CHAPTER

COMMON GYMNASTICS
INJURIES AND
CONTRIBUTING FACTORS

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Reading Resources
12
The Athlete’s Shoulder: 2nd Edition. Wilk, Reinold, Andrews
Current Concepts in the Treatment of Shoulder Instabiltiy – Wilk (DVD)
Current Concepts in the Treatment of Rotator Cuff Injuries – Wilk (DVD)
Recent Advances in the Evidenced Based Evaluation and Treatment of the Shoulder – Reinold
(Online Course)
Recent Advances in the Evidenced Based Evaluation and Treatment of the Knee – Reinold and
Macrina (Online Course)
Knee Disorders – Noyes
• Hip Arthroscopy and Hip Preservation Surgery Vol 1 and Vol 2- Sho, et al
• Ultimate Back Fitness and Performance – McGill
• Low Back Disorders – Mcgill
• Rehabilitation of the Spine – Leibman
• Recognizing and Treating Breathing Disorders – Chaitow
• The Lumbar Spine Vol 1 and 2 – McKenzie
• The Cervical Spine Vol 1 and 2 – McKenzie
• The Sensitive Nervous System – Mosely
• The graded Motor Imagery handbook – Moselt, Butler, Beames, Giles
• Functional Training Handbook – Liebenson
• Training = Rehab – Weingroff (DVD)
• Lateralizations and Regressions – Weingroff (DVD)
• Training = Rehab 3 – Weingroff (DVD)
• Spinal Control: The Rehabilitation of Back Pain: Hodges, Cholewicki, Van Dieen
• Princples of Athletic Training - Prentice
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• Clinical Sports Medicine – Brukner and Khan
• Periodization Training for Sports – Bompa
• Movement – Cook
• Assessment and Treatment of Common Muscle Imbalances: The Janda Approach – Page, Frank,
Larder
• Anatomy Trains – Meyers
• The Future of Exercise Program Design – Cook, Burton, Cosgrove (DVD)
• Key Functional Exercises You Shoulder Know – Cook (DVD)
• Essentials of Coaching and Training Functional Continuums – Cook, John, Burton (DVD)
• Sports Injury Prevention and Rehabilitation – Joyce and Lewindon
• Allostatis, Homeostasis, and the Cost of Physiological Adaptation – Schulk
• Sport, Recovery, and Performance – Kellman, Beckman
• The Physiology of Training for High Performance – MacDougall and Sale
• The Handbook of Stress Vol 1 and Vol 2 – Fink
• Progressions in Translational and Molevular Science Vol 126: Mechanotransduction – Engler,
Kumar
• The Science of Gymnastics: Advanced Concepts – Jemni
• The Sports Medicine Handbook: Gymnastics – Caine, Russell, Lim
• The Gymnast Care Book on Injuries Vol 1 – Eldridge

Gymnastics Injury Background, Themes, and Epidemiology

The discussion of injury rates, management, and prevention is without a doubt one of the most
daunting issues that gymnastics faces. There is no denying that the incredibly high rate of
overuse and acute injuries in gymnastics is a problem.

Having spent my entire life in gymnastics as an athlete, coach, and now medical provider, the
reality of the situation is we are not addressing this problem honestly and bluntly. Gymnasts
continue to get injured at a staggering rate, with reinjures or chronic pain plaguing many athletes.
It is one of the leading causes of burnout in gymnasts or athletes choosing to quit due to ongoing
pain or fear of injury.

In the last five years, I have talked with hundreds of frustrated coaches and gymnasts, as well
as worried parents and medical providers who want to help gymnasts. Throughout these
discussions common themes constantly repeat themselves. One, is that we still have a massive
problem related to injuries. Two, this is a multifactorial problem with many challenging questions,
and a need to really start digging into changing our cultural habits. Through this chapter, I hope to
help offer a blend of the science on gymnastics injuries and my experiences to help foster positive
change.

First, I must state something clearly. It’s time to have a brutally honest conversation about this
problem and stop sweeping it under the rug. It’s also time to stop downplaying the severity of
stress fractures, spinal fractures, and hip or shoulder injuries in young athletes. 13-year-old
gymnasts getting two spinal stress fractures, or needing bilateral elbow surgery due to cartilage
damage, is not “part of gymnastics”. Gymnasts requiring 3-4 shoulder surgeries throughout their
career should not be an accepted part of training. We should refuse to accept the fact that at

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least 10-20 college and elite athletes appear to be tearing their ACLs or Achilles every season.

We need to look our problems directly in the eyes. We need to talk about how equipment
technology, mismanaged work to rest ratios, and being too aggressive with young gymnasts in
relation to early specialization or year-round training is contributing to incredibly high injury
rates. We also need to take the best science available on injury mechanisms, combine them with
the expert opinion of gymnastics coaches, and look for innovative training approaches that help
reduce risk of overuse as well as acute injuries.

We also need to hold people accountable that are pushing athletes to train through pain for
the sense of “being tough” and address the lack of science being used in physical preparation or
the rehabilitation of gymnastics injuries. Insanely high skill numbers, poor flexibility methods,
not using periodization, and lacking specificity of medical care for gymnastics all need to be
addressed.

I’m sorry if I am blunt. But after seeing the exact same problems in our culture ruin gymnast’s
careers over and over, I refuse to accept the fact that we are doing all we can to reduce injuries
from occurring. I have watched gymnast, after gymnast, after gymnast lose their entire
competitive season or career to injuries that may have been preventable, or at least mitigated.

If I’m being honest, a few of these cases were gymnasts of my own as a younger coach. This is why
I may come off as overly aggressive on this topic. There is a very different level of impact that
occurs related to injury when you are working as a dual medical provider and a coach.

When I was just coaching, if a gymnast got hurt of course I felt bad and wanted to help. But I
largely did not see what they were going through when not visiting the gym. They would go to the
doctor, and then go through rehabilitation, and then come back to the full training once cleared a
few months later.

However, in the last five years working as a dual coach and medical provider my perspective has
shifted. There have been times when I was younger that athletes I coached suffered spinal stress
fractures or other injuries, despite our best efforts to prevent them. Instead of not seeing the
gymnast for a few months like I was used to, I now would see them every week for rehabilitation.
When you watch a career of overuse injuries and chronic pain stack up, with a gymnast you coach
deciding to quit gymnastics and not pursue the college opportunity they worked their whole
life for, it forces you to reconsider what you are doing as a coach and medical provider. I know
very few people operate in this dual role, but my hope is that through this chapter I can share my
unique experiences to help shed light and begin to solve this deep issue.

I fully understand gymnastics is rigorous. Accidents happen, and no matter what we do injuries
will occur. Also, there is no one person to point a finger of blame at within the gymnastics
community, as unfortunately happens with injuries.
I have seen cases of injury when most of the blame is on a gymnast, because they do not listen to
advice or put in the work needed to prepare their body for the forces of gymnastics.

I have seen times when the blame is on medical providers for not taking the time to understand
gymnastics fully or do advanced rehabilitation through strength and conditioning principles
before allowing a gymnast to return to training.

I have seen times when parents may to blame, as maybe they are pushing their children to a

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 higher level in gymnastics when this is not the athlete’s desire. Not everyone wants to compete
formally in gymnastics at a high level.

I have seen times when coaches are the main sources of blame, due to their lack of knowledge or
inability to suppress their ego. Sometimes it’s just a fact of not being able to embrace the reality
that a gymnast is hurt and shouldn’t be training certain skills or competing right now.

As I have stated multiple times in this book, I openly take blame as a younger coach for making
errors, and as a result feel no one person can point a finger at someone else without taking
ownership. I hope that with more information, self awareness, and humble collaboration, we can
start to make a dent in the rates of injuries in gymnastics.

Research on Rates, Types, and Patterns of Gymnastics Injuries

Research reviews on gymnastics have offered insight into the rates of injury, most common types
of injuries, and training profiles related to injuries in gymnastics. I will say before I present this
research, I take it with a grain of salt, as many readers should as well.

The reality of the situation in gymnastics is that our unhealthy cultural approach to injuries
encourages gymnasts to not speak up when injuries begin. Either verbally or non-verbally, they
are too often encouraged to train through their injury, and “toughen up” if they wish to reach
achieve their dreams.

While some bumps, bruises, and soreness are inevitable (and I see them weekly with gymnasts
I coach and treat), what currently exists as acceptable in our culture is far from “bumps and
bruises”. Often pain reports are serious issues that should be better handled. It starts with a with
a hard look at all the factors I mentioned above first, and then conscious collaborative efforts
to find ways to deal with an injury. Even if that means stopping training temporarily, removing
an athlete from a big competition, or undertaking a huge step back to physical preparation and
technique basics, to optimize health and long-term goals.

With this caveat mentioned, here are some of the available research studies on gymnastics injury
epidemiology that I have found over the years. I certainly have missed out on some research, and
only have what is available to me.

I will include some of the most prominent trends. I encourage people to look at The Sports
Medicine Handbook of Gymnastics released by Caine, The Science of Gymnastics: Advanced Studies
- 2nd Edition recently released by Jemni, and the numerous research articles that are available on
this topic.

