7_The Pediatric Endurance Athlete

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The Pediatric Endurance Athlete
Mary L. Solomon, DO; SusannahM. Briskin, MD; Nicole Sabatina, DO, ATC; and Jennifer E. Steinhoff, MD
Abstract
Youth sports participation numbers continue to grow in the United
States. A shift toward sport specialization has caused an increase in
sport training frequency and intensity that places the growing athlete at
risk for overtraining, nutritional deficits, and injuries. Individuals who
participate in endurance sports are at especially high risk. Youth runners
and swimmers are high-risk populations that require special attention to
their training schedules, nutritional intake, and injuries. Appropriate
scheduling of training, dedicating time to rest, and nutrition education
can help prevent problems in the endurance athlete.
Introduction
Youth athletes are participating in sports training for
longer and more intense hours than ever before. Travel and
club sports teams have replaced recreational sports partici-
pation and have seemingly turned youth sports into a pro-
fessional business that targets the dream of creating an elite
athlete. The youth athlete who desires to compete at higher
levels often train longer, harder, and with intense dedication
which presents unique challenges to the developing athlete’s
body. Individuals who specialize in a single sport are at in-
creased risk of overtraining syndrome, stress fractures, and
common overuse injuries, such as apophysitis (26,27). De-
spite this, the volume of young athletes becoming single-
sport specialists continues to grow.
In 2015 to 2016, the National Federation of State High
Schools Associations (NFHS) participation survey demon-
strated an increase in the total number of high school athletes
for the 27th consecutive year with 7,868,900 participants.
Cross country totaled 480,207 athletes and track totaled over
1 million participants nationwide, making it the second
largest sport among both sexes. NFHS data revealed over
300,217 swimming and diving participants, and U.S. swimming
membership exceeded 330,000 for year-
round membership in 2016 (1,38,50).
These data support that both runners
and swimmers are participating in
endurance sports in high numbers. The
training regimens these athletes follow
extend beyond a traditional sport sea-
son and places them at high risk for
overtraining, stress fractures, and com-
mon overuse injuries.
The sports medicine physician should
advocate for individualized training ef-
forts that recognize the unique devel-
opmental period when prepubescent
(child) and postpubescent (adolescent) athletes are maturing
physically and emotionally. Definitive statements regarding
the recommended training regimens for youth endurance
athletes are not uniformly accepted; however, conservative
increases in frequency, duration, and intensity of sports par-
ticipation may help decrease injury risk. The physician should
consider age, physical and psychological development, nu-
tritional needs, and the sport specific demands imposed on
the pediatric athlete when evaluating for endurance injuries.
The Youth Runner
Running has become increasingly popular among ado-
lescents, but participation in running often begins in early
childhood. This is in part due to parents who are themselves
runners and who strive to include their children in personal
recreational activities. City marathons offer family runs and
kid fun runs that range from one mile to 5K. Girls on the
Run is a growing program offered to young girls in grades
third through fifth that trains individuals to complete a 5K
while offering discussions and lectures that focus on per-
sonal development, self-empowerment, and self-esteem (2).
Such programs should focus on skill and fun rather than
competition to support healthy and active lifestyles among
the youth.
Competitive running programs emerge as early as middle
school. A 2008 initiative by the United States Government
has encouraged these programs at middle and high schools
to increase physical activity and battle obesity (14). During
summer months, high school runners are encouraged to self-
train and increase training distances to 35 to 40 miles weekly
before the start of official practice. High school cross-country
athletes will then customarily run 45 to 55 milesIwkj1 in
season in preparation for a 5K race. Sudden changes in
SPECIAL POPULATIONS
428 Volume 16 & Number 6 & November/December 2017 The Pediatric Endurance Athlete
Division of Pediatric Sports Medicine, University Hospitals Cleveland
Medical Center, Rainbow Babies and Children’s Hospital, Solon, OH
Address for correspondence: Susannah M. Briskin, MD, Division of Pedi-
atric Sports Medicine, University Hospitals Cleveland Medical Center,
Rainbow Babies and Children’s Hospital, Solon, OH;
E-mail: Susannah.briskin@uhhospitals.org.
1537-890X/1606/428Y434
Current Sports Medicine Reports
Copyright * 2017 by the American College of Sports Medicine
Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
running mileage, noncompliance to summer training regi-
mens, and nonsupervised running may increase an athlete’s
risk for injury (43).
