Considerations for the Rehabilitation Management of the Female Athlete

This article discussed the anatomic, physiologic, hormonal, and psychosocial factors unique to the female athelte that can affect a female athlete's injury risk and rehabilitation trajectory. A review of considerations unique to different stages of life in the female athlete and a discussion of the prevalence of certain injuries in female athletes are discussed. The purpose of this narrative review is to highlight how understanding the unique characteristics of the female athlete can allow for optimization of rehabilitation protocols.

Sex Differences in Youth and Young Adult Sport Training Patterns, Specialization, and Return to Sport Durations

BACKGROUND

Young female athletes may have higher rates of overuse injuries and sport specialization than male athletes. The association of sports specialization and return to sport (RTS) timeframe is also unknown.

HYPOTHESIS

Specialized female athletes will have more intense, year-round training patterns, more overuse injuries, and longer RTS times than male athletes.

STUDY DESIGN

Cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Injured athletes aged 10 to 23 years presenting to a sports medicine clinic reported their degree of sport specialization and training patterns. Skeletal maturity was estimated using the Khamis-Roche method. Injury type and RTS timeframes were categorized from electronic medical records. Chi-square tests and logistic regression analysis assessed associations between variables.

RESULTS

A total of 485 athletes (40.2% female) were enrolled. Higher degrees of sport specialization were associated strongly with overuse injuries (P < 0.01). After adjusting for specialization, female athletes were more likely to sustain an overuse injury (adjusted odds ratio, 1.49; P = 0.04). Female athletes participated in fewer total physical activity hours per week (P < 0.01), fewer free play hours per week (P < 0.01), and participated in their main sport for more months of the year than their male counterparts (P = 0.02). Female athletes were more likely to be at a higher developmental stage than male athletes (P < 0.01). RTS timeframes were increased in athletes with serious overuse injury; however, no association was found between degree of specialization and RTS time regardless of sex.

CONCLUSION

Female athletes are more likely to sustain overuse injuries with more organized, year-round, training and less free play compared with their male counterparts.

CLINICAL RELEVANCE

Female sex may be an independent risk factor of overuse injury. Future strategies to mitigate these risks may include increased free play hours and limiting year-round training through seasonal rest.

Holtz K, L. Downs Talmage J, Ulman S, Oliver GD. A Narrative Review of Softball Pitching Workload and Pitch Counts in Relationship to Injury

CONTEXT

Fastpitch softball is a popular women's sport in the United States, and participation rates are increasing. There is growing concern about the prevalence of overuse injuries in softball pitchers at all competitive levels. Pitching workload in softball may be a modifiable risk factor and will be discussed in this narrative review.

EVIDENCE ACQUISITION

A review of softball injury research related to workload available in electronic databases, including PubMed, Medline, and EBSCO.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

There is a paucity of research evaluating workload (inclusive of internal and external risk factors) including pitch counts in women's softball. In particular, research has shown that pitchers report increasing fatigue and pain over a game and weekend tournament, and that the number of pitches thrown by pitchers varies widely. One study showed that pitchers throwing >85 pitches per game had an increased risk of injury over the season. As of 2023, no established pitch count restrictions exist in the United States or Canada. Further research, particularly at high school and collegiate levels, is needed.

CONCLUSION

Softball pitchers are at an increased risk of overuse injury and further research is needed to recommend specific workload interventions such as pitch counts.Strength-of-Recommendation Taxonomy (SORT): B.

Youth Sport Specialization and Risk of Injury: A General Review

OBJECTIVE

The purpose of this literature review was to analyze, understand, and disclose prior empirical findings about the injury risks associated with youth sport specialization.

DATA SOURCES

Articles were included in this review if they examined the association between youth sport specialization status and injury. Nine articles from 5 journals met these criteria. All articles summarized the findings of cross-sectional (N = 5) or cohort studies (N = 4).

MAIN RESULTS

Each article included in this review indicated that specialized youth athletes are more susceptible to injury. Only 5 studies assessed the injury risks linked to specialization independent of sport training volume. These studies produced contradictory results.

CONCLUSIONS

Although specialized youth athletes are more prone to injury, future research is needed to determine the independent and inherent injury risk associated with specialization. Nevertheless, youth athletes should refrain from specialization until at least adolescence.

