From Playgrounds to Podiums: The Role of Physiotherapy in Youth Athletes with Dan Elias

Today on the podcast we're going to be talking to Dan Elias. Daniel is a highly experienced physiotherapist having worked within the NHS private practice and within elite sport with over 15 years clinical experience. Dan works as a physiotherapist for the England athletics team both nationally and internationally from under 13 to under 20 age groups assessing in treating young athletes as well as communicating with parents and coaches on ongoing management. Dan is also the clinic director of the Youth Physiotherapy Clinic in Bath, treating 8 to 18 year olds and working at balance performance physiotherapy in London as a consultant youth physiotherapist. Alongside his clinical work Dan has lectured within youth athletic field having presented on topics including overtraining in youth athlete, common injuries in the adolescent athlete and knowing the norm in the youth sporty child. Hi Dan, welcome to the pod. Hi guys, thanks so much for taking the time. I'm really excited to be able to chat about and be passionate about today. Likewise, great to have you Dan and thanks for your time. Let's jump right in. Can you tell us a bit about your journey and what led you to specialise in youth physiotherapy? Yeah of course. So had a really athletic background when I was younger, loved all sports, eventually specialised into the caplon when I was about 11 or 12 years of age. So although it's a specialised sport, it's almost a bit multi-sport as there's multiple events within that field. That was quite intense training six days a week but it was almost like a second family. So I was there Monday through Saturday or the day of and between but the key thing that my memories I've got from it was just pure joy. It was the love of me, it was the love competing but we still love the training with my friends as well. And then university happened and unfortunately it was a bit of a decision whether I kept on with the athletics or stopped so I had to make a decision. So then I went on to the sport and exercise science in Hertfordshire which was a good foundation for aspects of exercise prescription, physiology. And then I had a year out and I worked in the year, I worked in a stroke unit for a year again a really valuable year working with a multi-susblinary team and really different pace and populations. And that was a good year, I think I grew up in that year and that sounds a bit cheesy but I think being a university but going out to the real workplace and working within a real team I think that was good for me, I think it's setting on a good path. Then I went into my physiotherapy degree at St George's Medical School in London which was, I've gotten, it's because my age I think, but I was forgetting how many years ago, it's about 15 now and so it's getting on quite a while ago that I graduated. And in 2018 I did my master's in sports injury rehab from St George University and yeah so I've always, through the early years, more of an adult focus and then the big push for me to then specialise in physiotherapy was more just in conversations with my older patients about what they did when they were younger about how they used to love sport and then they stopped it or they got loads of injuries and they had to stop it and then I sort of got this in my head, I think I had this quote somewhere that it's much easier to build stronger children than fix broken adults and then that was that it developed into this real passion about really going to a deep dive about the differences in treating children versus adults and then that slowly led me into creating my own clinic which is purely specialised for eight days or eight to 18 years as I said and it's grown from there really so quite exciting but I want it to be I treat the children in the now but I've also got one on the future how can I keep these children loving their sport they're doing how can I try and mitigate any injuries so they don't drop out from sport and how do they live live a full life of it doesn't have to be sport it could be physical activity and we know that that pays dividends later on in life for so many health related outcomes so I feel that's the sharp end of the spear that I'd like to be part of. I laughed at quotes right there we're going to put it in one of the snippets that we take for the podcast. Definitely. Dan you so you're dealing now exclusively with young athletes what would you say are some of the biggest misconceptions that people have about physiotherapy for young athletes? Yeah that's a great question and I think it starts from the fact that the misconceptions that you can't treat a child like an adult the assessment the management the communication are completely different so as an adult as smash those leads to assessment you have to completely change that when you're treating a child you know you're dealing with the child you're also dealing with the the parents in the room maybe both parents sometimes the man might come along you've got the coach you've just got multiple stakeholders so you have to adapt your start of communication and the questions that you ask as well so I think there's that that misconception that you can just can do the same assessment for the adult for the due for a child and it is different as well and children are developing physically, psychologically, socially, emotionally so you've got all the and all these things happen at different parts of their growth as well and that also needs to be considered quite heavily. I think the other misconception is I suppose this is slightly similar to adults as well but you don't have to be broken for a child to see a physiotherapist there's you know I most of the time I do see them when the children have an injury or there's a concern but I'm really trying to grow that information space be it going out and and talking to the local clubs coaches parents about how we can mitigate injury and things that we can put in place for the children that stops them getting to that point where they do get injured in the first place because you know my holy thought is that children really shouldn't be getting the type of injuries that I'm seeing and there's definitely ways you can't stop all injuries and there's different types of injuries you've got the chronic and the acute but there there is there's lots of phenomenal research going on out there across multiple clubs so how we can manage these children much better and what I try and do is all the information from the elites that you can how can you try and distill that down to your amateur levels where when they're not quite reaching their peak elites when they're into an adulthood they don't really have that support package and that's what I'm trying to do with my clinic that we have that type of information they can start learning from an early age to try and get their bodies healthy as well and the other big one is I hope that