Health for Performance: a necessary paradigm shift for youth athletes

Gojanovic Boris^1,2, Tercier Stéphane^2,3
1 La Tour Sport Medicine, Swiss Olympic Medical Centre, Hôpital de la Tour, Meyrin, Switzerland
2 SportAdo Consultation, Interdisciplinary Division for Adolescent Health (DISA), Department of Women-Mother-Child, Lausanne University and Hospital, Lausanne, Switzerland
3 Unit of Paediatric Orthopaedic Surgery (UPCOT), Department of Women-Mother-Child, Lausanne University and Hospital, Lausanne, Switzerland

Abstract

Competitive and elite sport often challenges the balance between health and performance, especially when it involves youth athletes. As Lausanne was getting ready to host the 2020 winter Youth Olympic Games, we had the opportunity to reflect on these challenges and on what they mean for sports medicine practitioners. Elite sport pushes athletes to the limit, be it through their own intrinsic drive to achieve ever more, or through the pressures of the multiple stakeholders around sport. Whilst the occurrence of injuries and health problems are part of sport, our duty is to protect athletes, especially the younger ones. Beyond selection processes, talent identification and early-specialization, it is imperative to keep a strong focus on sustainable health and positive youth development. Our role is to support youth athletes (and non-athletes) in their complete maturation process, providing education towards health and physical literacy, competence and autonomy. It is also to support them in their quest for performance. This is why we introduce the concept of Health for Performance. Putting complete health first is the best guarantee to mitigate the occurrence of avoidable injuries and health issues, and to achieve sustainable performance. This may include athletic success, but must not. Performance must be understood as the realization of one’s potential on a path that involves growing, competing, learning, sharing and contributing.
As a model and philosophy, Health for Performance can only succeed with strong interdisciplinary work and alignment across all stakeholders in youth sport, but it must start within our own medical supporting staffs. It is only from there that we can start a network beyond our familiar field to involve the wider world of sport. The COVID-19 crisis has forced sport to take a back seat, in order to preserve health. It highlighted the fragility of the sport ecosystem. This should empower us to rethink its role in our society, in order to maintain its capacity to contribute to society in complex times, where health is at the center of everyone’s attention.

Résumé

Le sport de haut niveau vient souvent mettre à mal le difficile équilibre entre la santé et la performance, en particulier quand il s’agit des jeunes athlètes. Alors que Lausanne se préparait à accueillir les Jeux Olympiques de la Jeunesse d’hiver 2020, nous avons eu l’opportunité de réfléchir à ce défi et à ce qu’il signifie pour les professionnels de la santé du sport. Le sport d’élite force les athlètes à repousser les limites, soit par leur propre motivation à se dépasser, soit par les pressions des multiples acteurs autour du sport. Si les blessures et les problèmes de santé font partie du sport, notre devoir reste de protéger les athlètes, surtout les plus jeunes. Au-delà des sélections, identifications de talent et spécialisations précoces, il est impératif de garder le cap sur la santé durable et le développement positif de la jeunesse. Notre rôle est de soutenir les jeunes athlètes (et non-athlètes) dans leur chemin de maturation, en contribuant à une éducation vers les compétences en santé et en activité, et leur autonomie. Il est aussi de les accompagner dans leur recherche de performance, qu’elle soit sportive ou non. C’est pour cela que nous proposons le concept Health for Performance. Mettre la santé complète en premier reste la meilleure garantie de limiter les problèmes de santé évitables, et d’atteindre une performance durable. Elle peut inclure les victoires sportives, mais ne le doit pas. La performance doit être comprise comme la réalisation de son potentiel sur le chemin qui inclut le développement, la compétition, l’apprentissage, le partage et le fait de contribuer autour de soi.
En tant que modèle et philosophie, Health for Performance ne peut fonctionner qu’avec une forte interdisciplinarité et un alignement de tous les acteurs du sport des jeunes, et cela commence nécessairement par nos propres équipes médicales. Partant de là, nous pouvons tisser un réseau qui s’étend au-delà de notre domaine pour impliquer le monde du sport au sens large. La crise du COVID-19 a mis le sport au repos pour préserver la santé. Elle a mis en évidence la fragilité de l’écosystème du sport. Il est temps de repenser son rôle dans nos sociétés, afin de préserver sa capacité à contribuer à cette dernière dans les temps complexes où la santé doit prendre le centre de la scène.

