1056088

research-article2021
SPHXXX10.1177/19417381211056088Jayanthi et alSPORTS HEALTH

Jayanthi et al Jan • Feb 2022

Developmental Training Model for the

Sport Specialized Youth Athlete:
A Dynamic Strategy for Individualizing
Load-Response During Maturation
Neeru Jayanthi, MD,*†‡|| Stacey Schley, MD,‡ Sean P. Cumming, PhD,§
Gregory D. Myer, PhD, CSCS*D,‡||¶# Heather Saffel, MD,** Tim Hartwig, PhD,††
and Tim J. Gabbett, PhD‡‡§§

Context: Most available data on athletic development training models focus on adult or professional athletes, where
increasing workload capacity and performance is a primary goal. Development pathways in youth athletes generally
emphasize multisport participation rather than sport specialization to optimize motor skill acquisition and to minimize injury
risk. Other models emphasize the need for accumulation of sport- and skill-specific hours to develop elite-level status.
Despite recommendations against sport specialization, many youth athletes still specialize and need guidance on training
and competition. Medical and sport professionals also recommend progressive, gradual increases in workloads to enhance
resilience to the demands of high-level competition. There is no accepted model of risk stratification and return to play
for training a specialized youth athlete through periods of injury and maturation. In this review, we present individualized
training models for specialized youth athletes that (1) prioritize performance for healthy, resilient youth athletes and (2) are
adaptable through vulnerable maturational periods and injury.
Evidence Acquisition: Nonsystematic review with critical appraisal of existing literature.
Study Design: Clinical review.
Level of Evidence: Level 4.
Results: A number of factors must be considered when developing training programs for young athletes: (1) the effect
of sport specialization on athlete development and injury, (2) biological maturation, (3) motor and coordination deficits in
specialized youth athletes, and (4) workload progressions and response to load.

From †Departments of Orthopaedics and Family Medicine, Emory School of Medicine, Atlanta, Georgia, ‡Emory Sports Medicine Center, Johns Creek, Georgia, §Department for
Health, University of Bath, Bath, United Kingdom, ||Emory Sport Performance and Research Center, Flowery Branch, Georgia, ¶Department of Orthopaedics, Emory University
School of Medicine, Atlanta, Georgia, #The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts, **South Bend–Notre Dame Sports Medicine Fellowship,
Beacon Bone & Joint Specialists, South Bend, Indiana, ††School of Behavioural and Health Sciences, Strathfield Campus, Australian Catholic University, Strathfield, New
South Wales, Australia, ‡‡Gabbett Performance Solutions, Brisbane, Queensland, Australia, and §§Centre for Health Research, University of Southern Queensland, Ipswich,
Queensland, Australia
*Address correspondence to Neeru Jayanthi, MD, Emory Sports Medicine Center, 6335 Hospital Parkway, Suite 302, Johns Creek, GA 30097 (email: neeru.jayanthi@emory
.edu) (Twitter: @NeeruJayanthi).
The following authors declared potential conflicts of interest: N.J. received hospitality fees from WTA Medical advisor Player Development Panel, USTA Sport Science
Committee; has received American Medical Society for Sports Medicine Foundation grant $20,000 for Injury Outcome Study in young athletes; Emory Intramural grant (for
same study); royalties from Up To Date Royalties (topic tennis/golfer’s elbow); and payments for lectures from Washington University CME. S.P.C. is a consultant of Premier
League, reports grants from ESRC FA British Academy, and has received payment for development of educational presentations from FA. G.D.M. has consulted with commer-
cial entities to support application to the US Food and Drug Administration but has no financial interest in the commercialization of the products. G.D.M.’s institution receives
current and ongoing grant funding from National Institutes of Health/NIAMS Grants U01AR067997, R01 AR070474, R01AR055563, R01AR076153, R01 AR077248 and
has received industry-sponsored research funding related to brain injury prevention and assessment with Q30 Innovations, LLC, and ElMinda, Ltd. G.D.M. receives author
royalties from Human Kinetics and Wolters Kluwer. G.D.M. is an inventor of biofeedback technologies (2017 Non Provisional Patent Pending–Augmented and Virtual reality
for Sport Performance and Injury Prevention Application filed 11/10/2016 (62/420,119), Software Copyrighted) designed to enhance rehabilitation and prevent injuries with
potential for future licensing royalties. T.J.G. is a consultant to high-performance organizations.
DOI: 10.1177/19417381211056088
© 2021 The Author(s)

