We want to welcome everyone to tonight's webinar. My name is Patrick Buckley. I'm an orthopedic surgeon practicing in New Jersey at Rutgers. And I'm going to pull up my slide deck here. So tonight's topic that we're going to talk about is early sports specialization in youth athletics, how to balance sport participation while limiting injury risk. My disclosures are listed certainly on the website, but nothing really relevant here. And before I begin, I do want to thank Alexandra Campbell for all her work in organizing this. It's really been a pleasure to work with her, and we're looking forward to a great discussion tonight. I want to highlight this webinar and this topic is really something that is presented from the AOSSM Stop Youth Sports Injury Committee. This is something I think many of you know about, but certainly I want to remind you. And in particular, there's a lot of resources on the website that are out there. So there's injury tips based on sport that you can use in the office. And I use these a lot when I am talking to youth athletes. And they have a lot of really good synthesized information that I think is very applicable to what we're talking about tonight. This is just an example of that for gymnastics. But they're really well done. I think something that you can use a lot in your practice. It's also based on injury as well. So if you want to have a handout or you want to use this to facilitate discussion with your athletes, I think that would be something that I would point out to you and something I would send you to. It's really a great resource up there. So that mission of that committee is really to help work on preventing youth injuries. And certainly the topic tonight really lends itself to that discussion. Because we certainly have all seen this in the office and the clinic with athletes who are choosing to play one sport at a younger and younger age and certainly resulting in injuries. And so we're going to talk about that tonight and hopefully talk about the path forward and how we can work on improving that and keeping our athletes safe as well as playing the sport that they love. So it's an honor to be with our panel tonight. We have three really distinguished speakers. Dr. Catherine Logan, who's from Cosmo Orthopedics and Sports Medicine in Denver, Colorado. Dr. Minh Coker, who's from Boston Children's Hospital, as well as Dr. Kenneth Fine from the Orthopedic Center in Washington, DC. The plan today is going to go through three different talks. We're going to start off with Dr. Logan speaking about the definition, epidemiology, and landscape of current youth athletics. Then we'll have Dr. Coker talk about early sports specialization and the connection to injury risk and future sport advancement. And then Dr. Fine is going to bring us home talking about how he discusses sport specialization in the office. One quick note, Dr. Coker did have something come up. So he was able to pre-record his lecture, which we really appreciate that he was able to do. So with that as kind of the introduction, I am going to stop sharing my screen. And then I'm going to have Alex pull up our first talk, first speaker, who will be Dr. Catherine Logan. Hi, good evening. My name is Dr. Katherine Logan. I'm an orthopedic surgeon specializing in sports in Denver, Colorado at Colorado Sports Medicine Orthopedics. I'm also the medical director and head league physician for the Men's Premier Lacrosse League and a team physician for US Ski and Snowboard. I've been asked tonight to speak about early sports specialization in 2021, specifically the definition, epidemiology, as well as the landscape of our current youth athletics. So thanks for having me. I'm very happy to be here. And here are my disclosures. So there has been a steady increase in sports participation across all age groups within the United States. We also believe that this extends globally. Approximately 72% of school age youth participate in at least one organized sport, team or club, each year. And as sports become more popular, we're also seeing rise in single sports specialization, often among parents and coaches who believe it's the best way to develop an elite athlete and the best way to develop the skillset to the most highest level. So as far as the definition, we define sports specialization as intensive year-round training in a single sport at the exclusion of all other sports. As with most things, there's a spectrum to early sports specialization. So included is a chart taken from an article from Dr. Lyle McKaylee at Children's Hospital in Boston. And this chart talks about the degree of specialization and how it can vary. So what you'll see here is there's low specialization, moderate specialization, as well as highly specialized athletes, which are chosen based on meeting certain criteria. So low, zero to one of the following, moderate, two of the following, and three highly specialized includes all three. The options include year-round training, which is greater than eight months per year, choice of a single main sport, as well as quitting all other sports to focus on this sport. So a bit of history. Single sport specialization was first reported to begin in Eastern Europe with athletes involved in individual sport endeavors such as gymnastics, swimming, diving, figure skating, most commonly these Olympic level sports. The athlete selection process did eventually reach into the primary school years, and this included intense and high-volume training, as well as rigorous coaching, and included parental pressure, of course, for achievement. Despite the lower of these professional contracts, the actual statistic is somewhere about 0.2 to 0.5 percent of U.S. high school athletes which ever make a professional sports team or a professional level of their sport. A report published in AJSM in 2015 entitled Sports Specialized Intensive Training and the Risk of Injury in Young Athletes did indicate that nearly 30 percent of young athletes were highly specialized from a sample of approximately 1,200 young athletes. Factors such as pursuit of scholarships or professional contracts or the intense desire of talent recognition from parents, coaches, local media, and peers were all factors to fuel the interest in specializing in sports at an early age. So why do some specialize? This is likely driven by several factors and not just the ones listed on this slide, but it can be as simple as just ensuring participation in scholastic sports when the athlete is in high school or late adolescence, wanting to maintain potentially just for social reasons