SPECIAL ISSUE ARTICLE

Approach to the Underperforming

Athlete
Mary L. Solomon, DO; and Amanda K. Weiss Kelly, MD

ABSTRACT Athletes who follow rigorous train-

Children and adolescents who participate in intense sports training may face physical ing programs often seek to stand out
and psychologic stresses. The pediatric health care provider can play an important role in from their peers. For example, in prepa-
monitoring an athlete’s preparation by obtaining a proper sports history, assessing sleep ration for a 5-km race high school cross
hygiene, discussing nutrition and hydration guidelines, and evaluating physiologic causes country athletes will customarily run
of fatigue. Educating parents and athletes on the potential risks of high-intensity training, 45 to 55 miles per week. The amount
inadequate rest and sleep, and a poor diet may improve the athlete’s performance and pre- of time, energy, and physical demands
vent symptoms of overtraining syndrome. Infectious mononucleosis must also be consid- placed upon the competing youth may
ered a cause of fatigue among adolescents. The signs and symptoms of overtraining and lead to diminished rewards and over-
burnout are discussed in this article. [Pediatr Ann. 2016;45(3):e91-e96.] use syndrome if wellness is not also
maintained. A good example of this

T
he young athlete who desires to ize in a specific sport at an early age, concept would be a swimmer who
compete at higher levels must sacrificing multisport participation to routinely swims 8,000 yards in daily
train longer and harder than allocate time, skill development, and practice to train for a 100-yard sprint
athletes of previous generations. Suc- finances toward training year-round but then fails to turn in school assign-
cess among young athletes may be with talented peers and coaches in the ments, skips breakfast, oversleeps the
defined by invitation to national or in- pursued sport. The accolades that these morning alarm 2 to 3 times per week,
ternational competitions, or by college athletes receive from their parents and and presents to the doctor with fatigue.
scholarships. Although only .02% to coaches deliver a powerful message The pediatric health care provider may
.5% of high school athletes will go on to train above and beyond their fellow best identify, monitor, and treat causes
to participate at a professional level,1 competitors. The increased dedication of underperformance by obtaining a
the number of young athletes becom- to intense training regimens presents thorough sports history, comprehensive
ing single-sport specialists continues to physical, emotional, and cognitive physical examination, and laboratory
rise. challenges to the young athlete that analysis.
To reach the professional level, to- may put overall health at risk. The pedi- The sport-specific history should
day’s youth athlete often forgoes other atric health care provider has the oppor- identify type and position of sports in
opportunities while training for their tunity to educate the athlete and parent which the child participates, hours of
sport. Young participants may special- on these important issues. sports played per week, level of partici-
pation (recreational, high school, col-
legiate, travel team), number of weeks
Mary L. Solomon, DO, is an Assistant Professor of Pediatrics, Division of Pediatric Sports Medicine, or months of the year participating in
University Hospitals, Rainbow Babies and Children’s Hospital. Amanda K. Weiss Kelly, MD, is the Division a sport, and the recognition of other
Chief, Pediatric Sports Medicine, and an Associate Professor of Pediatrics, University Hospitals, Rainbow sport participation throughout the year.
Babies and Children’s Hospital. Those athletes who abruptly increase
Address correspondence to Mary L. Solomon, DO, Division of Pediatric Sports Medicine, University their amount of hours of practice, in-
Hospitals, Rainbow Babies and Children’s Hospital, 34055 Solon Road, Suite 202, Solon, OH 44139; tensify their training regimen (eg, in-
email: Mary.solomon@uhhospitals.org. creased volume, “play up” on a more
Disclosure: The authors have no relevant financial relationships to disclose. competitive varsity team as a younger
doi: 10.3928/00904481-20160210-02
athlete), or play an additional sport or

