February 2017

Early athletic specialization: Misconceptions and hazards

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Most elite athletes didn’t concentrate on one sport as adolescents, and there’s a strong link between early sport specialization and physical injury and emotional burnout. Yet, many parents think this risky path is the only route to high achievement and college scholarships. 

By P.K. Daniel

There is mounting evidence early specialization in sports not only increases the risk of overuse injuries, especially of the lower extremities, it also does not substantially increase the likelihood of competing in sports at college or professional levels.

The American Orthopaedic Society for Sports Medicine (AOSSM) concluded in its latest consensus statement that “there is no evidence that young children will benefit from early sport specialization in the majority of sports.” Additionally, it noted: “[Children are] subject to overuse injury and burnout from concentrated activity. Early multisport participation will not deter young athletes from long-term competitive athletic success.”1

Some experts have attributed the rise in overuse injuries and burnout among youth athletes to an overaggressive culture in competitive youth sports, including intensive training. Besides a 33.3% increase between 1997 and 2008 in organized sports participation among US children aged 6 years and younger, there has been an influx of travel teams (eg, baseball, softball, basketball) and club teams (eg, soccer, wrestling, volleyball, gymnastics) with players starting as young as 7 years.2

“[Parents] think those club sports are the exposure to the collegiate coaches, so they’ll forego playing another sport so they can have more exposure in that one sport in the club-type setting,” said Greg Myer, PhD, associate professor of pediatrics and director of research and the Human Performance Laboratory in the Division of Sports Medicine at Cincinnati Children’s Hospital Medical Center in Ohio.

Current evidence suggests delaying specialization for most sports until after puberty will minimize risks and increase chances of athletic success.

“The driving force is a college scholarship. They think they’re creating the most opportunities for their kids. I think it’s a very closed-minded approach. There are not many opportunities, but if their kid is an elite-level athlete, they’ll certainly emerge, and they won’t be missed by the recruiting coaches at the collegiate level,” he said. An elite-level athlete is going to be scouted and get opportunities regardless.
Early specialization among elite athletes

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The AOSSM defines early sport specialization with three criteria: Participation in intensive training and/or competition in organized sports greater than eight months per year; participation in one sport to the exclusion of participation in other sports (limited free play overall); and involving prepubertal children (younger than seventh grade or roughly age 12 years).1

Research shows those who played National Collegiate Athletic Association (NCAA) Division I sports were less likely to have specialized early than those who don’t.3 A study published in the November 2016 issue of Sports Health reaffirmed the AOSSM statement, concluding that, while most prospective college athletes will eventually specialize in their respective sports, early specialization is not necessary to achieve Division I athlete status.4

The study, conducted by University of Wisconsin-Madison researchers, surveyed 343 athletes (115 women) from nine sports from a Midwest Division I university. Most of these athletes did not specialize in high school. Although there was no difference between genders at any grade level, the percentage of athletes who specialized increased as they advanced through high school, with 16.9% of ninth graders specializing and 41.1% of 12th graders concentrating on one sport. The University of Wisconsin study also noted football players were significantly less likely to be highly specialized than nonfootball athletes for each year of high school.5

Specialization was classified as low, moderate, or high using a previously published three-point scale method that was based on a questionnaire completed by the athletes. Assessing their sports specialization, a “yes” answer was worth 1 point, a “no” answer, 0. The questions: 1) “Do you participate in year-round intensive training in a single sport at the exclusion of other sports?’’ 2) ‘‘Have you quit other sports to focus on one sport?’’ 3) ‘‘Do you train more than 8 months out of the year in one sport?’’ and 4) ‘‘Do you consider your primary sport more important than other sports?’’ A total score of 3 was defined as high specialization; a score of 2, moderate specialization; and a score of 0 or 1, low specialization.6

The American Academy of Pediatrics and its Council on Sports Medicine and Fitness in Pediatrics in September 2016 issued a report with statements similar to the AOSSM’s:
“Current evidence suggests that delaying sport specialization for the majority of sports until after puberty will minimize the risks and lead to a higher likelihood of athletic success.”7 Its report included data from TrackingFootball.com, which reported that, of the 322 players who were invited to the 2015 National Football League (NFL) Scouting Combine, 87% had played multiple sports in high school.18

Injury risks and management

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Cynthia LaBella, MD, contributor to several studies on early sports specialization, is associate professor of pediatrics at Northwestern University’s Feinberg School of Medicine in Chicago and medical director for the Institute for Sports Medicine at the Ann & Robert H. Lurie Children’s Hospital of Chicago. She noted the danger of early sports specialization to still-developing youth athletes, particularly in the lower extremities.

