Injuries are an unfortunate, but common experience for many athletes. The number and type of injuries in each sport vary, based on the motor and cognitive actions required for each unique sport (1–3). Artistic gymnastics has a particularly high rate of injury; it has the second highest injury rate during practice in collegiate sports, behind only spring football (1). Reported injury rates in gymnastics vary from 1.3 to 9.22 per 1000 exposure hours (1,4,5), which is approximately how many hours an elite gymnast trains per season (6). Although overuse and traumatic injury rates in gymnastics are among the highest of any sport per athletic exposure, there is limited information available to guide health care professionals for returning gymnasts to the highly technical demands of the sport (4).
Sports medicine clinicians face distinct challenges in managing injuries in gymnasts, as these athletes typically begin participation at a young age, and must adhere to unique physical demands to be successful. Many artistic gymnasts start participation in their sport between the ages of 4 and 8 yr (5). As gymnasts progress in their technical skills, training time tends to increase from less than 9 h·wk−1 as beginners, to between 20 and 40 h·wk−1 as elite gymnasts (4,7,8). In addition, gymnasts tend to be engaged throughout the year without a devoted rest period. Frequently, this uninterrupted and increased training occurs while young gymnasts also are going through many physiological and development changes relating to the adolescent growth spurt and puberty. Developing athletes during this time of life, especially when combined with long training hours, may be particularly vulnerable to injuries (9,10).
Overall, more than half of gymnastics injuries are to the lower body and are typically strains, sprains, or overuse-related (4). Using the National High School Sports-Related Injury Surveillance System, Reporting Information Online (RIO) database, researchers showed female gymnasts had the second highest rate of stress fractures (7.43 per 100,000 athlete exposures), just behind female cross country athletes (10.62 per 100,000 athlete exposures) (11). Furthermore, female gymnasts also had the highest rates of patellar instability injuries (6.19/100,000 athlete-exposures) of all high school athletes (12). The use of rehabilitation programs to treat these and other injuries is imperative to safely return athletes to their sport, reduce their risk of reinjury, and avoid chronic issues later in life.
Many sports medicine clinicians utilize return to play (RTP) protocols based on general guidelines for an injury or specific to a sport. These protocols allow athletes to progress from the time of injury until they can participate in their sport in a safe and effective manner. Return to play protocols typically aim to minimize pain levels, build strength, and improve range of motion while reducing reinjury risk in a stepwise and progressive manner (13). Because there tends be more reliance on a “one size fits all” approach for RTP protocols, gymnasts may have difficulty progressing back to the unique movements, high forces, and the different events in their sport. Current literature is scarce related to systematic RTP guidelines for gymnasts, making RTP decisions for these athletes difficult for clinicians.
Based on the stated gaps in the literature, our review had four purposes. First, we sought to define the guiding principles used to determine RTP in sports. Second, we identified factors that affect recovery progression among injured artistic gymnasts. Third, we determined how different injury type affects RTP protocols. Fourth, we created a structured RTP protocol specific to male and female artistic gymnasts for health care providers to use in clinical practice. By addressing each of these purposes, we provided RTP guidelines for artistic gymnasts who have sustained injuries to the back, upper extremity and lower extremity, stratified by sex. By establishing these guidelines, future studies will be able to address the efficacy of such standardized approaches and determine if further changes are required.
Among the many challenging aspects of clinical care within sports medicine, one particular challenge is determining the appropriate time when a RTP progression can be initiated and when full sport participation clearance can be given to an individual athlete. This is difficult for clinicians because each sport has a diverse set of demands, such as the motor skills required for successful completion and injury avoidance. In addition, each injury requires a different rehabilitative protocol and expected recovery timeline. Although it is important to institute a rehabilitation program for each individual athlete, this is difficult as sport- and body region-specific protocols and evidence-based guidelines are not widely available in the existing literature (13).
The development of sport-specific guidelines allows for individualized decision making and direction for rehabilitative pathways. This is typically done by a progressive and stepwise approach to ensure that the athlete does not return to sport while still vulnerable to further injury. Thus, recommendations have stated that it may be necessary to stay within a given step on the RTP timeline for a longer period if the athlete does not demonstrate the ability to progress to the next stage (14). While slow progression is not necessarily concerning, clinicians also may monitor progression through RTP protocols to identify if a patient may benefit from a specialist referral.