There also is growing attention directed toward the pedi-
atric marathon runner. Students Run Los Angeles marathon-
training program produced greater than 16,000 marathon
finishers from 1987Y2005 (36). The aspiring young endur-
ance runner may cover 10 to 15 miles daily while training for
a marathon, despite a high rate of overuse injuries (44). In
response to this, the International Marathon Medical Di-
rectors Association recommended an age minimum of 18 yr
for marathon entry (45). However, a study of 310 marathon
runners aged 7 to 17 yr who completed the Twin Cities
Marathon between 1982 and 2007, had a medical encounter
incidence of 12.9/1000 finishers, lower (but not statistically
significant) than the relative risk for an adult finisher (46).
Still, no widely accepted guidelines for running training in
youth athletes are published. The American Academy of
Pediatrics Council on Sports Medicine and Fitness (AAP
COSMF) advises against high training volume and recom-
mends that running participation should be driven by the
child instead of by the coach or parent.
Consensus emphasizes enjoyment of running and physi-
cal fitness rather than competition to decrease risk for
burnout, acute, and overuse injuries. The child who trains
with unrealistic expectations may encounter psychological
grief, especially when repetitive mechanical stress causes the
young runner to suffer an overuse injury. A young runner
should have a comprehensive medical team composed of a
physician, physical therapist, nutrition specialist, as well as
athletic trainers, and coaches, who may provide a reason-
able training program that is specific to age, development,
and skill level (10).
There are limited studies regarding how a child (prepu-
bescent) or adolescent (postpubescent) should start a run-
ning program. Safe building base running mileage, varying
running surfaces and alternating short and long mileage
days are recommended for summer training for high school
cross-country runners to help prevent injuries early in the
season (12,43). Supervised summer programs and coach-led
education for the runners before summer training also may
be beneficial to children and adolescents beginning a run-
ning program (43). The weekly training schedule should be
well designed with consideration given to age of the runner,
safe running conditions, and appropriate education on en-
durance training. Limiting weekly mileage to 30 to 40
milesIwkj1 in adolescents has been recommended (28). It is
advised that a child (prepubescent) not train more hours per
week than the child’s age in years. Also, it is recommended
that an adolescent (postpubescent) not train more than
16 hIwkj1 because there is a correlation with injury risk
above that level (9).
The Youth Swimmer
Swimmers follow rigorous training programs and often-
times begin training at a youngage. Competitive and elite
swimmers may practice 6 to 7 d weekly equaling 20 to 30 h
and cover between 10,000 and 14,000 mIdj1 (4,23). Many
swimmers will maintain practice year-round resting only
3 wk out of the 12-month calendar year. Even holiday
breaks from school allow time for coaches to work in
double practice sessions. During a typical training week,
each shoulder will perform an estimated 16,000 to 25,000
revolutions, and the majority of training is spent on the
freestyle stroke (4,47). The repetitive nature of swimming
and volume of upper extremity motion predisposes the
athlete to experience muscle soreness, muscle fatigue, and
overuse injuries, such as impingement and stress fractures
(23). Shoulder laxity coupled with improper stroke me-
chanics can place the pediatric swimmer’s shoulder at
further risk for these injuries (4).
A paucity of literature exists to offer clear guidelines re-
garding proper training volume and dryland conditioning
programs with respect to the athlete’s age or pubertal devel-
opment. Rehabilitation programs that focus on modification
of training, flexibility, range of motion, and balanced shoul-
der strengthening may guide the swimmer with overuse in-
juries to train and compete in a safe manner, but future
research should focus specifically on the pediatric swimming
athletes (49).
One common overuse injury in these endurance athletes
is swimmer’s shoulder, which presents with diffuse shoulder
pain during practice. Diffuse and constant shoulder pain
first presents as the fatigued swimmer pushes through prac-
tice. Pain with overhead activities of daily living, such as
combing hair, showering, or changing clothes then develops.
Musculoskeletal examination often reveals slumped posture
with anterior positioned shoulders due to weakened pos-
terior scapular musculature, tight anterior pectoral muscles,
and poor scapular control. Mild strength deficits may be
present. Scapular winging is prevalent on examination and
becomes more pronounced with shoulder abduction when
performing simple maneuvers such as wall push-ups. Impinge-
ment signs may be positive as well. Management should
include resting from swimming once pain is present (23).
Physical therapy should aim to address scapular stabiliza-
tion and anterior chest wall stretching. Stroke assessment
for arm cross-over, lack of lumbar roll when breathing, and
leading with the elbow during stroke advancement should
be performed (4).
Overtraining Syndrome
Individuals who participate in intense sports training,
including running and swimming programs, may be at in-
creased risk for overtraining syndrome due to the increased
demands the rigorous training places on the athlete’s phys-
ical and psychological health. Oftentimes adolescents will
forego participation in academic, social, and free play ac-
tivities to prepare for competition. Overtraining syndrome
may result as sport-specific isolation preventing equal at-
tention to emotional, social, and psychological development
during a critical period of adolescence.
