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i

Oxford Textbook of

Children’s Sport
and Exercise
Medicine
ii
iii

Oxford Textbook of
Children’s Sport
and Exercise
Medicine
Edited by
Neil Armstrong
Professor of Paediatric Physiology, Founding Director of the Children’s Health
and Exercise Research Centre, and Formerly Provost of the University of Exeter,
United Kingdom
and
Willem van Mechelen
Professor of Occupational and Sports Medicine, Director of the Amsterdam
Public Health research institute, VU University Medical Centre Amsterdam,
the Netherlands

1
iv

1
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© Oxford University Press 2017
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Second Edition Published in 2008
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Published in the United States of America by Oxford University Press
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v

Contents

Foreword xix Statural growth 14

Preface xxi Types of growth data 15
Growth in stature 16
Contributors xxiii
Patterns of growth 17
Introduction xxvii
Growth in body mass 17
List of Abbrevations xxix Development of shape 18
Adolescence and puberty 18
PART 1 Regulation of growth and maturation 19
Exercise science Biological maturity 21
Relationship of maturity to body size and function 21
1 Assessment of biological maturation 3
Robert M Malina Conclusions 22
Introduction 3 Summary 23
Chronological age and age groups 3 References 23
Brief overview of methods for the 3 Developmental biodynamics: the
assessment of growth 3 development of coordination 25
Growth status 3
James Watkins
Growth rate 4
Introduction 25
Assessment of maturity status 4
Skeletal age 4 Development of coordination and control 26
Secondary sex characteristics 6 Reference axes and degrees of freedom 27
Coordination and degrees of freedom 27
Assessment of maturity timing 7
Age at peak height velocity 7 Kinematics of coordination 28
Age at menarche 7 Kinetics of coordination 29
Other indicators of timing and interrelationships 7 Modelling 29
Tempo of maturation 8 Free body diagram 29
Components of net joint moment 30
Non-​invasive estimates of maturity
status and timing 8 Dynamical systems approach to the
Percentage of predicted adult height 8 development of coordination 32
Predicted maturity offset/​age at peak height velocity 8 Self-​organization and constraints 32
Coordinative structures, control parameters,
Conclusions 9 and order parameters 33
Summary 9 Patterns, attractors, and stability 34
References 9 Cyclicity in biological systems 35
Force-​driven harmonic oscillators 35
2 Growth and maturation 13 Self-​optimization of coordinative structures 36
Adam DG Baxter-​Jones
Dynamic resources 37
Introduction 13
A dynamical systems perspective of walking
Prenatal to postnatal growth 13 in children with cerebral palsy 39
vi

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Conclusions 39 Anaerobic metabolism 69

Aerobic metabolism 70
Summary 39
References 40 Maximal-​intensity exercise 72
Maximal anaerobic power 73
4 Motor development 43 Maximal aerobic power 73
David Sugden and Helen Soucie Comparison of maximal anaerobic and
aerobic power 73
Introduction 43
Recovery from intermittent maximal
General description of change 43
or high-​intensity exercise 73
Explanation of change 44
Muscle biopsies 73
Traditional maturational explanations 44
Muscle fibre types 73
Information processing and cognitive explanations 44
Muscle energy stores 74
Ecological psychology and dynamic systems 45
Muscle lactate production and blood
Early movement development 46 lactate accumulation 74
Spontaneous movements and reflexes 46 Muscle enzymes activity 75
Environmental affordances 47
Substrate utilization 76
Vision and visual perception development 48
Indirect calorimetry 76
Motor development 2–7 years of age 48 Stable isotope tracers 77
Motor development in later childhood 49 Magnetic resonance spectroscopy 78
Maximum performance 49 Methodological issues and theoretical concepts 78
Embodied cognition 50 Intracellular thresholds 79
Incremental exercise to exhaustion 79
Atypical motor development 50
Constant intensity exercise 80
Movements as early indicators of later difficulties 51
Intermittent exercise 80
Children with developmental
coordination disorder 51 Muscle phosphocreatine kinetics and
pulmonary oxygen uptake kinetics 81
Conclusions 52
Pulmonary oxygen uptake kinetics 81
Summary 52 Methodological issues 81
References 52 Moderate-​intensity exercise 81
Heavy-​intensity exercise 81
5 Exercise and hormones 57
Synthesis of data across methodologies 82
Alon Eliakim and Dan Nemet
Conclusions 83
Introduction 57
Summary 83
Exercise and the growth hormone—insulin-like
growth factor-​I axis 57 References 84
The growth hormone—​insulin-​like growth factor-​I axis 57
7 Muscle strength 89
The effect of an exercise bout 58 Mark BA De Ste Croix
Growth hormone 58
Introduction 89
Insulin-​like growth factor-​I 60
Defining muscle strength 89
Exercise and sex hormones 62
Definitions of force and torque 90
The hypothalamic-​pituitary-​gonadal axis 62
Assessment of muscle strength 91
Exercise and adrenal hormones 63
Determining strength in paediatric populations 91
Cortisol 63
Catecholamines 64 Development of muscle strength 92
Age-​and sex-​associated changes in force/​torque 92
Conclusions 64
Determinants of strength development 94
Summary 64
Stature, mass, and strength development 95
References 65 Maturation and hormonal influences
on strength development 96
6 Muscle metabolism during exercise 69
Fat-​free mass and strength development 96
Neil Armstrong, Alan R Barker, and Alison M McManus Muscle cross-​sectional area and strength development 96
Introduction 69 Biomechanical factors and strength development 97
Anaerobic and aerobic exercise metabolism 69 Muscle strength and tendon/​limb stiffness 98
High-​energy phosphates 69
Torque/​force kinetics 98
vii

contents vii

Neuromuscular function 99 Resting pulmonary function 133

Methodological issues in measuring
neuromuscular function 99
Neuromuscular feedforward and feedback
mechanisms 100
Conclusions 100
Summary 100
References 101
8 Maximal-​intensity exercise
Craig A Williams and Sébastien Ratel
Lung volumes 133
Flow rates 134
Dead space 134
Pulmonary responses to exercise 136
Breathing patterns during exercise 137
Responses to acute moderate-intensity exercise 137
Heavy, very heavy, severe, and
maximal exercise 139
105 Long-​term pulmonary adaptations
to exercise 140

Introduction 105 Breathing mechanics 140

Expiratory flow limitation 140
Definition of maximal-​intensity exercise 105
Control of breathing 141
Assessment of maximal-​intensity exercise 105
Jump tests 106 Future avenues of research 142
Monoarticular force-​velocity tests 106 Conclusions 143
Cycle tests 106 Summary 143
Running tests 108
References 143
Determinants of maximal-​intensity exercise 109
Cadence and neuromuscular inferences 109 11 Cardiovascular function 147
Power and muscle size related inferences 110 Thomas W Rowland
Power and muscle fibre type inferences 111 Introduction 147
Power and hormonal related inferences 112
Measurement of cardiac output 147
Maximal-​intensity exercise and age 112 Carbon dioxide rebreathing 148
Maximal-​intensity exercise and sex 114 Acetylene rebreathing 148
Maximal-​intensity exercise and maturation 115 Doppler echocardiography 148
Bioimpedance cardiography 148
Conclusions 117
Expressing cardiac output with
Summary 117 exercise to body size 148
References 117 Dynamics of cardiovascular responses
9 Neuromuscular fatigue 121 to progressive exercise 149
Total systemic vascular resistance: observed
Sébastien Ratel and Craig A Williams progressive decline 149
Introduction 121 Stroke volume change in various levels
The conceptual framework of fatigue 121 of exercise intensity 149
Definition 121 Left ventricular end-​diastolic dimension 150
Aetiology 121 Myocardial systolic and diastolic function 151
Fatigue protocols used with children 121 A synthesis 152

Age-​related differences in fatigue 122 Normative values 152

Whole body dynamic activities 122 Heart rate 152
Maximal voluntary contraction 124 Stroke Volume and cardiac output 153
Blood pressure 154
Factors underpinning age differences 125
Peripheral factors 125 The ‘meaning’ of cardiovascular fitness 154
Central factors 127 Myocardial damage 156
Interplay between peripheral and central factors 128 Conclusions 156
Conclusions 128 Summary 156
Summary 129 References 157
References 129
12 Aerobic fitness 161
10 Pulmonary function 133 Neil Armstrong and Alison M McManus
Alison M McManus and Neil Armstrong Introduction 161
Introduction 133 Measures of aerobic fitness 161
viii
viii contents
Maximal oxygen uptake 161
Blood lactate accumulation 162
Pulmonary oxygen uptake kinetics 164
Peak oxygen uptake 165
Methodological issues 165
Peak oxygen uptake and chronological age 167
Peak oxygen uptake and body mass 168
Peak oxygen uptake and biological maturation 171
Peak oxygen uptake and sex 171
Blood lactate accumulation 173
Methodological issues 173
Chronological age, biological maturity, and sex 174
Pulmonary oxygen uptake kinetics 174
Methodological issues 174
Exercise phases, exercise domains,
chronological age, and sex 175
Recovery kinetics 177
Conclusions 177
Summary 177
References 178
13 Pulmonary oxygen uptake kinetics
Alan R Barker and Neil Armstrong
Introduction 181
Kinetics of oxygen uptake at the
mouth and muscle 181
Exercise intensity domains 182
Methodological considerations 183
Pulmonary oxygen uptake kinetics: children
and adolescents 184
Phase I 184
Moderate-​intensity exercise 184
Heavy-​and very heavy-​intensity exercise 186
Severe-​intensity exercise 187
Synthesis 187
Mechanisms 187
Muscle phosphates 187
Muscle oxygen delivery 188
Muscle fibre recruitment 190
Conclusions 191
Summary 191
References 191
14 Temperature regulation 195
Bareket Falk and Raffy Dotan
Introduction 195
Physical and physiological child–​adult differences
pertinent to thermoregulation 195
Physical differences 195
Physiological differences 197
Physiological response to thermal stress 198
Physiological response to heat stress 198
Physiological response to cold stress 205
Adaptation to thermal stress 207
Heat acclimatization or acclimation 207
Training-​induced adaptations to heat stress 207
Training-​induced adaptations to cold stress 208
Conclusions 208
Summary 208
References 209
15 Effort perception 213
Kevin L Lamb, Gaynor Parfitt, and Roger G Eston
Introduction 213
Application and description of traditional adult
rating of perceived exertion scales 213
Estimation and production of exercise effort 213
The study of perceived exertion in
children: a historical perspective 214
The development of child-​specific rating scales 214
Pictorial versions of the Children’s
Effort Rating Table (CERT) 215
181
OMNI scales 216
Independent validation of the pictorial versions
of the CERT and OMNI scales 218
Methodological issues in children’s
effort perception research 218
Anchoring effort perceptions 218
Intermittent versus continuous exercise protocols 219
Effort perception scales: promoting and
regulating physical activity levels 219
Conclusions 220
Summary 220
References 220
PART 2
Exercise medicine
16 Physical activity, physical fitness, and health 225
Lauren B Sherar and Sean P Cumming
Introduction 225
Defining physical activity, sedentary
behaviour, and fitness 226
Physical activity and health 227
Overweight and obesity 228
Cardiometabolic risk and type 2 diabetes mellitus 228
Bone health 229
Psychological health 230
Other health issues 231
Physical activity and future health status 231
Direct effects 231
Indirect effects 231
ix

contents ix

Prevalence of activity, inactivity, and sedentary Effects of physical activity and physical
behaviour 232 fitness on bone mass 260
Guidelines for physical activity 232 Randomized controlled trials 260
Fitness and health 233 Systematic review of randomized control trials 261
Which is more important—​physical Long-​term effects of physical activity 261
activity or fitness? 233 Importance of physical activity in puberty 262
Physical exercise, inflammation, and bone mass 262
Physical activity and risks to the child 234
Conclusions 263
Conclusions 234
Summary 263
Summary 234
References 263
References 235
17 Physical activity, cardiopulmonary 19 Sport, physical activity, and other
fitness, and cardiovascular health 239 health behaviours 267
Stewart G Trost and Barbara Joschtel
Isabel Ferreira and Jos WR Twisk
Introduction 267
Introduction 239
Sports participation and other health behaviours 267
Physical activity and cardiopulmonary fitness in Cigarette smoking 267
youth and cardiovascular disease later in life 239 Smokeless tobacco 279
Tracking of physical activity and Alcohol use 280
cardiorespiratory fitness through childhood Illegal drug use 280
and adolescence to adulthood 240 Anabolic steroid use 281
Cardiometabolic risk factors 240 Dietary practices 282
Physical activity and cardiorespiratory fitness, and Inappropriate weight-​control practices 282
cardiometabolic risk factors in youth 240 Sexual risk behaviours 283
Cardiometabolic risk factors in youth and cardiometabolic Violence 283
risk factors or cardiovascular disease in adulthood 244 Physical activity and other health behaviours 284
Physical activity and cardiorespiratory fitness in youth Cigarette smoking 284
and later-​life cardiometabolic risk factors 244 Smokeless tobacco 284
Pre-​clinical signs of earlier vascular aging 245 Alcohol use 285
Atherosclerosis versus arterial stiffness 245 Illegal drug use 285
Physical activity and cardiorespiratory fitness and Anabolic steroid use 286
markers of early vascular aging in youth 245 Dietary practices 286
Physical activity and cardiorespiratory fitness in youth Inappropriate weight-​loss practices 286
and markers of early vascular aging in adulthood 247 Sexual risk behaviours 286
Conclusions 249 Violence 287
Summary 249 Conclusions 287
References 250 Summary 287
18 Physical activity and bone health 255 References 288
Han CG Kemper and Rômulo A Fernandes 20 Genetics of physical activity
Introduction 255 and physical fitness 293
Growth of bone 255 Nienke M Schutte, Meike Bartels, and Eco JC de Geus
Methods of measurement of bone mass 256 Introduction 293
Anthropometrics 256 Individual differences 293
Radiographics 256 The principles of family, twin, animal,
Dual energy X-​ray absorptiometry 256 and molecular genetic studies 293
Quantitative computed tomography 256 Family studies 293
Quantitative ultrasound 257 Twin studies 293
Mechanisms of bone formation 257 Animal studies 294
Natural course of bone mass development 258 Molecular genetic studies 294