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Conclusion: Load-sensitive athletes with multiple risk factors may need medical evaluation, frequent monitoring, and a
program designed to restore local tissue and sport-specific capacity. Load-naive athletes, who are often skeletally immature,
will likely benefit from serial monitoring and should train and compete with caution, while load-tolerant athletes may only
need occasional monitoring and progress to optimum loads.
Strength of Recommendation Taxonomy (SORT): B.
Keywords: young athlete; single sport; competition; injury prevention

H
istorically, participation in sport, including modest A theoretical approach for assessing risk and determining
amounts of athletic developmental training, has been workload progression through different developmental periods
associated with positive experiences and low injury is also provided (see the Appendix, available in the online
rates in adolescents.55 However, youth athletes are now version of this article). Evaluating each of these 4 components
increasingly engaging in higher volumes of sport-specific may allow for appropriate risk stratification and
training at an earlier age. There is also a rise in the number of recommendations on workload progressions and return-to-play
young athletes aiming to maximize performance-related goals strategies after injury.
by training and competing in a single sport,88 with
approximately 30% of young athletes highly specialized.47
A recent Delphi study defined sport specialization as: “. . . Sport Specialization and Athlete
Development
intentional and focused participation in a single sport for a
majority of the year that restricts opportunities for engagement A number of development pathways have been proposed
in other sports and activities.”5 While there exist little data to regarding sport selection and training of young athletes for
support a specific age of early sport specialization, this has success. These include sport sampling, accumulation of a
been suggested when a young athlete chooses a single sport substantial number of hours of training through specialized
before the age of 12 years.49 Early specialization has been sampling,15 and early sport specialization. Sport sampling
estimated in some studies to occur during prepubescent stages promotes participation in a variety of sports through
with mean ages of 10.4 years in tennis45 and 9 years in soccer.26 preadolescent and adolescent stages of development to improve
Sport specialization has been associated with increased risk long-term athletic development.15 Specialized sampling, which
for overuse injury and burnout3,8,36,48,63,85 and with an estimated involves a greater emphasis on domain-specific sport-related
60 million children participating in sports, it is now considered activities, has been evaluated in youth soccer players where it
a public health issue.3,48 While many medical and sport was shown to lead to higher likelihood of elite-level success.91
organizations recommend against sport specialization prior to Early sport specialization and focus on a single sport prior to
middle or late adolescence,6,11,23,49,52,103 the perception by young adolescence has been advocated by some stakeholders in the
athletes and parents that specialization improves athletic youth sports industry to theoretically enhance athletic success,
performance and long-term athletic career prospects means that but with little data to support this claim.48,49
while risks of injury and burnout may exist, some are willing to There is conflicting evidence relating to early specialization
specialize to increase their chances of success.4 and future sporting success. Nevertheless, there is a trend
Therefore, substantial numbers of youth athletes continue to toward earlier specialization in many sports (eg, gymnastics,
specialize and would benefit from individual guidance on how to tennis, swimming, diving, and soccer).88 Despite the popularity
effectively train through growth periods and adolescence to limit of specialization in a single sport at a young age, a recent
injury risk and continue to be successful. To our knowledge, a systematic review demonstrated no superior benefit on task or
model that assists sports medicine practitioners to individualize career performance in populations of specialized athletes and
training programs for specialized youth athletes based on the multisport athletes.48 These findings have led multiple some
athlete’s response to training load has not been fully developed. experts to suggest that diverse, multisport participation may
A theoretical framework was recently introduced by the authors result in enhanced skill acquisition and limit the potential risks
to offer different load progressions based on a youth athlete’s of injury.4,15,47,48
load tolerance but did not incorporate a number of other relevant A number of sports medicine organizations have
factors.46 In this article, we evaluate 4 key areas that underpin a recommended against sport specialization prior to middle or
novel athlete development model that could improve the late adolescence. Most of these organizations cite injury,
effectiveness of training young specialized athletes: (1) sport burnout, and potential for long-term health effects, although the
specialization and athlete development, (2) biological maturation data for long-term health consequences of sport specialization is
and utilization of percentage of predicted adult height, (3) motor relatively scarce. While the International Olympic Committee
deficits and neuromuscular training, and (4) recommendations for generally discourages early sport specialization, it also
overall workload progressions (including competition:training acknowledges that “appropriate diversity and variability of
load ratio). athletic exposure within a single sport, while supporting