PEDIATRIC ANNALS • Vol. 45, No. 3, 2016 e91


on another team at the same time are
likely to suffer overuse injuries.
The clinician should also discuss
time spent away from sports participa-
tion to identify nonsport interests and
to take care of the psychologic well-
being of the athlete. An athlete who loses
interest in school, friends, and hobbies
may be showing signs of overtraining
syndrome (Table 1). Additional symp-
toms include fatigue, chronic pain, and
elevated heart rate.2 For example, a
cross-country runner whose race finish
times increase despite continued perse-
verance in practice, complains of diffuse
body pain, or shows a lack of interest in
school may be experiencing overtraining
syndrome. Deficient scholastic perfor-
mance or inability to complete tasks may
alert parents to signs of overtraining.2
THE ROLE OF REST AND SLEEP
Athletes require sleep to allow for
rest and recover from injury. Adoles-
cents routinely do not obtain the 8 to 9
hours of sleep recommended by the Na-
tional Sleep Foundation.3 Students will
often do homework late into the night.
Evening practices may disrupt usual din-
ner times so that the athlete is eating just
before going to bed. Access to electron-
ics becomes a constant temptation that
may also compromise sleep. These is-
sues can lead to a constant state of sleep
deprivation.
Sleep is an important factor that af-
fects sports performance, physical
health, emotional well-being, and recov-
ery.2 Progressive sleep loss negatively
affects quality of training and increases
likelihood of injury.4 To better appreci-
ate the athlete’s sleep habits, the physi-
cian should discuss customary bedtime
and awakening periods, sleep latency
or disturbance experienced throughout
the night, napping habits, and loca-
tion of sleep. Discussing bedtime rou-
tines allows the pediatrician to identify
e92
SPECIAL ISSUE ARTICLE
problems and discuss the importance
of abstaining from electronics 30 min-
utes prior to bed and removing devices
(television, laptop, tablet, computer, and
phone) from the bedroom. It is helpful
to implement a bedtime routine of dim-
ming the lights, avoiding unnecessary
noise, and engaging in a calming activity
(reading, drawing, meditation) to ready
the mind for sleep. The physician may
also endorse sleeping in the same loca-
tion each night to allow the body to ac-
tivate sleep more easily. The bed should
be reserved for sleep, and a different lo-
cation should be sought to study, read, or
use electronics.
Rest or downtime also improves
sports performance so that the athlete
may recover from the physical demands
of practice and competition, rehabilitate
injury, and attend to school or social op-
portunities.2 Athletes who participate in
multiple sport appearances in a single
day (tournament schedule, football and
swimming two-a-days, multiple sports)
should schedule adequate rest periods
to allow for recovery between bouts.
The American Academy of Pediatrics
Council on Sports Medicine and Fitness
(AAP COSMF)5 recommends limiting
sports participation to 5 days per week
and scheduling at least 1 day of rest from
all physical activity per week. It is im-
portant to schedule time off from sports,
including weekly nonpractice days and
even months off to allow the body to rest
and prevent burnout and overtraining.
The AAP COSMF also advises that the
athlete participate in a different physical
activity (cross-train) for 2 to 3 months
per year to heal previous injuries and
reduce the likelihood of future injury.5
Lack of adequate rest may increase the
risk for burnout.2
NUTRITION
Parents and athletes are oftentimes
unaware of appropriate food choices,
diet composition, and timing of food
consumption that best support training
needs. Marketing campaigns target the
desire to improve performance by spon-
soring famous athletes who then entice
consumers to choose specific foods or
supplements. The consumer can be per-
suaded to purchase dietary supplements
over proper food items without realiz-
ing the potential harm these items may
cause.
As a result of the 1994 Dietary Sup-
plemental Health and Education Act,
supplements do not need to be approved
by the US Food and Drug Administra-
tion (FDA), and manufacturer claims
do not require proof before labels are
placed on packages.6 Many nutritional
supplements are contaminated with
other products that may cause harm to
the growing body. The consumer as-
sumes a significant risk when ingest-
ing dietary supplements.6 Athletes may
inadvertently consume contaminants
that are banned by the regulating bod-
ies of sports organizations. Identification
of performance-enhancing substances
through positive drug-screening tests is
grounds for immediate disqualification
in most organizations. The physician
may serve as a clarifying source of in-
formation by dispelling myths, identify-
ing false advertising, and educating the
athlete on proper foods choices.
Proper nutrition is critical for ath-
letic performance, and the developing
athlete must consume adequate calories
to support nutritional needs for growth.7
Young athletes must follow a high-
calorie, well-balanced diet to support
the energy demands of sports participa-
tion. Optimal performance necessitates
the athlete to consider quantity, quality,
and timing of food consumed. Proper
timing of food ingestion allows accessi-
bility of nutrients and energy while per-
forming, and eating during the recovery
period acutely replaces those expendi-
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 SPECIAL ISSUE ARTICLE

TABLE 1. TABLE 2.