to be on their team once they reach that age, or really just to continue to build their college application. So not often are these athletes under the illusion that they're going to play collegiately or potentially professionally, but just really want to be able to stay with their peers and feel that the only way to do so is if they specialize at an early age. Obviously some are specializing at an early age because they would like to garner a collegiate athletic scholarship and wish to participate in the sport in college, and then we do have those subgroups that their early specialization is because they wish to be on the National Olympic level team, as well as those who aspire to play professionally. So big difference between unrealistic goal-setting, understanding the statistics of who will make it to the professional level, versus just youth trying to keep up with their peers and continue to maintain on the teams that they do enjoy. There's many perceptions among parents and the athlete and their family, as well as influences from the outside community. So for parents, I think they're often led to believe that in order to gain an edge towards achieving success or maintaining on the team, they have to specialize in a single sport at a young age, and that's the only way necessary to maintain that skill. Otherwise, there's coaches and organizations that belabor this concept and make it such that it's essential to develop skills and to be provided with exposure to recruiters and colleges by participating in independent youth travel or select club teams. There's also many ancillary services in the community that exist that are offered as a necessary process for these athletes. This could include personal trainers, performance coaches, specialized youth training gyms, sports psychologists, nutritionists. There's quite a long list depending on the environment that the athlete lives in, whether it's a large based city or small town, but obviously these can get quite complex as far as what is offered in certain regions of the country. So it wouldn't be a thorough early sports specialization talk without mentioning the concept of deliberate practice. So deliberate practice is defined as highly structured activity with the explicit goal to improve performance. So this concept is that the level of performance an individual attains is directly related to the amount of deliberate practice they participate in or perform. This is where we have our 10-year, 10,000-hour rule, which many of us are very familiar with. However, this concept was really taken from studies on a small number of chess champions and highly selected elite musicians whose success was attributed to very high volumes of training in their disciplines. However, studies of athletes indicate that strategy of early sports specialization does not really pan out for the same level of success as it did with these musicians and chess champions. In fact, it might actually be detrimental to their long-term achievement and has potentially an associated increased injury risk or psychological burnout, dropout rates, and other sorts of risk factors associated with this deliberate practice. When we look at our own current professional athletes, there is some interesting data as well. So highlighting the NFL, 88% of NFL draft picks in 2018 and 2017 were multi-sport athletes in high school. The other sports most commonly played by football players were track and field and basketball, but pretty high number to achieve multi-sport status continuing through high school. So looking at elite hockey, so this study published in Sports Health looked at both professional NHL organization players as well as two NCAA organizations, one Division I and one Division III. In total, they had 91 athletes who participated with a mean age of 22.8 years, but quite a spread 18 to 39. And what they found was the mean age of sports specialization for these athletes was 14.3 years and still reaching elite status. So this is the league that I work closely with. This data is not yet published, but was taken by our players in the last year. So 158 PLL or Premier Lacrosse League players were surveyed about their specialization with regard to professional lacrosse. We had a response rate of 26.3%. So less than one-third, 30.4% specialized to play lacrosse at the exclusion of other sports during their childhood or adolescence. So of these that did specialize, they did so at an average age of 16.5 years, so much older than that early specialization group we are seeing. And the majority of these athletes classified themselves as multi-sport athletes during their high school careers. So with regard to specialization and later success, only a few select individuals who specialize at an early age really do achieve this elite level success. It's certainly not the standard to do early sports specialization to expect that the outcome is going to be elite and or professional status. Success at a young age, importantly, does not predict long-term success. And in some cases, early sports specialization and early success might be a limiting factor to achieving this elite status, whether it be from early dropout, psychological distress, or injury patterns. So the current data lends support to the concept of early sport diversification as opposed to specialization. And we all recognize that deliberate practice is certainly important and necessary for success in sport, but it's not sufficient as the only means to achieve elite status. The AOSSM did put together an early sports specialization consensus statement that is available for free on the website, which is helpful to look through. And certainly the youth athletes, their advocates, parents, clinicians, coaches should all be working together with the governing bodies to encourage not only the long-term health of these athletes, but just that the understanding that this early sports specialization is not the essential pathway for success in their sport. Thank you for your time and I look forward to our Q&A session. All right. So that was great, Katherine. We appreciate that overview, kind of setting the stage. And next we're going to have Dr. Coker's talk. Dr. Min Coker is a professor of orthopedic surgery at Boston Children's Hospital and the chief of sports medicine there. So with that, I'll have Dr. Coker's talk get loaded up. Good evening. I'm Min Coker from Boston Children's Hospital and Harvard Medical School. I'll be talking about early sports specializations, connection to injury risk and future sports advancement. Greetings from Boston. I'd like to acknowledge