Historically, gymnastics is one of the oldest competitive sports and dates back to the time of the ancient Greeks. Gymnastics performance requires strength, flexibility, agility, and coordination, coupled with precision and risk-taking. This required combination of athletic abilities makes gymnastics not only an exciting sport to watch, but also a sport with high injury rates (1,15,21).
The high incidence of injuries, along with the increased risk of catastrophic head and neck injuries, due to the aerial and acrobatic nature of gymnastics, makes medical coverage of gymnastics events rather challenging for the sports medicine physician unfamiliar with this sport. Optimal medical coverage requires an understanding of the type, level, and size of the gymnastics competition and a familiarity with common gymnastics injuries. This article will discuss the disciplines of gymnastics, injury epidemiology, and common acute gymnastics injuries, with a focus upon the features unique to gymnastics and of special importance when planning for and providing medical services for gymnastics competitions.
In the United States, there are more than 5 million participants in one of the six gymnastics disciplines offered by USA Gymnastics (USAG). USAG is the national governing body for U.S. gymnastics and has more than 100,000 members. The majority of participants are female (76%), 80% are 18 yr old and younger, and most compete in artistic gymnastics. Approximately 3500 sanctioned competitions and events take place in the United States every year (22).
Artistic gymnastics is the most common discipline of gymnastics and includes both men's and women's artistic gymnastics as separate programs. Women's events include vault, balance beam, uneven parallel bars, and floor exercise. Men's events include floor exercise, pommel horse, still rings, vault, parallel bars, and horizontal bar (22).
Rhythmic gymnastics, in the United States, is a women's-only discipline consisting of individual and group competitions. Events include rope, hoop, ball, clubs, and ribbon, and gymnasts compete in four of the five events on a rotating basis. Rhythmic gymnastics competitions take place on the floor exercise mat used in artistic gymnastics (22).
Trampoline and Tumbling
Trampoline and tumbling joined USAG in 1999, and trampoline was added as an Olympic sport in 2000. Athletes perform two competitive routines consisting of 10 consecutive skills each. Synchronized trampoline involves two trampolines and two athletes performing simultaneous identical 10-skill routines. Double mini trampoline, the newest of the trampoline sports, involves a short run, followed by a jump onto a small two-level trampoline. After landing on the first trampoline level, the gymnast performs an acrobatic trick, which is immediately followed by another acrobatic skill that finishes as a dismount onto a landing mat. Power tumbling is performed on an elevated spring floor strip runway and consists of a series of consecutive acrobatic maneuvers performed as a tumbling pass (22).
Acrobatic gymnastics merged with USAG in 2002. There are five events in acrobatics, consisting of men's pairs, women's pairs, mixed pairs, women's group (three members) and men's group (four members). Pairs or groups perform routines, which include gymnastic tumbling skills, partner balances, and dynamic skills with flight. Acrobatic gymnasts perform three routines (balance, tempo, and combined) to music on the floor exercise mat (22).
Group gymnastics is an activity available for all ages and ability level. Groups range from 10 to several thousands of people that perform exhibition routines using elements from artistic gymnastics, rhythmic gymnastics, aerobics, dance, jazz-dance, folk dance, mini-trampoline, and other elements (22).
An awareness of the type of injuries that occur in a gymnastics competition and knowledge of the apparatus and skills in which they occur will help prepare for covering a gymnastics competition. Studies in artistic gymnastics have demonstrated that the majority of absolute numbers of injuries occur during practice sessions (79%-96.6%) compared with competition (3.4%-21%) (2). However, when injuries are evaluated in reference to exposure hours, the rates are greater in competition (7.4 per 1000 hours vs 2.4 per 1000 hours) (2,15). During practice, gymnasts have the advantage of softer landing surfaces, such as loose foam pits and thicker mats, as well as spotting by coaches. Although spotting in competition is allowed (at the consequence of a heavy deduction), and the thin "sting" mat may be used for landings, the stress of competition along with the use of the required competitive equipment and matting specifications may contribute to the greater number of injuries.
Lower extremity injuries are the most frequent, followed by upper extremity injuries, then the spine/trunk. The majority of lower extremity injuries are ankle sprains and knee internal derangements (4,15,21). Upper extremity injuries occur most often in the wrist, elbow, and hand/fingers. Studies in male gymnasts are limited; however, it should be noted that the shoulder accounts for the most common injury location, followed by the wrist, then ankle (13). This difference likely is the result of the different types of apparatus used in men's as compared with women's gymnastics. Little is known about injury rates in rhythmic gymnastics. One prospective 8-month study of injuries in adolescent club-level rhythmic gymnastics found the ankle/foot was the most frequently injured body part, followed by the back (4).