we are listening to all the way over now but the weights aren't bad for children so the historically weight lifting was bad it was stunk growth and in cord injuries and and it's just not true we know that appropriate strength work at the right age and the right you know emotional ways and physical ways of that child maturation age it's really really important for bone health and lots of other physical outcomes and and at the right time it can sort of be one aspect of trying to mitigate injuries so that's one of the other big probably not within physiotherapy but maybe in the in the on social media or in the public that you know weights about for children so I do sometimes hear that and it's just a pride in the education yeah I think you already answered my follow up question what differentiates treating athletes or young athletes from from treating adults so I'll have another question for you I think in my experience sometimes I feel it's really easy to connect with children but sometimes really difficult do you have any special tip on how to connect with them in terms of communication special tips and I think it starts from the weight and room assessment so when I go into the weight and room I'll go to the the child first I'll get down to their level and I'll make a big effort to make eye contact and shake their hand because it's it's an alien well for them to become into they've not it's not a normal place like if they go to a doctor or someone else it's you need to make that a more comfortable environment so I greet them to them then I you know as I'm going up to the clinic room I'm asking about their day I'm trying to interact so how's your school day and if I know them a bit more how's that game that you played if they've I don't know if they've got a jump from with something on they're like oh you like that and just trying to develop that that rapport with them at their level actually in the clinic room I'll always ask the the patient to sit on the chair so I'm facing them and I try as much as possible to maintain eye contact and body language and not I don't want them sitting behind me I don't want to fill up I'm over the top and trying to do too much typing and because that can distract just trapped from that communication as well and then I generally start off my area session but I am like I want you know I want the parent and the child to tell me the story so I'll say I want you guys to tag team it I want you to tell me that start wherever you want to start from and tell me the whole story and then I just let them talk and I think quite often in healthcare people trying to interject I just want to tell me the story and at the talk but I think and also framing the right level of questions for them so some depending on the the maturation ways and psychological age some questions won't land we've cured and sometimes the pain score it's a really arbitrary score and difficult for a child maybe to understand and there's this sort of other scale called the one back of scale for just like the earlier kids which more like that pictures on on the opposite of pain But I think it's adapting some of those questions that, you know, it doesn't just make sense. Sometimes I don't struggle there, so. Okay. Yeah. Yeah. Getting back to the clinical questions again, I guess. Yeah. Yeah. So obviously, when you're seeing those young athletes, especially as they get to maybe more 11, 12, 13, that kind of age, they're starting to go through a major growth spurt. How do these growth spurt affect injury risk and recovery from those injuries, would you say? So it's, the peak of a losty phase is a tricky phase for children to go through. And I think we're just so more aware of it now. There's lots of fantastic research being done. But what I like to start with is bone health really. So it's important to know the differences with children's bone versus adult bones and just coming up to that peak of a losty phase. So your bone marrow, when your younger is more red than yellow, I mean, it slowly turns into yellow marrow, which then wears cartilage and bone is made. And that's at younger ages, that's still developing. So there's less yellow malmore red marrow. So the bones aren't going to be as strong at younger ages. So that comes back to the level of loading that we're doing for that child athlete. As they go through the peak of losty, they can be growing up to 7 to 14 centimeters a year. So quite rapid growth. And during this time, the bones become all the growth plates, which are called the fices, which is where you get your longitudinal growth. They go through a sort of a temporary, they're a bit more porous during that growth spurt. And the aspects of this semicircular congellistage, which predominate of the extracellular matrix. So it makes that own slightly less, slightly less formidable. And then you've got the aspects of just before the peak of losty, you tend to have sort of, the term previously was about adolescent awkwardness, but I think what it means is they just temporarily lose some of their motor coordination. And then if you've got this alongside the growth and they're doing all this sport, and they're not working on more neuromuscular control, or they're doing significant more hours a week than they rage or their biological age, this can then lead to those growth plates, or the fices type injuries. So that, for me, is important about the bones and during that peak up velocity. You can tend to, there's ways of mitigating this, but so there's aspects where you can get injuries. So there's the charge growing, and you can measure growth as in growth of height. The problem of this is it's already happened. So once you, oh, they've grown six centimeters, but it's already happened, so it's difficult to try and get in a step in front of that as well. What you can do, and I'm happy to give it to your list as well, so you can share, but there's a fantastic research so it's called J sort of J sort of J sort of, who has provided a formula such spreadsheet where you can measure the percentage of peak adult height, and also it measures their biological age. So this is really important, and the reason this is important is because we know that the peak height of velocity tends to go around 90% of your peak height, peak adult height. So if you've got a child and you're measuring an unit and they come in at 88 to 89% of their peak adult height, you know that not far around the corner, their peak height of velocity is heading quite quickly. So you can start putting things in place and monitoring aspects about you might be looking at their load per week, you might be looking at are there any warning signs of some of this lack of motor coordination, they've lost a bit of their sprint speed or the change of direction or they're feeling a bit more fatigued in the mornings, and just some early warning signs, they might be coming up to that peak of velocity, and then you can put things in place, and I