[Physio Explained] Not mini adults: rehab for youth athletes with Daniel Elias

In this episode with Daniel Elias, we discuss treating youth athletes. We explore:

·  Differences between treating youth vs adults

·  Rehabilitating youth athletes from ACL injury

·  Importance of milestones in ACL rehabilitation

·  High training loads in youth athletes

·  Exercise prescription for this population

·  Role of social media with adolescents

👉🏻 Learn more about Physio Network’s Research Reviews here - physio.network/reviews-elias

Daniel is a highly experienced Physiotherapist with more than 15 years of clinical experience across the NHS, private practice, and elite sport. He has worked with England Athletics for the past eight years, supporting athletes from Under 13 to Under 20 level at both national and international competitions. Daniel is also the Director of The Youth Physiotherapy Clinic at Team Bath, a specialist clinic focused on evidence-based rehabilitation tailored to the unique developmental needs of children and adolescents.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @James_Armstrong_Physio from Physio Network

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

Transcript

SPEAKER_00 0:05

The key thing is, can you get a smile on that child's face? Can you make them laugh? Can you make them feel like they're seen and they're heard? And do they look forward to coming towards your sessions? I know I'm doing something right when the mum or dad says afterwards or during that, oh, they're really looking forward to coming to see you today. And I've had that a few times.

SPEAKER_01 0:23

Welcome back to Physio Explained, the Physio Network podcast where we break down key ideas and clinical approaches to help you think differently about physiotherapy practice. In today's episode, we're focusing on treating youth athletes, a group that presents a unique clinical challenge and requires a very different approach compared to adult rehabilitation. I'm joined by Daniel Elias, a physiotherapist with over 15 years of experience working across the NHS, private practice and elite sport, and he's spent the past eight years working with England Athletics supporting athletes from the under-13s to the under-20 age groups at both national and international level. Daniel is also the clinical director of Youth Physiotherapy Clinic in Team Bath, which is founded on a simple but important belief children are not merely adults. His work focuses on delivering rehabilitation that reflects the developmental and maturation stages of young athletes. So in this episode, we're going to explore three key areas. We're going to look at how to rehabilitate a young athlete following ACL reconstruction from early stages through to return to sports, the belief systems that often drive high training and competition loads in youth sports, and finally the art of creativity and fun in youth rehabilitation, and why this can be crucial for successful return to play after injury or surgery. If you work with young athletes or want to better understand how to approach rehabilitation in developing bodies, this episode is packed with practical insights. I'm James Armstrong and this is Physio Explained. Dan, great to have you on the Physio Explained podcast. It really is, and we're going to be talking about a really interesting topic today. So it's great to have you on. Thank you so much for having me. So, youth athletes, we're going to be talking today all about treating youth athletes. And I thought it would be great to start the episode with just defining what we mean by youth athletes.

SPEAKER_00 2:23

So my clinic in Bath, so I'll treat anyone from eight to eighteen years of age. So I can't say that as sort of a youth area. It really also depends on when you break it down, whether there's a sort of a phase within growth called a peak kind of velocity phase. Girls and boys go through that different times. So within that sort of youth specialism, it will depend on whether they're pre-going through that fast velocity phase, they're in that fast velocity phase, or they're post that velocity phase. So there's there's within that youth age range, there's quite a few distinct areas where the body's changing quite a lot. So we break it down to those sort of areas on retreating.

SPEAKER_01 3:01

And are you talking sort of about sort of skeletal maturity and that sort of things as well around those phases?

SPEAKER_00 3:06

Yeah, so I will so it's there, um I I run a skeletal maturation score which uh looks at their percentage of their skeletal growth. Something like a peak velocity phase will begin around about 90% of their full adult height. That's when they really start to grow really fast, and it sort of can end around about 95 to 96%. So most of that growth is happening in the lower limbs at that point. So that's a time of high injury occurrence in certain athletes.

SPEAKER_01 3:32

Okay. Summarize for us a a little bit in terms of what seems to probably quite obvious, but why we separate this population compared to adults and why we treat them differently. That's a great question, James.