the Stop Sports Injury Program and AOSSM for organizing this webinar. I had the opportunity to work with Jimmy Andrews when he was president, and I was on the board of directors of AOSSM on the Stop Sports Injury Program. And it's great to see where this initiative has gone. My disclosures are shown in the program and there's no specific conflicts with this talk. Youth sports injuries has received increased attention. This was the front page of the San Francisco Chronicle, sports injuries getting worse, growing pains. And this was ABC World News with Diane Sawyer, patient of ours, age eight, who tours ACL and then got to meet Tom Brady. And this has reached the popular press as well. ProPublica, headline, hyper-specialization is ruining youth sports, and the CUNY Sports Journal ruining youth sports and the kids who play them. ESPN talking about everyone's concern, the youth sports arm race is ruining our kids and our country. So a lot of concern and hyperbole. And some of the stories are quite extreme. I was asked to comment on this example, young child in India who at age four years old was trained to run 42 miles in seven hours and two minutes. A controversy over the Ironman, which should be the youngest age allowed. And we see this controversy in our marathons as well, such as the Boston Marathon that we cover. And then this young boy who was taught bodybuilding at age two and at six years of age was able to bench 180 pounds, called the world's strongest boy. I think the two main questions that we have to tackle are, first, does early sports specialization increased injury risk? And second, does early sports specialization lead to sports advancement? And that's what we'll cover in this talk. We'll start with clinical reviews. And a number of clinical reviews have been published on this subject. And these are experts in the area who qualitatively review the literature and give recommendations. This article from Greg Meyer and colleagues in sports health. And we have this article in AJSM, when is it too early for single sports specialization? By Brian Feeley, Julie Agell, and Rob Leprod. And then this review article from Nirav Pandya and Chantal Parikh, consequences of single sports specialization in the pediatric and adolescent athlete. We then have consensus statements. Consensus statement, a group of experts will get together. They'll review the available literature. They'll go through a process of formal discussion and developing recommendations that eventually become a consensus statement. And that's frequently published in the medical literature. So this was a consensus statement from the International Olympic Committee consensus statement on youth athletic development that was published in BJSM in 2015. And this is a consensus statement from the American Medical Society for Sports Medicine, Overuse Injuries and Burnout in Youth Sports, a position statement from the AMSSM. This was published in the Clinical Journal of Sports Medicine in 2014. This was a consensus statement that we did from AOSSM that was published in the Orthopedic Journal of Sports Medicine, which was the AOSSM Early Sports Specialization consensus statement. And then this was a consensus statement from the AMSSM on Youth Early Sports Specialization Summit. Next, we look into systematic reviews. Systematic reviews are reviews of the literature that are quantitative, not qualitative. We published this systematic review in 2016 in the Physician in Sports Medicine. We've reviewed all the available literature, 413 articles were identified and three articles eventually included into the systematic review. Our conclusions were that few studies assess the effect of sports specialization on injury rate. The level of evidence was low, level three cohort case control studies. Specialization can increase the risk of certain overuse injuries. And the strength of the recommendation was a strong evidence-based and the strength of the recommendation was a sort recommendation B, which is limited quality patient-oriented evidence. Looking now at more recent studies that have been published in 2021, the first study was a survey in baseball, 129 college baseball players divided into low, medium and high early sports specialization by age 13. Croce et al found that the high specialization group had increased risk of shoulder injury, odds ratio 5.42 and increased risk of elbow injury, odds ratio 3.77. The second study looked similarly in elite wrestlers. And this survey was a survey of 143 college and Olympic wrestlers, early sports specialization by age 13 and found a 1.9 time increased risk of injury. Interestingly, this third study from Fromm and colleagues looked in elite male youth soccer players. So over 2000 youth male soccer players from the US development academies, of which 62% had early sports specialization. After controlling for volume, they found that ESS was actually associated with a slightly lower risk of injury with an odds ratio of 0.7. So is the question solved or should we reinvent the wheel? We've been interested in early sports specialization at the McAley Center for Sports Injury Prevention and one of the fundamental questions that we had is it was is it early sports specialization or is it the volume of training? We wanted to look at this with higher level data than survey data so we looked at data in a prospective cohort study, a level two evidence study, and this is the GUT study. The GUT study was established in 1996. Dr. Allison Field was the primary author on this study and the GUT study is the Children of the Nurses Health Study, a large many-year prospective cohort study and in GUTs we have over 9,000 girls and almost 8,000 boys and they were 9 to 15 years of age at baseline and they're followed up periodically through questionnaire data to the mothers who are nurses. These questionnaires ask about injuries such as musculoskeletal injuries shown here and they ask about their sports participation and the level of participation, which seasons and how many hours of participation. This is a chart showing the cumulative incidence of sports injuries in 56-25 boys and 67-74 girls in the GUTs prospective cohort study from 1997 to 2003. And when we published on this previously on the risk of developing a stress fracture fracture and we found that high impact activities had an increased risk of developing a stress fracture in girls. When we looked at developing an overuse injury prospectively, hours per week engaged in specific exercises, we found a number of associations with increased risk of injury based on activity as shown in the