Symptoms of Overtraining Suggested Food Choices to Support Training

Syndrome
Timing Description Examples
• Decline in physical performance despite
3-4 hours before Small balanced meal: protein Turkey and cheese sandwich with fruit
training
training and carbohydrates, low in Bean or chicken soup and yogurt
• Pronounced fatigue fiber Pasta with tomato meat sauce
• Psychologic disturbance: mood changes,
depression, agitation, restlessness, anxiety Peanut butter and bagel, fruit and
yogurt
• Apathy: loss of interest in school, friend-
ships, and family and inability to com- Smoothie with granola
plete daily tasks Oatmeal with almonds and fruit
• Chronic pain Skim milk and banana
• Deficient scholastic performance: trouble Cottage cheese, crackers, and grapes
concentrating, academic decline Small lean turkey/beef burger and
• Sleep disturbance: insomnia salad
• Lack of appetite 2 hours before Light snack Bagel with light cream cheese
• Loss of body weight training Banana and yogurt
Granola bar
Small fruit/vegetable and crackers
tures (Table 2). The American College Immediate Immediate carbohydrate Sports drink and protein bar
of Sports Medicine and the American replacement/ snack Low-fat chocolate milk
Dietetic Association recommend a diet recovery Yogurt smoothie and fruit
balanced in macronutrients (carbohy- Graham crackers and peanut butter
drates, protein and fats) to support sport 1-2 hours Meal balanced with protein Turkey, whole wheat pita, and
performance and decrease the risk of ill- postactivity and carbohydrates vegetable
ness.8 Chicken, brown rice, and milk
Carbohydrates allow quick access to Beans and rice with cheese and
energy during high-intensity periods of vegetable
activity, such as sprinting or weight lift- Stir fry with chicken, fish, or pork
ing. Carbohydrates prevent hypoglyce- Snack through- Light and on the go Trail mixes: dried fruits, nuts, and seeds
mia by replenishing liver and glycogen out day Fresh fruit or sliced vegetables
stores that are exhausted during exer- Bagels
cise. The daily amount of carbohydrate Dry cereals
consumption, carbohydrate loading Protein bars
prior to activity, and replacement after String cheese
the activity for an adolescent can be Yogurt
found in Table 3.8 Recovery carbohy- Almonds
drates should be consumed immediately
after and again 2 hours after exercise.
Whole grains, wheat breads, unrefined
pasta, and whole fruits and vegetables meet the daily and exercise requirements and the anaerobic athlete or power train-
are high-quality carbohydrates that pro- that support optimal sports performance. er should increase consumption to 1.6
vide macronutrients to support athletic The growing adolescent should con- to 1.7 g of protein per kilogram of body
training. sume .8 g of protein per kilogram of weight (Table 3).8
Protein intake may easily be achieved body weight to support daily metabolic Fats serve as a transporter for es-
through the consumption of meat, poul- needs.8 The endurance athlete should in- sential amino acids and carrier of fat-
try, fish, eggs, and nuts. Athletes do not crease daily requirement to 1.2 to 1.4 g soluble vitamins for daily physiologic
need to rely upon protein supplements to of protein per kilogram of body weight, function. Fats also serve as an energy

