HUTCHINSON, MARK R.
Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL 60612
Submitted for publication June 1998.
Accepted for publication September 1998.
Address for correspondence: Mark R. Hutchinson M.D., Director of Sports Medicine Services, University of Illinois at Chicago, 209 Medical Sciences South (m/c 844), 901 South Wolcott, Chicago, IL 60612; E-mail: firstname.lastname@example.org.
HUTCHINSON, M. R. Low back pain in elite rhythmic gymnasts. Med. Sci. Sports Exerc., Vol. 31, No. 11, pp. 1686–1688, 1999.
Background: Rhythmic gymnastics is a sport that blends the athleticism of a gymnast with the grace of a ballerina. The sport demands both the coordination of handling various apparatus and the flexibility to attain positions not seen in any other sport. To attain perfection and reproducibility of their routines, the athletes must practice and repeat the basic elements of their routines thousands of times. In so doing, the athlete places herself at risk of a myriad of overuse injuries, the most common being low back pain.
Methods: To document the presence and severity of low back pain in elite rhythmic gymnasts, a prospective study of seven national team members was undertaken that documented injuries and complaints with daily medical reports over a 7-wk period. These findings were correlated with a retrospective review of 11 elite level gymnasts followed over a 10-month period whose complaints ultimately required evaluation by a physician.
Results: Eighty-six percent of the gymnasts in the prospective study complained of back pain at some point over the course of the study. The only injury recorded that required a time loss from sport was a low back injury. The most common complaint requiring a physician’s evaluation was low back pain with the diagnoses varying from muscle strains to bony stress reaction or complete fracture of the pars inter-articularis (spondylolysis). No athlete had a spondylolisthesis or ruptured disk. Two had mild scolioses which did not appear to be associated with their low back pain.
Conclusions: It would appear that rhythmic gymnasts are at relative increased risk of suffering low back complaints secondary to their sport.
Rhythmic gymnastics is a sport that blends the athleticism of a gymnast with the grace of a ballerina. The sport demands both the coordination of handling various apparatus and the flexibility to attain positions not seen in any other sport. To attain perfection and reproducibility of their routines, the athletes must practice and repeat the basic elements of their routines thousands of times. In so doing, the athlete places herself at risk of a myriad of overuse injuries. The most common being low back pain.
Most reported series suggest that less than 10% of sports related complaints involve the spine (14,15). Specific sports such as gymnastics (1,2,4,5,10,12), dancing (9,12), football (2,11,13), rowing (6,7), and racquet sports (8,14) that require repetitive extension or repetitive high velocity twisting or bending have a significantly higher incidence of spine complaints. Rhythmic gymnastics is a sport that includes many of the demands of both gymnastics and dance and requires significant flexibility, particularly extension, of the lower spine. Very little material is available in the scientific literature regarding rhythmic gymnastics. Nonetheless, because of its sports specific demands, it is reasonable to hypothesize that rhythmic gymnastics is a sport at risk of low back complaints.
MATERIALS AND METHODS
To document the presence and severity of low back pain in elite rhythmic gymnasts two studies were performed. A prospective study of seven elite rhythmic gymnasts was undertaken which documented injuries and complaints. Each athlete was a member of the U.S. Rhythmic Gymnastics National Team with an average of 7 yr of gymnastics experience (range 6–8) and 2.3 yr of experience at the national level (range 2–4). The average age of the participants was 16 yr (range 15–17). The average training hours per week was 34. Daily medical reports noting complaints and defining injuries and treatments were recorded by the athlete and supervised by an athletic trainer over a 7-wk period. Pre- and post-practice evaluations were performed. Injuries were scaled in severity from 1 to 10 and each athlete was also asked to scale her assessment of general health and well-being.
The second study was a retrospective review of injuries in elite rhythmic gymnasts that required evaluation by a physician. Injuries were defined as those that required a physician’s evaluation. Time loss from sport was documented but not required for the definition of injury. Twelve elite level gymnasts were followed on average for 12 months (range 2–17) by a single physician. All were members of the national team, one at the junior level. The average age of the athletes was 16 (range 13–18). Weekly training site visits were available for nine of the girls. For the remaining three, the physician was immediately available by phone or urgent site visits.
Part 1: Prospective daily report of musculoskeletal complaints.
Four hundred seventy-four musculoskeletal complaints were recorded over the 7-wk course of the study which contained 490 athletic exposures. Each practice session or performance was defined as an athletic exposure. Each gymnast averaged 1.0 complaints per athletic exposure. On average over the course of the study, each gymnast reported 68 complaints (range 21–94) from nine separate anatomic sites (range 5–12). Only one injury required a time loss from sport (2 d). Eighty percent of the injuries were scaled as mild (1–3 of 10). Seventeen injuries (4%) increased in severity more than three levels secondary to continued participation in sport. Eighty-six percent of the gymnasts experienced back pain over the course of the prospective study. The distribution of injuries by anatomic site is seen in Table 1. Handedness was not related to the injuries. The athlete’s perception of health and well-being was correlated with her total number of injuries, severity of injuries, chronicity of injuries, exacerbation of complaints with practice, and back pain.
