Angela Jackson – Managing The Overloaded Younger Athlete – Injury Rehab Network Event

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Angela Jackson is a Chartered Physiotherapist who has spent the last 34 years seeking to understand why some young athletes get injured, yet others don’t. As a youngster, Angela played every sport going before developing a series of knee injuries that halted her sporting dreams. Her determination to educate young athletes on reducing their injury risk has fueled a career that has taken her from Canada to working with national teams, clubs, and schools across many sports becoming an expert in understanding all aspects of youth athlete development.

Angela was the latest expert guest speaker at the June Injury Rehab Network with BASRaT. Over 200 people joined live for the online event for Angela’s presentation ‘Managing the overloaded younger athlete’. Angela discussed how the pressures on young athletes often exceed the ability of their body to adapt and to cope.

Angela Jackson

For 15 years, Angela has been the Physiotherapist and Strength and Conditioning Consultant for Cheshire Cricket Board supporting the Emerging Player Programme, their coach education programme and providing workshops for parents and athletes on injury prevention and performance. She has also created coaching resources for the England & Wales Cricket Board Coaching Association “Wings to Fly” programme. Through her work with cricketers, Angela became aware of the number of young children playing sport with low back pain. She is passionate about reducing the incidence of lumbar stress fractures in younger athletes through raising awareness and education.

Her passion for sharing her knowledge is evident whether she is presenting on athlete development or the prevention of lumbar stress fractures through talks and workshops in schools, clubs, and sporting organisations. She has created the course Developing the Younger Athlete for fellow professionals available through SifCPD online.

Angela discussed the importance of education and early identification of the factors that contribute to injuries and illness in the growing athlete. Angela provided a summary of the key areas that need to be monitored and addressed when developing younger athletes, including Overtraining Syndrome and Relative Energy Deficiency in Sports. Angela shared how she monitors workload and the reaction to training including nutritional intake.

The recording of the event is available here.

Chartered Physiotherapist Angela Jackson

Angela is a passionate educator, is striving to raise awareness around overloaded younger athletes and to help reduce sports injuries in young people. Part of Angela’s role often involves upsetting young people as tells them, they must rest and take time out from the sport they love to ensure they can recover and prevent their injuries from worsening. Angela wants to help young people to enjoy and succeed in sport safely.

Through Angela’s work in cricket with the Cheshire Cricket Board, Angela has supported research into stress fractures of the lumbar spine and is now educating athletes, coaches, and parents about how to build a successful athlete.

Kids athletes

Why, Why, Why?

Angela discussed the importance of clinical reasoning skills when working with younger athletes and how therapists should channel their inner toddler to ask “Why?”.

By asking why, it is possible to establish what’s changed. Therapists can then identify what to measure and how to plan and support the rehabilitation and development of young athletes.

Demands on the Athlete

Angela discussed the importance of being aware of the many demands on young athletes and the impact these demands may have on a young person’s ability to train and perform in sport.

Demands include the wider demands of life such as time, sleep, growth, financial, academic, and social pressures. Therapists should also understand the demands of the sport and know the athlete’s history.

Risk Factors for Injury

When considering risk factors for injury, Angela described the importance of considering intrinsic or extrinsic factors. Intrinsic factors can cause decreased capacity in the athlete and extrinsic factors can be linked to environment or load.

Angela noted that injury and illness occur with not too much training but when load exceeds capacity. For example, inadequate sleep, too little recovery, poor fuel and lack of strength and fitness may all mean the athletes capacity does not align to the loads or demands of training and competition.

The Key to Performance

Angela discussed how previous thinking around performance was based on the principle of fitness minus fatigue. More recent studies have shown that optimum performance can only be achieved through structured planning and with adequate rest.

Athletes should aim for a good balance of intensity of training and rest. If this balance is achieved, then performance can increase with a reduced risk for injury and burnout.

Angela noted that our bodies can adapt to increase performance, but it is important to maintain a good balance between loads and capacity to achieve optimum performance. The aim is not to go through peaks and troughs or a boom-and-bust cycle where repeated high-intensity efforts can lead to diminished performance and increased risk of injury.

Monitoring and Planning

Angela described how to monitor and plan to understand the training response with a plan to train for a goal/ peak performance and continuous assessment. Regular adaptations should be made to ‘tweak the recipe’ for training volume, intensity, frequency, fuel, and recovery time. With good monitoring and planning, the risk of injury and illness can be controlled.

Ask the Right Questions

Angela reinforced the importance of therapists asking athletes the right questions with the need to:

  • Ask for an activity diary
  • Ask about intensity
  • Ask about diet
  • Ask about sleep
  • Ask about wellbeing

The Acute: Chronic Workload Ratio

Angela discussed how the acute: chronic workload ratio (ACWR) is referred to as the ‘Injury prevention vaccine’. The ACWR helps athletes to monitor training activity completed against the training load prepared for by recording their weekly training volume. Acute refers to the current week and chronic is in relation to the last 4 weeks.

As a guide, an increase in training load of around 10% is safe.

How Hard?

