Rob Steele, MD (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy Kansas City. Before we introduce our guest, I want to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/CMEpodcast and click the claim CME button. Today we are joined by Jason Yoder to talk about athlete burnout and overuse injuries. Jason is currently the Operations Manager at the Sports Medicine Center at Village West in Kansas City while continuing his role as a sports physical therapist.

He has nearly 15 years of experience in orthopedics and sports medicine. Jason's clinical practice focuses on operative and non-operative rehabilitation of the shoulder and elbow. During that time, he has also had the opportunity to complete a variety of professional presentations for peers, as well as community outreach, most notably regarding the athlete and adolescent injuries. Jason tries to take a holistic approach to the treatment and assessment of all his athletes with consideration for recovery from the specific injury, injury prevention and performance. He's also continued his role as adjunct faculty at the University of St. Mary's, where he is able to educate the second year physical therapy students during their sports medicine elective since 2019. Jason Yoder, thank you for joining us today.

Jason Yoder, DPT: Thanks for having me, Dr. Steele. Excited to be here.

Host: Great. Well, so now before we get started, it strikes me that you have extended your physical therapy and your foray into medicine because you've got four boys. And, I imagine what is it ranging from two to 11, that's essentially five boys for your wife. And I imagine there are a number of injuries that, you get to practice on straight at home. Is that a fair assumption?

Jason Yoder, DPT: Yes, it is a crazy household to say the least. And, let's just say I try to practice what I preach. So we've been fortunate to be relatively injury free by practicing a lot of these things we'll hopefully talk about today, prevention wise and, movement literacy wise. So, knock on wood, we try to keep the injuries to a minimum.

Host: Well, bless your wife. We'll give her a shout out for, uh, putting up with the five of you. That's great. Let's do jump right on into it. So can you explain what athlete burnout is and maybe what some of the common signs are?

Jason Yoder, DPT: In kind of preparation for this podcast today, I unfortunately came across a really interesting article in regards to Sean Burrow. So everyone probably isn't aware of who this young man is, but he unfortunately passed away at 43 years old, suddenly. He was a two time little league world series champion from, California. He was a 2000 Olympic gold medal winner for the baseball team, and was drafted in the first round of the MLB draft. And his story is pretty fascinating and would encourage those to maybe just search up some of his history. But when he walked away from the game, he had this quote where, he comments, "I just didn't have the drive or the passion. I was spent physically and spent mentally. It just wasn't there. I was emotionally drained. I still love the game and respected the game, but I didn't have the drive to go to the park every day. I kind of lost the desire." And so that really stood out and was perfect timing as we were preparing for today because it really aligns with more of the medical description that we see.

And that's probably best captured in the athlete burnout questionnaire, which Raedeke and Smith spent a lot of time on and developed over the years and they talk about these three domains that we tend to see highlighted and captured with these athletes. And it's what Sean commented on. We see physical and emotional exhaustion.

We get this reduced sense of achievement and this overall devaluation of sports. And so these kids are essentially done. They just are tired. They're fatigued. and so they kind of reach this point where they're unable to continue doing what they're doing, for a variety of reasons, as it relates to just the volume, the overwork, the demands.

And so I think that's kind of a great quote, from a, unfortunately, a player who had been through that. And then I think that athlete burnout questionnaire just provides a great kind of tridimensional framework for how we can maybe think about how these athletes are affected.

Host: That's such a tragic story. But yet a really fantastic illustration about how the experiences for the athlete in childhood can significantly affect those once they're in adulthood. So we're really talking about a lifetime prevention strategy, if you will. Is that fair to say?

Jason Yoder, DPT: A hundred percent. I mean, I think it starts younger and younger, right? I don't think any of us are naive to the way the evolution of youth sports has started, earlier in their development, and more serious and more intense earlier in childhood. And so I think, managing these burnout symptoms and all these factors, has very much become much more of a lifelong approach from our end medically on how we need to view and answer, how these patients are presenting to us with some of these symptoms.

Host: You know, I'm curious in your experience, as a pediatrician, and I even think back to my childhood, it seems like we, at least in the US have morphed, where we saw many children, they would do multiple different types of sports throughout the year, even up through junior high and high school.

My experience now with patients and athletes is that they've for the most part singled in on one and they're playing it year round. Is that a fair assessment or is that an exaggeration and does that contribute to burnout?