Several systematic reviews have provided qualitative syntheses of the literature pertaining to RTP following different orthopedic injuries, such as after anterior cruciate ligament reconstruction (15), clavicle fracture (16), tibial stress fracture (17), or ankle fracture (18). In addition, there has been a focus in the literature surrounding sport-related concussion in recent years. Although there are widely published RTP concussion guidelines (14,19,20), there is no evidence that RTP guidelines affect injury prognosis (21), and many athletes do not follow these recommendations (19,21). Many of these concussion protocols do not address factors specific to gymnasts; however, there is one recent report that provides guidelines specifically for artistic gymnasts who sustain a concussion which include the following steps (20):
- No physical activity
- Light aerobic activity: 10–15 min of walking or stationary bike
- Moderate aerobic activity: 20–30 min of jogging and body weight squats and push-ups (1 set of 10 reps)
- Vertical work: handstand skills (variable depending on level)
- Intro level tumbling and bar skills; basic vaults
- Full practice (after medical clearance)
- Unrestricted workouts and competition
Although this represents a step toward reducing the reliance on universal and non-individual approaches to reintegration in gymnastics, it also is necessary to understand how RTP demands may differ by injury type within the sport of gymnastics. Therefore, there is a clear need to develop step-wise gymnastics-specific RTP protocols beyond concussions. This development may assist sports medicine clinicians in appropriately guiding artistic gymnasts back to sport in a safe and appropriate manner.
Factors Affecting Return to Sport in Gymnastics
The diverse set of competition apparatus and specific body movements required for a successful artistic gymnast make the physical demands of the sport distinct. While lower extremity musculoskeletal injuries and spine injuries typically account for greater than 60% of the injuries sustained in gymnastics, all joint regions are at risk of injury during gymnastics (6,22,23). Therefore, it becomes challenging to rest or protect specific tissues during the recovery and RTP progression following an injury.
In addition to the whole body demands of the sport, artistic gymnastics also exposes the body to a high volume of force through repetitive stress and through compressive, distractive, and rotational forces. During events, varying levels of accelerations and forces are imparted onto musculoskeletal structures, potentially leading to injury. For example, during basic skills on the uneven bars, the spine can experience both compressive and distractive forces several times the gymnast’s body weight (24,25). This experience is not only responsible for unique injuries such as vertebral end plate damage of the spine, but also indicates that both compressive and distractive, forces should be considered during the construction of RTP guidelines and athlete progression following most gymnastics injuries. Providing guidelines for progressive increase in both intensity and volume of these specific forces is key to allowing appropriate tissue adaptation as the athlete returns to sport.
Many artistic gymnasts feel pressure to return to gymnastics quickly and often before they are physically and mentally ready after an injury. In addition, some gymnasts feel they should train through pain and may not divulge pain as they RTP. Therefore, medical providers should encourage clear and open communication between the athlete, coach and medical team during the RTP process to keep the athlete healthy.
The relatively young age of the vast majority of artistic gymnasts is another variable to consider in guiding return to sport (26). Furthermore, the skeletal maturity of athletes is variable across the competitive levels of the sport and in males versus females which can affect injury patterns and subsequent RTP decision. In addition to learning skills, improving technique, and developing strength, young gymnasts undergo a rapid development in growth (i.e., height and weight) and neurocognition. This puts high demands on the physical and cognitive systems during this period of life. The young age of many gymnasts also results in unique injuries such as apophysitis, growth plate fractures, and avulsion fractures that are critical to consider in light of the high incidence of repetitive stress-type injury in the sport (6,22,23). The volume of repetitions and adequate recovery time between bouts of exposure, as well as nutritional and psychological health, become paramount in managing successful progressive return to sport following injury.
While it is beyond the scope of this paper to describe in detail the specific skills that must be performed to achieve each progressive level of gymnastics, there are many reasons to consider the level at which an athlete is training when returning him or her to gymnastics. First, skills required at each level may put very different demands on healing tissues (e.g., impact, torsion, rotation). Second, the athlete may be competing with one set of skills while training a separate set of skills necessary for the next level of competition. Finally, the number of hours trained per week typically increases with level of competition. Thus, as a gymnast progresses to higher levels of competition, the technical skill expected for tumbling, release moves on bars, and dismounts from all apparatus becomes much higher, as do the potential forces experienced by the body. Medical providers should have a basic understanding of which skills the athlete will be training on returning to full sport participation to provide appropriate guidance regarding specific skill completion or avoidance. Tables 1 and 2 provide a general guideline of many skills required to progressively return to each event in gymnastics, but are not specific to each level of completion.