can hopefully stop them getting these growth related type injuries. You can, another so leg length is an other issue, there's a fantastic research called David Johnson, who works at West Ham Academy, and so he's PhD, and one of the things was that the acceleration of leg length can be at an injury risk. So I like to inform the parents so that what they can do is to get this estimated leg length is a subtract trunk height, sitting height from standing height and you get an estimated leg length, and depending on where they are in their growth, I might get into monitoring this every six weeks or three months, and if they're nowhere near their growth spurt, it might be every five to six months. But there's a way of just trying to put it into trap when they go through that phase, and the actual growth spurt can last up to two to three years, so it's quite a long period of time. But yeah, there's some of the ways that you can start thinking about mitigating the injury, and also during this time, what we've really got to consider with the young athlete is that the energy that's required during this growth phase accelerates as well, their resting energy expenditure will also go up as well. So on top of the fact that they're doing well, their sport, their body is even at risk, it's actually growing, so that takes energy. So then you've got to look at the nutrition side of it as well. Are they adequately fueled to be able to do to do their sport as well? So we know that under fueling, a whole realm of effects versus the male versus the female athlete as well, but that's another aspect of treating kids. I think we neglect as well that these growing bodies, it takes a lot of energy. And I like to discuss that with you know, look at things with my rest periods and the heavy days of the week, I'm asked them to do their exercise and talk to the coaches. Having this sort of information is really valuable to them, I'd be able to because if you just try and tell a really talented young athlete, you ain't too much, you've got to stop. They probably won't listen to you and there's no context to it as well. So given them informing them and informing the child to get them to understand is I think is a really valuable way to try and mitigate injury. Time for our sponsor. Elevate your physiotherapy practice with the Physiotutors app. The ultimate resource for clinicians worldwide. Access over 1000 articles, podcasts and events, all tailored to your interests and updated daily. Join a community of over 100,000 professionals and engage with cutting edge tools like our AI clinical assistant for instant, evidence-based answers and build your own personalized library to organize and access your go-to resources effortlessly. Customize your learning journey with our personalized discover feed ensuring you stay at the forefront of physiotherapy. Ready to take your expertise to the next level? Download the Physiotutors app today and become the best clinician you can be. Right lots lots of interesting stuff. And by the way you've thrown out a couple of authors feel free to continue because we'll put all of the links to the papers you mentioned in the in a podcast transcript for people to download. And the points that you mentioned I guess that's that's a lot of stuff you get from your patient history. How would a typical assessment with a young athlete look like? Yeah so I I value the subjective incredibly highly I think we all do with the adults but I think even so too and so it's quite detailed. I mean a lot of it does is similar to adults but there's a lot of different stuff so I want to obviously know I want to know the why why why and so and I asked this with that also I want to get to the bottom of how this has come about so I'm just like a bit of a detective the mystery is in the history I want to dig and not be super fist with it because you miss a lot of the important information. So injury so that how it's come about I want to know sometimes the monthly nut to an injury what was going on in their life. Was it during the summer holidays where they weren't doing as much sport and they came back to to score it again all of a sudden they're doing loads loads of sport which is really common so it's just trying to get an idea of what time of the year they've been they've just suffered the injury and I want to know whether it's a mechanical presentation whether there's anything in flammatory going on as well whether there's anything red flags that I need to know about as well within that history some of them are similar from the point of view of is the intermissile chronic constant pain. Is there any night pain that's waking them up and with children they might it just might be some subtle things that they behave you might be changing mom and dad might notice that you know they're not as active or talkative or just some screening of this is not my specific but just being aware of sometimes of developmental delay type or regressions so for example every is there is the pair of reports and all the child wants to be carried up the stairs more or they're struggling to get off the floor they walk in the hands out their thighs. It's a completely different assessment but it's raising my antenna to think okay is this a muscular skeletal issue or is it is anything neurological developmental or is it rheumatological so that's going to really differ there's a really quite I put can let you guys know so you can put the link there's a nice is called right path and it gives just quite a nice algorithm of how to break down if you need to refer on where that needs to go and does it do they need to go to the DNA have they got a suspected slipped up a femoral top of their thigh bone and like was called a soupy and they got septic arthritis that straight to a and is it a muscular skeletal orthopedic opinion that can be managed by physio or needs to be referred on. Is there anything pediatric or any red flags so if you consent by potential cancer and obviously then you've got anything neurological as well. So that's, I'm always, I'm just green to make sure that my area is massively tall and I need to know that that's what it is. And my threshold for children is really low compared to adults. So if I've got any suspicions, I've got a team around me that I will either ask questions too or I will normally refer them very, very quickly. So you get an idea that is much as lethal, then I want to go down to the things about how many hours of sport are they doing a week? So I get them to go, right, Monday to Sunday, hit me, go with it, how many hours, what are you doing a day? And that includes, in school, that includes break time, that includes after school club stuff, have they got, you know, for school, have they got any club games as well? And then you break that right down and then if it's a specific sport, if it's gymnastics, I want to say the specialisms within that sport as well. So I'm really getting down to nitty gritty of how