Development of bone density before puberty 258 Quantitative genetics of physical activity
Development of bone density during puberty 259 and exercise behaviour 294
Age at which maximal bone mass is reached Total physical activity 295
(peak bone mineral density) 259 Voluntary exercise behaviour 296
x
x contents
Molecular genetics findings for physical
activity and exercise behaviour 297
Quantitative genetics of physical fitness 297
Maximal oxygen uptake 297
Other fitness phenotypes 298
Molecular genetics findings for physical fitness 298
Genes and environment 299
Implications for paediatrics 300
Conclusions 300
Summary 300
References 300
21 The assessment of physical activity 303
Maria Hildebrand and Ulf Ekelund
Introduction 303
Key concepts in measuring physical activity 303
Definitions and dimensions of physical activity 303
Measurement metrics of physical activity 304
Reliability, validity, accuracy, and responsiveness
of physical activity assessment methods 304
Methods of physical activity assessment 305
Criterion methods 306
Subjective methods 307
Objective methods 308
How to choose the right measurement method 310
Conclusions 311
Summary 311
References 311
22 Systematic promotion of physical activity
Stef Kremers, Ree M Meertens, and Robert AC Ruiter
Introduction 315
Planned health promotion 315
Health promotion and physical activity 316
Problems and problem-​causing factors 316
Determinants of physical activity 316
Systematic development of physical
activity-promoting interventions 319
Implementation and diffusion of health
promotion interventions 320
Conclusions 321
Summary 321
References 322
23 Exercise, physical activity,
and diabetes mellitus 325
Edgar GAH van Mil
Introduction 325
Definition of diabetes mellitus 325
Diagnostic criteria for diabetes mellitus in
childhood and adolescence 325
Classification of diabetes mellitus 325
The aetiology and incidence of type 1
diabetes mellitus 325
The clinical spectrum of type 1 diabetes mellitus 326
The management of type 1 diabetes mellitus 326
The importance of physical activity
for the diabetic patient 327
Physical activity 327
The effect of physical activity on the patient
with type 1 diabetes mellitus 328
Strategies to optimize performance and prevent
complications in type 1 diabetes mellitus 330
Short-​acting insulin analogues and basal insulins 332
New technologies leading to more possibilities in
monitoring and adapting to the effects of physical
activity in type 1 diabetes mellitus 332
Conclusions 332
Summary 332
References 333
24 Exercise, physical activity, and asthma 337
Helge Hebestreit, Susi Kriemler, and Thomas Radtke
Introduction 337
Exercise-​induced asthma 337
Children at risk 337
Symptoms of exercise-​induced asthma 337
Pathophysiology of exercise-​induced
bronchoconstriction 337
Late response 338
Refractory period 338
Diagnosing exercise-​induced asthma 338
315
Physical activity and exercise capacity of
children and adolescents with asthma
or exercise-​induced asthma 338
Exercise-​related benefits to children
with asthma 338
Improvements in fitness 339
Psychological benefits 339
Reduction in asthma symptoms
and exercise-​induced asthma 339
Does regular exercise reduce airway inflammation? 339
Can physical training cause asthma? 339
Exercise testing in children with asthma or
suspected exercise-​induced asthma 339
Indications 339
Who should not be tested? 340
Preparation before the test and safety procedures 340
Conducting the exercise challenge 340
Criteria to identify exercise-​induced asthma
with an exercise challenge 341
Reliability of bronchial responsiveness to a
standardized exercise challenge 341
Prevention of exercise-​induced asthma
and exercise counselling 341
Control of asthma 341
xi

contents xi

Select the least asthmogenic activity 341 Physical activity 368

Select the right time to exercise 341 Physical activity in cerebral palsy 368
Prevention of exercise-​induced asthma shortly Sedentary behaviour 368
before and during exercise 342
Training recommendations 368
Treatment of exercise-​induced asthma 342
Aerobic training 368
Anti-​doping rules and exercise-​induced asthma 342
Anaerobic training 369
Conclusions 342 Muscle strength training 369
Summary 342 Conclusions 370
References 343 Summary 370
25 Exercise, physical activity, eating References 370
and weight disorders 347 27 Exercise, physical activity,
Andrew P Hills, Steven J Street, and Nuala M Byrne and cystic fibrosis 373
Introduction 347 Susi Kriemler, Thomas Radtke, and Helge Hebestreit
A central concern: fear of fatness 347
Introduction 373
Eating and weight disorders 348
Cystic fibrosis-​related pathologies
Contrasting scenarios: overnutrition and physical inactivity,
undernutrition and excessive physical activity 348 and exercise tolerance 373
General 373
Obesity 348 Respiratory system 373
Treatment and management 348 Cardiac system 375
Exercise, diet, and behavioural interventions 349 Habitual physical activity 375
From treatment and management to prevention 349 Nutrition, muscle mass, and muscle function 376
Body satisfaction during the growing years: implications Diabetes 377
for eating and weight disorders 351 Osteopenia/​osteoporosis 377
The influence of body composition on disordered Dehydration 377
eating tendencies of adolescents 352
Exercise motivations of adolescents 352
Beneficial effects of exercise and physical activity 378
Anorexia nervosa, bulimia nervosa, Harmful effects of exercise and physical activity 378
and binge eating disorder 352 Exercise testing and recommendations 379
Aetiology of anorexia and bulimia nervosa 353 Selection of the type of sport and training 380
The dieting and eating disorder continuum 354
Conclusions 381
Prevalence of eating disorders 354
Binge eating disorder 354 Summary 381
Prevention, treatment and management 354 References 381
Conclusions 355
28 Exercise, physical activity,
Summary 355 and children with physical
References 355 or intellectual disabilities 387
26 Exercise, physical activity, and cerebral palsy 361 Merrilee Zetaruk and Shareef F Mustapha
Annet J Dallmeijer, Astrid CJ Balemans, Introduction 387
and Olaf Verschuren A brief historical note 387
Introduction 361 Benefits of exercise and sport
Cerebral palsy 361 participation for children with physical
Classification 361 or intellectual disabilities 387
Exercise testing and physical fitness 361 Children with sensory impairments 389
Exercise testing 361 The deaf child 389
Aerobic fitness 363 The blind child 389
Anaerobic fitness 363 Children with physical impairments 389
Aerobic and anaerobic field tests 364 Children with cerebral palsy 390
Muscle strength 365 Children with myelomeningocoeles 390
Walking economy 365 Children with spinal cord injuries 391
Training effects 365 Amputees 392
Aerobic training 365 Specialized equipment and prosthetic devices
Anaerobic training 367 for sport 393
Strength training 367 Wheelchair sports 394
xii
xii contents
Children with intellectual disability 395
Down syndrome 395
Special Olympics 397
Conclusions 397
Summary 397
References 398
29 Exercise, physical activity,
and congenital heart disease 401
Roselien Buys, Tony Reybrouck, and Marc Gewillig
Introduction 401
Commonly used parameters to assess exercise
performance and aerobic exercise function
in children with cardiac disease 401
Cardiorespiratory response to exercise in
specific congenital heart defects 403
Left-​to-​right shunts 403
Valvular heart lesions 403
Cyanotic heart disease 403
Rhythm disturbances and conduction defects 404
Habitual physical activity in children
with congenital heart disease 405
Natural evolution of aerobic exercise
performance and daily level of
physical activity in children with
congenital heart disease 405
Exercise recommendations and rehabilitation of
children with congenital heart disease 406
Conclusions 407
Summary 407
References 407
PART 3
Sport science
30 Development of the young athlete
Neil Armstrong and Alison M McManus
Introduction 413
Genetics 413
Chronological age, biological maturity,
and the young athlete 413
Biological maturation 413
Body size and shape 414
Body mass 414
Body composition 415
Muscle strength 415
Muscle metabolism 416
Aerobic fitness 416
Anaerobic fitness 418
Resistance to fatigue 418
Speed 418
Chronological age, biological maturity,
and performance in youth sport 419
Early specialization in youth sport 419
Chronological age-​group sport 420
The relative age effect 420
Chronological age deception 420
Risks to young athletes’ health and well-being 421
Physical, psychological, and sexual abuse 421
Coach and parental pressure 422
Financial exploitation 422
Performance-​enhancing drugs 422
Dietary supplementation, disordered
eating, and eating disorders 423
Sport injuries 423
Conclusions 424
Summary 424
References 424
31 Molecular exercise physiology 429
Henning Wackerhage, Jonathon Smith,
and Darren Wisneiwski
Introduction 429
Definition of and introduction to molecular
exercise physiology 429
Development of key exercise organs 429
The development of muscle: myogenesis 430
The development of tendons 430
The formation of bone: chondrogenesis
and osteogenesis 431
Mechanical signals and cell differentiation 431
Epigenetic regulation of development: does maternal
nutrition and exercise affect the offspring? 431
The signal transduction model of adaptation 432
Genetics 432
Introduction to genetics and exercise 432
Sequence variations: large and small effects 434
Genotypic and phenotypic associations 434
413 The genetics of development, maturation,
and body height 434
Genetics of endurance and strength-​related traits 435
Genetic testing 436
Conclusions 437
Summary 437
References 437
32 The influence of physical activity
and training on growth and maturation 441
Robert M Malina
Introduction 441
Historical background 441
Physical activity ≠ training 441
Indicators of growth and maturation 442
xiii

contents xiii

Physical activity, growth and maturation Mechanistic bases of training adaptations on

in the general population 442 lactate and gas exchange thresholds 468
Height and weight 442 Exercise economy 468
Body composition 442 Pulmonary oxygen uptake kinetics 468
Maturation 443 Influence of training on pulmonary
Growth and maturity characteristics oxygen uptake kinetics 469
of young athletes 443 Mechanistic bases of training adaptations on
Limitations of studies of young athletes 443 pulmonary oxygen uptake kinetics 470
Size attained 443 Parameters of aerobic fitness
Body composition 444 and sport performance 470
Maturity status and timing 444
Maturation threshold 470
Training for sport and the growth Methodological issues 471
and maturation of young athletes 445 Conclusions 472
Studies from Poland and the former
Czechoslovakia 445 Summary 472
Training of Young Athletes study 446 References 472
Other studies 447
Overview of longitudinal studies 447 35 High-​intensity interval training 477
Two persistent questions 447 Keith Tolfrey and James W Smallcombe
Training and body composition 449 Introduction 477
Conclusions 450 High-​intensity interval training and the
Summary 450 young performance athlete 477
Cardiorespiratory fitness 478
References 450
Explosive strength 482
33 Hormones and training 455 Sport-​specific performance outcomes 483
Jaak Jürimäe High-​intensity interval training for health 483
Introduction 455 Cardiorespiratory fitness 483
Body size and composition 486
Sport training and the growth
Biochemical metabolites 487
hormone-insulin-like growth factor-​I axis 456
Vascular health 488
Sport training and the hypothalamic-​
Time efficiency and enjoyment of
pituitary-​gonadal axis 457
high-intensity interval training 489
Sport training and the hypothalamic-​
Conclusions 489
pituitary-​adrenal axis 459
Summary 489
Sport training and the peripheral signals
of energy homeostasis 459 References 490
Leptin 459 36 Resistance training 493
Adiponectin 460
Avery D Faigenbaum and Rhodri S Lloyd
Ghrelin 461
Introduction 493
Conclusions 462
Resistance training and physical development 493
Summary 462
Effectiveness of youth resistance training 494
References 462
Physiological mechanisms for strength development 494
34 Aerobic trainability 465 Detraining and persistence of training-​induced gains 494
Melitta A McNarry and Neil Armstrong Risks and concerns 495
Maximum strength testing 495
Introduction 465
Potential benefits of youth resistance training 496
Peak oxygen uptake 465
Bone health 496
Influence of training on peak oxygen
uptake 465 Adiposity and metabolic health 497
Mechanistic bases of training adaptations Motor skills and sports performance 497
on peak oxygen uptake 466 Injury reduction in youth sport 498

