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Clinics and Practice
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29 April 2025

Early Sport Specialization in a Pediatric Population: A Rapid Review of Injury, Function, Performance, and Psychological Outcomes

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1
Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA
2
UNC Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC 27514, USA
3
Duke University Medical Center Library, Durham, NC 27710, USA
*
Author to whom correspondence should be addressed.
Clin. Pract.2025, 15(5), 88;https://doi.org/10.3390/clinpract15050088
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Abstract

Background: Early sport specialization, involving intensive focus on a single sport for greater than 8 months per year at a prepubescent age, has become increasingly common in young athletes. While early sport specialization is often regarded as essential for success, there is growing concern that the potential risks to young athletes may outweigh the perceived benefits. Although numerous studies have explored early sport specialization, there has been no summative review on the topic in regard to the comprehensive impact on outcomes in these athletes. This study aims to systematically review the literature to determine the impacts of early specialization on injury, function, performance, sport success, and psychological outcomes. Methods: A review of Medline (PubMed) was conducted to search for studies relating to early sport specialization in pediatric patients (time of specialization < 18 years old) and outcomes. Extracted information included injury outcomes with a focus on overuse injuries, functional outcomes, performance outcomes, sport success, and psychological outcomes. For studies that reported relevant statistics, p < 0.05 was considered statistically significant. All studies were described qualitatively. Results: An initial search resulted in a total of 826 studies. After applying inclusion and exclusion criteria, 93 studies were included. A total of 62,327 athletes were included in the study. The average age of study participants was 15.9 years, with an average age at specialization of 11.6 years. Early sport specialization was associated with increased risk of injury, worse functional and physical performance, decreased or no benefit to sport success, and poor psychological outcomes. Conclusions: Early sport specialization was associated with increased risk of injury and negative impacts on functional and physical performance measures. There was also no clear advantage regarding sport success. Early sport specialization was linked to harmful effects on athlete psychological well-being. Late specialization, multisport participation, and following training volume guidelines can aid in mitigating these risks.

1. Introduction

As the realm of collegiate and professional sports has evolved, there has been an increased emphasis placed on early sport specialization in youth athletics. Early sport specialization is defined as prepubertal children participating in intensive training or competition in organized sports for greater than 8 months per year and excluding participation in other sports to focus on one sport []. As athletes commit to college programs at younger ages, many young athletes and parents perceive early sport specialization as crucial for sport success. Furthermore, with the National Collegiate Athletic Association (NCAA) implementing its Name, Image, and Likeness (NIL) policy in June 2021, young athletes may feel even greater pressure to specialize early []. Although athletes themselves are often the driving force behind early specialization, parents have also been shown to play a role [,]. Additionally, club coaches have been shown to view early sport specialization positively, reinforcing the trend []. A popular belief is that an athlete needs at least 10,000 h of practice to be successful in their sport, a misinterpretation that stems from a study conducted by Ericsson et al., which focused largely on musicians and has not been used as a guide in athletic development [,]. Even in Ericsson’s study, there was an emphasis made on recovery and avoiding overuse injuries in athletes, which has not been as popularized [].
Early sport specialization has been linked to numerous problems for these developing athletes. Numerous overuse injuries in the upper and lower extremities have been reported with early sport specialization []. Additionally, early sport specialization has been shown to lead to greater rates of reduced sense of accomplishment, sport devaluation, and exhaustion compared to multisport athletes []. In contrast, multisport participation has been shown to offer advantages for athletic development and success. For example, 88% of 2018 NFL first-round draft picks played multiple sports in high school []. In a survey of over 300 NCAA Division I athletes from 19 different sports, 94.7% had previously played another sport prior to college []. In addition to enhancing athletic performance and reducing injury rates, multisport participation, especially unstructured free play, has been linked to improvements in leadership, problem solving skills, decision making, self-control, emotional regulation, and social skills [].
Current guidelines recommend that adolescent athletes spend no more than 8 months per year in their primary sport, practice no more hours per week than their age (i.e., an 11-year-old should not participate in organized activity for more than 11 h per week) with a cap of 16 h/week []. Even with these standards in place, over 80% of parents are unaware of training volume recommendations or the potential negative effects of sport specialization [].
While numerous studies have explored early sport specialization in general and within certain sports, there has been no summative review on the topic in regard to the comprehensive impact on outcomes in these athletes. Prior reviews have only focused on the risk of injury in regard to early sport specialization [,]. Thus, the goal of our study was to systematically review the literature to answer the question on how early sport specialization may impact not only injury, but also functional, performance, sport success, and psychological outcomes.