yellow boxes. When we looked at the age-adjusted associations of sports specialization and developing an overuse injury, we found multiple associations as well as shown here in the yellow boxes. When we look prospectively at age and activity-adjusted associations of sports specialization and risk of overuse injury and controlling for vigorous activity, we found fewer associations. So in boys, cheerleading, gymnastics, and in baseball, and in girls, an association injury in volleyball. Our conclusion was total volume of activity was a robust predictor of injury. We found that sports specialization led to greater volume of activity, which explained most of the increased risk of injury with sports specialization. And we found that risk may vary by gender, age, and weight status in males. So going back to our two original questions, first, does early sports specialization increase injury risk? I think the data show that it does, but the injuries are mostly overuse injuries and not high consequential injuries in most cases. The second question, does early sports specialization lead to sports advancement? The data show that it does not, that specialized athletes actually are less likely to be successful at the college, professional, and Olympic level. Most successful athletes were not early specialized. They played in multiple sports. And I think this is the fundamental conundrum. We have data showing that early sports specialization leads to increased injury risk, and it doesn't lead to success in sports. So why is this happening? The reasons are multiple. I think we have a youth sports industrial complex that's very big and very organized. And I think we have parents who are confused, and this is the trend. If you want your kid to be successful, and not even to make a college or professional team, but just to make a travel team or make a high school team, the sense is they have to specialize at an early age. Our conclusions, I think in terms of the available literature, we need more studies that assess the effect of sports specialization on injury rate. We have level four, level three survey data. We need more prospective cohort studies. ESS is common. Specialization can lead, increase the risk of certain injuries, particularly overuse injuries, which are in general lower severity. I think future directions include hopefully less position statements and prevalence of ESS, more prospective cohort studies. We need to refine the definition of early sports specialization and look at other covariates. I think a fundamental question is, is it ESS or is it the hours of exposure? We need to think about both the individual risk and the population risk. And we need to assess, could there be benefits in certain sports of early sports specialization, gymnastics, figure skating, et cetera. And then can we get to interventional studies, randomized clinical trials, or efforts to reduce ESS and see what this does to injury rates. A big part of what we need to do is get the message out. And that's not just in the medical literature, but in the lay press. And this is through media, coaches, parents, and athletes. You keep working with the youth sports injury and trying to change overall culture. I think many of these media statements and media programs, when we get involved with them, tend to look at the dark side of sports injuries in children. You can see here in the last five years, fewer kids are active through sports due in part to early single sports specialization. Early sports specialization is killing the health of our kids. And I think these messages are very scary and are very negative. I do think we need to also keep in mind the positive aspects of youth exercise. So medically decreased risk of obesity, diabetes, better cardiovascular and bone health, psychosocially better self-esteem, lower rates of teen pregnancy, drug use, and greater career success later in life. We've worked with the Aspen Institute and Project Play in this concept of a spectrum where active kids do better in life. And this is a virtuous cycle as the active parents then have active kids. And so we need to keep in mind the positive aspects of youth sports and youth exercise. There are many challenges to youth sports and youth exercise, including cost, equity, spaces, casual play. Early sports specialization is one of them, injuries, untrained coaches, and childhood obesity. So from Boston Children's Hospital and Harvard Medical School, thank you very much for listening and participating in this webinar from AOSSM and the STOP Sports Initiative. Thank you. All right. So that was a great talk by Dr. Coker. And I think it really outlines the dilemma as well as the challenge as a provider in the current landscape, which is we know that specialization can certainly increase risk. I think there's a lot of understanding, or excuse me, lack of understanding on the other side that this is also something that will benefit the patient from getting to the end goal of playing at an elite level. And the challenge is how do we implement this in the office? And that's really what we're going to ask Dr. Fine to give us his thoughts on and kind of help us understand how he implements this and how he talks about this in the office. So with that, I'll ask Dr. Fine to speak. Hi, my name is Ken Fine. I am an orthopedic surgeon with a subspecialty in sports medicine. Orthopedic surgeons typically focus primarily on the care of musculoskeletal injuries. However, those of us who specialize in sports medicine must be responsible for the totality of athletic medical care. Many of us are team physicians and care for athletes outside of the usual office or operating room setting. Besides being concerned with the increased risk of overuse injuries due to the overtraining and early specialization in youth sports, we have also recognized that the current intense sports culture is sucking the fun and joy out of sports for kids. Statistics show that 70 percent of kids quit organized sports by age 13 and 76 percent of kids don't participate in calorie burning sports. These statistics don't even account for the lack of unorganized sports or free play for kids that may be even more important and more lacking than organized sports. If we ask why kids quit sports at such a high rate, the main reason can be summarized as that it's not fun. The too serious and too competitive nature of our sports model puts too much stress and pressure on kids. There's too much pressure from parents and coaches and kids lose ownership to have a say in what they want to do. Parents tend to play through their