SPEAKER_00 3:43

I mean, I think the tagline is like don't treat little kids like like adults, and they are different in the aspect. So sort of the big headline is that when children are growing, their bones are weaker than some of this uh contractile tissues, like your tendons, your ligaments, and your muscles, which is different to when you're an adult because that flip reverses, so you tend to have stronger bones and your soft tissue is a little bit weaker. So a good example of that would be you've got inferior knee pain in a let's say uh a 13 or 14-year-old boy. So there's lots of differential diagnoses, but if it's a an overload type issue, you're thinking something like an overload, sort of a tugging on the tibial tuberosity growth plate. Whereas in an adult, that's not gonna be the same because that that growth plate would fuse by that point. So to say that a 12 or 13-year-old has a patellotendinopathy is unlikely, and it's more likely they've got some growth-related presentation. Now that does vary, you get some very, very early maturers, um, so you can have a 13-year-old boy, but they can have the skeleton of a of a 16, 16-year-old boy. So there's a real difference between birth age and skeletal age. So that's where that gross maturation scoring that I do comes in because though we can't just treat them when they're aged. And sometimes it's it's a little bit obvious. You look at some boys or girls, you're like, you're definitely not sort of the skeleton age of a 12 or 13-year-old. Yeah, they're already like six foot, they tower over me. So you've got to have that flexibility. But in general, there's different sort of diagnosis that we'd be thinking of in a growing child versus a grown adult.

SPEAKER_01 5:17

Brilliant. It's really worth bearing in mind when we're seeing this population. So let's dive into this in terms of our rehabilitation. Um and we've picked out ACL reconstruction. So talk us through what seems like an incredibly broad question when we pop this across and planning for this episode. But uh how to rehabilitate a young athlete after an ACL reconstruction, early, mid, late.

SPEAKER_00 5:40

I think I could, as we discussed off air, I could talk about this for hours and I've presented on this four hours. So I suppose I'll give some of the headlines and how it's different. So I think I get a lot of my kids where they have come from diagnosis, but they haven't had the operation yet. And now I think this is an absolutely crucial phase with the parents and with the children. They have so many questions, and I try and lay the foundations of this is going to take quite a long time, and we're gonna work as a team, and I really try and get them to ask me as many questions as they can. Because with a kid, you've got to consider that they've they're gonna potentially be out of their sports or the activity they like to do. They're also going to be at school as well, so you've got to consider that, you've got to consider they're not gonna be with their peers. How you know, because ACL rehab, as we all know, is a long process, and it can be quite a boring, monotonous, lonely process. And in the kid, that's a real issue because you're taking them out from running around, having lots of fun, to then isolating them. So I'm very keen to try and get them to think in advance about the process and take them through the steps, and that really tends to reduce some of the anxiety because it's there's quite good research. They're anxious before the operation, their sort of post-op outcomes are not as great and they can take longer to recover in those early phases. So I think that's a really important phase. Going on to the post-op phase, I like to see my kids within a week after having it done. Sometimes people think that's quite early, but I think it's crucial because you can have a chat post operation and you can then start working on their gate and you can start putting in things like you know, by walking, you're not gonna, you're not gonna break the you're not gonna break the reconstruction if you're walking a certain way. And sometimes people really fear movement. And if there's good research that if you get the or you don't address the deficits that happen post-operating the gate, that can then carry on for years, and there's good evidence as well. The kids that have gone back to sport at 18 months to two years still have problems with their walking, isn't it? So I think that's a really important phase. So the first sort of three, three to five months is just getting, you know, trying to reduce all the muscle inhibition and really working on their neuromuscular coordination. So again, a bit of a minefield, but you've then got to factor in the skeletal maturation within this. And just because the child's had an ACO reconstruction doesn't mean they stopped growing. So if they've had you've had a child that's had their operation and they're mid their peak height of velocity, you've really got to consider yes, there's aspects of strength you need to address, but you've also got to address the consequences their body is still growing. So I like to really use the other limb as a bit of a guide to see what they were like beforehand. So things like what's the balance like on their non-operated leg, what's their single leg squat like, and you just really what's their trunk like? And if they're wobbling on that other side, then you know that you know there probably wasn't the best movement before they had the injury to start with. So we've got to really consider that new muscle cauldace we're going through. And I think sometimes that lengthens the journey. And I'm quite open with the patients and the parents that you know, when they ask when can I run, when can I jump, and when can I do those things? When I go back to sport, I'm like, you know, I'm not a huge fan of really concrete time frames. I'm like, we might be getting to it at this point, but you need to show me X, Y, and Z. And I think that that's really key to be open with the so they know what their expectations are. Going back to return to play, I mean, we wouldn't keep children off for this long, it's very difficult, but there's really good evidence as well that the ligamentisation process in a child can take up to two years for that ligament to fully fully bed down, which is a really long time. Generally, what I see with mine and with the consultants I work with, that you're looking at about 12 to 18 months on return to play. And very, very early on, I'm trying to get in that kid and that parent's head, what do you love to do? As if they're a hockey player, how can I get a hockey stick and a ball in your hand safely as early as I can? And that gave, I had one just in this week. She's about what are we now, about three or four months. And I had her on like a trampet, and that could be really boring to stay on a trampet, but I got her on a trampet, single leg standing, and she was showing me a sort of hockey stick, keepy uppies with a hockey stick and a ball. Absolutely loved it, smile on her face. So I think for your listeners, you need to really understand the children that you're working with. They are part of the process. Ask them to try and help them design the sessions as well and let their imagination go. And then I sort of adapt around that to really um uh make their sessions fun, which is which is really, really key.

