For children and teens, the advantages of sports participation are many – ranging from better heart health to less loneliness – but so are the risks, which include mostly preventable injuries and sleep deprivation. Pediatric sports medicine specialist Celina de Borja, MD, uses recent data to illuminate the real issues, with a focus on addressing early sports specialization to protect kids from such common repercussions as burnout and depression. Bonus: a quick way to calculate when a child is training too much.
Good afternoon everyone, I'm Selena devora, I'm a pediatric primary care, sports medicine physician here at UCSF Benioff Children's hospitals. Um and today we'll talk about some updates in sports medicine specifically for youth and teens. So we'll start by describing the current state of youth sports participation in the United States, we'll discuss the many benefits as well as the challenges associated with physical activity participation in youth and teens. And then lastly, we'll discuss some recommendations for safe sports participation for our Children and our adolescents. So we'll start by um um um 73 million Children um Are in the United States overall, which make up about 222% of our population. And while the proportion of Children has decreased in the last decade, we're actually seeing an increase in sports participation um with a shift from neighborhood games to organized sports as driven by coaches and their parents, a special attention given to, you know, specializing in sports and higher skill development at a younger age is Pre pandemic data showed that 73% of school aged Children so kids 6-12 years old participated in either a team or individual sport in 2019 with the bike riding as the most commonly performed activity followed by um team sports like basketball, baseball, soccer and football. Similar trends were seen in our teenage population. The participation has gradually increased for both boys and girls in the higher or teenage age group. However, we've also noticed that there has been a gap that has widened why more teenage boys participate in than teenage girls. Um it could be from a variety of reasons. So it could be from preference access to community programs or social stereotypes. However, I'm hoping that through the example of our successful female athletes, that these will improve in the future. The physical benefits of youth sports participation is widely documented and well accepted specifically in cardiovascular health and musculoskeletal health in Children. Specifically, sports can help with development of gross motor skills and high hand eye coordination and can also contribute healthier eating practices. So lower soda consumption, eating breakfast, eating their fruits and vegetables and drinking milk. Youth sports participation can also help a child with the cognitive growth and development. Studies show that student athletes have improved academic performance, attitudes and classroom behavior. They have increased interest in school, they have increased desire to maintain eligibility and a heightened sense of self worth. And these benefits hold true also for those families who come from lower income households, student athletes are also more likely to attend and complete college compared to their non athlete peers. The psychosocial benefits of youth sports participation cannot be overstated. There's plenty of evidence supporting a positive correlation between regular exercise, mental health and personal development. Student athletes are less likely to experience loneliness from low self esteem and that participating in a team sport has been found to be protective against feelings of hopelessness or suicidal ideations in our middle school and high school athletes and again, these manifests hold true even for those who come from lower income households or Children with developmental delays who participate in the special olympics. Student athletes are also less likely to participate in risky behaviors specifically smoke cigarettes, use illicit drugs, practice on safe sexual practices or carry weapons. However, it is important to know that they might be more likely to be able to drink alcohol or use smokeless tobacco, especially if they participate in contact and collision sports like football across or wrestling. The benefits of youth sports participation may extend into adulthood and maybe applicable towards life skills and career development. Studies show that teens who were physically active Are eight times more likely to be active at 24 years old And that majority or three quarter of adults who are greater than 30 who are still physically active, report being physically active when they were younger when they were Children or adolescents. And these are all important in helping reduce obesity, preventing hypertension and other chronic medical illnesses in adulthood. Because active Children tend to become active adults. The benefits of youth sports participation is not limited to the individual, but can extend into the community as well. A paper that was published in 2016 revealed that the estimated effects of physical and activity through healthcare expenditure and productivity losses Can be as much as $68 billion dollars globally And $28 billion dollars nationally. These losses are funded mostly by the public and the private sectors, While 11% is handled by the individual household. In this same study, they estimated that Um, each householder, each individual actually can save up to $2,500 annually if they only committed to moving 30 minutes a day, five days a week. However, with everything that's considered beneficial, there's always going to be challenges and we currently live in a society or an age where we are heavily dependent on our devices or technology devices