Overtraining syndrome has been described as chronic fa-
tigue and psychological burnout that impairs training, com-
petition, emotional health and nonYsport activities. It may
present with vague complaints, training fatigue, poor sleep,
and/or disinterest. Other common symptoms include chronic
pain, elevated heart rate, lack of appetite, or loss of body
weight. Worsening sports performance, deficient academic
performance, difficulty concentrating, or failure to complete
tasks throughout the school day may be signs of overtraining
or burnout (37).
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The athlete who presents with fatigue should be screened for
overtraining, burnout, and depression. Comprehensive train-
ing history, nutrition intake, sleep habits, sport and school
performance, and changes in mood should be reviewed.
Screening laboratory tests to rule out physiologic causes of
fatigue include comprehensive metabolic panel, complete
blood count, erythrocyte sedimentation rate, C-reactive pro-
tein, iron studies, creatine kinase, and thyroid-stimulating
hormone (29). Differential diagnosis should include hormone
imbalance, nutritional deficiencies, acute illness, such as
Epstein-Barr virus (EBV), and ergogenic supplement or illicit
drug use. Consultation and frequent follow-up with a
sports medicine provider and/or mental health professional
may work to promote psychological and physiologic rest
during recovery.
AAP COSMF has published guidelines that address the
development of overuse injuries, overtraining and burnout
in youth sports (10,11). The recommendations include lim-
iting participation in one sport to a maximum of 5 dIwkj1
with at least 1 d off per week from any organized physical
activity, having at least 2 to 3 months off per year from a
particular sport and increasing total training intensity or
mileage by no more than 10% per week (10).
Nutrition
Youth athletes must follow a high-calorie, well-balanced
diet to support the energy demands of sports participation
(5). The American College of Sports Medicine (ACSM) and
the American Dietetic Association (ADA) recommend a diet
balanced in macronutrients (carbohydrates, protein and
fats) to support sport performance and decrease the risk of
energy imbalance (32). Parents and athletes may require
education in selecting appropriate type, quantity, and quality
of food as well as timing of food consumption. Proper nu-
tritional intake can optimize energy availability, support
physical development and meet the athlete’s specific train-
ing needs (24). Table 1 may serve as a reference for ideal
food choices and timing of consumption in relation to train-
ing. Consultation with a registered dietician who specializes
in sports nutrition may be helpful for the young athlete.
Athletes with fatigue or poor performance, those who
limit caloric intake, limit food groups, train intensely, or
suffer from overuse injuries may benefit from laboratory
assessment to evaluate for vitamin and nutritional defi-
ciencies. Laboratory workup should include complete
blood count (CBC) with differential, reticulocyte count,
iron studies, ferritin, electrolytes, thyroid screening labo-
ratories, and 25-OH vitamin D. (29). Dietary sources of
calcium, vitamin D, and iron should be encouraged due to
improved bioavailability over nutritional supplements.
Nutritional and vitamin supplementation may be consid-
ered to correct deficiencies after diet has been optimized.
The AAP recommends a daily intake of 1300 mg calcium
for children and adolescents ages 9 to 18 yr (22). Daily in-
take of at least 600 IU vitamin D also is advised for children
and adolescents ages 1 to 18 yr, and higher doses may be
advocated for those who live in areas of limited sun exposure
(3). The Endocrine Society has defined vitamin D deficiency
as 25-OH Vitamin D concentration G20 ng/mL and insuffi-
ciency as 25-OH vitamin D concentration between 21 and
29 ng/mL (25). For those who are vitamin D deficient, a
supplementation of vitamin D2 or D3 50,000 IU weekly for
6 to 8 wk followed by maintenance dose of 600 to 1000 IU
daily is advised (22). The daily recommended intake of iron
for children is 6 to 8 mg until age 11 yr and increases to 10 to
13 mg daily for adolescents ages 12 to 18 yr to support
expansion of blood volume, increased lean body mass, and
menstruation in girls (42).
Female Athlete Triad
Female athletes may experience loss of menses during
periods of intense training. Although this is often perceived
by teenage female athletes, coaches, and parents to be a
normal occurrence, menstrual irregularity may be a sign of
inadequate nutrition that, when prolonged, has been shown
to correlate with loss of bone strength. Primary amenorrhea
is defined as the absence of menarche by age 15 yr or within
the 3 yr of thelarche (breast bud development). Secondaryamenorrhea is defined by the lack of menses for 90 con-
secutive days after menarche. All active females should be
thoroughly evaluated for all three components of the female
athlete triad: low energy availability with or without disor-
dered eating, menstrual dysfunction, and low bone density.
Further evaluation should be pursued if one or more of the
Table 1.
Recommended dietary allowance for the adolescent athlete.
