“My daughter plays select soccer and can’t afford to take any time off for her injury without the risk of losing her starting position on the team.”

Statements like this are commonplace in my world as a sports physical therapist. And while I genuinely believe that parents and coaches have their minds in the right place when it comes to wanting their child to be the best, the idea that this means you must specialize in your sport early in life is not supported.

Early sport specialization is defined as choosing to play only one sport, often without any breaks during the calendar year, while the body is still changing and growing.

As we are in the thick of another year of the NCAA college football national championship and bowl games, let’s revisit last year’s undisputed national champions as an example of one sport vs. multiple sport athletes. In early 2015, a social media post went viral detailing Urban Meyer’s recruiting record during his time as head football coach at Ohio State. Of his total of 47 recruits, 42 were multisport athletes in high school. Only 5 of his recruits played football alone.

Did you know?:

• Three-time Super Bowl champion, NFL Hall of Famer and Dallas Cowboys Ring of Honor inductee Troy Aikman played shortstop and pitched on his high school baseball team. He was drafted by the New York Mets out of high school and came close to choosing baseball over attending the University of Oklahoma, and later UCLA, to play football.
• Two-time women’s soccer Olympic gold medalist and 2012 FIFA World Player of the Year Abby Wambach credits her success as a soccer player to playing basketball in her youth.
• Eight-time NBA All Star and two-time NBA MVP Steve Nash did not start playing basketball until he was 12 or 13 and instead thanks his soccer background for his success in basketball.
• Six-time MLB All-Star Joe Mauer of the Minnesota Twins played football, basketball, and baseball in high school and was named USA Today High School Player of the Year in multiple sports.

An athlete like Tiger Woods, who started playing golf before the age of 2, is an extremely rare occurrence. It is by no means the norm and should not be expected.

In theory, specializing makes sense. After all, practice makes perfect, right? Wrong! In reality, research has shown the following:

Early specialization leads to overuse injuries.

More and more orthopedic experts are speaking out to shine light on the world of pediatric sports injuries. They have become increasingly alarmed by the skyrocketing rates of injuries in kids and some go so far as to describe it as an epidemic. Each year, roughly 3.5 million children, 14 years of age and younger seek medical treatment for sports injuries.

Of these, at least half can be attributed to overuse injuries. Repetitive activity leads to increased stresses on a growing child’s bones and muscles and can result in injuries such as Little League elbow, Little League shoulder, shin splints, Sever’s disease, Osgood-Schlatter disease, runner’s knee, jumper’s knee, or even stress fractures in areas like the back (spondylolysis or spondylolisthesis), hips, and feet.

So what’s the first line of prevention? Rest. Children should have at least two months off each year to recover from their specific sport. And if we’re talking about baseball, it’s recommended for those athletes to have three to four months of absolutely no throwing or overhead sports.

Early specialization interferes with healthy growth and development.

Playing a competitive sport is stressful, and just as the body must adapt to the changes and demands physically, handling the stresses around winning, losing, practice schedules, traveling, etc… in addition to regular schoolwork can be emotionally draining as well. Children may also struggle with identity and view themselves as solely an athlete. Playing a wide range of sports promotes diverse relationships and allows for a wide variety of experiences.

Early specialization increases the risk of burnout.

Playing only one sport, especially at a competitive or select level, can lead to burnout as a result of stress and physical and emotional demands. A history of injuries can also increase that anxiety. If a sport stops being fun or a child feels pressured to succeed, it can certainly lead to a desire to quit.

Early specialization reduces the chance that children will maintain an active lifestyle as an adult.

In 2013, researchers from The Ohio State University released a study that found that children who specialized in one sport early in life were more likely to be inactive as adults. Committing to a certain sport at too young of an age can lead to early burnout, quitting, and being reluctant to then rejoin physical activities as an adult. A history of injuries also contributes to an aversion towards exercise and a preference for a sedentary lifestyle.

Early specialization doesn’t guarantee future athletic success.

Consider these statistics from the NCAA regarding athletes during the 2013-2014 school year.

                              Estimated Probability of Playing in College

                           Estimated Probability of Playing Professionally

When you look at the numbers, the odds of playing a sport in college and especially professionally just aren’t in your favor.

So what does this mean for our kids?

• No, we shouldn’t put them in a bubble and shield them from sports. Athletic activity is extremely important.
• Children should learn the fundamentals of various sports and enjoy the experience.
• Sports should be fun at every age.
• Sports should create positive habits for later in life.
• Sports shouldn’t cause repetitive injury.