much loads they're doing. That's really, really important because I've had some cases of where I've had 10 or 11 year olds doing 17 to 18 hours a week of the same sport, early sports ventilation. And they're just starting to break down for loads of reasons, but I need to know that as well. I want to know whether they're taking victim in the E3, I've just spoken about before. With females, I want to know whether they've started their period or not. And I explain that to them by saying, it's really important because later that you start your period, that can impact on your bone health into adulthood as well. It can also impact on injury as well. So that's one of the important questions. And then I think, I do, I like to get the parents of Pina as well. And I last, I ask, I suppose with the kids and the adults as well, I want to know why they're here to see me today, especially the child, say sometimes I say, I don't know, and that's okay. But you're surprised when you've asked a question of what are your expectations of seeing me today? What are you worried about? Sometimes I'm like, I'm really worried about missing that game in two weeks time. And then you've got a little bit of a hook where you've got, in something that's really, really important to that child, you can either alleviate their fears or you can manage them appropriately from that point of view. No. All right. And it comes to screening, I think. Yeah. So we talked about a number of more serious issues that you screen for there, of course. But what are some of the most common injuries that you see in youth athletes and how can we better prevent them? I think injuries tend to follow the path of how the skeleton grows this via age. So we grow distantly to approximately. So you pretty much the feet start to grow first. And then it's slow. So the growth plates slowly fuse as we go up towards the shoulders. And you tend the injury pattern tends to follow that. So for example, of some like a calcaneal or a prophesitis, which people have probably heard as severs, that's more common in sort of the eight to 10 year olds that I see. And it fits with that 80, 85, 84% of their p-cutter height. Then we head up towards the knee and some of the common things with the odds good slatters. So the percentage is potentially 90 to 92% of their p-cutter height. Then we come up to the pelvis and then lastly the spine. And I tend-- so a lot of the times I tend to see a poffatial type issues where because that area, that feces hasn't fused yet. And it's more cartilaginous. That sort of age in children-- this is an important point, I think, that it's the reversed adult. So things like your ligaments, your tendons, are stronger than your bones. So you've got quite a strong tendon pulling on a cartilaginous growth plate. It can just get really, really irritated like a traction type induced. So I see that quite a lot throughout the growth. So you've got your heel, you've got your knee, then around the hamstring origin. But that's slightly later. Then we go up to the spine. The common one I'm seeing quite a lot at the moment. Lots of spondys. So basically injuries to the p-cutter arecras. See it like my cricketers. See it like my gymnast as well. Look. If you get hold of these early, you can calm the bone down. But my why tend to see-- because their natural history course is that the kids have pain. They rest. It goes away. They go back to sport again. It cars back again. They rest it goes away. But they never have enough time as in off-off from sport to let the bone calm down. So I always tend to get them. And they're difficult conversations, because a lot of these kids are incredibly swathe. And if it's a bone stress or it's a fracture, you look in a 10 to 12 weeks of nothing, complete and almost, complete rest. And that's really hard to tell a kid that you can't do that sort of stuff. So I like to try and get in there really with these. It just depends when they present to me as well. Yeah, I think that sounds like the question. With the weaker bones and the stronger tendons, do you see many evulsion fractures or is that not so common? I think they occur. I've always got at my radar. I wouldn't say I see a lot of them, though. But if, for example, this is where the differentiation between Adon and a child. So if I had to treat lots of sprinters, so by the sprinter, who was 15, 16 years of age and male, peak at a height around about 94, 95, I'm thinking of that age that the ishium, the hamstring and so on to ishium, that's not quite fused into bone, unless they were an early mature, right? But if they sprinted and they felt a pop, and it was more proximal, or my immediate impression is not necessarily a muscle injury, I'm thinking of an apothecial type injury, or are we talking that and it's pulled away from the bone. So I think it's on my radar, but it has to fit the injury mechanism. So if you say, for example, they were going up the stairs, and it has to be that high velocity that I'd be looking for as well. Have you already touched a little bit on the topic of over training in youth athletes? So how can parents and coaches recognize the early signs of overtraining? - I love that question. I really love giving them the lecture on overtraining 'cause it's almost a bit of a misnomer the term overtraining. So when I was formulating the presentation, I came across some research where they called it. It was an unexplained underperformance syndrome, which is an incredible mouthful, but the reason for that is 'cause when kids get into that, it looks like they're overtraining or they're a kid's overtrain, it's not just training volume. There's loads of different types of aspects that can cause that overtraining. But some of the symptoms, there's up to about 90 symptoms of signs of this type of presentation. So aspects of they might not be sleeping as well. They might be waking up in the morning, it's really incredibly tired. Their appetite might be reduced in as well, so normally this child eats three, four meals a day and all of a sudden they're not really that hungry as well. Really sore and heavy muscles. And they really shouldn't be feeling like the day off has an exercise, especially in a child. It's just a sign that they're just doing, is just doing way too much. Bad mood, which is always a bit tricky in adolescence 'cause is it normal for them or that's where you need to get a feel for the parents or is it something that they're changing? Some psychological stuff as well, like they're lacking confidence or they're not enjoying training or they've got a bit of apathy to go to training. So there's a psychological as well as the physical side, but really interestingly, there's the changes in the biochemical markers such as cortisol for some of the things that they were training. There's psychological scales get worse. So I tend to really, really keep your ears open for, you know, ask those questions about, are you really enjoying your sport