CHO Protein Fat
Daily requirement
g/kg 5Y7 1.2 to 1.7
Portion of total diet 55%Y58% 12%Y15% 25%Y30%
Additional needs to support exercise
Preparation 1Y2 h before 1Y3
Replacement/recovery: 30 min after and repeat every 2 h for 4Y6 h 1.5
Endurance training 1.2Y1.4
Anaerobic training 1.6Y1.7
Reference: J Am Diet Assoc. 2000 Dec;100(12):1543Y56. Position of the American Dietetic Association, Dietitians of Canada, and the American
College of Sports Medicine: Nutrition and athletic performance.
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components is identified. Females whose energy intake does
not meet or exceed energy output are at risk for decreased
estrogen secretion and stress fractures. If low energy avail-
ability is prolonged, female athletes are at risk for osteopenia
and osteoporosis later in life. Early diagnosis and compre-
hensive management should focus on proper nutrition to
prevent further risk (30).
AAP COSMF recommends complete nutritional, men-
strual, fracture, and exercise history be obtained (51). The
Female Athlete Triad Coalition has developed a physician
screening tool that focuses on the athlete’s goals regarding
body weight, food consumption and attitude towards food
as well as menstrual patterns and history of stress fractures
(16). A history of primary or secondary amenorrhea should
be assessed. A complete physical examination and pelvic
examination, as indicated, should be performed. In addition
to evaluating for nutritional and vitamin deficiencies as
previously discussed, laboratory evaluation for causes of
menstrual dysfunction may include pregnancy test, thyroid
stimulating hormone, parathyroid hormone, bone specific
alkaline phosphatase, and reproductive hormone levels (16).
Electrocardiography is used to evaluate for arrhythmia if
bradycardia is present. Bone mineral density testing by dual-
energy x-ray absorptiometry (DXA) is indicated if history
identifies eating disorder, body mass index (BMI) less than
18.5 kgIm2, menstrual dysfunction, history of recurrent or
high-risk stress fractures or if the athlete is on medication
or has a chronic illness that adversely affects bone health
(51). A multidisciplinary team of nutritional, psychologi-
cal, and adolescent or sports medicine providers may then
provide education and intervention techniques to normal-
ize eating habits, improve menstrual regularity, and pro-
mote balanced training.
Stress Fractures
A stress fracture is a common sports related injury that
has been reported as high as 20% of all overuse injuries
with the highest incidence occurring in running sports (7).
Stress fractures occur as a result of repetitive microtrauma
often associated with sudden increases in training or limited
rest intervals (7,35,41). The short rest interval, such as
double practice sessions, does not allow for adequate healing
of the bone via osteoblastic activity. Continual training on
relatively weakened areas of the bone can ultimately lead to a
stress fracture (40). Onset of pain is typically insidious,
worsens with impact or repetition of sports movement, and
eventually remains after training. The pain will localize to the
site of the stress fracture. The location is tender to palpation,
and pain can be reproduced by impact activity, such as a hop
test, if the stress fracture occurs in a weight-bearing bone.
A comprehensive history should focus not only on onset,
timing, and location of pain but also on volume and fre-
quency of sports training as well as any acute changes in
schedule. Plain radiographic films can often miss stress
fractures, especially if obtained within the initial 3 to 4 wk
of pain. Magnetic resonance imaging (MRI) is considered as
the gold standard to diagnose stress fractures if the clinical
suspicion is high despite negative radiographs (40,41).
Between 2005 and 2013, High School Reporting Infor-
mation Online (RIO) recorded the highest rates of stress
fractures(in descending order) among athletes were in the
lower leg, foot, low back, and pelvis (15). The following are
considered to be low-risk stress fractures: posteromedial
tibia, tarsal bones (except for navicular and talus), distal
metatarsals 2 to 4, fibula, and femoral shaft (41) (see Fig. 1).
These low-risk areas typically heal with conservative treatment
of relative rest, immobilization, and occasionally nonYweight-
bearing status (40). Acetaminophen or nonsteroidal anti-
inflammatories (NSAIDs) could be added for pain control;
however, there is controversy with NSAIDs because of a
study showing delayed bone healing in acute fractures in
animals (40,52).
High-risk stress fractures characteristically occur in areas of
high tensile load and poor blood supply. Sites of high-risk stress
fractures include tension-sided femoral neck (superiolateral
femoral neck), patella, anterior tibia, medial malleolus, talus,
tarsal navicular, proximal fifth metatarsal, and great toe ses-
amoids (35,41). These locations are associated with delayed
or nonunion, progression to complete fractures, and often
require surgical fixation (35).