Developmental activities of elite junior hockey players: an analysis of early sport specialization

Early sport specialization is a popular and contentious topic in the scientific literature and popular media. The lure of extrinsic rewards has led to increasing rates of specialization among young athletes, while expert recommendations promote multisport participation. The purpose of this study was to describe and analyze developmental activities of a group of elite junior hockey players in Canada. Within this context, elements of specialization were investigated in accordance with existing theoretical frameworks and long-term athlete development models to enhance the literature. Fifteen participants from the Ontario Hockey League completed quantitative retrospective interviews, detailing past sport and recreational activities. Thirty-one developmental milestones were assessed. Accumulated hours of activity were categorized in accordance with Côté's (1999) Developmental Model of Sports Participation, along with the number and types of sports in which they participated during childhood. Jayanthi et al.'s (2015) continuum was utilized to determine the age at which the athletes became moderately and highly specialized. Accrued hours of deliberate practice reported by participants increased from ages 6 to 16 years, as did competition in organized hockey games. Reported hours of deliberate play peaked at 9 years of age and decreased thereafter. Participants played a combined 16 sports other than hockey, ranging from an average of 2.0 at age 6, to a maximum average of 5.6 at 12 years old, and decreasing each year to 2.3 by age 15. The greatest number of hours in other sports was accumulated at 12 years of age. Using a three-point scale, participants considered themselves "highly specialized" at 14 years old; however, other quantitative indicators suggested this may have occurred at 12 years of age. Relative to previous research on early sport specialization, participants in this study spent more time practicing hockey, while ceasing hockey-specific play and other sports at younger ages. Despite a diverse sport history, hockey competition was initiated earlier than recommended, showing high levels of sport commitment as young as 9 years old. The early specialization path remains a popular trajectory among coaches, parents, and athletes in Canadian ice hockey.

Sport Specialization's Impact on Female Adolescent Athletes' Lower-Extremity Neuromuscular Control: A Critically Appraised Topic

CLINICAL SCENARIO

Nearly 60 million youth ages 6-18 participate in athletics within the United States. Over the last 30 years, the outlook on youth sport participation has drastically changed, resulting in an increased emphasis on performance and college sport participation. These evolving expectations have created a sense of perfectionism, demanding more time and energy to be placed into a single sport, resulting in an increased prevalence of sport specialization, and consequently, an increased rate of injury.

CLINICAL QUESTION

What is the impact of sport specialization on lower-extremity neuromuscular control in female adolescent athletes?

SUMMARY OF KEY FINDINGS

Four studies were included, all comparing movement efficiency and movement patterns among multisport and sport-specialized female adolescent athletes. Three studies showed that sport specialization is associated with lower-extremity biomechanical alterations that are indicative of altered levels of neuromuscular control, which can predispose an individual to an increased risk of injury. One study concluded that no differences in neuromuscular control exist when comparing sport-specialized to multisport adolescent female athletes.

CLINICAL BOTTOM LINE

Sport specialization has the potential to create negative alterations in a female adolescent athletes' lower-extremity biomechanics, leading to the creation of altered levels of neuromuscular control and a possible increased risk for injury.

STRENGTH OF RECOMMENDATION

Level B evidence exists to support the conclusion that sport specialization negatively affects a female adolescent athlete's lower-extremity neuromuscular control.

What place does elite sport have for women? A scoping review of constraints

Introduction

Despite increases in participation and raised attention for girls and women in sports, female sport is still based on male evidence that ignores gendered differences and experiences of unequal treatment and marginalization from grassroots to elite sport. This paper aimed to critically interrogate the place that women have in the male preserve of elite sport by conducting a two-part study.

Methods

First, we provided a brief sociohistorical analysis of gender in sport as a means to move away from a decontextualized and universalized approach dominating in sport science literature. We then conducted a scoping review following PRISMA-ScR guidelines to synthesize existing sport science literature that implemented Newell's constraints-led approach to examine elite performance.

Results

Ten studies were identified, none of which collected demographic data or centred on female athletes and the effects of sociocultural constraints on their performance. Instead, male-centred, masculine sports and physiological profiles dominated the identified studies.

