Br. J. Sp. Med; Vol 24, No.

4
Review

Br J Sports Med: first published as 10.1136/bjsm.24.4.237 on 1 December 1990. Downloaded from http://bjsm.bmj.com/ on November 8, 2023 by guest. Protected by copyright.
Intensive training in young athletes
N. Maffulli MD1 and E. Pintore MD2
1
University of Naples, First Medical School, Department of Human Physiology, Section of Sports
Physiopathology,
2
Naples, Italy
Epsom District Hospital, Department of Orthopaedics, Epsom, Surrey, UK

An increasing number of children take part in organized

sporting activities, undergoing intensive training and high
Physical, cardiovascular and muscular
level competition from an early age. Although intensive effects
training in children may foster health benefits, many are Increase in strength and endurance are an established
injured as a result of training, often quite seriously. This feature of growth and development9 and of train-
paper reviews some of the areas of research dealing with ing'0. The effects of physical training are difficult to
intensively trained young athletes, and focuses on separate from those of normal puberty9. Studies
physical, cardiovascular and muscular effects, sports involving children have detected a wide range of
injuries and psychological effects of intensive training. It results, from certain ill effects, such as growth
is concluded that measures should be taken to modify retardation", and no effects at alll1 12-14. It is known
present training and competition schemes to avoid the that a certain amount of physical activity is required
deleterious effects of intensive physical activity on these
children. for normal growth" 11, but the minimum needed has
not been identified, and the ill effects of intensive
Keywords: Intensive training, children, sports injuries training have not been fully darified" 9 11-14.
In girls, one of the most sensitive areas of research
In the past few years, competitive sport participation has been menarche and menstrual disorders. The age
has become an established feature of Western of achieving menarche, and the incidence and
society'. Youngsters in their early teens may have duration of menstrual disturbances in young athletes
already undergone intensive training and high level engaged in intensive training have been reviewed" 9.
competition for several years in sports like gymnas- With few exceptions, menarche is delayed in
tics, swimming or tennis2. Rowley has reported that athletes'. Moreover, female athletes engaged in
early participation of children in competitive training intensive training show an increased frequency of
activities is due to the 'catch them young' philoso- menstrual irregularities'2. The data dealing with this
phy3, and to the belief that, to be able to achieve issue have not been convincingly researched. Factors
international acdaim, it is necessary to start intensive that could influence the time of menarche, such as
training before puberty. genetic influences or nutritional status, must be
The number of children taking part in competitive systematically controlled for meaningful conclusions
sports is so high that some medical bodies have to be drawn.
issued guidelines regarding participation4 5. Also, the skeletal maturation of young male
Although all the risks of injury in these youngsters athletes engaged in cycling, rowing and ice hockey
are, at present, unknown6, an epidemic of sports was followed from 12 to 15 years by Kotulan et al.'3
injuries, as children change from free play to the who concluded that regular physical activity has no
stereotyped demands of the specialized patterns of effects on the growth of young male athletes.
movement imposed by a single sport, has been The question of athletic potential has been addres-
predicted7 8. sed. The response of a given athlete to a particular
The emphasis on intensive training and high level training regimen is due to an inherited genotype'5.
competition in a single sport begs the following Only approximately 30% of the maximal oxygen
questions: uptake (VO2 max) and maximal force and power of
Should young children participate in intensive top class competitors can be accounted for by
training and high level competition? training.
Are children involved in intensive training at risk Young athletes undergoing vigorous training were
of injuries to their developing musculo-skeletal found to be taller and to have less body fat and higher
system? VO2 max than sedentary controls'6. In another study,
Can psychological problems arise from intensive 34 boys aged between 12 and 16 years old engaged in
sports participation at a young age? competitive middle and long distance running were
compared with 56 controls not undergoing intensive
training'7. The runners had been training for 2 to 5
Address for correspondence: N. Maffulli, Institute of Child Health, years, and had less body fat and lower resting heart
Respiratory and Anaesthetic Unit, Sports Medicine Laboratory, 30 rates. Statistically significant differences were only
Guildford Street, London WC1N 1EH, UK
© 1990 Butterworth-Heinemann Ltd achieved between the 16 year olds. The young
0306-3674/90/040237-03 runners in this study also had larger heart volumes,

Br. J. Sports Med., Vol 24, No. 4 237

 Children and intensive training: N. Maffulli and E. Pintore
and a higher V02 max relative to body weight and serious injury of the weight-bearing joint surfaces37.
respiratory capacity. Due to the presence of growing cartilage, and the