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Table 1. Degree of sports specialization and risk of all-cause injurya

Risk of Serious Risk of Acute

Degree of Specialization Risk of Injury Overuse Injury Injury
Low specialization (0 or 1 of the following): Low Low Moderate
Year-round training (>8 months per year)
Chooses a single main sport
 Quit all sports to focus on 1 sport or have only ever played
1 sport
Moderately specialized (2 of the following): Moderate Moderate Low
Year-round training (>8 months per year)
Chooses a single main sport
 Quit all sports to focus on 1 sport or have only ever played
1 sport
Highly specialized (3/3 of the following): High High Low
Year-round training (>8 months per year)
Chooses a single main sport
 Quit all sports to focus on 1 sport or have only ever played
1 sport
a
Adapted with permission, from Myer et al.78 Copyright 2015.

sufficient learning of foundational skills and sport-specific stress fracture, navicular bone stress injury, etc).20 While it is
technique and biomechanics to minimize injury risk and critical to recognize and treat these injuries early (which likely
optimize performance, can be acceptable and healthy.”6 involves complete cessation of sport), other lower risk injuries
Many youth athletes are still choosing to specialize in a single such as muscular injuries, apophysitis, and anterior knee pain
sport. For these athletes, success may be achieved through syndromes may only require modification of workloads during
specialized pathways with the proper guidance.6 Unfortunately, rehabilitation, followed by staged progressions in training load.
there has been little guidance for athletes who specialize in a Despite these injury risks, health-related quality of life of
single sport at younger ages than recommended, leaving a large specialized young athletes may be high and equivalent to
gap in evidence for minimizing injury risks and training young, multisport athletes if they have mental resilience and a supportive
specialized athletes. parental environment.16 In fact, even sport-related injury in young
athletes has mixed effects on health-related quality of life indices
Overuse Injury Risk and Sport Specialization with a recent study reporting only a mild decrease in mobility in
Sport specialization has been defined on a continuum, and a young athletes with overuse injury, but otherwise no significant
degree of specialization can be used to stratify young athletes differences from the general pediatric population.16 Despite
and subsequent injury risk with the following factors: (1) theoretical risks, there is currently limited evidence to suggest that
choosing 1 main sport, (2) quitting all other sports, and (3) sport specialization results in more long-term negative health
training and competing >8 months in 1 year in 1 main sport.47 effects than multisport participation approaches.
Highly specialized athletes are those that choose 1 main sport, When accompanied by movement diversity and variability of
quit all other sports, and train/compete >8 months per year.47 athletic exposure, participation in a single sport may result in
This high degree of specialization has been associated with positive health outcomes.6 As such, in some instances, early
greater overall injury risk, specifically overuse, and serious specialization might be appropriate. It is likely that the influence of
overuse injury risk but not acute injury risk (Table 1).47 sport specialization on athlete development and injury risk is sport
Overuse injuries comprise >50% of injuries in young specific, and data are emerging on these risks.8,26,45 There may be
athletes,16,20,47,92 and these injuries can also be classified by their different times of optimal entry into sport based on the sport
level of risk. Serious overuse injuries have been defined as those type.78 Additionally, there are a number of factors that may
where the athletes’ physician recommended they stop sports for influence the inherent risk of injury with sport specialization (Table
1 month or longer (eg, bone stress injuries, and osteochondral 2). Consequently, certain individual athletes may carry more risk
injuries).47 High-risk overuse injuries were defined by the for overuse injury in the setting of sport specialization than others.
American Medical Society of Sports Medicine as injuries that Recommending that youth athletes avoid early specialization may
have a propensity to need surgery (eg, fifth proximal diaphyseal be an oversimplification that ignores the importance of providing