Discussion

We discussed these results considering critical sport research and cultural sport psychology literature to offer an integrative, interdisciplinary approach to advocate for more culturally sensitive, context-specific interpretations of gender as a sociocultural constraint. We put forth a call to action for sport science researchers, practitioners, and decision-makers to move away from implementing male evidence in female sport and attend to the unique needs of female athletes. Practical suggestions aimed to help stakeholders reimagine elite sport by celebrating these [potential] differences as strengths for promoting gender equity in sport.

INVESTIGATION AND PREVENTION OF SPORTS RISK IN THE TEACHING OF TABLE TENNIS

ABSTRACT Introduction: Among college students who are not majoring in sports, table tennis is well accepted, highly popular, and has low requirements regarding equipment investment. Therefore, many students choose this sport, although there are also certain sports risks in the course of the sport. Objective: Investigate the sporting risks of teaching table tennis and its preventive measures. Methods: Before each class exercise, the physical education teacher led the experimental class to rigorously complete the warm-up. In contrast, the control class maintained the basic program configuration without the warm-up phase. After 24 hours of practice, students in the experimental class and the control class were tested with the FMS. Results: The experimental class stability score increased from 1.58 points to 1.84 points, and the trunk rotation stability score increased from 1.68 points to 2.05 points. Conclusion: Warm-up activities before sports can further reduce sports risks in the table tennis teaching process by providing a better and safer higher education environment for students. Level of evidence II; Therapeutic studies - investigation of treatment outcomes.

Early Sport Specialization and Relative Age Effect: Prevalence and Influence on Perceived Competence in Ice Hockey Players

The relative age effect (RAE) and early sport specialization (ESS) have been of growing interest in the sports world, especially in ice hockey, because of their potential adverse effects. However, little is known about their distribution within each level of play in Canadian minor ice hockey, or whether they influence young people’s perceived competence, a variable of interest in long-term sports development. A sample of elite adolescent players (N = 204) and a sample of recreational and competitive players (N = 404) were used to measure these constructs, and chi-square tabulations were conducted to compare their distribution. Our results reveal that RAE (χ2 = 20.03, p < 0.01, Cramer’s V = 0.13) and ESS (χ2 = 66.14, p < 0.001, Cramer’s V = 0.24) are present, but there are apparently no gender differences in their distributions. Neither the level of RAE nor ESS seems to affect the perceived competence of the players, regardless of gender. The results of this study highlight the presence of RAE and ESS in Canadian minor ice hockey, especially at the elite level, but indicate that they do not affect the self-perception of ice hockey players. Additional research on these concepts is needed to obtain a complete picture of their potential impact on sports development.

Comparing High School Sport Specialization Trends Between Division I and Club Collegiate Athletes

BACKGROUND

Adolescent athletes report that sports specialization improves their ability to receive a collegiate athletics scholarship, though this is not well-understood. The purpose of this study was to examine self-reported trends in high school specialization and influences for sport participation between Division I (D-I) and college-aged club (club) athletes.

HYPOTHESIS

There would be no difference in high school sport specialization or sport participation influences between D-I and club athletes.

STUDY DESIGN

Retrospective cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A survey included specialization classification (low, moderate, and high) for 9th to 12th grade, age that the athlete started organized sport and his or her collegiate sport, and several influential factors for participation in one's primary high school sport (1 = no influence to 5 = extremely influential). Chi-square analyses were used to compare specialization classifications between groups. Nonparametric tests were used to determine significant differences in age-related variables and influential factors between D-I and club athletes. All analysis were also conducted with boys and girls separately.

RESULTS

Participants included 266 D-I (girls, 155; 58%) and 180 club (girls, 122; 68%) athletes. Club athletes were more likely to be classified as low specialization at every grade in high school, and this difference was more pronounced between D-I and club female athletes than male athletes. The number of years an athlete was classified as highly specialized in high school was not different between D-I and club athletes. Club athletes were more influenced by playing with friends than D-I athletes and D-I athletes were more influenced by pursuing a collegiate scholarship than club athletes.

CONCLUSION

High levels of specialization in high school sport may not be necessary for playing at the collegiate level, though some level of specialization in high school might be necessary.

CLINICAL RELEVANCE

Clinicians should advocate for healthy long-term athlete development, which does not support high specialization in high school sports.

