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The Young Injured Gymnast

A Literature Review and Discussion

Hart, Elspeth, PA-C, ATC; Meehan, William P. III, MD; Bae, Donald S., MD; d’Hemecourt, Pierre, MD, FACSM; Stracciolini, Andrea, MD, FACSM

doi: 10.1249/JSR.0000000000000536
Competitive Sports: Section Articles

Gymnastics is a sport requiring grace, strength, and flexibility, resulting in a wide variety of injuries. This article is an overview of the sport of gymnastics and associated injury trends in the artistic gymnastics population. Injury rates in gymnastics range from 1.08 to 50.3 per 1000 h of exposure. More injuries occur in competition versus practice. Fewer injuries occur in recreational gymnastics than competitive gymnastics. The most common injury in gymnastics occurs in the lower extremity, and is an ankle sprain, followed by knee internal derangement. However, in men’s gymnastics the most common gymnastics injury occurs in the upper body (specifically the shoulder). The most common skills causing injury to a gymnast are front/back handsprings and saltos/flips. Unique injuries commonly seen when caring for the young gymnast include spondylolysis, ostoechondritis dissecans of the capetillium and talus, Gymnast wrist, Grip lock, Osgood‐Schlatter, patellofemoral syndrome, Sever’s disease, and ankle sprains. Research efforts should focus on injury rates after the 2006 rule change, injury prevention, men’s gymnastics injury patterns, concussions, hip injuries, and ACL injuries in gymnasts.

Division of Sports Medicine, Department of Orthopaedics, Boston Children’s Hospital; Harvard Medical School, Boston, MA; The Micheli Center for Sports Injury Prevention, Waltham, MA

Address for correspondence: Elspeth Hart, PA-C, ATC, 45 Leland Rd. Chestnut Hill, MA 02467; E-mail: GymnasticsMedicine@gmail.com.

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Introduction

The demand for strength, flexibility, grace, and artistry makes gymnastics a sport that results in a unique spectrum of injuries. As described by Kruse and Lemmen (1), gymnastics includes a high level of proprioceptive control, extremity impact, hyper-lordotic positioning, and highly dynamic dismounts that can be taxing and difficult on young developing bodies. These factors combine to set the young gymnast apart with regard to injury risk.

Gymnastics is one of the oldest sports dating back to the ancient Greeks (2). USA Gymnastics (USAG), the governing body of United States gymnastics, reports 102,295 athlete members, including 86,800 artistic gymnasts (3). The different forms of gymnastics include artistic, rhythmic, tumbling and trampoline, acrobatics, and gymnastics for all (3). This literature review will focus on artistic gymnastics, rhythmic gymnastics, and gymnastics for all (specifically Power TeamGym). Artistic gymnastics is the most commonly known form of gymnastics and there are four events for women including the vault, uneven bars, balance beam, and floor exercise (3). There are six events for men in artistic gymnastics: floor exercise, vault, high bar, pommel horse, rings, and parallel bars (3). Rhythmic gymnastics has five events including the rope, hoop, ball, clubs, and ribbon and focuses more on flexibility (3). Gymnastics for all (specifically Power TeamGym) has two events, group floor exercise and group jump (tumbling, vault, and mini tramp), and focuses on performing gymnastics as a team and performing streaming (multiple gymnasts performing skills in a row and at the same time in a straight line) (3).

There are different levels of competitive gymnastics: recreational classes (beginner level), competitive teams (Excel/Prep-Optional and Junior Olympic levels 1–10, with 10 being the highest), and Elite (Olympic level) (3). Training time in gymnastics depends upon level and can vary greatly. For example, recreational gymnasts may train between 1 and 4 h·wk−1, while higher levels and elite gymnasts may train between 20 and 40 h·wk−1. Intense training for the young gymnast involves year-round training.

Every 4 years, concurrent with the summer Olympics, there are rule changes and new skills, which are incorporated into gymnastics by USAG (1,3). As a result, the skill level continues to evolve, changing the injury risk. In 2006, the “perfect 10” was eliminated from Elite/Olympic level gymnastics. Scoring in elite gymnastics is now based upon a combination of difficulty and skill, with the more difficult the skill, the higher the potential score. The score is broken down into execution (how well you perform the skill) and difficulty (what skills you perform and what values/points are associated with those skills). The execution score is out of a 10, and points are subtracted for skills done improperly (bent knees, flexed toes, falling off the apparatus, etc.). The difficulty is accessed by the “Code of Points” (a book containing all gymnastics skills and what they are worth). The two scores are then added together to give the gymnast her score for the event. The current average range is up to 16 points, however, there is no upper limit on how high a gymnast can score. This review discusses the most common injuries sustained during gymnastics participation by young athletes.

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Injury Epidemiology

The USAG safety manual defines a gymnastics injury as any injury sustained during gymnastics participation resulting in the gymnast missing any portion of a workout or competitive event (3). While acknowledging the many benefits of gymnastics participation, including discipline and physical fitness, most gymnasts do not pass through their years of training and competition without incurring injury (4).

