If you’ve been watching the Olympics, you may have been mesmerized by the physical abilities of the gymnasts competing. Their ability to run, jump, leap, twist, twirl and flip is awe-inspiring. It may also leave one wondering how prone to injury they are given the skills they need to perform and the training required to reach this elite level.
Different studies cite different overall injury rates, but gymnastics generally has a greater risk of injury than many other sports. Injury rates differ between male and female gymnasts, the events and the various apparatus. Females are more likely to suffer lower extremity injuries while their male counterparts have higher levels of upper extremity injury. Due to the upper body dominant skills of the male events, they are much more likely to suffer wrist and hand injuries, whereas women are more likely to have ankle and foot injuries. For females, the most commonly suffered injury is an ankle sprain on 3 out of 4 apparatus, except for uneven bars which is upper body injury of the shoulder or wrist.
As young gymnasts progress in skill and hours training, their risk of injury goes up since they spend more time under load practicing higher level skills. As they produce more force with their maneuvers, the risk of having an injury increases. Younger athletes are also prone to wrist injuries at the growth plate. As their wrists extend under a load, the forces are transmitted to the growth plate and can result in pain and injury. This is most pronounced in athletes aged 10-14 and care should be taken to assess total volume and pain at this level to avoid wrist injury or manage it early.
Injuries in competition are more common as a result of performing the high level skills at higher speeds and greater heights without the benefit of crash pads and landing pits utilized in practice. Unfortunately, traumatic knee injuries, including ACL tears, are the most common cause of long term time away from sport, surgery and medical disqualification from participation. Injuries as a result of floor routines are the most common mechanism for ACL injury in gymnastics.
Because of the nature of the sport, and the extreme flexibility needed to perform, gymnasts also sustain other injuries. Rates of back pain differ, but low back pain is one of the top 5 most commonly injured areas. The main concern with gymnastics is developing a stress related fracture from constant extension. With the extreme range of motion in the hip, there have been case reports of hip instability and impingement syndromes of that joint. The hours required to learn and master a maneuver can lead to gradual overload and overuse injuries.
Kerr, Z. et. al. (2015). Epidemiology of National Collegiate Athletic Association women’s gymnastics injuries, 2009-2010 through 2013-2014. Journal of Athletic Training: 50(8).
Kox, L. et. al. (2015). Prevalence, incidence and risk factors for overuse injuries of the wrist in young athletes; a systematic review. British Journal of Sports Medicine: 49.
Saluan, P. et. al. (2015). Injury types and incidence rates in precollegiate female gymnasts. Orthopaedic Journal of Sports Medicine: 3(4).
Tirabassi, J. et. al. (2016). Epidemiology of high school sports related injuries resulting in medical disqualifaction: 2005-2006 through 2013-2014 academic years. American Journal of Sports Medicine: 20(10).
Weber, A. et. al. (2014). The hyperflexible hip: managing hip pain in the dancer and gymnast. SportsHealth: 7(4).
Westermann, R. et. al. (2014). Evaluation of men’s and women’s gymnastics injuries: a 10 year observational study. SportsHealth: 7 (2).
ACL injuries continue to be a hot topic in the sport world. A big reason is that even though they are still not very common, percentage wise, they have a large impact on long term joint health, recovery, cost and ability to return. As reconstruction techniques continue to evolve, athletes are able to return to play, but how successfully?
After surgery, the treatment consists of rehabilitation to regain motion, function, proprioception, strength and control. Once athletes have completed about 6-9 months of rehab, they return to sport. Here’s the sobering news, of those who suffer an ACL reconstruction, only 65% return to their pre-injury level of sport, with only 55% returning to competitive play. Even more discouraging is the fact that of those that return to sport, up to 1 in 5 will suffer a tear to their reconstructed knee, or the ACL on the non-reconstructed side.