• First, the best definition of an injury is offered by Dr. William Sands as “any damaged body part
that would interfere with training”

• Injury incidence refers to “a simple count of the number of new injuries or the probability that
someone in a group will be injured over a particular period of time.” 1-2

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 • Whereas injury prevalence includes “the number of new and old injuries present in a specific
group, or the probability that someone is injured during a given period.” 1-2

• Risk factors are also commonly used to describe injuries, with intrinsic factors being mostly
related to the individual athlete and extrinsic factors being aspects of an injury the athlete
confronts in or out of training. 2 This is important to consider as it influences what aspects of
injuries are within or control to change and those that are not.

Research and Evidence on Gymnastics Injuries per Sands, Caine, Russell, and more

• Gymnastics injuries seem to be influenced by the time of season and duration of aspects of
training. In the context of an entire competitive season, injuries appear to occur more frequently
during early season when new skills are being performed in routines, early in competition season,
following vacation time (likely due to rapid increase in training after vacation, likely not the
vacation itself), or when new skills are attempted. 2-9

• Acute injuries (sudden fall causing bone break or ligament tear) and overuse injuries (cumulative
trauma like a stress fracture from over loading and under recovery) both occur in gymnastics. But
research suggests the majority of injuries, about 66%, have slow gradual occurrence indicating
overuse, while 33% of injuries from research appear to be more acute or accidental. 3-4, 10

• Unfortunately, it appears many gymnasts either fail to speak up about their injury and continue
to train or compete with their injury. 3, 11-15 This has even been shown in college gymnasts, who
when suffering injuries in the beginning of season continued to train and compete while injured,
or even through multiple seasons. 3,18

• Studies referenced within The Science of Gymnastics: Advanced Concepts have linked to this
massive problem with extremely high rates of stress fractures seen in the wrist, spine, elbow, and
clavicle of gymnasts. 16-28

• These studies have also linked this problem with extremely high rates of tendon or other “stress
related soft tissue damage” such as Achilles injuries or full ruptures. 29-30

• Other studies looking at gymnastics injuries during different lengths of time or competition levels
have become available.

o At the 2008, 2012, and 2016 Olympic Games for 81 injuries among 963 registered
gymnasts for all gymnastics domains,

The most frequently injured body part was the ankle, with sprains being most
common. No differences were observed between injury rates for males and
females. 31

o Over a 10-year period with 64 male gymnasts reporting 240 injuries, and 55 female
gymnasts reporting 201 injuries at a Division 1 college, 32

The hand and wrist were the most injured in male gymnasts (24%) with the foot
and ankle most injured in female gymnasts (39%),
Interestingly the freshman eligible athletes (those that just likely came from high

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 school JO or other programs) had the highest injury rates.
Female gymnasts were more commonly injured compared to men, and more
frequently underwent surgery. 32

o In a study covering a 21-year period with 3,681 reported injuries for “young precollegiate
female gymnasts” ranging from novice to elite, 33

Injury rates increased per training hour depending on level, with novice gymnasts
having a 0.687 injury rate per 1000 exposure hours, and elite gymnasts having a
2.859 injury rate per 1000 hours of exposure.
The lower extremity was most injured (60.9%) compared to the upper extremity
(22.6%) 33

My Thoughts on What This Research Means

These are just a few of my ideas based on this research, prior to moving on to specific joints most
commonly injured.

• The staggering amount of injuries, even when likely being under represented in the research,
highlights the fact that current approaches to injury management are not adequate. All these
studies show injuries are occurring across multiple ages, levels, and competition involvement
of male and female gymnasts. We need to change many aspects of training, ranging from the
culture we build to the medical rehabilitation practices we use.

• I was very surprised to see how under represented hip and elbow injuries were in female
gymnasts. Almost every female gymnast I have worked with has had some sort of serious hip
injury that was very much overlooked. Gymnasts, coaches, parents, or other people in the
gymnastics community often turn labral or hip ligament injuries into “just a pulled groin” or “a
hip flexor strain”. They also turn pelvic growth plate fractures into “just a pulled hamstring”.
I think the worst I have seen is when serious cartilage or growth plate fractures like OCD of
the elbow are claimed to be “elbow tendonitis”. Simple strains or muscle pulls go away in a few
days with proper rest and care. They do not last for months and continuously keep coming
back.

• In similar fashion, I was surprised to see how underrepresented shoulder injuries were in
male gymnasts. I do not know one male gymnast, including myself, who hasn’t had some sort
of rotator cuff or labral injury take them out of multiple weeks of training. I will speak to this
more below, but we must move away from just assuming hip and shoulder pain is part of
gymnastics, and that when it occurs we should just try to tough it out.

• It needs to be emphasized that way too many gymnasts are training through serious injuries.
This was mentioned in the research, but I have worked with countless athletes, that for a
variety of reasons, continue to train months or seasons while chronically injured. There
are multiple reasons as to why injuries are reoccurring, ranging from training factors to
nutritional factors or more. We need to deeply analyze each factor and have some tough
conversations about what level of soreness is expected and tolerable, versus unexpected and
inappropriate.

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• I feel that at the root of all these issues is a serious lack of monitoring for skill repetition,
routine repetition, and strength workloads. There is absolutely no surveillance system being
used day to day in practices to measure how many skills or routines athletes are performing
in one day, one week, one month, or across a season. This is a huge problem and opportunity
for improvement. Imagine a long-distance runner training for a marathon never counting
their miles, run times, or training hours logged on a daily, weekly, or monthly basis. Imagine
a weight lifter who never counts sets, reps, the pounds lifted, or the volume of their training.
It seems this is essentially what we are doing in gymnastics. I by no means am trying to
say I have the perfect answer for how to fix this or know what the best way to measure
training load in gymnastics. As a coach who works with a group of gymnasts that have a
large variability of skills as well as ability levels and goals, I know this is a daunting task. That
doesn’t mean we should just stop looking for innovative solutions to this challenging problem.

• In similar fashion to the cultural issues of allowing gymnasts to continue to train while hurt
(and I fully realize many gymnasts may not speak up about their injuries appropriately),
another serious cultural issue we need to face is assigning insanely high skill or routine
repetition numbers. Gymnastics has become way too difficult, and the accumulative amount
of force that skills repeatedly put through young gymnasts’ bodies is enormous. We cannot
just train an hour of an event and keep doing skills “until we get it right”. There must be some
sort of boundary to conscious thought to fatigue development, technical perfection, and the
cumulative forces of skills on athletes who are young and have not yet fully matured.

• As mentioned in the earlier chapters, there is a huge body of current science for strength,
energy systems, flexibility, periodization, and long term athletic development models that
must be put into practice. This includes both the training side and medical rehabilitation side
of gymnastics.

• The medical community needs better information, improved diagnostic tools, and superior
rehabilitative strategies for gymnasts. I have treated far too many gymnasts who received
very average and basic rehabilitation programs through their entire injury timeline. Many
of these basic approaches have their place for the first phase of injury management, but
they lack the essentials of progressive load management to meet the demands necessary
to safely return to a sport of gymnastic’s caliber. We must adopt formal strength and
conditioning principles in rehabilitation and grasp a much better understanding of gymnastics
biomechanics and return to sport programs if we wish to make a reduction in the reinjury
rates.

Based on these epidemiological studies, and the non-gymnastics medical research I have
studied, I hope to offer some more of my medical experiences. I certainly do not want to turn this
into a nerdy academic book, but I do think it is very important for everyone in the gymnastics
community to have a baseline understanding of these issues. By understanding the general
theories as to why many common injuries may come up in gymnastics, everyone can be much
better equipped when inevitable injuries pop up in training.

By becoming more educated on the most common types of injuries, we can not only keep an eye
out for something starting, but also start collaborating as a community to make a dent in the high
rates of injuries. Most importantly, the athlete’s health should always be priority. If a gymnast
is getting the same injury over and over, we need to take a step back and reflect on possible

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contributing factors rather than just demanding rest.

In another viewpoint, injured gymnasts can’t train to their full ability. An athlete can certainly
still do flexibility, conditioning, or bars when they hurt an ankle, but it is clearly not the same.
The training time and practice hours that are lost due to injury are enormous in gymnastics.
Every gymnast will have some accidents and injuries that pop up given the challenge of the sport.
However, the current state of gymnastics often has athletes missing multiple weeks or months
of training, up to entire competitive seasons, due to injuries. Being even more honest, it is insane
to see how many gymnasts quit the sport early due to having multiple reoccurring injuries. In just
the last twelve months, I personally have seen 7 high-level gymnasts decide to stop gymnastics
due to their continued injury rates.

If we can better understand how gymnastics injuries occur, we can create new innovative
approaches to training to prevent them. This will directly increase performance and reduce the
risk of reoccurring problems. I tell almost every gymnast I work with the same thing: what causes
your injury (unless a freak accident) also directly reduces your gymnastics performance.