The incidence of injury in gymnastics in both collegiate, precollegiate, artistic, rhythmic, and TeamGym ranges from 1.08 to 50.3 per 1000 h of exposure (Tables 1–3) (4–13). The wide variety of data on this is due to the fact that most studies performed had several different variables (e.g., age, time frame, level, etc.). Saluan et al., O’Kane et al., Lindner et al., Caine et al., and Zetaruk et al. investigated the injuries per 1000 h of exposure in precollegiate women’s artistic gymnasts and noted that the rate varied between 0.52 and 3.66 per 1000 h of exposure (Table 1) (4–7). Kerr et al., Westermann et al., Marshall et al., and Sands et al. investigated the rate of gymnastics injuries in women’s collegiate artistic gymnasts finding rates of 9.22 to 22.7 injuries per 1000 h of exposure (Table 2) (8–11). Lund et al. and Cupisti et al. investigated other forms of women’s gymnastics (TeamGym and Rhythmic respectively) and found injury rates between 1.08 and 50.3 per 1000 h of exposure (Table 3) (12,13). The wide variety of data previously mentioned is due to the fact that most studies performed had several different variables including age, level, time frame, location of the study performed, type of gymnastics, and different study methods/design. Of note, all studies included females and only in the Westerman et al. (9) study were men included and identified.

Table 1

Table 1

Table 2

Table 2

Table 3

Table 3

When investigating levels in gymnastics, the Junior Olympic system as mentioned in the introduction has levels 1 to 10, with 10 being the highest level. To summarize per this review findings two different sub level groups: precollegiate (Prep-Optional/Excel, Junior Olympic levels, and Elite), and collegiate (divisions I, II, and III), were created, and the injury rate was noted to be 0.52 to 2.155 vs 9.22 to 22.7 per 1000 h of exposure. This would indicate that precollegiate gymnastics has fewer injuries per 1000 h of exposure when compared to collegiate gymnastics.

Also, as mentioned in the Introduction, there are different types of gymnastics (Artistic [most commonly known], rhythmic, tumbling and trampoline, and group gymnastics [TeamGym]). This review does differentiate between artistic gymnastics and nonartistic gymnastics (TeamGym). When comparing artistic gymnastics to nonartistic gymnastics (excluding tumbling and trampoline as there is no specific data on this), injury rates are 0.52 to 22.77 vs 1.08 to 50.3 per 1000 h of exposure. This indicates that Artistic Gymnastics has less injuries per 1000 h of exposure when compared to nonartistic gymnastics. It would be important to note that not much research has been performed on nonartistic gymnastics and that the TeamGym study was performed outside of the United States. More research should focus on injury rates in nonartistic gymnastics.

To summarize injury rates per this review, precollegiate artistic gymnasts (0.52 to 2.155 per 1000 h of exposure), and rhythmic gymnasts (1.08 per 1000 h of exposure) have the lowest rates of injury followed by collegiate gymnasts (9.22 to 22.7 injuries per 1000 h of exposure), and then TeamGym gymnasts (50.30 per 1000 h of exposure).

When looking at specific diagnoses, the most common injuries are strains and sprains, accounting for 27.7% of overall injuries (5). Fractures represented a significant, but smaller number, 9% of overall injuries (5). Multiple studies have demonstrated that the most common location of injury in gymnastics is the lower extremity, specifically ankle sprains, and knee internal derangements (1,4,8,14). In men’s gymnastics, however, the most commonly injured body part is the upper extremity, specifically the shoulder and wrist (4).

Incidence rates of injury in gymnastics during competition are higher than during practice, despite the fewer hours spent in competition (1,14). Webb and Rettig (15) found that the incidence of acute injuries is 10× higher during competition than in practice. Marshall et al. (10) found that the rate of injury in competition was more than two times higher than in practice (15.19 vs 6.07 injuries per 1000 athlete-exposures). Marshall et al. (10) also found that a gymnast was almost six times more likely to sustain a knee internal derangement injury in competition than in practice, and almost three times more likely to sustain an ankle ligament sprain, and that the majority of these injuries (roughly 70%), occurred either on landings on the floor exercise or dismounts. The difference in injury patterns in practice versus competition likely is related to the fact that during practice gymnasts are very protected when performing skills/landings. Preventative measures in practice include spotting from a coach, use of foam pits and softer mats, and functional bracing or taping (4,14). There is a significant increase in nervousness and pressure when competing, which could result in a higher risk of injury. Typically, most gymnasts participate in “mock” meets or “practice competitions” to try to ease their nervousness. As stated previously, gymnasts are rewarded higher points for more difficult elements; gymnasts also are more likely to attempt a skill even if they feel that they “may not land the skill” due to the possibility of the reward for the higher score. This may cause a gymnast to attempt a skill he/she is not ready for to obtain a higher score. One possible solution may be higher deductions for falls, or deductions on execution of these skills, resulting in gymnasts being less likely to “take the risk” for the bigger skill.

