 1987:9–19.
28. Rians CB, Weltman A, Cahill BR, et al. Strength training for prepubescent males: is it
safe? Am J Sports Med 1987;15:483–9.
29. Siegal J, Camaione D, Manfredi T. The effects of upper body resistance training in
prepubescent children. Pediatr Exerc Sci 1989;1:145–54.
30. Ramsay JA, Blimkie CJ, Smith K, et al. Strength training effects in prepubescent
boys. Med Sci Sports Exerc 1990;22:605–14.
31. Faigenbaum A, Zaichkowsky L, Westcott W, et al. The effects of a twice per week
strength training program on children. Pediatr Exerc Sci 1993;5:339–46.
32. Ozmun JC, Mikesky AE, Surburg PR. Neuromuscular adaptations following
prepubescent strength training. Med Sci Sports Exerc 1994;26:510–14.
33. Faigenbaum A, Westcott W, Micheli L, et al. The effects of strength training and
detraining on children. J Strength Cond Res 1996;10:109–14.
34. Falk B, Mor G. The effects of resistance and martial arts training in 6- to 8-year old
boys. Pediatr Exerc Sci 1996;8:48–56.
35. Lillegard WA, Brown EW, Wilson DJ, et al. Efficacy of strength training in
prepubescent to early postpubescent males and females: effects of gender and
maturity. Pediatr Rehabil 1997;1:147–57.
36. Hetzler R, DeRenne C, Buxton B, et al. Effects of 12 weeks of strength training on
anaerobic power in prepubescent male athletes. JStrengthCondRes1997;11:174–81.
37. Sadres E, Eliakim A, Constantini N, et al. The effect of long term resistance training
on anthropometric measures, muscle strength and self-concept in pre-pubertal boys.
Pediatr Exerc Sci 2001;13:357–72.
38. Pikosky M, Faigenbaum A, Westcott W, et al. Effects of resistance training on
protein utilization in healthy children. Med Sci Sports Exerc 2002;34:820–7.
39. Flanagan S, Laubach L, DeMarco G, et al. Effects of two different strength training
modes on motor performance in children. Res Q Exerc Sport 2002;73:340–4.
40. Faigenbaum AD, Milliken LA, Loud RL, et al. Comparison of 1 and 2 days per week
of strength training in children. Res Q Exerc Sport 2002;73:416–24.
41. Tsolakis CK, Vagenas GK, Dessypris AG. Strength adaptations and hormonal
responses to resistance training and detraining in preadolescent males. J Strength
Cond Res 2004;18:625–9.
42. Coutts A, Murphy A, Dascombe B. Effect of direct supervision of a strength coach on
measures of muscular strength and power in young rugby league players. J Strength
Cond Res 2004;18:316–23.
43. Faigenbaum A, Milliken L, Moulton L, et al. Early muscular fitness adaptations in
children in response to two different resistance training regimens. Pediatr Exerc Sci
2005;17:237–48.
44. Gonzales-Badillo J, Gorostiaga E, Arellano R, et al. Moderate resistance training
produces more favorable strength gains than high or low volume during a short term
training cycle. J Strength Cond Res 2005;19:689–97.
45. Faigenbaum A, Mediate P. The effects of medicine ball training on physical fitness in
high school physical education students. The Physical Educator 2006;63:160–7.
46. Faigenbaum A, McFarland J, Keiper F, et al. Effects of a short term plyometric and
resistance training program on fitness performance in boys age 12 to 15 years.
J Sports Sci Med 2007;6:519–25.
47. Faigenbaum AD, McFarland JE, Johnson L, et al. Preliminary evaluation of an after-
school resistance training program for improving physical fitness in middle school-age
boys. Percept Mot Skills 2007;104:407–15.
48. Szymanski D, Szymanski J, Bradford J, et al. Effect of twelve weeks of medicine ball
training on high school baseball players. J Strength Cond Res 2007;21:894–901.
49. Channell BT, Barfield JP. Effect of Olympic and traditional resistance training on vertical
jump improvement in high school boys. JStrengthCondRes2008;22:1522–7.
50. Byrd R, Pierce K, Rielly L, et al. Young weightlifters’ performance across time. Sports
Biomech 2003;2:133–40.
51. Pierce K, Bryd R, Stone M. Youth weightlifting – is it safe? Weightlifting USA
1999;17:5.
52. Faigenbaum AD, Milliken LA, Westcott WL. Maximal strength testing in healthy
children. J Strength Cond Res 2003;17:162–6.
53. Volek JS, Gomez AL, Scheett TP, et al. Increasing fluid milk favorably affects bone
mineral density responses to resistance training in adolescent boys. J Am Diet Assoc
2003;103:1353–6.
54. Baker D. Differences in strength and power among junior-high, senior-high, college-
aged, and elite professional rugby league players. J Strength Cond Res
2002;16:581–5.
55. Kravitz L, Akalan C, Nowicki K, et al. Prediction of 1 repetition maximum strength in
high school powerlifters. J Strength Cond Res 2003;17:167–72.
56. Brown E, Kimball R. Medical history associated with adolescent power lifting.
Pediatrics 1983;72:636–44.
57. Risser WL, Risser JM, Preston D. Weight-training injuries in adolescents. Am J Dis
Child 1990;144:1015–17.
58. George D, Stakiw K, Wright C. Fatal accident with weight-lifting equipment:
implications for safety standards. Can Med Assoc J 1989;140:925–6.
59. Lombardi V. Resistance training. In: Caine D, Caine C, Linder K, eds. Epidemiology of
sports injuries. Champaign, IL: Human Kinetics, 1996:312–36.
60. Brady T, Cahill B, Bodnar L. Weight training related injuries in the high school athlete.
Am J Sports Med 1982;10:1–5.