What Defines Early Specialization: A Systematic Review of Literature

Introduction: While practitioners and organizations advise against early specialization, the lack of a consistent and clear definition of early specialization reduces the impact of recommendations and policies in youth sport. An important first step in understanding the consequences of early specialization is establishing what early specialization is. Objectives: This PRISMA-guided systematic review aimed to determine the types, characteristics, and general content of early specialization papers within the literature, and examine how early specialization has been defined and measured in order to advance knowledge toward a clear and consistent definition of early specialization. Data sources: Four different electronic databases were searched (SPORTDiscus, Web of Science, Sports Medicine and Education Index, and Scopus). Both non data-driven and data-driven studies were included to ensure a comprehensive understanding of the literature. Eligibility Criteria: In order to be included in the review, the paper must: (a) Focus on specialization and explicitly use the term "specialization" (b) Focus on sport and athletes (c) Be papers from a peer-reviewed (d) Be in English. And finally, (e) be available in full text. Results: One thousand three hundred and seventy one articles were screened resulting in 129 articles included in the review after applying inclusion/exclusion criteria. Results indicated a clear discrepancy between key components of early specialization and the approaches used to classify early specializers. Conclusion: Future research should work toward developing a valid and reliable approach to classifying early specializers and establishing a consistent definition across studies.

Sport specialization and sport participation opportunities and their association with injury history in female high school volleyball athletes

OBJECTIVE

Determine the association of sport specialization in female volleyball athletes with previous injury history and determine the association of sport specialization with volleyball participation opportunities.

DESIGN

Cross-sectional.

SETTING

Recruitment occurred from 83 Wisconsin high schools during the 2018 volleyball season.

PARTICIPANTS

Female volleyball athletes (N = 1,588, grades 9-12, age = 15.6 ± 1.1 years).

MAIN OUTCOMES

Participants completed a pre-season questionnaire soliciting information regarding 1) demographics, 2) sport specialization, 3) sport participation, and 4) sport-related injuries in the previous 12 months. Univariable logistic regression models were used to identify associations with previous injury. Chi-square analyses were used to investigate associations between sport specialization classification and other sport participation opportunities.

RESULTS

Both moderately and highly specialized athletes were more likely to report a previous injury compared to low specialized athletes (moderate OR: 1.84 [1.29-2.62]; p < 0.001 and high OR: 2.30 [1.64-3.24]; p < 0.001). Highly specialized athletes were more likely to report participating in club volleyball, summer tournaments, and training camps in the past 12 months. Participants who reported participating in club volleyball, summer competitions, and training camps last year were more likely to report an injury.

CONCLUSIONS

Specialization was associated with injury history and year-round volleyball opportunities among female adolescent volleyball athletes.

Risk of Injuries Associated With Sport Specialization and Intense Training Patterns in Young Athletes: A Longitudinal Clinical Case-Control Study

BACKGROUND

There are no clinical longitudinal studies exploring the associations between sport specialization and intense training patterns and injuries in young athletes.

PURPOSE

To prospectively determine the relationship between young athletes' degree of sport specialization and their risk of injuries and reinjuries.

STUDY DESIGN

Case-control study; Level of evidence, 2.

METHODS

Young athletes aged between 7 and 18 years presenting for sports-related injuries or sports physical examinations were recruited from either sports medicine clinics or pediatric/family medicine offices. Each participant completed a baseline survey at enrollment and an identical follow-up survey every 6 months for 3 years. Surveys assessed training patterns and injuries. Injury type (acute, overuse, or serious overuse) and clinical diagnosis were also recorded from electronic medical records.

RESULTS

Of the 1208 participants who provided consent, 579 (48%) completed the baseline survey and first follow-up survey at 6 months (mean age, 14.1 ± 2.3 years; 53% female). Of this sample, 27% (158/579) of participants were uninjured, and 73% (421/579) were injured, with 29% (121/421) of injuries classified as reinjuries. Consistent with previous studies, over the 3-year study period, the degree of sport specialization had an effect such that more specialized athletes were significantly more likely to be injured (P = .03) or have an overuse injury (P = .02) compared with less specialized athletes after adjusting for potential confounders. Additionally, female athletes were more at risk for all injuries (P = .01) and overuse injuries (P = .02) after adjusting for covariates. Finally, young athletes who trained in weekly hours in excess of their age or who trained twice as many hours as their free play were significantly more likely to be injured on univariate analysis (both P < .001).