After recovery of low- or high-risk stress fractures, a gradual
return to activity with recommendations to cross-train is
strongly emphasized (35,40,41). There also is strong evidence
to support physical therapy to address underlying strength
and flexibility deficits as well as biomechanical issues, such
as pes planus correction with orthotic (40).
A stress fracture of the pars interarticularis of the lumbar
spine, called spondylolysis, is a unique stress fracture that
should be considered in the endurance athlete with low back
pain. Individuals who consistently perform back extension or
rotation are at risk for spondylolysis. The microtrauma ex-
perienced from repetitive motion and the vulnerability of the
Figure 1: Tibial stress fracture. Periosteal reaction is seen on both AP and lateral views.
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skeletally immature spine contribute to the endurance ath-
lete’s risk (18). One prospective study of pediatric athletes
found that 40% of high school athletes with low back pain
persistent for greater than 2 wk may have lumbar spondylolysis
(39). Pain localized to the lower-lumbar region and exacer-
bated with lumbar extension while swimming butterfly or
breast stroke, or during lumbar rotation, such as with arm
crossing over midline while running or swimming, is
concerning for spondylolysis. Spondylolysis is diagnosed by
history, focal lumbar spine tenderness to palpation, pain with
range of motion (extension and rotation) and radiographic
imaging. Plain radiographs of the lumbosacral spine may re-
veal a stress fracture of the pars interarticularis, but most
often confirmation by MRI or computerized tomography
(CT) scan is necessary (see Fig. 2). To relieve the athlete’s pain,
avoidance of painful activity is warranted. A thoracolumbar
orthotic brace may be used for comfort, but it may not affect
healing rates (20). A comprehensive physical therapy protocol
that focuses on a neutral to flexion-based core strengthening
program and lower-extremity flexibility should be prescribed.
Pain-free progression to extension-based core exercises should
be encouraged before clearance. Return to sports should be
postponed until an athlete is pain free with sports specific ex-
ercises,however low impact cross training can often resume
earlier. Cessation of sports for 3 months is recommended to
allow for healing and safe return to sport (19).
Recurrent stress fractures raise the concern for low bone
mineral density. DXA should be ordered when there is a his-
tory of multiple stress fractures, stress fractures unexplained
by an increase in training, single stress fracture in a high-risk
location, family history of osteoporosis, prolonged cortico-
steroid use, and for athletes with amenorrhea (34). Norma-
tive data on DXA are based on postmenopausal women;
consequently, caution is advised when interpreting results in
children and adolescents who have not yet achieved peak
bone mass. For analyses, Z scores should be used instead of T
scores, and corrections should be made for size (22). Bone
mineral content or density that falls 92 standard deviations
below expected should be considered ‘‘low for age.’’ DXA
scans and dietary counseling should occur annually (6).
Apophysitis
Participation in endurance sports places youth athletes at
risk of overuse injuries. One of the most common overuse
Figure 2: Lumbar spondylolysis. AP view reveals left L5 lucency near pars interarticularis. Oblique view confirms unilateral (left) L5
spondylolysis with fracture line present at the pars interarticularis. This is a classic ‘‘scotty dog’’ sign on oblique radiographs.
Table 2.
Tendon attachments at lower extremity apophyses.
Location Muscle/Tendon Muscle Action
Pelvis
Iliac crest Abdominal obliques, transverse abdominis,
gluteus medius, tensor fascia latae
Trunk rotation, core stabilization
Anterior superior iliac spine (ASIS) Sartorius Hip flexion
Anterior inferior iliac spine (AIIS) Rectus femoris Knee extension
Ischial tuberosity Hamstring Knee flexion
Lesser trochanter Iliopsoas Hip flexion
Knee
Inferior pole of patella (Sinding-Larsen-Johansson) Patellar tendon Knee extension
Tibial tubercle (Osgood-Schlatter) Patellar tendon Knee extension
Foot
Calcaneus (Sever disease) Achilles tendon Ankle plantarflexion
Base of fifth metatarsal (Iselin disease) Peroneal Ankle eversion
432 Volume 16 & Number 6 & November/December 2017 The Pediatric Endurance Athlete
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injuries in the growing athlete is apophysitis. The apophysis is
the location where a tendon attaches to a bone (see Table 2).
The cartilaginous attachment is a weak link and can develop
pain when the muscle is used repetitively and the tendon ap-
plies traction (13,21). Athletes in all sports can develop
apophysitis, but endurance athletes may be at increased risk
because of the frequency and duration of their training (8,33).
Also, highly specialized athletes may be at increased risk for
apophysitis due to repetitive movement patterns (17). There
are many apophyses in the growing body, but for endurance
athletes, the lower-extremity apophyses are at the greatest
risk for developing apophysitis (33). For the purposes of this
article, apophyses of the lower-extremity sites are discussed.