at the moment? Or, you know, are you looking forward to that game on the weekend? And it's just, give you some ideas that they're, they've just lost the love of their sport and that is a fast track to apathy and from, pulling out from sport. And it's really quite common in females around about 11 to 12 is of age. There's a big drop off in girls doing sport on that age. And I truly believe that if we get things right just before that, we develop the right mindset and the right training programs and they maintain the love of their sport, I don't think they'll drop out as much as well. - It's quite subjective, right? It's, do you have like questionnaires that you can use to score people and see if they maybe fall into the category of overtraining or is it really a subjective assessment? - I think there, I mean, there's the biochemical side of it as well, but I think there's the ethical side of would you be going around, you know, taking bloods of choice to do if they're overtraising or not, I don't think that sits right with me. I mean, maybe even in a research study, but a lot of the stuff on overtraining has been done in adults from, I hope to read in whether there's new stuff that's come out before I last presented it. But I think you could pick up quite a lot from the psychology and just how they're presenting. There are scores out there. There's the POM score, which is psychological score. But I think I'm not 100% sure on specific ones for children as well to make sure we're getting the right, aspects come from my arrest and that questionnaires as well. But I think what I'm aiming to do is, I tend to get through this quite a lot of my assessments, but I'm thinking the future that let's something like we just said, like a questionnaire where you can get them to maybe tick box that sort of stuff. The problem with questionnaires, is sometimes if the child's smart stuff sometimes, never certain A's, they might not answer truthfully to that. And if they really don't want to be pulled out from their sport, they might not give an accurate answer. And again, there needs to be questions that the child can understand for their maturational age as well. So it could have value, but I think a lot of it is quite subjective, but they're fairly overt symptoms that a child shouldn't be present with. - I think just a quick follow up question because I feel like we could fill a whole episode, a whole episode on overtraining in a whole separate podcast. So what's the consequence if you figure out someone is overtraining? Is it just reducing or taking leaf from the sports that they do? It's just that simple. - I wish it was, I really wish it was. I think it's about reverse engineering it. So I go looking at where are they at the moment and how have they got there really? And that comes back to the wire question. And then it's just cast in the net really wide and then picking up things and then funnel it down to specific. So for me, how much are they sleeping? It's not just hours, it's quality. Are they sleeping hour and hour's but they're waking up to the night? That's poor sleep quality. Are they trying to catch up on their sleep on the weekends? And that's sleep death and that's detrimental as well, especially for those athletes that I find that sometimes they're at boarding school. So they get incredibly early to get the bus to school. They sometimes do sport before school. They do sport after school and they're sleeping, they're sleeping late and they're sleep suffer. So sleep's important. Then I come back to, are they adequately fueled? They got low energy availability. And this is where it comes back to. It's not necessarily just the training of the loadings of the aspects. So are they adequately fueled? How many, I tend to ask, how many meals do you have a day? Do you eat breakfast? I tend to, with modern times, are you more plant-based? Do you eat meat? To get a really broad idea of their diet as well. I also then ask about if they're doing, if they're multi-sport or specialist. And how many rest days do they have in the week? So it was true rest days. But either they do nothing or they're going to do some free play or they might go for a frisbee or they might do something else that's not their main sport. And then you start to really peel back on how have they got to that point in the first place. Because then you can give the family and you can give the child context. Because just by pulling someone from something and putting them back in, you're just going to make the same mistake. Because the definition of his sanity of just doing the same thing over and over again. So it's worth situation. I might ask them to fully rest. But that has to be quite severe. I'm always looking for ways to keep them moving. But they protect their bodies still as well. Yeah, great. Thank you. And I mean, are there specific sports that immediately raise your suspicion for overuse injury or is it not sort of biased to any particular sports? I think you have some of the sports where the kids are slightly early maturing. So it's quite common in gymnastics. So they're under quite high loads. An hour's from a really early age. Because they're competing at a high level from an early age. The problem with that is that it's an immature skeleton and it can't take those type of loads. So that can be quite common. But again, it can be managed. I do see quite a lot of cricketers as well. So that's quite high volume sport. Lots of the same repetitive action with the bowling. And there's much of the new ones going into how they get into a position but crickets and other ones. And then I'm seeing lots of football injuries. The academy is around the UK. I've got some phenomenal practitioners who are doing some amazing things about trying to reduce these injuries. The guy that said before, they were Johnson also sure coming. And there's-- but it's about how we could distill that down to the amateur level as well. There's a lot of these behaviors and patterns start from an early age. I think I just want to bring in here as well that I think sometimes this comes from the belief systems. I've been-- not always coaches, but sometimes the parents that you have to be an elite junior to be an elite senior. And the significant amount of sports, that's not the case. Very few elite juniors going to make elite seniors. You've got your few. You've got your serena Williams and you've got your Tiger Woods. But most of the time senior athletes, they were slightly late developers in performance. So I always try and tell that especially if they're doing every hour underneath the sun, you've time is on your side. Sometimes I'm getting quite a lot of ACL injuries at the moment. And they've got a year of rehab. But I'm like, don't worry, time is on your side. It's your friend, not your foe. You don't need to be the best you can be at the age of 15. And we know the Olympics that a lot of the gold medalists are well into their 20s. So I try and