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 SPECIAL ISSUE ARTICLE
TABLE 3.
Recommended Dietary Allowance for the Adolescent
Athlete
Recommended Allowance CHO (g/kg) Protein (g/kg) Fat (% total kcal)
Daily requirement 5-7 .8 20-35
Preparation 1-2 hours before 1-3
Replacement/recovery after endur- 1-1.2 1.2-1.4
ance training
Replacement/recovery after anaero- 1-1.2 1.6-1.7
bic training
Abbreviation: CHO, carbohydrate.
source during low-intensity endurance at specific time intervals. Reducing
activity through release from storage via weight too quickly or unsafely (through
triglycerides in the muscle. Twenty per- use of diuretics, laxatives, and emetics)
cent to 35% of total daily caloric intake can cause an energy-deficient state and
should consist of fat to sustain daily ac- increase risk for dehydration and heat
tivity.8 Decreasing percentage fat below injury. If not executed properly and with
the recommended amount may cause the guidance of a health professional and
athletic performance to suffer. registered dietician, the process of ob-
To properly advise the athlete on the taining a smaller body size/weight may
importance of a balanced diet, a detailed be detrimental to athletic performance
history of typical meals and snacks eaten and increase likelihood of injury.
or skipped throughout the day should be It is also important to discuss hydra-
obtained. The athlete’s energy reserves tion with the young athlete. Dehydration
are best identified through a food diary negatively affects the body’s ability to
that records type and amount of food regulate basal temperature, increases
consumed and notes the time in relation risk for heat illness, and impairs athletic
to practice or competition. This tool may performance. Dehydration in excess of
then teach the athlete to focus on tim- 3% to 5% percent may lead to reduced
ing of food consumption in relation to strength and endurance performance,
exercise. Once educated, athletes may reduced plasma and blood volume,
plan appropriate meals and snacks to compromised cardiac output (elevated
eat before, during, and after sports ac- heart rate, smaller stroke volume), and
tivity to properly prepare for caloric impaired thermoregulation, glomeru-
expenditure and replace energy stores. lofiltration, and liver glycogen stores.
Consultation with a registered dietician Athletes should avoid consumption of
who is sports trained may be helpful for alcohol, caffeine, and nicotine as these
the young athlete. A list of sports trained substances may also increase risk for
and registered dietitians can be found at dehydration through diuresis, vasodila-
the Sports, Cardiovascular, and Wellness tation, and vasoconstriction.
nutrition website.9 Athletes should be encouraged to
The athlete who desires weight loss drink before, during, and after sports
should also discuss how weight reduc- participation for proper hydration.
tion and target weights will be obtained Drinking two or more 8-ounce cups of
e94
water 1 hour before exercise and one
4-ounce cup of water 10 minutes prior
to activity assures proper hydration. As
exercise continues, 8 ounces of water
should be consumed for every 20 min-
utes of activity. When exercise exceeds
90 minutes, the athlete may consume a
carbohydrate beverage or sports drink
to properly replace electrolytes lost dur-
ing exercise and to increase water re-
tention. After the sporting activity, the
athlete should drink 16 to 24 ounces of
water for every pound of weight lost or
until they void a large amount of clear
urine. All fluid replacement should oc-
cur within 2 hours after exercise to prop-
erly rehydrate. It has been demonstrated
that athletes will consume more fluids if
they are flavored and served cold.9 Con-
sultation with a registered dietician who
is sports trained may be helpful for the
young athlete.10 (A list of sports trained
and registered dietitians can be found at
the Sports, Cardiovascular, and Wellness
nutrition website.9)
LABORATORY EVALUATION
Other causes for fatigue, disinter-
est, and poor performance may include
use of illicit substances and ergogenic
drugs. These substances alter mood, en-
hance athletic performance, or are used
for recreational purposes. The National
Collegiate Athletic Association, Ameri-
can Medical Association, and American
College of Sports Medicine do not con-
done the use of nontherapeutic drugs by
student-athletes. Examples of such sub-
stances include, but are not limited to,
alcohol, amphetamines, ephedrine, ma
huang (ephedra), anabolic-androgenic
steroids, barbiturates, caffeine, cocaine,
heroin, lysergic acid diethylamide,
phencyclidine, marijuana, and all forms
of tobacco. The use of many of these
substances may be identified through
drug-screening tests. Athletes who test
positive for banned substances may be
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Suggested Laboratory Assessment for the Overtraining Athlete
Laboratory Assessment
CBC and differential
Ferritin
Iron panel (TIBC % saturation)
Electrolyte panel
Calcium
Vitamin D 25-OH
TSH
Free T4
EBV screen
EBV panel
VCA IgG/IgM
Abbreviations: CBC, complete blood count; DHEA-S, dehydroepiandrosterone sulfate; DXA, dual X-ray absorptiometry; EBV, Epstein-Barr virus; IgG, immunoglobulin G; IgM, immunoglobulin M; LSD,
lysergic acid diethylamide; 25-OH, 25-hydroxy vitamin D; PCP, phencyclidine; PES, performance-enhancing substance; T4, thyroxine; TIBC, total iron binding capacity; TSH, thyroid-stimulating hormone;
VCA, viral capsid antigen.
subjected to immediate disqualification
from the regulating sporting body.
Laboratory evaluation for hormonal
and nutritional deficiencies may be
needed in the endurance athlete, men-
struating female athlete, female athlete
with menstrual dysfunction, or in those
who limit caloric intake or avoid specific
food groups. These people may be at in-
creased risk for micronutrient deficien-
cies, iron-deficiency anemia, and poor
bone mineral density. Laboratory test-
ing can help guide recommendations for
nutritional and vitamin supplementation
(Table 4).
Intense athletic training by children
has been shown to delay sexual matura-
tion, and those athletes who train at the
highest levels are at increased risk.11 A
history of primary or secondary amenor-
rhea should be assessed by performing
a complete physical examination, pelvic
examination (as indicated), and labora-
tory assessment. A pregnancy test may
be warranted. Tests of thyroid-stimu-
lating hormone, prolactin, and follicle-
PEDIATRIC ANNALS • Vol. 45, No. 3, 2016
SPECIAL ISSUE ARTICLE
TABLE 4.
Female Athlete with Repeat/High-Risk Stress
Amenorrhea Fractures
Urine pregnancy test DXA
Estradiol
Prolactin
Follicle-stimulating hormone
Luteinizing hormone
Testosterone
DHEA-S
17-hydroxyprogesterone
stimulating hormone will assess for pitu-
itary tumors, thyroid dysfunction, poly-
cystic ovarian disease, premature ovarian
failure, and chronic illnesses.11 Lutein-
izing hormone, testosterone, dehydroxy-
progesterone sulfate, and 17-hydroxypro-
gesterone may be indicated if androgen
excess (hirsutism or acne) is present or if
low estrogen levels are identified.11
Menstruating female athletes who
present with a history of secondary
amenorrhea often report loss of men-
ses during the most strenuous season
of sports participation. Although this is
often perceived by teenage female ath-
letes, coaches, and parents to be normal
behavior, bone mineral density may
suffer as a result of prolonged amenor-
rhea.11 As estrogen secretion decreases
during the endurance or training sea-
son, athletes are more likely to develop
stress fractures and endure osteopenia
and osteoporosis later in life. By coun-
seling young female athletes to decrease
their training regimen or increase caloric
consumption to support return of regu-
PES/Drug Test
(with consideration)
Alcohol
Amphetamines
Ephedrine
Ma huang
Steroids
Barbiturates
Cocaine
Heroin
LSD
PCP
Marijuana
Tobacco
lar menses, these risks can be reduced.
Calcium and vitamin D supplementa-
tion may also be advised. The recom-
mended daily allowance of calcium for
adolescents is 1,200 mg, and this should
be increased to at least 1,500 mg for
amenorrheic athletes.11 One may also
consider obtaining a dual-energy X-ray
absorpiometry test to assess bone min-
eral density to guide management in ath-
letes who have had a high risk for stress
fractures (such as the femoral neck),
multiple stress fractures, or amenorrhea
for more than 6 months.
MONONUCLEOSIS
Infectious mononucleosis is another
possible cause of chronic fatigue syn-
drome among adolescents. Athletes
involved in high school, collegiate,
and Olympic-level competition are at
increased risk for infection when trav-
eling and living in close-contact envi-
ronments. Mononucleosis and the symp-
toms of Epstein-Barr virus (EBV) can
adversely affect athletic performance
e95

