Text generated with master prompt (see methodology article) + additional prompt to integrate growth chart discussion and a figure.
AI Model: Sonnet 4 (Claude, Anthropic) on September 26th, 2025.
Expert: Dr Daniela Marx-Berger

Clinical case

14 yo male soccer goalie comes to your sports medicine clinic because the second goalie of his team has grown much more during the last months and the coach has moved him to the bench, favoring the taller player. In reaction, he increased his strength training and endurance training besides the normal team training. He is now often tired and has had a few episodes of viral infections the last months.
He wants to know how tall he will get and why his teammate is growing much more than him. He is also concerned about being tired and sick on multiple occasions.
How do you address these questions?

Introduction

In my practice as a sports physician, I frequently encounter adolescent athletes grappling with the complex interplay between pubertal development, training demands, and performance expectations. The adolescent period represents a critical window where growth velocity, hormonal fluctuations, and sport-specific pressures converge to create unique clinical challenges. Recent consensus statements from the International Olympic Committee (IOC) and British Journal of Sports Medicine (BJSM) emphasize the importance of understanding these developmental considerations in young athletes [1,2].
Adolescent soccer players face particular challenges, with studies indicating that approximately 15-20% of youth soccer players experience symptoms consistent with overtraining syndrome, while growth-related concerns affect nearly 40% of players aged 13-16 years [3,4]. The psychological impact of perceived underperformance during critical developmental periods cannot be understated, particularly in competitive environments where selection pressures intensify.

Case Integration and Clinical Pitfalls

The constellation of symptoms presented by this young goalkeeper—growth concerns, fatigue, recurrent infections, and reactive training intensification—represents a common yet complex scenario I encounter regularly. This case highlights several critical pitfalls: the tendency for adolescent athletes to self-medicate performance anxiety through increased training, the misconception that linear growth patterns are universal, and the failure to recognize early signs of overreaching in developing athletes.
Cultural pressures within soccer, particularly for goalkeepers where physical presence is highly valued, can create psychological stress that manifests through maladaptive training behaviors. The competitive environment often fails to account for individual developmental trajectories, leading to premature performance judgments that can trigger counterproductive responses.

Clinical Background

Growth velocity in adolescent males typically peaks around 13.5-14.5 years, with significant individual variation ranging from 11-16 years for peak height velocity [5]. Tanner staging remains the gold standard for assessing pubertal development, though bone age assessment via left hand and wrist radiographs provides more precise growth potential estimates.
The differential diagnosis for this presentation includes functional overreaching, non-functional overreaching progressing toward overtraining syndrome, constitutional growth delay, underlying endocrinopathies (growth hormone deficiency, hypothyroidism), and immunodeficiency states. Recent evidence suggests that high training loads combined with inadequate recovery can suppress the hypothalamic-pituitary-gonadal axis, potentially affecting growth hormone release and overall development [6].
Growth monitoring using standardized charts (WHO, CDC) remains fundamental in adolescent athlete assessment. I routinely plot height, weight, and BMI on appropriate growth curves while calculating growth velocity over 6-12 month intervals. Mid-parental height calculations provide target height ranges, while bone age assessment offers growth potential estimates. The pattern shown in Figure 1 illustrates the considerable variation in growth velocity timing among adolescent males, explaining why direct peer comparisons can be misleading and anxiety-provoking.
Recurrent upper respiratory tract infections in athletes often indicate compromised immune function secondary to excessive training stress. The “open window” theory describes periods of immunosuppression following intense exercise, though recent research suggests this relationship is more nuanced than previously understood [7].

[A line graph showing height velocity (cm/year) on the y-axis (0-12 cm/year) versus age (10-18 years) on the x-axis. Three curves are displayed: 1) «Early maturer» – peaks at age 12 with maximum velocity of 10 cm/year, 2) «Average maturer» – peaks at age 14 with maximum velocity of 9 cm/year, and 3) «Late maturer» – peaks at age 15.5 with maximum velocity of 11 cm/year. The curves demonstrate how peak height velocity timing varies significantly among individuals, with late maturers often achieving higher peak velocities despite delayed onset.]