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Table 2. Sport specialization factors influencing risk for injury

High Risk Lower Risk

• High socioeconomic status • Low socioeconomic status
• Geographic location: suburban • Geographic location: rural
• Female gender • Male gender
• Overuse injury • Acute injury
• Earlier sport specialization (before adolescence) • Later sport specialization (after adolescence)
• Individual, skill-specific sports (gymnastics, dance, tennis) • Team sports (soccer, football, volleyball)

specialized youth athletes with training and competition guidance individuals experiencing the growth spurt well in advance or
and monitoring through vulnerable periods. delay of their peers.56 During this phase of development, youth
experience rapid gains in stature and then mass, typically
What Environments Can Give Early Specialized peaking between 9 and 10 cm per annum in boys and girls.100
Athletes the Best Chance of Success?
An equivalent growth spurt in mass occurs 6 to 9 months later,
Although early specialization has been associated with negative with girls and boys experiencing peak gains of approximately 8
outcomes, there are some general guidelines that can be to 10 kg per year.100 Pubertal gains in mass occur predominantly
followed to provide specialized youth with the best as a result of increases in fat and fat-free mass (ie, muscle,
environment for physical and psychological development, skeleton, soft tissues, organs); however, there is variance
reduced injury risk, and long-term sporting success. First, a between the sexes.58 Whereas girls experience greater gains in
well-rounded training program that includes strength, absolute and relative fat mass during puberty, boys experience
conditioning, and sport-specific skills should be a priority. greater gains in absolute and relative lean mass.58 Percentage of
Targeting physical qualities that are protective against injury (eg, predicted adult height (PPAH), using methods advanced by
muscular strength and aerobic fitness)32 and associated with Malina et al57 (requires assessment of child’s age, height, mass,
improved performance94 represents an appropriate use of and midheight of biological parents) and growth rates (height
training time. Allocating training time to interventions that are and mass) can be used to estimate when athletes are entering
known to decrease injury risk (eg, integrated neuromuscular and exiting the adolescent growth spurt (Figure 1). For
training)65 should be encouraged. example, PPAH values can be used to estimate age at take-off
Second, in the off-season, highly specialized youth athletes (85%), the interval of peak height velocity (PHV) (~91%), or the
with an athletic development pathway within a single sport end of the deceleration phase of the adolescent growth spurt
should be encouraged to play a different sport. While this might (~96%).89 A percentage band (~85%-96% of PPAH) was shown
seem contradictory to the premise of specialization, there are to correctly identify 91% of players as being within or outside
some advantages and these are unlikely to undermine the adolescent growth spurt in a longitudinal study of academy
investment in their main sport. Participation in a secondary sport soccer players.82
provides a break from the repetitive movements of their primary The prevalence of overuse injuries across youth sports
sport (eg, repetitive throwing, hitting, or jumping activities), may programs ranges from between 37% and 68%.20 Overuse injuries
result in the development of more adaptable movement are especially common during the adolescent growth spurt and
patterns,18,79 has been associated with superior perceptual include Sinding-Larsen-Johansson syndrome, chondromalacia,
expertise (decision making and ability to “read the play”),7 and Osgood-Schlatter and Sever disease, osteochondritis dissecans,
may help protect against some factors associated with burnout.35 and lower body stress fractures. The majority of these injuries
relate to the physeal plate, and their occurrence follows a
pattern of distal-to-proximal growth.20,68 Retrospective analysis
Biological Maturation
of maturation and injury incidence in academy footballers
The adolescent growth spurt is recognized as a stage of reveals that cases of Sever disease (ie, heel) cluster around the
development when athletes are more susceptible to certain start of the growth spurt (85% PPAH), whereas the peak
types of injury, specifically those injuries associated with the incidence of Osgood-Schlatter disease (knee) approximates the
growth plate and overuse.64 Onset of the growth spurt typically peak of the adolescent growth spurt (89% PPAH).68 In contrast,
occurs at 9 to 10 years of age in girls and at 11 to 12 years in cases of spondylosis (lower back) tend to cluster around the
boys, yet this can vary substantially across children with some deceleration point of the adolescent growth spurt (96% PPAH).