We often forget that there are “basics of the basics” when it comes to gymnastics. The most basic
flat body shape requires quite a bit of joints to be working well. Multiple body parts must have
adequate range of motion, strength, control, dynamic stability and coordination to successfully
perform even basic gymnastics skills.

By taking a step back to address a gymnast’s movement-based issues, flexibility deficits, or

strength limitations, a significant amount of headache and time can be saved. Not to mention, by
discovering and correcting these “bottleneck” type movement problems, the athlete can attain
significantly higher levels of performance when they finally recover from their injury.

I will start with the most common injury sites and offer a small background on my thoughts
for why or how certain injuries occurs. I will then offer more of a “bullet point” type approach
underneath each body part as to what the current body of medical science, as well as my
experiences from the rehabilitation world, on strategies to help. This will be more of an overview,
but I will be sure to include more in-depth articles for each area of the body at the end of this
chapter.

Please remember, that this is not a rehabilitation book. No coach, parent, or gymnast themselves
should be attempting to diagnose and treat an injury. This is a very easy way to make a gymnast
much worse. Gymnasts who have reoccurring pain or injuries must be taken to a medical provider
for the appropriate diagnosis, treatment, and return to sport program.

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 Contributing Factors to Lower Back Pain

I will start with this area of the body, and spend a little more time on it, due to how prevelant it is
in gymnastics. The rates of lower back pain in gymnastics are staggering, with rates of lower back
injury in gymnastics being reported from 20% - 60% in some studies. 34

In other studies, the lower back is noted as the second or third most commonly injured body
part, peaking at 43.6% of all injuries in one study, and 31.3% of all injuries in another. 35-39 Again,
remember this is probably a massive under representation of how common lower back injuries
really are in gymnastics. Most gymnast unfortunately do not formally report or seek medical care
for their back pain.

I have yet to meet a gymnast who did not have a back injury during their career. I have talked with
hundreds of gymnasts who suffered one or more stress fractures that caused them to be braced
for 3 – 6 months, miss one or multiple seasons, or ultimately was the reason they quit gymnastics.

I do not think that people in the gymnastics community appreciate the insanely high forces, and
the insanely high repetition numbers, that a gymnast’s spine is subject too during training.

Based on research from Bruggemann and Hume in The Handbook of Sports Medicine:
Gymnastics 40-41 some of these forces have actually been measured.

• The compressive forces at the middle spine experience some of the highest numbers
recorded, which are between 11.6 – 20 times body weight upon ground contact during
dismounts. 35

• Shear forces to the disc of the lower back are estimated at 3.5x body weight.

• When landing from a dismount, the compression and shear forces a gymnast must handle
every repetition have been seen to increase 130-150%.
• During the take-off of a tumbling pass on floor, maximum compression forces at the lower
back have been recorded at 6.5-8.5x body weight, with maximum shear loading forces of
3.0-3.5x body weight.

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Even more concerning are the massive rates of chronic lower back pain re-injury, and concerning
imaging findings (x ray, MRI, etc.) for the spines of gymnasts. Studies have indicated;

• When comparing the lower spine vertebrate in 16 female gymnast ages 10-19 compared to
16 matched controls, 3D MRI images showed

“a significant higher frequency of structural changes and morphological abnormalities in

gymnasts and increased number according to age”.

• These changes included lower vertebral height and increased end place surface area to
bear load. 40 The effects of these changes related to injury were not correlated, but they are
significant and worth noting.

• Changes in the ring apophysis of vertebral bodies in gymnasts, as well as injury to this area,
has been suggested to occur through repetitive flexion and extension of the spine during
swinging elements or shape changing, and also high landing forces being incorrectly absorbed.
41

• Another study in 2005 by Bruggerman looked at 37 female gymnasts over three years. They
found landing from dismounts or vaulting showed the highest loading forces followed by floor
or vault takeoffs, followed by impact on balance beam, and finally by swinging on bars. They
used these loading estimates across, days, week, and years to correlate cumulative spinal
loading with spine structure changes. They found that in 23 of the 37 gymnasts studied (62%),
the structural changes of the lower back vertebrae and middle back vertebrae were explained
by the loading over three years. 42

• In a study in 200 by Froehner, structural changes were seen in the thoracic and lumbar spine
of former elite athletes with an average of two effected vertebrae for female gymnasts and
even more for male gymnasts 43

From these studies and others, the authors within Caine and Russell offered this, 35

“The numbers of repetitions, the loading amplitude, and the pauses between loading sessions
should be of major importance and must be documented. Biomechanics is strongly related to acute
and overuse injuries in gymnastics… Greater focus for injury prevention is required in the early years of
gymnastics when the fundamental motor skills and the musculoskeletal systems are being formed.”

“…The cumulative spinal loading from training on the balance beam should not be
underestimated given the extensive time spend and the high frequency of skills and repetitions on this
apparatus.”

“…hyperextension with high tensile strain on the anterior vertebral ligament and high tensile
stress on the insertion to the vertebrae may explain tissue failure [in relation to giant swings for
dismounts and high energy release skills on bars]”

Along with these training realities, many other factors like skill technique, growth rates, physical
preparation, genetics, the training environment, individual health of the athletes, and how well a
gymnast cares for themselves, also contribute to the huge issue of lower back pain in gymnastics.

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 We need to remember that the forces on the spines, and rest of the body, of young gymnasts
cumulatively take a toll during their career, but also during the rest of their life.

Take this very concerning, yet interesting, finding from a paper published by Froehner in 2000,
that investigated reports from 42 female and 27 male elite gymnasts (all competed at world
championship or Olympic level).

“…Froehner (2000) reported deformities and disorders of the spinal structures and peripheral joints
of 42 female and 27 male former top German gymnasts 8.9 +/- 5.2 years after retirement from
competitive Artistic Gymnastics.” 43

Close to 10 years after their career,

o more than 90% of the male and female former gymnasts suffered from moderate to severe
disorders of the spine,
o moderate to severe disorders existed in 40% of knee and ankle joints, and more than 30% of the
male gymnasts of shoulders, elbows, and wrists.
o Severe discomfort of the spine was demonstrated in 57% of the female gymnasts (21% cervical
spine, 17% thoracic spine, 53% lumbar spine) and in 58% of the male gymnasts (23% cervical
spine, 19% thoracic spine, 50% lumbar spine).”

“In 32 female former elite gymnasts, Froehner (2000) identified structural changes and deformities in
42 vertebrae of the thoracic spine and in 21 vertebrae of the lumbar spine, which gives an average of
two affected vertebrae per gymnast. The numbers for the male gymnasts are even higher (58 thoracic,
21 lumbar) with 3.76 affected vertebrae per gymnast.”

Just to emphasize the importance of those studies, keep in mind that 90% of the male and
female gymnasts had “moderate to severe” disorders of the spine, with “severe discomfort” in
the lower back of half the male and female gymnasts 10 years following retirement.

Obviously, there are hundreds of factors contributing to why someone has back pain or a spine
“deformity” 10 years after ending gymnastics. We must also consider the study was in elite
gymnasts of one specific country.

But we cannot sweep aside the gravity and seriousness of the data presented. Those numbers,
along with many other studies on the injury demographics of lower back pain in gymnasts, must
be recognized as reasons to look for more optimal methods to protect the health of the gymnast
spine.

Although there are a few different categories of back pain in gymnasts, the most common are extension,
compression, and flexion-based injuries.

“Extension” refers to the movement of the body bending backwards. “Flexion” refers to the movement of
the body bending forwards. “Compression” refers to axial loading of the body due to gravity forces, as is
seen in the take-off or landing of a tumbling pass or dismount. For more spinal biomechanics and specific
loading statistics, be sure to check out the work of McGill 44-45 and Paul Hodges’s book, Spinal Control: The
Rehabilitation of Back Pain.

Female gymnasts more commonly encounter extension-based overuse injuries to the spine, although
compression-based factors are directly related. Stress fractures of the spine, and variants of
spondylolisthesis, occur from repetitive hyperextension and rotation of the spine. 47-51

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In gymnastics, this typically refers to repetitive stress from:

• Back walk overs

• Back or front handsprings on beam

• Back or front handsprings during floor tumbling

• Front aerials and layout step out series on beam

• Yurchenko style vaulting

• Twisting skills, particularly take off

• Hyperextension releases like Pac saltos or Tkachevs

• High energy Chinese style tapping for releases or dismounts as commonly seen in male
gymnasts

• Other dance, jumps, leaps, or choreography skills with notable spinal hyperextension like ring
or sheep jumps

Female gymnasts typically do a much higher volume of these extension-based skills within their
respected four events. However, I have treated a few cases of flexion or compression based back pain in
female gymnasts. They are just less common compared to male counter parts.

It has been outlined that small bony irritation may start with pain and stress reactions, or pre-stress
fractures. As the gymnast continues to train and perform excessive repetitions of hyperextension and
rotation skills, the bone continues to be stressed until it fully fractures. 47, 50-51 The end result often
requires hard rigid bracing to stabilize the fracture, and extended time away from training, along with
extended periods of rehabilitation. Although bracing is still controversial within the literature, due to
its ability to relieve pain and help reduce motion at the fracture site it remains as a present course of
treatment in the current medical management of gymnasts.

