Gymnastics
John P. DiFiori
Dennis J. Caine
INTRODUCTION
Gymnastics is an extremely popular sport in the United States and worldwide. There are an estimated 90,000 competitive gymnasts and an additional three million recreational gymnasts in the United States (78). Almost 1,500 athletes participate in National Collegiate Athletic Association (NCAA) gymnastics each year (60).
Gymnastics training begins at very young ages. The average age at onset is 5-6 years for girls and 6-7 years for boys (52). Most girls reach their highest competitive level by age 16 due to the biomechanical demands for a small, lean, prepubertal physique (3). Peak performance for males is often at a later age because of the requirements for greater levels of strength that occur after puberty.
Physicians caring for gymnasts must be familiar with the requirements of the sport, common and unique injuries, and potential methods to prevent such injuries.
GYMNASTICS FACTS
Current-day gymnastics at the Olympic level includes men’s artistic gymnastics, women’s artistic gymnastics, rhythmic gymnastics, and trampoline gymnastics. The focus of this chapter will be artistic gymnastics.
Male and female gymnasts compete in different individual events. Male gymnasts compete in floor exercise, still rings, horizontal bar, parallel bars, pommel horse, and vault. Female gymnasts compete in floor exercise, uneven parallel bars, beam, and vault. Most gymnasts train for all of the events. Gymnasts acquire new skills for each event via repetition of individual elements and series (groups of elements).
The competitive levels in women’s gymnastics are levels 1-10 and elite, with level 10 and elite being the most advanced. Collegiate gymnasts are typically the equivalent of level 9 or higher. Male gymnasts currently compete in classes 1-7; class 1 is the most advanced. There are also over 150 elite male gymnasts in the United States (78).
The code of points dictates the degree of difficulty for each skill. There is a specific list of requirements for each level of competition. The code of points evolves with the sport and is revised every 4 years, essentially increasing the required levels of difficulty with each revision.
The training regimen for gymnastics is rigorous. An advanced or elite level gymnast practices an average of 25-35 hours per week throughout the year. Even young, beginning level gymnasts may train 10 hours per week or more.
Special equipment used by gymnasts includes grips with or without wooden dowels for the bars, beam shoes, and wrist supports. Gymnasts may also train using crash mats, foam pits, beam and bar pads, low balance beams, and twisting or spotting belts.
INCIDENCE OF INJURY
During 1988-2004, gymnastics had the highest incidence rate of practice-related injury among all women’s intercollegiate sports, followed by soccer. Women’s gymnastics had the second highest injury rate during competition, preceded by women’s soccer (31).
The incidence of injury in women’s club gymnastics ranges from 0.5 to 5.4 injuries per 1,000 hours of participation, with practice and competition exposures combined (39,43). During 1988-2004, practice and competition injury rates for NCAA women gymnasts were 15.84 and 7.96 injuries per 1,000 athletic exposures, respectively (48). A more than twofold increased risk of injury in competition versus practice has also been reported in girls’ club-level gymnastics (2). This finding may be explained by the fact that gymnasts are better protected in training because of landing in foam pits, spotting, and softer mats (71).
There is a paucity of epidemiologic research on injuries affecting male gymnasts. Most of the club-level studies were carried out in the 1980s and 1990s and were reported with reference to participant seasons, which do not account for differences in exposure to injury risk (26). Available injury surveillance data for male collegiate gymnasts are also dated. During 1985-1994, NCAA male gymnasts incurred an overall injury rate of 5.33 injuries per 1,000 athletic exposures (57).
INJURY CHARACTERISTICS
Injury Onset
High-level performance in artistic gymnastics requires long hours of training and the practice and performance of high-risk skills. As a result, it is not unexpected that both acute and overuse injuries will occur. Generally, studies involving male and/or female gymnasts and reporting on injury onset report a slightly greater proportion of acute versus overuse injuries (15). This likely reflects the different types of apparatus used in men’s gymnastics that place greater demands on the upper body (14).