Lactate and gas exchange thresholds 467 Youth resistance-​training guidelines 498
Influence of training on lactate and Choice and order of exercises 499
gas exchange thresholds 468 Training intensity and volume 499
xiv

xiv contents

Rest interval between sets and exercises 500 Recovery and prevention 524
Repetition velocity 500
Conclusions 525
Training frequency 500
Long-​term physical development 500 Summary 525
Conclusions 502 References 525
Summary 502 39 Physiological monitoring of
References 502 elite young athletes 527
Neil Armstrong and Alan R Barker
37 Speed and agility training 507
Introduction 527
Jon L Oliver and Rhodri S Lloyd
Rationale for physiological monitoring 527
Introduction 507
Ethics of physiological monitoring 528
Speed 507
Development of a physiological
Natural development of speed 507
monitoring programme 528
Growth, maturation, and spatio-​temporal
Validity 528
determinants of speed 509
Reliability 528
Speed training 509 Physiological variables and sport performance 529
Short-​term speed training interventions 509 Identification and selection of physiological tests 529
Longitudinal monitoring of speed
in sporting populations 511 Primary components of physiological
monitoring programmes 530
Agility 511 Body composition 530
Testing agility 512
Muscle strength 530
Natural development of agility 512 Anaerobic fitness 531
Change-​of-​direction-​speed 513 Aerobic fitness 531
Perceptual and decision-​making processes 513
Field tests 534
Agility training 514
Scientist, coach, and athlete relationship 534
Effect of targeted training on change-​of-​direction-​speed 514
Effect of targeted training on perceptual Conclusions 534
and decision-​making processes 514 Summary 535
Conclusions 515 References 535
Summary 515
References 515 PART 4
38 Overtraining syndrome 519 Sport medicine
Richard J Winsley
40 Epidemiology and prevention
Introduction 519 of sports injuries 541
Clarity among complexity 519 Joske Nauta, Willem van Mechelen,
Why we should care about overtraining and Evert ALM Verhagen
in the young athlete 519 Introduction 541
Definition of overtraining 519 Conceptual models for sports injury
Prevalence rates 520 prevention 541
Sequence of prevention 541
Signs and symptoms of overtraining
Translation research into injury prevention
syndrome in children 520 practice framework 542
Markers of overtraining syndrome Knowledge transfer scheme 543
in young athletes 521 Research in sports injuries 543
Causes 522 Defining sports injury 543
Are training loads responsible? 522 Sports injury incidence 544
Coach and parent pressure 522 The severity of sports injuries 544
Lack of perceived control 523 Research design 545
Active burnout and entrapment 523 Conclusions 545
Single identity 523
Perfectionist traits 523 Summary 545
Early specialization 524 References 545
xv

contents xv

41 Epidemiology and prevention 43 Epidemiology and prevention of injuries

of injuries in physical education 547 in competitive non-​contact sports 565
Dorine CM Collard, Joske Nauta, and Frank JG Backx Luiz Carlos Hespanhol Junior, Saulo
Introduction 547 Delfino Barboza, and Per Bo Mahler
Injury incidence 547 Introduction 565
Risk of injury in physical education classes 548 Bicycling 565
Physical education versus (un-)organized sport 548 Epidemiology of cycling injuries 565
Gender 549 Aetiology of cycling injuries 565
Age 549 Preventative strategies 566
Aerobic fitness, weekly physical activity, Dance 566
and body composition 549 Epidemiology of dance injuries 566
Location of injury 549 Aetiology of dance injuries 566
Preventative strategies 567
Type of injury and injury mechanism 550
Acute injuries 550 Gymnastics 567
Overuse injuries 550 Epidemiology of gymnastics injuries 567
Aetiology of gymnastics injuries 567
Severity of injuries 551
Preventative strategies 568
Nature of the injury 551
Nature of the treatment 551 Running 568
Costs of the treatment 551 Epidemiology of running injuries 568
Time lost from (un)organized sport or school 551 Aetiology of running injuries 568
Preventative strategies 568
Aetiology 551
Skiing and snowboarding 569
Prevention 552
Epidemiology of skiing and snowboarding injuries 569
Conclusions 553 Aetiology of skiing and snowboarding injuries 569
Summary 553 Preventative strategies 569
References 553 Swimming 569
Epidemiology of swimming injuries 570
42 Epidemiology and prevention of injuries Aetiology of swimming injuries 570
in competitive contact sports 555 Preventative strategies 570
Joske Nauta and Evert ALM Verhagen Tennis and badminton 570
Introduction 555 Epidemiology of tennis and badminton injuries 570
Soccer 555 Aetiology of tennis and badminton injuries 570
Epidemiology of soccer injuries 555 Preventative strategies 571
Preventative strategies 556 Volleyball 571
American football 556 Epidemiology of volleyball injuries 571
Epidemiology of American football injuries 556 Aetiology of volleyball injuries 571
Preventative strategies 557 Preventative strategies 572
Ice hockey 557 Conclusions 572
Epidemiology of ice hockey injuries 557 Summary 572
Preventative strategies 558
References 572
Basketball 558
Epidemiology of basketball injuries 558
44 Upper extremity and trunk injuries 577

Preventative strategies 559 Christopher M Shaw, Akin Cil, and Lyle J Micheli
Martial arts 559 Introduction 577
Epidemiology of martial arts injuries 559 Upper extremity injuries 577
Preventative strategies 560 Shoulder injuries 577
Wrestling 560 Elbow injuries 582
Epidemiology of wrestling injuries 560 Wrist and hand injuries 586
Preventative strategies 561 Trunk injuries 589
Conclusions 561 General 589
Spondylolysis and spondylolisthesis 590
Summary 561 Discogenic disorders 592
References 561 Scoliosis 593
xvi

xvi contents

Scheuermann’s disease 593 Sports helmets and head injury 618

Fractures 593 Cervical spine injuries 618
Mechanical back pain 593 Epidemiology 618
Conclusions 594 Initial assessment 619
Summary 594 Imaging 619
Fractures 620
References 594 Neuropraxias 620
45 Lower limb injuries 599 Ligamentous injury 621
Umile Giuseppe Longo and Nicola Maffulli Treatment 622
Return to play 622
Introduction 599
Conclusions 623
The musculoskeletal system in childhood 599
Summary 623
Different metabolic and psychological
aspects of childhood in sport 599 References 623
Endogenous risk factors 599 47 Nutrition and eating disorders 625
Epidemiology of lower limb injuries 600 Christine Sundgot-​Borgen and Jorunn Sundgot-​Borgen
Injury characteristics and severity 600 Introduction 625
Ligament, muscle, and tendon injuries 600 Energy and nutrient requirements
Muscle injuries 600 for young athletes 625
Ligament injuries 601 Energy 625
Tendinopathy 601 Macronutrients 626
Micronutrients 627
Joint injuries 602
Hip 602 Disordered eating and eating disorders 629
Knee 602 The continuum of disordered eating 629
Foot 602 Prevalence of disordered eating and
eating disorders 629
Bone injuries 602 Risk factors for the development of disordered
Epiphyseal injuries 602 eating and eating disorders 630
Fractures 603 Consequences and complications 630
Avulsion fractures and apophysitis 606 Prevention of eating disorders in athletes 631
Osteochondritis dissecans 607 Recovery from eating disorders 632
Stress fractures 607 Treatment of eating disorders in athletes 632
Legg-​Calve-​Perthes disease 607
Tarsal coalitions and sinus tarsi problems 607
Ethical and methodological considerations in
Navicular problems 608
sport and exercise medicine research 632
Prevention 608 Conclusions 633
Conclusions 608 Summary 633
Summary 608 References 633
References 609 48 Dietary supplements 637
Ronald J Maughan and Susan M Shirreffs
46 Injuries to the head and cervical spine 613
Robert V Cantu and Robert C Cantu Introduction 637
Prevalence of supplement use 637
Introduction 613 Ethical issues in supplement use 638
Types of head injury 613 Supplements in a balanced diet 638
Concussion 613 Assessing nutrient intake and status 639
Post-​concussion syndrome 614 Supplements and health 639
Malignant brain oedema and second-​impact syndrome 615 Macronutrients 639
Intracranial haemorrhage 615 Vitamins and minerals 640
Epidural haematoma 616
Subdural haematoma 616
Supplements and performance 640
Assessing performance and supplement effects 641
Subarachnoid haemorrhage 616
Supplements that may benefit performance 641
Intracerebral haematoma 617
Diffuse axonal injury 617 Risks of supplement use 641
Skull fracture 617 Quality assurance issues in the supplement industry 641
xvii