Male gymnasts tend to get more flexion, compression, and traction-based injuries caused by the many
unique skills across their six events. Repetitive flexion type injuries can put notable stress on the lower
back musculature, as well as the posterior spinal elements, disc, and neural tissue. 44-45 Higher impact
forces are typically seen in the more aggressive tumbling passes, vaults, and high bar/ring dismounts
they train.

Male gymnasts are also exposed to more forward bending type skills (jams or endos on high bar, peaches
on parallel bars, etc.), and heavy traction forces seen during aggressive giant taps on high bar (especially

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dismount tap) or rings. Male gymnasts also typically train many less hyperextension-based skills, and a
lower volume of them due to the nature of the six events vs. the four events female gymnasts train.

These are general observations from my years in gymnastics, but as always there are exceptions to the
trends. This is especially true with more specialists being seen in the college and elite level gymnastics.

In its most basic form, lower back injuries occur in gymnasts because the tissue load is greater than the
tissue capacity. For whatever reason, the spine is taking more than it can handle.

Tissue overload occurs as damage over timespans of weeks to months, accumulates from high numbers
of skills with more force being trained daily. This rarely occurs in one sudden incidence, like when a
gymnast peels off high bar and suffers an acute injury due to the spine being forced into hyperextension.
This is rare, however it does unfortunately happen.

This overload in loading is almost always being compounded by incomplete recovery periods. With this,
it creates a situation where the spine or other structures within the core cannot regenerate and adapt
to get stronger. Instead, the spine slowly starts to trend downward into states of fatigue, overuse injury,
and under performance.

To reverse this problem, hybrid strength and conditioning programs using body weight and resistance
training to increase tissue capacity through appropriate loading, and bridging educational gaps that may
exist between the medical literature and gymnastics training environment is necessary.

For extension-based injuries, it tends to create a presentation where forms of bending backwards bring
about pain, but forward bending or flexing in a toe touch motion doesn’t really cause a problem.

Compression-based injuries can also come from similar mechanisms but tend to spark more from high
impact landings or tumbling skills. Many of these same skills, along with high impact landings/dismounts,
create enormous compression-based forces on a gymnast’s body.

This is especially true when the athlete’s landing technique does not utilize a more hip dominant squat
based technique, and instead uses a more upright knee dominant strategy. This creates a situation
where a gymnast cannot optimally dissipate the high forces going through the body during landings.
More on that important topic later.

Extreme amounts of force and repetitions, are well known in gymnastics. Other factors can increase risk
even further, for example when a gymnast also shows faulty extending patterns during skills. This simply
means the athlete tends to dominate the back-bending motion with their lower back as the “go to” point
of movement. Because the lower back becomes the area of least resistance for the motion, it is very
common for a gymnast to develop what is known as a “hinge” point.

A hinge point is when a few segments of the lower back seem to bend much more than the other areas of
the body. I have found this most commonly shows up in the lowest portions of the spine (L4-S1), which is
right above their belt line. The next most common area tends to be upper levels of the spine between the
last thoracic spine segment and highest lower back segment (T12 – L1).

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I do not feel this is a coincidence that the most commonly reported sites for spinal injuries and stress
fractures are also the locations of highest forces recorded during gymnastics skills.

My experience and the research available make it logical to think these locations of high force and
repetition may lead to tissue injury or stress fractures over time, creating notable pain and time lost
from training.

An important note here is just because someone has a hinge point, does not mean they are going to
automatically develop a back injury. Hinge points are not inherently bad or dangerous. Someone who
sees this hinge point should not instantly get concerned and scare the athlete. Many elite level athletes
show these hinge points during some skills and do just fine.

It comes down to being aware of the hinge point and factoring it in as a potential risk while also
paying special attention to other pieces of training. Things like avoiding sudden spikes in the volume
of hyperextension skills, developing the physical preparation of the athlete, managing ideal recovery
environments or time periods between training sessions, the fluctuating fatigue level of the athlete, and
monitoring for periods of rapid growth.

The take away here is that hinge points and training proper back bending patterns are important things
we should take note of, as it may not be ideal to have all the motion for extreme backwards bending
coming from one spot.

A more ideal way of extending is a “spread out” extension pattern. In this more global extension pattern,
the athlete aims to utilize their hips, lower spine, thoracic/middle spine, and shoulders equally with core
bracing. This helps in preventing force overload to hinge points and serves to help protect the spine
against overuse injury.

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Dispersing load across multiple body parts helps to take excessive strain off any one body segment. It
reduces placing all the workload for creating and absorbing force on the low back musculature. Utilizing
more of the entire body (hips, shoulders, upper back) compared to relying on certain areas to do all
the work is our goal. It’s a simple distinction – exaggerating the lower back extension vs. a “spread out”
extension – but this concept also leads to a very important point related to optimizing performance and
power.

More thoughts on Factors Related to Lower Back Pain

• Sudden spikes in training, or high weekly and monthly workloads for the number of hyperextension
or impact skills, continue to be the main driver of serious spine injuries in gymnastics

Without a doubt, I feel this is the biggest risk factor for a gymnast developing back pain. The
research available on spine fractures in gymnasts, and colleagues of mine would also agree.
This stems from a large body of research on workload ratios and injury risk in other sports
like baseball and soccer. In theory these findings correlate well when applying this concept to
gymnastics. 52-59

This can very easily occur if a gymnast has an “extension” based skill profile. By this I mean
they are typically good at back handspring type skills, and as a result when moving up in
levels do more skills of the back-bending type. Female gymnasts who have two or three back
handsprings in a beam routine, back handspring tumbling on floor, and do Yurchenko style
vaulting can quickly accumulate hundreds of repetitions per week or month, and thousands
per year. This may seem unrealistic, but when you count how many hyperextension turns are
taken across all warm ups, skill practice, routines, and competitions, it starts to add up. I feel
this creates a very high chance of overuse injury.

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 If the repetitive loading continues, low amounts of muscular pain can quickly become a bony
stress reaction, then possibly cause a bony stress fracture or spondylolisthesis (sliding of one
spine segment forward due to a stress fracture and repetitive hyper extension movements).

I do not want to say that extension movements automatically cause back fractures, because
that is not the case. However, we must take serious consideration into how many extension
skills gymnasts are doing per day, per week, and per month. This balance of performing
enough back-bending skill practice to develop appropriate physical fitness, but not crossing
the line of doing too many back bending skills is extremely challenging as a coach. It’s where
the art and science of coaching intersect. Here are the best methods I have found to help with
this

• 1) Rotate the events that a gymnast is doing hyperextension skills. If a gymnast is

tumbling on floor, doing series on beam, and doing arching skills on bars, it may be a
good day to not do hyperextension drills for Yurchenko’s on vault. Spend the time on
roundoffs or other technical development. The next day, if a gymnast can take beam
series off and instead perform full vaults, this rotates which events are reducing
hyperextensions each day.

o It can be very helpful to set up a schedule based on the number of practices

per week, events for the day, and time on each event. As a coach I understand
that it is very challenging to apply this in such a large gym with other programs
training, or with a large group of gymnasts on a team. I also understand there
will be times such as before larger competitions that things may get scattered.
It’s not that we have to be perfect, we just have to attempt a new method of
drawing awareness and varying the amount of hyperextension skills a gymnast
is doing per day, week, or month.

• 2) Put a “limit” on the total number of hyperextension skills. We must move away
from the “beam series for 45 minutes until you get it right” approach. If a gymnast is
allowed to do this, they may quickly accumulate 50–100 hyperextensions within one
practice. Without any research for normative data or what number per day or week
carries elevated injury risk, I can’t claim to say I know what number of back bending
skills is concerning. I suggest coaches and gymnasts give a top number, say 5–7, as a
max number of hyperextension skills before moving on. From there you can increase or
decrease the number based on how athletes respond.

• 3) Diversify skill profiles when possible. Even if a gymnast has a beautiful back
handspring, do your best to not over use it as the main focus on events. Gymnasts who
are naturally mobile tend to do back handspring types skills on every event. Switching
a few skills (Geinger release instead of Pac or Ray, roundoff dismount on beam vs back
handsprings, etc.) can chop down the total number of extensions performed per week
by a substantial amount.

• Gymnasts very commonly do not learn proper “global extension” patterns from a young age. Often

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 very flexible young gymnasts will use their lower back as the “go to point” for back bending skills,
when they should be taught to use their shoulders, upper back, and hips to dominate the back-
bending motion. When this improper back bending movement pattern is learned, it becomes a
habit transferring into harder skills down the road like back handsprings, beam back walk overs,
Yurchenko’s, and more. When the gymnast does 1000’s of repetitions with this improper movement
pattern, it may set the stage for lower back pain or injuries.