2. Methods

2.1. Literature Search and Screening

This study was a rapid review that followed PRISMA guidelines where applicable for a rapid review article. The search protocol was not registered. We searched Medline (PubMed) using a combination of keywords and database-specific subject headings for the concept of early sport specialization, pediatrics, and outcomes. The complete, reproducible search strategy can be found in Appendix A. The search yielded 826 total citations. All citations were then imported to Covidence (Veritas Health, Melbourne, Australia), a review screening software. One duplicate was removed manually, leaving eight hundred and twenty-five studies to screen. Inclusion criteria involved adolescent athletes/players and/or youth athletes of all sports, discussion of early sport specialization compared to other forms of specialization or non-specialization, and outcomes relating to injury, function, performance, sport success, and psychological impact. Review articles, case reports, non-English texts, opinion pieces, letters to the editor, studies with non-pediatric sport specialization, and studies that did not compare levels of sport specialization were excluded. Following title and abstract screening, 228 full-text studies remained. In full-text screening, 135 studies were excluded for the following reasons: different study design (73 studies), different outcomes (39 studies), different patient population (19 studies), and not in English (4 studies). A total of 93 studies remained for inclusion into our review (Figure 1). All voting disagreements at abstract and full-text levels were resolved with discussion. Manual data extraction was performed with one reviewer extracting each study.
Figure 1. PRISMA flow chart.

2.2. Quality Appraisal and Risk of Bias

All included studies were assessed for risk of bias and study quality using the Methodological Index for Nonrandomized Studies (MINORS) criteria []. The MINORS criteria include a 12-item checklist, with each item receiving a score of either 0 (not reported), 1 (inadequately reported), or 2 (adequately reported). Noncomparative and comparative studies have a maximum score of 16 and 24 points, respectively. The full assessment of risk of bias and quality assessment can be found in Appendix B.

2.3. Statistical Analysis

Due to the heterogeneity of data, all studies were described qualitatively. Descriptive statistical analysis was performed utilizing R version 3.6.1 (R Foundation, Vienna, Austria).

3. Results

3.1. Patient Demographics and Cohort

A total of 62,327 athletes were included in the study. The average age of study participants was 15.9 years, with an average age at specialization of 11.6 years. There was a broad spectrum of sport activity described, including youth/school-level, club-level, collegiate-level, professional-level, and world/Olympic-level athletes. The most frequently analyzed sport was soccer, followed by basketball and volleyball. Additional study information including risk of bias assessment scores can be found in Table 1.
Table 1. Descriptive table. Abbreviations: SD = standard deviation. NR = not reported.