“In young kids who are still growing, the most common are overuse injuries [Osgood-Schlatter syndrome], which is inflammation of the patellar ligament at the tibial tuberosity causing knee pain, and Sever disease [inflammation in the heel] to the growth centers,” LaBella said. “Less commonly, these athletes will get stress fractures in the common places [ie, metatarsals, tibia, femur].”

LaBella said lower extremity clinicians can advise young athletes and their families not to play through pain. “Typically, the main culprit for developing an overuse injury is an abrupt change to the training schedule, or inadequate time off during the week or over the course of the year,” she said. “We advise at least one to two days off per week, and one to two months off per year [from the child’s main sport]. There are sometimes additional factors contributing to their injury, such as imbalance of muscle strength or flexibility, generalized ligamentous laxity, or anatomic variants of normal alignment such as pes planovalgus or femoral anteversion. Physical therapy, shoe inserts, and temporary functional bracing are often helpful to address these additional factors.”

Research on injury prevention in youth athletes supports some of these strategies, though the precise degree of sport specialization among study participants isn’t typically specified. Emery et al,9 for example, found a home‐based proprioceptive balance‐training program improved static and dynamic balance in healthy adolescents and reduced incidence of self‐reported injury over six months. Similarly, Wedderkopp et al10 found young female handball players using an ankle disc along with functional strengthening at each practice session were less likely to be injured than a group that did functional strength training only.

“There is limited data on the effect of braces on injury prevention,” said LaBella. “The few studies on knee braces have shown no significant reduction in injury rates.11,12 However, studies of high school football and basketball athletes have shown that a semirigid ankle brace was effective in reducing the risk for both first-time ankle sprain and recurrent sprain.”

A 2010 study found lace-up ankle braces can significantly reduce the risk of ankle sprain in high school basketball players, even those with no history of injury (See “Lace-up ankle braces reduce risk of sprain in basketball players regardless of history,” LER, May 2011, page 24). Other research has found prophylactic ankle braces increased dynamic postural control and functional test scores among high school basketball players,13 and a review of prophylactic ankle bracing studies found moderate evidence to support using prophylactic ankle braces in adolescent athletes, particularly football and basketball players, to reduce acute ankle injury incidence.14

LaBella also said that in her subspecialty clinic, which focuses on young athletes, clinicians take a detailed history about sports participation, including how many and which sports patients play, how much they train, and any recent changes in intensity, volume, or frequency.

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“We then recommend temporary modification to their training regimen to keep them active but within a pain-free window of activity, and then, once their injury has healed, we advise them how to structure a gradual progression back to their sport to avoid recurrence,” she said. “Sometimes with an athlete who is specialized in a single sport, we may recommend they participate in a complementary sport at a recreational level to help balance their muscle recruitment. For instance, for a swimmer, we might advise cycling or running.”

In cases in which specialization is presumed to be nonnegotiable, such as with elite-level gymnasts, the injury-prevention model and rehab may differ from the prevention and rehab for a multisport kid. “The main focus should be balancing muscle strength and flexibility deficits, and encouraging recreational activities that are complementary and, most importantly for kids, fun,” said LaBella.

Neeru Jayanthi, MD, a contributor to the AOSSM consensus statement and associate professor of sports medicine at Emory University in Atlanta, GA, said individual and technical sports like gymnastics, tennis, and dance, present a higher risk of injury to children who specialize.

USA Gymnastics, the sport’s governing body, advises the optimal training plan for elite gymnasts is two workouts per day, totaling five to seven hours, six days a week. Jayanthi said the gymnastics community believes in putting in whatever time is necessary—even if that means risking injury. “In those individual, technical sports, the mindset isn’t going to change anytime soon,” he said. “[But] you have to work within that context. Until we put out a gymnastics study that really outlines performance and [shows the current methods are counterproductive], it’s just accepted that some people are going to get hurt.”

Jayanthi, who is also president of the International Society for Tennis Medicine and Science, suggested during the AOSSM consensus development that getting governing bodies on board requires large, sport-specific studies looking at the performance benefits of not specializing.