kids. Also, our sports model is shaped like a pyramid where only the more talented or serious athletes continue to play and there is not an opportunity for all the other kids to continue playing through adolescence. Other reasons for kids dropping out of sports include overuse injuries, burnout, too much structured time rather than free play, and not getting enough playing time. The concept of kids at young ages sitting on the bench while the more talented kids get more playing time is mind-boggling. Even if you consider developing talent to be important and teaching life lessons and having fun should be more important than talent and winning, you never know who will be more talented at older ages. For example, both David Robinson and Michael Jordan, depicted on the right, were cut from their high school basketball teams. Not only did both of them go on to play in college and the NBA, but both of them became superstars. Lionel Messi, who some considered to be the best soccer player in the world, was obsessed with soccer and needed no parental pressure to become great. Even though I am going to talk about some negative aspects of our current sports model, it should be clear, especially because our careers center around sports, that sports medicine specialists believe in the importance of sports, especially for children. Kids who play sports are more successful in school, are healthier both mentally and physically, with lower rates of obesity and depression. Sports done in the right way teach teamwork, cooperation, and hard work. I show this picture of Congress with the thought that if our politicians had played more sports, especially in the right way, our political system would probably be more functional. Parents are definitely one of the biggest problems when it comes to youth sports. Even when parents think they are being benign, they are often acting in ways that are damaging to our children. For example, even yelling at the refs or yelling instructions to kids should be avoided. At the most, a parent should say, I love watching you play, and should stay out of any type of coaching. Kids often say that they prefer their grandparents to watch them play rather than their parents, because grandparents are usually happy to sit quietly and just enjoy watching. Youth sports have become a form of socialization and entertainment for parents, which is to the detriment of the kids. It has also become a multi-billion dollar industry, which influences parents and often leads in directions that are not the best for the kids. Many kids feel that their parents' involvement sucks the fun and joy out of their sport for them. In this picture, you can see these hyper-concerned parents watching these kids play soccer. Coaches are another source of difficulty in youth sports. While many coaches have good intentions and may know a lot about their sport, they often don't know how to coach or teach kids. Coaches should therefore be trained. One organization that helps train coaches in the proper approach to youth sports is the Positive Coaching Alliance, or PCA. This slide depicts examples of poor coaching and good coaching. On the lower right is Phil Jackson, who is a major proponent of the PCA. On the upper right is a coach named John Gagliardi. He was the coach of a Division III football team in Minnesota named St. John's and has the record as the winningest college football coach in history. He never cut a player, never had to practice more than 90 minutes, and had only one rule, which was the Golden Rule. So whenever a football coach tells me that in order to win you have to be tough and yell at your players, I ask them how John Gagliardi was able to be the winningest coach without doing these things. Another problem with youth sports is early sports specialization. We have already talked about how early sports specialization can increase the risk of injuries. However, early specialization is also detrimental to youth development and happiness. This quote by J.J. Watt emphasizes this point. He says, if someone encourages your child to specialize in a single sport, that person generally does not have your child's best interests in mind. Specialization is also not necessary to become proficient at a sport, as this list of superstar athletes who played multiple sports attests. In one year, for example, 88% of NFL draft picks were multi-sport athletes. Playing multiple sports in many cases may help an athlete get better in the sport that they may eventually want to focus on. Wayne Gretzky, arguably one of the greatest hockey players of all time, credits his lacrosse experience with teaching him how to avoid checks, which made him a better hockey player. This slide mentions several reasons why early sports specialization is detrimental, but I would like to summarize by saying simply that most kids enjoy variety. Kids like the opportunity to try different sports in different seasons, and these varying opportunities are beneficial for their development. Youth sports have become so out of control, and we have allowed it to happen. One explanation for how this has happened is the analogy of the frog in water. If you put a frog in regular water and slowly heat it, the frog will remain in the water until it eventually dies. If you put a frog into water that is already boiling, it will jump out. Similarly, in the book Lord of the Flies, a group of boys shipwrecked on a deserted island become more and more primitive and warlike. The stark realization about how far they have devolved becomes immediately apparent when the rescuing marines land on the island. The same thing has happened in our youth sports culture. Some have likened what is going on in our youth sports programs to what is done in authoritarian regimes where children are chosen for certain sports and then subjected to strict regimented training. It seems the same thing is happening in our country, but we are doing it to ourselves from the bottom up rather than from the top down. So, how do we fix the problem? We need to emphasize more fun and learning life lessons in sports rather than winning, understanding that failure is also an important life lesson. We should modify parental involvement to a supportive role only and let children have more say in their activities. Children should be encouraged to play multiple sports and have equal playing time. We should avoid specialization in travel teams especially before age 13 and make sure parents are not living their dreams through their children. Some may be surprised about what children themselves say is important to them. High on their