SPEAKER_01 9:57

Are you struggling to keep up to date with new research? Let our research reviews do the hard work for you. Our team of experts summarise the latest and most clinically relevant research for instant application in your clinic. So you can save time and effort keeping up to date. Click the link in the show notes to try Physio Network's research reviews for free today. I think that's is really key. And and all the time we were talking there, Dan, all I could think of was, yeah, we could probably do some of this with our adult ACL reconstructions, which would help a lot as well in terms of bringing them in and all that, maybe a little bit earlier on to approach some of those deficits in both beliefs and and their anxieties, but also their gait and things like that as well. Like you said, around the evidence around that long-term gait, uh inefficiencies and and poor gates. So, yeah, really interesting. So, uh about belief systems then, you know, and in general in youth sports around high training, competition loads, and things like that, what are we seeing in in youth athletes?

SPEAKER_00 10:58

Again, I think it depends on where you're at in the country, what's your social demographic area that you're working in as well. So I um I tend to work in an area that's fairly affluent, and kids are doing lots of sports within school, outside of school, and I suppose they're afforded that because they can given those opportunities. What tends to happen in in some clubs and with some parents, not all the time, but it's just setting expectations that through the grown body of a child, you've got to be really careful at certain stages of not doing too much. And sometimes this doing so much is because that child might be very good at a particular sport, and they think that the more that we do, the better they're gonna be for when they're an adult. And there's great evidence, again, that there's very, very, very few, almost minuscule amount of elite junior athletes that go on to be a professional elite adult athlete. There's so many reasons why adults then will go on to be elite in that area, but the these years of growth, it's not especially when they're in their you know 10 to 15 years of age, it shouldn't be about competition at that age. Kids play for fun, yes, they like to win, and then it's managing how they lose, but it's a year of exploring how they move, is it's working on their fundamentals and their technique. You've got to keep them in love with the sport that they've got, and they're not just because they're not the best at 15 or 16, I tend to say doesn't mean you're then going to go on and not be amazing when you're in 20s. And I tend to say to a lot of my athletes, if you look around, a lot of the the especially the Olympians, they don't peak until they're mid to late 20s. So if you're having a coach or somebody that's really, really pushing this child too much, they're getting fatigued, they're losing their control, they're waking up tired in the mornings. What are we doing? So I just try and educate the parents on that belief system that take the pressure off, it doesn't matter if they have some time off, that they've got many, many million years, money more years to become proficient if that's what they're looking for.

SPEAKER_01 12:51

Definitely. From my experience, I don't know if you've you've seen it as well, Dan. You see, some sports do tend to lead to greater loads. I think swimming comes to my mind straight away where we see these belief systems where more is better.

SPEAKER_00 13:05

Yeah, I mean they're the early mature of us. So you've got your swimmers and gymnasts as well. So they are quite a lot as well. Football is a lot, but if you look at a lot of the academies around the country, they're they're really leading the way, I think. Because there's a lot of fantastic clinicians out of um quite a lot of the um the premiership football clubs are doing some really good work in managing children's load, although they're specialised, they're in it's in quite a good world. I think sometimes football gets a bad rep, but I see much better practices within football than some other sports. Interesting. Yeah, definitely.

SPEAKER_01 13:33

So then with this population, we we look at sort of rehab, and as we alluded to earlier, or you no, you you stated earlier, ACL rehab can be boring, it can be, especially in those early stages, quite monotonous, quite repetitive, and especially that age, probably feel like they're being held back a little bit to we know they need to get certain things right before they move on, but that can not they may not kind of get that completely. So we talk about creativity and and fun and and how your tips around how we engage these athletes and these kids in their rehab and also return to play.

