Risks of Endurance Training in Minors - A Narrative Review
DOI:
https://doi.org/10.6000/1929-4247.2026.15.03.1Keywords:
Pediatric sports medicine, adolescent athlete, endurance training, athletic injuries, pediatric sports risksAbstract
Background: Participation in endurance sports among children and adolescents is increasing. Pediatric athletes differ physiologically from adults due to ongoing somatic growth, biological maturation, and endocrine development, which modify both adaptive responses and injury susceptibility.
Aim: This review synthesizes current evidence on physiological adaptations to endurance training in youth and examines the major musculoskeletal, cardiovascular, metabolic, endocrine, and psychosocial risks associated with high training loads.
Materials and Methods: A narrative review of literature published between January 1990 and January 2026 was conducted using PubMed and MEDLINE, supplemented by consensus statements from major sports medicine organizations.
Results: Endurance performance improvements in youth are influenced more by neuromuscular maturation than by large central cardiovascular adaptations, with modest training-induced changes in VO₂ max before puberty. The developing musculoskeletal system demonstrates high adaptive plasticity but increased vulnerability to overuse injuries, including physeal stress injuries and bone stress injuries. Inadequate energy availability may disrupt endocrine function and impair growth and bone development.
Conclusions: While endurance training promotes beneficial physiological adaptations, the developing athlete remains vulnerable to overuse injuries, low energy availability, psychosocial stressors, and long-term health risks. Recognition of these mechanisms is essential for accurate risk interpretation and safe training practices.
References
Myer GD, Jayanthi N, DiFiori JP, Faigenbaum AD, Kiefer AW, Logerstedt D, et al. Sport specialization, part I. Sports Health 2015; 7: 437-42. DOI: https://doi.org/10.1177/1941738115598747
Caine D, DiFiori J, Maffulli N. Physeal injuries in children’s and youth sports: reasons for concern? Br J Sports Med 2006; 40: 749-60. DOI: https://doi.org/10.1136/bjsm.2005.017822
Micheli LJ, Fehlandt AF. Overuse injuries to tendons and apophyses in children and adolescents. Clin Sports Med 1992; 11: 713-26. DOI: https://doi.org/10.1016/S0278-5919(20)30480-4
Mountjoy M, Ackerman KE, Bailey DM, Burke LM, Constantini N, Hackney AC, et al. International Olympic Committee (IOC) consensus statement on relative energy deficiency in sport (RED-S). Br J Sports Med 2023; 57: 1073-98. DOI: https://doi.org/10.1136/bjsports-2023-106994
Elliott-Sale KJ, Tenforde AS, Parziale AL, Holtzman B, Ackerman KE. Endocrine effects of relative energy deficiency in sport. Int J Sport Nutr Exerc Metab 2018 [cited 2025 Nov 17]. DOI: https://doi.org/10.1123/ijsnem.2018-0127
Armstrong N. Paediatric exercise physiology. Churchill Livingstone; 2007.
Rowland TW. Children’s exercise physiology. 2nd ed. Champaign (IL): Human Kinetics; 2005.
Malina RM, Bouchard C, Bar-Or O. Growth, maturation, and physical activity. Human Kinetics; 2004. DOI: https://doi.org/10.5040/9781492596837
Warden SJ, Mantila Roosa SM, Kersh ME, Hurd AL, Fleisig GS, Pandy MG, et al. Physical activity when young provides lifelong benefits to cortical bone size and strength in men. Proc Natl Acad Sci USA 2014; 111: 5337-42. DOI: https://doi.org/10.1073/pnas.1321605111
Farrell C, Turgeon DR. Normal versus chronic adaptations to aerobic exercise. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. Available from: http://www.ncbi.nlm.nih.gov/books/NBK572066/
Payne VG, Morrow JR Jr. Exercise and VO₂max in children: a meta-analysis. Res Q Exerc Sport 1993; 64: 305-13. DOI: https://doi.org/10.1080/02701367.1993.10608815
