Types: acrobatic, artistic, rhythmic, tumbling, and trampoline ( Tables 90.1 to 90.4 )
Competitive levels: 4–10
First competitive level: 4
Uneven parallel bars
Junior Olympic Program
Competitive levels 2–10
First competitive level: 2
Talent Opportunity Program (TOPS)
HOPES (10–12-year-old pre-elite)
Junior and Senior International
Junior Olympic Program
Competitive levels: IV–X
First competitive level: IV
Future Stars Program
Junior National Team
Senior Elite Team
Competitive levels: 5–8
First competitive level: 5
Individual and group competitions
Individual and group competitions
Competitive levels: 1–10
First competitive level: 1 (except synchronized trampoline: level 10)
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
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
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:
Training for >15 – 20 hours/week
Gymnasts are both lower and upper extremity weight-bearing athletes; therefore, injuries incurred during gymnastics participation are comprehensive (see Table 90.5 ).
Lower Extremity Injuries
Calcaneal Fat Pad Contusion
Calcaneal Stress Fracture
Stress Fractures: Navicular and Metatarsals
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
Posterior Tibialis Tenosynovitis
Osteochondritis Dessicans of the MFC
Acetabular Labral Tear
Femoral Acetabular Impingement
Femoral Stress Fracture
Upper Extremity Injuries
Fractures related to grip lock
Scaphoid Fractures/Stress Fractures
Scaphoid Impaction Syndrome
Medial Epicondyle Apophysitis
Medial Epicondyle Avulsion Fractures
Osteochondritis Dessicans of the Capitellum
Ulnar Collateral Ligament Injuries
Rotator Cuff Strain/Tears
Discogenic Back Pain
Mechanical Lower Back Pain
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.
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.
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