Management Approach

My clinical approach begins with comprehensive history-taking, including detailed training logs, sleep patterns, nutritional intake, and psychosocial stressors. Physical examination focuses on Tanner staging, anthropometric measurements (height, weight, arm span), and signs of overtraining including resting heart rate variability and orthostatic vital signs.
Growth monitoring forms a cornerstone of my assessment protocol. I systematically plot current measurements on age-appropriate growth charts, calculate growth velocity using measurements from the previous 6-12 months when available, and determine mid-parental height using the formula: [(maternal height + paternal height + 13cm)/2] ± 8.5cm for males. Growth velocity below the 10th percentile or crossing major percentile lines warrants further investigation. I maintain growth charts in the athlete’s medical record and schedule follow-up measurements every 3-4 months during periods of concern.
Initial investigations include complete blood count, comprehensive metabolic panel, inflammatory markers (CRP, ESR), vitamin D, iron studies, and thyroid function tests. If growth delay is suspected, I obtain bone age radiographs and consider growth hormone stimulation testing in consultation with pediatric endocrinology.
The multidisciplinary team approach is essential and includes a sports physician as the coordinator, physiotherapist for movement assessment and load management, sports psychologist for coping strategies and performance anxiety, and nutritionist for growth and recovery optimization. Collaboration with parents, coaches, and school personnel ensures consistent messaging and support.
Training modifications follow a systematic approach: immediate reduction of additional strength and endurance training by 50-70%, implementation of periodized training with adequate recovery, and introduction of heart rate variability monitoring where appropriate. I emphasize to families that this temporary reduction serves long-term athletic development rather than hindering it.

Return to Play Framework

Return to sport progression follows established IOC consensus guidelines for young athletes, modified for individual circumstances [8]. The framework outlined in Table 1 provides structured progression criteria based on physiological and psychological readiness indicators.
For adolescent athletes, I emphasize that return to full training intensity should only occur after demonstrating consistent energy levels, absence of illness for 2-3 weeks, and psychological readiness to engage appropriately with training loads. The progression timeline typically spans 4-6 weeks, though individual variation is significant.
Sport-specific considerations for goalkeepers include graduated return to diving and reaction training, as these activities place high demands on neuromuscular systems that may be compromised during recovery from overreaching states.

Prognosis and Athlete Counseling

Recovery from functional overreaching typically occurs within 2-4 weeks with appropriate intervention, while non-functional overreaching may require 2-3 months. Growth concerns generally resolve with time and appropriate nutrition, though constitutional delay may extend into late adolescence.
Predictors of prolonged recovery include concurrent psychological stressors, inadequate sleep (less than 8 hours nightly), poor nutritional status, and continued high training loads despite symptoms. Family dynamics and coaching philosophy significantly influence recovery trajectories.
Counseling focuses on education about normal growth variation, the importance of individualized development timelines, and the counterproductive nature of reactive training increases. I routinely show families growth charts demonstrating the wide range of normal growth patterns and explain how peak height velocity can occur anywhere from 11-16 years in healthy males. Using visual aids, I illustrate how their athlete’s growth trajectory compares to population norms while emphasizing that being a “late bloomer” often correlates with extended growth periods and ultimate height advantage. I emphasize that temporary performance decrements during adolescence are normal and that appropriate management now optimizes long-term athletic potential. Shared decision-making involves the athlete, parents, and coaching staff in developing realistic expectations and modified training plans.