The vast majority of acute injuries occur on vault and floor exercise, and usually are sustained during dismounts and landings of floor exercise tumbling (15). Again, few studies have looked at men's gymnastics, but one study that evaluated injuries during practice (13) reported that floor exercise was the most common event to incur an injury, followed by still rings, horizontal bar, parallel bars, pommel horse, and then vault.
Based upon the available gymnastics injury data, it is recommended that the sports medicine staff members should station themselves in close proximity to each apparatus and pay extra attention to the floor exercise and vault events, along with tumbling and dismounting activities.
COMPETITIVE GYMNASTICS EVENTS
Administrative Oversight of Gymnastics Competitions
USAG sanctions the vast majority of U.S. gymnastics competitions in all six disciplines. International competitions hosted in the United States fall under the jurisdiction of the Federation of International Gymnastics (FIG). Other sports administrative bodies, such as the National Collegiate Athletic Association (NCAA), YMCA, Amateur Athletic Union (AAU), National Federation of State High School Associations (NFHS), and United States Association of Independent Gymnastics Clubs (USAIGC), also conduct gymnastics competitions and may have somewhat different competitive rules and competition procedures than USAG. The Rules and Policies Manuals that govern the various disciplines of all sanctioned USAG competitions can be found at www.usa-gymnastics.org. These manuals also describe the extent of medical coverage required to be provided at various competitions (22).
Types of Competitions
Prior to providing coverage at a gymnastics competition, it is important to determine the details of that specific gymnastics competition. Important things to consider are the gymnastics disciplines competing, dates, location, type of venue, level of competition, administrative body responsible for meet organization, anticipated number of competitors, training days, and training venue locations. There are large gymnastics events hosted in this country that have men's and women's artistic, rhythmic, and tumbling and trampoline competitions going on simultaneously over one weekend! It also is important to determine whether it will be an international competition, because caring for athletes from other countries can have special challenges.
The USA Gymnastics National Championships and a handful of international meets, such as the Olympics, Olympic Trails, World Championships, and American Cup, are conducted on a podium. The podium is a raised competition surface for placement of all competitive equipment rather than the equipment being set up directly on the arena floor. Podium meets can provide special logistical issues for the sports medicine personnel to consider, such as the increased distance and time it may take the medical staff to reach an injured athlete.
It is important for the medical personnel at any gymnastics competition to be aware of two key gymnastics personnel who are present at gymnastics meets: the meet director and the meet referee. The meet director and the meet referee usually will be involved in, from an administrative point of view, any injuries that occur on the competitive floor. The meet director is responsible for the meet organization, equipment safety, and the correct application of the competition policies and procedures as described in the USAG Rules and Policies Manual. The meet director is required to pass a meet director's examination, which covers the information contained in the Rules and Policies Manual. The medical director generally will have direct contact with the meet director regarding the organization and implementation of medical services.
The second key person is the meet referee. The meet referee is a gymnastics official whose job it is to oversee the other officials, in addition to serving as a liaison between the coaches and the judges. The meet referee also serves as the final authority on all technical matters regarding rule interpretations and infractions. The medical director and/or medical staff should identify this official and introduce themselves prior to the start of competition (22).
PLANNING MEDICAL COVERAGE
Planning the medical coverage of a gymnastics competition can be a daunting task, particularly for multiday, multidiscipline, and multicompetition venues. The planning is more manageable when broken down into three phases: precompetition, competition, and postcompetition.
Precompetition planning will be the most labor- and time-intensive portion, but if done well will lay the groundwork for coordinated and comprehensive medical coverage. As previously discussed under the types of gymnastics competitions, understanding the structure and make-up of the gymnastics event for which you are planning medical coverage is critical. The best way to grasp a complete understanding of your specific event is to arrange a meeting with the meet director and ask questions until you have a thorough grasp of the meet specifics and your responsibilities. See Table 1 for a gymnastics competition medical coverage planning checklist.
The main responsibility of the medical staff, once the competition/training sessions begin, is to be available readily to assess and treat injured or ill gymnasts or possibly coaches and officials. Remember to check in with the meet director to review any changes or clarifications of procedures that could affect medical services and take the time to meet the meet referee. Also review logistics, communication, and injury procedures with other medical staff as they arrive.
One important point of emphasis for injury assessment during gymnastics competitions is that if the gymnast is injured during a routine, there is a limited amount of time for the gymnast to remount the equipment and continue the routine before the routine is terminated. For example, a gymnast who falls off the balance beam has 30 s (timed by a separate beam fall timer) to remount and begin her routine from the point of interruption. If she is unable to do so, then her routine is over. These rules are in place to protect the athlete from attempting to continue a routine in the face of a serious injury. Usually, by the time the medical staff reaches the injured gymnast, the time to remount has expired and the routine is terminated, thus taking this decision out of the hands of the medical staff. Of course, decisions regarding safely returning to compete on other events in the same competition may need to be made and would fall in the realm of the medical staff.