McNarry M, Jones A. The influence of training status on the aerobic and anaerobic responses to exercise in children: a review. Eur J Sport Sci 2014; 14 Suppl 1: S57-68. DOI: https://doi.org/10.1080/17461391.2011.643316
Maron BJ, Pelliccia A. The heart of trained athletes. Circulation 2006; 114: 1633-44. DOI: https://doi.org/10.1161/CIRCULATIONAHA.106.613562
Turley KR, Wilmore JH. Cardiovascular responses to treadmill and cycle ergometer exercise in children and adults. J Appl Physiol 1997; 83: 948-57. DOI: https://doi.org/10.1152/jappl.1997.83.3.948
Aucouturier J, Baker JS, Duché P. Fat and carbohydrate metabolism during submaximal exercise in children. Sports Med 2008; 38: 213-38. DOI: https://doi.org/10.2165/00007256-200838030-00003
Boisseau N, Delamarche P. Metabolic and hormonal responses to exercise in children and adolescents. Sports Med 2000; 30: 405-22. DOI: https://doi.org/10.2165/00007256-200030060-00003
Kostyak JC, Kris-Etherton P, Bagshaw D, DeLany JP, Farrell PA. Relative fat oxidation is higher in children than adults. Nutr J 2007; 6: 19. DOI: https://doi.org/10.1186/1475-2891-6-19
Falk B, Dotan R. Children’s thermoregulation during exercise in the heat: a revisit. Appl Physiol Nutr Metab 2008; 33: 420-7. DOI: https://doi.org/10.1139/H07-185
Gomes LHLS, Carneiro-Júnior MA, Marins JCB. Thermoregulatory responses of children exercising in a hot environment. Rev Paul Pediatr 2013; 31: 104-10. DOI: https://doi.org/10.1590/S0103-05822013000100017
Saunders PU, Pyne DB, Telford RD, Hawley JA. Factors affecting running economy in trained distance runners. Sports Med 2004; 34: 465-85. DOI: https://doi.org/10.2165/00007256-200434070-00005
Krahenbuhl GS, Williams TJ. Running economy: changes with age during childhood and adolescence. Med Sci Sports Exerc 1992; 24: 462-6. DOI: https://doi.org/10.1249/00005768-199204000-00012
Radnor JM, Oliver JL, Waugh CM, Myer GD, Moore IS, Lloyd RS. The influence of growth and maturation on stretch-shortening cycle function in youth. Sports Med 2018; 48: 57-71. DOI: https://doi.org/10.1007/s40279-017-0785-0
Mersmann F, Bohm S, Schroll A, Marzilger R, Arampatzis A. Athletic training affects the uniformity of muscle and tendon adaptation during adolescence. J Appl Physiol 2016; 121: 893-9. DOI: https://doi.org/10.1152/japplphysiol.00493.2016
Brenner JS; Council on Sports Medicine and Fitness. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics 2007; 119: 1242-5. DOI: https://doi.org/10.1542/peds.2007-0887
DiFiori JP, Benjamin HJ, Brenner JS, Gregory A, Jayanthi N, Landry GL, et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med 2014; 48: 287-8. DOI: https://doi.org/10.1136/bjsports-2013-093299
Rosendahl K, Strouse PJ. Sports injury of the pediatric musculoskeletal system. Radiol Med 2016; 121: 431-41. DOI: https://doi.org/10.1007/s11547-015-0615-0
Meyers AL, Taqi M, Marquart MJ. Pediatric physeal injuries overview. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024. Available from: http://www.ncbi.nlm.nih.gov/books/NBK560546/
Guldhammer C, Rathleff MS, Jensen HP, Holden S. Long-term prognosis and impact of Osgood-Schlatter disease 4 years after diagnosis: a retrospective study. Orthop J Sports Med 2019; 7: 2325967119878136. DOI: https://doi.org/10.1177/2325967119878136
Maruszczak K, Madej T, Gawda P. Lower limb osteochondrosis and apophysitis in young athletes—a comprehensive review. Appl Sci 2024; 14: 11795. DOI: https://doi.org/10.3390/app142411795
Costa TM, Borba VZC, Correa RGP, Moreira CA. Stress fractures. Arch Endocrinol Metab 2022; 66: 765-73. DOI: https://doi.org/10.20945/2359-3997000000562
Mara F, Plasa M. Optimizing physical performance and nutritional strategies for young basketball players: training load distribution and recovery approaches. Int J Child Health Nutr 2025; 14: 398-407. DOI: https://doi.org/10.6000/1929-4247.2025.14.04.7
Loud KJ, Gordon CM, Micheli LJ, Field AE. Correlates of stress fractures among preadolescent and adolescent girls. Pediatrics 2005; 115: e399-406. DOI: https://doi.org/10.1542/peds.2004-1868