CONCLUSION

Our study confirms that over time, young athletes, and in particular young female athletes, were more likely to be injured and sustain an overuse injury if they had a higher degree of sport specialization. Similarly, those athletes whose training hours exceeded thair age or whose sports hours exceeded their free play by a factor of greater than 2 were also more likely to develop injuries and overuse injuries.

Exploring Early Sport Specialization: Associations With Psychosocial Outcomes

Sport specialization has been linked to multiple negative health related outcomes including increased injury risk and sport attrition, yet a gap remains in our understanding of potential psychological outcomes of early specialization (≤ age 12). The current study evaluated the associations between retrospective athlete reports of sport specialization and both retroactive and current psychological health outcomes. Early specializers reported significantly higher levels of multiple maladaptive psychological outcomes (e.g., global athlete burnout, emotional and physical exhaustion, sport devaluation, amotivation). Overall, findings suggest that specialization environment factors, in addition to the age of specialization, are potentially critical factors in determining health and well-being outcomes. Findings support prominent position statements suggesting early specialization may be associated with increased health risks. Study findings may also inform the development of guidelines and recommendations to aid parents, coaches, and athletes in positively impacting athlete psychosocial outcomes.

Health Consequences of Youth Sport Specialization

Sport specialization is a training method now commonly used by young athletes who hope to achieve elite-level success. This may be defined as (1) choosing a main sport, (2) quitting all other sports to focus on 1 sport, and (3) year-round training (greater than 8 months per year). A number of sports medicine organizations have published recommendations based on the limited evidence available on this topic. The objective of this article was to perform a narrative review of the currently available evidence and sports medicine organizational recommendations regarding sport specialization and its effects on health to guide athletic trainers and sports medicine providers. To accomplish this goal, we conducted a narrative review of articles and position statements on sport specialization published from 1990 through 2018. Injury, overuse injury, serious overuse injury, and lower extremity injury were likely associated with higher degrees of sport specialization in various populations. Sports medicine organizations in general recommended against sport specialization in young athletes and instead promoted multisport participation for physical and psychological benefits. Few long-term data suggest that sport specialization has negative health-related quality-of-life consequences. Higher degrees of sport specialization likely pose risks of overuse injury; however, the age of specialization at which this risk occurs is not known. Because different populations and sports activities may put children at risk for certain injuries, future researchers should monitor large populations with sport-specific prospective active surveillance.

Sport Specialization and Single-Legged-Squat Performance Among Youth Baseball and Softball Athletes

CONTEXT

Previous research has indicated that throwing sports expose athletes to overuse injuries and that specialization in sport is linked to injury. However, the effect of overexposure to a throwing sport on a dynamic movement task is unknown.

OBJECTIVE

To determine if sport specialization in youth throwing athletes affected performance on the single-legged squat (SLS).

DESIGN

Descriptive laboratory study.

SETTING

University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 49 youth baseball and softball athletes (23 baseball, 26 softball; age = 12.96 ± 2.32 years, height = 165.01 ± 13.05 cm, mass = 61.42 ± 13.04 kg) were recruited.

MAIN OUTCOME MEASURE(S)

Participants were grouped into 3 categories based on specialization definitions: (1) 8 months or longer in season, (2) 8 months or longer in training, or (3) 8 months or longer in season and previously quit another sport. We measured SLS kinematics and used a set of 1-way multivariate analyses of variances to determine if trunk kinematics differed by group.

RESULTS

Athletes who spent 8 months or more in sport-specific training exhibited significantly more trunk control, revealed by less trunk lateral flexion (Λ = 0.69, F_6,38 = 2.89, P = .020) and less trunk flexion (Λ = 0.69, F_6,38 = 2.88, P = .021) throughout an SLS.

CONCLUSIONS

These results agree with the principle of specific adaptation to imposed demands. Surprisingly, athletes who spent 8 months or more playing a unilateral sport showed no differences in SLS performance. Clinicians should emphasize that neuromuscular adaptations of the lumbopelvic-hip complex for dynamic movement, such as an SLS, may be achieved through training instead of strict sport participation. Future researchers should consider how much of the training protocol is actually specialized for sport training.