Apophysitis is a clinical diagnosis. The most common
symptom reported is pain at the apophysis which increases
with physical activity. The pain may extend after sports
participation and affect activities of daily living. Examina-
tion findings may include swelling and/or tenderness of the
apophysis, pain at the apophysis with activation or flexi-
bility testing of the corresponding muscles as well as de-
creased flexibility of the involved muscles. Range of motion
is typically normal, although a stretch on the muscle may
increase the pain. Functional examination may reveal limping
and/or asymmetric hop test due to pain or weakness. Radio-
graphs will display an open apophysis at the location of pain.
Widening of the apophysis and/or ossicle formation also may
be seen (21).
The main treatment goal for apophysitis is to limit pain
so an athlete can participate comfortably. Athletes should
be restricted from activity if pain is severe or they cannot
participate without limping. General treatment consists of
NSAIDs as needed, icing directly over apophysis, and lim-
iting painful activity. Physical therapy can be prescribed to
help treat pain, address mechanical issues, and improve
flexibility and core strength. Good shoe wear should be en-
couraged to help with shock absorption. Immobilization is
rarely used (21).
Location specific treatment also can be beneficial. In-
dividuals suffering from apophysitis in the pelvis may ben-
efit from wearing compression shorts that fully cover the
painful area. Athletes with Osgood-Schlatter and Sinding-
Larsen-Johansson may find relief from wearing a patellar
tendon strap or Osgood-Schlatter knee brace while physi-
cally active. Quality viscoelastic (gel) heel cups can relieve
symptoms associated with Sever, also known as calcaneal
apophysitis (48). Athletes and parents should be warned
that signs/symptoms can reoccur during times of increased
training intensity/frequency or during growth spurts as long as
the apophysis is open (17). Parents also should be reassured
that apophysitis is rarely linked with growth disturbance
after the injury (31).
Summary/Conclusions
Youth sport participation should support lifelong physi-
cal activity, enjoyment, and healthy competition. Parents,
coaches, and youth athletes should be educated regarding
the signs and symptoms of common problems that youth en-
durance athletes may face, such as overtraining, nutritional
deficits, female athlete triad, stress fractures, and overuse in-
juries. Prevention should focus on avoiding training errors,
improper technique, excessive sport participation, inadequate
rest, poor nutritional intake, and early specialization. Rest
should be encouraged because it improves sports performance
by allowing the athlete to recover from the physical demands
of practice and competition, rehabilitate injury, and attend
to school or social opportunities. By scheduling weekly
nonpractice days and sport-free months, the developing
athlete’s body may prevent burnout, overtraining, and overuse
injuries. The athlete, rather than the coach or parent, also should
drive training to focus on fun, skill development, and per-
sonal fitness goals. A comprehensive team of health care pro-
viders may serve as a resource to promote early recognition,
proper evaluation, and thorough rehabilitation of overuse
injuries to promote recovery and ensure lifelong enjoyment
of active lifestyle.
The authors declare no conflict of interest and do not
have any financial disclosures.
References
1. 2010Y11 High School Athletics Participation Survey Results [Internet].
website: National Federation of State High School Associations [cited 2010
January 25]. Available from: http://www.nfhs.org/content.aspx?id=3282.
2. Girls on the Run, Our Mission and Core Values [Internet] [cited 2017 Sept. 20].
Available from: https://www.girlsontherun.org/Who-We-Are/Our-Mission.
3. Ackerman KE, Misra M. Bone health and the female athlete triad in ado-
lescent athletes. Phys. Sportsmed. 2011; 39:131Y41.
4. Allegrucci M, Whitney SL, Irrgang JJ. Clinical implications of secondary
impingement of the shoulder in freestyle swimmers. J. Orthop. Sports Phys.
Ther. 1994; 20:307Y18.
5. American Academy of Pediatrics. Council on Sports Medicine and Fitness.
Intensive training and sports specialization in young athletes. Pediatrics.
2000; 106(1 Pt 1):154Y7.
6. Bachrach LK, Gordon CM. Section on endocrinology. Bone densitometry in
children and adolescents. Pediatrics. 2016; 138. e20162398.
7. Bennell KL, Malcolm SA, Thomas SA, et al. The incidence and distribution
of stress fractures in competitive track and field athletes. A twelve-month
prospective study. Am. J. Sports Med. 1996; 24:211Y7.
8. Bennell KL, Crossley K. Musculoskeletal injuries in track and field: inci-
dence, distribution and risk factors. Aust. J. Sci. Med. Sport. 1996; 28:69Y75.
9. Blankson KL, Brenner JS.Anticipatory guidance for long-distance running in
young athletes. Pediatr. Ann. 2016; 45:e83Y6.