Baumgartner L, Weberruß H, Schulz T, Oberhoffer-Fritz RM, Agbaje AO. Longitudinal association of peak oxygen uptake with vascular and cardiac structure and function in German pediatric athletes. Am J Physiol Heart Circ Physiol 2025; 329: H959-68. DOI: https://doi.org/10.1152/ajpheart.00570.2025
Braunstein GD. The hypothalamus. In: The pituitary. Academic Press; 2011; pp. 303-41. DOI: https://doi.org/10.1016/B978-0-12-380926-1.10009-4
Viswanathan V, Eugster EA. Etiology and treatment of hypogonadism in adolescents. Pediatr Clin North Am 2011; 58: 1181-x. DOI: https://doi.org/10.1016/j.pcl.2011.07.009
Angelidi AM, Stefanakis K, Chou SH, Valenzuela-Vallejo L, Dipla K, Boutari C, et al. Relative energy deficiency in sport (REDs): endocrine manifestations, pathophysiology and treatments. Endocr Rev 2024; 45: 676-708. DOI: https://doi.org/10.1210/endrev/bnae011
Brook CGD, Clayton P, Brown R. Brook’s clinical pediatric endocrinology. John Wiley & Sons; 2009. DOI: https://doi.org/10.1002/9781444316728
Leproult R, Van Cauter E. Role of sleep and sleep loss in hormonal release and metabolism. Endocr Dev 2010; 17: 11-21. DOI: https://doi.org/10.1159/000262524
Soliman A, De Sanctis V, Elalaily R. Nutrition and pubertal development. Indian J Endocrinol Metab 2014; 18: S39-47. DOI: https://doi.org/10.4103/2230-8210.145073
Gould RJ, Ridout AJ, Newton JL. Relative energy deficiency in sport (RED-S) in adolescents: a practical review. Int J Sports Med 2022; 44: 236-46. DOI: https://doi.org/10.1055/a-1947-3174
Borowiec J, Banio-Krajnik A, Malchrowicz-Mośko E, Kantanista A. Eating disorder risk in adolescent and adult female athletes: the role of body satisfaction, sport type, BMI, level of competition, and training background. BMC Sports Sci Med Rehabil 2023; 15: 91. DOI: https://doi.org/10.1186/s13102-023-00683-7
Sundgot-Borgen J, Torstveit MK. Prevalence of eating disorders in elite athletes is higher than in the general population. Clin J Sport Med 2004; 14: 25. DOI: https://doi.org/10.1097/00042752-200401000-00005
Martinsen M, Sundgot-Borgen J. Higher prevalence of eating disorders among adolescent elite athletes than controls. Med Sci Sports Exerc 2013; 45: 1188-97. DOI: https://doi.org/10.1249/MSS.0b013e318281a939
Jayanthi N, Pinkham C, Dugas L, Patrick B, LaBella C. Sports specialization in young athletes: evidence-based recommendations. Sports Health 2013; 5: 251-7. DOI: https://doi.org/10.1177/1941738112464626
Rejeb A, Johnson A, Vaeyens R, Horobeanu C, Farooq A, Witvrouw E. Compelling overuse injury incidence in youth multisport athletes. Eur J Sport Sci 2017; 17: 495-502. DOI: https://doi.org/10.1080/17461391.2016.1275820
Beck B, Drysdale L. Risk factors, diagnosis and management of bone stress injuries in adolescent athletes: a narrative review. Sports (Basel) 2021; 9: 52. DOI: https://doi.org/10.3390/sports9040052
Haines M, Pirlo L, Bowles KA, Williams CM. Describing frequencies of lower-limb apophyseal injuries in children and adolescents: a systematic review. Clin J Sport Med 2022; 32: 433-9. DOI: https://doi.org/10.1097/JSM.0000000000000925
Wedderkopp N, Wang C, Steele R, Hebert J, Rexen C, Jespersen E, et al. Incidence of and risk factors for lower extremity apophysitis in children and adolescents. Sports Med 2025. DOI: https://doi.org/10.1007/s40279-025-02328-w
Published
How to Cite
Issue
Section
License
Policy for Journals/Articles with Open Access
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are permitted and encouraged to post links to their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work
Policy for Journals / Manuscript with Paid Access
Authors who publish with this journal agree to the following terms:
- Publisher retain copyright .
- Authors are permitted and encouraged to post links to their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work .