From a very young age, teach gymnasts proper progressions of using their hips, upper back,
and shoulders to be the primary movers in hyper extension skills. Emphasize proper core
control, and teach them how to brace their core during movements to protect their spines
against overuse injury. Try not to allow a gymnast to continue to train back bending skills with
improper technique, using communication and education about how this may lead to reduced
skill performance/progression, and increased injury risk. If needed use different skill methods
such as elevating the feet of a gymnast up on a block to reduce the amount of lower back
extension needed for bridges, back walk overs, and back handsprings.

• Limited overhead shoulder flexibility or hip flexibility is often a culprit to lower back pain. As
mentioned in the chapter above, I feel that our limited application of current science or updated
flexibility methods is causing many gymnasts to lose their flexibility over time. We must make
sure we understand these flexibility concepts, screen hip and shoulder flexibility regularly, work
with medical providers for assistance, monitor times of rapid growth, and integrate new flexibility
approaches with well-balanced strength programs for optimal results.

Remember, whatever motion is not occurring from the shoulder joints and hip joints during
back bending skills must be made up in other areas of the body. The lower back being
pushed to hyperextension or hyperflexion when training skills is typically the most common
compensation for missing hip or shoulder flexibility. By incorporating proper movement
assessments, soft tissue work, proper stretching, and following up with strength/technique
drills we can take significant strain off the lower back over time.

• Lacking core control can also be an issue. It’s not always about how many leg lifts, L rope climbs, or V
ups a gymnast can do. Those movements tend to bias core strength.

• Core control has to do more with a gymnast’s ability to consciously contract the entire group of
core musculature in a “braced” manner, without excessive arching or hollowing in the lower back.
With this approach the front core muscles (rectus abdominis), back core muscles (paraspinals or
extensors) lateral or rotary core muscle (obliques), top core muscles (diaphragm) bottom core
muscles (pelvic floor) and deeper core muscles (transverse abdominis, multifidi, rotares) all work in
unison.

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 I always credit my good friend Dr. Josh Eldridge for being the first person to really introduce
this idea into the gymnastics community.

It’s definitely important that gymnasts have strong and powerful core musculature (check out
the strength and conditioning chapter for resources on that topic). However, all that strength
and power will go nowhere if a gymnast does not understand how to consciously brace their
core in a neutral position. The inability to consciously brace the core just lying flat on the floor
typically transfers to more incidences of “buckling” when landing improperly or shows up in
skills as force going through the lower back repeatedly. I feel training this every day with basic
core control drills in a warm up is quite important. From here, we must teach proper basics
and shaping that helps this transfer over to actual skill work. A balance of core strength,
control, and power is the optimal approach.

• Lacking core strength or force absorbing capacity is another closely related factor to consider. If a
gymnast does understand how to brace their core with proper control, the next step is building their
capacity to handle more force.

This is definitely where many traditional gymnastics core exercises come in to play. Plank
crawlers, L rope climbs, leg lifts, arch ups, and other great exercises can help increase the
core’s ability to function during skills. However, I feel only gymnastics shaping or body weight
core strength is not enough to really prepare a gymnast’s lower back for high level, high
force skills. The impact compression force that goes through a gymnast’s body can be up to
14 times body weight. Due to this, I feel some core training that utilizes external loading and
incorporates the upper/lower body is important.

Gymnasts must be able to control their core under load, especially when in a fatigued state
with heavy breathing. Gymnasts should be adding in loaded core work such as farmers
carries, suitcase carries, overhead carries, sled pushing or pulling, and the use of weight vests
to train this important fitness quality. I think this will not only have a huge positive training
effect for skills, but also can help substantially to build the core’s capacity to absorb or
transfer force.

We have to make sure we train all aspects of the core as well. The front, back, sides, rotational
musculature, top (diaphragm) as well as bottom (pelvic floor) all need to be balanced so
they can work as a unit to handle force. If one area is very over developed while others are
neglected, it can lead to issues during skills.

• Core power, along with force transfer through the arms and legs is also very important. I often see
that many gymnasts have a strong core in body weight specific conditions but lack the ability to
express or absorb high amounts of force.

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 This comes down more to a concept known as “rate of force development” to create power,
and “force absorption” to transfer and disperse power throughout the body. This aspect of
core training is sometimes overlooked in gymnastics physical preparation but can maximize
performance gains if utilized. I think that exercises like medball slams, medball throws,
battling ropes, kettlebell swings, and again speed sled pushing/pulling all apply here.

• Gymnasts must also be sure to land in a correct manner. I will touch on this more in the knee/ankle
injury section, but improper landings mechanics can put enormous force through the lower back
of gymnasts. Proper landing mechanics that enforce squat based eccentric control with the leg
musculature must be taught, trained, and enforced.

• Proper skill technique, development, progressions, and athlete readiness are of paramount
importance for lower back injury prevention. If gymnasts are performing skills well above their
progression level, technical abilities, physical preparation, or mental capacity, many times they are
unable to perform the skill without risk of injury. This applies to risk of acute injury from a one-time
event, or an overuse injury that progresses slowly over time.

• It is very important that a programmed return to hyperextension skills is outlined following a back
injury. If there is not a clear roadmap that outlines what skills, how many of them, and what days of
the week they should perform them, there is a high chance of pain reoccurring. Following 2 weeks
of general strength, flexibility, and basics, I always write a very in depth return to hyperextension
and impact program for gymnasts to follow. I send it to their parents, their coach, and the athlete
themselves, so everyone is on the same page.

There is almost always some degree of soreness from deconditioning, but this drastically helps
reduce the risk of reinjury and makes everyone feel better when a plan is in place. Here is an example
of a female and male gymnast’s return to sport program following a stress fracture, which starts in
the 3rd and 4th week following basics. Please do not just take this program and apply it to a gymnast
coming back from an injury. This is very dangerous and does not meet the specificity of their
gymnastics skill profile. I’m just sharing to help readers understand the concept.

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• There is a lack of easy to use screens for coaches to detect the start of back pain or an injury. I have

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 created a cluster of tests I teach coaches, parents, and gymnasts to use when ongoing pain is present.
An article and in-depth videos can be found in the link below. Generally, I tell gymnasts that if they
have an onset of pain, they should monitor to see if it changes within three days of modified training.
If it does not subside, or they start to have more serious issues such as numbness or traveling pain,
they must be evaluated by the appropriate medical professionals.

Read More About Screening Gymnasts for Lower Back Pain Here
https://shiftmovementscience.com/screening-back-pain-in-gymnasts/

• There are times when the gymnast needs to take more responsibility for their training approaches,
effort to flexibility programs, effort to strength programs, and recovery methods outside the gym
(sleep, hydration, nutrition, etc). These issues can certainly contribute to the risk of lower back pain.
There are also problems that exist within the medical community of not having specific enough
assessments to detect categories of lower back pain, or adequate rehabilitation to help a gymnast
fully prepare to return to training after an injury.

• The need for specific interval skill programs and objective training workloads when returning
from a lower back injury is necessary in gymnastics. With all this being said, the role we all have is
to communicate on these issues and work collaboratively towards a solution. Gymnasts must be
educated on their role in preventing lower back pain. Medical providers and medical doctors should
be educated on getting a better understanding of the sport. Everyone has a unique and important
role to play in helping reduce the injury rates of lower back pain in gymnasts.

Keeping these factors in mind, the topic of lower back pain in gymnastics is incredibly complex
and multifactorial. Training in gymnastics is a challenge itself, with the addition of a back injury the
complexity substantially increases; thus, supporting the importance of a well-educated return to
gymnastics plan. These are just some of my thoughts based on my experiences, the gymnasts I have
treated, and the available science. With this as a foundation, we will now transition to other areas of
the body that are commonly injuried in gymnasts.

Blog Posts Related to Lower Back Pain

o Fixing Bridges and Preventing Back Pain – 5 Common Issues and How To Address Them
o 5 Easy Screens for Detecting Back Pain in Gymnasts

o Rehab Tips For Clinicians To Treat Gymnasts with Extension Based LBP – Part 1: Acute
Phase

o Rehab Tips For Clinicians To Treat Gymnasts with Extension Based LBP – Part 2: Subacute
Phase

o Rehab Tips For Clinicians To Treat Gymnasts with Extension Based LBP – Part 3:
Intermediate Phase

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 o Rehab Tips For Clinicians To Treat Gymnasts with Extension Based LBP – Part 4:
Advanced Phase

o Rehab Tips For Clinicians To Treat Gymnasts with Extension Based LBP – Part 5: Return
To Training

Contributing Factors to Shoulder Injuries

The shoulder joint is also a very common source of problems in the sport of gymnastics. Despite the
severity of common shoulder injuries, they are almost always present in the study of gymnastics
epidemiology.23,34-35,37, 60-61

Male gymnasts are known to have more shoulder injuries, as the nature of men’s gymnastics is much
more shoulder intensive. 35, 60 It very often ranks as the number one issue that male gymnasts struggle
with throughout their career, next to wrist pain or lower body injuries.