SPEAKER_00 14:08

I think the key thing is can you get a smile on that child's face? Can you make them laugh? Can you make them feel like they're seen and they're heard? And do they look forward to coming toward your sessions? So I I know I'm doing something right when the mum or dad says afterwards or during that, oh, they're really looking forward to coming to see you today. And I've had that a few times. It doesn't get it right every time. I mean, that that's life, that's communication, and that's personalities, but I'd say most of the time I really, really try and, you know, understand what's going on in that child's world. I'm really interested in what's going on at school, what are their hobbies? If they come in and they've got a jump and it's got something on it, I talk about that. They've got new trains, well, you've got new trainers today. Like it's everything that's outside of focusing just on, oh, let's have a look at your lift leg up. Are you in pain today? Like it's just they just don't get it, and they're just not really that interested. When you get into later adolescence, you've obviously got the hormones kicking in as well. So you've just got to try and I like I like to try and find the banter so I can make them look laugh, and and then if they trust me, then they will engage with me, and they're much liker to do their exercises. And they're also trying, I drip feed exercises. I don't tend to give lots and lots and lots of exercises all in one go because it again, they're just I a lot of times I'll have well-reading clinicians of giving really nice exercises to these kids, but the receipt of 12 or 13 exercises in a 14, 15 while doing the GCSEs, they're never gonna do it. So I do think we need to be very mindful of what we give and be really specific on what we're doing. But a really, a really guy that I take a lot of my motivation from was that is a guy called Richard Cheatham. I think he works at the University of Winchester. So if you have a look at him on YouTube, he describes rehabilitation of fun and children like no one have ever seen before. So it's really interesting how you can create an environment that's fun, and then you've just got to let your creativity and imagination go wild. So I don't I have a loose framework in my sessions, but I I try and flow with what's going on within the sessions, and I loads of equipment around me and I'll try and make it fun. I might try 10 things and I'll give them one. So it's just what lights up. They're like, oh, they really like that. And the kids really are they're very bad at hiding their emotions. So if they smile and like that one in my head, I'm like, I'm gonna leave that to them because I like it. If they're literally losing concentration and looking around the room, or and they do something else, I'll follow where they go. And if they pick up a ball, well, let's play with the ball a little bit. So less rigidity and more flexibility. I think sometimes there's a I think we're scared till our imaginations go wild when we're doing rehab. It's all sometimes we don't have much time, but I think with kids, you need that imagination with them when you're really trying to think back to when you were a kid and what did you really like to do?

SPEAKER_01 16:37

Definitely, definitely. And have you noticed anything? Obviously, I say I was about to say with the advent of social media. It's not really an advent now, is it? But do you do you find that that comes into play at all with maybe our slightly older adolescents in terms of the use of it, them seeing things? I know I've had youngsters that have followed certain influences on social media, seen certain players recover from an ACL. I'm thinking Neymar, I think coming back very, very quickly. And how do you approach that with the parent with the child?

SPEAKER_00 17:07

Sometimes I've had the parents say, I mean, they've been on social media and they've seen some 15-second video on Instagram where someone's back in seven months playing playing football. And I I just try and it's a balance between they've obviously looked at it for a reason. So I try and explore why they are searching for more information and I try and make it quite open. Like if you're worried about anything, come and speak to me. I said, you know, with the problem with social media is you never see what's behind the screen, and a lot of it can be non-evidence-based, it looks really flashy, but there's more, there's more to it than that as well. But that comes full circle a little bit of background to do they trust me in the first place. If I don't trust me and they haven't engaged with me and they're looking elsewhere, why are they looking elsewhere as well? So they're trying to get other answers. That's why I always say as well, if you've got any questions, just let me know. When they pop into don't look on social media, ask me, I'll give you a much more detailed reply. It might be that they want to do weight or they might, why am I doing weightlifting? Yeah, I'm like, okay, well, let's explore that. What are your beliefs behind it? Why do you want to do weightlifting? I get a lot of kids that want to do weightlifting at the moment, so that's quite a popular thing in the boys, especially. And it's not to say that don't do it, but it's is it the right time? Why are you doing it? Have you got a good technique? How far into your maturation are you? Have you got the right hormones to be able to be able to get the gain some resistance training? So yeah, I think so it's it's tricky social media. Social media also the problem I do see is lack of attention. So kids have slightly delayed sort of reticular system, so their attention span is quite minimal anyway. So uh with the advent of or the plague of phones, if you want to put it that way, I think that you know I can't talk to them for ages and ages and ages and ages because they'll lose attention. So I keep things short. I always sometimes they ask them to repeat back to me what they understand. And again, you're more likely to they're if they get bored, it's really obvious. They start looking around the room, they're not interested. Mum and dad's talking, they look at the floor and you've lost them. So it's trying to build them back in if that happens.

SPEAKER_01 18:57

Brilliant, brilliant. Well, as I thought might happen, Dan, time has flown by and we have run out of time, unfortunately. But I'm sure we can probably come uh carry this conversation on another time if you're if you're happy to come back on at some point, maybe in in the new year. But thank you so much, Dan. Really interesting, and I think really an important topic for us to bear that in mind. And and for the next time you've got a youngster coming in, maybe just think a little bit differently how you might approach and support their rehabilitation. Fantastic. I hope your listeners got um got a lot from the episode. I'm sure they did, Dan, and I'm sure they'll get more when you come on next time. Brilliant. Thanks a lot, Dan. You take care, have a good rest of your evening.