Introduction
- •
Types: acrobatic, artistic, rhythmic, tumbling, and trampoline ( Tables 90.1 to 90.4 )
TABLE 90.1
ACROBATIC GYMNASTICS (MEN AND WOMEN)
Events
Levels
Women’s pairs
Junior Olympic
Elite
Men’s pairs
Levels 1–10
Junior
Mixed pairs
Competitive levels: 4–10
Senior
Women’s group
First competitive level: 4
Men’s group
See www.usa-gymnastics.org .
TABLE 90.2
ARTISTIC GYMNASTICS
Women
Men
Events
Vault
Uneven parallel bars
Balance beam
Floor exercise
Floor exercise
Pommel horse
Still rings
Vault
Parallel bars
High bar
Levels
Junior Olympic Program
Levels 1–10
Competitive levels 2–10
First competitive level: 2
Elite Program
Talent Opportunity Program (TOPS)
HOPES (10–12-year-old pre-elite)
Junior Pre-Elite
Junior and Senior International
Junior Olympic Program
Levels I–X
Competitive levels: IV–X
First competitive level: IV
Elite Program
Future Stars Program
Junior National Team
Senior Elite Team
TABLE 90.3
RHYTHMIC GYMNASTICS (WOMEN ONLY)
Events
Levels
Rope
Junior Olympic
Elite
Hoop
Levels 1–8
Junior
Ball
Competitive levels: 5–8
Senior
Clubs
Ribbon
First competitive level: 5
Individual and group competitions
Individual and group competitions
TABLE 90.4
TUMBLING AND TRAMPOLINE (MEN AND WOMEN)
Events
Levels
Double minitrampoline
Synchronized trampoline
Trampoline
Tumbling
Junior Olympic
Elite
Levels 1–10
Competitive levels: 1–10
First competitive level: 1 (except synchronized trampoline: level 10)
Junior
Senior
- •
Over 97,000 competitive gymnasts register yearly with USA Gymnastics, and up to 5 million recreational gymnasts in the United States.
- •
>70% female artistic gymnasts
Epidemiology
- •
Injury rates: vary greatly depending on the level of the gymnast and hours spent training
- •
0.687 – 2.859 injuries per 1000 hours of training
- •
6.07 – 9.22 injuries per 1000 athletic exposures in collegiate athletes
- •
- •
Higher incidence during dismounts and floor exercise
- •
Contributing factors:
- •
Poor landing technique including landing short
- •
Landing with overly upright posture, decreased knee flexion, and relative joint stiffness
- •
- •
Sprains most common, followed by strains
- •
The ankle/foot is the most commonly injured body part, except in men and acrobatics (where it is the hand/wrist)
- •
The incidence of injury during competition approximately two times the practice incidence.
- •
Higher incidence of growth plate injuries owing to an immature skeletal system
- •
Injury risk factors:
- •
Larger size
- •
Rapid growth
- •
Training for >15 – 20 hours/week
- •
Life stress
- •
- •
Gymnasts are both lower and upper extremity weight-bearing athletes; therefore, injuries incurred during gymnastics participation are comprehensive (see Table 90.5 ).
TABLE 90.5
DIFFERENTIAL DIAGNOSIS OF GYMNASTICS INJURIES
Lower Extremity Injuries
Foot
Calcaneal Apophysitis
Calcaneal Fat Pad Contusion
Calcaneal Stress Fracture
Lisfranc Injury
Stress Fractures: Navicular and Metatarsals
Turf Toe
Ankle
Anterior and Posterior Ankle Impingement
Distal Fibular Salter-Harris I Fracture
Ankle Sprains: High, Lateral, and Medial
Os Trigonum Fracture
OCD of the Talar Dome
Osteochondritis Dessicans-Talus
Posterior Tibialis Tenosynovitis
Knee
ACL Tear
MCL/LCL Sprain/Tear
Meniscal Injuries
Osgood–Schlatter Syndrome
Osteochondritis Dessicans of the MFC
Patellofemoral Syndrome
Patellar Subluxation/Dislocation
Hip
Acetabular Labral Tear
Apophysitis
Femoral Acetabular Impingement
Femoral Stress Fracture
Hip Instability/Hypermobility
Upper Extremity Injuries
Hand/Wrist
Fractures related to grip lock
Ganglion Cysts
Gymnast Wrist
Rips
Scaphoid Fractures/Stress Fractures
Scaphoid Impaction Syndrome
TFCC Tears
Elbow
Elbow Dislocations
Medial Epicondyle Apophysitis
Medial Epicondyle Avulsion Fractures
Osteochondritis Dessicans of the Capitellum
Ulnar Collateral Ligament Injuries
Shoulder
Impingement Syndrome
Labral Tears
Multidirectional Instability
Rotator Cuff Strain/Tears
Shoulder Dislocations/Subluxations
Other
Head
Concussions
Cervical Spine
Cervical Fractures
Cervical Strain
Lumbar Spine
Discogenic Back Pain
Facet Syndrome
Lumbar Strain
Mechanical Lower Back Pain
Sacroilitis
Scheuermann Disease
Spondylolisthesis
Spondylolysis
Common Injuries and Medical Problems
Mild Traumatic Brain Injury (MTBI)
Mechanism of injury: Hitting the head on the mat/floor or apparatus during a fall or dismount
Incidence: A study found a 30% lifelong occurrence
Return to play: Several activities are aerial in nature; hence, the graduated return protocol will have to be modified to meet the demands of the gymnast while maintaining their safety until the athlete has been fully cleared.
