Jan 29, 2015
A Tough Age

Student-athletes in their early teens are no longer “kids” but not yet adults. When they’re injured, everything from your communication to assessment and treatment methods must follow an age-appropriate strategy.

By R.J. Anderson

R.J. Anderson is an Assistant Editor at Training & Conditioning. He can be reached at: [email protected].

Place an 18-year-old and 20-year-old side by side and try to guess who is older. That can be a tough task. Unless the 18-year-old is a late bloomer, they both typically look like young adults.

Now, put a 14-year-old and a 16-year-old side by side. In most cases, you can immediately tell who’s who. Even when a 14-year-old has the physical maturity of someone older, once you start talking to the athlete, it becomes clear pretty quickly that he or she is not yet a young adult.

If you’re in a setting with high school athletes, it’s easy to lump them all together. But in reality, the 13-, 14-, and 15-year-olds are very different–physically, mentally, and emotionally–from the 16- to 18-year-olds. When working with what we’ll call pre-varsity athletes, you need to alter your communication style, evaluation, and treatment plans to provide the best care.


Communicating with any high school athlete can be a challenge. When they are pre-varsity age, it’s important to adapt your communication techniques even further to match their listening and comprehension abilities.

“Athletic trainers need to realize that these younger athletes are not simply mini adults, and they shouldn’t be treated as such,” says Ryan Hedstrom, PhD, ATC, Assistant Professor of Physical Education at Manchester College, who has an educational background in counseling and sports psychology and worked with Michigan State University’s Institute for the Study of Youth Sports and the Michigan High School Athletic Association from 2001 to 2006. “Athletic trainers should be very clear and concise in their communication with pre-varsity athletes. They receive and interpret feedback differently than older adolescents, so you have to be very careful about how you talk to them.”

P.J. Gardner, ATC, CSCS, PES, Athletic Trainer at the Colorado Sports & Spine Centers and at Liberty High School in Colorado Springs, Colo., says one common mistake athletic trainers make is overwhelming young athletes with too much information. “Using complicated medical terminology and describing the names of ligaments and tendons is not a good way to reach them,” he says. “If you get too technical, younger kids won’t understand and they’ll tune you out.

“Also, if you give these kids too many options or descriptions, they won’t retain any of the information you’ve given them,” Gardner adds. “Instead, I try to spoon feed them just a little at a time. Over the years I’ve learned that the kids remember so much more of what I tell them when I boil it down and describe their injury in two or three sentences.”

For Gardner, an example of streamlining a message might go like this: Your tendon is irritated. We’re going to ice it and then tape it. If you do these two exercises daily, it will help you get better. Do you have any questions?

To make sure her instructions sink in, Mary Shinkwin, PT, ATC, Head Athletic Trainer at Cambridge (Mass.) Rindge and Latin School, uses repetition. “You can’t take for granted that they understand or remember what you tell them,” she says. “When I’m teaching them about ice and compression, I ask them to repeat any instructions I gave. Or I may quiz them: ‘How long do you need to ice it for?'”

Although you need to simplify communication with pre-varsity athletes, be careful not to talk down to them, says Hedstrom. “Educate them in a simplified manner about what you are rehabbing and why, and include them in the decision-making,” he explains. “This helps them become invested in the process. Pre-varsity athletes are at an age when they’re leery of being treated like children and are starting to want more autonomy in their lives, so they crave control. For example, give them a choice of exercises, brace colors, or other options whenever possible.”

Communicating effectively with pre-varsity athletes also means understanding that they want very specific truths. “Be careful what you say because they always take you at your word,” Gardner says. “For instance, if you say they are going to be out for three days and you keep them out for four, they are likely to become upset and may not trust you the next time they get hurt.”


When Shinkwin sees a 13-, 14-, or 15-year-old athlete go down with an injury, she takes a deep breath. For example, when a freshman girls’ soccer player begins rolling around on the field screaming bloody murder, Shinkwin, who has been an athletic trainer at the high school level for over 18 years, knows the situation may not be as dire as all the howling would indicate.

“Freshman athletes are very, very emotional, especially girls at that age,” she says. “Some freshmen will cry and scream like they have a really serious injury, and it turns out they have a minor finger sprain. So when one of them has an injury on the field, I spend a good amount of time trying to calm them down before I do anything medically. That way, I can get a truer indication of what’s really wrong.”

