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The Artistic Gymnast

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

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  1. The Artistic Gymnast Teri M. McCambridge, MD, FAAP Assistant Professor of Pediatrics Johns Hopkins School of Medicine

  2. OVERVIEW • Background Information • Types of gymnastics • Participation • Injury Epidemiology • Special Preparation • Unique Injuries • Important complaints • Medical Concerns • Injury Prevention

  3. Types of Gymnastics • Artistic • Rhythmic • Trampoline & Tumbling • Acrobatic • Aerobic Gymnastics (FIG) • General Gymnastics • “Gymnastics for All” • Group Gymnastics (USAG)

  4. 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

  5. Rhythmic Gymnastics • Women • 5 apparatus • Ribbon, hoop, ball, rope & clubs • Men • New, mostly in Asian countries • 4 apparatus • Rings, stick, rope, & clubs

  6. Trampoline & Tumbling • Women & Men • Trampoline • Power tumbling • Synchronized tramp • Double mini-tramp

  7. ACROBATIC • Men, Women & Mixed • Pairs, Groups

  8. Background: Artistic Participants • Recreational 5.2 million • High School unknown • 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 Level 280 men/women

  9. USA Gymnastics Levels • TOPS • Levels • Level I-IV (pre-competitive) • Level V, VI (compulsory) • Level VII, VIII, IX, X. • Elite

  10. 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

  11. USA-Gymnastics Artistic Participants2004

  12. 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

  13. INJURY EPIDEMIOLOGY • Most acute injuries on floor exercise • Dismounts • Overuse injuries are common • 43-64% overuse • Sprains common

  14. 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.

  15. Intrinsic Factors Associated with Increased Injury Risk • Atypical Body type • Larger height or weight • Advanced age • Increased Body fat • Stressful life events

  16. 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

  17. Common Injuries: Chronic • Spondylolysis/listhesis • Type I. Salter fracture to distal radius • Stress fractures • Tendonitis • Kienbock’s • Apophysitis • Osgood-Schlatter • Sever’s disease

  18. Catastrophic Injuries Julissa Gomez 1988 World Sports Fair San Lang 1998 Goodwill games

  19. 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

  20. PIT • 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

  21. PIT • 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

  22. MAT IN PIT TECHNIQUE

  23. Why the unique Injuries? • High impact on all extremities • Repetitive extension and torsion of spine • Year round involvement before puberty • Unique apparatus

  24. “RIPS” • Friction blisters • Hands & forearms • Calluses • Infection • Painful • Hurts to grip bar which can be dangerous

  25. “RIPS” • Prevention • Ice hands after bar/ring workout • Pumice stone/shaver for calluses • Lotion • Grips • Antiperspirant for sweaty hands • Chalk

  26. “RIPS” • Treatment • Wash with soap & water • Clip away loose skin • Gymnasts should have own “rip scissors” • Triple antibiotic ointment & bandaid • Cover with DuoDERMor OpSite

  27. GRIPS • 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

  28. “GRIP LOCK” • 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

  29. WALKING ON YOUR HANDS… • Injuries from using UE for wt bearing • Forces (x body weight) • Back handspring 2.37-3.6 • Round-off 2-3 • Yurchenko vault (round-off) 2.38 • Pommel horse 1.5-1.6 Markolf 1990, Koh 1992, Seeley 2004

  30. WRIST PAIN • 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

  31. Osseous Distal radius stress rxn Scaphoid impaction Lunate impaction Scaphoid stress fx Kienbock’s Ulnar abutment Carpal chondromalacia Soft tissue Doral wrist impingement capsulitis Wrist splints TFCC tear Ganglia Distal radioulnar instability Carpal instability What is your differential diagnosis? Gabel GT. Clinics in Sports Med 1998; 17(3):611-623

  32. 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)

  33. Radiographic findings • Widening of distal radial physis • Cystic changes on metaphyseal side of growth plate • Volar radial beaking • Indistinct appearance of physis

  34. 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)

  35. 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

  36. 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)

  37. Treatment • 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

  38. ELBOW OCD • Mechanism • Repetitive valgus overload • Using UE as wt bearing joint • Compressive & rotational forces • Gymnasts tend to have hypermobility • Risk ↑ with >carrying angle?

  39. 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. et.al. J Bone Joint Surg 2007:89:1205-1214

  40. ELBOW OCD: Return • 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

  41. 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%

  42. Common Spine Problems: • Spondylolysis • Scheurmann’s • Intervertebral pathology • Mechanical Sources

  43. Spine Pain:Prevention

  44. Evaluation of Back Pain Curr Sports Med Reports 2009;8(1):20-8.

  45. Possible Health/Medical Issues: • Growth Retardation • Bone density • Female Athlete Triad (F.A.T)

  46. Growth • 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

  47. Growth? • 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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