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Figure 1. Use of PPAH (EASA) to determine location in adolescent growth curve. EASA, estimate adult stature attained; PPAH,
percentage of predicted adult height; YPHV, years from peak height velocity.
Reproduced with permission from Towlson C, Salter J, Ade JD, et al. Maturity-associated considerations for training load, injury risk, and physical performance
in youth soccer: one size does not fit all. J Sport Health Sci. 2021;10(4):403-412. doi:10.1016/j.jshs.2020.09.003. Copyright 2021.102

Bio-Banding encouraging, further research is required to validate these

A number of strategies can be employed to reduce the risk of findings, to better understand how changes in training load and
overuse and acute injuries during the adolescent growth spurt, content may mitigate injury risk through the adolescent growth
including the routine measurement of growth and maturation, spurt. It is equally important to consider the impact of pubertal
the prediction and identification of the adolescent growth spurt, timing, as youth who experience growth spurts at an older age
the monitoring of injury symptomology, and the prescription of may be at greater risk because of increased training load and
developmentally appropriate training programs (load and competition demands. The period of growth prior to and during
content). Jan Willem Teunissen, a former movement scientist at the PHV is when an athlete may be most vulnerable to injury
Ajax Football Club (AFC), widely recognized as one of the and when it is most important to modify training and
world’s leading soccer academies, described a bio-banded (ie, competition loads.
maturity matching) training intervention108 that was employed to
Motor and Coordination Deficits
help academy players transition more effectively through the
adolescent growth spurt and reduce injury risk. Players entering Sport specialization has typically been associated with overuse
the growth spurt were assigned to a “conditioning program” that injury, while neuromuscular deficits are primarily thought to be
involved reductions in training load and activities that involved a major contributor to acute injury such as anterior cruciate
significant amounts of acceleration and deceleration. These ligament (ACL) tears. Coordination deficits have recently been
changes were coupled with an increased emphasis on activities identified in specialized, young female athletes.19 This could
that developed and/or maintained coordination, balance, core potentially draw a theoretical association with sport
strength, and mobility and involved the retraining of specialization and acute injuries such as ACL tears. Risks of
fundamental and sport-specific skills.108 Applying an equivalent acute knee injuries such as ACL tears are reduced with proper
bio-banding strategy across a competitive season, sports neuromuscular training83 and to an even greater extent when
scientists at AFC Bournemouth reported marked reductions in applied in younger athletes.81 Neuromuscular training, targeting
both injury incidence and burden among players who were coordination deficits that increase injury risk, may ultimately
within the adolescent growth spurt (Cumming SP. Advances in prove useful for reducing the incidence of both acute and
the study and consideration of growth and maturation in youth overuse injuries in young athletes.40,41,70-77,80,81,93,95-99
football. Paper presented at: Manchester United Football Club A recent study examined relative hip and knee joint angular
Sports Science and Medicine Conference; November 13, 2020; motion variability among adolescent female sport-specialized
Manchester, UK). Although the results of these studies are and multisport athletes to determine how sport specialization

