In season training load management
Neeru Jayanthi, M.D.
Director, EMORY Tennis Medicine
Director EMORY SM Research/Education
Co-Director Emory Youth Sports Medicine
Emory Sports Medicine Center
Past- President, International Society for Tennis and Medicine Science (STMS)
Team Physician Atlanta Braves, Georgia Tech Tennis, Gwinnet Stripers
Associate Professor
Orthopaedic Surgery
Family Medicine
[email protected]@neerujayanthi
CHANGING YOUTH SPORTS
• Overuse injuries in Young Athletes AMSSM Panel/Writing Group• Collaborative Research with Lurie Children’s (multiple AMSSM grants)• Consultant (Unpaid):• American Academy Pediatrics (AAP) Council of Sports Medicine Fitness
(COSMF)• Aspen Institute (Project Play) • Mom’sTeam Institute• WTA medical advisory board (Age Eligibility Rule)
COVID-19 has just treated most every overload injury
Prolonged periods of restNo coachingSelf-directed rehabilitation
What will post-Covidtraining look like?
In season young athlete load management
Why training too much causes overuse injury
Why high training loads alone may not be the
right way to determine risk of injury
What are novel ways to train an elite young
athlete
TOYA (TRAINING OF YOUNG ATHLETES)
• A longitudinal cohort training of young athletes (TOYA) study of 453 elite young British athletes between 1992-1996 outlined the positive benefits of sport (soccer, tennis, swimming and gymnastics), while acknowledging that there is a gap in knowledge of when coaches, parents, and athletes should initiate intensive training.
• Relatively low rates of injuries
• Relatively low rates of exposures (weekly hours) around 10 hrs/week.Low exposure
Low injury rates
Positive benefits
AMERICAN YOUTH SPORTS MODEL…CRAZY
`
Hours per week
Stage of Development
Early Middle Late Adult
Adolescence
Onset of Specialization
EARLY SPECIALIZATION MODEL
4 years
Hours per week
Stage of Development
Early Middle Late Adult
Adolescence
Onset of Specialization
LATE SPECIALIZATION MODEL
WHAT ARE THE HEALTH CONSEQUENCES OF
YOUTH SPORTS INTENSE TRAINING MODELS?
60 MILLION KIDS PLAY SPORTS1/3 SPECIALIZED
YOUTH SPORT SPECIALIZATION MODELS CREATED WITH DISREGARD FOR THE HEALTH EFFECTS TO YOUNG ATHLETES
Increase risk of overuse injury
Decreased opportunities
• Overuse injuries occur due to repetitive submaximal loading of the musculoskeletal system when rest is not adequate to allow for structural adaptation to take place.
Approximately 49-53% of injuries in young athletes are overuse rather then acute.
YOUTH SPORTS OVERUSE WORLD TOUR
MEDIA
INCREASE RISK OF OVERUSE INJURY WITH SPECIALIZATION (
AMSSM FOUNDATION GRANTS
AMSSM (American Medical Society for Sports Medicine) (two time recipient)
Foundation Grant to continue this study in Collaboration with Lurie Children’s Memorial Hospital, Chicago, IL
Jayanthi et al, 2015
• Independent dose-dependent risk of injury with the degree of sports specialization • Overuse, serious overuse injury• NOT ACUTE injury
• Relationship of volume-based risks of injury:• Weekly total physical activity
hours and organized training hours
• Age versus hours rule• 2:1 Sports Training Ratio• >8 months/year
1200 young athletes
EXPOSURE RISKEMERY ET AL.
SPORTS TRAINING RATIO (2:1) FREE PLAY
• The total hours of organized sports (training, practicing, competition, etc.) per week should be less than twice the number of hours playing sports just for fun (like playing basketball with friends at recess or after school—“free play”). (14) (SORT B)
• (e.g., an athlete who does organized soccer for 10 hours during the week and has 6 hours of “free play” during the week by playing volleyball at recess and basketball with classmates after school)
Increase self-directed free play
Work with coaches to consider specialized sampling models
3 YEAR FOLLOW UP
52.4% subjects injured over study period (most reinjuries)
3 year follow up. (in press OJSM. Jayanthi et al)
2.3 X risk overuse injury
RISK PRONE PITCHING ACTIVITIES
• Pitching with: (754 pitchers)
• Risk of arm pain• arm pain/fatigue (OR 7.9)
• Pitching on consecutive days (OR 2.5)
• Pitching on multiple teams (OR 1.9)
• Pitching multiple games/day (OR 1.9)
• Yang, et al. 2014
• 95 youth baseball pitchers compared to 45 healthy controls:
• Odds Ratio: 5.05 (405% increased risk) of shoulder/elbow surgery with > 8 months/year pitching.