Keller (16) found that the most common skills, which cause injury to a gymnast, are back/forward handsprings and flips/saltos (42% of injuries). This is not unexpected as back/forward handsprings are typically skills used to generate angular velocity, momentum, and kinetic energy in preparation for subsequent maneuvers and are skills that are performed often by all gymnasts and are one of the first “big skills” to master as a young gymnast (typically in level 3 on floor). Flips/saltos only become more complex and difficult as the gymnast increases his/her level and difficulty. Cartwheels and roundoffs are the second most common skill causing injury (31%) (16). These are skills learned at a young age as well and also are used to generate angular velocity, momentum, and kinetic energy in preparation for subsequent maneuvers. Floor is the most common event causing injury, as back/front handsprings, flips/saltos, cartwheels, and round offs (the most common skills causing injury) are all performed on the floor exercise. Multiple studies support this same finding (8,10,17). Kirialanis et al. (17) found that 40% of acute injuries occur on landings. Marshall et al. (10) reported that almost one third of all competition injuries occurred during the floor routine, and for nonfloor events, dismounts accounted for most of the injuries.

Injury rates also are tied to the level of the gymnast. Saluan et al. (5) and Webb and Rettig (15) have noted that there is a 25-fold higher injury rate in the highest level of the United States Gymnastic Federation as compared with the lowest level of competition. Similarly, Keller (16) found that a child participating in recreational gymnastics experienced fewer injuries than higher level gymnasts. Saluan et al. (5) note that there is a significant increase in injury rate when practice hours per week increase from 12 to 16 h or higher.

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Injuries by Body Part

Spine

The rigorous training schedule and repetitive nature of the sport of gymnastics imparts great stress to the spine. Extension, axial loading, and traction forces are estimated to be 6.5 to 9.2 times body weight during the downward ring swing (1). The most common causes of back pain in a gymnast include spondylolysis with or without spondylolisthesis, discogenic back pain, spondylogenic/mechanical back pain, Scheurmann’s disease/“atypical” Scheurmann’s disease, and vertebral body fractures (Fig.) (18). The prevalence of back pain among gymnasts ranges from 25% to 85%, with some studies noting the incidence of back injuries as high as 65% to 86% (1).

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Spondyloysis/Spondylolisthesis

Young gymnasts presenting with extension-based low back pain require comprehensive evaluation for spondyloysis prior to return to sport clearance. Spondylolysis is a repetitive stress fracture of the pars interarticularis of the lumbar vertebrae that occurs from repeated hyperextension and twisting/rotation of the spine (1). This motion occurs during, but not limited to, back/front walkovers, back/front handsprings, and the Yurchenko vault. Spondylolisthesis is a translation of one vertebra with respect to the others that can occur in the anterior (anterolisthesis) or posterior (retrolisthesis) direction (1). Current incidence of spondyloysis occurring in artistic gymnastics is 16.96% (19). Typically, the gymnast will present with the insidious onset of low back pain that is worse with extension. On physical examination the gymnast will have pain with extension particularly in a single leg stance (positive stork test), and tenderness to palpation at the L4 and L5 level (18).

Radiographic confirmation is necessary prior to the start of treatment, however there are many differing opinions on what the first diagnostic test should be. X-rays, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) bone scans and computed tomography (CT) scans all may provide useful information. X-rays have been found to be 32% to 78% sensitive (20,21) in detecting spondyloylsis, although the typical AP and lateral views are less sensitive than oblique views. It is important to note that X-rays are insufficient for diagnosing and determining the treatment protocol. Kobayashi et al. (22) performed a study to determine what test may be most sensitive and specific to evaluate low back pain. Of 200 athletes with back pain who had negative X-rays, 48% of the subjects had spondylolysis that was diagnosed by MRI or CT scans. A SPECT scan or CT scan, some argue, provides the best visualization of spondyloysis; however, there is substantial radiation exposure associated with these studies. As noted above, an MRI, which is not associated with radiation, also can be used to make the diagnosis. For the MRI to be as effective as possible, it has been suggested edema sensitive sequences (Short-TI Inversion Recovery [STIR] and T2 fat saturated) and cortex sensitive sequences (T1 or T2 non fat saturated) be performed. The MRI views should be done with multiplanar (axial, sagittal, coronal, and oblique) views, along with thin slices (<3 mm) to provide the best views. The MRI will show bone edema of the posterior bony elements of the lumbar spine with the edema sensitive sequences. The actual fracture lines of spondylolysis are best seen with the cortex sensitive sequences. A CT scan also may be considered to classify the fracture as early, progressive, or terminal. The early fractures have minimal displacement while the progressive fractures may have more displacement. The terminal fractures display widening with sclerosis. Spondyloysis is most commonly observed at L5 level, followed by the L4 level.

