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In the past 20 years, competitive youth sports have changed considerably.

Participation is higher than ever: 76 percent of children aged 6-12 and 73 percent of children 13-17 reported playing an individual or team sport in 2020. With more participation, there’s also greater pressure on young athletes to succeed. For highly competitive athletes, sports are played earlier and more intensely than previous generations. And while high school athletes used to play three different sports in the fall, winter and spring seasons, more are opting for single-sport specialization. Children as young as pre-pubescent ages are participating in year-round club teams and academies.

All of this adds up to more opportunities for play, but also potential problems for young athletes.

“All of us in Sports Medicine love sports – many of us are former competitive athletes ourselves, and we know that sports can help young people thrive physically, mentally and socially,” said Michael Maloney, M.D., chief of the Sports Medicine division in UR Medicine Orthopaedics. “But there’s no doubt that the emphasis on athletic performance in young athletes, rather than age-appropriate skills development, can result in overtraining and more injuries. We want to help kids and their parents find a balance, so they can have the safest, best experience possible.”

There is limited evidence that intensive training and specialization before puberty are necessary to achieve elite status, but some kids still push themselves too hard.

“We’re seeing a concerning trend in injury patterns among youth athletes,” said Brian Giordano, M.D., associate professor in the Department of Orthopaedics. “The underlying causes include single-sport participation at a young age, a focus on early performance enhancement, and a lack of proper physical development for the demands they’re putting on their bodies.”

Giordano continues, “The days of kids climbing trees seem to have disappeared, and in its place, kids’ time is spent transitioning quickly from one sports season to the next. If they are overtraining for a particular sport before puberty, an athlete hasn’t yet developed the hormonal drive at that point to make rapid fitness gains, and the tolerance of the athletic youth body is being overwhelmed by the intensity of training.”

To meet the challenges of this new landscape, sports medicine itself has evolved. Once a specialty unto its own, it is now aligned with pediatric health at UR Medicine.

“Twenty or 30 years ago, most of pediatric sports medicine was just a part of pediatrics,” said Christopher Cook, M.D., chief of the Orthopaedics Pediatric Division at URMC. “Instead of having two silos, we have now brought sports medicine and pediatrics together.”

This merger is helping GCH to meet the new challenges of youth sports, including partnerships with athletic trainers at area high schools, improved understanding of common injuries like ACL tears and hip displacements, state-of-the-art injury prevention and performance regimens, and a commitment to expanding sport psychology resources. This collective effort has a clear mission: treat the whole child, and emphasize the ‘youth’ in youth athlete.

From Injury Treatment to Injury Prevention

Injuries can happen to any competitor, but clinicians in the Department of Orthopaedics have noticed that a certain type of youth athlete is at greater risk.

Starting players are usually secure in their role and feel they can afford to take adequate recovery time. Casual athletes feel less urgency toward keeping their role on the team. The athlete in the middle, however, who has fought hard for their playing time, often has trouble switching off.

“They feel the pressure to participate in these clubs and travel teams and not be held back by injuries,” said Maloney.

“There’s a perception that if you miss time for injuries, the college or club coach won’t look at you,” echoed Giordano.

Cook, Giordano, and Maloney see all types of sports injuries, but the hip represents a unique challenge. The most common hip injury varies by sport -- whether it’s a hockey goalie executing a butterfly motion or a soccer player running continuously for 90 minutes -- but the level of risk increases when these athletes are competing year-round, before and during the critical puberty years.

“There are growth plates all over the pelvis and the knee,” said Cook. “When kids play all year long more frequently in a single sport, they’re doing the same physical motions all of the time, they’re not cross-training, and these muscles are under constant stress.”

Cook started his career treating hip dysplasia in teenagers and adolescents at other medical centers before joining Giordano at UR Medicine as part of the Hip Preservation Program, which launched a decade ago and has earned a national reputation. Giordano and Cook collaborate on treatment of complex hip problems in adolescents and young adults as well as common sports hip conditions like labral tears, hip impingement, and instability. They often see athletes still in their teens who have badly damaged hip joints requiring surgical repair.