instill that it's how you develop your movements, it's how you develop your psychology, how do you get good nutrition practices, how do you learn all this sort of stuff early? And then you get into the real nitty gritty of the elite level training when you've come out of that late adolescent phase. And we know that strength training can play quite a role in injury prevention for adults. Is this the same for young athletes and maybe if it's different, how is it different? So the answer is yes, it's incredibly important. So you lay down about 50% of your bone content in those adolescent years. And we know that strength training is good for increasing bone, bone strength as well. However, it has to be done appropriately. So for an example, to make it an ugly black and white, if you have a 10-year-old that has never been in a weight room before, has never worked on their fundamentals of movement. And you give them a bar and put some weight stones. They understand you're doing squats. That for me is inappropriate because you haven't developed them appropriately. So they have to be at the right developmental age physically and psychologically. So can they understand the instructions that you're giving them? Before they go for their peak height of velocity and they're slightly earlier, it's a bit of a false errand to be doing any type of hypertrophy training. Because I haven't got the anabolic hormones to be able to make those gains. So that I wouldn't be doing that at that age. I'll develop on them. I call it their move and vocabulary. So the more diverse that can be, the better sportsman they're going to be. But there is an aspect of having the ability to squat, to push, to pull alongside developing other aspects of moving to adversity. But at a young age, when it gets to strength, sometimes carrying a medicine ball or your trying to play tag or you're trying to have a wrestle with your friend, I like to do the side plank wrestle pretty much. They're on the two kids' face each other. And they're trying to pull each other over. So you work on aspects of strength with the control. It just depends on what you're talking about with the guy's to strength. So I think it has to be age appropriate. And it has to be part of a well-balanced approach. Because you could injure a child. I think that's down to the fact that you're not doing the right type of strength training or the right type of age. So it's about that long term athlete development that is fortunate at the right time. But as I said at the start, the idea that it stuns growth is an MSI K. No, it just doesn't. Right. Dan, we've seen in your-- some of your online literature that you believe that rehabilitation should be fun for the youth athletes. How do you design rehab plans that engage and they feel are fun and that they'll stick with? So the first thing I do when I'm doing the rehab is I have an idea about what I need to do. But I'll take-- we've got Bath for also in my London clip was in my London clip at Balance Performance London. We've got a huge gym with loads of equipment. I take him into the gym and I watch them for a little bit. And I watch what they go towards and what they're interested in. And then I might base it on the back of that. But in essence, I'm the big fan of animal flow type exercises. So you've got your bare crawls, your bare holes, your crab toe touches. I like to challenge them. I like any sort of big Swiss balls that challenges their trunk. If the age appropriate, a chase and a raid games, trying to get their parents involved, trying to get their siblings involved. And you can tell whether they enjoy someone because their face lights up. A child finds it incredibly-- sometimes you need to do some of the boring stuff with them. I'm not saying that sometimes you need to do squats and you need to do push and pull. You might do some single leg idea always. But it has to be at the right age for them. I had like-- I've had some elbow injuries. Some really young children, eight, nine years of age, and they've had surgery. And it's the case of just trying to get them moving again. I'm not going to sit there and just worry about mobilizing their arm or getting to the bend arm. I'm going to get at the right age or the right time. Am I getting to throw a ball or catch a ball? Am I getting them to get a tenon's record and bounce a ball and turn their wrist over or bounce a ball and have a bit of a bounce a ball race forward and backwards? The other example I like to do is about reacting to something. And so it may be the latest in stage of rehab where you know, two people are on the floor, but their eyes closed. I stand in between and my bounce of ball really hard on the floor. I don't want them to then, and I say go and they have to try and get to that ball before it bounces twice. So I'm just trying to think of making things fun. And I think we could do this more with that option as well. Sometimes we just, the monotony of what we give people is hard. And so I think less is more with children as well. If you're going to give them the 10 exercises to do for four days a week, you're dreaming because it's just they're not going to do it. I haven't got the time. So things that fit easily into their day, whether they do it before and after sport, but I do, I'm a big fan of getting other people involved. I'm not a big fan of doing things in social isolation. Kids want to be with other kids. They want to be with maybe their friends. And you'll get a much better buy. And especially as they go past 11 and 12 when peer influence is quite important. So some kids want to go to the gym with their friends. Brilliant. My strength, the conditioning coach will take them into the gym or teach them how to lift in a safe way, a safe age. But it's, you know, it's the same with that. I was just well and aware you've got to find their why what they love to do. And don't try and force what you think's right on them. Want to stay ahead in physiotherapy? Whether you're looking to master ACL rehab, optimize tendinopathy treatment, or refine your approach to spinal assessment. Physiotutors has you covered with expert lead online courses. Our courses bridge the gap between research and practice, giving you evidence-based strategies you can apply immediately. Learn from world-class instructors at your own pace. Anytime, anywhere. Thousands of physios worldwide trust physiotutors to sharpen their skills and elevate their clinical outcomes. Join them today. Visit physiotutors.com/courses and take your expertise to the next level. Okay, great stuff. Hey, and we touched on, I think, a couple of dimensions, such as sleep, nutrition. And I think, or that's, I think, my opinion, one of the goals that we have with patients in general is also to change their habits for the better to develop healthy habits. What would you say is your strategy, or how do you help young athletes to develop long-term habits to stay injury-free throughout their young careers