contents xvii

Adverse health effects 642 Possession, administration, complicity,

Positive doping outcomes for athletes 642 and prohibited association 652
Conclusions 643 Advanced analytical techniques 653
Anti-​doping analytical methods 653
Summary 643
Pharmaceutical industry collaboration with
References 643 the World Anti-​Doping Agency 653
Designer drugs 653
49 Doping and anti-​doping 645
Sample storage and re-​analysis 654
Alan Vernec and David Gerrard Anti-​doping research 654
Introduction 645 The ethics and values of sport 654
A brief history of doping in sport 645 Why fight against doping? 654
Early history 645 Values of sport 654
Creation of the World Anti-​Doping Agency What is values-​based education? 654
and the World Anti-​Doping Code 646 Vulnerability to doping 655
Young athletes in elite sport are subject to Recognizing doping 655
financial and competitive pressures 646
Conclusions 655
Classes of prohibited substances 646
Evolution of the Prohibited List 646
Summary 656
Criteria for inclusion of substances and References 656
methods on the Prohibited List 647
Categories of the Prohibited List 647
50 Protecting child athletes: medical
The principle of Strict Liability 647 mismanagement and other forms of
non-​accidental violence 659
Therapeutic Use Exemption 648
A brief history 648
Margo Mountjoy, Sandi Kirby, and Anne Tiivas
Fairness in sport and the Therapeutic Introduction 659
Use Exemption process 648 Protecting child athletes from forms
Diagnostic criteria 649 of non-​accidental violence 660
Roles and responsibilities of physicians 649 Non-​accidental violence: the science base 660
Fundamental responsibilities 649 Groups of children in sport vulnerable
Health and rights of young athletes 649 to non-​accidental violence 662
Supporting clean athletes and anti-​doping initiatives 650 Medical mismanagement: a form of
Knowledge of prohibited substances in sport 650 non-accidental violence in sport 664
Awareness of the Therapeutic Use Exemption Process 650 Child athlete protection in sport 665
Understanding major doping side effects 650 Action plan 668
Ethical responsibilities of physicians 651 Conclusions 668
Current anti-​doping strategies 651 Summary 669
Anti-​doping rule violations 651 References 669
Use or attempted use: The Athlete Biological Passport 651
Out-​of-​competition testing and whereabouts 652
Investigations 652 Index 671
xvii
xix
Foreword
Physical inactivity is one of the biggest public health problems of
the 21st century. Modern society has been busy engineering human
energy expenditure out of life for decades. It is possible for many
people to spend most of their time sitting and living at a very low-​
energy expenditure. Most people spend far fewer calories in house-
hold maintenance, at work, during leisure time, and in most other
lifestyle activities than people did several decades ago. To address
this serious problem we need initiatives in many sectors of soci-
ety, including worksites, education, environmental planning, and
governmental initiatives. Clinical medicine is an area where much
more attention must be given to encouraging more physical activity
for patients. There is a major initiative called Exercise Is Medicine,
which was started in 2007 by the American Medical Association
and the American College of Sports Medicine. Many other scien-
tific and clinical organizations have joined the effort, and the pro-
gramme now exists in dozens of countries around the world. Much
of the early efforts have focused on getting physicians to do more
patient counselling about exercise. Most of the effort has been for
adults, but clearly children and adolescents are also susceptible to
the aspects of modern society that have made it easier and more
attractive to sit, rather than move.
Professors Armstrong and van Mechelen have not only focused
on incorporating exercise into medical counselling in paediatric
settings, but also on providing a comprehensive resource for clini-
cians and scientists teaching and researching in paediatric exercise
science and sport medicine. The first two editions of their book
have been very informative and influential, have received excel-
lent reviews, and have been widely used. The new edition includes
17 new chapters on emerging topics of importance to the under-
standing of exercise and health in young people. The prior chapters
in the book have been completely rewritten, and include the latest
information on the wide variety of topics. The editors have retained
a great majority of the international experts who wrote chapters
in the previous editions, and there also are several new authors
who have made numerous contributions to the various scientific
areas on which they focus. I am extremely impressed with the
overall expertise of the authors, who are an outstanding group of
top-​quality scientists in the multiple topics addressed in the book.
I do not think it would be possible to assemble a more high-​quality
group of experts on these topics. They present the latest evidence-​
based research on a wide variety of issues.
Professors Armstrong and van Mechelen are exceptional sci-
entists who have made many important contributions to physical
activity and exercise science and medicine. They have addressed
a wide variety of topics investigated by their research groups,
and have publication records that are matched by few exercise
scientists.
The chapters in this edition of Children’s Sport and Exercise
Medicine are all up to date and supported by strong evidence-​based
research. There are extensive important references in each chapter,
and each chapter ends with a bulleted summary of the key points.
Dr Steve Blair
Professor (Retired)
Arnold School of Public Health
University of South Carolina
xx
xxi
Preface
The first two editions of Paediatric Exercise Science and Medicine
were welcomed by international reviewers as volumes which offered
‘state of the art’, evidence-​based coverage of the topic by recognized
leaders in the field. In the Preface to the first edition we referred
to ‘this emerging discipline’ and in the Preface to the second edi-
tion we commented on the ‘dramatic increase in published research
focusing on the exercising child and adolescent’. Since publication
of the second edition, experimental techniques initially pioneered
with adults and new non-​invasive technologies have been success-
fully developed and modified for use with children. The recent
emergence of molecular exercise physiology has unlocked new ave-
nues of research and knowledge in paediatric exercise science and
medicine. The discipline is now well-​established internationally,
numerous professorial appointments have been made in interna-
tional universities, postgraduate and postdoctoral research activ-
ity is flourishing, and publications in the field are growing at an
ever-increasing rate. The material presented in the second edition
is approaching the 10 years mark, and in a rapidly developing disci-
pline it requires regular updating, refreshing, and re-​appraising in
the light of recent developments.
This edition has retained the ethos of previous editions. Each
comprehensively referenced chapter critically analyses the research
literature, establishes what we know, and identifies gaps in our
knowledge. Where appropriate, chapters examine how recently
developed experimental techniques, technologies, and methods of
interpreting data have provided new insights into understanding
the physically active child and adolescent. Contributors are inter-
nationally recognized experts in their field and they draw upon
their own research to enrich the text and to inform and challenge
readers. Chapters are cross-​referenced to promote access to com-
plementary material and each chapter ends with a bulleted sum-
mary and extensive reference list to support the rapid identification
and further study of key issues.
Millions of young people enjoy and benefit from physical activity
and sport participation and it is estimated that in England ~80% of
youth partake in competitive sport each year. International organi-
zations, such as the International Olympic Committee (IOC), are
devoting resources to support the optimum development of the
young athlete, as evidenced by the initiation of the Youth Olympics
and the IOC investment in a series of Consensus Statements on
youth athlete development, health of the youth athlete, and train-
ing elite young athletes. However, winning margins in elite-level
sport competitions are small, and financial and other rewards for
success are extremely large. Therefore, there is a concerted effort by
some National Governing Bodies of sport, clubs, agents, coaches,
and other interested parties to identify talented children and train
them intensively from a young age to compete at an elite level. This
is exemplified by English Premier League football clubs investing
heavily in youth academies and comprehensive scouting networks
to actively recruit and contract children still in primary schools.
This activity has led to a plethora of concerns about the current and
future health and well-being of young athletes.
The mass participation of children and adolescents in commu-
nity sport programmes and the challenges faced by elite young ath-
letes have resulted in a surge of research into youth sport and the
development of the elite young athlete. This is reflected in the cur-
rent edition, which retains its comprehensive coverage of paediatric
exercise science and medicine but offers more extensive coverage
of sport science and sport medicine than in previous editions. As a
result the book has been retitled the Oxford Textbook of Children’s
Sport and Exercise Medicine to better describe its content.
Chapters on 17 new topics have been added to this edition, and
even where chapter titles remain the same or similar to the sec-
ond edition, the content has been comprehensively updated and
rewritten, often by new contributors who have emerged as leading
researchers in their field since the publication of the previous edi-
tion. Twenty-​eight scientists and clinicians from the first edition
and 45 from the second edition once again contribute to this edi-
tion, with 39 new authors from 17 countries enhancing the content.
The primary aims of the Oxford Textbook of Children’s Sport and
Exercise Medicine are to provide an up-​to-​date, comprehensive ref-
erence work with a sound scientific evidence-​based foundation to
support and challenge scientists, medical practitioners, profession-
als allied to medicine, senior coaches, physical educators, and stu-
dents involved in youth physical activity, sport, and/​or paediatric
exercise science and medicine. If the book stimulates the initiation
of innovative research programmes, informs best practice in chil-
dren’s sport and exercise medicine, and thereby contributes to the
promotion of young people’s personal development, health, well-
being, and enjoyment of physical activity and sport, it will have
served its purpose.
Neil Armstrong
Willem van Mechelen
xxii
xxii
Contributors
Neil Armstrong, PhD, DSc, Professor, Children’s Health and
Exercise Research Centre, St Luke’s Campus, University of
Exeter, Exeter, EX1 2LU, England
Willem van Mechelen, PhD, MD, Professor, Department
of Public and Occupational Health, Amsterdam Public
Health research institute, VU University Medical Center
Amsterdam, van der Boechorststraat 7, 1081 BT, Amsterdam,
The Netherlands
Frank JG Backx, MD, PhD, Professor, Department of
Rehabilitation, Physical Therapy Science and Sports, University
Medical Center Utrecht, Huispostnummer W01.121,
Postbus 85500, 3508 GA, Utrecht, The Netherlands
Astrid CJ Balemans, PhD, Department of Rehabilitation Medicine,
VU University Medical Center Amsterdam, PO Box 7057,
1007 MB, Amsterdam and Brain Center Rudolf Magnus and
Center of Excellence for Rehabilitation Medicine, University
Medical Center Utrecht and De Hoogstraat Rehabilitation,
Rembrandtkade 10, 3585 TM, Utrecht, The Netherlands
Saulo Delfino Barboza, Department of Public and Occupational
Health, EMGO+ Institute for Health and Care Research, VU
University Medical Center Amsterdam, van der Boechorststraat
7, 1081 BT, Amsterdam, The Netherlands
Alan R Barker, PhD, Children’s Health and Exercise Research
Centre, St Luke’s Campus, University of Exeter, Exeter,
EX1 2LU, England
Meike Bartels, PhD, Professor, Department of Biological
Psychology, Amsterdam Public Health research institute,
VU University and VU University Medical Center
Amsterdam, van der Boechorststraat 1, 1081 BT, Amsterdam,
The Netherlands
Adam DG Baxter-​Jones, PhD, Professor, College of Kinesiology,
University of Saskatchewan, 87 Campus Drive, Saskatoon,
Saskatchewan, S7N 5B2, Canada
Roselien Buys, PhD, Department of Rehabilitation Sciences, KU
Leuven, Tervuursevest 101, Bus 1501, 3001 Leuven, Belgium
Nuala M Byrne, PhD, Professor, School of Health Sciences,
University of Tasmania, Launceston, Tasmania, Australia 7250
Robert C Cantu, MD, Professor, Neurosurgery Service, Service of
Sports Medicine, Emerson Hospital, Concord, MA 01742, USA
Robert V Cantu, MD, Orthopaedic Surgery, Dartmouth-​Hitchcock
Medical Center, One Medical Center Drive, Lebanon, NH
03756, USA
Akin Cil, MD, Division of Shoulder, Elbow and Sports Medicine,
Department of Orthopaedics, University of Missouri-​Kansas
City, Kansas City, MO, USA
Dorine CM Collard, PhD, Mulier Instituut Centre for Research
on Sports in Society, Postbus 85445, 3508 AK Utrecht,
The Netherlands
Sean P Cumming, PhD, Department for Health, University of
Bath, Bath, BA2 7AY, England
Annet J Dallmeijer, PhD, Department of Rehabilitation Medicine,
Amsterdam Public Health research institute, VU University
Medical Center Amsterdam, PO Box 7057, 1007 MB,
Amsterdam, The Netherlands
Eco JC de Geus, PhD, Professor, Department of Biological
Psychology, Amsterdam Public Health research institute,
VU University and VU University Medical Center
Amsterdam, van der Boechorststraat 1, 1081 BT, Amsterdam,
The Netherlands
Mark BA De Ste Croix, PhD, Professor, Exercise and Sport
Research Centre, Oxstalls Campus, Oxstalls Lane, University of
Gloucestershire, Gloucester, GL2 9HW, England
Raffy Dotan, Faculty of Applied Health Sciences, Brock University,
St Catharines, Ontario, LS2 3A1, Canada
Ulf Ekelund, PhD, Professor, Department of Sport Medicine,
Norwegian School of Sport Sciences, PO Box 4014, 0806 Ulleval
Stadion, Oslo, Norway
Alon Eliakim, MD, Professor, Pediatric Department, Meir Medical
Center, Sackler School of Medicine, Tel-​Aviv University, Israel
Roger G Eston, DPE, Professor, Alliance for Research in Exercise,
Nutrition and Activity, Sansom Institute for Health Research,
School of Health Sciences, University of South Australia,
Adelaide, Australia
xxiv
xxiv contributors
Avery D Faigenbaum, EdD, Professor, Department of Health
and Exercise Science, The College of New Jersey, Ewing,
NJ 08628, USA
Bareket Falk, PhD, Professor, Department of Kinesiology, Faculty
of Applied Health Sciences, Brock University, St Catharines,
Ontario, LS2 3A1, Canada
Rômulo A Fernandes, PhD, Department of Physical Education,
School of Science and Technology, Sao Paulo State University
(UNESP), Roberto Simonsen 305, 19060-​900, Presidente
Prudente, Brazil
Isabel Ferreira, PhD, Division of Epidemiology and Biostatistics,
School of Public Health, University of Queensland, Public
Health Building, Herston Road, Herston 4006, Brisbane,
Queensland, Australia
David Gerrard, MD, Emeritus Professor, Dunedin School of
Medicine, University of Otago, PO Box 56, Dunedin 9054,
New Zealand
Marc Gewillig, PhD, MD, Professor, Cardiovascular
Developmental Biology, University Hospitals Leuven,
Herestraat 49—​box 7003 64, 3000 Leuven, Belgium
Helge Hebestreit, PhD, MD, Professor, Paediatric Department,
Julius-​Maximilians University of Würzburg, Josef-​Schneider
Strasse 2, 97080 Würzburg, Germany
Luiz Carlos Hespanhol Junior, Department of Public and
Occupational Health, Amsterdam Public Health research
institute, VU University Medical Center Amsterdam, van der
Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
Maria Hildebrand, Department of Sport Medicine, Norwegian
School of Sport Sciences, PO Box 4014, 0806 Ulleval Stadion,
Oslo, Norway
Andrew P Hills, PhD, Professor, Sports and Exercise Science,
School of Health Sciences, Faculty of Health, University
of Tasmania, Building C, Room C114, Locked Bag 1322,
Newnham Drive, Launceston TAS 7250, Australia
Barbara Joschtel, School of Human Movement and Nutrition
Sciences, University of Queensland, Brisbane QLD 4072,
Australia
Jaak Jürimäe, PhD, Professor, Institute of Sport Sciences and
Physiotherapy, University of Tartu, 18 Ulikooli Street, Tartu,
50090, Estonia
Han CG Kemper, PhD, Professor Emeritus, Department of
Public and Occupational Health, Amsterdam Public
Health research institute, VU University Medical Center
Amsterdam, van der Boechorststraat 7, 1081 BT, Amsterdam,
The Netherlands
Sandi Kirby, Professor Emerita, University of Winnipeg,
515 Portage Avenue, Winnipeg, Manitoba, Canada R3B 2E9
Stef Kremers, PhD, Professor, Department of Health Promotion,
NUTRIM School of Nutrition and Translational Research
in Metabolism, Maastricht University Medical Centre,
P. Debyeplein 1, 6200 MD Maastricht, The Netherlands
Susi Kriemler, MD, Professor, Epidemiology, Biostatistics and
Prevention Institute, University of Zürich, Hirschengraben 84,
8001 Zürich, Switzerland
Kevin L Lamb, PhD, Professor, Department of Sport and Exercise
Sciences, Parkgate Road, University of Chester, Chester,
CH1 4BJ, England
Rhodri S Lloyd, PhD, Cardiff Metropolitan University, Cardiff
School of Sport, Cyncoed Campus, Cyncoed Road, Cardiff,
CF23 6XD, Wales
Umile Giuseppe Longo, PhD, MD, Department of Trauma and
Orthopaedic Surgery, Campus Bio-​Medico University, Via
Álvaro Del Portillo 200, 00128 Trigoria, Rome, Italy
Nicola Maffulli, PhD, MD, Professor, Centre for Sports and
Exercise Medicine, Queen Mary University, London E1 4DG,
England, and Department of Trauma and Orthopaedic Surgery,
Faculty of Medicine and Surgery, University of Salerno, Italy
Per Bo Mahler, MD, Service de Santé de l’Enfance et de la Jeunesse,
Canton de Genève, and La Tour Sport Medicine SOMC, Hôpital
de La Tour, Meyrin, Switzerland
Robert M Malina, PhD, Professor Emeritus, Department of
Kinesiology and Health Education, University of Texas at
Austin, Austin, TX, USA
Ronald J Maughan, PhD, School of Medicine, University of
St Andrews, North Haugh, St. Andrews, KY16 9TF, Scotland
Alison M McManus, PhD, Centre for Heart, Lung and Vascular
Health, School of Health and Exercise Sciences, University of
British Columbia, 1147 Research Road—​ART 360, Kelowna,
British Columbia, V1V 1V7, Canada
Melitta A McNarry, PhD, Applied Sports, Exercise, Technology
and Medicine Research Centre, Bay Campus, Swansea
University, Swansea, SA1 8EN, Wales
Ree M Meertens, Department of Health Promotion, P.O.
Box 616, 6200 MD Maastricht, The Netherlands. Visiting
address: P. Debijeplein 1, 6229 HA Maastricht, The Netherlands
Lyle J Micheli, MD, Professor, Children’s Hospital, Boston and
Harvard Medical School, 319 Longwood Avenue, Boston, MA
02115, USA
Margo Mountjoy, PhD, MD, IOC Medical Commission Games
Group and Michael G DeGroote School of Medicine, McMaster
University Hamilton, Ontario, Canada
Shareef F Mustapha, MD, Department of Pediatrics and Child
Health, University of Manitoba, A8025-​409 Tache Avenue,
Winnipeg, Manitoba, R2H 2A6, Canada
Joske Nauta, PhD, Department of Public and Occupational Health,
Amsterdam Public Health research institute, VU University
Medical Center Amsterdam, van der Boechorststraat 7, 1081 BT
Amsterdam, The Netherlands
Dan Nemet, MD, Professor, Child Health and Sports Center,
Meir Medical Center, Sackler School of Medicine, Tel-Aviv
University, Tel-​Aviv, Israel
xxv
Jon L Oliver, PhD, Cardiff Metropolitan University, Cardiff School of
Sport, Cyncoed Campus, Cyncoed Road, Cardiff, CF23 6XD, Wales
Gaynor Parfitt, PhD, Alliance for Research in Exercise, Nutrition and
Activity, Sansom Institute for Health Research, School of Health
Sciences, University of South Australia, Adelaide, Australia
Thomas Radtke, PhD, Epidemiology, Biostatistics and Prevention
Institute, University of Zürich, Hirschengraben 84, 8001 Zürich,
Switzerland
Sébastien Ratel, PhD, Université Clermont Auvergne, Université
Blaise Pascal, EA 3533, Laboratoire des Adaptations Métaboliques
à l’Exercice en conditions Physiologiques et Pathologiques
(AME2P), BP 80026, F-​63171 Aubière, Cedex, France
Tony Reybrouck, PhD, Emeritus Professor, Department of
Rehabilitation Sciences, KU Leuven, Tervuursevest 101,
Bus 1501, 3001 Leuven, Belgium
Thomas W Rowland, MD, Professor, Tufts University School of
Medicine, Boston, MA, and Pediatric Cardiologist, Baystate
Medical Center, Springfield, MA, USA
Robert AC Ruiter, PhD, Professor, Department of Work
and Social Psychology, Faculty of Psychology and
Neuroscience, Maastricht University, 6200 MD Maastricht,
The Netherlands
Nienke M Schutte, Department of Biological Psychology, EMGO+
Institute for Health and Care Research, VU University and VU
University Medical Center Amsterdam, van der Boechorststraat
1, 1081 BT, Amsterdam, The Netherlands
Christopher M Shaw, MD, Division of Shoulder, Elbow and Sports
Medicine, Department of Orthopaedics, University of Missouri-​
Kansas City, 2301 Holmes Street, Kansas City, MO, 64108, USA
Lauren B Sherar, PhD, School of Sport, Exercise and
Health Sciences, Loughborough University, Epinal Way,
Loughborough, Leicestershire LE11 3TU, England
Susan M Shirreffs, PhD, School of Medicine, University of St
Andrews, North Haugh, St. Andrews, KY16 9TF, Scotland
James W Smallcombe, School of Sport, Exercise and Health
Sciences, Loughborough University, Loughborough,
Leicestershire, LE11 3TU, England
Jonathon Smith, School of Medical Sciences, University of
Aberdeen, Aberdeen AB25 2ZD, Scotland
Helen Soucie, PhD, #103, 100 rue Marcel-​R.-​Bergeron, Bromont,
Québec, J2L 0L2, Canada
Steven J Street, PhD, School of Health Sciences, University of
Tasmania, Launceston, Tasmania, Australia 7250
David Sugden, PhD, Professor, School of Education, University
of Leeds, Leeds, LS2 9JT, England
Christine Sundgot-​Borgen, Department of Sport Medicine,
Norwegian School of Sport Sciences, PO Box 4014, 0806 Ulleval
Stadion, Oslo, Norway
contributors xxv
Jorunn Sundgot-​Borgen, PhD, Professor, Department of Sport
Medicine, Norwegian School of Sport Sciences, PO Box 4014,
0806 Ulleval Stadion, Oslo, Norway
Anne Tiivas, National Society for the Prevention of Cruelty for
Children (NSPCC), Child Protection in Sport Unit. c/​o NSPCC
National Training Centre, 3, Gilmour Close, Beaumont Leys,
Leicester LE4 1EZ, England
Keith Tolfrey, PhD, School of Sport, Exercise and Health Sciences,
Loughborough University, Epinal Way, Loughborough,
Leicestershire, LE11 3TU, England
Stewart G Trost, PhD, Professor, Institute of Health and
Biomedical Innovation, Queensland University of Technology,
60 Musk Ave, Kelvin Grove QLD 4059, Australia
Jos WR Twisk, PhD, Professor, Department of Epidemiology
and Biostatistics, Amsterdam Public Health research
institute, VU University Medical Center Amsterdam, van der
Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
Edgar GAH van Mil, PhD, MD, Department of Paediatrics,
Jeroen Bosch Hospital, Henri Dunantstraat 1, 5223
GZ,‘s-Hertogenbosch, The Netherlands
Evert ALM Verhagen, PhD, Department of Public and
Occupational Health, Amsterdam Public Health research
institute, VU University Medical Center Amsterdam,
van der Boechorststraat 7, 1081 BT, Amsterdam,
The Netherlands
Alan Vernec, MD, World Anti-​Doping Agency, 800 Place Victoria,
Bureau 1700, Montreal, Quebec H4Z 1B7, Canada
Olaf Verschuren, PhD, Brain Center Rudolf Magnus and
Center of Excellence for Rehabilitation Medicine, University
Medical Center Utrecht and De Hoogstraat Rehabilitation,
Rembrandtkade 10, 3585 TM, Utrecht, The Netherlands
Henning Wackerhage, PhD, Professor, Technical University of
Munich, Uptown München-​Campus D, Georg-​Brauchle-​Ring
60, D-​80992 München, Germany
James Watkins, PhD, Emeritus Professor, College of Engineering,
Swansea University, Bay Campus, Fabian Way, Swansea,
SA1 8EN, Wales
Craig A Williams, PhD, Professor, Children’s Health and Exercise
Research Centre, St Luke’s Campus, University of Exeter, Exeter,
EX1 2LU, England
Richard J Winsley, PhD, Children’s Health and Exercise Research
Centre, St Luke’s Campus, University of Exeter, Exeter,
EX1 2LU, England
Darren Wisneiwski, School of Medical Sciences, University of
Aberdeen, Aberdeen AB25 2ZD, Scotland
Merrilee Zetaruk, MD, Department of Pediatrics and Child
Health, University of Manitoba, Section of Pediatric Sport
and Exercise Medicine, 14-​160 Meadowood Drive, Winnipeg,
Manitoba, R2M 5L6, Canada
xxvi
xxvi
Introduction
Children and adolescents are not mini-​adults. They are growing
and maturing at their own rate, and the assessment and interpre-
tation of their responses to exercise are complex as they progress
through childhood and adolescence into adult life.
Historically, research with healthy young people has been con-
strained to measuring variables such as power output or the
examination of blood and respiratory gas markers of exercise per-
formance, as ethical considerations have restricted more informa-
tive research at the level of the myocyte. The development of
non-​invasive technologies such as 31P magnetic resonance spec-
troscopy, near infra-​red spectroscopy, and stable isotope tracers;
the application of appropriate mathematical modelling techniques
to interpret physical and physiological variables during growth and
maturation; and the emergence of molecular exercise physiology
have provided new avenues of research and novel insights which
have greatly enhanced the knowledge base and research potential
in children’s sport and exercise medicine.
The Oxford Textbook of Children’s Sport and Exercise Medicine
provides the most comprehensive and in-​depth coverage of the