Athletes often don’t want to get treated and miss playing time, but find a silver lining when their injury deteriorates to the point where they need a procedure.

“The side-benefit of surgery – when it’s necessary – is that for the first time in many years, athletes are forced to completely shut down and take a rest,” said Giordano. “Ultimately they come back in a better condition, because in the recovery and rehabilitation from surgery, they have a chance to focus on the small things that matter. Form, mechanics, fundamentals, all of which are critical to sustainable athletic performance.”

While the immediate focus of the Â鶹ÊÓƵPediatric Orthopaedics and Sports Medicine teams is getting athletes back into the sports they enjoy, their long-term objective is to help them establish the building blocks for an active life, whether they become professional athletes or recreational fitness enthusiasts. To that end, the program has shifted a lot of its focus to injury prevention.

GCH sports medicine clinicians regularly partner with athletic trainers and coaching staff at local schools to encourage best practices that emphasize skills development and cross-training. In addition, clinicians across specialties are tracking muscular enzyme levels, electrolyte levels, and general wellness metrics to help athletes become more resilient and recover faster.

A key strategy: encourage teams to emphasize technique over strength training – particularly for developing kids – and work to correct existing training methods.

“The traditional focus of sports training has emphasized conditioning of the front of the body, the quads, core, and groin,” Giordano said. “We have observed a trend towards muscular imbalance with increased tension in the front of the body, but weakness through the lumbar spine, glutes, and hamstrings. Properly balanced muscular conditioning, properly directed active muscular recruitment, and myofascial health have been cornerstones to our training approach.”

“Ninety percent of what I do is counseling, discussion with families and personal trainers and reaching out to coaches, doing everything from proposing better strategies for warm-ups and cool-downs, active release therapy, to emphasizing smaller-sided games for scrimmaging and less high-velocity training in general,” said Giordano.

Building Better Fitness Science

This focus on injury-preventive training in pediatric sports medicine has paid dividends in recent years. One example is female athletes and ACL injuries. A dramatic increase in the number of youth female athletes in high-demand sports in the past few decades has also resulted in increased injuries to the Anterior Cruciate Ligament (ACL); young women are 6-8 times more likely than men to experience ACL tears.

While research is ongoing about the risk factors, emerging evidence suggests the way female athletes execute high-intensity “cuts” during play – often in a more upright position than men – has resulted in more ACL injuries.

“We worked on re-training athletes to perform these maneuvers in a better position to get improved dynamic control, and this ACL prevention program showed a significant reduction in injuries,” said Maloney.

Better, safer training measures are only part of the game plan. URMC’s Center for Human Athleticism and Musculoskeletal Performance and Prevention (CHAMPP) gives youth athletes at Â鶹ÊÓƵpartner schools access to fitness and injury prevention training that harnesses research, data science and clinical expertise from several disciplines to provide an innovative approach to health, wellness, and physical performance.

The program works with athletes from multiple area high schools, including East High School, Webster Schroeder, Webster Thomas, Churchville-Chili, Fairport, and Spencerport.

“We have training programs tailored for every type of sports team. Fitness Science provides tools to improve mobility, flexibility, strength and conditioning, nutrition, and sport mindset,” said Zachary Ferrara, health project coordinator at CHAMPP.

CHAMPP also works with individual athletes to optimize their performance. Tori Kotalik, a Junior from Brighton High School, is a three-sport athlete who competes in diving, Nordic skiing, and pole vaulting on the track team. She got involved in the program for pole vault-specific training, but it evolved to include all of her sports.

“It’s a really nice, high-quality program and they really tailor the training for the specific sport you’re doing,” she said.

