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The Artistic Gymnast. Teri M. McCambridge , MD, FAAP Assistant Professor of Pediatrics Johns Hopkins School of Medicine. OVERVIEW. Background Information Types of gymnastics Participation Injury Epidemiology Special Preparation Unique Injuries Important complaints Medical Concerns

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The artistic gymnast l.jpg

The Artistic Gymnast

Teri M. McCambridge, MD, FAAP

Assistant Professor of Pediatrics

Johns Hopkins School of Medicine

Overview l.jpg


  • Background Information

    • Types of gymnastics

    • Participation

  • Injury Epidemiology

  • Special Preparation

  • Unique Injuries

  • Important complaints

  • Medical Concerns

  • Injury Prevention

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Types of Gymnastics

  • Artistic

  • Rhythmic

  • Trampoline & Tumbling

  • Acrobatic

  • Aerobic Gymnastics (FIG)

  • General Gymnastics

    • “Gymnastics for All”

    • Group Gymnastics (USAG)

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Artistic Gymnastics

  • Women

    • 4 events: vault, uneven bars, beam & floor ex

    • Competitive levels

      • Junior Olympic (3)4-10

      • Elite

  • Men

    • 6 events: vault, parallel bars, horizontal bar, pommel horse, still rings & floor exercise

    • Competitive levels

      • Same as women

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Rhythmic Gymnastics

  • Women

    • 5 apparatus

    • Ribbon, hoop, ball, rope & clubs

  • Men

    • New, mostly in Asian countries

    • 4 apparatus

    • Rings, stick, rope, & clubs

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Trampoline & Tumbling

  • Women & Men

  • Trampoline

  • Power tumbling

  • Synchronized tramp

  • Double mini-tramp

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  • Men, Women & Mixed

  • Pairs, Groups

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Background: Artistic Participants

  • Recreational 5.2 million

  • High Schoolunknown

  • USA Gymnastics

    • Male (’07)12, 120 participants

    • Female (’07)67,626 participants

  • College Level (women’s)

    • Division I.1043 participants

    • Division II.99

    • Division III.224

  • Olympic Level280men/women

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USA Gymnastics Levels

  • TOPS

  • Levels

    • Level I-IV (pre-competitive)

    • Level V, VI (compulsory)

    • Level VII, VIII, IX, X.

    • Elite

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Talent Opportunity Program (TOPS)

  • Introduced in 1991

  • 7-11 year olds

  • Tested on a regional basis

  • National TOPS team (20 girls/per age) train at the National training camps

  • Essentially an Olympic development program

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USA-Gymnastics Artistic Participants2004

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Injury Epidemiology

  • NEISS Injury Data

    • 6-17

    • 1990-2007

    • 26,6000 injuries annually

    • Similar injury rates to cheerleading, soccer, and basketball

  • Injury rates

    • 7.8/1000 12-17

    • 3.6/1000 6-11

Singh S. Pediatrics 2008;121:e954-e960

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  • Most acute injuries on floor exercise

  • Dismounts

  • Overuse injuries are common

    • 43-64% overuse

  • Sprains common

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Factors associated with increased injury rate

Extrinsic Factors

  • Enforced breaks

  • Practice sessions >20h/wk

  • Long practice sessions on 1 apparatus

  • No spotting or poor spotting techniques

  • Performing Floor exercise

  • Competitive setting

Daly, RM, et al. Balancing the risk of injury to gymnasts: how effective are the counter measures? Br J Sport Med 2001:35:8-20.

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Intrinsic Factors Associated with Increased Injury Risk

  • Atypical Body type

  • Larger height or weight

  • Advanced age

  • Increased Body fat

  • Stressful life events

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Common Injuries: Acute

  • Female:

    • Lower extremity>upper>spine/trunk

      • Ankle>knee

      • Wrist>Elbow>Fingers

      • Low back

  • Male

    • Upper extremity>lower

      • Shoulder>wrist

      • Ankle

Caine, D. Nassar L. Epidemiology of Pediatric Sport Injuries. Individual sports. Med Sport Sci 2005;48: 18-58