topic to date. It is presented in four sections, namely exercise sci-
ence, exercise medicine, sport science, and sport medicine, which
between them systematically address the science and medicine
underpinning sport, health, and exercise during childhood and
adolescence. Fifty innovative chapters are extensively referenced
to promote further study and are cross-​referenced across sections
where appropriate to enable interested readers to easily access com-
plementary information.
Current knowledge in exercise science is discussed in the first
section of the book. As growth and biological maturation are fun-
damental to understanding paediatric exercise science, the book
opens with a critique of methods of assessing maturation, followed
by a review of the processes of growth and maturation. The next
two chapters focus on developmental biomechanics and motor
development. Subsequent chapters rigorously examine muscle
strength and aerobic and anaerobic metabolism during exercise,
and focus on ‘what we know’ and ‘what we need to know’. The
physiological responses of the muscular, pulmonary, and cardio-
vascular systems to exercise of various types, intensities, and dura-
tions in relation to chronological aging, biological maturation,
and sex are critically reviewed. The exercise science section ends
with chapters which analyse young people’s kinetic responses at
the onset of exercise, scrutinize their responses to exercise dur-
ing thermal stress, and evaluate how the sensations arising from
physical exertion are detected and interpreted during youth.
Noteworthy additions to this edition include chapters devoted to
peripheral and central neuromuscular fatigue and to the responses
of hormones to exercise.
The beneficial effects of appropriate physical activity during
adult life are well-​documented, but the potential of physical activ-
ity to confer health benefits during childhood and adolescence is
controversial and has not been explored fully. There is widespread
concern about the prevalence of childhood physical inactivity and
the supposed decline of physical activity over the last two decades,
but it is difficult to determine what is fact and what is fiction. How
much exercise is necessary to promote children’s health and well-​
being? Do we know? The tremendous success of the Paralympic
Games has stimulated interest in sport and exercise for youth with
physical or intellectual disabilities, but evidence-​based literature is
sparse. Similarly, knowledge of the therapeutic role of exercise with
young people with chronic diseases is growing, but much remains
to be researched and, importantly, disseminated.
These health-​related issues are addressed in the section on exer-
cise medicine, which critically reviews the extant literature and
explores young people’s health behaviours and the role of physical
activity and physical fitness in the promotion of health and well-
being. The opening chapter provides a foundation by overview-
ing the relationship between physical activity, physical fitness, and
health. Subsequent chapters are dedicated to the effects of physical
activity and physical fitness on cardiovascular health, bone health,
health behaviours, diabetes mellitus, asthma, cerebral palsy, eating
and weight disorders, cystic fibrosis, congenital heart disease, and
physical and intellectual disabilities. The assessment and systematic
promotion of physical activity are addressed and a notable addition
to this section is a chapter on the genetics of physical activity and
physical fitness.
Participation in youth sport provides a positive environment for
the promotion of enjoyment, health, and personal development,
but evidence is accumulating that youth sport also presents risks
to health and well-being. The growing participation of children
in organized sport and intensive training (~30+ h per week) from
a young age (~5–​8 years); concerns over the (mis)use of nutri-
tional supplements; the use of performance-​enhancing drugs; the
effect of training on normal growth and maturation; the preva-
lence of disordered eating and eating disorders, overtraining syn-
drome, child abuse in sport, and sport-​related injuries; the role
and potential influence of genetic factors in youth sport; and the
premature involvement of youth athletes in senior international
competition have brought new challenges as sport becomes ever
xxvi
xxviii introduction
more pressurized, professionalized, and politicized. These issues
are addressed in the sections devoted to sport science and sport
medicine.
The sport science section, which consists of ten completely new
chapters, begins with a review of the development of the young ath-
lete which also serves as an introduction to the sport science and
sport medicine sections. The chapter initially discusses the interac-
tion of chronological aging, biological maturation, and sport per-
formance in youth before identifying some of the key challenges
facing the young athlete. The next chapter introduces molecular
exercise physiology and examines its current and potential appli-
cation to youth sport. The influence of training on growth and
maturation and hormonal adaptations to training are addressed in
the following chapters. Subsequent chapters evaluate the evidence
underpinning current training regimens during youth and ana-
lyse aerobic, high-​intensity, resistance, speed, and agility training.
The penultimate chapter in the sport science section examines the
prevalence, causes, and prevention of the overtraining syndrome.
The final chapter in this section focuses on the rationale, ethics,
development, and implementation of a physiological monitoring
programme for elite young athletes.
In the European Union there are ~1.3 million annual cases of
sports-​related injuries requiring hospitalization for children
younger than 15 years of age. Data from the American Academy of
Orthopedic Surgeons show ~3.5 million annual youth sport-​related
injuries in the US require a medical visit. The aetiology, prevention,
and treatment of sport injuries and the management of the long-​
term health of young athletes provide major challenges for medical
practitioners, sport scientists, physiotherapists, coaches, and others
supporting youth sport.
The sport medicine section opens with an insightful overview
of the epidemiology and prevention of sports injuries. Subsequent
chapters address the topic with specific reference to physical edu-
cation, contact sports, and non-​contact sports. These chapters are
followed by three chapters that focus on the diagnosis and manage-
ment of sport injuries to the upper extremity and trunk, the lower
limbs, and the head and cervical spine. The sport medicine section
concludes with four intriguing new chapters which address current
concerns in youth sport about disordered eating and eating disor-
ders, dietary supplementation, performance-​enhancing drugs, and
the medical management and protection of child athletes.
Overall, the Oxford Textbook of Children’s Sport and Exercise
Medicine is a comprehensive, evidence-​based text in which interna-
tionally recognized scientists and clinicians enrich their contribu-
tions with their own research and practical experience and present
complex scientific material in an accessible and understandable
manner. The book is designed to inform, challenge, and support
research scientists, medical practitioners, professionals allied to
medicine, physical educators, teachers, students, and coaches.
It will be of interest to all involved in the study of the exercising
child and adolescent, the promotion of young people’s health and
well-being, youth sport, and the optimum development of young
athletes.
Neil Armstrong
Willem van Mechelen
Another random document with
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Princess, brought forward all his arguments, laying stress not only on
the wealth and personal charms of the Duke, but on the joy such an
alliance would give her father in the other world. Now Isabel had
previously sent secret messengers to report on the respective
appearance and bearing of Ferdinand and the French Duke, and the
comparison was hardly favourable to the latter, who was a weakling
with thin ungainly limbs and watery eyes. She could thus estimate
the worth of the Cardinal’s statements and replied firmly that “she
could not dispose of her hand in marriage save by the advice of the
leading nobles and knights of the kingdoms, and that having
consulted them she would do what God ordained.”
This was equivalent to a refusal; and the Cardinal, having exerted
his eloquence once more in vain, returned to France, nursing his
resentment and wrath. He left the Princess in a critical position; for
her brother could draw but one conclusion from her refusal of such
an advantageous match; and he and the Master of Santiago now
strained every effort to stop her marriage with the King of Sicily.
Unable to leave Andalusia themselves, they warned the citizens of
Madrigal that any favour shown to the Princess would be regarded as
an act of treachery to the Crown, while she was so surrounded by
spies and enemies that even her faithful lady-in-waiting, Beatriz de
Bobadilla, grew frightened and besought her to break off the
Aragonese alliance. Isabel knew that, once intimidated into doing
this, she would remain absolutely at her brother’s mercy, and she
therefore implored the Archbishop of Toledo to come to her
assistance before it was too late. A lover of bold and decisive actions,
that warlike prelate was soon at the gates of Madrigal at the head of
an armed force; and Isabel, refusing to listen to the threats of the
Bishop of Burgos, at once joined him, going with him to Valladolid,
the headquarters of the Admiral, Don Fadrique.
She had burned her boats, and it only remained for the man on
whom she had pinned her faith to play his part in the drama
adequately. Both Ferdinand and his father realized the seriousness of
the situation. If the treaty of Fuenterrabia had spelled trouble and
disaster for Castile, it had been the source of even greater evils in
Aragon; for the Catalans, far from returning to their old allegiance,
as they were advised, had continued to maintain their desperate
resistance in Barcelona. They had elected as their Count first one
prince of royal extraction and then another; each new puppet
doomed to ultimate failure, but leaving behind him a defiance
increasing in ferocity as it lost power in other ways.
Nor was chronic rebellion John II.’s only serious trouble. The
important counties of Roussillon and Cerdagne, pledged to Louis XI.
in return for troops, had been seized by that monarch, as soon as he
saw his neighbour too involved in difficulties to show practical
resentment; and the web of French diplomacy was now being spun
over Navarre, through the medium of the King of Aragon’s son-in-
law, the Count of Foix. Personal sorrows added their quota: the loss
of sight at a time when political clouds looked blackest, followed by
the death of Queen Joanna, whose courage and brains had made her
a fitting helpmate for her ambitious husband, whether in the council-
chamber or on the battlefield. John was indeed repaid with added
measure for the turbulence and treachery of his early days; but like
many men of his type he showed better in adversity than in success.
Doggedly he laid fresh plans, and Providence that seldom hates the
brave rewarded him by the recovery of his eyesight.
The realization of his son’s marriage with Isabel of Castile, always
favoured by him, was now his dearest ambition; for he believed that
the final union of the two kingdoms would mean the death-blow to
Louis XI.’s hopes of dominating the Pyrenees, as well as the building
up of the power of the Crown at home against unruly subjects. Such
designs were, however, of the future, while the immediate steps to
achieve them were fraught with danger.
Isabel, the bride-elect was at Valladolid, temporarily protected by
the Archbishop of Toledo and the Admiral; but to the north lay the
hostile Bishopric of Burgos, to the south-east a line of fortified
strongholds, all in the hands of the Mendozas, the chief supporters of
Joanna La Beltraneja and therefore enemies of the Aragonese match.
It only needed the return of Henry IV. from Andalusia to make her
position untenable.
Isabel and the Archbishop of Toledo therefore dispatched
messengers to Aragon in haste to insist that the King of Sicily should
come to Valladolid. They found him in Saragossa, and suggested
that, as every moment of delay increased the danger, he should
disguise himself and go to Castile with only a few adherents, thus
hoodwinking the Mendozas, who would never expect him to take this
risk, and who also believed the negotiations for the marriage to be at
a much earlier stage.
Notwithstanding his later reputation for a hard head and a cool
heart, Ferdinand in his youth possessed a certain vein of
adventurous chivalry. It was with difficulty that he had been
prevented from leading an entirely rash expedition to Isabel’s rescue
at Madrigal, and he now readily agreed to a scheme, whose chief
merit lay in its apparent impossibility.
Sending one of the Castilian messengers on before to announce his
coming, he and a few of the most trusted members of his household
boldly crossed the frontier. The rest were disguised as merchants,
Ferdinand himself as a servant; and at the inns where they were
forced to halt he played his part, waiting at table and tending the
mules. They did not stop often, riding in spite of the intense cold by
day and night; with the result that they arrived before they were
expected at the friendly town of Burgo de Osma. Ferdinand, whom
excitement had rendered less tired and sleepy than the others,
spurred forward as they came in sight of the gates, narrowly escaping
death at the hands of an over-zealous sentry. Soon, however, their
identity was explained, and amid the blowing of trumpets and joyful
shouts the young King was welcomed by his allies.
At Valladolid the news of his arrival into safe territory was the
signal for feasting and jousts, and preparations for the marriage were
pushed on apace. Ferdinand came by night to Valladolid, and, being
met at a postern gate by the Archbishop of Toledo was led to the
house where the Princess lodged.
Four days later, on October 18, 1469, the formal betrothal took
place. Isabel and Ferdinand as second cousins stood within the
prohibited degrees of consanguinity; but the Archbishop of Toledo
produced a bull, affording the necessary dispensation. This bore the
signature of Pius II., who had died in 1464, and authorized
Ferdinand to marry within the third degree of consanguinity, on the
expiration of four years from the date of the bull. Granted its
authenticity, the marriage was perfectly legal; but it is almost certain
the document was an elaborate forgery, constructed by John of
Aragon and the Archbishop to meet their pressing needs.[2] The
dispensation was essential to satisfy, not only Isabel, but any
wavering supporters of orthodox views. On the other hand, apart
from the haste required and known dilatoriness of the Papal Court,
Paul II., who at that time occupied the See of Saint Peter, was the
sworn ally of Henry IV.; and those who were negotiating the
Aragonese alliance recognized that there could be no successful
appeal to his authority.
2. See Clemencin, Elogio de Isabella, Illustracion II.
Another matter requiring delicate handling had been the marriage
settlement that, signed by Ferdinand and ratified by his father, was
read aloud at the betrothal ceremony by the Archbishop of Toledo. In
it Ferdinand declared his devotion to the Mother Church and
Apostolic See, and his undying allegiance to Henry IV. The document
then went on to say that the signatures of both husband and wife
must be affixed to all ordinances and public deeds; while the
remainder of the clauses were directed to allaying the suspicions of
those who feared that the King of Sicily might use his new position
for the good of Aragon rather than Castile. In them he promised not
to leave the kingdom himself without consent of the Princess, nor to
remove any children that they might have, whether sons or
daughters. He would not on his own account make peace nor war nor
any alliance. He would not appoint to offices any save natives of
Castile; while he pledged himself to take no new steps with regard to
the lands that had once belonged to his father but had since been
alienated.
After the ceremony was over, Ferdinand retired with the
Archbishop to his lodging in Valladolid; and the next day, October
19th, he and Isabel were married; and for six days the town kept
festival in honour of the event.
Henry learned of his sister’s marriage from the Master of Santiago,
and naturally nothing of the insolence of such proceedings towards
himself was lost in the telling. The news found him in broken health,
the result of his life-long self-indulgence, and with his vanity badly
wounded by the scorn and defiance he had encountered in
Andalusia. He was therefore in no mood for conciliation, and
received Isabel’s letters, explaining the necessity under which she
had acted and her assurances of loyalty, in gloomy silence, lending a
willing ear to the Master of Santiago’s suggestion that he might
retract the oath he had taken at the Toros de Guisandos.
 Circumstances favoured such a course; for Louis XI., who looked
on the Castilian-Aragonese alliance with alarm as inimical to French
expansion, offered Isabel’s rejected suitor, Charles, now Duke of
Guienne, to the Infanta Joanna, the underlying condition being of
course that Henry should disinherit Isabel in her favour.
Negotiations were at once begun; and in 1470, the Cardinal of Arras
appeared at the Spanish Court charged with the final conclusion of
the terms. He had never forgiven the Infanta’s indifference to his
oratory; and, as diligent enquiry had made him cognizant of the fact
that Pius II.’s bull must be a forgery, he proceeded to denounce her
in words, according to Enriquez de Castillo, “so outrageous that they
are more worthy to be passed over in silence than recorded.”
Henry far from being shocked was obviously pleased; and, having
completed the agreement with the Cardinal, in October, 1470, he
publicly withdrew his oath, taken at the Toros de Guisandos, and
acknowledged the Infanta Joanna, then nine years old, as his
daughter and heir. Her formal betrothal to the Duke of Guienne
followed, and then the little Princess was handed over to the care of
the Master of Santiago, much to the indignation of the Marquis of
Santillana and the Mendozas, in whose keeping she had hitherto
been.
Henry now published a manifesto, in which he declared that his
sister had broken her oath in marrying without his consent, and had
aggravated her offence by her choice of an enemy of Castile, and by
not waiting to obtain a dispensation from the Pope. He had therefore
judged her unfit to succeed to the throne and had restored Doña
Joanna to her rights.
This document did not meet with general approval. Indeed the
principal towns of Andalusia, already disaffected, openly expressed
their refusal to consent to its terms. Yet to Isabel in Dueñas, where
her first child, a daughter named after herself, had been born in the
October of this year, the prospect seemed bleak enough. Her
difficulties in Castile were intensified by the ill-fortunes of John of
Aragon in his war against Louis XI. for the recovery of Roussillon
and Cerdagne; so that in spite of the critical position of affairs at
home, she was forced to let Ferdinand go to his father’s assistance.
Hiding her fears, she replied to Henry’s manifesto by a counter-
protest, in which she recalled her own moderation in refusing the
crown on her brother Alfonso’s death, and vindicated her marriage
as performed on the advice of the wiser and larger section of the
leading nobility. Henry, she declared had broken his oath, not only in
acknowledging Joanna, who was known to be illegitimate, as his
daughter and heiress; but long before, when he had failed to divorce
and send away the Queen as he had promised, and when he had tried
to force his sister to marry the King of Portugal against her will.
In the meanwhile, in spite of the flourish of trumpets with which
the betrothal had taken place, the French marriage hung fire. Gossip
maintained that the Duke of Guienne’s interest in Joanna had been
merely the result of pique at Isabel’s refusal; while Louis XI. had
used it as a temporary expedient against his enemy, the King of
Aragon. At any rate the French Prince was openly courting the
heiress, Mary of Burgundy, when death cut short his hopes in May,
1472.
Various bridegrooms were now suggested for the Infanta Joanna;
amongst them her own uncle the King of Portugal.
Henry IV. was at this time at Segovia, whose Alcayde, Andres de
Cabrera, husband of Isabel’s lady-in-waiting, Beatriz de Bobadilla,
had always been one of his faithful adherents. In the Alcazar was
stored a considerable sum of money; and the Master of Santiago now
advised the King to demand its surrender and also that of the
fortress, hoping to get them into his own hands, as he had done with
the Alcazar at Madrid. Cabrera, suspecting rightly a plot for his own
ruin, stoutly refused; and his enemy, after stirring up in the town a
rebellion which the Alcayde promptly quelled, left the city in disgust.
Henry, who loved Segovia, remained behind, unable to make up his
mind to any decisive action.
The favourite’s departure was the opportunity for which those
inclined to Isabel’s interests had long been waiting; and Beatriz de
Bobadilla urged her husband to effect a reconciliation between the
King and his sister. This plan met with the approval of no less
important a person than Pedro Gonsalez de Mendoza, Bishop of
Siguenza, whose material position had been lately increased, not
only by the Archbishopric of Seville, but also by receiving a long-
coveted Cardinal’s hat. At the time of the Aragonese marriage the
Mendozas had been amongst Isabel’s most formidable opponents,
but their enforced surrender of the Infanta Joanna to the Master of
Santiago after the French betrothal, had quite altered their views;
and the Cardinal of Spain, as Pedro Gonsalez was usually called, now
worked to secure Isabel’s accession, as the best means of ruining his
rival.
Another person, who had set himself to negotiate an agreement,
was the Papal Legate, Cardinal Rodrigo Borgia, by birth a Valencian.
John of Aragon’s old enemy, Paul II. had died in 1471; and Sixtus IV.,
his successor, when dispatching Cardinal Borgia to Castile, in 1473,
to demand a clerical subsidy, gave him at the same time a bull of
dispensation, which legalized Ferdinand and Isabel’s marriage, and
also affirmed the legitimacy of their daughter and her rights of
inheritance.
Isabel’s prospects had considerably brightened, and a bold action
on her part was to put them to the test. One day, Beatriz de
Bobadilla, who had secretly kept her informed of the current state of
affairs, disguised herself as a countrywoman and, mounted on an ass,
rode out to the city of Aranda, where her mistress was living. She
begged her to come to Segovia immediately; and, on a day arranged,
Isabel and the Archbishop of Toledo appeared in the city before
dawn and were received into the Alcazar. Henry was then in his
hunting-box in the woods outside, but that evening he returned to
the palace and saw his sister. With his usual impressionability he
echoed the joy of all around him, and embracing her informed her of
his goodwill and the pleasure her coming had given him. The next
day they rode through the city together, his hand on her bridle-rein;
and some little time afterwards Ferdinand, who had been hastily
summoned, was reconciled to his brother-in-law.
Andres de Cabrera, delighted at the success of his hazardous
scheme, arranged an elaborate dinner on the Feast of the Epiphany
of that year, 1474, in order to celebrate the occasion; but
unfortunately Henry, who was in delicate health, fell ill. Secret
supporters of the Master of Santiago cleverly suggested that he had
been poisoned, and that this had been the main object of the
reconciliation. Henry, thoroughly alarmed, in spite of all his sister’s
efforts to allay his fears, left Segovia, as soon as he was well enough
to bear the journey, joining the Master of Santiago and the Infanta
Joanna at Madrid.
 All the old trouble and discord seemed destined to begin once
more, but in reality the labours of both schemer and dupe were
nearly at an end. Early in the autumn the Master of Santiago
hastened to Estremadura to gain possession of a certain fortress, and
there, on the eve of achieving his purpose, he fell ill and died.
Henry, though almost inconsolable at the news, transferred his
affections to his favourite’s son, the Marquis of Villena, confirming
him in all his father’s offices and titles and creating him Master of
Santiago. It was to be almost the last of the many honours and gifts
that he bestowed in the course of his long reign, for on December 11,
1474, a few weeks before his fiftieth birthday, he also died.
The same atmosphere of vacillation, in which he had moved in his
life, enveloped his death-bed. When questioned as to the succession,
the chronicler, Alonso de Palencia, declares that he equivocated,
saying that his secretary knew what he wished; other writers that he
confessed to a friar that the Princess Joanna was indeed his
daughter, and that he left a will to this effect. Enriquez del Castillo,
his chaplain and chronicler, makes no mention of Joanna’s name.
Henry’s personal beliefs and wishes had availed little in his own day,
and he may have guessed that they would carry no weight after his
death. One at any rate was fulfilled, and he was buried, as he had
asked, in the Church of Sancta Maria de Guadalupe, at the foot of his
mother’s tomb.
 CHAPTER IV
ACCESSION OF ISABEL: THE PORTUGUESE
WAR
1475–1479