The CHAMPP program is very similar to the way the highest-performing professional collegiate teams train their athletes. The Â鶹ÊÓƵSports Medicine program is furthering its commitment to this state-of-the-art approach by hiring new faculty, such as Sarah Lander, M.D., who recently worked with the football, basketball, and soccer teams while a fellow at Duke University.

Sport-specific training and injury treatment can provide needed resources for athletes who push their bodies to the limit.

“For how many people participate in running recreationally, there’s not a lot of scientific evidence out there. You google ‘how to run’ and there’s a lot of bunk information out there,” said Katherine Rizzone, M.D., M.P.H., associate professor of Orthopaedics and a primary care Sports Medicine physician. “We’re building a comprehensive clinic where you adjust the physics of your entire body to run in proper form and correct future injuries.” (read more on the Runners Clinic).

Addressing the Mental Health Challenges

Pediatric sports medicine specialists at GCH also focus on young athletes’ mental wellness.

“The psychology of youth sports is enormous; 90 percent of high school sports is as much in the head as it is physical,” said Cook. There’s more pressure on youth athletes through greater exposure and single-sport specialization, which in turn requires practitioners to help manage expectations and prevent burnout.

“Burnout happens over time. If you’re a hockey player who’s the best at their age group at 8 years old, but over time they become middle of the pack, they’re ready to hang up their equipment at 16,” said Cook.

In response to these challenges, the Â鶹ÊÓƵsports psychology program, led by Craig Cypher, Psy.D., has programs to help athletes balance demands, maximize performance, and practice healthy coping strategies in response to setbacks.

Cypher has a dual appointment as assistant professor in the departments of Orthopaedics and Psychiatry at UR Medicine. His practice has three components: helping the mindset of athletes who are doing well, but want to be the best in their sport; helping with recovery from major injuries such as concussions and ACL tears, as well as the emotional and mental fallout that comes from them; and assisting with overall mental health issues, including managing the stress inside and outside of athletic competition.

For injury recovery, Cypher helps athletes stay positive and confident during recovery.

“The big risk is that there’s a drop-off in mood. They become isolated socially, and a lot of things change in terms of your physical mobility. Then there’s the challenges of trusting their body and getting ready mentally when they prepare to return to competition. Throughout the process, we try to emphasize meditation and mindfulness, and help them develop coping strategies to stay calm and relaxed.”

As both a clinician and psychologist, Cypher has seen treatment standards evolve for complex, serious injuries, such as concussions. “What’s crucial now is that we get athletes active in small and manageable ways fairly quickly after a concussion, such as light movement and exercise. It used to be that we shut everything down and encouraged people to stay in a dark room.”

Cypher views the landscape of modern youth athletics as a double-edged sword. There’s no denying the excitement of elite competition, but the increased pressure of single-sport specialization and rigorous training contributes to burnout.

“You start to see more negativity, cynicism, and a tendency to start avoiding workouts due to nagging injuries,” Cypher said. “We’ve seen that if we delay specialization to ages 14, 15, 16, we’re getting better outcomes and less burnout.”

Cypher, along with Maloney, Giordano, and Cook, also don’t shy away from indicating that outsized expectations – particularly in the area of sports scholarships – can contribute to this culture.

“If parents want their kids to get a scholarship, it will likely be through academics; there’s a small, small percentage of kids who are getting athletic scholarships,” said Cypher.

In the end, Cypher, and the Â鶹ÊÓƵsports medicine program in general, stress balance and moderation for all athletes, from the casually involved to the highest performers. Not only will this prevent psychological and physical burnout, but evidence suggests that performances will benefit as well. It’s important for everyone involved – from coaches to parents to trainers – to remember that these athletes are kids, and the primary goal should be teamwork, fun, and personal growth.

“It’s critical to teach balance and help them understand, whether they’re a casual athlete or they want to compete at the highest level, to give themselves physical and mental breaks,” said Cypher.

“Habits young athletes form can stay with them into adulthood – we want to build a safe, effective athletic approach that will help them stay active, healthy and happy throughout their lives,” added Maloney.

 

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