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may affect motor coordination acquisition in young athletes.19 Alternative solutions to sports specialization, including planned
Via questionnaire data analyses, sport-specialized athletes were diverse motor skill opportunities and strength development
defined as having ≥2 years of participation in 1 sport and fewer during the growing years, combined with planned integrative
than 2 years participation in any other sports. The sport- neuromuscular training, may help optimize the potential for
specialized group exhibited increased variability in hip flexion/ success in young athletes.6,24
knee flexion coordination, knee flexion/knee abduction, and
knee flexion/knee internal rotation while landing during a drop
vertical jump task.18 The authors concluded that these altered Overall Workload and Training
Load Progressions
coordination strategies involving the hip and knee joints, which
may underpin unstable landings, inefficient force absorption Competition to Athletic
strategies, and/or greater contact forces, can place the lower Development Training Ratio
extremities at higher risk of injury in athletes who specialized Talented youth athletes have opportunities to train and compete
earlier in their young careers.18 for a number of different teams or representative levels within
In the largest investigation to date, 782 soccer, basketball, and their primary sport and some late specializing athletes
volleyball players were classified as prematurational at the initial participate in more than 1 sport. This presents challenges that
visit, were followed longitudinally, and then were reassessed at are unique to youth athletes. For example, managing individual
a second visit in which they were classified as player load and recovery to optimize performance and health of
postmaturational.10 In this longitudinal cohort, sport-specialized youth athletes requires a coordinated approach across various
athletes exhibited a smaller increase in peak knee extensor teams, representative levels, and sports not typically required for
moment (desirable sagittal plane power) and a larger increase elite adult athletes.10,90 These challenges, along with the
in peak knee abduction moment (injury risk–related frontal tendency for stakeholders in youth sport to prioritize short-term
plane load) across visits compared with the multisport group.19 performance achievements over long-term athlete
Thus, sport specialization before pubertal maturation may development,20,69 mean that some talented youth athletes are at
promote worsened biomechanics that can propagate through risk of experiencing high training and competition loading,
maturational development in young athletes. insufficient recovery, and a high competition-to-training ratio.
Children who specialize early (eg, prior to maturation) in a This might be especially true for specialized youth, for whom a
single sport may execute less diverse movement capacity even main goal of participation may be to reach elite-level status.
within a given sports skill execution. This theory of shunted Substantial research has explored the relationship between
diversity in movement skills was evaluated in a soccer-specific training load and negative health outcomes, including injury.21
virtual reality header assessment to characterize the movement The role of competition-to-training ratios within overall load has
of young athletes who were grouped by their degree of sport received comparatively little attention. One of the earliest
specialization (Riehm C, Bonnette S, Riley M, et al. Movement models of long-term athlete development recommended that
complexity differentiates specialized and non-specialized youth progress from a competition-to-training ratio of 25:75
athletes in a virtual reality soccer header task. Paper presented during early adolescence to a 50:50 ratio in late adolescence.2
at: The 14th Annual Emory Sports Medicine Symposium; May Importantly, competition-specific training was intended to be
1-2, 2021; Atlanta, GA). During the virtual reality header task, included in the proportion of time spent in competition. For
the early specialized and nonspecialized athletes demonstrated example, minutes of time spent in game-based training drills
differences in gross body movement complexity during the should be included as competition minutes. The value of these
soccer-specific header task. Specifically, the nonspecialized recommended competition-to-training ratios have not been
athletes exhibited more complex movement profiles during the empirically tested, and optimal ratios are likely to vary by sport.
soccer header than the specialized athletes (Riehm et al, The Other widely implemented youth athlete development
14th Annual Emory Sports Medicine Symposium). Although not frameworks14,34 and consensus statements6 do not make specific
empirically tested in their study, the authors postulated that the recommendations for competition-to-training ratios but
more complex movements of the nonspecialized athletes, over generally advocate that youth athletes aspiring to transition to
time, would lead to a lower likelihood of overuse injury due to elite representation progress training in order to develop the
less homogenized muscle activation patterns, while the competencies required to perform in higher levels of
constrained movements in specialized athletes may increase competition. Consequently, exposure to a higher competition
chronic joint load and increase risk of overuse injury (Riehm load or competition at higher levels without first accomplishing
et al, The 14th Annual Emory Sports Medicine Symposium). the goals of focused, intensified training is discouraged
Without opportunities to naturally experience a variety of load (Cumming SP. Advances in the study and consideration of
adaptive stimulus from sport diversification during maturation, growth and maturation in youth football).14,34
youth athletes may not fully develop neuromuscular patterns A number of studies have explored the training and
that may be protective against injury and potentially develop competition practices of youth athletes, but very few of these
movement strategies that increase injury risk.17,19,25,36,40,72,86 have distinguished the separate contributions to load of training