• Regularly Pitching with fatigue Odds Ratio 36.18 (3518% increased risk for surgery!!)
• Fleisig, et al. 2006
OVERUSE INJURY RISK FACTORS
• Intrinsic• Extrinsic• Training Load• Prior Injury• Sports specialization• Age
•50% overuse injuries
PREVENTION
• Are overuse injuries more preventable?• Volume related
• Sports specialization (young athletes)
• Age related
• Sports specificity
• Biomechanical load
• Prior injury
• TRACK research (interventional counseling)
Injury containment?
WHAT CAN YOU DO TO PREVENT OVERLOAD INJURIES?
Change the environment
Change the athlete
• May Lower Risk of Overuse and Serious Overuse Injury By
• Being less specialized in sports
• Doing less hours of sports in a week than your age
• Increasing Free Play so your Sports Ratio is NOT >2:1.
• Having at least 1 month off after completing a season
• Having at least 1 day off a week
11 recommendations (youth sports)
• May Lower Risk of Overuse and Serious Overuse Injury By
• Being less specialized in sports
• Doing less hours of sports in a week than your age
• Increasing Free Play so your Sports Ratio is NOT >2:1.
• Having at least 1 month off after completing a season
• Having at least 1 day off a week
11 recommendations (youth sports)
COMPLIANCE
Recommendation OR 95% CI p-value
Athlete should play two or more sports 1.31 0.66, 2.57 0.44
Take 3 months off during a calendar year 1.30 0.80, 2.13 0.29
Ratio of sports to free play 1 day 1.16 0.51, 2.65 0.72
ARE YOUNG ATHLETES TRAINING ENOUGH?
INJURED VS UNINJURED (JAYANTHI ET AL, 2017)
TRAIN LESS?
TRAINING ELITE YOUNG ATHLETES
INTENSE SPECIALIZED TRAINING
I’m going to train a lot…can
you still help me?
I’m going to train a lot…can
you still help me?
Sport specialization NM deficits
ACL tearsOveruse injuries
• “Health-Related Quality of Life and Parental Influence of Specialized Child Athletes: A Qualitative Evaluation”
• Reasonably good quality of life measures and positive experiences(as well as their parents)
• Patel, Jayanthi 2017 Qualitative parent-child study
• There is insufficient evidence to suggest that Early sports specialization leads to long term poor health related outcomes
PARENTS AND CHILDREN MEET ACSM EXERCISE GUIDELINES
PARENT-CHILD HRQOL IN SPECIALIZED ATHLETES It is possible for athletes
who specialize at an early age to have a positive
experience
• Acute to chronic workload ratio
IS UNDERTRAINING A RISK FACTOR FOR INJURY?
•Are medical providers contributing to injury risk?
Training Load
Performance
LOW
LOW HIGH
HIGH
Range for Potential harm
Local minima/maxima (smoothing spline)
Range for Potentialbenefit
INCREASE load for performance
SPORTS-SPECIFIC GUIDELINESSTAY in SPORTS
Performance
Injury ceiling
• Avoid the chronic rehab-low volume training cycle
• Understand that HIGHER training loads may REDUCE injury risk (perhaps increase soft tissue/lower risk injury)
• Lower training loads INCREASE injury risk
• Need to build RESILIANCE
• Does not include young athletes, individual sports
• Build resilience to tolerate higher training loads (Gabbett)
G A B B E T T E T A L . B J S M
WHO IS REALLY ELITE?
Skeletally immature
“Average” performance
Resiliantmotivated
support system
RISK AND RTP TABLE
(INDIVIDUAL) TRAINING
LOAD
• Hours/week
• Intensity (RPE)
• Frequency
• RATE OF INCREASE
INDIVIDUAL ATHLETES WITH INDIVIDUAL “INTERNAL” WORKLOAD
External workload
(eg.Time, distance, serves, pitches)Internal workload (eg. RPE, Heart rate response)
What is the reason for the young athlete
overload injury?
Acute spike in load?
Exceed the ceiling?
Mixed picture?
WHAT ARE THE CHALLENGES OF
TRAINING YOUNG ATHLETES?
