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The Young Gymnast Athlete: Upper Extremity Injury Prevention

Written by:

Jessica Heffner, MS, OTR/L

VHSF Fellow ‘23


I started my journey as a young gymnast athlete at the age of three. As my personal favorite Olympic sport, I have become passionate to spread awareness of the most prevalent injuries experienced, and to attempt to mitigate the extent of these acute injuries and their possible secondary prolonged complications.

Approximately 4.6 million children participate in gymnastics worldwide, and generally they tend to be very young at both the novice and elite levels. The median age of a U.S. Olympic gymnast prior to the Tokyo Olympics was 16 years old. The training is very demanding with young gymnasts dedicating 12-40 hours per week depending on their level of competition.

Gymnastics is a rapidly growing sport and even becoming a popular after-school activity for our children. Parents who are new to the sport may not realize that gymnastics skills require an extremely high level of physical performance that employs the upper extremities to serve as weight-bearing limbs that are repeatedly subject to repetitive axial loads. This predisposes young gymnast athletes to a broad range of injuries ranging from skeletal trauma to a multitude of muscular and ligamentous injuries (Hart et al., 2024).  “These high-impact forces can impact the wrist through torsional forces, axial compression, and distractive forces on the hyperextended joint. It can also affect the elbow through high valgus and varus stresses. The ligaments surrounding these joints very often undergo plastic deformation following continuous microtrauma, resulting in increased laxity and instability” (Pei et al., 2022).

Research conducted from 2013-2020 investigated gymnastics related injuries that presented to the emergency department, with the findings concluding that gymnasts between the ages of 6-10 years of age were more likely to experience lower arm fractures from improper or incorrectly taught landing techniques (Albright et al., 2022). I have often witnessed young gymnasts using their arms to brace their falls rather than rolling into a tucked position to fall safely. With these statistics it would seem fair to suggest that these young gymnasts are very likely being taught new higher-level skills and techniques that they are unfamiliar with and possibly not ready for; further placing this population at higher risk for acute injury.




 

 

Common Upper Extremity Injuries:


 There are various injuries that a young gymnast may sustain, but the most common seen by orthopedic and sport medicine clinicians include:  “(1) “gymnast wrist” (distal radial physeal injury); (2) grip lock (acute radius and ulna fracture); (3) osteochondritis dissecans (OCD) of the capitellum; (4) medial tensile injuries (medial epicondylar apophysitis, medial epicondyle fractures, and partial or full ulnar collateral ligament [UCL] tears); and (5) shoulder instability (including labrum tears)” (Hart et al., 2024). 

 

(1) The gymnast wrist is a result of repetitive weight-bearing onto the hands/wrist, leading to injury or inflammation to the radial growth plate of the wrist.  The axial loading and forearm rotation on balance beam, wrist hyperextension and ulnar deviation during vaulting, and wrist hyperextension with use of soft mats during back handsprings place gymnast at higher risk for this injury, especially between ages 10-16 years when gymnast are going through rapid growth.  “Untreated gymnast wrist can have long-term effects, including chronic wrist pain, distal radial physeal arrest, and positive ulnar variance due to ulnar overgrowth. Ulnar positive variance may in turn lead to secondary problems, including but not limited to triangular fibrocartilage complex tears, ulnar impaction syndrome, extensor tendon ruptures, and continued ulnar-sided wrist pain and decreased range of motion as an adult” (Hart et al., 2024).

(2) Grip lock is an injury which occurs while wearing grips while swinging on uneven bars, high bars or rings. The leather grip can overlap or fold over, causing the hand to stay in place while the forearm continues to rotate. This can result in an acute radius and ulna fracture.


(3) The exact cause of elbow osteochondritis dissecans (OCD) is unknown, but research suggests “OCD is caused by repetitive loading of the developing distal humeral chondroepiphysis, which in skeletally immature athletes has a relatively limited vascular supply.” This injury is commonly seen in gymnasts ages 10-14 years old, and commonly due to shearing and compressive stress on the hyperextended elbow” (Hart et al., 2024).

(4) Medial epicondyle apophysitis occurs in gymnasts with open growth plates. This injury is similar to gymnast wrist, as it is a repetitive stress injury to the apophysis of the medial epicondyle. A medial epicondyle fracture typically results from a fall onto an outstretched arm with a valgus moment. The ulnar collateral ligament (UCL) is located on the medial aspect of the elbow and is the main stabilizing ligament that can have partial or complete tearing with a valgus force, most commonly with hyperextension (Hart et al., 2024).