There also is a substantial amount of controversy on the treatment of spondylolysis. Current treatment recommendations may include some or all of the following: limitation of activity, bracing (Boston overlap brace [BOB]/soft brace), bone stimulator, and physical therapy. The purpose of the BOB is to improve sagittal alignment of pars, limit extension, and limit axial rotation to optimize treatment for bony union. Sairyo et al. (23) found that with the BOB brace union rates were 94%, 64%, 27%, and 0% for the early, progressive with high signal intensity, progressive with low signal intensity, and terminal defects, respectively; thus indicating the benefits for using the BOB brace. It should be noted that Klein et al. in a meta-analysis found that there was no significant difference in clinical outcome between bracing and nonbracing (24). In addition, the use of bone stimulators for treatment of spondylolysis may be employed. There has not been much research in this field. One case study performed by Fellander-Tsai and Micheli (25) showed that the bone stimulator did help increase healing. Typically, there is a restriction of gymnastics activity for the first 4 to 6 wk. If, at the end of that period, the athlete is asymptomatic with a normal examination, then return to activity is allowed in the brace if there is no pain. In the young gymnast with a fracture, the treatment goals are pain relief and, ideally, bony union of the fracture. Bony union, however, is not always achieved, and confirmation of bony union is not typically sought.

Prevention of spine injuries is preferable to treatment after the injury has occurred. The gymnast, along with the coach, should work on proper technique for spinal extension-based skills as well as abdominal stabilization and antilordotic conditioning exercises. Proper landing mechanics also are important to decrease forces on the lumbar spine. One injury prevention tactic may be limiting the repetition of spinal extension-based skills, especially during rapid periods of growth. Moreover, the choreography of routines, as currently governed by USAG, could include limitations on either the number of skills involving spinal extension or decreasing the repetitions of skills involving spinal extension during practice. Working with a physical therapist or athletic trainer to increase muscle flexibility of the anterior chain musculature (hip flexors quadriceps), increasing shoulder flexibility and thoracic flexibility (to decrease the load on the lumbar spine), and strengthening the abdominal and spinal core muscles also may decrease the risk of spondylolysis (26).

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Upper Extremity

Gymnastics involves multiple skills that result in considerable forces and torques imparted to the upper extremity. A gymnast uses his/her upper extremity as a high-impact, weight-bearing limb. In men’s gymnastics, the proportion of upper extremity injuries (53.4%) is greater than lower extremity (32.8%) injuries (4). The most common location of injuries of the upper extremity in men’s gymnastics is the shoulder, followed by the wrist (14). Among female gymnasts, the wrist is the most commonly affected structure of the upper extremity, followed by the elbow (14). The incidence of injuries sustained by the upper extremity ranges between 11% and 53% (14). Multiple prospective observational studies have suggested that in the course of a single season, more than 80% of the athletes will experience some wrist and elbow pain; however, this will not necessarily result in missed practice or competition (27–30).

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Shoulder

The shoulder is the most common area of injury in men’s gymnastics (4,14,16). It is hypothesized that the men’s events — including, rings, high bar, parallel bars, and pommel horse, which are not performed by female gymnasts — increase the stress and load to the upper extremity, causing injury. The most common gymnastics shoulder injuries include rotator cuff impingement, rotator cuff strain, labral tears, acute shoulder dislocations, and multidirectional instability (Fig.). The most common diagnosis is muscle strain (16).

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Elbow

The repetitive high-impact loading of the upper extremity that occurs during gymnastics can result in multiple elbow disorders. The most common elbow injuries are osteochondritis dissecans (OCD) of radiocapitellar joint, ulnar collateral ligament sprains and tears, medial epicondyle apophysitis or avulsion fracture, elbow dislocation, and tendinosis (Fig.) (5,14,31).

One of the most frequent osteochondral lesions (OCD) in a gymnast is of the capitellum, typically seen between the ages of 10 and 14 years (31). Juvenile gymnasts are at a higher risk for osteochondral lesions of the elbow than athletes without excessive stress on the upper extremities (31). Dexel et al. (31) describes how repetitive high impact in sports stresses the elbow joint into the valgus position, and forces the capitellum to withstand compression and shear forces, which can then lead to OCD of the capitellum. Young athletes are at greater risk owing to the relatively limited vascular supply to the developing distal humeral chondroepiphysis; for this reason, capitellar OCD rarely occurs in skeletally mature gymnasts. OCD of the capitellum is found almost exclusively in gymnasts and young baseball pitchers (31). Timely diagnosis of capitellar OCD is necessary to avoid an increased risk of progression to loose body formation, joint incongruity, and premature degenerative changes of the elbow joint (32). Gymnasts typically present with insidious onset of lateral or posterolateral elbow pain. In advanced cases, athletes may report loss of terminal elbow flexion or extension as well as locking or catching of the elbow. On physical examination, the gymnast may have tenderness to palpation over the capitellum, decreased range of motion when compared to the contralateral side and swelling. Plain radiographs should be obtained initially and may show a lucency in the capitellum or even a loose body within the elbow joint. Advanced imaging with MRI is used in cases of suspected OCD lesions with negative radiographs for diagnosis and cases of confirmed OCD lesions to determine the stability of the lesion and guide treatment (16,31). Current treatment recommendations based off this literature review and clinical practice for a stable OCD include rest from gymnastics, particularly in younger athletes, followed by serial evaluations and physical therapy. For gymnasts with OCD instability or those unresponsive to conservative treatment, surgical treatment in the form of loose body removal, internal fixation of an unstable osteochondral fragment, marrow stimulation, and/or osteochondral grafting is considered.