Shinkwin makes a point of not arriving on the scene breathless and panicked. “I don’t rush out–I walk out so that I’m more composed when I get there,” she says. “I ask them what’s going on and remain calm. Sometimes, if they’re really hysterical, I just wait until they’re able to collect themselves.

“If they don’t calm down, I tell them, ‘Okay, I’m going to start my evaluation,'” Shinkwin continues. “But I start by feeling around an area far from where I think they’re having pain. I don’t want to start twisting or poking the injury site because they might just shut down and not let me touch them anymore.”

During the assessment, Andrew Gregory, MD, FACSM, Assistant Professor of Orthopedics and Pediatrics at Vanderbilt University, says growth plates are the biggest concern athletic trainers need to be aware of. “A lot of young teens have open growth plates, so they are at greater risk for fracture than sprain,” says Gregory, who is also Team Physician for Hillwood (Tenn.) High School and Vanderbilt and Belmont Universities. “The same mechanism of injury that’s probably going to result in a sprain in a more physically mature varsity athlete might be a fracture in a pre-varsity kid.”

When assessing whether an injury is a sprain or a fracture, Gregory says locating bone tenderness is the key. “If you press on the bone and it causes pain, you can be pretty confident it’s a fracture,” he says.

Palpating the injured area is especially important with younger athletes who have never been injured before. “They might not be able to explain an injury as well as an older athlete because they’re not sure of their body mechanics or able to describe different pain levels accurately,” Hedstrom says.

The rehab process also requires special strategies. Shinkwin makes it very clear to her athletes what they need to do and reminds them that there is no instant gratification. “I spend a lot of time telling the younger kids there’s no magic cure and that it’s important for them to comply with the instructions I give them,” Shinkwin says. “I tell them they have to apply ice on a consistent basis and do all the exercises I prescribe.”

Hedstrom makes it a point to carefully explain every exercise in detail. “Be clear with your expectations for each exercise and make sure the athlete knows what is and isn’t proper form,” he says. “Since they are less familiar with exercise and their bodies, understanding both the right way and the wrong way is very important.”

When rehabbing pre-varsity athletes, it’s critical to not push too hard. “Because their bodies are likely not yet fully mature, a pre-varsity athlete cannot be pushed like an adult can,” Hedstrom says.

The difference in rehab capacity should also be factored into return-to-play decisions. “I am more apt to keep younger athletes out a little longer than varsity athletes because they’re less familiar with their pain tolerance and what they can and shouldn’t play through,” says Eric Scott, ATC, Head Athletic Trainer at Ashland (Mass.) High School. “You don’t want to push them too hard because there is still a lot of growth and development going on and you don’t want them doing anything that could exacerbate a problem or predispose them to another injury.”


Addressing the physical aspects of rehab is only part of the puzzle. Gardner makes sure he is acutely aware of how younger athletes deal with the psychological side of their rehab. “I try to find out how they’re handling their injury mentally and tap into any emotional issues they’re going through because of it,” he says.

For example, some younger athletes may be embarrassed by their injury or the extra attention it brings. “Some athletes need to be part of the background, doing their thing without me making them the focal point of the athletic training room,” Shinkwin says. “If a kid is particularly shy, I might even ask if they’d rather meet in a one-on-one setting during school when the other kids aren’t around.

“With pre-varsity athletes, you also have to be very sensitive to how they think they look when doing an exercise,” she adds. “I once had an athlete with a groin injury who was totally embarrassed doing the exercises I gave him, which I didn’t realize at the time. He did his reps the first day, but I didn’t see him for a while after that because he was so embarrassed. Since then, I make sure to ask athletes how they feel about specific exercises.”

Keeping motivation levels high is also important. “To avoid overstress and burnout when rehabbing younger athletes, athletic trainers need to take creative measures and use variety to keep their interest,” Hedstrom says. “Maybe even provide a rehab teammate or incorporate games and goals into the rehab process. These athletes really need to see success and accomplishment to stay motivated.”

Another major difference between a pre-varsity athlete and an older adolescent is their comfort level communicating with adults. Many are very shy around authority figures, including athletic trainers.

