COMMENTARY

How Specializing in One Sport Can Break Young Bodies

Bert R. Mandelbaum, MD, DHL (Hon)

Disclosures

July 24, 2018

When Striving for Greatness Ends in Injury

I often see parents pushing their kids, and kids pushing themselves, to be the next sports star. They understand that it takes a lot of hard work to be Simone Biles, Tom Brady, Hope Solo, or LeBron James. What they don't understand is that 35 hours a week of specialized training can do more harm than good.[1]

Becoming a superstar requires the right combination of mental and physical characteristics, a lot of which comes with genes. At the end of the day, hyperspecialization can't make up for winning the athletic talent lottery. Kids repeating the same movements over and over often wind up in our offices with serious injuries, some of which can affect them for the rest of their lives. And the injuries can be as much emotional as physical.

I advise these kids to think about what they're trying to achieve through their participation in sports. To me, that list should include life skills, character, teamwork, positive self-esteem, and an optimistic outlook. All that should come before a million dollar contract and a sold-out stadium.

The world of sports is full of aphorisms, like "no pain, no gain" and "practice makes perfect." And when we look at the stars, those sayings appear true. Tiger Woods in golf and the Williams sisters in tennis come to mind. They trained intensely from a very early age, and it served them well. But when you apply an approach of endless training to the average person, you realize that it doesn't have the intended effect.

In baseball, we're seeing younger and younger patients with elbow injuries. We're even performing Tommy John surgery in a growing number of high school players. Too often, these kids see the procedure as a badge of courage because so many older athletes have undergone it. But scouts for Major League Baseball don't see it that way. They rarely look at California or Arizona for young pitchers. They turn to cold states such as Michigan or Minnesota, because they know that high school pitchers in those states are forced to take a break for the winter.

The Perils of Superspecialization

Early in my career, I managed the gymnastics program at the University of California, Los Angeles. Many of these gymnasts, hungry for gold medals, were practicing more than 20 hours a week. We noticed that they were experiencing pain in their wrists.

We found that they were damaging their growth plates in their radiuses. Their ulnas were growing relatively long, but their distal radiuses remained short in proportion. As a result, they were tearing the triangular fibrocartilage. We defined the pathogenesis of that sequence and published it in the American Journal of Sports Medicine.[2]

That was some of the first evidence that superspecialization in young athletes can manifest in significant musculoskeletal maladaptations, with the consequences of a diminution in performance and career.

When you're sailing a high-performance boat or driving a high-performance car, you have to know the limitations of the machine. The same applies to the human body. Very often, less is more.

In golf, for example, after a certain number of repetitions, swinging a club can start to cause strain. So these athletes need to spend time on cross-training, cardio fitness, and strength training. They need to learn imagery techniques with a sports psychologist. In these ways, the young athlete can maximize the adaptations necessary for a sport, while minimizing the risk for harm.

What's Required of Clinicians

As sports medicine doctors, we have to send a clear message. We want young athletes to develop to their fullest potential, have fun, gain self-esteem, become leaders, and adopt a positive outlook on life, all without being injured. That requires us to plan ahead, be nimble on our feet, and make changes as we go along.

We have to recognize the times that young athletes can adapt to their training, and the times when they will adapt poorly. Often, in the fall, we see injuries among athletes in their early teens. Those who have gone through puberty need a different regimen from those who haven't. Two athletes may be the same age, but one may be 4'8" and the other 6'8". The less developed kids can't play full-court basketball 5 days a week.

We have learned with gymnasts that when they train more than approximately 24 hours a week, the regimen can not only cause wrist pain but actually suppress their growth. That's why so many gymnasts are much smaller than other people in their families. Sometimes gymnasts fall, hurt their knees, and have to stop training. All of a sudden, they're not training 45 hours a week and they grow from 4' 4" to 5' 6" in a matter of months.

When I went to Moscow in 1991 with the US Soccer team, we got a tour of the Soviet sports facilities. The Soviet gymnasts had dominated the previous Olympics. I noticed that these gymnasts started very young, but they spent a lot of time stretching and no time dismounting. They didn't do the kind of repetitive training that could cause an injury. I realized that participation matters a lot, but it's essential to be specific and selective about what the participation includes and doesn't include.

Prescribing a Variety of Sports

So how do we talk to our young patients about the risks of specialization? When they wind up in my office, I say to them, "What is the benefit of this training? If you want to be an Olympic athlete, this is not the way. If it were, you wouldn't be here. Let me show you a better approach."

To make the case, you have to be articulate and understand the evidence, because you are going to have to convince people who don't want to be convinced. Often, that includes the coaches and the parents as well as the athletes.

I'm not saying we should squelch the enthusiasm of young athletes. We should encourage all of them to keep playing, and we should identify those few who have outsize potential. That can be a challenge. Occasionally, the son or daughter of a successful athlete, such as Ken Griffey Jr, appears to have a predilection. But these instances are rare.

In other cases, athletes may be best suited for a sport different from the one they originally pick. Clint N'Dumba-Capela started out playing soccer in his native Switzerland. But by the time he was 13 he was 6' 3" and decided to switch to basketball. Now he plays for the Houston Rockets.

But sometimes the genius is plain to see. If a 14-year-old, left-handed baseball pitcher throws 90 miles per hour, you have to figure out how to optimize that talent and support that person.

Whether or not the athlete has outsize talent, injury prevention is essential. In addition to learning that less repetition can sometimes result in more improvement, young athletes can often benefit from specific training aimed at injury prevention. For example, many anterior cruciate ligament tears can be attributed to kids jumping, landing, and taking off with lack of neuromuscular control, even kids who are very good at their sport. I and other researchers have shown that the Fédération Internationale de Football Association (FIFA) 11+ program can significantly reduce the risk for lower-extremity injuries.[3]

Meanwhile, I encourage all young athletes to try multiple sports, to alternate among them, and, above all, to treat sports as fun, not work.

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