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and competition. Studies also typically report group average Adolescents Are Not Mini Adults!
training and competition loads making it difficult to determine In an attempt to understand the positive and negative effects of
the competition-to-training ratios of individual athletes. training, we recently systematically reviewed the relationship
Information on individual athletes would be particularly useful between workloads and physical performance, injury, and
because it is the most talented individuals who are more likely illness in adolescent athletes.33 Of the 23 articles that met the
to represent different teams, participate in different selection criteria, only 4 were associated with negative
competitions, and even play different sports.1 This pattern of outcomes. Of these,
participation is likely to disproportionately increase competition
exposure. In a small number of studies that have reported •• greater training duration and poorer stress/recovery scores
training and competition loads, and also highlighted individual were associated with greater illness12
athlete loads, there are some examples of youth experiencing •• rapid increases in training load were associated with
very high competition loads.37,38,84 In studies of youth rugby increases in injury rates30
players, Hartwig et al37,38 and Phibbs et al84 showed that in some •• greater increases in training load led to more groin pain53
weeks during a season some individual athletes played between •• 1.0% to 3.8% of athletes (1) were both highly stressed and
3 and 6 competitive matches. Competition-to-training ratios poorly recovered; (2) had high training volumes and were
were not reported in these studies. poorly recovered; or (3) had high training volumes, were
The impact of high competition-to-training ratios on youth highly stressed, and poorly recovered.39
athlete health and performance is not known, but negative
outcomes are possible.13,37,59 Across a wide range of sports, These findings suggest that (1) negative responses to training do
youth competition injury incidence is consistently higher than happen, but not often (at least not commonly researched and
injuries sustained during training.13,59 Competition, but not reported) and (2) clearly there is a point where training (and
training workloads, increases injury risk in youth team sport other physical activity) shifts from providing benefits to
athletes.37 A recent study showed a 32% higher match volume in becoming a problem.
youth rugby players who sustained an injury than those who When training youth athletes, 1 factor (among many) that
did not, whereas there were no differences in training volumes warrants consideration is age. When prescribing training load,
between injured and noninjured players.37 Also, in this study practitioners often refer to age-appropriate training. We can think
each 1-hour increase in weekly match volume increased injury of age in 3 ways: (1) chronological age, (2) biological age, and
risk by 41% (odds ratio = 1.41; 95% CI = 1.14-1.74; P = 0.001). (3) training age. Age is a moderator of the training load–injury
One interpretation of these findings is that spending a high relationship. In other words, depending on their chronological
proportion of time in competition results in athletes’ spending age, athletes have a better (or worse) ability to tolerate training
insufficient time preparing physical capacities during training. load. However, the moderating effect of age is not limited to
These physical capacities are likely to be protective against chronological age. Training age (analogous to training history)
injury and to ensure athletes are prepared for the demands of and biological age can also affect an athlete’s ability to tolerate
competition.31 training load. PHV (where maximum rate of growth occurs) is
Compared with training, competition also increases exposure commonly associated with increased injury risk.87,105
to injury risks that are nonmodifiable. For example, in many A recent study investigated anthropometric measures and
team sports, collision events contribute disproportionately to growth as risk factors for overuse injuries in youth (aged 10-15
injuries.27 As these inciting events are usually unavoidable, the years) soccer players.87 An increase in leg length over the
risk of collision injuries increases with increasing exposure to season was associated with an increased risk of overuse injuries.
competition. Interestingly, the risk of collision injuries and also In another study, van der Sluis et al105 examined the relationship
overuse injuries may actually increase during adolescence as a between adolescent growth spurts and overuse injury. Later
result of a developmental shift toward greater risk-taking maturing players had a higher incidence of overuse injury than
behavior.9,22 For example, in a study of talented youth tennis their earlier maturing counterparts both in the year before PHV
players, higher risk-taking behavior was related to a higher and the year of PHV. Players were especially susceptible to
number of time-loss overuse injuries and to higher overuse injury between 13.5 and 14.5 years of age. Common
severity.104 A culture of risk taking during sports competitions recommendations for training adolescent athletes include (1)
along with an increased tendency for the developing youth monitoring age-specific anthropometric and growth-related risk
athlete to take risks provides further evidence for the need for factors and (2) minimizing abrupt changes in training load
practitioners to carefully monitor competition-to-training ratios. during these growth spurts.
Practitioners can easily calculate competition-to-training ratios
by determining the number of minutes spent in these activities Increasing Capacity Involves More Than
each week. While there are no clear guidelines for prescribing Simply Progressing Training Load
optimal ratios, practitioners in specific sports will likely be able Although progressive and gradual increases in training load are
to determine when competition is being disproportionately known to improve load-capacity,31 health factors can also
prioritized over training. influence performance and injury outcomes.106 For example,