and so a lot of our Children or adolescents are spending more time on their screens for non school related work and are and can be causing them to become less active. Recent data, uh completed in 2019 revealed that about a quarter, 24% of Children from 6 to 17 years old um reported participating in a physical activity for at least 60 minutes every day. There also seems to be some disparities um, with youth sports participation, as you can see on the image on the right lower corner, the figures and yellow and orange show that there's a lack of access specifically to physical space, um, or safe space for Children of color or those with lower socio economic backgrounds. These resource limited Children rely mostly on school for their physical activities. However, there has been a steep decline in physical education in the recent years. So in 1991, About 41% of Children had pe classes, five days a week. That's significantly decreased to only 25% in 2019. In addition only half or 52% of Children report having pe classes at least one day in an average week. Because of these limitations, the burden the financial burden of participating in youth sports is now shouldered by the individual household In 2019. Uh an average each household spent an average of $1,500 per year on club sports. And that's just the average. Um Numbers can go upwards of five figures, spending is mostly on travel registration fees, private coaching equipment etcetera. And because of that Um in 201933% are are about one in three. Children from lower socioeconomic backgrounds were considered physically inactive compared to those um Children who are from a higher socioeconomic backgrounds. So this causes the disparities because those who can't afford can't really participate um you know without their resources. And so um we can't have a sports medicine topic right without talking about sports injuries. Um The C. D. C. Has found that 3.5 million Children or more Um who are under the age of 14 has received medical treatment For sports injuries. In 2019 more than a half of these sports injuries are considered preventable and overuse injuries are responsible for nearly half of all sports injuries to these middle school and high school athletes. Young athletes have increased risk for injuries because they are skeletal e immature. They have open growth plates. There liga mantis, relax, They have underdeveloped muscles which could all lead to poor technique and certain variants in an atomic alignment that are seen during normal growth and development can also predispose them to sustaining injuries. It's extrinsic factors that increase risk for injuries include rapid increase in training. So this is something that we see Or we saw most definitely in 2021 as Children eagerly returned to sports following a year long lockdown from the pandemic. Those who also train at a high volume. So teenagers who trained more than 16 hours per week. Or younger Children who who trained in more hours per week than their age and years were also found to have increased rates of overuse injuries. And then lastly even if you account for your hours per week or exposure. Um Recent studies have shown that those who practice early sports specialization are also at a significantly increased risk of overuse injuries. Early sports specialization has been described in scientific literature for almost a decade now. Um There's a couple of different definitions out there, but essentially it's a young athlete who chooses to participate in one sport, quit all other sports um and participates all year round or at least at least eight months each year. Um And they can do that by participating in multiple teams, their schools through clubs or through travel. Um There's no specific age for what early means for sports specialization. The american Academy of the american orthopedic society for sports medicine mentioned specializing before the age of 12 as early. Um While the A. Ap. Or the A. M. S. S. M. Or Medical Medical american Medical Society for sports medicine considers, you know, specializing before adolescence as early, About 10-30% of Children. And in the United States are considered early sports sports specialized. These are traditionally seen in those who participate in individual or technical sports, such as tennis, gymnastics, dance, swimming or diving With gymnastics and dance as early as the specialize ear's at eight and 10 years of age. However, the this trend has started to change for those who participate in team sports specifically amongst baseball pictures and soccer athletes where an athlete lives also influences their sports practice. Studies show that high school athletes who live in the suburban regions participate in more competitions Play are more likely to play in leagues outside of their school and are more likely to train more than 16 hours per week for more than eight months each year, compared to their counterparts from rural areas. Studies have also found that high school pictures who live in one weather regions pitched an average of nine months each year, which is significantly greater than their counterparts who live in cooler weather regions who only pitched about six months each year. Socio economic factors may also influence practices. Uh, surrounding sports specialization as you can see on the middle as socioeconomic status increases. So does their specialization practice and then as you can see on the left, those who are probably insured are more likely to specialize compared to their counterparts who are on public assistance. When asked about their attitudes and beliefs towards sports specialization, 79% of high school baseball parents and 86% of youth basketball parents believe that specialization is necessary because it will increase their child's