The sports therapist should always examine a junior athlete's coaching regime for injury potential, says Sean Fyfe
Over the past year I have been working almost exclusively with junior athletes, an experience which has caused me to reconsider my view of the role of the sports injury practitioner when working with younger clients.
The conventional role of the sports therapist is to see a client, assess them, put together a clinical picture that includes diagnosis and causes, give hands-on treatment where appropriate, advise about the recovery period and prescribe exercises and a plan for the athlete’s return to sport. This approach is good, and perfectly effective when treating adults. But my recent work with many elite junior tennis players makes me think that with youngsters the picture is more complicated if the sports therapist is going to help young players stay injury free.
In particular, to be truly effective in determining the cause(s) of an injury, the therapist needs a thorough understanding of their young client’s training programme.
Using tennis as our example, let’s look at training volume and distribution. As a rule of thumb, the weekly on-court training hours for elite junior tennis players should be the same as their age. On top of this they should spend half the amount of time again working off-court on physical development training. Thus a 14 year old should spend 14 hours a week working on their game on-court and another seven hours on physical training, which includes speed and agility, strength and stability, endurance, flexibility and recovery.
In my physiotherapy work with juniors I refer to this rule daily. All too often I see them training on-court for far longer hours than recommended, while spending little time on physical development. Not only is this bad for their development as tennis players, it is a recipe for overuse injuries – and it is no surprise when these youngsters turn up at my door with such injuries.
It is almost impossible for juniors to remain injury free with these kinds of training schedules. Even if you help them overcome one injury, it will soon return, or another will arise. So it has to be the job of the sports injury practitioner to discuss training volumes and programmes with parents and coaches, in the context of how a young athlete’s body responds to exercise.
The sports therapist also needs a good understanding of when and why the young player should be undertaking different types of training. I regularly come across the problem of young athletes doing speed and agility training (including plyometric exercises) after their on-court training, at a point when they are fatigued.
These exercises require the stabilising muscles to be working optimally to ensure that loads are absorbed effectively and correct body alignment is maintained, which suggests that this type of training should be undertaken when a young player is fresh and recovered, rather than straight after a hard on-court session. Otherwise you can expect to see lower-limb injuries.
During assessment therapists should ask questions about training load and programming to ascertain exact causes. If you do not, the same mistakes will continue to be made and the young athlete will keep breaking down.
It is also important to understand the athletic qualities a player requires for their sport. For example, in tennis or other court sports, such as basketball, players are continually jumping, loading heavily through one limb to change direction and accelerating and decelerating. The legs must be able to absorb shock during eccentric contraction prior to concentric contraction. It is this process that the athlete replicates during plyometric drills.
In my experience, juniors demonstrate huge variations in their ability to master plyometric drills. Those who perform them well are less likely to get lower-limb overuse injuries.
If a player continues to struggle with a particular or multiple overuse injuries of the lower limbs, the therapist may need to consult the coach or strength and conditioning specialist to discuss the addition of certain exercises in training.
Some will argue that it is the role of the coach, not the sports injury practitioner, to set the overall training programme and determine training volumes. But the reality is that many good coaches – who have great practical experience and information to pass on to juniors – do not understand the way the body responds to training and exercise. This highlights the need for communication and a partnership approach between coach and sports-injury practitioner.
Recovery is important for two reasons: to help prevent injury and to improve the quality of the next training session. In junior sport in general, the importance of recovery tends to be overlooked. With schooling commitments and a heavy training load, juniors rarely get to do any specific recovery work beyond a quick cool-down stretch. This is another topic the therapist should raise with the coach.
The case of Rachel
Rachel is a 12-yer-old elite tennis player who I have seen regularly over the last six months. Her case highlights all the key training points that concern me here. Rachel’s parents first asked me to assess her after multiple ongoing injuries kept on interrupting her training schedule. It was one of those cases of ‘where do I start?’ Table 1 above sets out her injuries.
Rachel’s training schedule consisted of approximately 15 hours a week on-court plus tournament play at weekends (more than is recommended for a 12 year old) and no physical training programme.
To compound the effects of this inappropriate training schedule, Rachel was extremely hypermobile, just starting to grow and had very poor single leg, lumbopelvic and shoulder girdle stability. No wonder she was getting injured. On and off, she was carrying five different injuries. As in most sports, tennis requires quality training for improvement. Rachel’s on-court training was being severely hampered.
It was going to take time to get Rachel pain free and able to complete her ideal training programme. After six months we are getting close. We have come a long way and I predict that by next year Rachel will be able to undertake her new training programme of 13 hours on-court and 7 off-court.
The first step was to adjust her schedule. We reduced her on-court hours and began her physical programme. To have given her a full physical development regime from scratch would have made her injuries worse because of the increased training volume. Instead, we decided to prioritise stability.
Rachel’s back was of most concern. She was definitely at risk of a stress fracture, a very common injury in elite junior tennis players. We retrained her lumbopelvic stability, beginning with activation and awareness exercises for spine and pelvic positioning. Gradually she progressed to high-level exercises in and out of neutral spine.
Once Rachel could perform these regularly, we began her on single leg stabilising exercises, with the usual progressions, followed by shoulder girdle and gleno-humeral joint stability exercises. This gave her a progressive stability programme that addressed her injuries. The plan was to improve her stability to a point where I was satisfied that Rachel’s body could handle an increased physical programme.
The other aspect of Rachel’s physical condition was that her play lacked any explosive and/or elastic athletic qualities. For example, when trying to perform a single leg mini-hurdle jump, Rachel landed very heavily, unable to absorb the impact by bending through the hip and knee while keeping her back straight. When she landed, she would also lose her knee position in relation to both foot and trunk/pelvic alignment. In fact she would often have to do another little jump on landing to absorb the force because she couldn’t do it on the first impact.
Rachel needed to practise some plyometric drills to learn how to jump and land properly. Progressions include learning how to land and absorb the impact by bending through the hip and knee while maintaining correct body alignment and balance; moving from double-to single-leg exercises. Ground contacts could then be made continuous, so that Rachel had to jump, land, absorb and jump again as quickly as possible.
Rachel is now completely pain free and has been for some time in four of her five injuries. Her heel is the only injury still giving her some pain, although it is significantly better. She only gets pain now at the end of a long session. She is wearing orthotics which help, her calf range is good and single-leg stability is still improving. She is training on-court approximately 10 hours a week and is managing the heel with ice after training and regular calf massage. I think her heel pain will continue to improve as she improves with her stability and plyometric exercises.
In conjunction with her coach and parents we are putting in place a long-term plan for her physical development. If Rachel is to continue to increase her training schedule and play pain free, then she must continue to improve her stability, strength and athletic qualities with an ongoing commitment to physical development.
In summary, then, if you are dealing with injured junior athletes who are undergoing heavy training schedules, you have to consider their overall programme, because if this is wrong in terms of overtraining and/or an inappropriate physical development regime, successful rehabilitation of an injury and injury prevention becomes near impossible.