Anatomic Location
The lower extremity is the most frequently injured body region among female and male gymnasts, followed by the upper extremity and spine/trunk (15). However, Dixon and Fricker (22) examined injuries among top-level gymnasts over a 10-year period and found that the upper extremity was the site of a greater proportion of injuries for males (53.4% of injuries) than females (32.7% of injuries).
A more specific look at body regions reveals that injuries to the knee are most common among female gymnasts, followed by those to the ankle and lower back. Among male gymnasts, the shoulder and wrist are more commonly injured, likely reflecting the different kinds of apparatus and related training in men’s gymnastics. However, male gymnasts also experience a high rate of ankle and knee injuries (15).
Injury Severity
Pain: Many gymnasts continue training with pain. Studies have found that as many as 71% of female gymnasts train with an injury (71). Wrist pain, for example, is a common complaint among gymnasts, with prevalence estimates ranging from 46% to 87.5% (11,19,20,21). Gymnastics may be unique in that the injured gymnast can alter his or her workout depending on the injury; for example, a gymnast with an ankle injury can continue full training on the uneven bars, provided he or she avoids the dismount.
Time loss: Severity of injury has been assessed by calculating the duration of restricted training. While most injuries are minor, resulting in less than a week away from training, 12.5% (2) to 25.9% (5) result in a time loss of greater than 3 weeks. One study found that the average time until full participation resumed was almost 4.5 weeks per injury (43). Several studies involving female gymnasts have reported that mean time loss per injury was greater for advanced than for lower level gymnasts (2,38,40). Similarly, Caine (8) found that advanced level participants experience a greater proportion of severe injury (≥ 21 days of time lost) than beginning level gymnasts (37.5% vs. 10.2%). Among NCAA female gymnasts followed for 16 years, 39% of competition injuries and 32% of training injuries resulted in a time loss of 10 days (48).
Catastrophic injury: Although direct catastrophic injuries are relatively rare in most sports, including gymnastics, the risk of these injuries appears to be greater in gymnastics than in other sports. Rates for nonfatal catastrophic injuries (i.e., permanent severe functional disability such as quadriplegia) were highest for male and female gymnasts at both the high school and college levels during 1982-2007 (56). Data on catastrophic injuries are unfortunately lacking for club-level gymnasts, where most competitive gymnasts participate.
Nonparticipation: An important reason for participation in sports is of course the health benefits that can be accrued from physical activity. An important question and concern that arises, therefore, is how many athletes drop out of their sport due to injury. In their study of Australian elite gymnasts over 10 years, Dixon and Fricker (22) reported that 9.5% of gymnasts retired as a result of injury. Three studies reported that between 16.3% and 52.4% of club-level gymnasts were injured at the time they withdrew (2,42).
Residual effects: Despite the high incidence and severity of injury among gymnasts, very little research has examined the long-term effects of these injuries. One survey of former collegiate gymnasts found that 45% of previous injuries were still symptomatic (79). Despite the large number of young gymnasts with back pain, a study comparing former elite gymnasts with age-matched controls concluded that fewer former gymnasts (27%) had subjective back problems than did the controls (38%) (77). The lack of follow-up research on the residual effects of gymnastics injuries is a concern given evidence of a link between youth sports injuries, particularly of the knee or ankle, and early-onset osteoarthritis (13).
COMMON INJURIES IN GYMNASTICS
Sprains are the most common types of injury in women’s gymnastics, followed by strains. Other types of injuries that are common include contusions, fractures, and inflammatory conditions (15). Common injuries are discussed in more detail below.
Ankle ligament sprains: Typically caused by inversion injuries, ankle ligament sprains are the most common acute injuries in gymnastics (5,22,43). They are usually the result of an incorrect landing or fall. One study found an alarming number of ankle injuries from gymnasts landing with their foot inside a crack in the floor or between mats (45). Evaluation and treatment of gymnasts’ ankle injuries are similar to those in other athletes (see Chapter 65).
Once the gymnast has completed a functional rehabilitation program, he or she should initially attempt to return to sport with the use of an ankle brace or tape for support. However, many gymnasts do not tolerate long-term use of
ankle braces since the brace may cause slipping from the apparatus, and it alters their form and appearance. Flesh-colored tape is typically the best-tolerated intervention.