The news of Henry IV.’s death was the signal for Isabel’s
proclamation as Queen in Segovia. Riding through the crowded
streets, her palfrey led by two of the “regidores” of the city, she came
amid the shouts of the people to the principal square. Before her
walked four kings-at-arms, and after them Gutierre de Cardenas,
bearing a naked sword, emblem of the justice that should emanate
from kingship. In the square stood a high scaffold, hung with rich
embroidered stuffs, and on it a throne, raised by three steps from the
surrounding platform. Isabel ascended these and took her place; and
then, a king-at-arms having called for silence, a herald cried in a loud
voice: “Castile! Castile for the King Don Fernando and the Queen
Doña Isabel, his wife.” Those watching below took up the shout, and
amid cheers the royal standard was raised.
Ferdinand was in Aragon; but news had at once been sent him of
the King’s death, and in the meanwhile Isabel received the homage of
the great nobles and knights who were ready to pledge themselves to
her cause. Chief amongst them were the Admiral of Castile, the
Cardinal of Spain, his brother, the Marquis of Santillana, and the rest
of the Mendozas; while they brought with them Beltran de La Cueva,
Duke of Alburquerque, whose fortunes scandal would naturally have
linked with the cause of the Infanta Joanna.
Significant was the tardy appearance of the Archbishop of Toledo,
once so hot in Isabel’s cause. Now he came in the train of all the rest,
with little enthusiasm in his homage or in the oath he took in the hall
of the palace, his hand resting on a copy of the Gospels. On the 2d of
January he and the Cardinal of Spain rode out to meet the King of
Sicily, returning with him, one on either side, amid such crowds that
it was past sunset before they reached the palace.