In terms of prevention, gymnasts should work on proper technique while performing weight-bearing upper extremity skills. Additionally, it is important to encourage the athlete to inform their coach and guardian if they are having elbow pain to identify this diagnosis early and decrease the risk of irreversible damage to the joint. Limiting the amount of torsion on the elbow during significant periods of growth and limiting the number of upper extremity skills could help decrease the incidence of OCD of the capitellum in the young gymnast. Working with a physical therapist or athletic trainer to increase shoulder flexibility and thoracic spine mobility also may help decrease the forces on the elbow.

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Wrist

During gymnastics the wrist can experience forces up to 16× a gymnast’s body weight making it the 3rd most common site for injury in gymnastics (28). The prevalence of wrist pain ranges from 46% to 79% of gymnasts (16,28), and there are reports as high as 70% to 88% of gymnasts (15,17). The most common wrist injuries in gymnastics include gymnast’s wrist (distal radial physeal injuries), scaphoid fracture, triangular fibrocartilage complex (TFCC) tear, scapholunate dissociation, scaphoid impaction syndrome, fractures related to grip lock, ulnar impaction syndrome, acquired Madelung’s deformity (premature closure of the ulnar aspect of the distal radial growth plate), dorsal impingement syndrome/wrist capsulitis, carpal instability, distal radial ulnar instability, and ganglion cysts (Fig.) (28). In men’s gymnastics the most common events causing wrist pain include the pommel horse and floor exercise, whereas in women’s gymnastics, the floor exercise and vault are the most common causes (28). Factors which increase the risk of wrist pain include very soft mats (causing increased wrist extension), twisting elements on the upper extremity with fixed forearms, improper technique, repetitive skills performed on the wrists, previous injury, delayed skeletal maturity, and growth spurts because of the transient weakness in the physis (15,28). Recently, there has been a slight decrease in wrist pain due to the change in the vaulting table, which is now larger and wider (10). A larger vaulting surface allows for multiple “sweet spots” and, thus, is more forgiving of alterations in preflight approach and hand positioning compared to the prior smaller vaulting tables (10).

Figure

Figure

Two very specific injuries found almost exclusively in gymnasts include gymnast’s wrist, and grip lock. Gymnast’s wrist refers to stress injury of the distal radial physis and results from repetitive compressive loading and shearing forces on an extended wrist (28,33). As the distal radius typically bears 80% of the axial load imparted on the extended wrist, the distal radius is at increased risk (28). Caine et al. (4) estimate that there are radiographic abnormalities consistent with distal radius physeal-stress reaction in 10% to 85% of gymnasts. These gymnasts will commonly present with chronic wrist pain with no acute trauma (28,33). The gymnast will locate his/her pain to the radial growth plate (15). Physical examination will show tenderness to palpation along the distal radius growth plate, swelling, decreased grip strength, and pain with hyperextension and axial loading. Radiographic findings include abnormalities at the distal radius: widening or haziness of the growth plate, especially on the volar and radial aspects, cystic changes of the growth plate, a beaked distal volar and radial physis, and sometimes positive ulnar variance (15,28). An MRI may be ordered; however, it is not usually necessary to make the diagnosis. Current treatment recommendations include rest from gymnastics, physical therapy, and sometimes bracing or casting. DiFiori et al. explained specific return to gymnastics criteria stating that if the physical examination is unremarkable and the imaging studies demonstrate resolution of physeal injury, training may resume, and that compression-loading activities (i.e., handstands, tumbling) should be gradually reintroduced (28). DiFiori et al. came up with the 75% reduction rule, meaning that gymnasts should return at 25% of their previous skill level and then each week reassess and increase the amount of load gradually (28). Prevention strategies for gymnast’s wrist includes working on proper technique for weight-bearing upper extremity skills, proper equipment usage, the use of wrist guards and/or supportive braces and decreasing repetition of elements on the wrist during periods of significant growth. Wrist guards/ braces (Tiger Paws, Ten-O to name a few) are worn by many gymnasts, however, no studies have been done to prove the efficacy of the use of wrist guards/braces in reducing axial loads on the distal radial physis or the incidence of distal radial physeal disturbance. Working with a physical therapist or athletic trainer to increase shoulder flexibility and thoracic spine mobility also may help decrease the forces on the wrist.

Grip lock is a dangerous acute injury. Grip lock occurs while wearing grips on the uneven bars, high bar, or the rings. While the gymnast performs a circling element (i.e., giant, clearhip), the leather grip overlaps/folds over causing the hand to stay in place while the forearm continues to rotate. This may result in an acute fracture of the forearm (2). The gymnast is then either suspended from the bar with the hand grip-locked in place or sometimes released and flung from the bar. Covering medical staff and coaches need to be aware of this issue and the proper techniques to stabilize the athlete after such an injury. If the gymnast is still on the bar, stabilization techniques of the fractured arm need to be in place prior to “unlocking” and removing the grip. If a gymnast is flung from the event, basic emergency planning should be in place, which may include attention to the airway, breathing, and circulation, as well as cervical-spine stabilization and transfer techniques. Prevention techniques for this injury include the proper fitting of grips.