The process of acquiring a new skill not only puts increased forces on tissues, but it often involves higher repetitions and inherently requires more energy to perform than a proficient skill (27–29). In addition, psychological factors such as anxiety, fear of decreased performance, and fear of reinjury have been established as some key barriers to successful return to sport following injury (30,31). As a means to instill progressive levels of confidence, it has been advocated to initiate return to sport with previously mastered skills (32,33). They may then slowly begin training the skills they were working to acquire one skill at a time. Progressive volume of exposure also is critical in RTP protocols for gymnasts. An artistic gymnast can train anywhere from 3 to 6 h·wk−1 in the recreational levels to 30 to 40 h·wk−1 for the level 10 or elite gymnast (7,8). If an injured gymnast is cleared to do certain activities or events, he or she should still avoid overtraining that event to avoid a new overuse injury. Then, as the gymnast progresses back to more skills, slowly increasing the amount of time training will allow for progressive adaption of other non-injured joints and tissues. Thus, modifying and progressing time of training relative to these expectations will be critical for successful return to sport and to decrease the risk of reinjury or onset of new acute or overuse injury.
A factor connected to the skills being trained is the constant evolution of scoring and rules within the sport of artistic gymnastics. From year to year, the point value given to a specific skill may be changed, and thus the athletes may have to change the skills they are performing to attain the score they need to compete successfully. In addition, rules regarding body positions during skills and on landings may put the athletes at greater risk for injury. For example, more vertical torso and knee positions when landing dismounts, vaults, and tumbling skills is often rewarded with more points, but there is evidence that this position increases joint reaction forces throughout the lower extremity joints and spine (24,25) and is linked to significant knee injuries (25,34–37). As such, during RTP progression following lower extremity or lumbar spine injury, educating the athlete to land with more knee and hip flexion to reduce forces may be a beneficial strategy.
Injury Type and RTP Protocols
After injury, clinicians should consider the type of the tissue injured, body part injured, and type of injury (overuse vs. traumatic/acute) to successfully guide gymnasts in their RTP protocols. When considering the specific type of tissue injured, it is helpful for clinicians to divide them into two categories: tissue that is most impacted by compressive forces (e.g., cartilage/joint surface, bone) and tissue that primarily provides power, force, or stability (e.g., musculotendinous unit, ligament).
Tissue impact alteration can be considered using two mechanisms during the RTP progression in gymnastics: utilizing equipment that reduces impact forces during landing (tumble track/trampoline, rod floor, mats) and using momentum to transition into and out of a skill. For example, initially a gymnast would tumble a series of skills on a tumble track (e.g., a long trampoline) before moving to the floor. He or she would then progress to individual skills (e.g., back handsprings or saltos) on the regular floor and then on the beam. Finally, the gymnast would complete more complex skills, such as dismounts or vaults. When considering force production and stabilizing tissues, movements would start on a stable surface in a slow, controlled manner working toward fast or ballistic movement on a compliant surface. For example, after an ulnar collateral ligament injury, a gymnast should perform static handstands on a stable surface, such as the regular competitive floor, before progressing to a more dynamic handspring skill on an unstable surface, such as a trampoline. As previously mentioned, when considering repetitive stress injuries, the most critical consideration is volume of training allowing for tissue recovery and adaptation between bouts of exposure. Both the number of exposures per training session and number of training days per week will progressively increase over the course of weeks to months depending on the injury.