by producing symptoms of fever, fa-
tigue, and spleen enlargement. Labo-
ratory assessment with heterophile
antibody (monospot) may screen for
presence of EBV, but the false-nega-
tive rate of 25% supports the use of
confirmatory laboratory assessment
for EBV-specific immunoglobulin G
(IgG) and immunoglobulin M (IgM)
antibodies. The presence of IgM an-
tibodies indicates an acute infection,
and an elevated level of IgG antibod-
ies indicates prior infection, and both
are seen within a few weeks of initial
infection.
Although splenic rupture is a rare
complication of EBV infection, sple-
nomegaly occurs in up to 50% to 100%
of athletes due to lymphocytic infiltra-
tion, which also causes splenic fragil-
ity.12 Splenomegaly may be identified
through abdominal palpation on phys-
ical examination, but physical exami-
nation is unreliable so all athletes with
EBV infection should be considered at
risk for splenic rupture. The finding
of splenomegaly in an athlete who has
complaints of fatigue requires a serum
heterophile antibody (monospot) test
and/or EBV panel to test for infec-
tious mononucleosis. Once symptoms
of fever, fatigue, and muscle soreness
have resolved and a minimum of 3
weeks since onset of symptoms has
passed, the athlete may slowly return
to light, noncontact activity.13 All ath-
letes who have splenomegaly should
be withheld from contact sports for a
minimum of 28 days from the onset
e96
SPECIAL ISSUE ARTICLE
of symptoms to reduce risk for splenic
rupture.13 Any identified hepatic or
splenic enlargement must be resolved
before any sport training can be re-
sumed.
CONCLUSION
Clinical judgment is essential when
evaluating an athlete who presents
with fatigue. The signs and symptoms
of overtraining may be similar to those
presented by poor sleep, inadequate
diet, or infectious mononucleosis. The
clinician should screen for symptoms
of disinterest, depression, and poor
school and sport performance in addi-
tion to obtaining a thorough sport and
diet history. Laboratory assessment
will assist in the evaluation of the
physiologic cause of fatigue. It is im-
portant to discuss the athlete’s goals,
desires, and personal motivations in
confidence to support continued psy-
chologic development. Youth sport
participation should support lifelong
physical activity, enjoyment, and
healthy competition. The pediatric
health care provider can serve as an
educator to promote healthy participa-
tion and provide guidance.
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