3.2. Injury Outcomes

Fifty-five studies analyzed injury outcomes associated with level of sport specialization (Table 2). Twenty-four studies found that early sport specialization was significantly associated with injury, a higher risk of total number of injuries (most commonly overuse), and increased time missed from sport. Specific injuries associated with early sport specialization included lower extremity conditions such as patellofemoral pain, patellar tendinopathy, Osgood–Schlatter disease, Cam deformity, and hip and groin dysfunction [,,,,]. Upper extremity injuries were primarily overuse injuries of the shoulder and elbow [,]. Ha et al. and Okuruwa et al. also noted increased risk of lower back injury, stress fractures, injury history, and concussion in specialized athletes [,]. Rate of injury could be modulated by patient-specific factors such as gender, with one study demonstrating that the relationship between injury and sport specialization is more likely in female athletes []. Sport specialization may have long-term effects as well, with Wilhelm and colleagues finding that early youth sport specialization was significantly associated with increased injuries in professional baseball [].
Table 2. Injury outcomes.
Fifteen studies found no significant difference between sport specialization and injury. Fourteen studies demonstrated mixed results within their analysis. Of these fourteen studies, eight studies found negative outcomes with sport specialization in regard to certain injury outcomes such as overuse injury, pain, or injury necessitating surgery but otherwise noted no significant differences on other injury measures [,,,,,,,]. Moseid et al. found negative outcomes associated with sport specialization that were non-significant when adjusting for sex, sport category, and training load at baseline []. Four studies found mixed results based on sport specialization [,,,]. Allahabdi et al. found that while multisport athletes were more likely to suffer a sports injury, single-sport athletes had more medical appointments []. Frome and colleagues found that specialized compared to non-specialized athletes were at lower odds of any previous injury, similar odds of previous lower extremity overuse injury, and greater odds of missing more practices []. Lenz et al. noted a higher percentage of head and neck injuries in late specialization athletes versus a greater percentage of wrist injury in the early specialization group []. Post et al. demonstrated that the impact of sport specialization could be dependent on sport, as overuse injury was prevalent in volleyball but not in basketball or soccer [].
One study found that early sport specialization was associated with positive outcomes []. More specifically, Chen et al. noted that regarding lifetime injury and injury within the last 12 months in rock climbers, late specialization was associated with a significantly higher rate of injury compared to early specialization [].

3.3. Functional and Performance Outcomes

Thirty studies analyzed functional and performance outcomes in regard to sports specialization level (Table 3). Fifteen studies found negative functional and performance outcomes associated with early or high specialization [,,,,,,,,,,,,,,]. More specifically, sport specialization was significantly associated with worse performance testing, particularly on the squat jump, countermovement jump, 20 m sprint, Functional Arm Scale for Throwers (FAST) score, Youth Throwing Score (YTS), and Landing Error Scoring System (LESS) score [,,,,,]. Sport specialization was also noted to be associated with negative biophysical outcomes. Two studies found significant variability on the Drop Vertical Jump task that could be indicative of altered coordination strategies of the hip and knee joints [,]. Single-sport athletes also displayed greater asymmetry, lower bone density, decreased quality of life scores, and increased daytime sleepiness [,,]. One study found that even after discontinuing sports, highly specialized youth athletes prior to high school demonstrated clinically significant deficits in lower extremity function as adults []. Playing multiple youth sports was also found to be particularly beneficial, with multisport athletes showing improved function, performance, gross motor coordination, higher physical activity levels as adolescents, increased game participation, and longer careers overall [,,].
Table 3. Functional and performance outcomes. Abbreviations: LESS = Landing Error Scoring System. TGMD2 = Test of Gross Motor Development. FAST = Functional Arm Scale for Throwers.
Nine studies reported no significant differences between sport specialization groups [,,,,,,,,]. Six studies noted mixed findings regarding sport specialization [,,,,,]. Bonnette et al. found that while highly specialized athletes demonstrated greater degrees of coordination compared to the non-specialized group, they were able to break coordinated patterns of joint angle changes, requiring asymmetric demands on the lower extremities []. Camp and colleagues found no differences between single- and multisport athletes in regard to range of motion, strength, or pitch velocity, but did note greater external rotation strength in the dominant extremity for multisport athletes when analyzing based on hand dominance []. Similarly, Sugimoto found increased ankle plantarflexion but decreased muscular strength of single-sport athletes, but otherwise no significant differences []. Two studies noted that the benefits of sport specialization were found to be insignificant depending on the type of functional test or if certain factors such as age were controlled for [,]. Interestingly, when sport specialization was further divided into low, moderate or high specialization, moderate specialization was found to have improved movement quality and significantly better LESS scores than either the high or low groups, indicating that a certain amount of specialization could be beneficial [].