Jason Yoder, DPT: I think that's a very accurate statement. The evolution of the sports specialization, as you mentioned, with our club sports, our leagues and the way they're structured. And there's this demand to perform at a high level and be technically sound at a young age and have this culturally monetized and corporate entities that dictate a lot of our tournaments and a lot of our structure and a lot of I need to keep up with Sally and Joe down the street and like, there's so many variables, that a lot of times, parents and patients aren't quite sure what to do or how to handle it. And so it's a hundred percent become an issue where kids feel like they need to do a sport year round, or maybe the club is forcing that structure or, Hey, we need you on our team in the spring, but we also have an expectation that you need to do stuff with us in the summer and the fall.

And so you have this subset of athletes that are specializing in one sport. And then what we've also seen is parents are taking pieces of this education where we're telling them to do different things, but they're doing multiple sports year round, which defeats the purpose of what we were after when we tried to start providing this education. And so you continue to get this workload and overload and just physical and mental exhaustion.

Host: Well, I mean, you've done a fantastic job of defining the problem. How do we go about trying to prevent this burnout?

Jason Yoder, DPT: As always, it's a complicated answer, there was a quick fix, right? Like, in my world of UCL reconstruction, if someone had the answer, we wouldn't be losing guys, in the millions of dollars of payroll every year, right? And so I think this is a topic that's very complicated, but I think you have to start just trying to provide education and making an impact where you can and depending on your touchpoint within the medical model, as much education as you can.

And so, simple rules, you shouldn't be practicing and training more hours in a week than your age. So, if you have a nine year old and you look at their cumulative workload, they shouldn't be practicing and playing more than nine hours a week. I think movement literacy is a huge issue. We're asking these young athletes to do very complicated, repetitive tasks throughout the week, throughout the year, but they maybe don't have a foundation in place.

So how can we teach them how to push, pull, do a hinge, do a squat, control their core, foundationally so that they have a better structure from a physical standpoint to handle some of these demands. And then, I think something I try to practice with my own athletes when I coach them through the kids is like, it's fun.

It sounds cliche, but I think too soon, too quick. We make it more competitive than fun. So we have every kid play a different position. We have kids batting different spots in the lineup. It's crazy. Like if you have a stud soccer player, where does that kid play? He plays forward and no one else on that team is going to get the opportunity.

Or I've got a stud first baseman. He's going to play first and then another kid may never get that opportunity and it goes on and on, no matter what the sport is. And so I think we all want to win, right? Like it's that old adage. Do you like to win or hate to lose? I hate to lose as much as anyone, but I also, we have to develop these kids and give them exposure and opportunities to get different experiences, whether it's movement wise, engagement wise, it just helps them learn and develop and experience different things on the field.

Host: Yeah, Jason, that's fantastic insight. You know, we have a lot of physicians that'll listen to this podcast, many of whom are parents. I think you've resonated with both. I mean, certainly what you're describing resonates with practice, but I think it also resonates with just what parents are feeling with their own kids.

Let me pivot just slightly. So, maybe you don't have a child that is going through burnout, but certainly is practicing and playing quite a bit, particularly if they're hyper specialized, which we touched on. That can often lead to overuse injuries. So, for the audience, could you explain what an overuse injury is and how our discussion really plays into that?

Jason Yoder, DPT: An overuse injury is essentially any joint, tissue, aspect of the body that has become overused and overstressed. That's how I kind of describe it at a high level, right? And I think, sometimes we try to, like, avoid a sport that maybe is predisposed to a certain injury or type.

And what we like to remind folks is that every sport has its inherent risk if done too much and every aspect of the developing body can become injured, if stressed inappropriately. Right. And so a lot of times we think about our big money sports, baseball, softball. We know that we're predisposed to little league elbow, little league shoulder, which is irritation to the medial epicondyle, the proximal epiphysis, and we see these things.

And then maybe sometimes we're like, well, I'm not going to have them throw, but we're going to do X, Y, and Z. And so I think that's the big thing. We try to emphasize is it doesn't matter what the sport is or what the body part is; they can only handle so much load, so much volume, so much repetitive task.

And so, our job as clinicians is to provide that education and help them understand that, Hey, maybe you're not throwing a baseball, but you're running too much. So now we're predisposed to metatarsal tibial stress fracture, stress reactions, or we get into our whole Osgoode Slaughter and Cindy Larson issues around the patellofemoral joint.