61. Smith A, Loud K. Special populations. In: Chan K, Micheli L, Smith A, et al, eds.
F.I.M.S. Team Physicial Manual, 2nd edn. Hong Kong: CD Concept, 2006:206–34.
62. Caine D, Caine C, Maffulli N. Incidence and distribution of pediatric sport-related
injuries. Clin J Sport Med 2006;16:500–13.
63. Benton J. Epiphyseal fractures in sports. Phys Sports Med 1982;10:63–71.
64. Ryan J, Salciccioli G. Fractures of the distal radial epiphysis in adolescent weight
lifters. Am J Sports Med 1976;4:26–7.
65. Gumbs V, Segal D, Halligan J, et al. Bilateral distal radius and ulnar fractures in
adolescent weightlifters. Am J Sports Med 1982;10:375–9.
66. Jenkins N, Mintowt-Czyz W. Bilateral fracture separations of the distal radial
epiphyses during weight-lifting. Br J Sports Med 1986;20:72–3.
67. Weiss AP, Sponseller PD. Salter–Harris type I fracture of the distal radius due to
weightlifting. Orthop Rev 1989;18:233–5.
68. Browne T, Yost R, McCarron R. Lumbar ring apophyseal fracture in an adolescent
weight lifter. Am J Sports Med 1990;18:533–5.
69. Dufek J, Bates B. The evaluation and prediction of impact forces during landings.
Med Sci Sports Exerc 1990;22:370–7.
70. McNitt-Gray J, Hester D, Mathiyakom W, et al. Mechanical demand on multijoint
control during landing depend on orientation of the body segments relative to the
reaction force. J Biomech 2001;34:1471–82.
71. Zaricznyj B, Shattuck L, Mast T, et al. Sports-related injuries in school-age children.
Am J Sports Med 1980;8:318–24.
72. Centers for Disease Control and Prevention. Sports-related injuries among high
school athletes—United States, 2005–06 school year. MMWR Morb Mortal Wkly
Rep 2006;55:1037–40.
73. Potach D, Chu D. Plyometric training. In: Baechle T, Earle R, eds. Essentials of
strength training and conditioning, 2nd edn. Champaign, IL: Human Kinetics,
2000:427–70.
74. Faigenbaum A, Farrell A, Radler T, et al. Plyo Play: a novel program of short bouts of
moderate and high intensity exercise improves physical fitness in elementary school
children. The Physical Educator 2009;69:37–44.
75. Myer GD, Ford KR, Palumbo JP, et al. Neuromuscular training improves performance
and lower-extremity biomechanics in female athletes. J Strength Cond Res
2005;19:51–60.
76. Marginson V, Rowlands A, Gleeson N, et al. Comparison of the symptoms of
exercise-induced muscle damage after an initial and repeated bout of plyometric
exercise in men and boys. J Appl Physiol 2005;99:1174–81.
77. Kotzamanidis C. Effect of plyometic training on running performance and vertical
jumping in prepubertal boys. J Strength Cond Res 2006;20:441–5.
78. Clarkson P. Case report of exertional rhabdomyolysis in a 12 year old boy. Med Sci
Sports Exerc 2006;38:197–200.
79. Caine D, Maffulli N, Caine C. Epidemiology of injury in child and adolescent sports:
injury rates, risk factors, and prevention. Clin Sports Med 2008;27:19–50.
80. Micheli L, Glassman R, Klein M. The prevention of sports injuries in children. Clin
Sports Medi 2000;19:821–34.
81. Gould J, DeJong A. Injuries to children involving home exercise equipment. Arch
Pediatr Adolesc Med 1994;148:1107–9.
82. Jones C, Christensen C, Young M. Weight training injury trends. Phys Sports Med
2000;28:61–72.
83. Heidt R, Swetterman L, Carlonas R, et al. Avoidance of soccer injuries with
preseason conditioning. Am J Sports Med 2000;28:659–62.
84. Hewett T, Riccobene J, Lindenfeld T, et al. The effects of neuromuscular training on
the incidence of knee injury in female athletes. Am J Sports Med 1999;27:699–706.
85. Mandelbaum B, Silvers H, Watanabe D, et al. Effectiveness of a neuromuscular and
proprioceptive training program in preventing anterior cruciate ligament injuries in
female athletes. Am J Sports Med 2005;33:1003–10.
86. Myer GD, Ford KR, Brent JL, et al. The effects of plyometric vs. dynamic stabilization
and balance training on power, balance, and landing force in female athletes.
J Strength Cond Res 2006;20:345–53.
87. Cahill B, Griffith E. Effect of preseason conditioning on the incidence and severityof
high school football knee injuries. Am J Sports Med 1978;6:180–4.
Review
62 Br J Sports Med 2010;44:56–63. doi:10.1136/bjsm.2009.068098
group.bmj.com on January 4, 2010 - Published by bjsm.bmj.comDownloaded from
88. Hejna W, Rosenberg A, Buturusis D, et al. The prevention of sports injuries in high
school students through strength training. NSCA J 1982;4:28–31.
89. Olsen O, Myklebust G, Engebretsen L, et al. Exercises to prevent lower
limb injuries in youth sports: cluster randomised controlled trial. BMJ
2005;330:449.
90. Wedderkopp N, Kaltoft M, Holm R, et al. Comparison of two intervention
programmes in young female players in European handball: with and without ankle
disc. Scand J Med Sci Sports 2003;13:371–5.
91. Risser WL. Weight-training injuries in children and adolescents. Am Fam Physician
1991;44:2104–8.
Review
Br J Sports Med 2010;44:56–63. doi:10.1136/bjsm.2009.068098 63
group.bmj.com on January 4, 2010 - Published by bjsm.bmj.comDownloaded from