3.4. Sport Success

Thirteen studies analyzed sport success outcomes in specialized/early-specialized versus non-specialized/late-specialized athletes (Table 4). Compared to non-specialized/late-specialized athletes, specialized/early-specialized athletes were reported to have mixed results on sport success with three studies showing worse outcomes, four studies showing better outcomes, and six studies showing mixed or non-significant differences in outcomes between the two specialization groups. Ahlquist et al. reported a significant positive correlation between early specialization and the likelihood of being recruited by a college or receiving a college scholarship []. However, other studies found that non-specialization was significantly associated with higher level sport participation compared to specialization in one sport and specialization was also not associated with playing at a professional level [,]. The majority of the studies showed mixed or similar sport success outcomes between specialized/early-specialized and non-specialized/late-specialized athletes. For example, Meisel et al. showed there was no significant difference between the number of high school athletes that ranked inside the top 250 as compared to outside the top 250 athletes in their class between specialized and non-specialized athletes []. Additionally, there was shown to be no significant difference in the percentage of specialized versus non-specialized athletes that received scholarships or had longer college career lengths according to Rugg et al. [].
Table 4. Sport success outcomes.

3.5. Psychological Outcomes

Eighteen studies analyzed psychological outcomes in specialized/early-specialized versus non-specialized/late-specialized athletes (Table 5). Specialized/early-specialized athletes were reported to have either worse or the same psychological outcomes when compared to their non-specialized/late-specialized athlete counterparts, with seven studies showing worse outcomes, nine studies showing similar outcomes, and only two studies showing better outcomes. Chou et al. showed that specialization was significantly associated with higher odds of reporting severe depressive symptoms on PHQ-9 and reduced PedsQL than non-specialized athletes []. Other studies also reported that specialization was associated with feelings of excessive competition load and significantly higher fatigue, anxiety, and depressive symptoms than less specialized athletes []. In contrast, Zeller et al. reported significantly lower PHQ9 and GAD-7 scores in youth softball athletes who were more specialized compared to those who were less specialized, while HuardPelletier and colleagues elucidated an overall positive correlation between increased specialization and perceptions of sport competency.
Table 5. Psychological outcomes.

4. Discussion

4.1. Summary

In summary, early sport specialization was generally associated with a higher prevalence of overuse injuries, negative physical and functional metrics, mixed evidence with no definitive advantage in sport success, and potentially worse psychological outcomes (Table 6).
Table 6. Summary table of study breakdown and outcomes.
Early sport specialization has been a growing topic of interest. For parents and youth athletes, this desire to play at the elite level has been a major factor in the decision to specialize []. However, while information discouraging sport specialization has been widely available, a majority of parents have been found to have no knowledge of sport volume recommendations, and high rates of sport specialization are still being reported [,]. This belief has not been shown to be shared by youth sport coaches, the majority of whom recommend playing multiple sports during childhood, thus highlighting the need for providing a more comprehensive overview of the impacts of early sport specialization [].

4.1.1. Summary of Injury Outcomes

In this study, a total of 54 articles discussed injury-related outcomes relating to sport specialization, with a majority finding that early/high sport specialization was associated with a higher risk of injury. The heightened risk of injuries, particularly overuse injuries, is one of the primary concerns of early or high sport specialization [,,,,]. These studies have aided in informing volume recommendations and caps on the number of hours of practice per week for young athletes []. In the upper extremity, high levels of early sport specialization have demonstrated increased risk of injury and surgery, particularly in sports with high training volume and repetitive motions such as baseball, swimming, and volleyball [,,,]. An emphasis has also been placed on adolescent athletes participating in multiple sports or free play, as more unstructured free play can help improve athleticism and increase participation in sports throughout an athlete’s lifetime []. Our review of the literature confirms prior reviews that have noted the increased risk of injuries in highly/early-specialized youth athletes [,,].