Every event in men’s gymnastics involves the shoulders, but three more specifically (rings, high bar, and
parallel bars) place enormous demands on the shoulder joints of male gymnasts. These forces exist for
women’s gymnastics, just in different variants and intensities.

We have to appreciate that the forces generated by gymnastics skills are insanely high.62 It’s worth
remembering,

“upper extremity forces [on a gymnast’s body] have magnitudes of approximately 1.5x body weight for vault,

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 3.9x body weight for horizontal bar, 9.2x body weight for rings, 2.0x body weight for pommel horse, and 3.1x
body weight for uneven bars.” 63

In my experience from reading sports medicine shoulder research 63-70 and treating many male and
female gymnasts for shoulder injuries, the main contributing factors include;

• Again, spikes in shoulder specific training volume, and suboptimal short term to chronic
workloads (this will be repeated often).

o Shoulder specific training volume includes men’s ring strength, advanced

pirouetting on bars for both male and female gymnasts, heavy traction force skills
like release moves, and upper body impact skill like beam, floor, and vault tumbling.

• Inadequate physical preparation that fails to use a hybrid model of body weight and external
loading to enhance the shoulder joints ability to handle force, as well as general physical
preparedness programs in the off season creating lacking shoulder capacity to handle force.

• Progressive loss of soft tissue flexibility for extreme ranges of motion paired with natural
ligament hypermobility.

• Limited attention to hypertrophy of the rotator cuff and scapular muscles in proportion to the
larger prime mover muscles (lats, pecs, triceps/biceps).

• Limited attention to maintaining strength and flexibility balance around the shoulder and
upper spine through an entire competitive season or multiple years.

• Lack of delaying high intensity ring strength or release moves until puberty is reached.

• Lack of medical assessments, medical treatment, and medical maintenance care for
gymnastics specific sport demands.

Female gymnasts also struggle with shoulder injuries 32,35, 64-65 but they are not as common compared
to the rates of lower back and hip injuries. Female gymnasts do not require nearly as much upper body
strength as male athletes do based on their event and skill requirements.

However, the flexibility demands of female gymnastics paired with strength requirements for upper
body based skills does create a recipe for injuries. For this reason, the contributing factors and types of
overuse injury seen in female gymnasts are a bit different. Some issues overlap, but many do not. These
include;

• Similar issues of workload management, and acute to chronic ratios

• High degrees of hypermobility in the shoulders of female gymnasts, often with paired under
development of the upper body for strength and stability of the joint

• Overly aggressive shoulder stretching methods that give athletes more range than is needed
for the skills they are training

• Lack of clarity from gymnasts, coaches, and parents on what may be a warning sign indicative
for the start of an injury

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 • Lack of medical assessments, medical treatment, and medical maintenance care for
gymnastics specific demands

As noted, for many gymnasts problems can come up related to flexibility. As has been outlined
extensively in the flexibility chapter, lots of issues related to underlying laxity or natural hypermobility,
paired with limited overhead flexibility from soft tissue stiffness, can contribute to a range of shoulder
injuries. 64-65, 69-73,75-76

There are hundreds of coaches and athletes who have contacted me asking for advice on how to
improve overhead shoulder flexibility or reduce shoulder pain that results from limited flexibility during
overhead based skills.

If an athlete struggles with this type of mobility, they will see a huge negative impact on their ability
to perform skills (mainly handstands, overhead swinging skills, and setting during tumbling), and may
quickly spark overuse injuries in the shoulder. These injuries include rotator cuff tendonitis, bursitis,
labral irritation or tearing (SLAP tears), and microinstability. 68-71, 74,77

On the other side of the spectrum, there are many of the same naturally hypermobile athletes who have
problems related to excessive flexibility in their shoulder joints. 66-72,75 These gymnasts tend to have
natural laxity in their shoulder ligaments, but then also are grossly under developed in their strength
and stability.

Despite being from a different underlying cause, these gymnasts too can often struggle with pain
as well as limited power to perform high level skills. Power comes from a base of strength. Without
the underlying strength and stability in their shoulders, these gymnastics typically are unable to
appropriately handle the high forces of skills.

The end result tends to be a frustrating lack of strength, and force or power development needed
for skills. Along the same lines, these athlete’s frequently develop overuse-based injuries in their
shoulders. As the smaller rotator cuff and scapular muscles struggle to help keep the shoulder joint in a
proper position, sometimes the high forces can cause irritation of underlying structures. The resulting
injury is very similar to the issues mentioned above (rotator cuff, labrum tear), but with a different
causal mechanism. In these gymnasts, the rates of gross instability (shoulder joint subluxation or full
dislocations) is unfortunately much more of an issue.

Moving away from flexibility, there are a lot of gymnasts who develop shoulder injuries because they are
not physically or technically prepared for the skills they are performing.

We have to remember that the upper body (wrist, elbow, shoulder) are not inherently weight bearing
joints, unlike our legs (ankle, knee, hip) that have been evolutionarily developed to handle our body
weight. The lower body has very thick and durable cartilage, unique bone shapes, and much larger
muscle groups that allow the joints to safely handle higher impact forces. Our upper body has not had
the same exposure to weight bearing over thousands of years of evolution. As a result, the upper body
joints have significantly less cartilage, bone adaptation, and muscular support to deal with huge weight
bearing forces seen regularly in gymnastics skills.

Gymnastics is extremely unique in the way that it demands so much upper body weight bearing.
The shoulder joint has a significantly different shape and force absorbing capacity than the hip. The
shoulder has a much shallower socket to bear load, lacks the giant support structure of the pelvis, and
has significantly less musculature to provide stability. It also has a unique “floating” shoulder blade
articulation that limits its ability to absorb force.

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For these reasons, the shoulder joint requires much more development to safely handle weight bearing
forces seen in gymnastics. Although proper shaping and skill progression are essential for this, a very
large amount of physical preparation also must be undertaken for the shoulder joints to produce power,
absorb force, and remain healthy during the training process.

This concept goes back to the strength chapter, and my argument for why gymnastics must evolve
its thinking in physical preparation. The injuries seen regularly in the upper body of gymnasts are the
biggest reasons for adopting more of a “hybrid” model of strength training.

Even the most high-level body weight strength program will eventually reach a ceiling effect
yielding limited returns on building tissue capacity to absorb force. Many gymnastics skills have
been scientifically shown in biomechanics research to place enormous forces on the upper body of
gymnastics, often at the 2x – 4x body weight level or more. In order for the shoulder joints to create and
absorb above body weight level forces of gymnastics skills, we must think about higher level strength,
stability, and power training.

The Need to Understand Basic Shoulder Anatomy

I touched on this extensively in the flexibility chapter, but due to its huge role in shoulder injury as
well as rehabilitation, I want to touch base again here. I will apply these concepts more for injury
pathomechanics, and less for skill performance.

The shoulder joint itself can be thought about as a “golf ball sitting on a tee”. The golf ball (ball of the
upper arm bone or humerus) is inherently larger than the tee (socket of the shoulder or glenoid fossa).

The bones themselves, and the shape/fit of these bones is often referred to as the first layer of the
shoulder joint.

This creates a huge range of mobility for the shoulder joint, but in exchange for inherently less stability.
This is unlike the hip joint, which due to having a deeper hip socket (remember the conversation about
being built for weight bearing) has more inherent stability with less mobility.

Surrounding the ball and socket of the shoulder is something called the “joint capsule” as well as

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ligaments. The capsule resembles a balloon type structure that completely surrounds the shoulder joint,
and serves as a thickened blending of ligaments.

The ligaments and joint capsule, along with the alignment of the ball on the socket, create what is known
as the “passive” structures or stabilizers. They also represent layer two of the shoulder joint. 72-74

To help clarify, many use the analogy of the sleeve of a shirt to visually highlight the joint capsule. The
actual arm within the shirt sleeve represents the first “golf ball on a tee” bony layer, and the shirt sleeve
surrounding the arm represents the second layer made up of joint capsules and ligaments.

This second layer of joint capsule and ligaments helps provide more stability to the joint, with different
portions of the capsule limiting certain ranges of motion. Just as with the sleeve of a shirt, depending on
where your arm is in space, different parts of the shirt sleeve are more taught.

The research noted in the flexibility chapter has been very insightful to learn about certain ligaments
and capsule areas that aid in preventing the ball of the shoulder from moving outside the joint and
subluxing. 72-74

Returning to the analogy of a shirt sleeve, more naturally mobile athletes (gymnasts, baseball players)
usually have a “baggier” shirt sleeve. Other more naturally stiff individuals who excel in other sports
may have a tighter shirt sleeve. This allows for more or less inherent flexibility, but as always many other
factors contribute.

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This capsular and ligamentous hypermobility is not inherently a bad thing, as it is part of what makes a
gymnast good at the sport. However, as noted in earlier chapters their natural hypermobility can be an
area of caution. We want to make sure we are not over-stretching or over stressing passive structures
like the shoulder ligaments and capsule.

For many people in the gymnastics community, it comes down to a professional discussion on taking
away overly aggressive flexibility methods, following the science of shoulder anatomy, and making
subtle changes in training.