Introduction

In the recent early months of 2020, and for the first time in decades, the coronavirus pandemic has put health ahead of competition and performance [1,2]. The world of sports did not have a choice and we all wish it had not been the case. All the sporting events were put on hold and athletes instructed to stay at home and find ways to stay fit and healthy in a more or less confined and isolated environment. This was out of necessity and not philosophy.
These events have highlighted many things, as every crisis does. Amongst them, the fact that sport plays an important role in our society, albeit non-essential. Not only does it encourage people to embrace physical activity, but it also brings people together in multiple ways: either by participating in sporting activities together or by uniting (or opposing) fans in stadiums, arenas and streets across the world. It has also become an economic juggernaut, which keeps growing with enormous financial stakes. This brings one question to mind: what drives sport today?
The emphasis is systematically put on competition, performance, entertainment, sponsorship and TV ratings. Those are the elements of sustainability in the sporting world. Whilst we all understand the reasons behind this, and the necessity for all stakeholders (including athletes themselves) to develop the “show” component of sport, it does come at a high cost. Health usually has to take a back step. Since the show must go on, athletes will do everything they can to push through, even in the face of significant health risks.[3] The high stakes and pressures around them reinforce their intrinsic drive and competitiveness – which enabled them to be part of the elite. In the 2019 NBA finals, the Golden State Warriors lost two superstars to serious injuries – Kevin Durant with an Achilles tear and Klay Thompson with an ACL injury – as both had returned to play in the Finals with injuries that could not have completely healed yet.[4] Playing through injury and illness is part of the rhetoric we value as spectators, and legendary athletes are those who come out on top. The Last Dance documentary (on the 1998 Chicago Bulls and Michael Jordan) gives it even more resonance and validation.[5]
This is professional sport, where the athletes are grown-ups who can make their own choices, even though the system pushes and influences them. But what about youth athletes? In this article, we wish to present the challenges we (and they) face and propose a concept that we developed for the 2020 Youth Olympic Games in Lausanne: Health for Performance.

The challenges of youth sports medicine

There is undeniably a trickle-down effect from the highest level of adult competition. Organizations, teams, coaches, parents, fans and the media value performance at the early developmental stages, with the attribution of medals and the crowning of champions at a young age. This also drives selection processes that struggle to be justified by the data on talent development and adulthood performance.[6] Young athletes are pushed to train more and harder, oftentimes ignoring their physiological (growth) and psychological (development) rhythms and needs. With early specialization comes an increased risk of overuse injuries and persistent fatigue, leading to early dropout from sports.[7]
The generalization of invalid models of talent development – like the so-called 10 000 hours rule of deliberate practice[8] – may still push a parent to coach their 3-year-old, just like Tiger Woods (golf) or André Agassi (tennis). They were exceptions that succeeded, but paid a high price during childhood and adolescence Simply listen to what Agassi has to say in his book, Open.[9]
Sports medicine clinicians are in a difficult position. Parents and children/adolescents usually come to us with injuries to repair, or performance to recover. Sometimes the injuries are serious and will have lifelong consequences (ACL injury in a 14-year-old competitive skier), sometimes the persistent underperformance is linked to an imbalance between the requirements and pressures of the sport, and the current resilience and capacity of the developing child/adolescent.[10] Other examples include the frequently encountered weight issues and eating disorders partially induced by specific sporting environments and requirements.[11] Sometimes, we must face even more difficult issues linked to harassment and abuse in sport.[12] Not only do these sadly exist, but they are underestimated and underreported, in spite of dreadful and potentially lifelong consequences (Figure 1).