list is playing with friends, positive coaches, learning, positive team dynamics, and trying hard. Low on the list are winning, playing in tournaments, cool uniforms, and expensive equipment. The Aspen Institute's Project Play in Baltimore included research on sports that kids wanted to play which often differed from what their parents wanted for the kids. For females, the most wanted sports were gymnastics, swimming, track, basketball, and rock climbing. For boys, the sports they most wanted to play were basketball, baseball, soccer, tackle football, and parkour. The Aspen Institute also studied sports that kids wanted to play in other locations. In Hawaii, the two sports with the most interest were skiing and snowboarding. In Seattle, the sports were martial arts, boxing, surfing, parkour, and lacrosse. In Harlem, in New York City, the sports were ice hockey and fencing. In many locations, the most requested sports were not available or accessible to these children. What can we do to improve youth sports? This slide gives guidelines for children less than 13. Seasons should last no more than three to four months. Travel should be discouraged. Children should try multiple sports, and it is too early to select more talented athletes for special teams. Winning should not be emphasized, and children should try all positions on a sport. Play beyond organized competition, especially free play, should be encouraged. Play should be focused on fun and short-term rewards. This is why kids like playing video games. Focus should be on fun and mastery, not the scoreboard. In thinking about recommendations for youth sports, it is helpful to think about three stages of youth development. The sampling years are between 6 and 12. The specialization years are between ages 13 and 15. And investment should only occur at age 16 and above. These are some precepts from the Positive Coaching Alliance, which strives to promote the proper values in sports. The concept of enjoyment of playing of the game, rather than winning or losing, or getting promoted to the most competitive team, is paramount. This quote from Boris Becker, the tennis player depicted in the lower right, best summarizes what sports should be about. I love the winning, I can take the losing, but most of all, I love to play. Also in this picture, you can see examples of bad coaching and good, positive coaching. Bobby Knight in the black and white picture is obviously an example of what not to do as a coach. And Pat Fitzgerald, the Northwestern football coach, shows what positive coaching is about, and he is indeed a big proponent of the Positive Coaching Alliance. This slide shows some recommendations from the Aspen Institute. We should listen to what kids want. We should emphasize free play and encourage sports sampling. There should be more in-town leaves, as opposed to significant travel, and coaches should be properly trained. Kobe Bryant's quote is important. The most important thing for parents is establishing an element of fun and imagination. I think that's really key. The picture on the right is Ted Lasso, a fictional soccer coach played by Jason Sudeikis. He truly believes that his job as a coach is more about developing good men, rather than winning. This concept should be a cornerstone of good youth coaching, although perhaps things may be a little different at the professional level, which his assistant coach at one point reminds him. This slide illustrates further recommendations for youth sports. We should make sure we have the correct goals, which for most ages should be development and fun. The goals we set for kids should be achievable goals, such as effort, fun, and development, rather than scoring or winning. We should find the right fit for our kids, which might not always be going to a higher level or playing the sport your parents think you should play. Sports should be more like a fun game, with more free play and less regimentation. All athletes should have at least one full season off, and positive coaching should be emphasized. The picture on the lower right illustrates a game that the players I coached love to play called Head Catch. This is a game that I was taught to play with kids and is the kind of thing about which all coaches need to be trained. Some experts believe that the lack of success for U.S. athletes in some sports may be due to the over-professionalization of youth sports. For example, despite the academy system in youth tennis, the U.S. has not produced a men's champion since Andy Roddick in 2003, and we currently have no men ranked in the top 30. In contrast, we do very well in basketball because in addition to formal basketball leagues, kids also play for fun on playgrounds without parents and coaches. So despite torturing our kids with early specialization and over-training, it doesn't help us to become champions. For the same reason, although the U.S. has produced some very good soccer players, we have not yet produced a legitimate soccer superstar. The two American players on the right, Gio Reyna and Christian Pulisic, are excellent players, but at least so far cannot be considered superstars like Lionel Messi and Cristiano Ronaldo on the left. Although many other countries have similar issues in youth sports, many believe that the problem is worse in the U.S. where winning, even at early ages, is considered important. In most European countries, there is no focus on physical development until age 14, and there must be downtime with no more than 42 weeks of sport per year. In Norway, there is no keeping score until age 13. One amazing paradox is that elite athletes limit their training to 30 hours a week, with proper consideration for recovery after matches or intensive training. In contrast, in the U.S., many youth sports have tournaments where kids play 3-4 games in one single weekend. It can be very difficult to figure out how to talk to families about some of these over-training and over-specialization issues in the office setting. It's amazing the panicked looks on the faces of families, especially parents, if the doctor recommends a period of rest or relative rest from sports. It's interesting that the panic is often worse in the parent than it is in the kid. The parent is more worried about the consequences of the kid's missing training time, rather than the health of the kid. One of my approaches is to reassure the family that a period of rest will not hurt the kid's career and actually, in many cases, the rest causes the kid to eventually perform even better because he or she had been over-training. As I will