At the end of the competition, complete and review any necessary documentation, including any required injury forms for insurance purposes. USAG requires an incident/injury form (separate from the official medical record) to be completed by the medical staff if any injury occurs at a USAG-sanctioned event. The meet director will provide the medical personnel with an incident/injury report form containing the sanction number of the competition and the meet director's signature. The responsible medical personnel complete the appropriate sections of the form, and this form is then given to the coach or the parents of the injured gymnast. It is then the responsibility of the parents or legal guardian of the gymnast to submit the paperwork to the insurance company (22).
Check in with the meet director one final time before departure for any unresolved issues that might need medical attention. Thank and also solicit input from other medical staff for ideas for future improvement. Finally, clean up the training room and any equipment used, and properly dispose of medical waste.
Gymnastics is an explosive and risky sport and, as previously mentioned, has a high incidence of injuries. Because it is not practical to cover all of the potential acute injuries that a physician might encounter while covering a gymnastics competition, the following discussion will be limited to the more commonly seen acute gymnastics injuries, along with acute injuries that are specific to gymnastics and may need to be managed somewhat differently than is standard at other sporting events.
Head and Neck
A gymnast may sustain a concussion by hitting his or her head on the mat/floor or apparatus during a skill, fall, or dismount. A rhythmic gymnast may additionally suffer a concussion from being hit in the head by a piece of the apparatus (e.g., clubs). An acrobatic gymnast may suffer a head collision from contact with another member of the group. Concussions in gymnasts are treated the same as in other types of athletes, although special consideration should be given for more conservative return to play recommendations, due to the potential for catastrophic injury, if the athlete has any symptoms such as headache, dizziness, abnormal balance, change in reaction time, or visual disturbances that could affect performance (7).
Due to the acrobatic nature of gymnastics, gymnasts are at risk of cervical spine injuries (3,10,18,20). Mechanisms of injury include landing on the head, landing on the upper back with the neck hyperflexed, and landing on the chest with the neck hyperextended (7). During a practice session at a venue with a loose foam pit, the gymnast could mistakenly land head first in the pit and suffer a cervical spine injury. As is the standard of care with any athlete with a suspected cervical spine injury, the gymnast should have his or her neck stabilized manually while airway, breathing, circulation, and disability are assessed. Gymnasts are often rather small and may require a pediatric cervical collar and a pediatric-sized back board.
While loose foam pits and resi-pits are not competitive equipment for gymnastics, they are training tools that may be found at practice venues or at competitive events hosted at a gymnastics club. A loose foam pit is an in-ground or above-ground, 6- to 8-ft deep hole, of varying length and width, filled with loose foam blocks and provides a soft and "relatively safe" environment for training new skills. A resi-pit is a 32-in deep, soft, single mat placed in a large hole in the ground that provides a soft landing surface. A competitive trampoline stands almost 4 ft above the floor and is exceedingly springy, thus making it a difficult and unique surface upon which to care for an injured athlete. The trampoline, resi-pit, and loose foam pit are all unstable surfaces, and the mere presence of a person walking onto those surfaces can disturb the injured athlete in a manner that could worsen the initial injury.
Stabilizing a cervical spine injury and back boarding a gymnast injured on the trampoline or in a resi- or loose foam pit requires pre-injury training and practice based on a protocol for safe removal (7). A suggested protocol for accessing and removing an injured gymnast from a loose foam pit can be found in Table 2. Similar principles and precautions should be used for accessing and removing an injured athlete from a resi-pit or trampoline.
Sports-induced eye trauma is generally associated with sports such as baseball, hockey, tennis, and racquetball, but the eye is also at risk from a variety of factors specific to gymnastics. Gymnasts use chalk, which is generally made from magnesium carbonate, to improve their grip on the equipment. Gymnastics chalk is particulate and can cause eye irritation. Rhythmic gymnasts may suffer an injury to the eye from being hit with a piece of their equipment, such as the stick of the ribbon or the ribbon itself. Acrobatic gymnasts may have an eye scratched or poked by another member of their group. At times, gymnasts may perform an acrobatic skill poorly and hit their eye with their own knee, resulting in eye trauma. Female gymnasts often accessorize their leotards and their hair and faces with glitter and sequins, which can increase their risk of suffering a foreign body in the eye and a possible complicating corneal abrasion. Due to these factors, it is suggested that an eye kit containing fluorescein strips and a cobalt blue light source be part of the sports medicine supplies at gymnastics competitions.