YOUNG ATHLETE CONSTANTLY CHANGING
Hours per week
Stage of Development
Early Middle Late Adult
Adolescence
Onset of Specialization
LATE SPECIALIZATION MODEL
Training plans and potential outcomes differ based on an athlete’s ‘floor’ capacity
Train your age
Weekly training hours ≤ age
A
Injured player
Reduction of weekly training to a new (lowered) floor and ceiling
B
Elite player
Consider increases of weekly training to a (higher) floor and ceiling
C
Time
Capacity
FLOOR
CEILINGHIGHERFLOOR
RE-EVALUATEDCEILING
NEW FLOOR
INJURY
C
A
B
G A B B E T T
IN SEASON/PRE-SEASON TRAINING LOAD AND RISKS
• Increased risk in college athletes with academic/social stress
• Pre-season stress
PRE SEASON INJURY RISKSWATSON ET
AL., OJSM 2017
LOWER VO2, HIGHER INJURY RISK
TRAIN DURING THE “OFF SEASON”?
Sole CJ et al.: Injuries in Collegiate Women’s Volleyball: A Four-Year Retrospective Analysis, Sports, 5(26), 2017.
“ADJUSTABLE CEILING/FLOOR”
Hours per week
Stage of Development
Early Middle Late Adult
Adolescence
Onset of Specialization
LATE SPECIALIZATION MODEL
Understand the INDIVIDUAL “ceiling”
of your athlete
CALCULATING LOAD AND ACWR
• Current week training + competition (hours, mileage, pitches)• Last 4 weeks of training + competition (hours, mileage, pitches)
ACWR DATA IS PRIMARILY IN PROFESSIONAL AND TEAM SPORTS ATHLETES
• UNDERSTAND floor and ceiling concepts• Understand that this needs to be adjustable in a young athlete
(as they mature/develop)• Understand that this needs to be adjustable if they are injured
16 yo male tennis player with shoulder pain.Diagnosis: R shoulder impingement
Do you stop training?Do you treat/rehab?Do you have a return to play plan or do just ask them to return slowly??
Training load history• Chronic Training Load PRIOR to injury - Last 4 weeks
• Acute Training Load
Hours or miles/wk (training + competition) x Rate of Percieved Exertion (circle) = ______
4 wks prior to injury ___10__+___0___ x 1 2 3 4 5 6 7 8 9 10 = ____50_____
Type of training:_On Court Tennis practice Type of competitions:__None__
3 wks prior to injury ___6___+__4____ x 1 2 3 4 5 6 7 8 9 10 = __60__
Type of training:_On Court Practice___ Type of competitions:___Tournament____
2 wks prior to injury __10____+__0___ x 1 2 3 4 5 6 7 8 9 10 = __40__
Type of training:_On Court Practice_ Type of competitions:____None________
1 wk prior to injury __6__ +__4____ x 1 2 3 4 5 6 7 8 9 10 = __60__
Type of training:_On Court Practice_ Type of competitions:___None_________
Avg of 4 week totals: _52.5__
Current week __10_ + __6_(comp)___x 1 2 3 4 5 6 7 8 9 10 = __96__
Acute total/Chronic average = __1.8____ Acute: Chronic Workload Ratio
Risk (low, moderate, high) = ___Intermediate______
Training Load Plan
Diagnosis: ___Shoulder impingement__________
75% ceiling = ______7.5_______________ hours per week
25% floor = ________2.5______________ hours per week
Return to Sport PLAN:Week 1: _2.5_ hours at 1 2 3 4 5 6 7 8 9 10
Week 2: _3-3.5 hours at 1 2 3 4 5 6 7 8 9 10
Week 3: _3.5-4_ hours at 1 2 3 4 5 6 7 8 9 10
Week 4: _4-5_ hours at 1 2 3 4 5 6 7 8 9 10
14 yo year-round soccer playerDiagnosis: Returning from L5 pars bone stress injury• She has not played in 4 weeks• Previous load 16 hours/week
Training Load Plan
Diagnosis: _____________
75% ceiling = ______12______________ hours per week
25% floor = ________4_____________ hours per week
Return to Sport PLAN:Week 1: _4_ hours at 1 2 3 4 5 6 7 8 9 10
Week 2: _5-6 hours at 1 2 3 4 5 6 7 8 9 10
Week 3: _7-8_ hours at 1 2 3 4 5 6 7 8 9 10
Week 4: _10_ hours at 1 2 3 4 5 6 7 8 9 10
Young athlete overuse injuries
Training volume rules for young, skeletally immature, non-elite athletes (most)
(Elite) Skeletally mature athletes need to have individualized adjustable ceiling/floor that is protective of injury
Develop load and resilience, AEROBIC FITNESS for the elite skeletally mature athlete
USTA Junior Competition
Summit
Neeru Jayanthi: Evidence-based recommendations for USTA Junior Tennis
Happy young athletes
http://www.olympic.org/
THANK YOU!