discuss in a few minutes, this is often more important to parents than the risk of overuse injury. I also simply educate the family about some of the ideas that I have been discussing in this presentation. I am careful to do this education in a global manner, rather than accusing the family of doing anything wrong. And actually, it would be wrong to be accusatory because most families, my own family included, are victims of this culture in sports, which is really like an arms race, and unilaterally disarming can be very difficult. Unfortunately, I have found that parents in many cases are not influenced by data or discussions showing the risk of injury, burnout, and lack of joy with over-training in sports. There is the lottery mentality, or the psychology of intermittent positive reward, whereby they think their child is the one that will not suffer from these issues and will get a scholarship or pro-contract. The athletic director of the university whose teams I take care of told me recently that every men's basketball player thinks that they will play professionally. For the most part, parents want their kid to do anything possible to be the best. So I have found that the most persuasive idea for parents is showing them that the over-training that is being thrust upon them is not making them better, and in some cases, is making them worse. Much of the training in sports is based on tradition and not rational science. What is needed is more research to give coaches more scientific guidelines so that they can be more rational in their approach. For example, is it helpful for a 10-year-old swimmer or gymnast to be doing two-a-day practices? Is it helpful that the NCAA now allows Division I basketball players to practice in the summer so that these poor kids never have a significant amount of time off to be with their friends and families? The study referenced here with Barry Bowden as the primary researcher has shown that many football deaths have been caused by irrational training. He is currently working on research studying safer and more rational guidelines for football conditioning programs. All of us in sports medicine, including sports medicine physicians and surgeons, athletic trainers, and exercise scientists should help develop more scientific guidelines for athletic conditioning and skill training. The truth is, how can we expect non-medical people to do the correct thing in sports training if we don't supply them with appropriate medical guidance? It is our responsibility. So how do we disarm? I really don't know the answer to this. I think we'll need some brave people to simply start doing the right thing. As Arlo Guthrie says in the song Alice's Restaurant, if enough people start doing it, it becomes a movement. Some have recommended legislation to protect kids from overtraining. On the left of the slide is an x-ray of the tibia of an athlete with a stress fracture in a case where I had a hard time convincing the family for the need to take some time off from impact activity. I do know some heartening examples of gifted athletes in my region who have resisted forces to go to more advanced teams or transfer to more athletic-minded high schools and have still made it to the college and professional level. I try to tell parents that if kids have the desire and talent, they will be found. So it's more important to let them enjoy their childhood and do what they prefer. Another simple suggestion to parents is to pretend you are a grandparent. This could go a long way to preventing the ruining of youth sports. This is a list of some organizations that can provide resources to help educate about the issues I have presented. Thank you for your attention. All right. That was great, Dr. Fine. Thank you for all those thoughts. And I'm going to have Dr. Logan and Dr. Fine turn their cameras on and kind of have a discussion here. So if there's anyone here that has any questions, please feel free to put them in. We'll bring them up, and certainly we look forward to having a good discussion here. So I want to start with Dr. Logan and Dr. Fine. I think that Ken outlined a lot of great suggestions and kind of things that he does in the office, but I think the practicality of this is we're not going to change the entire landscape of youth sports. And we have to start looking at both on the individual level with the patient in front of you, as well as on kind of the, you know, bigger picture level to work with organizations and other youth leagues to try to make change and help athletes and parents find that balance. So, you know, Dr. Logan, when you talk with a patient and you're trying to have them, you realize it's an overuse injury. What's that like for you? How are you trying to convey to them, you know, that both, yes, it's good to be active in sports, but at the end of the day, you're doing too much. And how do you get them on board with that? I think my approach is to, you know, try and find some common ground, try and not be too extreme of, especially at that first approach to say, you know, this is a total no, this is a never, you need to shut this down completely versus trying to sort of make a little bit of a compromise for that first step, and then sort of grow from there. So, for example, you know, what other sports or activities might actually help them grow with their primary interest or their favorite sport, I think is a good first step into sort of gaining some common ground, because I think to go from zero to 100 on that first visit, it, you know, it's probably not realistic. So, I think the example, you know, would be, you know, what is the shared sort of like fundamental cognitive skills of like different sports. So, if you're playing lacrosse, you know, and one of the skills that you're developing is like how to read the field, how to understand how to move, you know, there's plenty of other sports that do the same thing, you know, whether it's like hockey, you know, and kind of understanding moving behind the net and, you know, what that might change for an athlete and reading the field. So, really just trying to introduce to them, it doesn't always have to be the same exact sport to feel that, you know, you are going to continue to grow and develop and gain potentially advantages by moving away from your sport. Yeah, I think that's a great point and something that I find resonates, you know, with patients that if they think they're going to gain an edge by balancing and diversifying their sport, I think they tend to buy into it pretty well. You know, Ken, as you start extrapolating this to kind of