Take-Home Messages

• Growth velocity varies significantly among adolescent athletes; constitutional delay is common and typically resolves without intervention, requiring patience and appropriate counseling
• Systematic growth monitoring using standardized charts, growth velocity calculations, and mid-parental height assessments provides objective data to counter subjective peer comparisons and performance anxiety
• Reactive training increases in response to performance concerns often exacerbate underlying overreaching and should be immediately addressed through load reduction and multidisciplinary support
• Recurrent infections combined with fatigue in adolescent athletes warrant systematic evaluation for overtraining syndrome and underlying medical conditions
• Bone age assessment provides valuable information about growth potential and can guide realistic timeline expectations for physical development
• Multidisciplinary care involving sports medicine physicians, physiotherapists, psychologists, and nutritionists optimizes outcomes for complex adolescent athlete presentations
• Return to play progression should be individualized and gradual, with emphasis on physiological and psychological readiness rather than arbitrary timelines.

Image credits: Open AI, Model: Dall-E 3.
https://chatgpt.com/
Prompt: “A photorealistic scene of two adolescent soccer goalkeepers standing side by side on a pitch. One is noticeably shorter and slimmer, the other taller and more physically mature, both wearing modern goalkeeper kits and gloves. The contrast highlights growth variability in youth athletes, with neutral facial expressions and natural daylight stadium background”.

References

1. Bergeron MF, Mountjoy M, Armstrong N, et al. International Olympic Committee consensus statement on youth athletic development. Br J Sports Med. 2015;49(13):843-851.
2. Ratel S, Blazevich AJ. Are prepubertal children metabolically comparable to well-trained adult endurance athletes? Sports Med. 2017;47(8):1477-1485.
3. Jayanthi NA, LaBella CR, Fischer D, et al. Sports-specialized intensive training and the risk of injury in young athletes. Am J Sports Med. 2015;43(4):794-801.
4. Malina RM, Cumming SP, Kontos AP, et al. Maturity-associated variation in sport-specific skills of youth soccer players aged 13-15 years. J Sports Sci. 2005;23(5):515-522.
5. Tanner JM, Davies PS. Clinical longitudinal standards for height and height velocity for North American children. J Pediatr. 1985;107(3):317-329.
6. Cadegiani FA, Kater CE. Hypothalamic-pituitary-adrenal (HPA) axis functioning in overtraining syndrome: findings from endocrine and metabolic responses on overtraining syndrome (EROS) study. Sports Med Open. 2017;3(1):45.
7. Walsh NP, Gleeson M, Shephard RJ, et al. Position statement. Part one: Immune function and exercise. Exerc Immunol Rev. 2011;17:6-63.
8. Soligard T, Steffen K, Palmer D, et al. Sports injury and illness incidence in the Rio de Janeiro 2016 Olympic Summer Games. Br J Sports Med. 2017;51(17):1265-1271.
9. Meeusen R, Duclos M, Foster C, et al. Prevention, diagnosis, and treatment of the overtraining syndrome: joint consensus statement of the European College of Sport Science and the American College of Sports Medicine. Med Sci Sports Exerc. 2013;45(1):186-205.
10. Lloyd RS, Oliver JL, Faigenbaum AD, et al. Long-term athletic development, part 1: a pathway for all youth. J Strength Cond Res. 2015;29(5):1439-1450.
11. Armstrong N, McManus AM. Elite young athlete’s consultancy: physiological issues. Scand J Med Sci Sports. 2011;21(6):e473-e482.
12. Malina RM, Rogol AD, Cumming SP, et al. Biological maturation of youth athletes: assessment and implications. Br J Sports Med. 2015;49(13):852-859.
13. Drew MK, Vlahovich N, Hughes D, et al. A multifactorial evaluation of illness risk factors in athletes preparing for the Summer Olympic Games. J Sci Med Sport. 2017;20(8):745-750.
14. Mountjoy M, Sundgot-Borgen JK, Burke LM, et al. IOC consensus statement on relative energy deficiency in sport (REDs): 2018 update. Br J Sports Med. 2018;52(11):687-697.
15. Bell DR, Post EG, Trigsted SM, et al. Prevalence of sport specialization in high school athletics. Am J Sports Med. 2016;44(6):1469-1474.