chances of getting better. However, only 47% of the high school baseball parents, Um, and 41% of these youth youth basketball parents believe that specialization would increase their child's chance of injuries. Similar trends were seen when the club athletes were asked themselves. Now, you might wonder how we got here, right? So how did you know? Well meaning families end up in this situation that increases the risk of injuries and their Children. The answer is, the culture of youth sports has significantly changed in the recent years. Um And youth sports is now a multibillion dollar interest industry in the United States. It is fueled by organizations that do not always align with the long term health and development of its participating youth. So it's more than just organizing local or regional tournaments. There's actually technology money in it. They stream, they live stream the events for the games or the tournaments and can generate income through ads. They create apps that track the athletes that track their stats, the track the tournaments or where the next college recruitment is going to be. There's a special focus on elite status and performance that's reinforced by social media, college scouts and professional organizations. So it's created this frenzy that's caught the attention of very well meaning families who just want to give their Children their best. However, while these stories might sound impressive, the statistics show us a different reality. The chance that a high school athlete will play in the college level with a scholarship is about 1%. The average athletic scholarship is less than $18,000, while the average tuition fee For public and private colleges are 22,000 And 36,000, respectively. And even if they make it to the college level, the chance of playing professionally um are even more slim And some parents or families might say, well, you know, my child's worth it, right. I think my child will be that 1%, so I'm willing to invest in them. However, the science says that early sports specialization may not even be necessary because it does not necessarily ensure elite level of success. Maybe the exceptions include gymnastics or figure skating, where in technical skills have to be developed before puberty and adolescence. What's found to be beneficial or linked to athletic success um is family history suggesting that genes play an important role in an individual's athleticism. So several studies have been done on the topic. one study on a Danish elite athletes revealed that the successful athletes specialized at a later age and trained less compared to their near elite peers. Another study on Olympians who participated in 2004 Revealed that their average age of sports initiation was at 11.5 years old. Which is actually considered um late or old in you know today's athletic culture. Um And then an older study on N. C. Double A. Division one athletes revealed that 70% of these athletes did not specialize until after 12 and that most of them played more than one sport growing up. In addition these athletes also reported That about 40% of them had a parent who competed at the college or professional level. You know further supporting our genetic theory. A recent study um performed in N. C. Double A. Athletes who participate between Between 1960 and 2018 revealed that only 18% of these athletes specialized before 15 specialization was more common amongst female athletes and those that participated in gymnastics. Tennis, swimming and diving. This uh study, however was unique because it was one of the first studies that showed that there was this trend in soccer athletes specializing. It was also one of the first studies to show specialization um was being more popular in more recent college graduates from their study. Ah The results showed that there was no difference in terms of scholarship attainment whether you specialized or not and while the injury profile may not be statistically different, they found that burnout was more common amongst those who specialized early A study performed on n. b. a. first round draft picks between 2008 and 2015 revealed very high specialization rates up to 85%. However, it is the multi sport athletes or those who played multiple different sports during high school um that are less likely to sustain a major injury, They are more likely to play more games and had longer professional careers. A study performed in a professional baseball athletes who participated in the atlantic leak That in 2016, That revealed that almost half or 49% of these athletes specialized earlier before high school. These athletes who specialize early reported more serious injuries that required rest from sports for an entire year or had an injury that required surgery. What was interesting about this study was that 63% of all athletes surveyed did not believe that early sports specialization was necessary to master the skills needed to play at the professional level. The problem with early sports specialization is that the lack of diversified activity may not allow for appropriate neuro muscular skills that are effective in injury prevention. In other words, we're teaching our young baseball pictures to throw faster at higher skill levels without focusing on core strength or cardio vascular fitness, which are essential and injury prevention, repetitive use of the same segments in the body without adequate rest also increases their risk for physical injuries going back on this image that we saw earlier that the more they specialize, the more serious overuse injuries are prevalent and by serious overuse injuries. We're not just talking about osgood Schlatter um or receivers of Pappas itis here. We're talking about injuries that require at least one month of rest from sports specifically