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Common Injuries: Chronic

  • Spondylolysis/listhesis

  • Type I. Salter fracture to distal radius

  • Stress fractures

  • Tendonitis

  • Kienbock’s

  • Apophysitis

    • Osgood-Schlatter

    • Sever’s disease

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Catastrophic Injuries

Julissa Gomez

1988 World Sports Fair

San Lang

1998 Goodwill games

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Unique preparation:C-spine immobilization

  • Trampoline & Pit

    • Difficult surfaces to stabilize a possible c-spine injury

    • Work-out a plan ahead of time

      • Control other athletes from helping

    • Practice with EMS, coaches & ATC

  • Need pediatric collar

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  • Loose foam blocks

  • 6-8 ft deep, different sizes (length/width)

  • Hard to access

  • Enter pit directly if evidence of airway compromise (ie CPR needs to be initiated)

    • Take off shoes & socks

    • Slow, steady movements

    • Stabilize c-spine as best as possible

    • Avoid moving foam from under gymnast

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  • 4-6 adults needed to extract athlete

  • Not life threatening

    • 4 in mat in front of head &/or on side(s) of gymnast (crawl on mat)

    • Ladder across width of pit for stable surface

  • Try to place gymnast on backboard in pit

  • Use mat or ladder to bring them out on board

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Why the unique Injuries?

  • High impact on all extremities

  • Repetitive extension and torsion of spine

  • Year round involvement before puberty

  • Unique apparatus

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  • Friction blisters

    • Hands & forearms

  • Calluses

  • Infection

  • Painful

    • Hurts to grip bar which can be dangerous

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  • Prevention

    • Ice hands after bar/ring workout

    • Pumice stone/shaver for calluses

    • Lotion

    • Grips

    • Antiperspirant for sweaty hands

    • Chalk

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  • Treatment

    • Wash with soap & water

    • Clip away loose skin

    • Gymnasts should have own “rip scissors”

    • Triple antibiotic ointment & bandaid

    • Cover with DuoDERMor OpSite

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  • Not everyone uses them

  • Different types

  • Benefits

    • Less rips

    • Able to work out longer

    • Easier to hang on

  • Must be sized for individual

    • Need extra pair

  • Wear them with wrist bands

    • Neoprene &/or cotton

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  • Dowel grips

    • Leather

    • Stretch out

    • Overlapping parts

    • Grip doesn’t rotate

    • Forearms break

  • Avoid

    • Check grips & replace when stretched out

    • Don’t borrow grips or use “old” grips

    • Avoid changing to rails with smaller diameter

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  • Injuries from using UE for wt bearing

  • Forces (x body weight)

    • Back handspring2.37-3.6

    • Round-off2-3

    • Yurchenko vault (round-off)2.38

    • Pommel horse1.5-1.6

Markolf 1990, Koh 1992, Seeley 2004

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  • Wrist pain is common in gymnasts

    • Chronic wrist pain in 33% of female & 75% of male UCLA gymnasts (Mandelbaum 1989)

    • 57-87.5% non-elite gymnasts (DiFiori 1996 & 2002)

  • Important to ask gymnast’s about wrist pain

    • Most don’t see a physician despite pain (DiFiori CJSM 2002)

  • Large differential dx

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Distal radius stress rxn

Scaphoid impaction

Lunate impaction

Scaphoid stress fx


Ulnar abutment

Carpal chondromalacia

Soft tissue

Doral wrist impingement


Wrist splints

TFCC tear


Distal radioulnar instability

Carpal instability

What is your differential diagnosis?

Gabel GT. Clinics in Sports Med 1998; 17(3):611-623

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Distal Radial Physeal Stress Injury

  • Overuse injury to distal radial physis

  • Mechanism?

    • Repetitive hyperextension of wrists with impactful, compressive & rotational forces

    • Alters metaphyseal perfusion & chrondocyte mineralization

  • Gymnasts & acrobats

  • 2.7 injuries/100 participants/year (Caine 1992)

  • 25% of non-elite gymnasts with xray changes c/w this dx(DiFiori AJSM 2002)

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Radiographic findings

  • Widening of distal radial physis

  • Cystic changes on metaphyseal side of growth plate

  • Volar radial beaking

  • Indistinct appearance of physis

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Ulnar Variance

  • Positive Ulnar Variance

    • Ulna longer than radius

    • Changes load sharing properties of radius & ulna (Palmer 1984)

    • Neutral UV axial load: radius 82% ulna 18%

    • +2.5mm UV axial load: doubles the ulnar load

  • Increased prevalence of +UV in elite gymnasts (Mandelbaum 1989; DeSmet 1994)

  • Relatively more + UV in non-elite gymnasts compared to norms(DiFiori 1997)

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Ulnar Variance

  • Mechanism (?)