 

(4) Shoulder instability commonly occurs in gymnast athletes because of high-intensity and repetitive training and can result from a fall or landing with the shoulder abducted and externally rotated.  “The rotator cuff muscles may fatigue and lose their dynamic stabilizing effect, leading to subluxation or dislocation of the humeral head, glenoid labral tears and/or increased capsular laxity. Labral pathology is seen particularly after acute trauma. Anterior labral tears (Bankart lesions), humeral avulsions of glenohumeral ligaments (lesions), anterior labral periosteal sleeve avulsions (lesions), and concomitant bony injuries of both the glenoid rim (bony Bankart lesion) and posterior superior humeral head (Hill-Sachs defect) have all been described in gymnasts” (Hart et al., 2024).



How can injury be prevented?

 

The findings of research suggest a need for education to coaches and parents regarding injury prevention and training programs for young athletes. It is essential for gymnastics coaches to understand proper training volume and adequate rest, as this is crucial to musculoskeletal pain management and recovery. The following list below are injury prevention strategies obtained from current research:

1)    To prevent gymnast wrist, “decrease repetitive impact/pounding, strengthen your wrist, shoulder, and periscapular muscles, and use proper technique when performing upper extremity weight bearing gymnastics skills.”  (Gymnastics Medicine et al., 2022)

2)    “Prevention of grip lock is critical and may be facilitated by simply checking the fit of the athlete’s grips.  Grips that are “stretched out” or too long for the gymnast are more likely to lock the dowel in place; thus, it is recommended that gymnasts and coaches check the fit of their grips every three to six months and always have an extra pair of well-fitting grips in their gym bag” (Hart et al., 2024).

3)    “Focusing on posture and strengthening, as well as avoiding hyperextension of the elbow and limiting repetitions are important in preventing OCD lesions” (Gymnastics Medicine et al., 2022).

4)     “Posture correction, periscapular and rotator cuff strengthening, wrist strengthening, and limiting number of impacts on the arms can help prevent medial epicondyle apophysitis.” To prevent UCL injury, “gymnasts should avoid hyperextending their elbows to prevent valgus collapse by working on their posture, shoulder mobility, and periscapular strength (Gymnastics Medicine et al., 2022).

5)    “To prevent shoulder instability/dislocations focus on posture correction, rotator cuff strengthening, periscapular strengthening, and practice falling safely” (Gymnastics Medicine et al., 2022).

6)    Technical regulations and routine surveillance should be implemented to ensure early injury detection (Pei et al., 2022), along with a medical evaluation at the first manifestation of painful symptoms, to promptly investigate for an early detection of injury (Farì et al., 2021).

Research supports the importance of preventative strengthening and conditioning programs for specific injury prone areas of the body, and specific return-to-gymnastic protocols/guidelines as an important tool for injury prevention and communication among patients, providers, therapists, and coaches.


Conclusion:

It is essential for trainers, coaches and parents to be aware of injury risk and implement targeted injury prevention protocols into young gymnasts’ training regimen and routines. Understanding common extremity injuries associated with gymnastics can better equip health care providers to guide the expectations for these athletes, optimize patient-athlete relationships, and establish programs geared toward helping young gymnasts participate at their desired level while keeping our young gymnasts safe.

 



 

 

 

References

 

Albright, J. A., Meghani, O., Lemme, N. J., Owens, B. D., & Tabaddor, R. (2022). Characterization of musculoskeletal injuries in gymnastics participants from 2013 to 2020. Sports Health: A Multidisciplinary Approach15(3), 443–451. https://doi.org/10.1177/19417381221099005 

Farì, G., Fischetti, F., Zonno, A., Marra, F., Maglie, A., Bianchi, F. P., Messina, G., Ranieri, M., & Megna, M. (2021). Musculoskeletal pain in gymnasts: A retrospective analysis on a cohort of professional athletes. International Journal of Environmental Research and Public Health18(10), 5460. https://doi.org/10.3390/ijerph18105460 

Hart, E., Bauer, A. S., & Bae, D. S. (2024). Common upper extremity gymnastics injuries and gymnastic specific return to play protocols. Journal of the Pediatric Orthopaedic Society of North America6, 100016. https://doi.org/10.1016/j.jposna.2024.100016 

Home. Gymnastics Medicine. (2022). https://gymnasticsmedicine.org/ 

Pei, Y. A., Mahmoud, M. A., Baldwin, K., & Franklin, C. (2022). Comparing musculoskeletal injuries across dance and Gymnastics in adolescent females presenting to emergency departments. International Journal of Environmental Research and Public Health20(1), 471. https://doi.org/10.3390/ijerph20010471 

 

 

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