spawn did low license stress fractures, osteoarthritis, dissidents and ligament. This elbow injuries that may warrant surgery. There also seems to be a dose dependent relationship between the degree of sports specialization and the risk for serious overuse injuries within those who are considered highly specialized. So checking off three out of the three components of the definition to have highest risk for serious overuse injuries compared to their non specialized peers. The relationship between early sports specialization and physical injuries has significantly caught the attention of sports medicine research um, and policy development. However, less attention is given on its psychosocial outcomes. Prior position statements have suggested that early sports specialization um can increase the risk for mental health issues and also cause burnout. However, we have far limited um data on this, which is why I just wanted to spend a little bit more time on it today to increase awareness and also encourage discussion. So, before we focus on the athletes, I just wanted to highlight that mental health conditions aren't uncommon in pediatrics. Data shows that 50% of, individuals with mental health conditions will first show signs during their teenage years by 14 And that 75 Will begin in early adulthood by 24 years old. Numerous studies support early intervention as helpful in preventing in in preventing negative functional outcomes and negative developmental outcomes. However, only less than 20% of Children and adolescents received treatment. And while um youth sports participation has these benefits for psychosocial reasons, it does not mean that the athletes are immune from these conditions. The the competitive nature of sports can definitely provoke or exacerbate any underlying mental health issues. Um certain personality traits, for example, perfectionism which are considered beneficial in athletics can also be linked to mental health issues. And lastly, the athletic culture that usually downplays these issues and instead focuses on winning and success and you know, meeting expectations um can definitely contribute, you know, to these issues and we're learning more and more each day that even those that are considered the greatest of all time in the respective sports are also vulnerable to these mental health conditions. So injuries may trigger or unmasked mental health conditions and may influence the recovery including their postoperative outcomes. So this is very important to know, as primary care providers who are seeing seeing them at the front lines. It is also important to know that under reporting maybe higher mile student athletes because of the social stigma and that female athletes may prefer discussing these issues on mental health and reproduction with athletes of the same gender sleep is an essential component of a young athletes, health and well being. A recent study has shown that middle school athletes who practiced more than 10 hours a week, slept half an hour less each night. The American Academy of Pediatrics recommends at least nine hours of sleep for our school age Children and at least eight hours of sleep for our teenagers. In this same study, they found that 26% of Middle Middle School athletes And 45% of high school athletes were not getting their age recommended amounts of sleep after correcting for age, gender, homework load, social media use and other factors. They found that those who participated in sports competitively and those who reported depressive and anxiety symptoms, we're more likely to not get their age recommended amount of sleep, suggesting that um increased training load may affect sleep quantity, which can also affect someone's mental health factors unique to athletes that may increase their risk for mental health issues include fear of failure, perceived negative consequences of performance, social judgment from the crowds, their coaches, teammates or families, an injury history history, and while it may be difficult to detect pathologic anxiety and competitive environment, it is important to know that athletes are most vulnerable in the setting of an injury. It is more than just excessive worry retention as a response to an injury, A recent study shows that in young athletes who sustained a cl rupture. About 75-87% of these athletes reported avoidance symptoms, symptoms of intrusion and hyper arousal, which are symptoms that are most commonly seen in post traumatic stress disorder. These pTSD symptoms are more common amongst female athletes and those with higher athletic identity. Another study um a systematic review reveal that 37% of athletes who underwent an A. C. L. Reconstruction, we're not able to return to their pre injury level And that 65% of these athletes cited a psychological reason specifically fear of re injury and lack of confidence moving on, rates of depression amongst the athletes have been increasing um in the recent years compared to what's previously reported in the recent large multi year study on Mt double A. Division one athletes, They found a 23% prevalence of clinically relevant depressive symptoms, which is very close or very similar to the general or non athletic population. Depressive symptoms were more common amongst female athletes, those who are younger. So freshman versus upper class and those who participate in individual sports studies that focus specifically on injured athletes showed higher rates of these oppressive symptoms. Certain factors that increase um an athletes risk for depression may include um you know, trying to meet performance expectations, having a very high athletic identity. Um an injury causing significant time away from sport. So especially if this injury requires at least one full month or 30 days out from