Our role as healthcare practitioners is clearly to enable children and adolescents to thrive in the complex sporting environment, enjoy participation at all levels, to mitigate the health risks and to promote a sustainable approach to physical and mental wellbeing.[13]

Existing frameworks for youth athletes

When facing these complex challenges, it is useful to consider existing frameworks that can help shape the path for our actions. On the one hand, we need to look at sports development pathways that can guide to sporting success; on the other hand, more holistic youth development models help us keep a focus on global health. Understanding their determinants, as well as the similarities and tensions between them, can help us define our roles and positioning.
In 2016, a framework illustrating the holistic integration of active lifestyle, sports participation and sporting excellence as potential outcomes for engagement in sport was introduced in Switzerland.[14] The Australian Institute for Sport (AIS) originally developed the FTEM framework; F stands for Foundations, or foundational movement skills, a concept associated to that of physical literacy.[15] Three stages are described (Figure 2). T stands for Talent and represents the entry into the sporting excellence journey. Its four stages lead to the recognition of sporting achievement and the first rewards like a scholarship or sponsored/paid participation. The next stages of E (for Elite) and M (for Mastery) are the ultimate steps from representing your country to repeated world-class performance. FTEM Switzerland proposes a transversal tool and an integrated approach for all stakeholders in the promotion of sports: sporting federations, cantonal and communal authorities, schools, clubs, coaches and parents alike. The overarching goal of the Swiss model is to achieve higher athletic performance, whilst it does not neglect systemic and environmental factors. The focus remains however on the goals of Elite and Mastery, which still carries the risks for youth athletes described previously.
Looking more broadly at the harmonious development of children/adolescents, an interesting model is Positive Youth Development (PYD). It was introduced in the 1990s and expanded by Richard Lerner in 2005 with the addition of the five Cs concept (competence, confidence, connection, character, and caring).[16] In a very simplified summary, PYD aims to move away from traditional development approaches, which focus on deficits and avoidance of negative outcomes (risk taking, substance abuse, etc.). Here, youth are considered as potential talents to grow into productive and happy members of society, through reinforcement of positive experiences, environments and relations. It takes its roots in Social Cognitive Theory (self-efficacy – Bandura) and Social Determination Theory (competence, relatedness and autonomy – Ryan and Deci).[17,18] The 5 Cs have been conceptualized in the sporting environment by Côté (simplified in 4 Cs, as he considered caring as an attribute of character).[19] He also showed in various studies that successful patterns of coach-athlete interactions included elements of PYD.[20,21] The ultimate goal of PYD, as per Lerner, is to enable the 5 Cs, a prerequisite to thrive and access the final C, contribution: to self, family, community and society (we would add “team” in the sport context).[22]
It appears from the previous paragraphs, that we must consider an umbrella model for these frameworks in order to guarantee positive outcomes in youth athletes. This is why we introduce Health for Performance (Figure 2).