and also in the future? It's a really good question. It just starts with the right level of communication and education as well, and just drip-feeding stuff. You need to consider the psychological maturation of that child. You can tell very quickly when you're talking to child. I also, I like to feed back to me as well. I'm very open. I'm like, can you turn what I just said, does it make sense? And I also ask them to challenge me. I stay a lot of the time. I want them to be confident. They need to be confident to know their bodies. They just need to be confident to know, to go and talk to the coach, to say, I'm just not quite feeling right today. It's okay if I don't put so much intensity in or I have a rest today as well. So they develop that in a confidence. But knowledge and understanding is incredibly important. So understanding how they're feeling or that they've done too much this week and wrong. They can feel that they're getting tired in the mornings. They need to have a control and a real input in their process of their rehabilitation. The quote that comes to mind as well, I think was by the, there's a guy over in this country who I was a CEO of a company called Timpsons, which this is really random tangent, but to do with fixing shoes and keys and things. But he, one of his motto is his employees is, if you try and control people, they rebel. But if you give them control and an input, they tend to conform to the situation. So I've really, when some kids are really chatty and we'll talk for our, some are really reserved. So it's just adapting your communication style. But I think given them the room to ask questions is a good place to start, I think. Because it just doesn't feel like you're telling them off. Because it could feel like that. Imagine you went into a physio waiting room and all of a sudden someone was going, "You need to start this. You've done that wrong. You've done this wrong." They're not really going to listen. I try and get them to ask me questions as much as possible as well. It's a little bit of motivational interviewing style. Is it a bit better with the kids maybe? Yeah, and you get some cracking answers. Kids give cracking answers. So yeah, I think it makes it more fun. And I, Jim, I'm not a live love tree in adults, but there's something about kids can be actually hilarious as well. And sometimes they've got a very mature head on a young body. They talk to them about a good old conversation. So that's where you need to warp your communication a little bit. Because sometimes they can take a lot more than you think even at a younger age. They might be slightly mature, psychologically as well. You're obviously very good at communicating with all these young athletes that you're seeing. When they're trying to come back from an injury, what advice do you try and give them, both on the physical and the mental side? So the mental side, I've got a sports psychologist I work with. So again, I tend to try to pick up some of the flags and refer on it if I think it's appropriate. But it's a long, it's a game of questions again for me. So it's about, you know, are you excited to be going back? Are you worried about anything going back? Do you want to go back to what you were doing before as well? Again, it's about that given them the opportunity to take control of the situation as opposed to the parents. Most of the time I find parents, they're really concerned for their children. They don't want to do the job up the best. But sometimes there's external pressures. So they got pressure from the parent. Had they got pressure from a coach. If they're doing really well at a young age, they got sponsorship and pressures. I find a lot of the sports scholars have a lot of external pressures from the school. Because they're at the school, they're there because they're really good at two degrees. They're in every team. They're the first pick on the team sheet. So when they're out, there's lots of pressure from different coaches and people to come back earlier. So you start to pick up, you know, how they're feeling from that point of view. And that you've also got to consider at that age, they're different to adults. So they're very much governed by their emotional system versus their cognitive system. And that cognition comes in a little bit later. So things like how they react to an injury might be more emotional. They're not sometimes they're not so good at picking up the perceptions of other people as well. So again, you just need to not take that face value and delve a little bit deeper. So there's some of the questions I would ask. And then I then would try and refer to my sports like if they've had a big injury, where they've had high trauma and early age. Sometimes they might not have the words or they might not feel confident to talk maybe to me about it or to their parents. But it might that might be sort of because that's slightly outside of my field. So sports like holidays might be really valuable. Because if they carried out thought with them, it's so much like the film inception. It just grows if you don't ask the right questioners and you don't get the right information from them, that little seed that plants can grind to something where it might end up that they stopped doing their sport. So my sports are growing. She's wonderful. So I'm trying to always think of that with my children as well. From a physical point of view, they need to be, how I look at this with adults as well, but are they a plug that fits the socket of their activity? So can they do everything that's demanded of them for that sport? I know very on the sport, can they, I try and go from very controlled form of rehab to then complete chaos or controlled chaos? Because that's what sport is. So, you know, and that's where the fun stuff is as well with the kids as well. You know, looking at getting the hockey stick out, getting the balls out, getting them to, you know, to change direction, getting them to play tag. There's lots of stuff that you can do, but it's trying to get them to see, see their face light up to start as they're back to doing their sport, but also getting to see that they can do physically what they need to be able to do as well. And kids are really, really adaptable. I work closely with my orthopedic colleagues, both in Bath and London, and sometimes you need to take things a bit slow, but sometimes they turn around really, really quickly as well. So, yeah, it's that thing. They need to be able to do that sport and move, but they need to be able to do it as well. But an injury, another way of framing it is an injury is an opportunity. I never look at as an injury as a bad situation, because I try and say that, you know, let's get you out the other side of this better than when you came into it. Sometimes they come to me and I can give them all this information. If I hadn't injured themselves, they might have not been got this information. It might have been