4.1.2. Summary of Functional/Performance Outcomes and Sport Success

In addition to a heightened risk of injury, 24 studies found that early sport specialization was also either negatively associated with function and physical performance or demonstrated no significant difference with low- or non-specialized athletes. Early sport specialization and performance has been highly studied in sports such as baseball with a high risk of overuse injury and with validated outcome metrics such as the Youth Throwing Score to assess upper extremity health []. Biomechanically, the greatest decline in total range of motion in youth baseball players is seen between the ages of 13 and 14, in the year prior to the peak incidence of proximal humeral epiphysiolysis, also known as Little Leaguer’s shoulder. It is thought that this decrease in rotational motion may cause increased stress at the physis during throwing []. In regard to sport performance, there have generally been no differences in range of motion, strength, or pitch velocity between multisport and single-sport athletes, thus indicating that the perceived benefits of early sport specialization do not balance the negative impacts on performance and function in the long run [].
In our study, we also found that across 13 studies describing sport success, there was no clear advantage to early/high sport specialization. Furthermore, in the literature, playing multiple sports has also been shown to benefit sport performance significantly. At the NCAA Division I level, athletes were found to either specialize at an older age or play multiple organized sports prior to college [,]. When considering sport success at the professional level, NFL first-round draft picks were more likely to be multisport athletes in high school, and multisport NFL quarterbacks were shown to play in more games, have higher touchdowns per game, more playoff game and Pro Bowl appearances, MVP awards, and Super Bowl victories [,]. Similar results were demonstrated with first-round NBA draft picks, with multisport athletes demonstrating significantly greater percentage of total games played, lower likelihood of major career injury, and increased longevity in the NBA [].

4.1.3. Summary of Psychological Outcomes

In addition to the impacts on physical function and performance, early sport specialization can also have profound effects on the mental and psychological health of these youth athletes. Out of the 18 studies that discussed psychological outcomes relating to sport specialization, the literature was mixed, with seven studies noting a negative association, two finding positive outcomes, and nine studies finding non-significant results. Recent studies have suggested that high sport specialization can be linked to depression, anxiety, burnout, and the internalization of feelings of shame []. Early sport specialization has also been associated with a lower health-related quality of life compared to late sport specialization []. These findings were similarly reflected in our review. These psychological consequences can be significant, with potentially long-term effects such as jeopardizing return to play, increasing subsequent reinjury risk, and the development of mental health disorders, maladaptive perfectionist traits, clinical eating disorders, or other harmful behaviors that will result in decreased performance, physical health, and overall well-being [,]. Thus, it is crucial for athletes, parents, and families to be holistically informed regarding the potential effects of early sport specialization.

4.2. Strengths and Limitations

This study had some limitations. Due to the heterogeneity of data and reporting metrics, only qualitative analysis was performed, which could limit the generalizability of our findings. Participant demographics and sports were pooled for many of the studies that were included as well as in our analysis, which may explain the frequency of mixed findings and limit the interpretability of our results. Future sport specialization studies should standardize analysis by patient demographics and compare same or similar sports utilizing well-validated outcome metrics. The strength of this review is the comprehensive synthesis of data regarding sport specialization across multiple outcomes including function, physical performance, and psychological effects, while prior reviews have tended to focus exclusively on injury. We also included a diverse array of sports and levels of competition, which can help inform athletes with a variety of backgrounds and sport involvements.

5. Conclusions

In conclusion, early sport specialization was found to increase risk of injury, negatively affect functional, physical performance, and psychological outcomes, as well as limit sport success. Athletes can aim to mitigate these effects through late sport specialization or playing multiple organized sports, increased time of unstructured free play, and adhering to guidelines regarding training volume. Ultimately, we hope that this review can build upon the current body of evidence in the literature to better inform athletes, families, coaches, and providers regarding the potential risks and outcomes associated with early sport specialization.