In order to determine what risk factors existed, and ways to modify them, researchers looked at elite soccer players who had their ACL reconstructed and then followed them. They looked at the type of surgery they had, their rehabilitation process and their return to sport. What they discovered was that athletes who did not meet certain bench marks in rehab were 4 times more likely to have another ACL injury. The following shows the exercises and the discharge criteria that was deemed successful:
Discharge tests and criteria used during the study period
6 part return to sport tests with Discharge permitted when criteria was met
In addition to the tests above, athletes that had lower hamstring to quadriceps strength ratio were also more likely to injure their ACL. Since strong hamstrings act as an assistant to the ACL, weakness there can mean more stress on the ligament.
This study highlights a couple of key points when rehabilitating ACL injuries:
Kyritsis, P. et. al. (2016). Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. British Journal of Sports Medicine, 50. http://bjsm.bmj.com/content/early/2016/05/23/bjsports-2015-095908.abstract
Athletes who tear their ACL and want to return to their sport usually opt for surgical reconstruction. This is primarily done with either using the patient’s patella tendon or hamstring tendon to graft a new ACL. After surgery, patient’s need to perform rehabilitation in order to regain their range of motion, strength and function. Some reviews have been performed that can help guide the rehab and return to sport process. Interestingly, even though there has been a lot of research performed on ACL’s in general, there is not a lot of information on return to sport criteria.
For rehabiliation, the following has been recommended:
1. Forgo the brace. Post operative bracing is not effective for improving pain, range of motion or preventing a potential re injury and is not necessary.
2. An accelerate rehab is safe for patients and they can begin early weight bearing exercise, range of motion from 0-90 degrees and close chain strengthening exercising. Adding in eccentric quad strengthening after 3 weeks was also beneficial in recovery.
3. Focus on strength and range of motion. Adding neuromuscular strengthening is somewhat helpful, but the focus for rehabilitation should be on improving strength and range of motion. Once this is restored, neuromuscular training can be helpful to relearn movement patterns.
4. Single leg cycling can be performed in order to maintain cardiovascular fitness.
Returning to sports?
1. Many athletes do not return to their previous level of sport participation, in fact, only 50% may return.
2. The decsion to return is multifactoral, but there is a general lack of evidence to determine the best testing criteria to signal return to play. In general, the decision to return is based on the following;
a. Higher quadricep strength
b. Less swelling
c. Less pain
d. Fewer episodes of instability
e. Low kinesiophobia (fear of moving)
f. Higher athletic confidence
g. Higher motivation
3. Part of the challenge is the psychological componenet of returning to sport. The fear of moving (kinesiophobia) may prevent some patients from returning. Patient’s that have more confidence have a greater chance of returning to their sport.
The current research shows plenty of gaps in following a standard program for rehabilitation and return to play, but patient’s and their providers can use what we do know to customize a plan.
Patient’s should start moving as tolerated shortly after surgery. They can walk as they are able and perform range of motion exercises and strengthening as tolerated progressing the intensity as they heal.
When their graft is healed and they have regained strength and motion they can add in neuromuscular training to improve movement patterns. This is also a good time to work on building up their confidnce in a controlled setting. Allowing them to get into a position can improve their confidence as the speed and force of the movement is increased.
Consistently working on the psychological aspect of rehab should not be ignored. Rehab is a chance to control the environment so that patient’s can gradually tolerate the load. As they improve, their rehab should adjust to mimic the functional tasks they will need to perform in life and on the field. Once they have reached their healing, they should re-integrate into their sport (once again in a controlled setting) and progressively increase their activity.
While there is a lot of flexibility in these guidelines, this can serve as a framework for the rehabilitation and reintegration process. Discussing the steps with the patients, their support groups and providers can help to get everyone on the same page and understand the steps required to resume their active lifestyle.
Czuppon, S., Racette, B., Klein, S. & Harris-Hayes, M. (2014). Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review. British Journal of Sports Medicine, 48 (5). 356-364.
Kruse, L., Gray, B. & Wright, R. (2012). Rehabilitation after anterior cruciate ligament reconstruction. Journal of Bone Joint Surgery, 94 (19). 1737-1748.
I write on sport management, fitness, sports medicine and business topics to help you reach your goals
To learn more about what services we offer, to schedule an appointment or to get prices please contact me at
*This site is for educational purposes only, it is not meant to diagnose, treat or replace medical advice. Before starting an exercise program always make sure that you are healthy and able to do so safely.*