10. Brenner JS. American Academy of Pediatrics Council on Sports Medicine and
Fitness. Overuse injuries, overtraining, and burnout in child and adolescent
athletes. Pediatrics. 2007; 119:1242Y5.
11. Brenner JS. Council on Sports Medicine and Fitness. Sports specialization
and intensive training in young athletes. Pediatrics. 2016; 138: 10.1542/
peds.2016-2148.
12. Caine D, Maffulli N, Caine C. Epidemiology of injury in child and adolescent
sports: injury rates, risk factors, and prevention. Clin. Sports Med. 2008;
27:19Y50.
13. Caine D, Caine C, Maffulli N. Incidence and distribution of pediatric sport-
related injuries. Clin. J. Sport Med. 2006; 16:500Y13.
14. CDC. Results from the School Health Policies and Practice Study 2012.
Available from: https://www.cdc.gov/healthyyouth/shpps/2012/pdf/shpps-
results_2012.pdf; 2012; 153 p.
15. Changstrom BG, Brou L, Khodaee M, et al. Epidemiology of stress fracture
injuries among US high school athletes, 2005Y2006 through 2012Y2013.
Am. J. Sports Med. 2015; 43:26Y33.
16. De Souza MJ, Nattiv A, Joy E, et al. 2014 Female Athlete Triad Coalition
Consensus Statement on treatment and return to play of the female athlete
triad: 1st International Conference held in San Francisco, California, May
2012 and 2nd International Conference held in Indianapolis, Indiana, May
2013. Br. J. Sports Med. 2014; 48:289. 2013-093218.
17. DiFiori JP, Benjamin HJ, Brenner JS, et al. Overuse injuries and burnout in
youth sports: a position statement from the American Medical Society for
Sports Medicine. Br. J. Sports Med. 2014; 48:287Y8.
18. Dizdarevic I, Bishop M, Sgromolo N, et al. Approach to the pediatric athlete
with back pain: more than just the pars. Phys. Sportsmed. 2015; 43:421Y31.
www.acsm-csmr.org Current Sports Medicine Reports 433
Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
http://www.nfhs.org/content.aspx?id=3282
https://www.girlsontherun.org/Who-We-Are/Our-Mission
https://www.cdc.gov/healthyyouth/shpps/2012/pdf/shpps-results_2012.pdf
https://www.cdc.gov/healthyyouth/shpps/2012/pdf/shpps-results_2012.pdf
19. El Rassi G, Takemitsu M, Glutting J, Shah SA. Effect of sports modification
on clinical outcome in children and adolescent athletes with symptomatic
lumbar spondylolysis. Am. J. Phys. Med. Rehabil. 2013; 92:1070Y4.
20. Frennered AK, Danielson BI, Nachemson AL. Natural history of symptom-
atic isthmic low-grade spondylolisthesis in children and adolescents: a seven-
year follow-up study. J. Pediatr. Orthop. 1991; 11:209Y13.
21. Gholve PA, Scher DM, Khakharia S, et al. Osgood Schlatter syndrome. Curr.
Opin. Pediatr. 2007; 19:44Y50.
22. Golden NH, Abrams SA. Committee on Nutrition. Optimizing bone health
in children and adolescents. Pediatrics. 2014; 134:e1229Y43.
23. Hibberd EE, Myers JB. Practice habits and attitudes and behaviors
concerning shoulder pain in high school competitive club swimmers. Clin. J.
Sport Med. 2013; 23:450Y5.
24. Hoch AZ, Goossen K, Kretschmer T. Nutritional requirements of the child
and teenage athlete. Phys. Med. Rehabil. Clin. N. Am. 2008; 19:373Y98.
25. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment,
and prevention of vitamin D deficiency: an Endocrine Society clinical prac-
tice guideline. J. Clin. Endocrinol. Metabol. 2011; 96:1911Y30.
26. 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; 43:794Y801.
27. Jayanthi N, Pinkham C, Dugas L, et al. Sports specialization in young ath-
letes: evidence-based recommendations. Sports health. 2013; 5:251Y7.
28. Krabak BJ, Snitily B, Milani CJ. Running injuries during adolescence and
childhood. Phys. Med. Rehabil. Clin. N. Am. 2016; 27:179Y202.
29. Kreher JB. Diagnosis and prevention of overtraining syndrome: an opinion
on education strategies. Open Access J. Sports Med. 2016; 7:115.
30. Loveless M, Hewitt G. Committee Opinion No. 702: Female Athlete Triad.
Obstet. Gynecol. 2017; 129:E160Y7.
31. Maffulli N, Longo UG, Spiezia F, Denaro V. Sports injuries in young ath-
letes: long-term outcome and prevention strategies. Phys. Sportsmed. 2010;
38:29Y34.
