How to Manage Adolescent Pain, Injury and Training – Part 2/3

Introduction

The purpose of part 2 of this blog is to outline simple processes that should be considered when creating a management plan for children/adolescents with pain or injury. We will cover how to achieve buy in, the long term athletic development model (LTAD) and implications for treatment along this continuum. If you haven’t read it already, click here for Part 1 outlining the anatomy/physiology of growth and development along with unique paediatric red flags.

Kids are Not Little Adults

Dr Teddy Willsey has a great research review in the November 2020 issue of Physio Network, where he outlines evidence-based methods to engage adolescent patients in the rehab process. This review outlined 3 key barriers to effective interventions with adolescent patients and recommendations to overcome them. These were:

Capability

Which was the physical and psychosocial ability of the patient to actually adhere to the intervention. The most effective interventions here involved clear and appropriate education around how the intervention would help, and how it could be carried out in the child’s context.

Opportunity

Which encompassed the unique logistical and environmental barriers children face. Individualisation of the prescriptions of the intervention to meet the child’s context was the most important thing.

Motivation

Which encompassed the child’s willingness to engage in the rehab process. Unsurprisingly, realistic goal setting, performance tracking and making the intervention enjoyable were the most important aspects here (1).

When working with youth athletes with disabilities one of my mentors pointed me in the direction of the “F words of childhood disability” paper. This had a profound impact on how I structure sessions with children and adolescents. The article outlines what I believe is best practice when creating an effective treatment plan, and ties in to the previous review findings.

Function

Kids won’t do things that don’t directly relate to the thing that they want to do. Focus on function, not impairments and how your intervention will improve their function for buy-in.

Family/Friends

A child’s closest network must be involved in the development of the treatment plan. Family and friends can be primary facilitators of it actually getting done.

Fitness

Childhood is one of the most important times to promote physical activity for lifelong health. Find a way to keep the child’s positive relationship with exercise during this rehab period.

FUN

A rehab intervention for a child should be based around play and enjoyment with the secondary side effect of the intended intervention. Please design your rehab this way. You are so much more likely to get the required dosage of wall sits for Osgoods Schlatters, if while the child is sitting there they are playing patty cake with mum, or seeing how many hoops they can shoot before they drop, than you will with a boring timed isometric hold (2).

Implications of the LTAD Model on Management

The LTAD model helps us simplify our advice and education around the types of physical activity and what intensity is appropriate for the patient.

FUNdamental (6-10 years old)

Learn the prerequisite movement patterns, squat, lunge, run jump/land, strike, roll, throw, hit etc. The focus of this time should be developing a broad movement base with structured and unstructured play. Learning how to manipulate one’s own body at an intensity of maximum 15 repetition maximum (RM) should be the bulk of training here. Therapeutic interventions should be based around play and fun, while still targeting the specific orthopedic condition. Sports specialisation at this age is a risk for overuse injury.

Train to train (11-13 years old)

During this age group improving general physical condition and capacity in the prior movements is the key. We may also have to regress to some fundamental strategies around the time of peak height velocity (PHV) if it has coincided with a loss of neuromuscular coordination, resulting in acute injury or at risk motor patterns. Most children of this age can tolerate external resistance training if required (10-15RM’s). Some sports specificity in rehab/training is likely needed here.

Train to compete (14-17 years old)

By this age, about 50% of training/rehab can be tailored towards sports specificity. Training with moderate to high intensities (8-15RM’s) can be considered in rehab and training programs, focusing on highly technical lifting.

Train to win (18+ years old)

By this age sports specialisation is completely normal and generally the focus is on specific performance as the body is mostly matured and has successfully built through the requisite stages. In this age group, there are very few considerations around rehab/training that are different to adults (1-4).

The 10000 Hour Rule Myth

I really want to break the myth that the 10000 hour rule will help improve little Jill or Johnny’s performance. If anything this mentality has been shown to lead to a relatively lower number of high performing athletes and increase the incidence of injuries mentioned in part 3. If anything, multi-sport athletes who focus on play-based development are better performers and have less risk of injury.

As a general rule, total training/rehab hours per week should never exceed the patients years of age. Put simply, if you allow kids to be kids, they are unlikely to push themselves to the point of overuse injury. It’s only when they are forced into high levels of repetitive structured training that injury risk increases. It’s also important to promote an off season for every adolescent for at least 12 weeks of no structured sports training. Here, they can self-direct their physical and emotional capacities, while maintaining skill through sport specific and diverse play (3-6).

Youth/Adolescent High Performance Sports Specialists

The following is for those of you working with high performance youth sports specialists (even though this category is hopefully decreasing due to all I mentioned above). Management of the amount of training stress these athletes can be exposed to has been split into 3 categories. It is worth considering these categories for the return to training/sport as it can help to determine the rate of reloading/return and mitigate risk of re-injury. These categories are:

• Load sensitive athletes who are high performing sports specialists showing consistent intolerance to highly specific training stress. Progress rehab and training loads with caution.
• Load naive athletes who are high performing sports specialists with low training ages and skeletal immaturity. Avoid spikes in rehab/training loads until skeletally mature.
• Load tolerable athletes are either skeletally mature and/or have a history of training successfully at or above the recommended 1 hour/year of age sport specific training stress. Still ensure the child is psychologically tolerating training and not burning out (7).

Conclusion

So that’s part 2 done and dusted! Hopefully it has you considering how to practically build an intervention for children of all ages and goals. Next up in part 3 we will cover commonly encountered conditions.