How to Ease Back Into Sports Without Hurting Yourself

The day sports went dark has turned into the year sports went dark. Early March 2020, usually the time for track, baseball, and lacrosse, instead ushered in a year of loss. The games and competitions that marked adolescence, offered identity, formed friendships, and led to an understanding of what it means to be on a team were gone.

Underneath a range of restrictions, the pandemic turned daily life upside down, but the effects on kids’ sports have been particularly devastating, both physiologically and psychologically. It’s been almost exactly a year since most of the 8 million young athletes who participate in high school sports have played a soccer game, suited up for a basketball game, or played any sport.

For youth sports, once criticized for a relentless year-round schedule, the drop-off in participation was steep. According to Project Play survey data from the Aspen Institute, published last September, time spent playing games declined by 59 percent and practice hours went down 54 percent during the pandemic.

That was especially true of older, high-school-aged athletes. Parents of 15- to 18-year-old athletes reported a 65 percent reduction in time spent on practices or games, compared to 37 percent for 6- to 10-year-olds. Restrictions on high school and travel sports likely explain the differences.

Now, with restrictions in many states easing as Covid-19 numbers drop, vaccinations rise, and evidence emerges that playing sports are a less likely cause of viral transmission, sports are resuming.

With strict rules and a large population, California might be the most populous example of a restrained athletic populace now given the green light to continue. As the first state to shelter in place and one of the last to open, many of the state’s over 815,000 high school athletes are finally able to return to school sports, albeit in an abridged fashion.

No matter the state, when sports do return, they will do so under unprecedented circumstances.

It isn’t just games—practices have been severely limited, as has access to gyms and weight rooms for strength and conditioning. Because the end of the academic year is just months away, and many schools are trying to fit three seasons into one, schedules have been compressed. In some sports that will mean four games a week.

The pandemic-related halt in sports is an opportunity for overscheduled and overtrained young athletes to get a good rest, right? It might’ve been, maintained Nirav Pandya, a pediatric orthopedic surgeon and researcher at UC San Francisco, but parents may not heed the advice. “I was hoping that families would frame shift a bit, use the opportunity to try different sports,” said Pandya. “But it’s been the opposite. There’s been increasing anxiety among parents and athletes, thinking, ‘Now I really need to specialize.’ Parents and kids think they can pick up in a week what they lost for 8 months.”

Part of the rationale for getting back to playing and training harder may be a desire to line children up for college scholarships, but it’s more than that. Many in sports medicine fear that this long period of pandemic-enforced rest will leave athletes, young and old, vulnerable to injury. Injury isn’t just the result of too many games and practices, though we saw plenty of that with pre-pandemic year-round sports.

Like the heart and lungs, our ligaments, tendons, and muscles all benefit from use, especially for sports that require quick and explosive bursts of activity, like basketball, soccer, and volleyball.

“We need a certain level of activity for tendons, ligaments, and bones to be ready to experience more stress,” said Pandya, “But we haven’t thought about the necessary load for kids who play sports, because they were getting enough. Now they need load and strain for tendons to be ready. Exercise that primes the engine so that the structures don’t weaken.”

The focus now is on noncontact soft-tissue injuries—the ones that don’t occur as the result of hitting another player or surface—as those are typically more preventable. After all, one has far less control over injuries that occur because of contact. Soft tissue injuries—collectively ligaments, tendons, muscles, and cartilage—can, in some sports like soccer, make up more than three-quarters of ACL injuries.

That means, in most cases, a torn ACL, Achilles, hamstring, or sprained ankle isn’t the result of one athlete hitting another, but rather the consequence of a quick cut, jump, or awkward landing, overloading the strength of a tissue. Usually something the athlete has done hundreds, if not thousands of times.

By themselves, ligaments like the ACL aren’t strong enough to withstand the forces of one hard cut or a big jump. That’s where the muscles and other secondary support structures come in, literally holding the knee together with precisely sequenced contractions that, when things are working well, gives athletes the ability to safely move and play. But, when coordination is off, balance is shaky, or muscles are deconditioned, the ligaments or tendons are exposed to the forces that can ultimately tear tissue.

In a frequently referenced research article, Tim Hewett, an expert in ACL injuries, analyzed football players returning to the field after the 2011 NFL lockout. Though players had plenty of “rest” after the previous season—the outcome of a four-month lockout from NFL facilities—there was a 500 percent increase in Achilles tendon ruptures during the abbreviated preseason. With limited access to team medical staff, facilities, and the typical 14-week structured preseason training program, players had only 17 days to get ready for preseason games. The result wasn’t pretty.