As a result of the variety of demands put across joint regions by the events in gymnastics, it is not sufficient to lump multiple joint regions together for return to sport protocols. Thus, we have created RTP protocols for lower extremity, back, shoulder, elbow, and wrist in both male and female artistic gymnasts (Tables 1 and 2). An injury to some joint regions, such as lumbar spine or hip, will require specific progression of skills on all events. However, an injury to other regions such as ankle or knee, may allow for training nearly all skills on uneven bars for females and on high bar, parallel bars, pommel horse, and rings for men as long as the gymnast is performing skills they have previously mastered early in the RTP process. Strength and flexibility is a large part of a gymnast’s training; however, we have not included this in our RTP protocols as the number of conditioning exercises that are possible is so extensive that it is beyond the scope of this article. Nevertheless, injured gymnasts may be asked to do very long periods of conditioning or flexibility which could lead to a new injury. Therefore, medical providers, coaches, and gymnasts should discuss and plan for an appropriate amount of time, exercises, and repetitions that will be indicated for each individual gymnast based on their level in the sport, maturity level, and injury.
Return to Gymnastics in Clinical Practice
To develop the conceptual understanding of gymnastics injuries, we created a clinical practice guide for systematically returning athletes to artistic gymnastics. This document, which includes progressive return to gymnastics tables, was developed for patients, parents, coaches, physical therapists, athletic trainers, physicians, and other health care providers who are involved in a gymnast’s care, whether at a recreational, club, or elite level. Although this development represents a progression toward individualized injury care for gymnasts, it should not be considered the current standard of care, as it is based on clinician opinion and not on original research. This document is only a guide, and is of a general nature, consistent with the reasonable practice of a health care professional. While author agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of gymnastics injuries is evolving and therefore individual management and RTP decisions remain in the realm of clinical judgment. Individual treatment will depend on the facts and circumstances specific to each individual case and may not be appropriate for every gymnast or every gymnastics injury.
Male and female artistic gymnasts compete in several different events that require different skills and strengths. Therefore, these RTP protocols were developed specifically for anatomic location and sex. Prior to starting each return to gymnastics protocol, the health care provider should confirm that the athlete has minimal to no pain at the area of injury, full and pain-free range of motion, near equal strength of the extremity or joint as compared to the contralateral side and has performed satisfactorily on functional testing (13). These criteria are usually met after completion of a rehabilitation program addressing underlying inflexibility, core weaknesses, inadequate proximal control, lack of proper technique, faulty movement patterns, and/or musculoskeletal deformities placing particular joints at increased risk of injury. Gymnasts with impact-related pathology, such as stress fractures, ankle impingement, apophysitis, and osteochondral defects, should start with connected skills on a tumble track before progressing to the floor and firm surfaces. In contrast, gymnasts with stability-related pathology, such as patellar dislocations, ACL injuries, and ankle sprains, should begin with individual skills on a firm surface and add rotational and twisting skills later in the progression.
Prior to starting a RTP protocol, gymnasts should be aware of additional variables that can affect successful return to gymnastics, such as proper sleep and nutrition. Each protocol should be tailored to the athlete’s injury, handedness, skill level, and the skill demands required for their individual events. In addition, gymnasts should start with approximately 50% of the standard number of repetitions of each skill typically performed. The protocol should be stopped with any return of pain during any of the stages.
In Tables 1 and 2, each column represents a different event in which artistic gymnasts compete, as well as a tumble track column. The tumble track is a long trampoline where gymnasts often learn tumbling skills. Each row in the tables represents a new step. Gymnasts should not perform more than one step per day; in fact, some gymnasts may need to stay at a specific step for more than 1 d if there is difficulty completing the indicated skills or if the gymnast had a more severe injury. For each step, the gymnast may add the indicated new skills as listed in the row for all the events. A rest day should follow any stage that has reproduced pain in the area of injury. After a day of rest and complete resolution of pain, the gymnast should start again at the previous, non-painful stage and progress as tolerated. Mild-to-moderate pain or soreness in muscles that resolves within 1 to 2 d of a training session and is not in the area of injury should not cause the athlete to stop the progression through the protocol. If a gymnast reaches a point in which they are not able to progress through the stages due to recurrent pain, the athlete should be referred back to their treating physician.
Artistic gymnasts have a unique set of requirements to successfully participate in their sport. The current literature is limited in guiding these athletes through RTP protocols. We reviewed the literature and created RTP protocols specific for male and female artistic gymnasts based on the body part that was injured. Readers are encouraged to use this guide for the basis of future research studies. In addition, health care providers, patients, parents, and coaches may use this as a guide for prevention of future injuries and to aid gymnasts in a RTP progression after an injury.
The authors declare no conflict of interest and do not have any financial disclosures.
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