Not all references were assigned by AI.

The expert’s review

Dr Daniela Marx-Berger

First of all I would like to say that I am impressed. I must admit, that I haven’t really used AI so far, but the result of this experiment is good. But by looking into details I find things that aren’t perfect and even wrong, but that is the same in the real world.
I tried to choose a case with different interacting problems and AI managed well to pick up most of them.
The introduction nicely presents the common problem of youth athletes who struggle with growth/puberty delay, comparison with peers and performance pressure because of selections. A problem we indeed face often in our daily work.

• The differential diagnosis is not complete in my opinion. I am missing celiac disease as a major differential, which is more common in this kind of situation than the mentioned growth-hormone deficiencies and hypothyroidism or even immunodeficiencies. I am also missing the term RED-S, though AI used the term functional overreaching and there is certainly an overlap.
• I like that AI stresses the importance of using growth charts in daily life with youth athletes as they help to detect problems. It is also correct that Tanner stages and bone age determination by X-ray might be needed in certain situations and that we should calculate mid-parental height and check growth velocity.
• Regarding recurrent respiratory infection I miss the information that a lack of energy due to insufficient nutrition might be a major driving force.
• The paragraph “Management Approach” starts with a comprehensive history, a term I appreciate and is often overlooked nowadays. Missing in this case is the family history that often shows that one or both parents also suffered from growth/puberty delay. But what is wrong is that a growth velocity under the 10th percentile is concerning. Correct is that a growth velocity below the 25th percentile is already a sign for concern.
• Personally I would change the suggested investigations regarding laboratory tests a bit: as mentioned before, I would add IgA and anti-transglutaminase IgA to exclude celiac disease.
• A bone age radiograph is often helpful, but a growth hormone stimulation test is rarely necessary. So the wording of AI is a bit too straight-forward.
• The statement that late maturers will often achieve greater height (under figure 1 and in the part “prognosis and athlete counselling”) is misleading. This “fact” was new for me and I asked two pediatric endocrinologists who also contradict this statement from AI. The late maturers achieve a normal height but not necessarily on the taller end. This statement from AI might raise false hope.
• I miss a summary with a final main differential diagnosis before the section of management starts. I like the point of a multidisciplinary team approach, though not all are necessary in every case.
• The return-to-sport section sounds strict, but is also a helpful tool and could be adopted on a case-by-case basis.
• I really appreciate the section about education regarding normal growth variation.

My overall impression

The outline of the text is sometimes a bit confusing, I miss a common structure.
Regarding references, one reference is presented as “recent evidence” but dates from 2011. Overall the references seem a bit on the “older” side. Not all references are up-to-date. The cited “Update RED-S paper” is from 2018, but there already is a more recent update from 2023.
AI can be definitely used in this case and points out many things that are correct. On the other hand, there are also wrong aspects as mentioned. AI is a bit black & white and absolute, this is something I observe throughout the whole text. The fact that we, as humans, can add subtle findings/feelings/expectations in our overall summary in a case like this is our big advantage.

Author profile

Dr Daniela Marx-Berger
daniela.marx-berger@kispisg.ch

Affiliation: Children’s Hospital of Eastern Switzerland
Specializations: Pediatrics, pediatric nephrology, sports medicine
Year of my medical school graduation: 2001
Sports organizations/federations I work with: Schweizerischer Turnverband STV-FSG, SEMS board member, BASPO, GPS (Gesellschaft pädiatrische Sportmedizin), Sportschule Appenzellerland, Talentschule St. Gallen.
Fields/topics I am fond of: growth and development, ­nutrition, safe and healthy environment for youth athletes.
Outside of Sports & Exercise Medicine, I also love: ­travelling, hiking, triathlon, cooking.
How I use AI: not really so far, I am a bit “old fashioned”, – still love paper when reading.