He was a young man of twenty and two years ... [says Colmenares, the historian
of Segovia, commenting on Ferdinand’s appearance], of medium height, finely
built, his face grave but handsome and of a fair complexion, his hair chestnut in
shade but somewhat spare on the temples, his nose and mouth small, his eyes
bright with a certain joyful dignity, a healthy colour in his cheeks and lips, his head
well set on his shoulders, his voice clear and restful. He carried himself boldly both
on horse and foot.

His character, his new subjects could not fully gauge; but the
contrast with Henry’s vacillating puerility was obvious. Here at any
rate was a man, who would not fail in what he undertook through
indecision or lack of courage.
The Cardinal of Spain and Archbishop of Toledo proceeded to
draw up “Provisions” for the future government of the kingdom,
adjusting the exact relations of the sovereigns on the basis of the
marriage settlement. Royal letters and proclamations were to be
signed by both, the seals affixed to be stamped with the joint arms of
Castile and Aragon, the coinage engraved with the double likeness.
Justice was to be awarded by the two sovereigns, when together; by
each, when separated. Castile safeguarded her independence by
placing the control of the Treasury in the hand of the Queen, and by
insisting that the governors of cities and fortresses should do homage
to her alone. She alone, also, might appoint “corregidores” and
provide incumbents for ecclesiastical benefices, though the
nominations were to bear Ferdinand’s signature as well as her own.
 FERDINAND OF ARAGON

FROM “ICONOGRAFIA ESPAÑOLA” BY

VALENTIN CARDERERA Y SOLANO

It can be imagined that such a settlement would depend for its

success largely on the goodwill and tact of those called on to fulfil it;
and Ferdinand though he consented to sign his name to the
document did so with considerable reluctance. Many of the nobles in
Segovia, though mainly those of Aragonese birth, had professed their
annoyance that Ferdinand’s position should be in any way
subordinated to that of his wife. They declared that the Salic law,
excluding women from the royal succession, should hold good in
Castile as well as in France; and that, the Castilian House of
Trastamara having died out in the male line with Henry IV., the
crown should pass directly to the Aragonese branch, in the person of
King John and his son, the King of Sicily.
Loud was the indignation of Isabel’s Castilian supporters at this
suggestion. The Salic law, they maintained, had never been
acknowledged in Castile; on the contrary, cases could be cited in
which women had succeeded to the throne to the detriment of the
obvious male heir.
Thus, between arguments on the one side and the other, feelings
ran high, for Ferdinand himself inclined to a theory that flattered his
love of power and independence. Isabel, who had no intention of
ceding her rights, at length exerted her influence to win him to her
point of view.
“Señor,” she said, after a stormy council-meeting that had in the
end upheld her right of succession, “this matter need never have
been discussed, because, owing to the union that, by the Grace of
God, there is betwixt us, there can be no real disagreement.”
She then alluded to her duty of obedience as his wife; but perhaps
to Ferdinand her most convincing argument was the pertinent
suggestion that if the Salic law were acknowledged and they should
have no male heirs, their daughter Isabel could not lawfully succeed
them. It would ill have pleased Ferdinand to leave his possessions to
any of his Aragonese cousins. “The King,” we are told, “having heard
the Queen’s reasons was highly pleased, because he knew them to be
true; and both he and she gave orders that there should be no more
talk on this matter.”
The chronicler then goes on to remark on the complete concord
that ever afterwards existed between the sovereigns.

And when it was necessary that the King should go to look after affairs in one
part of the kingdom and the Queen in another, it never happened that he or she
issued a command that conflicted with those that the other gave. Circumstances
might separate them, but love held their wills joined.