Health for Performance – an overarching holistic model for youth development

In preparation of the Lausanne2020 Youth Olympic Games (YOG), the opportunity presented itself to establish a ground philosophy that defined our engagement for youth in general. The important reflection on “why we do what we do”, as popularized by Simon Sinek,[23] strengthened our beliefs that the youth athlete oriented event should be used as a gateway to communicate on sustainable health values.
The aims of the YOG are not only to compete, but also to “learn & share”, for the participating athletes and for the local youth. There are multiple positive values linked to sports participation and international competitions, and these are welcome contributions to the development of youth athletes. They benefit from their shared experiences, the opportunity to travel and meet people from other countries and cultures. However, we are well aware of the tension existing between Health and Performance, with the potential negative consequences outlined earlier (Figure 1).
Sports medicine evolved from the early years in the 1970s and 1980s, where the focus was primarily on treating injuries and assisting performance, to a gradual understanding of the more complex issues permeating the quest for athletic results. This brought, in the last decade, many discussions on the global health of the athlete, the importance of stress, recovery, sleep and nutrition, and finally the necessary consideration of the complete biopsychosocial sphere in caring for the athlete’s wellbeing and mental health.[24] Sports medicine as a field of expertise understands that performance is inherent to sporting activities and supports participants in their endeavor. Its mission must include the dimensions mentioned above and extend it further to promote an active lifestyle for all young people.
In recent years, many national sports medicine societies have changed their name to add the “E” for “exercise”, just like the Sport & Exercise Medicine Switzerland (SEMS) did. The message is clear: sports medicine plays an active role in health, beyond sports. This role is more than ever important in public health strategies in the fight against chronic diseases (and potentially communicable diseases as well), and it must start with our youth. Physical activity promotion and health prevention benefits from youth-friendly programs and professionals sensitized to youth developmental needs and concerns.
The tenets of Health for Performance are the following: the reunion of three domains – sports medicine, sports performance and public health – enables a coherent and adapted integration for the benefit of youth, athletes or not. First, performance must be understood beyond centimeters, seconds or goals, to move towards the positive outcomes described in PYD and the 5 Cs: competence (physical and health literacy), confidence, connection, character and last but not least, caring for others (=sportsmanship for sports). The refinement of these positive values help to access the stage where one can contribute to his or her environment. Second, we can use performance in its usual sports-related meaning, by ensuring that the systems in place respect the progression, inclusion and equal opportunities principles outlined in the FTEM model. The road to the late stages (E and M) begins with foundational movement acquisition and requires health literacy, resilience and injury/illness prevention efforts. These are not possible without the support of interdisciplinary teams that convey consistent messages, and refrain from short cuts that put health at risk. The Health for Performance model promotes the imperative of health (all aspects of it) to realize one’s performance potential, not only in athletic endeavors. It is applicable to multiple facets of life and thrives on the smart and aligned collaborative interaction of stakeholders who share the same “why” (Figure 3).

Where do we go from here?

Models and frameworks are nothing without implementation, and there is no implementation without willingness to change.[25] As a first step, it is necessary to reflect on the problems youth sports presents regularly: injuries, overuse and fatigue, early specialization, pushy parents and/or coaches, early financial incentives, a winning-at-all-costs culture and dropout.[26] All this in the context of a period in life that is supercharged emotionally, physically (puberty) and logistically (school and social demands).
Sports medicine cannot address these issues directly, but needs to build strong partnerships with all the stakeholders involved, at least within the following sectors: sports governance (national, federations, clubs), public health, healthcare partners, physical activity promotion, schools and education, coach education agencies and, last but not least, parents and families.
Once given partners can agree on a set of issues that need addressing, it pays to share a common philosophy – Health for Performance. This can develop a joint culture, leading to effective interdisciplinary collaboration. However, before we address joint cultures across sectors, it is imperative to ascertain alignment of thought and practice within our own sector. We, as sports medicine practitioners, must walk the talk; we must develop our teams to optimize care of youth athletes, as well as the ones in need of more movement. True interdisciplinary work starts with the realization that we can do better when we share and gain knowledge from each other. It is only from there that we can start a network beyond our familiar field, and we will understand that we need political support to move forward.
During the Lausanne2020 YOG, we could develop a few innovative educational modules for the young competing athletes as well as for the local youth.[27] Not only did the target population enjoy them, but they also attracted a lot of media and political attention. The message that health comes first in order for performance to be possible is one that resonates loudly with many stakeholders, and we look forward to the future collaborative developments in sports prevention and active health literacy.

Conclusion

We must appraise and address the health risks that come with youth sports. Some of them are inherent to systemic flaws in the way performance is approached and defined: short-term wins for long-term costs. We propose a model that integrates the principles of positive youth development with those of progressive and adapted talent development pathways: Health for Performance. Putting complete health first is the best guarantee to achieve sustainable performance, which may include athletic success, but must not.
We are currently experiencing an unprecedented crisis (COVID-19), which highlights the lack of sustainability in the sports and performance economic systems. This should also empower us to rethink the role of sport in our society, starting at a young age, to maintain the capacity for sport to contribute to society in complex times, where health is at the center of everyone’s attention.

Acknowledgments, conflict of interest and ­funding

None declared.

Corresponding author

Boris Gojanovic
Swiss Olympic Medical Center,
Hôpital de La Tour,
Avenue J.-D. Maillard 3,
1217 Meyrin, Switzerland
Tel: +41 22 719 63 63
Email: boris.gojanovic@latour.ch 

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