32. Manore M, Barr S, Butterfield G. Nutrition and athletic performance: position
of the American Dietetic Association, Dietitians of Canada, and the American
College of Sports Medicine. J. Am. Diet. Assoc. 2000; 100:1543Y56.
33. Martı́nez-Silván D, Dı́az-Ocejo J, Murray A. Predictive indicators of overuse
injuries in adolescent endurance athletes. Int. J. Sports Physiol. Perform.
2017; 12(Suppl 2):S2153Y6.
34. Marx RG, Saint-Phard D, Callahan LR, et al. Stress fracture sites related
to underlying bone health in athletic females. Clin. J. Sport Med. 2001; 11:73Y6.
35. McInnis KC, Ramey LN. High-risk stress fractures: diagnosis and manage-
ment. PM&R. 2016; 8:S113Y24.
36. McMahan I. How is too far for kids to run? The Atlantic. 2014: p Available
from: https://www.theatlantic.com/health/archive/2014/10/kids-and-long-
distance-running-how-much-is-too-much/380857/.
37. Meeusen R, Duclos M, Foster C, et al. Prevention, diagnosis, and treatment
of the overtraining syndrome: joint consensus statement of the European
College of Sport Science and the American College of Sports Medicine. Med.
Sci. Sports Exerc. 2013; 45:186Y205.
38. National Federation of State High School Associations. 2015Y2016 High
School Athletics Participation Survey. Available from: http://www.nfhs.org/
ParticipationStatistics/PDF/2015-16_Sports_Participation_Survey.pdf; 2016; 19 p.
39. Nitta A, Sakai T, Goda Y, et al. Prevalence of symptomatic lumbar
spondylolysis in pediatric patients. Orthopedics. 2016; 39:e434Y7.
40. Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and pre-
vention. Am. Fam. Physician. 2011; 83:39Y46.
41. Pegrum J, Crisp T, Padhiar N. Diagnosis and management of bone stress
injuries of the lower limb in athletes. BMJ. 2012; 344:e2511.
42. Petrie HJ, Stover EA, Horswill CA. Nutritional concerns for the child and
adolescent competitor. Nutrition. 2004; 20:620Y31.
43. Rauh MJ. Summer training factors and risk of musculoskeletal injury
among high school cross-country runners. J. Orthop. Sports Phys. Ther.
2014; 44:793Y804.
44. Rauh MJ, Margherita AJ, Rice SG, et al. High school cross country running
injuries: a longitudinal study. Clin. J. Sport Med. 2000; 10:110Y6.
45. Rice SG, Waniewski S. Children and marathoning: how young is too young?
Clin. J. Sport Med. 2003; 13:369Y73.
46. Roberts W, Nicholson W. Youth marathon runners and race day medical risk
over 26 years. Clin. J. Sport Med. 2010; 20:318Y21.
47. Scovazzo ML, Browne A, Pink M, et al. The painful shoulder during freestyle
swimming. An electromyographic cinematographic analysis of twelve mus-
cles. Am. J. Sports Med. 1991; 19:577Y82.
48. Soprano JV, Fuchs SM. Common overuse injuries in the pediatric and ado-
lescent athlete. Clinical Pediatric Emergency Medicine. 2007; 8:7Y14.
49. Tate A, Harrington S, Buness M, et al. Investigation of In-Water and Dry-
Land training programs for competitive swimmers in the United States. J.
Sport Rehabil. 2015; 24:353Y62.
50. USA Swimming. Available from: https://Usaswimming.Org/News-Landing-
Page/2017/02/24/Lsc-Statistics. Available from: https://usaswimming.org/
news-landing-page/2017/02/24/lsc-statistics; 2017. 36 p.
51. Weiss Kelly AK, Hecht S. Council on Sports Medicine and Fitness. The Female
Athlete Triad. Pediatrics. 2016; 138: 10.1542/peds.2016,0922. Epub 2016 Jul 18.
52. Wheeler P, Batt ME. Do non-steroidal anti-inflammatory drugs adversely
affect stress fracture healing? A short review. Br. J. Sports Med. 2005;
39:65Y9.
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http://www.nfhs.org/ParticipationStatistics/PDF/2015-16_Sports_Participation_Survey.pdf
http://www.nfhs.org/ParticipationStatistics/PDF/2015-16_Sports_Participation_Survey.pdf
http://Https://Usaswimming.Org/News-Landing-Page/2017/02/24/Lsc-Statistics
http://Https://Usaswimming.Org/News-Landing-Page/2017/02/24/Lsc-Statistics
https://usaswimming.org/news-landing-page/2017/02/24/lsc-statistics
https://usaswimming.org/news-landing-page/2017/02/24/lsc-statistics