“You sometimes have to go out of your way to introduce yourself to these athletes,” says Scott. “It helps to initiate conversations with kids by saying, ‘Hey, I saw you limping that last lap. Is everything all right? Are you experiencing pain?’ and go through the diagnostics that way.”

For extremely shy kids, Scott calls on older siblings and varsity athletes to act as conduits. “I’ve had pre-varsity athletes who had a hard time approaching me when they got hurt, so I would ask an upperclassman to talk to them and introduce them to me,” he says.

It can also be effective to ask younger athletes to bring along a friend or a coach they trust when visiting the athletic training room. “Having just the kid and the athletic trainer in a one-on-one situation is intimidating for some younger athletes,” Scott says. “But if they have a friend with them, the three of us can develop a dialogue and the other person can help them answer questions. The friend may say, ‘Remember last practice you were limping after we ran that one play?’ The injured kid might reply, ‘Oh, yeah. My ankle twisted this way.’ The two of them are having a comfortable conversation while I’m listening and asking questions to keep it going and find out what’s wrong.”

Making your athletic training room a welcoming environment can also help put young athletes at ease. Going to see you should never feel like a trip to the principal’s office.

“I try to make our athletic training room a safe haven,” Shinkwin says. “When they’re in here, I want them to feel open to tell me about whatever is going on. There shouldn’t be the same expectations about being tough that they get from their coaches.”

“When they’re in the athletic training room, I tell them it’s okay to cry or scream, just don’t curse or bash their coach,” Gardner says. “I also let non-injured athletes come in and hang out. A lot of times younger kids’ parents can’t pick them up right after practice, so they’ll come to the athletic training room and read or do their homework.”


Though pre-varsity athletes can be a difficult age group to reach, doing so effectively can be very rewarding for both the athlete and the athletic trainer. Having a positive experience with an injury early in an athlete’s career can help ease the emotional pain and distress of future injuries. And more than one athletic training career got its start from an injury suffered in the early teen years.

For Shinkwin, the rewards of working with pre-varsity athletes far outweigh the difficulties. “One of the things I love about this age group is that they are blank slates and very impressionable,” she says. “There are so many opportunities to teach kids things that can really help them throughout the rest of their lives.”


While pre-varsity athletes crave autonomy, they still rely on their parents for many things. That’s why it’s important to involve parents in any injury discussions as early as possible.

For Eric Scott, ATC, Head Athletic Trainer at Ashland (Mass.) High School, that means speaking at preseason parents’ meetings. “It’s so important to open the lines of communication and introduce yourself early on,” he says. “We do that before each season during meetings that involve every player and their parents. That way, parents see us and know who we are. If their son or daughter goes down on the field and we go out there to treat them, the parent knows who is standing there touching their kid.”

Like most athletic trainers, Scott calls or e-mails a student-athlete’s parents anytime he refers the athlete to an orthopedist or other medical professional. He also contacts them for less severe injuries that might require missing a day or two of practice or competition, or to keep them abreast of any medical concerns he has about their child.

“It shows that we really care about their kids,” Scott says. “And it’s also good for us. Parents can be your best ally for getting a pre-varsity athlete to complete in-home treatment and rehabilitation exercises.”

Mary Shinkwin, PT, ATC, Head Athletic Trainer at Cambridge (Mass.) Rindge and Latin School, also recruits parents to reinforce rehab work. “If a younger athlete sprains an ankle for the first time and doesn’t know they have to RICE it and be vigilant about treating it, I’ll call the parents and tell them what needs to be done,” she says. “The kid is then getting the message from me and at home.”

When a young athlete is hesitant to let P.J. Gardner, ATC, CSCS, PES, Athletic Trainer at the Colorado Sports & Spine Centers and at Liberty High School in Colorado Springs, Colo., evaluate an injury, he’ll immediately bring a parent into the process. “Sometimes I have to call the parents and tell them their son or daughter came off the field with a knee injury and wouldn’t let me touch them because they were scared and very emotional,” he says.

“I explain that their child maybe doesn’t know or trust me yet, so I’m not getting a good read on things,” Gardner continues. “I then tell the parents I would like to see the athlete the following day when he or she has had a chance to calm down. The parents are usually very appreciative of that call and can prep their child for seeing me.

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