And so I think sometimes we maybe think we're doing the right thing by avoiding a certain movement or a certain task and we do something else in excess and it's still going to potentially lead to that overuse injury of a maybe separate body part, region, tissue.

Host: In your experience, with that overuse, is that a function of playing and practicing a lot, regardless of sport. Is it more common in those that really do single in on one particular sport? What's your experience with that? Or is it really all comers? It's really just a matter of how much they're playing and participating and competing.

Jason Yoder, DPT: I think it's definitely both pieces. As you mentioned, we certainly see it in the hyper specialized. I mean, there's no doubt you do any task over and over repetitively, right? Like us sitting here at our desk. We know that's a problem sitting too long during the day. And then it's the same when they're younger.

So these athletes are doing consistent rotational tasks through the upper body, or they're doing consistent loading through the lower body impact wise with excessive running, jumping, cutting; the developing, in our case, in my PT world, we talk about this, the developing physis, the growth plate can only handle so much load and stresses.

And so we'll tend to see fractures and stress reactions and a lot of these bony injuries and tendinitis and other issues versus maybe your ligament tears and rotator cuff tears as you develop and age. And so yeah, to go back to answer your question, I think it's very multifactorial. The hyper specialized is certainly more at risk just because of the repetitive nature of the movement; but there is a hundred percent at risk across the board if you're doing too much of any of these things.

Host: Great insight. One last question, and it really it speaks to burnout, but also those patients that do have overuse injuries and the interplay between the physical ailment, say for with the, overuse injury as well as the burnout and their overall mental health. We think about sports as really being a significant help for mental health but, I imagine those that are overdoing it, if you will, for burnout; there's really some significant, mental health implications to that as well. Is that, is that your experience?

Jason Yoder, DPT: Yeah, 100%. And, just again, try to lean all of our resources. And so we're fortunate to have Casey Lawless, who's a sports psychologist on our team and collaborate with her on a regular basis. And that was something we had talked about recently. And, it's interesting how there's a pendulum because, on one end of the spectrum as it relates to the mental health and mental performance of these athletes, we see one end where they shut down.

They're done. Right. Kind of like Shawn commented on when we read his quote to start. They don't have the ability to show up. They don't have the ability to engage. Their interactions with teammates and coaches and parents are very poor. They're done and checked out. And then the crazy thing is we also see on the other end of the spectrum where they push harder, which is crazy to think about, but they don't know any better.

So they're again, maybe frustrated with their performance. They don't know how to stop. So they further push, they further engage. Sports is how they identify and it's all they know. And they don't want to accept the fact that they need to take a break and walk away and step away. And so it's a very dynamic interaction with some of these athletes on how they become almost obsessed with their sport and their engagement.

And so, yeah, it's an interesting end of the spectrum depending on how this whole idea of burnout and overuse can affect them because we certainly see both ends of it, and neither one is arguably a good thing, right? And so, I think it's recognizing, like, me as a PT, I live in the MSK world, I work on the rehab, the movements, but there are certainly a lot of other factors that play in, with these young kids, as it relates again to their mental health, as you mentioned.

Host: Jason Yoder, thank you so much for your time. I said that was the last question. That was a lie. I've got one last really key question. As a family, with four boys, rumor has it you're heading down to Gulf Shores sometime this summer. I don't know if you've ever been there before. I've been a bazillion times. You're going to have a great time. But my question is with your family, particularly your boys, are they going to go to Lambert's Home of the Throwed Rolls? Are they going to be getting beach burgers or are they seafood folks? Where are you going to get your dinner?

Jason Yoder, DPT: We are carnivores. So, the fish is a hit or miss with the crew. So yeah, somewhere we can get a steak or some burger sounds good. And, we plan to go fishing. So hopefully we'll catch a fish. Maybe that'll help, improve their interest in it. But yeah, definitely, carnivores, red meat type of family. Gotta get protein in them boys.

Host: Well, fantastic. There's lots of choices down there. You'll really enjoy it. Thank you again, Jason, for joining us today. As a reminder, claim your CME credit for listening to our show today. Visit cmkc.link/cmepodcast and then, click the claim CME button, there on the page. This has been another episode of Pediatrics in Practice, a CME podcast. See you next time.