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Demise of the fittest: are we destroying our biggest talents?
  1. Roald Bahr1,2
  1. 1Department of Sports Medicine, Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
  2. 2Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  1. Correspondence to Professor Roald Bahr, Department of Sports Medicine, Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, PB 4014 Ullevål Stadion, Oslo 0806, Norway; roald.bahr{at}

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Let us call her Liza. Liza is a very talented volleyball player. Last year, 15 years old, she entered high school at a ‘Toppidrettsgymnas’, one of 19 schools in Norway which combine an elite training programme with a 3-year senior high school programme. She soon became the starting setter for the school team, the local club's under 17 team, their under 19 team, their second division women's team, as well as for the under 17 and under 19 junior national teams. Her training volume was doubled when school started in August. A few weeks later, her elbows started to hurt. She did adjust her training, but played as many as 35 volleyball matches before she was diagnosed with bilateral ‘tennis elbow’ in December and finally had to throw in the towel.

The pathophysiology—Liza did not suffer an ‘accident’

Unfortunately, Liza's story is not unique. I could have shared the story of Jonas, Anna, Yuichiro, Hendrik, Karim and many more. Many gifted young athletes’ careers have been halted or even ruined by overuse injuries or other health problems caused by what seems like an inappropriate training and competition programme. Using patellofemoral pain as his case, Dye1 described the relationship between loading conditions and tissue injury (figure 1). The model depicts how load/loading conditions may exceed the safe load acceptance capacity of the tissue, and describes a zone of load acceptance, the ‘zone of homeostasis’. By increasing impact load and volume beyond this, in the ‘zone of supraphysiological overload’, there is gradual adaptation of tissue properties to the increased load. However, if even greater load and/or volume are applied, structural damage will occur.

Figure 1

Relationship between structural adaptation and load as modified from Dye's model for patellofemoral pain (2005).1 Load volume can be characterised as training volume (frequency, duration, intensity), match frequency, etc. Impact load can be characterised as …

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