Angela recommends that athletes should use session Rate of Perceived Exertion (sRPE). Using a scale from 1-10 for each session, it is possible to closely monitor intensity and effort as part of good monitoring and planning.

Athletes should be encouraged to think about intensity and to be aware that they have the option to control intensity. For example, athletes may choose not to work at 100% all the time and to make a conscious decision to work at a lower intensity in some training and competition. This is particularly important where young people may be playing sport for their school, local club and as part of an academy/ talent set up.

The Importance of Sleep

Angela discussed the science of sleep and its importance for growing young people. Lack of sleep can lead to lack of bone formation, potential bone loss and a subsequent increased risk of stress fractures.

Low Energy Availability = LEA

Angela described LEA which is when energy expenditure exceeds energy intake, leading to Low Energy Availability (LEA).

LEA can be intentional or unintentional and Angela highlighted the importance of therapists, parents, and coaches to be aware of attitudes to foods.

Is the Balance Right?

Angela discussed how younger athletes need to get the right balance. Athletes can be supported to focus on and to be aware of fatigue, sleep, soreness, and stress. Angela described how a simple scoring system can provide cumulative data that may support decisions around whether athletes should train or just train lightly.

Under Performance Syndrome and RED-s

Angela’s presentation showed how under performance syndrome can occur when there is a sustained long-term shortage of energy and periods of recovery.

Angela described how Relative Energy Deficiency in sports RED-s is a condition of low energy availability affecting female and male athletes. RED-s can impact an athlete’s wellbeing, growth, and performance.

Angela provided useful advice on how to spot the signs of RED-s with low energy availability potentially causing physical and mental issues such as weight loss, reduced growth, poor performance, poor concentration, and loss of periods.

Stress Fractures and Nutrition

Angela is passionate about education and through decades of experience as a Chartered Physiotherapist and consultancy in cricket, Angela has developed an understanding of the causes of stress fractures in young athletes. This is particularly relevant in cricket where bowlers may suffer stress fractures in the lumbar spine.

Good nutrition is vital to maintain good energy availability and good bone health. Angela discussed how low fuel intake can lead to changes in the body such as non-essential systems shutting down causing reduced bone density which can, in turn, lead to stress fractures.

Differential Diagnosis

Angela highlighted that RED-s can only be diagnosed if there are no signs of other illness or disease. Therapists should therefore work closely with and encourage athletes to seek advice from medics for health problems. Medics may test for endocrinological disorders, vitamin D deficiency, infections and viruses and cardiac conditions.

Uncomfortable Questions

Angela described how therapists should get comfortable asking uncomfortable questions and go back to the ‘why, why, why’. Angela highlighted how being curious can help to ensure all parties are informed, outcomes are achieved, injuries prevented and ultimately promote the long-term health and wellbeing of athletes.


As a passionate educator, Angela has developed training and resources to help educate athlete, therapists, parents, and coaches. For more information, please see https://angelajacksonphysio.com/.

Angela’s Recipe for Success

Angela shared her recipe for success with a recap on the points covered in the presentation including:

  • Avoid spikes in training – aim to increase by no more than 10%.
  • Plan for recovery.
  • Sleep.
  • Fuel for energy.
  • Stay fit and strong.
  • Adapt load during growth spurts.
  • Manage stress.


Angela’s presentation stimulated some brilliant questions from the group which Angela kindly answered as follows:

Question 1 – Which tools can be used to educate about stress?
Answer – Blaise Dubois has developed an excellent Stress Modification Tool which can be used freely – https://az675379.vo.msecnd.net/media/7841453/07c_quantifying-stress.pdf

Question 2 – Can you recommend any digital tools for tracking activity and workload?
Answer – There is not currently an app that is fit for purpose and freely available to those involved in amateur/ grassroots sport. Some athletes use a spreadsheet to track and monitor sleep, load and to help with planning. A diary is also a useful option.

Question 3 – How do you involve parents and coaches in work with young athlete?
Answer – Parents and coaches are always involved to ensure everyone is informed and educated. Advice often needs to be direct as athletes may need ‘telling’ that they must rest to prevent further injury or risk serious injury. Education is vital.

Question 4 – What is for your advice for supporting patients with intentional LEA?
Answer – Therapists should work with professionals in safeguarding and medical roles to ensure the appropriate action is taken and support available. Work closely with a nutritionist and psychologist to ensure athletes can access support easily.

Question 5 – How should therapists balance young athletes’ perception of intensity vs parents’ perception of intensity?
Answer – Parents should be encouraged to attend all sessions, so they are fully aware of the demands placed on their child. Young people should not feel like they need to work at 100% all the time.

Question 6 – Are young people best to participate in multiple sports or to specialise and focus on one sport?
Answer – Evidence shows that performance at elite level is achieved by athletes who took part in three sports up until the age of 16 and that athletes should not specialise before then. Children who participate in different sports will develop a great range of skills and abilities and become more capable athletes.

Learn More

Angela’s website https://angelajacksonphysio.com/ includes information and resources about athlete development and back pain.


Follow Angela on Twitter at https://twitter.com/angiejphysio and Instagram at angiejphysio.


The recording of Angela’s presentation is available to view here.

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