Ferdinand and Isabel had shown their wisdom in refusing to let

the rift between them widen into an open quarrel. In a crisis the least
straw may turn the balance; and the condition of affairs required
their combined energies in the one scale. It is true that the majority
of nobles and knights had either in person, or by deputy, expressed
their allegiance; but there still remained a small though powerful
group, headed by the young Marquis of Villena, who maintained that
the Infanta Joanna was the rightful Queen.
That their objective was rather self-interest than any deep loyalty
to the little Princess was obvious from Villena’s letter, mentioning
the terms on which he and his followers would consent to submit.
For himself he demanded, first his acknowledgment as Master of
Santiago, next the confirmation of all lands, castles, and revenues
that had belonged to his father, including the Alcazar at Madrid, and
thirdly a yearly income of over two million maravedis to be paid by
the Crown. The Count of Plasencia, his ally, whom Henry IV. had
created Duke of Arévalo with the gift of that town (taken from the
widowed Queen Isabel for the purpose), sought also the confirmation
of his honours.
With regard to Joanna, whom Villena and his followers styled
“Princess of Castile,” they insisted that she should be suitably
married; and on this demand all negotiations ultimately broke down.
Ferdinand and Isabel were willing to grant the Marquis the
Mastership, in spite of the clamours of seven other candidates; they
agreed to the idea of Joanna’s marriage; but their stipulation that,
while this subject was under consideration, she should be handed
over to some trustworthy person, virtually put an end to all hopes of
reconciliation. Joanna was the Marquis’s trump card, and he had no
intention of playing her until he was certain of his trick, far less of
passing her into the hands of anyone, whom her rivals would
consider trustworthy.
Dazzled by the schemes he had planned, he believed it would be an
easy matter to secure Isabel’s ruin, and in this view he was
strengthened by the secret correspondence he had been carrying on
with his great-uncle, the Archbishop of Toledo. The latter’s conduct
is on the surface inexplicable; for, having maintained Isabel’s cause
with unswerving loyalty throughout the negotiations for her
marriage, when she was in danger of imprisonment and he of
incurring, on her account, not only papal censure but the loss of his
archbishopric, he had yet at the end of Henry IV.’s reign reconciled
himself to that monarch and his favourite the young Marquis of
Villena, to the weakening of his old allegiance. His tardy appearance
at Segovia, and the sulky manner he had adopted towards Ferdinand
and the Queen, were alike in keeping with a change of policy that in a
man of his ambitions seemed as shortsighted as it was
unaccountable. The explanation lies in Carrillo’s lack of self-control
that made his ambition the plaything of his besetting vice.
Like Juan Pacheco, he loved wealth, the more that he was in secret
an alchemist and squandered the revenues of his see in a vain
endeavour to make gold; but even the glitter of precious metals lost
its charm beside his lust for power and influence. He must be first.
This was the motive that had driven him to desert Henry IV., to
break with his nephew in the revolt of the League, and now, finally,
when the cause for which he had laboured was on the eve of success,
to renounce his allegiance to Isabel, because of his jealousy of her
new adviser the Cardinal of Spain.
In vain the Queen, who knew his character, tried to dissipate his
suspicions. Carrillo’s temperament set his imagination afire at the
least glimmer of insult or neglect; his manner grew morose and
overbearing, his desire for gifts and rewards every day more
rapacious. At length, when Ferdinand ventured to oppose his
demands, the Archbishop openly expressed his anger and, leaving
the Court, withdrew to his town of Alcalá de Henares, where he
began to plot secretly with Joanna’s supporters.
Between them he and the Marquis hatched a scheme, whose
success would, they hoped, make them the arbiters of Castile. This
was nothing less than a Portuguese alliance by which Alfonso V.,
married to his niece, would in her name cross the border, and aided
by his Castilian allies drive out Ferdinand and his Queen. With this
intention, the Marquis dispatched a letter to Alfonso full of showy
promises. The most important Castilian nobles, he declared,
including himself and all his relations, the Duke of Arévalo, and the
Archbishop of Toledo, were pledged to Joanna’s cause; while
numbers were only waiting to follow their example as soon as they
were reassured by the first victory. Furthermore, he guaranteed the
goodwill of fourteen of the principal towns in the kingdom; while,
alluding to the factions that convulsed the rest, he prophesied that
one side would be certain to adopt the Portuguese cause and with a
little help secure the upper hand. Victory was the more certain by
reason of the penniless state in which Henry IV. had left the treasury.
It was impossible that Ferdinand and Isabel could compete without
financial assistance against the wealth and well-known military
strength of Portugal.
Such arguments had a surface plausibility; though a statesman
might have asked himself if they did not take Fortune’s smiles too
much for granted. Was it safe to ignore the deep-rooted dislike that
Castile bore Portugal, or to assume the friendliness of the larger
towns, on whose possession the ultimate victory must depend?
Alfonso V. was not the type of man to ask uncomfortable questions.
He saw the object of his desire in a glamour that obscured the pitfalls
along the road on which he must travel; and where courage and
enthusiasm were the pilgrim’s main requisites he was rewarded by
success. Three times he had defeated the Moors beyond the sea; and,
dowered with the proud title “El Africano,” he now aspired to be the
victor of a second Aljubarrota. The rôle pleased his romantic and
highly strung nature for, while posing as the defender of injured
womanhood in the person of his niece, he could also hope to avenge
on Queen Isabel the slight his vanity had suffered from her persistent
refusal of his suit.
Practical-minded councillors shook their heads over his sanguine
expectations and pointed out the untrustworthy reputations of the
Marquis of Villena and the Archbishop of Toledo. That these same
men had sworn to Joanna’s illegitimacy and made it a cause of
rebellion against King Henry looked as if love of self rather than love
of justice were now their inspiration.
Isabel and the Cardinal of Spain wrote letters of remonstrance to
the same effect, begging Alfonso to submit the matter to arbitration;
but that credulous monarch chose to believe that their advice arose
merely from a desire to gain time, and therefore hurried on his
preparations for war.
In May, 1475, having collected an army of 5600 horse and 14,000
foot, he crossed the border and advanced to Plasencia. His plan of
campaign was to march from there northwards in the direction of
Toro and Zamora, as secret correspondence had aroused his hope of
winning both these strongholds. At Plasencia he halted, until the
Marquis of Villena and the Duke of Arévalo appeared with his niece,
and then he and Joanna were married on a lofty platform in the
centre of the city, the marriage awaiting fulfilment pending the
necessary dispensation from Rome. A herald, however, using the old
formula at once proclaimed the union: “Castile! Castile for the King
Don Alfonso of Portugal and the Queen Doña Joanna his wife, the
rightful owner of these kingdoms.”
From Plasencia the Portuguese at length marched to Arévalo,
where another delay, this time of two months, took place, Alfonso
determining to await the troops that had been promised him by his
Castilian allies. He had with him the chivalry of his own Court, young
hot-bloods, who had pledged their estates in the prospect of speedy
glory and pillage. In their self-confidence the easy theories of Villena
found an echo; and they loudly boasted that Ferdinand and his wife
would never dare to meet them, but were in all probability on the
road to Aragon. “Before gaining the victory they divided the spoil,”
comments Pulgar sarcastically.
The Castilian sovereigns were far from meditating flight. The war
had not been of their choosing, but, since it had been forced upon
them, they were ready to prosecute it to the end. For the moment
affairs looked threatening. Not only was their treasury practically
empty, and a hostile army on the march across their western border,
but news came from France that Louis XI., who had at first
expressed his pleasure at their accession, was now in league with
their enemies and intended to invade the provinces of Biscay and
Guipuzcoa; Villena and his companions were in arms; the
Archbishop of Toledo sulking in Alcalá de Henares.
To him the Queen determined to go and address a last appeal in
person, leaving her husband to watch the movements of the
Portuguese from Valladolid. Some of those at Court, who knew the
pitch of resentment and fury to which the old Primate had brought
his broodings, assured her that her mission would be in vain, saying
that it was beneath her dignity to thus humble herself to a subject.
Isabel replied that she counted as little on his service as she feared
his disloyalty, and that if he had been anyone else, she would most
certainly have weighed the matter more carefully, but she added, “I
would not accuse myself later with the thought that if I had gone to
him in person, he would have withdrawn from the false road he now
seeks to follow.”
She then set out southwards, accompanied by the Marquis of
Santillana newly-created Duke of Infantado, and the Constable of
Castile, the Count of Haro, sending the latter on in advance as they
drew near to Alcalá to announce her coming. Carrillo listened to the
Constable’s skilful reasoning in uneasy silence; but he was not to be
cajoled either by his conscience or by appeals to his vanity, and at
length burst into a storm of passion, declaring that it was his
intention to serve the King of Portugal, and none should turn him
from it. If Isabel entered Alcalá by one gate, he himself would leave
by another.
This was plain speaking; and the Queen, who had planned the
interview less from policy than out of regard for the old man, whose
restless jealousy she knew so well, continued on her way to Toledo,
where she intended to make preparations for the defence of
Estremadura and Andalusia.
Ferdinand, in the meanwhile, mustered his forces in Valladolid. So
great was the hatred of the Portuguese that many of the towns of Old
Castile sent citizens equipped at their own expense; while nobles in
mail, and ginetes, or lightly-armed horsemen, flocked to the royal
standard along with Biscayan archers and hardy mountaineers from
the north. Joined with the levies of Segovia and Avila, that Isabel had
collected on her journey to Toledo, the whole army mustered about
12,000 horse and 80,000 foot, as it advanced to the relief of the
citadel of Toro, both that town and Zamora having surrendered to
the Portuguese through the treachery of their respective governors.
The enthusiasm was general, and Ferdinand himself burned with the
desire to achieve some great deed.
Unfortunately Toro, flanked by fortresses in the power of the
Portuguese, and protected on the rear by the Douro, whence
provisions could be passed into the town, proved altogether too
strong for the besiegers. A stormy council-of-war was held in the
Castilian camp, it being decided that the only wise course would be
to retreat. This rumour spread, gradually taking the shape that the
nobles were forcing the King for their own ends to give up the siege;
and in a fury the ordinary soldiery rushed to the royal tent, swearing
to stand by Ferdinand in whatever act of daring he sought to do, and
above all to protect him from traitors. In bitterness of spirit they
learned that he also counselled retreat, and in disorderly fashion they
shook the dust of Toro from their feet and returned to Valladolid.
Their departure resulted in the surrender of the citadel to the
Portuguese, with whom the Archbishop of Toledo now openly allied
himself, rancorously declaring that he had called Isabel from her
spinning-wheel and would send her back to it again.
From Valladolid Ferdinand was summoned to Burgos. The city
was almost entirely in his favour, but the fortress and the church of
Santa Maria La Blanca were held by the men of the Duke of Arévalo,
whose catapults caused so much destruction that the inhabitants
declared unless help was given they must surrender. In one of the
principal streets alone, over three hundred houses had been burned,
while the firing never ceased by night or day.
Ferdinand and his illegitimate brother, Alfonso, Duke of
Villahermosa, were soon on the scenes, for Burgos was too important
a place to be lost; and earthworks and fortifications were hastily
constructed over against the citadel to prevent help reaching it from
the King of Portugal. All this, however, cost time, and, still more
disastrous, money; for the contents of the treasury in Segovia,
handed over by Andres de Cabrera, were exhausted, and the land,
impoverished by Henry IV.’s misgovernment, could obviously yield
few taxes.
The sovereigns, in deep gloom, called a meeting of the Cortes in
Medina del Campo, and laid their monetary difficulties before it.
How was the army to be paid? The problem was the harder for the
reckless generosity of the Portuguese, who gave fine promises of
lands and revenues to all who joined them, the fulfilment depending
on the success of the war. One solution was to permit the Castilian
troops to provide for themselves by pillage and robbery. This the
sovereigns at once rejected, nor would they consent to alienate the
few royal estates still remaining to them. A third suggestion was to
exact a loan from the Church, and it speaks well for the reputation
that Ferdinand and Isabel had already established, that the clergy at
once consented to this arrangement. In the end it was settled that the
Church should surrender half her silver plate to specified royal
officials, and that this should be redeemed at the end of three years
by the payment of thirty millions of maravedis.
The war now continued with unabated vigour, not only in the
north-west corner, occupied by Alfonso V., but throughout Castile
and even across the Portuguese border. On hearing of the
proclamation at Plasencia, Ferdinand and Isabel, by way of
retaliation, had added to their titles that of King and Queen of
Portugal. This encouraged their partisans in Galicia and
Estremadura to cross the frontier and seize certain of the enemy’s
strongholds, from which they raided the country round, carrying off
cattle and burning villages. In the neighbourhood of Toledo, those
who were discontented with the over-lordship of Archbishop Carrillo
and his nephew the Marquis of Villena took the opportunity to
proclaim their allegiance to Isabel, and in the latter’s name threw off
the yoke they hated. The Count of Paredes, an old warrior who had
fought against the Moors, and who was one of the candidates for the
Mastership of Santiago, joyfully went to their assistance with a large
body of troops, collecting his rival’s revenues at the point of the
sword, until the turmoil forced Villena to leave the King of Portugal
and hurry to the protection of his own estates.
He did not attempt to conceal his indignation with his ally,
insisting that Alfonso should go immediately to Madrid, that from
there he might aid those who had put their trust in him. To this the
King replied with equal bitterness that he saw no reason to risk the
loss of Toro and Zamora by leaving the north; nor was his conscience
burdened with the ill-luck of his allies, seeing that their help had
fallen far short of their promises. This was very true. But a small
portion of the nobles committed to Joanna’s cause had appeared
when expected at Arévalo, the majority of the defaulters not having
dared to leave their own territory, where Ferdinand and Isabel’s
partisans kept them occupied in the defence of their houses and
lands.
Isabel herself from Valladolid placed careful guard over the road to
Burgos, that the King of Portugal might not send relief to that citadel.
Ever since the beginning of the war, she had spared herself no pains
or trouble, in her effort to aid Ferdinand in his campaign. At one
time she had journeyed to Toledo to raise the levies of New Castile, at
another hastened northwards to rescue Leon from a governor
suspected of treachery; then again collected and dispatched troops to
the help of Guipuzcoa, where Louis XI. was endeavouring to win a
stretch of coveted seaboard. One evil result of the strain entailed by
such exertions had been her miscarriage in the summer of 1475. Her
daughter Isabel was now doubly precious; and her parents for her
better safety had sent her to Segovia, where she remained in the
charge of Andres de Cabrera, lately created for his services Marquis
of Moya.
While the siege of Burgos still delayed, Ferdinand succeeded in
gaining possession of the town of Zamora, after secret
correspondence with the captain who had guard of the main
entrance, a strongly fortified bridge. The Portuguese King was forced
to retreat to Toro, and the Castilians, entering at once, placed siege
to the citadel; Isabel supplied troops and artillery from Valladolid,
while each day fresh loyalists appeared from Galicia.

TOLEDO, LA PUERTA DEL SOL

FROM A PHOTOGRAPH BY
ANDERSON, ROME

Alfonso now found himself cut off from Portugal, and, aware that
his fortunes had not matched his hopes, began to try and negotiate
favourable terms of peace. These were still in keeping with his lofty
pretensions; for, in addition to a large sum of money and the