Another study recently conducted by the University of Wisconsin-Madison concluded injury rates for athletes who specialized in one sport were higher than for athletes who played multiple sports, and that rates for lower extremity injuries were significantly higher.15 The researchers surveyed 1500 student-athletes–750 girls and 750 boys–during the 2015-2016 school year at 29 Wisconsin high schools. The student-athletes were defined “specialized” if they answered “yes” to at least four of the following six questions: 1) “Do you train more than 75 percent of the time in your primary sport?” 2) “Do you train to improve skill and miss time with friends as a result?” 3) “Have you quit another sport to focus on one sport?” 4) “Do you consider your primary sport more important than your other sports?” 5) “Do you regularly travel out of state for your primary sport?” and 6) “Do you train more than eight months a year in your primary sport?”15

More than a third (34%) were specialized. Girls, at 41%, were more likely to specialize than boys (28%). Soccer had the highest percentage of sports specialists among all sports for both genders (girls 48%, boys 45%). Next was softball (45%), followed by volleyball (43%) and basketball (37%) for girls and basketball (37%), tennis (33%), and wrestling (29%) for boys.15

The study, funded by the National Federation of State High School Associations (NFSH) and published in the January 2017 issue of High School Today, said student-athletes who specialized were nearly twice as likely (46%) to report previously sustaining a lower extremity injury while participating in sports than athletes who did not specialize (24%). Also, these single-sport athletes had 60% more new lower extremity injuries, which were defined as “any acute, gradual, recurrent or repetitive-use injury to the lower musculoskeletal system” suffered during the 2015-2016 school year.15 

The most common type of previously self-reported ailments were ligament sprains at 51% and muscle/tendon strains at 20%. The ankle (43%) and the knee (23%) were most often identified by the student-athletes as the injured area among previous lower extremity injuries. The ankle (34%), followed by the knee (25%) and upper leg (13%) led the list of locations of new injuries reported during the yearlong study. Ligament sprains (41%), muscle/tendon strains (25%), and tendinitis (20%) were the most common type of injuries.15

Multisport benefits

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Greg Myer noted, “Some of our most elite-level athletes have played multiple sports, even at the high school level.”

Jared Goff, the number-one overall pick in 2016’s NFL Draft, played football, basketball, and baseball in high school, while number-four overall pick Ezekiel Elliott played basketball and ran track. In fact, 26 of the 31 first-rounders played multiple sports in high school, according to TrackingFootball.com.8

Myer said parents should know early sports specialization “is probably not going to make their kid the best athlete they can be, but if you are going to specialize and be skill-oriented, you need periods of resistance training and neuromuscular training to help build some of those motor-control strategies you might miss by playing specialized sports.”

As he’s pointed out, the chances of playing at the next level are limited. Even the likelihood of playing at the high school level, let alone in college or the pros, is relatively poor. Little League International reports that fewer than 10% of the five million kids who play youth baseball will play baseball in high school. The NCAA reported in 2016 that only 7% of the 486,567 high school baseball players in 2014-2015 advanced to play in college. Only 2.1% made it to Division I.16,17 And chances of making it to the pros? Even slimmer. Multiple sources report only .5% of high school seniors will ever be drafted by a Major League Baseball team.18 The figures for other sports are similar. Fewer than 1% of athletes aged 6 to 17 years will reach elite status in basketball, soccer, softball, or football.2

Myer also thinks there’s a presumption by parents and coaches that they know which sport is in the child’s best interest even when his or her exposure has been limited. “The biggest concern I have with early sports specialization is how do any of these kids know the sport that they’re specializing in is their true sport or what they’re good at?” he asked. He attributes part of that issue to the lack of access today’s children have to physical education at school, which once exposed children to multiple sports. “Now, these kids are having fewer opportunities there, and then they’re being pushed to specialize,” he said. “They are more than likely not even specializing in their best sport.”

John Labeta is the assistant commissioner of the California Interscholastic Federation-San Diego Section (CIF-SDS). Over his three-decade career, including roles as a coach, athletic director, and administrator helping oversee 127 high schools, Labeta has seen the change in emphasis from multisport athlete to specialist.