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Lower Extremity

The most common gymnastics injuries occur in the lower extremity (4,5,14). The rate of injury ranges from 54.1% to 70.2% (4). The most common injury is an ankle sprain, followed by internal derangement of the knee (4,14). The lower extremity takes substantial load from tumbling and landings, imparting great forces to the hip, knee, and lower leg.

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Hip

The hip is not a common place for injury in a gymnast, and per this literature search there are no current articles on gymnasts with hip injuries. There are several articles on dancers with hip injuries describing a labral tear, femoroacetabular impingement, and apophysitis of the iliac crest (Fig.). Gymnasts may have similar injury patterns about the hip although current available research is limited. Future studies investigating hip injury incidence are required.

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Knee

The knee is reported as the second most common body part injured in gymnastics (4,14). Kerr et al. (8) found that the knee had the largest proportion of severe injuries (30.2%–47.1%) when compared to all other gymnastics injuries. Kerr et al. also found that the knee was the most likely body part requiring surgery in a gymnast, and these were mostly due to anterior cruciate ligament (ACL) tears (8). Kerr et al. (8) further noted that competition injury rates of internal knee derangements were 5.43 times that of practice. Gymnastics-related knee injuries include ACL tear, medial collateral ligament (MCL) and lateral collateral ligament (LCL) sprains or tears, meniscal injuries, Osgood‐Schlatter’s disease, patellofemoral syndrome (PFS), and patellar subluxation/dislocation (Fig.) (2,14). Overlin et al. noted that gymnasts have a higher rate of noncontact ACL tears than their male counterparts (14). Most ACL tears occur during landings on the vault, dismounts from the uneven bars or beam, tumbling passes during floor routines, and falls from an apparatis (14).

Osgood‐Schlatter’s disease and PFS highlight knee injuries in the growing gymnast. Gymnasts typically practice and compete during peak growth years, thus growth plate injuries are likely to occur. Daly et al. (34) explains that adolescence appears to be associated with the highest incidence of injury, which may be partially due to the growth process itself inducing an imbalance between strength and flexibility. Daly et al. also found evidence that the growth plate cartilage is less resistant to repetitive stress than adult articular cartilage, and that the ligaments of children are stronger than the cartilage and bone to which they are attached, resulting in an increased likelihood of injury to the open epiphysis (34). Osgood‐Schlatter’s disease is described as injury to the apophysis at the tibial tubercle from repetitive stress and traction of the patellar tendon. Gymnasts will present with anterior knee pain, tenderness over the tibial tubercle, and report pain with jumping or running skills. On physical examination there is focal tenderness of the tibial tubercle, pain with resisted knee extension, typically a large protuberance/prominence at the tibial tubercle, and a positive Ely test. A lateral plain radiograph can be used as a diagnostic test to be sure that there is no avulsion fracture from the tibial tubercle, as this may change the course of treatment if pain is persistent. Treatment for Osgood‐Schlatter’s disease includes rest from gymnastics, physical therapy (focusing on stretching the quadriceps muscle and strengthening of atrophied or weak musculature of the lower extremity), and possibly bracing (Cho-Pat® strap or GenuTrain® brace). Prevention techniques include working on proper technique while performing new skills and landings, with emphasis on quadriceps muscle stretching and flexibility, along with decreased repetitive landings during peak periods of growth.

Patellofemoral syndrome (PFS) is another frequent injury of the young gymnast. Keller et al. describes PFS as “abnormal patellofemoral tracking” (16). Overall PFS is found more commonly in females than male athletes due to increased Q angles causing the patella to track more laterally (16). This lateral tracking of the patella can lead to further injury including chondromalacia patella, patellar subluxation, and patellar dislocation. The gymnast will present complaining of chronic knee pain in the shape of a “C” around the patella. Physical exam will show a decreased muscle bulk of the oblique head of the vastus medialis (VMO) when compared with the contralateral side, and a positive Ober test. An X-ray, specifically a sunrise view, may be obtained to look at the position of the patella (which may sit laterally in the groove). Current treatment per this literature review and clinical practice includes physical therapy (including ITB stretching, and VMO strengthening with straight leg raises), activity modification, and bracing (simple hinged or GenuTrain® brace). O’Neill et al. performed a study on the treatment of PFS with conservative treatment including VMO strengthening (straight leg raising with external rotation), stretching of the ITB and hamstring, and anti-inflammatory agents which corrected 50% to 80% of PFS (35). If this fails, then an arthroscopic procedure with lateral release, due to the tilt of the patella, may then be warranted. Prevention techniques include working on proper technique while performing new skills/landings (specifically being sure the gymnast does not have a valgus collapse indicating gluteus medias weakness and increased risk of knee injury), an emphasis on ITB stretching, quadriceps muscle strengthening, and hip abduction/peripelvic strengthening and stabilization.