In conjunction with this, due to the gymnast’s underlying lack of static stability from the ligaments and
capsule, they will need absolutely pristine strength, physical preparation, and dynamic stability from
their muscles around the joint. This helps to enhance strength, power, and reduce the risk of instability-
based shoulder injuries. This is where the third layer comes into play, the muscular soft tissue.

That is all I want to repeat in related to shoulder anatomy. Despite seeming dry or a bit complex for
readers, I promise understanding this can have a huge impact to understanding, combatting, and
reducing the shoulder injuries we see in gymnastics all the time.

How this All Relates to Shoulder Injuries

As I mentioned in the beginning of this chapter, one of the biggest contributing factors to shoulder
injuries and gymnastics is often too little or too much shoulder flexibility, paired with lacking strength
and high workloads.

In the first case, as mentioned many times the larger muscle groups such as the lats, pecs, and teres
major muscles can get overworked and very stiff. If these muscle groups are not properly managed with
soft tissue work and stretching, they can limit overhead shoulder flexibility or behind the back shoulder
flexibility.

If you look at the deeper anatomy of the shoulder, you can see that the rotator cuff tendons are located
between the arm bone (humerus) and the collarbone (acromion).

They come from the shoulder blade, weave between these two bones in a sandwich type fashion,

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and then insert on the arm bone itself. This allows it to help stabilize the shoulder joint. However, the
position of the rotator cuff tendons in between these two shoulder bones puts it at risk for being overly
compressed. It has been shown that this compression naturally occurs every time we raise our arms.
Keep in mind this doesn’t automatically mean we are going to cause injury.

However, if a gymnast gets in a situation where the rotator cuff becomes constantly compressed,
overused, irritated, or inflamed, it can quickly cause shoulder pain. This tends to happen more often
when a gymnast has limited shoulder flexibility (lat, pec, teres major stiffness), may be excessively
hypermobile with under developed strength, or is simply doing too much shoulder intensive work in a
short amount of time.

As you will remember, those are two situations I mentioned earlier above. The situation where a
gymnast is lacking flexibility and compressing these rotator cuff tendons causing inflammation is what
most people hear about as “rotator cuff impingement”, “bursitis or “tendonitis”. This term is often not
super helpful in getting to the root cause of the problem, but it helps understand the basic nature of
what structures are problematics sites of pain generation.

Moving to the other side of the spectrum again, I mentioned that many gymnasts have issues related to
excessive flexibility around their shoulder joint. If an athlete has too much flexibility without the proper
strength/stability from the muscles, it usually can feel as though the shoulder joint is sliding around
too much during high force skills like swinging bars or tumbling. This often happens to gymnasts upon
the impact of back handsprings, vaults, and catching skills in handstands (Stutz for male gymnast, Pac
release move on bars for female gymnasts).

The other more common scenario occurs when heavy traction forces pull on the shoulder joint. This
is commonly seen in catching of release moves (Geingers, Tkachevs, etc.) or doing powerful giant
taps (bars and rings). In the most drastic situation, the golf ball falling completely off the tee would be
analogous to a full shoulder dislocation.

Even if the shoulder joint is just mildly unstable, over time it can cause a lot of stress on the rotator cuff
tendons, and ligaments of the shoulder, and the deeper labrum within the joint. This often surfaces not
from one skill causing pain, but a slow and gradual worsening pain in the front or top of the shoulder
joint.

This usually is a sign that the rotator cuff tendons or deeper structures are getting small amounts of
damage, that progressively snowball and worsen over time. It starts with gymnasts only being sore
when raising their arms, putting their hands behind their back, or doing daily activities. But progresses
to significantly interfere with training.

Many times, gymnasts will have the development of rotator cuff tears, or labral tears. A “SLAP” tear
simply refers to a deeper labral tear in the front and top/back of the shoulder joint (SLAP = Superior
Labrum, Anterior to Posterior).

Those few paragraphs are just to give a little bit of the background to the major causes of over shoulder
injuries seen in gymnastics. Obviously, there are also times when accidents happen resulting in acute
fractures, dislocations, or other more major unfortunate problems. These tend to be rarer in gymnastics,
as well as unavoidable sometimes, and I will steer away from discussing them. The progressive, overuse
type injures like rotator cuff issues, labral tears, and instability are what are much more commonly
seen. They also are what I feel we can make a massive dent in within the sport to reduce injury risk and
enhance performance.

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Now that I have covered some background, here are some bullet point type concepts that are important
to reducing the risk of these injuries from occurring.

• Physical preparation, strength, and conditioning programs are absolutely essential for young
gymnast to focus on in relation to shoulder injuries (and all upper body injuries). If a gymnast
hopes to do very high-level skills down the road (blind changes, release moves, high impact
tumbling) safely, we must prepare them adequately over multiple years of training starting
when they are young.

I have all the young gymnasts, especially male gymnasts, I work with do some sort of
regular maintenance care that encourages soft tissue management, specific stretching,
high level strength for the rotator cuff and scapula, and dynamic stability work.
This is done for years well before they are asked to do release moves, advanced bar
pirouetting, or ring work.

• Proper technical skill development, progressions, and body shaping is crucial to make sure
we are not overloading the shoulders of young gymnasts. It is very easy for young male
and female gymnast to “throw” skills on bars and get away with it for the short amount of
time. However, I’ve seen hundreds of times this approach causes a slow, progressive onset
of shoulder pain. Not being physically or technically prepared for higher-level skills almost
always comes back to cause shoulder pain. Coaches, gymnasts, and medical providers must
work collaboratively to ensure these baseline physical preparation and technical progression
points are put in place.

• Managing muscle flexibility with regular soft tissue care (foam rolling, sticks, manual therapy,
etc.) and proper stretching can help reduce shoulder pain significantly. As I will touch upon in
the medical maintenance care chapter, I believe there is huge value in working with medical
providers weekly to screen for losses in motion and assist with manual therapy to maintain
flexibility.

• A combination of manual therapy and self-care from the gymnast can make a huge different
in shoulder flexibility. The extreme end ranges of motion needed for skills can be developed
through proper assessments, soft tissue management, proper flexibility training, progressions
of skill and technique, and proper strength programs.

Again, this all comes down to if the gymnast is someone who is stiff and in need of
more motion. Some athletes get shoulder pain from being too mobile. Although they
can certainly do soft tissue and stretching work, their main focus should be physical
preparation, enhancing strength, and enhancing dynamic stability.

• Along with combating the soft tissue adaptations that occur with growth or training, we also
must make sure we constantly are developing balance around the shoulder joint. Very often in
gymnastics we see the larger muscle groups developed with pull-ups, push-ups, rope climbs,

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 and leg lifts. What we don’t see is the same amount of attention in a strength program being
dedicated to the opposite areas of the shoulder joint such as the upper back, the rotator cuff,
and the scapula, as well as drills to enhance working dynamic stability. We must make sure
these are all well represented in a physical preparation program.

• An emphasis must be placed on the upper back and scapula muscles being developed. This
can be done with various band, dumbbell, or rowing exercises (articles below). This not only
helps maintain the balance mentioned, but also can solidify flexibility ranges. I find myself
still giving basic dumbbell programs to almost all the gymnasts I treat in our clinic, due to
them being largely overlooked in traditional gymnastics strength programs. I also am sure to
program them at least 1-2x/week for all the gymnasts we coach. I highly recommend readers
check out these articles below and imbed both the “basic rotator cuff circuit” and some upper
body horizontal pulling exercises into their strength programs.

• Mobility Exercise’s To Boost Shoulder Health In Male Gymnasts (Part 1)

http://shiftmovementscience.com/mobility-exercises-to-boost-shoulder-health-in-
male-gymnasts-part-1/

• Rotator Cuff Strength and Horizontal Pulling Exercises for Shoulder Health

https://www.youtube.com/watch?v=YR6TZS7N9RE

• Renegade Rows for Core Strength and Horizontal Pulling Balance

https://shiftmovementscience.com/renegade-rows-for-core-strength-and-horizontal-
pulling-balance/

• Being aware of the early signs of a shoulder injury is very important. Gymnasts who complain
of pinching type pain in the top or back of their shoulder, who also feel a deep ache in the
front of their shoulder, or report feelings of their shoulders “sliding out” need to be carefully
evaluated. Gymnasts will most often complain of these pains with overhead hanging, impact,
or handstand-based skills. However, other times it may be more prominent during tumbling or
vaulting.

The ability to catch the warning signs of shoulder injury early, get the athlete to a
sports medical provider, and get to the root cause of their pain can be extremely
helpful to reduce potential lost training time. It not only allows the gymnast to correct
the underlying issue for better gymnastics performance, it also helps prevent the issue
from slowly getting much worse. Too many times I have seen a shoulder injury start
small, but progress to much worse situations of surgery, missing entire seasons, or
athletes quitting because the problem was not addressed and snowballed into much
bigger issues.