“Very few specialized [25 years ago], as coaches encouraged participation in more than one sport,” Labeta said. “Most athletes did something else after their season of sport. Field hockey players did soccer or softball. Football players wrestled, played basketball, or soccer. Basketball players ran track or cross country or played baseball. Athletes were athletes, and you improved your skill level by playing more than one sport.”

In those days, Labeta noted, some athletes played on more than one team in the same sport. “But not because they thought they were going to get a scholarship or their parents got to brag about them being on a select team,” he said. “They played because they loved the sport.”

REFERENCES

1. LaPrade RF, Agel J, Baker J, et al. AOSSM Early Sport Specialization Consensus Statement. Orthop J Sports Med 2016;4(4):2325967116644241.

2. Jayanthi N, Pinkham C, Dugas L, et al. Sports specialization in young athletes evidence-based recommendations. Sports Health 2013;5(3):251-257.

3. American Medical Society for Sports Medicine. Effectiveness of early sport specialization limited in most sports, sport diversification may be better approach at young ages. ScienceDaily website. www.sciencedaily.com/releases/2013/04/130423172601.htm. Published 23 April 2013. Accessed February 6, 2017.

4. Post EG, Thein-Nissenbaum JM, Stiffler MR, et al. High school sport specialization patterns of current Division I athletes. Sports Health Oct 1 2016. [Epub ahead of print]

5. Bell DR, Post EG, Trigsted SM, et al. Prevalence of sport specialization in high school athletics: a 1-year observational study. Am J Sports Med 2016;44(6):1469-1474.

6. Jayanthi NA, LaBella CR, Fischer D et al. Sports-specialized intensive training and the risk of injury in young athletes: a clinical case-control study. Am J Sports Med 2015;43(4):794-801.

7. Brenner JS. Sports specialization and intensive training in young athletes. Pediatrics 2016;138(3):e20162148.

8. Spilbeler B. Multiple sport athletes dominate 1st round of NFL Draft again. Tracking Football website. https://www.trackingfootball.com/blog/multiple-sport-athletes-dominate-1st-round-nfl-draft/. Published April 29, 2016. Accessed February 8, 2017.

9. Emery CA, Cassidy JD, Klassen TP, et al. Effectiveness of a home‐based balance‐training program in reducing sports‐related injuries among healthy adolescents: a cluster randomized controlled trial. CMAJ 2005;172(6):749-754.

10. Wedderkopp N, Kaltoft B, Rosendahl M, et al. Prevention of injuries in young female players in European team handball. Scand J Med Sci Sports 1999;9(1):41-47.

11. Deppen RJ, Landfried MJ. Efficacy of prophylactic knee bracing in high school football players. J Orthop Sports Phys Ther 1994;20(5):243-246.

12. Pietrosimone BG, Grindstaff TL, Linens SW, et al. A systematic review of prophylactic braces in the prevention of knee ligament injuries in collegiate football players. J Athl Train 2008;43(4):409-415.

13. Crockett NJ, Sandrey MA. Effect of prophylactic ankle-brace use during a high school competitive basketball season on dynamic postural control. J Sport Rehabil 2015;24(3):252-260.

14. Farwell KE, Powden CJ, Powell MR,  et al. The effectiveness of prophylactic ankle braces in reducing the incidence of acute ankle injuries in adolescent athletes: a critically appraised topic. J Sport Rehabil 2013;22(2):137-142.

15. Howard B. Injury Rates Higher for Athletes Who Specialize in One Sport. NFHS website. https://www.nfhs.org/articles/injury-rates-higher-for-athletes-who-specialize-in-one-sport. Published December 20, 2016. Accessed February 7, 2017.

16. National Federation of State High School Associations. 2014-15 High School Athletics Participation Survey. NFHS website. http://www.nfhs.org/ParticipationStatistics/PDF/2014-15_Participation_Survey_Results.pdf. Accessed February 6, 2017.

17. Student-athlete participation 1981-82 – 2015-16. NCAA Sports Sponsorship and Participation Rates Report. NCAA Publications website. http://www.ncaapublications.com/productdownloads/PR1516.pdf. Published October 2016. Accessed February 7, 2017.

18. Wilson A. “Odds long on earning college athletic scholarships.” NFHS website. http://www.nfhs.org/uploadedfiles/3dissue/hstoday/2013issues/april2014/files/34.html. Published April 2014. Accessed February 13, 2017.

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