sports and very high demands on their time. So these athletes usually Practice and compete approximately 40 hours each week in addition to their academic demands and depression in young athletes may present atypically specifically lack of focus, fatigue, sleep disturbance, behavioral changes but pretty commonly physical or somatic muscular skeletal pain. So they can have these chronic joint pains or back pain that may mean that are very non specific and can mean an underlying mental health issue. Well it may be difficult to elicit this on the initial visit. Um It should highly be suspected especially if it's interfering with their optimal recovery or causing delays in the return to play. So because mental health is such a big aspect in young athletes, the most recent version of the American Academy of Pediatrics. Pre participation evaluation has included the physician health questionnaire four or P. H. Q. Four. So It now includes four questions that which first two of them screen for anxiety and the last to screen for depression. Um Anyone who scores three or greater in each sub scale um should warrant a more thorough discussion and um potentially a referral if these formal mental health screening tools may seem um inappropriate in the context of you know, the patient's nature of visit. Um Using the basic method has been very helpful in primary care. Um So asking these five simple questions um can help encourage discussion, take away the stigma and also acknowledge the fact that mental health is very important in an athlete's health and well being burnout is a is defined as a response to chronic stress. We're in a young athlete stops participating in a previously enjoy Your bowl activity is also described as emotional and physical exhaustion, reduced sense of accomplishments and sport devaluation. There are four stages to burnout, as described by Smith and his colleagues. Way back in 1986, It starts with a young athlete that is placed in a situation that involves varying demands and can ultimately lead to the various um consequences of burnout that can lead to early withdrawal from sports the same external and personal factors that increase this is a young athletes risk for mental health conditions are also implicated in burnout, which may present as ambiguous muscle or joint complaints, fatigue or poor academic performance. So, in addition to evaluating them for structural ideology for these complaints, it's also very important to evaluate them for metabolic ideology or understand and athletes motivation for participating in sports and potentially offer psychological assessment. As I mentioned earlier, Early sports specialization has been linked to higher rates of burnout and young athletes um and is implicated in early withdrawal from sports, especially for girls, Um as young as 11 years old. And their primary reason for no longer joining sports is that it's no longer fun. And so this is very unfortunate, right, because Even though I just spent the last 20 minutes talking about all these challenges we faced with use force participation, the benefits still outweigh these challenges. And so I'd like to end this session by encouraging everyone on the call to join the sports medicine community as persons of influence in your respective fields. You know, we need your help in consistency and messaging towards our young athletes and their families. You can participate as a health care provider, as a parent, advocating for your child as a coach or someone who's participating in youth sports organizations. We need to be consistent in our messaging and encourage early diversification for our young athletes. We also want to encourage free unstructured play because this helps in overall neuro muscular skill and skill development. We also want to avoid over scheduling and help them manage their load. A quick rule of thumb is that their hours per week of sports participation should not exceed their agent years, so 12 year olds shouldn't be playing more than 12 hours hours of sports each week. We recommend taking breaks for their bodies used to recover. So we recommend at least 1-2 days per week And also 2-3 months per year that may be divided into one month increments. And lastly we also encourage age appropriate sports participation for all our Children and adolescents and then um clinically, I think it's very important to normalize these discussions on mental health, you know, um utilize the multidisciplinary approach, Be transparent with your limitations and encourage referrals as indicated. Um for those who are interested in research for quality improvements subjects projects, there's still a lot of work that needs to be done on the topic specifically. You know, is there right age to specialize? And then lastly as we work together to help improve the future for our Children and adolescents, I hope that everyone thinks about extending our programs to underserved communities. And so with that I'd like to end my talk. Um I just wanted to share um an event coming up in June 17, 2022. Um If you are still if you are interested in learning more about musculoskeletal care for pediatric patients, we have an event coming up. Our topics include scoliosis, hip issues, foot issues, primary care fractures. Um We also have um faculty from the department of pediatric rheumatology, pediatric endocrinology and um physical medicine and rehabilitation um participating. So it would be a good way um to interact and meet our faculty um This is our orthopedic team here at UCSF Benioff Children's Hospitals and we'd love to meet you all um during these activities um so that we can better serve our bay area community and if you have any questions about referrals or sending patients, please feel free to reach out to your physician liaisons