Author Contributions

Conceptualization, E.J.L., L.V.K. and B.C.L.; methodology, E.J.L., L.V.K. and S.H.; formal analysis, E.J.L.; investigation, E.J.L.; resources, S.H.; data curation, J.R., J.K.M. and E.D.; writing—original draft preparation, E.J.L., J.R. and J.K.M.; writing—review and editing, Z.W.H. and B.C.L.; visualization, E.J.L.; supervision, B.C.L.; project administration, E.J.L. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Data Availability Statement

The original data presented in the study are openly available.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix A. Search Terms

Clinpract 15 00088 g0a1

Appendix B. Full Quality Assessment and Risk of Bias

MINORS A Clearly Stated Aim Inclusion of Consecutive Patients Prospective Collection of Data Endpoints Appropriate to the Aim of the Study Unbiased Assessment of Study Endpoint Follow-Up Period Appropriate to the Aim of the Study Loss to Follow Up Less Than 5% Prospective Calculation of the Study Size Total
Ahlquist 2020 []2202012211
Allahabadi 2022 []2202112212
Allahabadi 2023 []2202122213
Arede 2019 []2202021211
Arnold 2019 []2002121210
Barfield 2019 []2102122212
Beese 2015 []2202122212
Bell 2016 []2102121211
Biese 2020a []2202220212
Biese 2020b []2002220210
Biese 2021 []2102221212
Biese 2022 []2101121210
Biese 2024 []2002121210
Bonnette 2023 []2202122213
Bridge 2013 []2102121211
Bush 2021 []2202221213
Butler 2024 []2102121211
Camp 2023 []2201111210
Chen 2022 []200202129
Chou 2023 []2102122212
Confino 2019 []2101022210
Croci 2021 []2102122212
Dahab 2019 []2202121212
DiCesare 2019a []2102021210
DiCesare 2019b []2202021211
DiStefano 2018 []2201221212
Dobsacha 2023 []200212029
Field 2019 []2102120210
Fransen 2012 []2202122213
Frome 2019 []2102120210
Gallant 2017 []2202120211
Garcia 2021a []2102120210
Garcia 2021b []2102120210
Ha 2023 []1202221212
Hall 2015 []2102121211
Heath 2021 []1202121211
Herman 2019 []2102121211
HuardPelletier 2022 []2202021211
HuardPelletier 2024 []2102121211
Iona 2022 []200202028
Jayanthi 2015 []2202121212
Jayanthi 2020 []2201120210
Larson 2019 []2202021211
Lear 2024 []2202020210
Lenz 2024 []2201211211
Lima 2020 []1102121210
Li 2023 []2202021211
McDonald 2019 []2002121210
McGowan 2020 []2102021210
McGuine 2017 []2202021211
McKay 2023 []2202021211
Meisel 2022 []2202020210
Miller 2017 []2202021211
Moseid 2019 []2202021211
Murday 2024 []2202021211
Nagano 2023 []2202021211
Nguyen 2023 []2202021211
Okoruwa 2022 [] 2102122212
Pasulka 2017 []2202121213
Post 2017a []2202021211
Post 2017b []2202121212
Post 2020a []2102021210
Post 2020b []2202121212
Post 2021a []2202121212
Post 2021b []2202121212
Post 2021c []2202121212
Post 2024 []2202121212
Rauh 2020 []2202111211
Riehm 2023 []2102121211
Root 2019 []2202122213
Ross 2022 []2102111210
Rugg 2018 []2102022211
Rugg 2021 []2102121211
Sheppard 2020 []2202021211
Soderstrom 2023 []020212029
Staub 2020 []2202222214
Steinl 2021 []2202221213
Stockbower 2022 []2202221213
Sugimoto 2019 []2202221213
Sweeney 2021 []2202021211
Swindell 2019 []2102220211
Valenzuela-Moss 2024 []2202221214
Vernick 2021 []2202221213
Watson 2019 []2202221213
Watson 2022 []2202221213
Whatman 2023 [] 2202221213
Whatman 2021 [] 2212121213
Wilhelm 2017 []2202121111
Wilkins 2023 []2202121111
Wilkins 2024 []220202109
Xiao 2021 []2202021211
Zeller 2024 []2202221213
Zoellner 2022 []2202122213

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