Part 2: Retrospective review of injuries evaluated by physician.
Fifty-four complaints over the course of the retrospective review were deemed severe enough to seek a physician. Eight complaints were medical in nature (bronchitis, traveler’s diarrhea, tonsillitis, etc.), leaving 46 musculoskeletal injuries. The distribution of injuries by anatomic site is seen in Table 2. One injury, a cervical spine strain secondary to collision with another gymnast, was acute. All others were related to repetitive practice of specific elements and overuse. Ten injuries required a time loss from sport (Table 3). The average time loss was 11 d (range 2–14). One athlete retired from the sport secondary to chronic low back complaints.
Low back injuries and complaints are not uncommon in athletic individuals or in the general population. Athletes participating in specific sports such as gymnastics, dancing, football, rowing, and racquet sports have been shown to be at increased risk of developing low back complaints (1–15). When evaluated prospectively with daily injury reports, 86% of rhythmic gymnasts reported low back pain. Low back pain was the most common site of complaints and accounted for 25% of the total complaints registered by the rhythmic gymnasts and 24% of the injuries that required a physician’s evaluation. Fifty percent of the injuries that required a time loss from sport were low back in nature. Certainly, rhythmic gymnastics should be included in the list of sports at risk of low back injury.
Previous studies have associated the risk of developing low back complaints with the specific sports that demand repetitive or high velocity twisting or repetitive bending flexibility particularly in extension (3,8,13). Tennis players who have pain associated with the twist of service, football lineman who complain when hitting the blocking sled from a crouched position, divers who complain with hyperextension maneuvers, or gymnasts who complain with lumbar extension while performing walk-overs are common mechanisms associated with low back complaints. Rhythmic gymnastics is a sport that demands flexibility. Poor flexibility is a deduction in judging. Back extensions, arches, stag leaps with back extensions, and split leaps with back extensions are common elements in rhythmic routines. To perfect these routines, the athletes will practice single elements and the entire routines hundreds of times. This emphasis on flexibility and repetitive demand of back extensions places the lumbar spine of the rhythmic athlete at risk. Muscle strains are most common, but bony stress reactions or fractures of the lumbar vertebrae (a.k.a., spondylolysis) are not infrequent.
The risk of low back injury in rhythmic gymnasts may be related to conditioning and proper technique. When rhythmic athletes perform a back scale (a position in which the back is fully extended and one leg points straight up and the second remains in contact with the floor), beginners or lesser performers tend to rise from this position by dropping their leg first in contrast to elite or high level performers who rise from their torso using their abdominal muscles. By dropping their leg to lift their torso, poor performers are using their lumbar spine as a fulcrum placing significant compressive forces on the vertebrae (especially the pars interarticularis). To reduce low back injuries, care must be taken to optimize abdominal strength and perform techniques properly.
In addition, the incidence of low back complaints may be able to be reduced by gradually attaining flexibility and avoiding ballistic stretching. Flexibility should also be optimized at joints above and below the lumbar spine. By optimizing flexibility of the thoracic spine and extension of the hip, less stress would be placed on the lumbar spine to accomplish the same position. Perhaps the most important step to reduce low back complaints would be to reduce the number of extension positions required in a given routine and the total number of repetitions in practice. The Federation International Gymnastics, the international governing body of rhythmic sportive gymnastics, has recognized the problem and has begun to institute such requirements, including limiting the number of extension elements in a given routine to a single element.
Treatment of low back pain is generally conservative with a reduction in activity and the exacerbating stresses. Occasionally, a brace or lumbosacral corset can be used to provide additional support and comfort. Antiinflammatory medications can be added to reduce inflammation and pain. Muscle relaxant medications can be added if spasm is present. Icing, massage, ultrasound, stretching, and other modalities may also be beneficial. If pain resolves, preventative exercises are begun, and a gradual return to sports specific skills is instituted. If the pain does not resolve with in a week, additional studies may be warranted. Plain radiographs are rarely positive but are an inexpensive first step. Bone scans, especially tomographic SPECT scans, are the most sensitive and valuable tool to identify either a bony stress reaction or a stress fracture (spondylolysis). Magnetic resonance imaging is generally not necessary unless radiculopathy is present and the presence of a herniated disk must be excluded.
In conclusion, rhythmic gymnastics is a sport at increased risk of low back injuries. The mechanism is probably secondary to repetitive lumbar extension. Further studies are necessary to assess whether interventions including abdominal strengthening, optimizing adjacent joint flexibility, reducing extension elements in routines, and assuring proper technique will indeed reduce the incidence of low back complaints in this sport.
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