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Below-the-knee Injuries

Gymnastics injuries that occur distal to the knee affect the tibia, fibula, ankle, and foot. Multiple studies have shown that an ankle sprain is the most common injury in gymnastics (2,4,14). Kruse and Lemmen (1) have noted that the foot experiences loads of 3.4 to 5.6 times the body weight of the gymnast during the take-off for a backward somersault/back handspring. The Achilles tendon during a back takeoff experiences forces measured at 16 times body weight (1). The floor exercise is the most common event during which ankle injuries occur (8). The most common gymnastics injuries that occur below the knee include lateral ankle sprains, stress fractures of the tibia/fibula, medial tibial stress syndrome, talar OCD, distal fibula physeal fracture, anterior ankle impingement, posterior ankle impingement, posterior tibialis tenosynovitis, talar fracture, lisfranc injury, stress fracture of the metatarsals, tarsal, or navicular, turf toe, calcaneal stress fracture, and calcaneal apophysitis (Sever’s disease) (Fig.).

Ankle sprains most commonly occur during take-off and landings in gymnastics; however, some reports have shown that inversion and eversion sprains have occurred from stepping off landing mats or landing with the foot in the seams of the mat (2). Upon presentation for a lateral/inversion ankle sprain, the gymnast will explain or demonstrate how the injury occurred (inversion mechanism). Physical examination will show tenderness on the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), ecchymosis, swelling, a positive anterior drawer (demonstrating increased motion/laxity of the ligament), and a positive talar tilt (demonstrating increased motion). An x-ray may be needed in the acute setting of an inversion ankle sprain to rule out bony injury in the setting of boney tenderness. If there is tenderness on the growth plates, imaging should be performed. Current treatment of lateral ankle sprains are mixed among providers but may include an immobilized ankle in a tall Aircast® walking boot and crutches for comfort, and once the athlete feels he/she can discontinue the crutches, he/she may. Typically, the gymnast weans him/herself out of the boot with the help of physical therapy, as tolerated. Physical therapy plays a big role in the treatment of inversion ankle sprains focusing not only on strengthening, but also on proprioception and balance. Bracing (lace up ankle brace) or taping also may play a role after a gymnast has an inversion sprain. Prevention techniques for ankle sprains would include proprioception exercises prior to the start of practice for injury prevention, being sure proper placement and use of mats are correct, as well as considering taping or bracing prior to floor or vault prophylactically, particularly in the setting of prior ankle sprains.

Talar osteochondritis dissecans (OCD) often occurs after a “short landing” while tumbling, meaning landing in a hyperdorsiflexed position, causes the talus to drive into the tibia (14). This repetitive trauma in a hyperdorsiflexed position is presumed to cause OCD lesions of the talus. A gymnast with a talar OCD will present with anterior ankle pain and describe how multiple times he/she has had a “short landing.” Physical exam will show tenderness of the anterior ankle, swelling, and pain with an anterior drawer test. X-ray images are necessary and may show a lucent or loose body of the superior talus on the mortise view. An MRI is used to assess if the OCD is stable or unstable as well as to assess the skeletal maturity of the athlete. Treatment of talar OCD depends on stability of the lesion. Stable lesions are treated with rest from gymnastics, a short Aircast® walking boot, physical therapy and, depending on the size of the lesion, possibly crutches. If the lesion is unstable, surgery is considered for drilling and fixation. Prevention techniques include working on proper technique while performing new skills/landings, having correct landing surfaces, strengthening the stabilizers of the ankle, working on proprioception, and limiting the amount of load or force on the talus during peak periods of growth.

Calcaneal apophysitis, also known as Sever’s disease, is similar to Osgood‐Schlater’s disease by mechanism, but occurs at the posterior calcaneal physis. Some studies have shown that the physis is at a great risk for injury during adolescent growth (28). This will present in a growing gymnast who explains he/she has chronic medial or posterior heel pain. Physical examination will show swelling, tenderness to palpation on the posterior aspect of the heel, tight Achilles tendon and gastrocnemius muscle, and a positive calcaneal squeeze test, whereby squeezing the calcaneal physis results in pain. X-rays can be used diagnostically to ensure that there is no avulsion or stress fracture of the heel. Current treatment recommendations include rest from gymnastics, physical therapy, including heel cord stretching and foot intrinsic strengthening, and bracing (Cheetahs®, Tuli heel cups, or the X-brace). Prevention techniques include working on proper technique while performing new skills/landings, stretching of heel cords, and using preventive/padding devices such as Cheetahs® during significant growth periods.