    • Premature closure of distal radial physis

    • Stimulation of ulnar growth

    • Combination

  • Complications

    • TFCC tears

    • Degenerative changes of carpal bone & ulna

    • Alterations of DRUJ articulation

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UV: The Rest of the Story…

  • Approx 50% of gymnasts with +UV not symptomatic (Chang 1995)

  • Ulnar length in elite gymnasts in upper limits of normal (Claessens 1996)

  • Ulnar overgrowth not associated with early maturity of distal radius in elite gymnasts (Beunen 1999)

  • +UV not associated with wrist pain or xray findings of distal radial physeal stress injury in non-elite gymnasts(DiFiori 2002)

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  • Relative rest

    • No wt bearing on hands for 4-12 wks

    • +/- brace or casting

    • PT: ROM, especially wrist & finger flexors, grip strengthening

    • Address technique

  • Gradual return to wt bearing

  • Consider “Tiger Paw” wrist braces

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  • Mechanism

    • Repetitive valgus overload

    • Using UE as wt bearing joint

    • Compressive & rotational forces

  • Gymnasts tend to have hypermobility

  • Risk ↑ with >carrying angle?

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Elbow OsteochondritisDissecans(OCD)

What is it?

“Localized injury to an articular surface resulting in separation of a cartilage segment from the subchondral bone”

Takahara M. J Bone Joint Surg 2007:89:1205-1214

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  • Need more data on gymnasts

  • Small numbers in literature

  • 3-5 months

  • Literature suggests most gymnasts don’t return to competitive gymnastics (20-92%)

    • Bojanic 2005: 3/3 returned 5 mo post-op & symptom-free at 1 year

Singer 1984, Maffuli 1992, Baumgarten 1998, Krijnen 2003

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ELBOW OCD: Long Term

  • Bauer 1992

    • 31 pts with OCD

    • Followed out up to 23 years

    • 50% with symptoms (decreased ROM, pain)

    • >50% had evidence of DJD

    • ↑ diameter of radial head in 67%

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Common Spine Problems:

  • Spondylolysis

  • Scheurmann’s

  • Intervertebral pathology

  • Mechanical Sources

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Spine Pain:Prevention

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Evaluation of Back Pain

Curr Sports Med Reports 2009;8(1):20-8.

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Possible Health/Medical Issues:

  • Growth Retardation

  • Bone density

  • Female Athlete Triad (F.A.T)

Growth l.jpg


  • Study of 22 high level female gymnasts demonstrated limited acceleration in growth during puberty over a 2 year period.

  • Case studies of identical twins and triplets demonstrated decreased growth during periods of training and accelerated growth during injury and retirement.

Theintz GE, et al. Evidence for reduction of growth potential in adolescent female gymnasts. J pediatr 1993; 122 (2):306-313

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  • Reduced growth during puberty in 13 of 22 Swedish female gymnasts between 11-14 followed for 5 years.

  • Study has demonstrated greater deficit in stature with longer durations of training.

  • Studies of male gymnasts demonstrated no reduction in growth during training.

Lindholme C. et al.. Acta Obstet Gynecol Scand 1994; 73(3): 269-273.

Bass, et al. J pediatr 2000; 136(2): 149-155

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Skeletal and Sexual Maturation?

  • Theinz, et al. Delay in skeletal maturation did not worsen with continued training.

  • Bass, et al. Maturation was delayed by 1.8 years and increased after 2 years training. (considerable variability)

  • Sexual Maturation delayed on average in female athletes over non-athletes.

  • Case studies of identical twins demonstrated delayed menarche of 1- 4.5 years in twin involved in gymnastics vs. “control”

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Adult Height?

  • Lindholm, et al. Final height in 6 of 21 gymnasts was 1.4 to 3 inches shorter based on mid-parental height equation.