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Figure 2. Workload progression flowchart for uninjured and injured elite specialized youth athletes.

academic and emotional stress,44 anxiety,51 and stress-related maximize positive outcomes (ie, fitness, performance), while
personality traits54,101 all increase injury risk. Furthermore, 1 study minimizing negative outcomes (ie, fatigue, burnout, injury).
showed that adolescent athletes who slept fewer than 8 hours Decisions on training load progressions may be based on
per night were 1.7 times more likely to sustain an injury than whether the athlete is injury-free, at low risk of injury, or at
those who slept 8 or more hours per night.67 In a study of 496 higher risk of injury. Athletes need to progress from their
adolescent athletes from 16 different sports, sudden increases in current capacity (ie, their “floor”) to the capacity required of the
training volume and intensity combined with a reduction in sport (ie, their “ceiling”).28 The rates of progression may vary
sleep volume were associated with a 2.3-fold higher injury based on risk stratification, particularly the presence or lack of
risk.107 Given that adolescents can be particularly vulnerable to injury. Athletes with lower risk injuries may continue to load
poor sleeping habits, academic stress, and psychological stress, and progress, but with a modified ceiling, while athletes with
these factors should be considered when planning and higher risk injuries need to be evaluated and return to play with
prescribing training programs for these individuals. a slow rate of workload progression (Figure 2).
The training dose-response is of importance to coaches and Although higher chronic training loads have been associated
practitioners in order to determine the optimum training load to with better performance43 and lower injury risk42,43 in adults,

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Figure 3. Youth Athlete Action Plan: risk stratification and return to sport for the specialized adolescent athlete. ACWR,
acute:chronic workload ratio; PPAH, percentage of predicted adult height.

both low and high training loads are associated with greater risk differences in training age. Importantly, adolescent athletes do
of injury50 and poor well-being66 in adolescent athletes. not need excessive training loads to elicit positive training
Performance changes in response to a conditioning program in adaptations. These findings, taken with those of others,107
adolescent (mean age = 16.9 years) and adult (mean age = 25.5 suggest that prescribing moderate training loads with small
years) athletes have been investigated.29 Despite having lower fluctuations is best practice for most adolescent athletes.
training loads, adolescent athletes exhibited greater
improvements in maximal aerobic power and muscular power. Developing Load-Capacity in
Collectively, these results demonstrate that adolescent and adult Specialized Adolescent Athletes
athletes adapt differently to a given training stimulus and that Several factors (eg, age, injury history, training history, lower-
training programs should be modified to accommodate body strength, and aerobic fitness) moderate the
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workload-injury relationship, resulting in some athletes having •• More rapid progressions in workload can be prescribed in
greater load tolerance than others.60-62 Consequently, these skeletally mature, load-tolerant young athletes, while changes
historical factors, along with information on sport specialization in workload should be smaller for load-naive (skeletally
risk, PHV, and motor and coordination deficits can be used to mature) or load-sensitive young athletes. (SORT B)
prescribe and manage training loads in load-tolerant (low risk),
load-naive (moderate risk), and load-sensitive (high risk)
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