Cervical Spine Fracture, Subluxation, and Dislocation
Mechanism of injury: Complex aerial and acrobatic nature of gymnastics places athletes at a risk of catastrophic neck injuries. Cervical spine fractures, subluxations, and dislocations can occur through various mechanisms:
- •
Landing head first in a loose foam pit, on a trampoline, or on a mat
- •
Failure to complete rotation or over-rotating on aerial or salto maneuver.
- •
Landing on the upper back with the neck in a hyperflexed position
- •
Landing on the chin or chest with the neck in a hyperextended position
- •
Specific consideration to standard evaluation and treatment:
- •
Pediatric cervical spine collar availability
- •
Loose foam pit injuries:
- •
Foam blocks that fill the pit are easily disturbed, and the athlete is typically buried in the blocks.
- •
Avoid jumping into pit to help an injured athlete because the disruption of foam blocks could worsen the injury and make it more difficult to remove the athlete.
- •
Considering the difficulty of removing a gymnast with a cervical spine injury from a loose foam pit, physicians, trainers, coaches, and local paramedics should practice emergency removal as part of an emergency action plan.
- •
Gently placing a mat into the pit and then using this as a means to reach the athlete is one method to minimize disturbing the foam blocks.
- •
- •
Shoulder Injuries
Anterior Dislocation, Labral Tears, and Multidirectional Instability
See Chapter 49 : Shoulder Injuries.
Rotator Cuff Syndrome, Impingement, and Tears
- •
More common in male gymnasts
- •
Rings, high bar, and parallel bars all put substantially increased stress on the shoulder.
Elbow Injuries
Dislocation
- •
Upper extremity weight-bearing activities can be gradually introduced, once a gymnast has full range of motion (ROM) and strength in the upper extremity and is pain free.
Ulnar Collateral Ligament (UCL) Sprain
Mechanism of injury: Valgus stress to the medial aspect of the elbow causes traction injury to the UCL; may occur acutely due to a fall on an outstretched hand or chronically due to repetitive upper extremity weight bearing.
History: Valgus mechanism; may be acute or chronic
Physical examination: Findings typical of UCL injuries; evaluate for an increased carrying angle and elbow hyperextension bilaterally, which may be a risk factor for this type of injury
Imaging: Radiographs: Check for medial epidondylar apophyseal avulsion fracture or chronic changes consistent with medial epicondylar apophysitis. Magnetic resonance imaging (MRI) arthrogram may be needed to determine the degree of ligamentous tear.
Treatment: Surgery is reserved for complete rupture of UCL with resultant chronic instability.
Complications: Chronic instability, ulnar neuritis
Capitellar Osteochondritis Dissecans (OCD)
Mechanism of injury: Repetitive weight bearing causes valgus stress with medial elbow tension and lateral radiocapitellar joint compression.
History: Gradual onset, elbow pain with weight-bearing activities; pain relieved by rest; decreased elbow extension; in more advanced cases, mechanical symptoms of catching and locking noted
Physical examination: Tenderness to palpation over radiocapitellar joint; effusion may be present; ROM, particularly extension, may be decreased.
Imaging: Radiographs: If positive will show a radiolucency or fragmentation within the capitellum, with irregular ossification and crater next to articular surface; MRI arthrogram helps determine integrity of articular cartilage, or if radiographs are negative and there is a high clinical suspicion.
Classification and treatment of OCD lesions ( Fig. 90.1 ) :
- •
Type I: No displacement of lesion or fracture of the articular cartilage
- •
Treatment: Conservative; no upper extremity weight-bearing or strengthening activities until radiographs show evidence of healing and pain resolves completely; consider splint if pain not relieved by discontinuing upper extremity weight-bearing activities or to improve compliance
- •
- •
Type II: Evidence of fracture of articular cartilage or partial displacement of lesion
- •
Treatment: Controversial; ranges from conservative to surgical intervention
- •
- •
Type III: Complete detachment of lesion with resulting loose body
- •
Treatment: Typically, surgical
- •
- •