There is little information on the use of prophylactic bracing and taping in gymnasts.
Low back pain: Back pain caused by lumbar strain and sprain injuries is common in gymnasts. Gymnasts place demands on the lower back that are unparalleled in most other sports. Demands on the gymnast’s back include flexion and hyperextension postures during vaulting, dismounts, and somersaults. In addition to the hyperlordotic postures, vertical impact loading occurs as the gymnast lands on both feet during dismount activities. Low back pain should be managed as with other athletes (see Chapter 45). However, care should be taken to exclude spondylolysis as a cause of the symptoms (see below). Strengthening and core stability are especially important in gymnasts.
Spondylolysis: Spondylolysis (or stress fracture of the pars interarticularis) is a common cause of lower back pain in young gymnasts, especially those between the ages of 9 and 13. It occurs in gymnasts secondary to repetitive flexion and hyperextension of the spine: backbends, walkovers, tumbling, and high-impact landings (28). The prevalence of spondylolysis is higher in gymnasts (range, 5.9%-33.8%) than in the general population (5%-6%) (15,25,33).
Gymnasts with spondylolysis typically have unilateral back pain that localizes to the lumbar area. The pain increases with activity (especially hyperextension) and decreases with rest. Physical examination may find tenderness to palpation at the lower lumbar spine. A single-leg standing hyperextension test (stork test) is sensitive and specific for spondylolysis (34).
Diagnostic testing begins with plain radiographs, which may show the classic pars interarticularis fracture on the oblique view: the “collared Scottie dog.” Single photon emission computed tomography (SPECT) bone scans are highly sensitive for diagnosing active spondylolysis. The study should be performed to confirm the diagnosis of an active lesion because spondylolysis seen radiographically may be asymptomatic (51). Thin-sliced computed tomography (CT) is more specific than bone scan and can also be used to confirm the diagnosis. CT is especially helpful in determining the healing potential of an active spondylolysis and is typically used in conjunction with SPECT once an active lesion has been identified. Magnetic resonance imaging (MRI) with thin slices has been reported to be effective in visualizing the pars interarticularis (16). MRI is perhaps most helpful in identifying other causes of lower back pain when a SPECT scan is negative for active spondylolysis (51).
Treatment initially involves modification of activity (no running, jumping, or gymnastics activities that cause pain) for at least 4-6 weeks (51,54). Physical therapy should target spine stabilization, abdominal muscle strengthening, and hamstring flexibility. The use of bracing is controversial. Some recommend the use of bracing if a SPECT scan demonstrates an active lesion (51). A CT scan can also be used to help guide the decision regarding bracing. If the CT demonstrates that an active lesion has healing potential, bracing may be the preferred initial intervention. Decisions regarding bracing should be made on an individual basis (54). The role of bone stimulators to potentially aid in healing of active lesions is not well defined (51).
Return to sport depends on progress with activity modification and physical therapy. Many gymnasts can return to an initially low level of participation after 4-6 weeks (51). Activity is then advanced as tolerated. Maintenance exercises should be continued for the remainder of the gymnast’s career.
Traumatic knee injuries: Knee injuries can be severe and disabling (50). The typical mechanism is a landing or fall while the gymnast is still completing a twisting rotation. Anterior cruciate ligament (ACL), medial collateral ligament (MCL), and meniscal injuries are the most common and may predispose the gymnast to early-onset osteoarthritis (13). Most gymnasts require surgical reconstruction of an ACL tear in order to continue gymnastics. In young athletes, this procedure may be delayed until after physeal closure. Whether early or delayed ACL reconstruction results in the best outcome in skeletally immature patients is not yet clear (55). Gymnasts do not tolerate large knee braces because bulky braces impair the gymnasts’ form and appearance. See Chapters 60 and 61 for further description of the evaluation and treatment of acute knee injuries.
Overuse injuries of the knee: These injuries result from the repetitive running, jumping, and landing required in gymnastics. Common diagnoses include Osgood-Schlatter disease, patellofemoral pain syndrome, and patellar tendinopathy. The differential diagnosis for knee pain may also include stress-related injury to the distal femoral and/or proximal tibial epiphyseal plate (12Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