The reason, Hewett theorized, was that the lack of offseason and preseason conditioning left the soft-tissue structures vulnerable, which set players up for injury.

In a more recent, soon to be published study, with measurements taken before and during the Covid-19 pandemic shutdown, Hewett and others looked at markers of performance and injury risk in 483 NFL players over four seasons. After the extended layoff from training and participation because of the Covid-19 lockdown, athleticism and explosiveness decreased—notably the rate of force development and maximal force development—leading researchers to suggest a higher risk for soft-tissue injury.

“What the study we did with the NFL football players clearly showed was, when you do tests measuring whole body power, athleticism and explosiveness dropped after a pandemic related rest. Which correlated with increases in injury risk, specifically to the lower body,” said Hewett.

For parents and young athletes, the implications of this research are concerning. This isn’t just about being a little winded running up the field after being away for months, the loss of training time could mean young people are more prone to serious, life-changing injuries early in their sports careers.

Hewett is also concerned about the risk to all athletes, not just the ones that play on Sunday. “It appears very likely to me from where we are now that we are going to have problems coming up. It is worrisome. The things that are positive about injury prevention work: that good neuromotor training is good for injury prevention and performance,” said Hewett. “When you don’t have that training, when you decrease it, all those things go in the reverse direction. That’s what we saw in NFL players and that’s what we are afraid we will see in young recreational athletes.”

Pandya has already begun to see these pandemic-related effects in evaluations of young athletes. “In my clinic, I have seen simple tests, single-leg balance and single-leg squat, change pretty remarkably in my athletes. Twelve to eighteen months ago 90 percent of the kids who play sports would nail the tests,” said Pandya. “Out of 10 kids I tested today, eight of them are falling over doing a single squat. These are kids that want to go back to competitive soccer, and they can’t even stand on one leg for 10 seconds. Pretty striking about basic things we took for granted—balance, stability, strength, and flexibility—have completely degraded over the past year. I tell the kids, ‘If you can’t balance on one leg in the clinic, what will happen in the 75th minute of a soccer game when you try to cut?’”

Of course, injuries can happen to even the strongest and most coordinated athletes. But enhancing neuromuscular coordination, strength, and balance have been shown to have a beneficial effect on injury risk, reducing the incidence of noncontact ACL injuries by well over 50 percent. So it stands to reason that reducing those same attributes will send injury risk the other way.

“I think the one I worry about most is the neuromuscular timing, the timing of contraction of muscles. Deficits in that are associated with ACL injuries, but probably more injuries than just that,” said William Meehan, director of the Micheli Center for Sports Injury Prevention at Boston Children’s Hospital.

“The risk to tissue depends on the sport. Repetitive stress injuries occur with endurance sports when there is a big change in activity, like now,” clarified Meehan. “I also worry about it for precision sports—gymnasts, figure skaters—because they rely on precision timing and feel. They are going to lose that neuromuscular timing feel for sure.”

For many in the sports medicine community, the question isn’t whether a year off of sports has increased the risk of injury, but how bad will that spike be. Here are a few steps to reduce that risk.

Pandya says, “Use these three simple tests to assess general readiness to begin playing sports. Symmetry between legs is the main marker”:

• Single leg balance (should be able to stand for at least 10 seconds without touching the other foot)
• Single leg squat (try to do 10 deep squats in a row without the knee collapsing inward or losing balance)
• Single leg hop for distance (compare distances between legs)

Hewett says, “Ideally young athletes should take a minimum of 6 weeks, preferably 8 weeks, to train for a return to competition. Really, to be as safe as possible, 12 weeks. That training should include a progressive regimen of aerobic and anaerobic fitness (endurance and speed training) and resistance and plyometric training. They need to do this a minimum of three times a week. An injury prevention program like the FIFA 11+, while not comprehensive enough, would give athletes a baseline to work from.”

“If we are talking about sprinting and jumping athletes, one of the best ways to be ready is to do those things in dedicated sessions, not just in the sport,” said Tim DiFrancesco, a physical therapist and former head strength and conditioning coach for the Los Angeles Lakers.

“To do that, training has to include both strength and explosive training,” said DiFrancesco. “You have to have a preparation approach to the jumps, the landings, and the changes of directions. Every sport needs to train jump-landings, cutting, acceleration/deceleration, and rotational power. How much of each can depend on the needs of the sport.”