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Emergency Injuries

The sport of gymnastics has the potential for serious emergent injuries related to the amount of saltos/flips and twists a gymnast performs and the extreme forces generated during these maneuvers. The higher the level of the gymnast the more complicated and difficult the skills become, and the higher the risk for an emergent injury. Reports show that there are 26,000 trips to the emergency department (ED) annually due to gymnastics injuries (36). Singh et al. found that the most common injuries requiring a gymnast to go to the ED included cervical spine fracture, concussion, limb fractures, and acute sprains (36). There is a higher incidence of injuries sustained by older gymnasts ages 12 to 17 years old (7.4 per 1000 h) when compared to younger gymnasts ages 6 to 11 years old (3.6 per 1000 h) (16,36). This could be due to the fact that the older you are in gymnastics typically the higher level you are competing at and the more complicated and difficult skills you will be performing. It is interesting to note that the most common place of injury causing a gymnast to go to the ED was at school (40.0%), followed by the gymnastics facilities (39.7%), then home (14.5%), or on other public property (5.8%) (36). This supports the fact that gymnasts should not be performing gymnastics skills away from proper facilities, nor when not monitored by trained coaches. Singh et al. (36) found that upper extremity injuries occurred 42.3%, lower extremity 33.8%, head/neck 12.9%, trunk 10.4%, and other 0.6%. The most common diagnoses made by the ED as found by Singh included strain/sprain 44.5%, fracture/dislocation 30.4%, abrasion/ contusion 15.6%, laceration/avulsion 3.7%, concussion/closed head injury 1.7%, and other 4.2% (36). Singh noted that the majority (97.1%) of patients with gymnastics-related injuries were treated and released from the ED with the most common reason for an admission being a fracture (36).

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Cervical Spine

There is a definite risk for cervical spine acute injuries, however these rates are extremely low (16,36). Gymnastics involves multiple flips, twists, dismounts, and the occasional slipping/falling off of an event which could lead to potential for cervical spine injuries. Keller and Singh noted that in a 16-year compilation of data not one catastrophic pediatric gymnastics injury was noted (16,36). Hecht et al. (2) found that there is a potential for cervical spine injuries when using the foam pit, as a gymnast typically learns a new skill in the pit, and thus there is a potential for landing on the head. There was one highly publicized cervical spine injury that occurred on May 5, 1988. Julissa Gomez, a 15-year-old gymnast from the United States, was paralyzed after hyperextending her neck while attempting a Yurchenko vault during warm-ups at the World Sports Fair in Tokyo, Japan (4,36). Julissa later died of complications. After this incident, the International Gymnastics Federation significantly increased vaulting safety, which required all gymnasts performing a Yurchenko vault to use a U-shaped safety mat around the springboard (36). Since that time, the U-shaped mat is mandatory, and results in an automatic score of 0 if not used during a Yurchenko style vault. In 2001, another change to the vault was made. Instead of a horse, a table is now used (36). The table is a wider and more stable surface, which adds additional safety for the gymnast. In terms of prevention of cervical spine injuries proper technique, landings, and spotting all play a large role.

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Concussion

Concussion is an injury that occurs in gymnasts; however, we found no current studies specifically investigating the incidence of concussion in gymnastics. Kruse and Lemmen (1) found that concussions typically occur when there is either a lack of supervision or a mismatch between the ability of the gymnast and the skill level attempted. Hecht et al. (2) explained that a gymnast could sustain a concussion by hitting his/her head on an apparatus/event or mat when performing a skill. During a tucked salto or rotation, a gymnast also could cause his/her knee to hit his/her chin (flip/tucked position) and therefore cause a concussion. Concussion symptoms present the same way as with any other athlete. The gymnast describes an injury that caused a rotational acceleration of the head, typically after direct trauma to the head. A comprehensive physical examination, including a neurological examination, should be performed. Symptom inventories, balance assessments, and assessments of cognition are useful in diagnosing and monitoring recovery from concussion. All such assessments are ideally used in conjunction with a preinjury baseline evaluation. Injury prevention techniques include neck-strengthening exercises, use of proper techniques for learning new skills, and proper equipment and safety mat use. Gymnasts also should be trained on how to land effectively in the unfortunate even that they should fall. A return-to-play progression in a gymnast can be very challenging given that the athlete not only needs to return to exertional tolerance and show proper sport-specific return of visual tracking and reaction time, but a gymnast also must return to positions of inversion, as well as additional dynamics of flipping, twisting, and air-awareness. This can be challenging, with easy symptom provocation, but also essential for safe return to sport and avoidance of future falls.

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Conclusions

Gymnastics is a sport requiring grace, strength, and flexibility, and is associated with a wide variety of injuries. Current research shows that the injury rates in gymnastics include a wide range, from 1.08 to 50.3 per 1000 h of exposure, more injuries occur in competition versus practice, and fewer injuries occur in recreational gymnastics than competitive gymnastics. The most common injuries are sustained by the lower extremity and include sprains of the ankle and internal derangement of the knee. In men’s gymnastics, the upper extremity, specifically the shoulder, is the most commonly injured body part. The most common event during which an injury occurs is the floor exercise and during tumbling. The most common skills resulting in injury to a gymnast are handsprings and flips. Important injuries to understand when treating a gymnast include spondylolysis, OCD of the capetillium, gymnast wrist, grip lock, Osgood‐Schlatter’s disease, PFS, lateral ankle sprain, OCD of the talus, and calcaneal/Sever’s apophysistis. There is limited research regarding the incidence of injuries sustained during gymnastics. Future research should focus on injury incidence since the 2006 rule change eliminating the “perfect 10” from Elite/Olympic level gymnastics, male versus female differentiation of current injury patterns, concussion rates and recovery patterns in gymnasts, and the potential for injury prevention during gymnastics.

The authors would like to thank Rebecca Zwicker and Dai Sugimoto for their support and expertise in research.

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