the more, you know, organizational levels and trying to apply this to leagues and things like that, have you ever, you know, talked or worked with leagues and how would you suggest orthopedic surgeons try to do that, you know, as we start globally try to look at this picture in a bigger way? Well, you know, I think in my area where I live, there are leagues that really try to do it in the right way and have good, you know, good values and at least they try. But then there are other leagues that are selling a bill of goods to the parents saying join our league and your kid will get a college scholarship or be a pro and they're not doing the right thing. So, I think we should try to support the better leagues. One of the things that I noticed recently is Dominique Dawes, who is an ex-gold medal winner in gymnastics for the U.S., has set up a gym basically in my neighborhood and she has really been vocal about trying to do things the right way and literally says I want the kids walking out the door at the end of our practice to have a smile on their face in her opinion. And I would have to agree on what I've seen. There are many gymnasts who are really kind of, they work hard and they have friends and they to some degree enjoy it, but there's a lot of pain, both emotional and physical in the gymnast and she's trying to do it a different way. And I think we should encourage those types of things. Yeah, I think in many ways the simple lesson and the obvious thing, you know, really goes a long way. And I think that makes sense, I think, to everybody. I think when you see it in practice, sometimes that's where it differs and, you know, I want to be clear, obviously there's a number of benefits to youth exercise and sport involvement and we're trying to help counsel the athletes and the parents and the coaches we take care of to find that balance. And I think what we all see in our line of work is often the pendulum has swung so far one way, and we're seeing many of those athletes that, you know, you really, sometimes it's disheartening because you're trying to find and encourage athletes to have that balance. And that's, I think, what we're all trying to do and what I think we did well with the topics tonight to really, you know, define that, hey, this is a problem, this is something that we're all struggling with. And then as we look to, you know, ways to develop programs, to facilitate research, I think that's where we can all in our society continue to work on that. One of the things I think that certainly for a throwing athlete, you know, the Pitch Smart program and giving data to leagues, I think, has been really successful. But frankly, we need to, you know, extrapolate that to other sports and try to do that in many ways, almost as a model based on the baseball, you know, model that they have. So I don't know if you guys have any thoughts on that or, you know, how we extrapolate this to a number of different sports, which all have different nuances of challenges that you're going to run into. Yeah. I mean, I completely agree. Obviously, baseball is, at least for throwing, is a little bit easier, right? Because there's a discrete number of pitches or throws that you can talk about and it's not as concrete in other sports. But I really do think we need some data to show what the optimal amount of training is. And there's two parts of the training, right? There's the skill training, how much do you need and how, and then there's just conditioning, strength and endurance. And, you know, I think that we're going to find out that in the irrationality of what we're doing, which is just tradition, not based on science, we are actually doing way too much, even if our goal is to actually optimize the talent of an athlete or the ability of an athlete, which maybe shouldn't be our goal. But even if that were the goal, I think we need some more science. So coaches and trainers, you know, team conditioning coaches know the right things or the best things to do. And I think it's a little bit easier, say, when you get to, and I'm thinking about the Olympics now, track and field or swimming, I mean, they know what to do to optimize the speeds of those athletes. And it's maybe a little bit more of an easy thing, but when it comes to other sports like gymnastics or soccer or tennis, we don't really know what the optimal amount is. Yeah. Any thoughts, Katherine? Yeah, no, I agree. I think we can't really expect the community of coaches, athletic trainers, therapists, whatever it might be to sort of stay within guidelines if we don't present guidelines. So I think whether, you know, we have a good understanding of pitch count, but if you look at analogous things, you know, again, back to lacrosse, like how much, how many times should they shoot, you know, in a given practice? You know, we've no understanding of that at all. And it's a very similar asymmetric type of sport. So I think there's a lot to learn. And also there's a lot of gender differences to really pan out to that haven't been explored. So I think, you know, we, you know, are sort of presenting these, don't specialize, don't do this, but we also have to sort of, as a community, put together more research to get a better understanding. And then also there's plenty of sports that we don't really know what the specialization data is. So when are these different athletes specializing, the ones that end up playing in college or professional organizations? We don't have that across the board for all sports. We have it for a handful of sports. So I think that's a, you know, sort of an open area for people to start to conduct some research. Yeah. Well said. So I think we're just at the time here, we're at nine o'clock in my time. So, you know, I want to thank the presenters tonight, Dr. Logan, Dr. Fine, and Dr. Coker for their really great presentations. I think as with many things, you know, we are starting to understand and define the problem, but really the solution is continuing to be out there and something we're going to talk about probably every day in the office when we see patients and continue to focus on the research that will continue to define this. So again, I appreciate everything from AOSSM and the STOP Committee for putting this together. Thank you everyone for their attention and for joining in. We look forward to talking again soon. Thank you.

early sports specialization

youth athletics

balance sport participation

limit injury risk

orthopedic surgeon

sports medicine

diversifying sports activities

multiple sports

parental involvement

coaching practices