The American Medical Society for Sports Medicine position statement that appears in this issue is thoughtful and well supported; it adds to the literature a guide for clinicians, youth sports providers, and policy directors.1 What becomes clear on reading the statement is the dearth of data regarding overuse injury and “burnout” among youth age group athletes. Many of the recommendations and suggestions to be found in the document reflect extrapolations derived from limited high school and college data. The document can thus be seen as a call for the development of a national research agenda to more carefully examine all aspects of youth sport programs.
Many epidemiological questions remain unanswered; it is evident, for instance, that we lack an accurate denominator when assessing youth sports participation. At the high school level, the available numbers reflect “athlete-seasons” and not “unduplicated athlete years” of participation. If Minnesota is a reflection of the national averages with 2.3 sport seasons per student-athlete, the number of unduplicated high school athletes in the United States (2012-2013) is approximately (7 713 577/2.3 = ) 3 353 729.2,3 The athlete season data may be appropriate for research involving a particular sport but does not permit generalized statements regarding the “high school athlete.” Data regarding rates of participation among younger age athletes are even less concrete and make the preparation of statements regarding injury and dropout rates in youth athletes more difficult…and, ultimately, less reliable.
This lack of age-based data renders recommendations for participation and training problematic—extrapolation across age groups is fraught with hazard, especially when seeking to make broad suggestions that would involve those from childhood to college age. Future research examining youth athletes should focus on age groups likely to differ in injury risk. Age can be used for convenience (6-10, 11-15, 16-18, 19-25 years), although it would be best to group children by the developmental stages (prepubescent, pubescent, postpubescent, and late-stage maturation). Investigating girls and boys will be critical to assess risk; and age groupings might be different when determined by sex to account for the earlier maturation of girls compared to boys.
Children left to themselves in spontaneous and unstructured sport and recreational activity are generally free of overuse injury; when adults step into the picture that “injury free” status seems to change. How much training, practice, and game time is optimal for a young athlete? How much activity is necessary for the pursuit of sporting excellence? Sometimes “less is more.” Clearly, overuse injury risks and patterns differ by sport—sport governing bodies might usefully fund sport-specific research to further understand the problems that the youth athletes face as they proceed through the ranks of both recreational and elite sports programs.
The issue of sport dropout is complicated and will require a continuing and concentrated effort to understand. Once again, we encounter an absence of reliable data that might inform public opinion and sport policies. Ironically, the source of the often quoted statistic “80% of youth athletes drop out by age 13” is impossible to find.
I am always intrigued by the cultures that surround and support youth sport activities and the selectivity of the recommendations we make regarding the well-being of sport and its participants. One of my interests is youth marathon participation, frequently the recipient of criticism or condemnation, yet little is ever said about the life-changing injuries (anterior cruciate ligament disruption or concussion) occurring in “mainstream” youth sports like ice hockey, football, gymnastics, soccer, baseball, volleyball, and others.4
An enhanced understanding of youth sports with regard to acute and overuse injuries will require a concerted effort from the sports community to develop a funding stream to support the much-needed research to advance the health and safety of our young athletes. Children and adolescents should be performing well in all domains of life—physical/physiological, psychological, cognitive/academic, social, and spiritual—to be considered “healthy,” and youth sport can either contribute to or detract from child well-being; “overuse” may have ramifications well beyond musculoskeletal injury. Keeping sport fun will keep kids in the game and hopefully permit the development of lifelong exercise behaviors and the acquisition of an array of attitudes and skills that will afford lifelong benefit. Sport warrants careful and thoughtful stewardship; an understanding of the risks of youth sport participation acquired through careful research, not guessing, will help us keep even more kids “in the game.”
1. Di Fiori JP, Benjamin-Rakos H, Brenner J, et al.. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Clin J Sport Med. 2014;24:3–20.
2. Roberts WO, Stovitz S. Incidence of sudden cardiac death in Minnesota high school athletes 1993-2012 screened with a standardized preparticipation evaluation. J Am Coll Cardiol. 2013;62:1298–1301.
3. National Federation of State High School Association. 2011-12 High School Athletics Participation Survey. http://www.nfhs.org/
. Accessed November 2, 2013.
4. Roberts WO, Nicholson WG. Youth marathoner runners and race day medical risk over 26 years. Clin J Sport Med. 2010;20:318–320.