Gymnasts will, at times, hit their nose on the apparatus or matting, be hit by their apparatus or partner, or hit their nose directly with their own knee. This can result in nosebleeds, nasal contusions, nasal fractures, and lacerations. Remember to assess these athletes for other comorbid injuries, such as concussion. It is important to stock supplies for managing a nosebleed (i.e., nasal tampons) as well as for cleaning up the spilled blood from the athlete, equipment, and matting.
Gymnasts can dislocate, fracture, and/or sprain their elbows during a fall. Attempting to reduce an elbow dislocation in the competitive arena depends upon the comfort level and judgment of the sports medicine personnel. It generally is recommended that an attempt at reduction be undertaken if there is evidence of neurovascular compromise and the medical staff has appropriate experience in this procedure. It is important to have splints in a variety of sizes, including pediatric sizes, to stabilize the injury for transportation.
"Grip lock" is an injury specific to gymnastics and occurs when leather grips overlap while the gymnast is performing circling elements on the uneven bars or horizontal bar. This overlapping results in the grip catching or locking in place while the gymnast continues to circle around the bar. Since the grip is stuck in place, the forearm ends up wrapping around the bar and ultimately fracturing. Removing a gymnast from the bar in this situation is difficult and requires one to two people to support the hanging and distressed athlete, while one to two people loosen the grip, gently stabilize the arm(s) involved, and get the athlete off the equipment. This injury can be prevented by replacing stretched out grips and refraining from borrowing other gymnasts" grips (7,19).
Rips and blisters
Many gymnastics events require gripping of the apparatus. Gripping causes friction to be generated between the hand and equipment or between the hand and the leather grip and can lead to blister formation. When blisters tear, this is known in the gymnastics community as a "rip." Leather grips are used by gymnasts to increase their ability to grip the equipment, as well as to decrease blisters and rips. Blisters and rips also occur on the wrists and forearms of gymnasts from their grips.
Gymnasts and their coaches are well versed in the care of blisters and rips, since this is a common gymnastics injury, and may not pursue medical advice unless it appears infected, won't stop bleeding, or is unusually large and painful. The sports medicine professional should treat these blisters the same as they would in other athletes, with the caveat being that gymnasts may not be able to maintain their grip on the apparatus, thus placing themselves at increased risk of suffering other injuries. Try to assess their risk from a painful compromised grip, along with input from the athlete and the coach, to determine whether that individual athlete should compete on apparatus requiring significant gripping such as uneven bars, horizontal bar, parallel bars, rings, and pommel horse. Additional considerations for the sports medicine staff are to remember to clean off blood left on the equipment from the tear, minimize the risk of subsequent infection by cleansing and covering the open wound, and require the athlete to cover the rip to avoid leaving blood or serous drainage on the apparatus to prevent transmission of infectious agents to other athletes. DuoDerm or OpSite can be used to cover rips and remain secure while competing on apparatus that requires confident gripping ability (17).
Fingers and hands
Coaches and athletes frequently need to adjust equipment settings to fit the size of the athlete. The equipment adjustments need to be made quickly and efficiently during the limited amount of time given for timed warm-ups and competition, thus placing fingers and hands at risk of getting caught in between the moveable parts and cables. Skin abrasions, lacerations, fractures, dislocations, and even amputations are known to occur under these circumstances.
Knee injuries are common acute injuries in gymnastics (2,5,11). Gymnasts are at risk of anterior cruciate ligament (ACL) tears (8,16). ACL tears can occur from landing with the knees hyperextended or from a valgus or varus load while attempting to land a twisting skill without fully completing the twist. A 10-yr study of 7769 sports-related knee injuries revealed that lateral collateral ligament sprains and lateral meniscal tears were associated with gymnastics activities (14). Other potential acute knee injuries include growth plate fractures, patellar dislocations/subluxations, and bone contusions.
Ankle and foot
Ankle and foot injuries are common in gymnastics, with ankle sprains frequently reported as the most common acute gymnastics injury (2,4,6,11,12). The ankle is vulnerable to injury from landings with the joint in an inverted or everted position. Other ankle/foot injury mechanisms include stepping off landing mats or landing with the foot in mat seams. It is important to remember that younger gymnasts are vulnerable to growth plate fractures (7).
Anterior ankle pain, either from bony and/or soft tissue injury, can occur acutely or from repetitive "short" landings from performing under-rotated skills. Under-rotation causes the ankle/foot to absorb significant forces in a hyperdorsiflexed position. Achilles tendon injuries may occur on the take-off phase of tumbling skills or upon landing (9). Calcaneal contusions and fractures can occur from a single poor landing such as landing off the landing mats on a non-padded floor and from hitting the heels on the apparatus (7).
Gymnastics is a dynamic and high-risk sport, involving a variety of disciplines and unique features that are important to understand before providing medical services for a gymnastics competition. Precompetition planning is critical to success.