Br J Sports Med: first published as 10.1136/bjsm.24.4.237 on 1 December 1990. Downloaded from http://bjsm.bmj.com/ on November 8, 2023 by guest. Protected by copyright.
In another study, the effects of endurance and process of growth itself, the skeletal system of a
sprint training were studied on the vastus lateralis young athlete is more prone to specific types of
musdes of boys aged 16 and 17 years18. Endurance injuries . In addition, ligaments in children are two
training resulted in a significant increase to type I and to five times stronger than the cartilage and bone of
HA fibre areas, together with increased activity of the epiphysial plate to which they are attached39','.
some of the enzymes of the Kreb's cyde. On the other This results in a greater likelihood of fracture of the
hand, sprint-trained boys showed a significant epiphysial-metaphysial junction rather than the
increase in the activity of glycolytic enzymes. ligamentous tears seen in adults.
Fewer controlled studies have dealt with the Over-use injuries are characterized by chronic
trainability of muscular strength in children. Pre- and inflammation due to repeated microtrauma. Young
post-pubescent children of both sexes can significant- athletes may develop one or more of a group of
ly increase their muscular strength by resistance over-use injuries referred to as osteochondroses4'. In
training'9 20. The traditional view19 in this respect is some instances, an osteochondrosis involves de-
that the potential to develop strength is not at its generation of the centre of ossification where a major
maximum before puberty. Nevertheless, according to tendon attaches to the bone (an apophysis). Common
Pfeiffer and Francis, pre-pubescent children are likely sites are the posterior aspect of the calcaneus (Sever's
to have a greater muscular strength trainability than disease), the tibial tubercle (Osgood-Schlatter dis-
older age groups21. When interpreting the effects of a ease), and the lower pole of the patella (Sinding-
strength training programme, one should consider Larson-Johansson syndrome). The small carpal and
that the natural increase in strength in boys reaches tarsal bones may also be affected. Young athletes are
its maximum only approximately 1 year after the therefore at risk of developing stress lesions to these
growth spurt, while in girls this occurs during the susceptible growth areas. In childhood, compression
period of growth spurt itself2. stress fractures occur more commonly than the
Intensive training may result in staleness. There oblique type seen in adults42' 3. Endurance training
have been a number of reports of a fatigue syndrome regimens are probably responsible for at least 60% of
in top dass athletes. However, no controlled studies all over-use injuries sustained' and could be avoided
have been performed. Some possible important by appropriate changes in training.
contributing factors to fatigue indude an increased In case of injury, the first therapeutic measure is
predisposition to viral infections, fatigue from over- rest41. At high performance level, it is important to
training or combination of physical and psychological know whether an alteration of training regimen after
fatigue analogous to the 'burn out syndrome' an injury can maintain fitness and ensure rapid
reported in other contextsl0 23 24. Keast et al. have healing. Very little research has been performed in
stated that sports mediated immune response altera- this area, although in one study that replaced
tions may play a major role in determining increased endurance running with endurance cycling for 4
susceptibility to infections'. weeks it was observed that maximal aerobic power
and submaximal running performance for moderate-
Sports injuries ly trained women runners was maintained".
Some epidemiological studies have shown that
between 3% and 11% of school-aged children are Psychological effects
injured each year due to sports activity26'27. Physical
characteristics can play a major role both in the choice Young competitors undergo increased stress and
of sport and on the pattern of injuries28. For example, anxiety due to competition the outcome of which
joint laxity may result in a child's choice of can be influenced by parents;, potentially leading to
gymnastics, but is associated with recurrent sprains a greater incidence of aggression in the young
and dislocations29. athletes47. These concerns have led to the extreme
During the growth spurt, adolescents are particu- position of calling for a complete ban on high level
larly vulnerable to injuries, partially due to imbalance competition in pre-adolescence because of the possi-
in strength and flexibility7. The huge increases in ble long term deleterious effects'8. Detailed reviews
participation, training and competition have resulted of the psychological effects of intensive training on
in children incurring injuries previously seen almost young athletes have recently been published3".
exclusively in adults 30 31.
The skeletal system is extremely plastic in children Conclusions
and shows pronounced adaptive changes to intensive
sports training32. The long-term effects on bone of The physiological responses to training in children
participating in intensive training during the period appear to be similar to those found in adults and, in
of growth and development are still obscure. the short term at least, seem beneficial. Definitive
Low-intensity training can stimulate bone length, but statements about the effects of intensive training on
high intensity training may inhibit it33 3m. young athletes cannot yet be made. However,
Sports injuries could result in damage to the concerns about the physical and psychological injury
growth mechanisms with subsequent life-lasting remain, and it is likely that the age of the child and
damage'. Physiological repetitive loading is indeed the particular sport should influence the type and
beneficial', but excessive efforts may result in intensity of training.

238 Br. J. Sports Med., Vol 24, No. 4

 Children and intensive training: N. Maffulli and E. Pintore
Health professionals dealing with young athletes 19 Nielsen, B., Nielsen, K., Behrendt-Hansen, M. and Asmus-
should be aware of these controversial issues. sen, E. Training of 'functional' muscular strength in girls 7-19

Br J Sports Med: first published as 10.1136/bjsm.24.4.237 on 1 December 1990. Downloaded from http://bjsm.bmj.com/ on November 8, 2023 by guest. Protected by copyright.
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