And if your child happens to be one of the lucky few who go on to play in college or even professionally, a history of playing multiple sports is clearly of great benefit.

About the author

Melissa Bro, PT, DPT, SCS, is a physical therapist for the Cook Children's SPORTS Rehab program. Our physicians, therapists, nurses and technologists work exclusively with kids and understand the unique needs of a growing athlete's bones, muscles, body and mind. As a part of Cook Children's integrated pediatric health care system, our patients have access to a multitude of pediatric specialty areas with board certified doctors, as well as laboratory services, nutritional consultations and sports medicine counseling.

The more frightening thing is the amount of patients that we don’t read about who are undergoing the same surgery. More and more, young baseball players ages 15-19 years old are sustaining this same injury and having to undergo this surgical procedure.

Ulnar collateral ligament reconstruction used to be an injury that we saw in ball players later in their careers. John Smoltz played for the Atlanta Braves and was recently inducted into the Baseball Hall of Fame. His career benefitted from Tommy John surgery. Currently, he's the only player inducted into the Hall of Fame who received Tommy John surgery. But he warns against the number of young people receiving the surgery today, calling it an "epidemic."

"I want to encourage the families and parents that are out there that this is not normal to have a surgery at 14 and 15 years old," Smoltz said. "That you have time, that baseball is not a year-round sport. That you have an opportunity to be athletic and play other sports. Don’t let the institutions that are out there running before you guaranteeing scholarship dollars and signing bonuses that this is the way….

I want to encourage you, if nothing else, know that your children’s passion and desire to play baseball is something that they can do without a competitive pitch. Every throw a kid makes today is a competitive pitch. They don’t go outside, they don’t have fun, they don’t throw enough — but they’re competing and maxing out too hard, too early, and that’s why we’re having these problems. Please, take care of those great future arms.”

So are his concerns warranted? In short, yes.

A recent study showed that 15-19 year-olds accounted for 56.7 percent of the ulnar collateral ligament reconstructions performed in the U.S. between 2007-2011.

This is a scary statistic considering this means that over half the UCL reconstructions done in the U.S. are performed on patients who haven’t finished their freshman year of college. So why has this become so much more prevalent in younger athletes?

I think the simple answer is the volume of pitches being thrown. If we look at the trends with today’s young baseball players, more often than not they are playing year round, playing on multiple teams, and at times playing on multiple teams at the same time. At some point kids have to put down the baseball and give their arm a break.

Little leaguers who pitch have a major disadvantage compared to their major league counterparts: they are still growing. This means that each time they take the mound they are pitching with a new body. As kids grow taller, it means they have longer limbs that they have to control, and this takes more strength and more coordination, strength and coordination that often doesn’t keep pace with how fast the athlete is growing.

So how do we reverse the trend of these young baseball players dealing with this terrible injury? Here are four recommendations.

1.Decrease the volume of throws

2.Don’t pitch with fatigue

3.Don’t throw breaking pitches (until skeletally mature enough and skilled enough to do it correctly)

4.Delay specialization (play multiple sports)

Decrease the volume of throws

Decreasing pitch volume I feel is the most important of these three recommendations. It’s not just following pitch counts it’s avoiding playing multiple positions with a high volume of throws. I have had many patients come in and say “we follow all the recommended pitch counts,” but as I dig deeper I find out that, yes, they are following pitch counts, but the child is playing catcher when he isn’t pitching. The bottom line is that it isn’t just pitch count alone, it is the total volume of throws we need to think about.

Don’t pitch with fatigue

Making sure our players aren’t pitching fatigued is also a big part of keeping our young throwers safe. If a player is fatigued and continues to pitch, even if they haven’t reached their pitch count, they are putting themselves at risk. The National Athletic Trainers’ Association (NATA) Position Statement on Prevention of Pediatric Overuse Injuries cited a study showing that a greater percentage of pitchers with shoulder or elbow injuries started at another position and pitched with arm fatigue. So if a player has been out in the hot sun playing short stop in the first game of a double header it probably isn’t a wise decision for him to pitch in the second game

Don’t throw breaking pitches (until physically mature enough and skilled enough to do it correctly)

I think most parents of young baseball players have at least heard the recommendations to avoid curveballs and sliders until the player is older, but for some reason we still have young pitchers throwing these breaking pitches. Another study cited in the NATA Position Statement on Prevention of Pediatric Overuse Injuries showed the risk of elbow pain increased 86 percent in youth pitchers throwing sliders, and the risk of shoulder pain increased 56 percent for pitchers throwing curveballs. We as parents need to remember our kids are going to watch their favorite big league pitcher and want to throw all the same pitches it is up to us as parents to step in and say you aren’t ready for that.