too late, but if they don't injured themselves really bad, I can give them the stuff of any nutrition, about getting on the vitamin D3, about the importance of sleep, about, you know, chuckling in a couple of days a week of some fun movements with their brothers and sisters. So, it's always an opportunity, the I see, it's not always a negative situation. It's funny that if you say that, I feel like in my own experience, like the injuries that I had looking back now, they were all great opportunities to learn a lot about my body. They pushed me towards picking up weight training. So, looking back, they were always good things that I can do. actually happened, although at the time it was a bad injury or a bad situation. But it's the Carol Dewey growth mindset approach. If you go into it with a fixed mindset that my life's over, I can't do my sport over again, whereas if you put the growth hat on, and I try, if I try and get parents to read the Carol Deweyx work, it's fantastic and you can really apply it to kids as well. Yeah. It's slowly coming towards the end of the podcast, so I think we have like one or two questions left and one is, what would you say is the biggest mistake parents or coaches make when it comes to youth athletic development? I don't think anyone's intentionally making mistakes. I think there are certain practitioners out there that are pushing children way too hard. Now whether that's, they don't believe the research or they're a little bit old school, but most of the time I find parents and coaches really very receptive to information about how they can keep that child injury free and enjoying their sport. Social media is not the best place I don't think for parents. You go to Google and there's so many incorrect bits of information out there and there's too much information. So I try and get parents to stay well away from social media, so they've got any questions asking me about it. But I think the biggest mistake that I would probably say is that I think that there's too many hours doing a single sport across all the months of the year. So they're doing 12, 12 or 13 and they're doing 12 months a year of sport. That's too much. We know that they, we should only really do about 7 to 8 months and there's a lot of push for free play outside of that as well. So that physical literacy aspect where they can develop really a wide variety of movement and that has a really impact on their movement and their performance. The people that come to mind the two big hitters that were more diversified on the younger was Roger Federer and Janik Sinner. So they were both very much multi-sport. Janik Sinner I don't think started taking tennis seriously since he was 19. So look at looking at him now. I mean a fantastic move from tennis players. So it's not supposed to be a mistake but I think people, because they see all the money in the elite game and they try and bring that down to the kids, you can't treat a kid like a kind of lead adult, just, it just can't do it. So that for me is just, just breathe, take some time and if they're enjoying things and they're talented, they'll reach their potential. They just need time. I'm so happy that you touched on early sports specialisation because I was going to bring it up anyways. So great that you mentioned it and I think there are many more examples. For example Sebastian Traveinstegger, like German national soccer, same story was number one skier in Germany and the youth. So I think there's many more examples. And it can be a little bit, it's not so binary. I think you can, you know, there are downsides to sport, nearly sport specialisation but as opposed to throwing the toys out the prime and going, oh that's wrong. What can you do with that athlete that is doing that? You can't just tell them to stop doing it but you need to inform on, okay, how do you manage this situation? I know when you're going maybe go near your growth spurt, can I manage you during that time? And there are still ways of, there's some great history of some good gymnast who have gone through and had great coaches and they just backed their load off during their peak high velocity and they didn't really get injured and they had a last-dressed career. So you will encounter early sports specialisation, it's just about how you adapt to it. Okay, great stuff. Alright, I think we're coming towards the end of the podcast. Anything that we haven't touched on that you'd like to add or discuss? I don't think that's covered everything. I think there's the work on nutrition, I think, that needs more attention to it. But my real gut feeling is that because sport has been done to such a high volume in these children, I think more so than ever now. And sport is a absolutely wonderful medium for the physical, for the socials. So it is good, but I just don't think that these children I adequately feel to be doing this type of sport as well. So I think my, my big, which I've got, I've got a, I've worked with a fantastic sport nutrition as well, but how, how they can get in early with education on nutrition versus waiting for when they actually have a problem as well. So the early day and the week and teach about a healthy balanced diet and it's already individual with children and with adults as well because your energy expenses is different from for the child that just walks to school every day to a child that does 16 hours of sport a week. Their energy input is going to be vastly different and their requirements of nutrition will differ as well. So yeah, that balanced healthy diet will go a long way into hopefully reducing the low energy of ability and those red type symptoms. All right. Hey, and lastly, where can people find you if they want to reach out or learn more about you? So the best so I am on Twitter, but I'm not, I'm not massively out of Twitter, but my handle is at believe move grow. I'm just in the midst of forming my website, so that's under construction, so that will be done soon. But if you just type in, if you go to Google and type in Youth Physiotherapy Clinic and Team Bath, I can't tell you to be on there and then I can provide my email address if people are interested in no more. Okay, Dan, thank you so much for your time and for your insights. It was a pleasure to have you on the podcast. No worries, it was great fun. Okay, and to everyone out there, thanks a lot for listening to this episode and to listen to this and other episodes in your own language, including German, French, Spanish, Italian, Portuguese and Dutch. Download our new and free physiotherapist app and additionally you can access the transcript and infographic and also find more useful physiocontent. And as always, if you enjoyed this episode, hit the subscribe button or follow our podcast of Spotify or Apple podcasts and also consider leaving your review if you really enjoyed it. And with that being said, this was Kai and Steve for Physiotutors and until next time. See you, bye bye.