  • Ziemilska 7 of 9 females and 10 of 16 males were 0.4 to 3.1 inches shorter than predicted.

  • Bass, et al. and others have observed no loss of predicted final height, just a temporary decreased growth velocity during puberty.

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Summary of impact on growth

  • No permanent effect on growth, maturation, and final adult height

  • However, reduced growth and maturation has been reported in some individuals

  • “Catch up” growth supports notion of reduced growth and maturation during training.

  • Difficulty to assign causality to gymnastics because of complex interaction between genetics and environmental factors (diet, stress)

Daly RM, et. Al. Does Training Affect Growth?. Phys. Sportsmed. Oct 2002; 30 (10).

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Impact on Bone Density Premenarcheal Gymnast?

  • 2000 study 16 female gymnasts and 16 age matched controls

  • Bone density of L-spine/femoral neck were significantly greater then controls

  • 1995 Study, 14 Elite 7 to 9 year old swimmers, gymnasts, and 17 controls

  • Increased in BMD per unit increase in body weight present in gymnasts, but not swimmers or controls.

Nickols-Richardwson SM, et al. Med Sci Exerc. 2000 32(1): 63-69

Cassell, C. et al. 1995 Med Sci Exerc. 28 (10): 1243-1246

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What is the effect on bone density? (Collegiate gymnast)

  • 2002 Study

  • 25 Collegiate gymnasts vs Control

  • Dexa Scan of body, lumbar spine, femur

  • BMD of gymnasts was greater at all sites

    • Body 8%

    • 18-19% in L-spine and femur

    • 17% in upper arm and no difference in dominant arm

Proctor Kl, et. Al. Med Sci Sport Exer 2002: 34(11): 1830-1835

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Female Athlete Triad (F.A.T.)

  • Disordered Eating

  • Menstrual irregularity

  • Osteoporosis

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“Coaching Issues”

  • No national coaching requirements except safety certification

  • Primary role model during developing years

  • Encouraging participation during injury

  • Body frame/puberty

  • Safety

Kerri Strug 1996 Olympics

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“Judging Issues”

  • Subjective sport: comments on physique

  • Discuss improved scores with weight loss

  • Modification of rules

    • “sticking landings”

    • Devaluation of skills

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The press:

  • NEJM July 25, 1996

    • “Physical and Emotional Problems of Elite Female Gymnasts”

  • Articles claim “Achievement by Proxy”- Gymnastics considered a form of child abuse

  • Self-abuse

  • Book and article written after well publicized deaths

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Injury Prevention (General):

  • Omit mantra “no pain no gain”

  • Bi-annual joint exam

  • Team ATC or Doctor

  • Improve strength

  • Proper spotting/ Equipment/padding

  • Teach proper “fall”

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Injury Prevention (bracing):

  • Heel cup with ankle support (severs)

  • Wrist splint with block against excessive dorsiflexion (gymnast wrist)

  • Hand grips

    (“rip” prevention)

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ELBOW OCD: Prevention

  • Avoid hyperextension

  • Strengthen muscles around elbow

  • L-grip giants

  • Avoid training one arm skills

  • Don’t ignore elbow pain

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Injury Prevention (Equipment modifications):

  • Foam-padded spring floors/tumble track

  • Foam pits

  • Modified vault

  • Padded beam stand

  • Incr. Mat thickness

  • Composition and positioning of uneven bars

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Preventative Strategies: Growth

  • ? Limiting training during puberty

  • Plotting height quarterly and addressing decreased height velocity

  • Females encouraged to keep records of menstruation and evaluate more than 2-3 missed periods.

  • Encourage proper diet (adequate protein and caloric intake)

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Prevention:Concussion Education

  • Watch out for these!

  • Most coaches & gymnasts not aware of concussion symptoms & signs

  • Educate coaches on signs and symptoms

  • Be careful with RTP

    • Consequences of wrong decision could be catastrophic due to inherent danger of gymnastics

Hecht 2001

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Want to be involved?

  • National Healthcare Referral Network

    • Medical Professionals with background &/or special interest/expertise in gymnastics

    • List in USA gymnastics member publications

    • List on USA Gymnastics web site

    • Application process

      • Kathy Kelly at USA Gymnastics if interested (317-829-5626).

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Gymnastics “Links”





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Thank You

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