Delaying Specialization

There is an interesting study finding that more of the successful, Hall of Fame–type pitchers come from up north, where Hall of Fame hitters come from all over — a lot of them from the South. The gist of the study was that because there are several months of the year in these northern states that it is too cold to be outside playing baseball these pitchers couldn’t participate in baseball year round. During the winter months they had to put the baseball down and do something else. Once again referring back to the NATA’s position statement they state, “Young athletes who participate in a variety of sports tend to have fewer injuries and play longer, thereby maintaining a higher level of physical activity than those who specialize before puberty.” Delaying specialization is also a big part of decreasing volume, because if kids are playing another sport they will get that nice break that they need from throwing.

This blog by no means touches on all the factors that lead to these injuries, and the four recommendations are by no means the complete list of ways to prevent these injuries, but following these recommendations is a good place to start to keep, our young ball players’ arms nice and healthy.

Resources

• Baseball Injury Prevention
• Top 10 questions parents have about sports injuries
• Young athlete's injury prevention guide
• Strength training in children/adolescents

Water sports are great because it allows one to exercise at a high intensity, there is not that much stress on the back and legs. It is great for a whole body work out and allows someone, in one hour, to be able to burn as many calories as in a one-hour run.

Typically, one doesn’t think of swimming as a sport that leads to many injuries. Swimming is an overhead sport and the human body is not made to handle a lot of overhead activities. Swimming too much can lead to overuse injuries. The main ones are shoulders pain and occasionally knee pain.

The training for competitive swimmers has changed in recent years. Training now requires swimming a lot of laps. All this swimming leads to more overuse injuries, like the ones we see in baseball pitchers and runners. Shoulder pain is the major problem swimmers will “swim” into because using the same muscles over and over can lead to the muscles in the chest and back being unequally strong. These muscles not being equal can lead to bad swimming form which will then lead to shoulder pain. Swimming strokes that can lead to shoulder pain are freestyle, back stroke and butterfly. Swimmers that participate in breast stroke are as at risk as other strokes for shoulder pain, but can also develop knee pain. This comes from the knee cap shifting and rubbing on other parts of the knee joint leading to knee pain.

It is important for coaches and parents to know how to keep their young swimmers safe, what to look for, and what questions to ask their kids to ensure that they are staying safe and not injuring themselves.

KNOW WHAT’S BEST FOR YOUR YOUNG SWIMMER:

Parents and coaches can help their swimmers by being an extra pairs of eyes, because the young athletes don’t know any better.

Rest: Athletes participating in overhead activities should not participate in these activities for at least three months out of the year. This means that it is good for parents to encourage their child to try different sports, specifically ones that don’t involve overhead activities.

Warmup: Ensure that your swimmer is warmed up properly. It is never good to get into a pool cold. The type of warm up is important too. Make sure that the warm ups are active and not passive stretches. There are a lot of traditional stretches that swimmers do to warm up their arms. These warm ups target parts of the shoulders that keep the joint stable. It is important to warm up and actively stretch the muscles themselves and not the shoulder joint.

Hydration: Lastly, make sure to drink a lot of water. Being in a pool dehydrates the body on top of the sweating that occurs while working out.

THINGS TO AVOID:

• Incorrect swimming form
• Excessive training without rest days
• Swimming the same stroke every time

WHAT TO WATCH FOR:

• GREEN LIGHT- Good: Muscle soreness is OK if it last 2-3 days
• RED LIGHT- Bad: If soreness last more than 2-3 days, or gets worse, and/or is sharp

(If it is a red light item one should seek help from a medical professional)

NOW WHAT:

Young Kids AGE: 5-9

• Training should not exceed 60 minutes and no more than three times a week.
• Learn how to properly perform the basics of the strokes.

Older Kids AGE: 10-16

• Training should not exceed 120 minutes and no more than 6 times a week.
• Learning how to decrease wasted energy with strokes.

PROPER WARM UP:

• 5 minutes of light swimming
• 15 minutes of active stretching
• 10 minutes of stroke and breathing exercises in the pool

At Cook Children’s, our SPORTS physical therapists are trained in proper rehabilitation of overuse injuries and work to restore full function and safely guide return to athletic activities. If your child has a history of injuries from swimming or you are concerned about risk of future injury, talk to your pediatrician about a referral to physical therapy.

Learn more here:

• USA Swimming
• Ovoiding overuse injuries
• Swimming Injury Prevention