• Just as with the lower back section, I make the same return to sports program for male or
female gymnasts who are returning to training. It considers their skills, event specialties, days

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 per week of training, and goals. By building numbers and splitting up volume with rest and
continued at home therapy, it helps reduce the risk of injury or gymnasts feeling lost with
what to do. Here is another example, but please do not take this and try to blindly use it with
a male gymnast coming back from a shoulder injury.

• The last point that I will make before moving on is to highlight the importance of monitoring
for rapid growth. Gymnasts who grow rapidly may have issues where the muscular system
cannot keep up with the bone growth, and it may be challenging to control force during
gymnastic skills. This has been looked at extensively in relation to growth plate injuries that
plague young gymnasts. 78-82 The growth plates of a young gymnast that are open and not
yet developed are very at risk for injury. Reducing the volume or intensity of training during
these periods, while focusing on flexibility, technique, and physical preparation, can lead to
substantially lower injury risk and higher long-term performance. There will be an entire
chapter dedicated to this coming up.

So that concludes the shoulder injury overview section. For those interested in more, here are a few
more articles on this
o 5 Tips To Reduce Shoulder Injuries In Men’s Gymnastics
http://shiftmovementscience.com/5-tips-for-reducing-shoulder-injuries-in-mens-gymnastics/

o Screening Overhead Mobility Update For Coaches and Clinicians

http://shiftmovementscience.com/screening-overhead-mobility-update-for-coaches-and-
clinicians/

o High Level Gymnast With Shoulder Pain During Releases and Chronic Wrist Pain: From
Clinic To Practice #5
https://shiftmovementscience.com/high-level-gymnast-with-shoulder-pain-during-releases-
and-chronic-wrist-pain-from-clinic-to-practice-5/

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 Contributing Factors to Elbow Injuries

For this section, I am going to combine a few popular blog posts I have written with some newer
thoughts, to help give readers an overview of elbow problems in gymnastics.

Overuse elbow injuries have become the most rapidly growing area of problems within the last decade
for the sport of gymnastics. I will be completely honest in saying that I feel this is one of the most over
looked, and downplayed injuries gymnasts face.

Too many gymnasts, coaches, and parents are writing off the start of serious elbow injuries like growth
plate fractures, stress fractures, or serious cartilage damage (Osteochondritis Dissecans) as “elbow
tendonitis” or “growing pains”. Young gymnasts should not have extended weekly or monthly bouts
of elbow pain, losses of elbow motion, or instances of buckling when trying to support load during
gymnastics training. There are serious problems behind these complaints that I have seen take gymnasts
away from a full year of training or cause them to quit.

There is a huge growing body of literature on elbow injuries in athletics as well as weight bearing
sports like gymnastics. 83-94 It’s essential that the gymnastics community takes time to understand and
brainstorm why so many gymnasts are being crushed by chronic elbow injuries like OCD. I also think it’s
important we frame injury prevention, diagnostic, and rehabilitation methods in the larger context of
strength and conditioning research, as well as work load management research, to consider all factors
that may contribute.

For gymnasts I have treated for injuries in the last few years, elbow injuries have consistently ranked in
the top five most common. A few of them have been more accidental trauma injuries, like falling onto
an outstretched arm or peeling off bars. These injuries are usually elbow fractures, dislocations, or Ulnar
Collateral Ligament tears (UCL or “Tommy John”). These more accident-based injuries are unfortunately
many times just part of the risk associated with gymnastics. They can happen to anyone. Thankfully,
these types of elbow injuries are much more rare in gymnastics.

What has been alarming to me is about 80% of all the elbow injuries I have treated were overuse based,
falling into the “repetitive microtrauma” category. That term simply means that the elbow joint takes
a bit more than it can handle, doesn’t fully recover between flare ups, and slowly starts to break down

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over time.

The available research on overuse elbow injuries in gymnastics tends to follow the same trend as other
common overuse injuries. I have no doubt that across the country hundreds of gymnasts are losing
multiple months of training, entire competitive season, or are quitting gymnastics because of overuse
based elbow injuries. This is something that everyone in gymnastics should really take a step back and
ponder. If we don’t meticulously analyze why this may be happening, and how we can address this issue,
we are going to see the rate of overuse injuries continue to sky rocket.

The elbow joint is made up of three bones: the upper arm bone (humerus), the outside lower arm bone
(radius), and the inside lower arm bone (ulna). These three bones come together to make a “hinge” based
elbow joint that bends/extends, but also rotates the palm up and down.

A very large amount of force goes through the wrist and elbow joint, and more specifically the outside
part of the elbow joint (radiocapitular joint). 63-63, 95 Remember as I mentioned above, the elbow joint is
not nearly as prepared for heavy weight bearing as the knee joint. The elbow joint does have a layer of
cartilage and shock absorbing structures, but they are very limited in their force absorbing capability.

On top of this, there are very large growth plates and underdeveloped cartilage in the elbows of young
gymnasts. The under developed elbow cannot inherently handle high force or high repetition. Due to the
nature of gymnastics requiring very high impact-based skill training, this tends to be at the foundation to
why so many gymnasts start to experience pain or injury.

These injuries are usually what is known as Osteochondritis Dessicans (OCD), growth plate stress
fractures, and triceps apophysitis. When severe enough, they tend to lead to huge problems ranging
from time away from training, to surgery, and sometimes gymnasts choosing to quit gymnastics.

OCD in its most simple form refers to a progressive inflammation, breakdown, and injury to the cartilage
of the elbow joint. When high forces are put through the elbow joint repetitively, the elbow joint as
well as the cartilage can become inflamed. If the high force and repetitive irritation continues, it can
progress to cause the cartilage or bone to break off, or even die. This can cause large amounts of pain, an
inability to fully bend/straighten the elbow, and “buckling” to occur when trying to weight bear during
gymnastics skills.

Growth plate stress fractures or apophysitis comes from the same mechanism but effects a slightly
different area of the elbow. 78 Sometimes instead of the cartilage being the structure that breaks down,
it is the growth plate itself or areas where the triceps tendon attaches to the bone that become irritated.

There are many factors that influence what type of elbow injury a gymnast may obtain. As frequently
mentioned, a few of the larger ones include workload ratios, age/developmental level, skills being
trained, physical preparation level, technique, and individual anatomical difference between athletes.

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After seeing first-hand how tough some of these injuries can be for gymnasts to rehabilitate and
overcome, I have spent a surplus of time reading research on these elbow issues in gymnastics. In
digging through the science on this topic, I have found an abundance of information on diagnosing/
imaging of the injury site, as well as the main treatment options after the injury occurs (usually 3-6
months rest vs surgery). 83, 86-87, 89

What I have unfortunately not found, are thorough research papers on the mechanisms specific to
gymnastics. There seems to be a lack of empirical evidence on why we have such an insanely high rate
of elbow injuries in gymnastics or how to prevent them. There was one recent paper on the location of
OCD injuries in gymnasts compared to baseball players, as well as the implications for imaging, which is
helpful to understand the differences in forces being applied. 93

The useful conclusion from the authors outlines some theory behind why gymnastics has such a
different yet high rate of OCD injuries. 93
“Due to differences in applied stress, capitellar OCD lesions in baseball players were located more
anteriorly compared with those seen in gymnasts. Therefore, although AP radiographs with the elbow
in 45 of flexion are optimal for detecting OCD lesions in baseball players, radiographs with less elbow
flexion or full extension are more useful in gymnasts, especially in early-stage OCD.”

I’ve been lucky to collaborate with elbow surgeons and high-level coaches to generate ideas as a
framework. However, I think we still need to dig a little deeper into these issues by applying the latest
scientific research, as well as discussing how it links to some cultural components in our sport. We also
need to translate the medical jargon into what we can practically apply in gymnastics training and at the
clinic to make a practical difference.

These injuries can be devastating, with treatments ranging from less severe injuries needing a
mandatory 3-6 months of not using the elbow, 89 to much more serious injuries needing large surgeries
and a year off from training to correct due to significant cartilage damage. 85-87 Not to mention, the
massive negative effects on a young gymnast’s mental health and quality of life.

I won’t dive too deep into the really nerdy biomechanical/medical concepts, but if this type of
information interests you, feel free to check out the research articles listed in the references section.

I have come up with a handful of ideas behind why these elbow issues occur and how to combat them.
My thoughts come from combining the research I have read, my experiences treating gymnasts with a
range of elbow injuries, and coaching concepts from training. Here they are again, in more of a bullet
point type style.

• It bears repeating, but at the most basic anatomical level elbows are not built like knees. This one
may seem really blunt and obvious, but I think it continues to be overlooked in gymnastics. We
have to remember that our arms do not have 1/10th of the mileage our legs have over thousands
of years of evolution. Inherently our wrists, elbows, and shoulders are not made to bear weight
like gymnastics requires. As a result, they do not have the same weight bearing structures that
our legs do (thicker bones, cartilage, shock absorbing surfaces).

o Obviously, we cannot do much about this, but it is important to know. This idea requires
gymnastics coaches and medical providers to be meticulous in making sure a gymnast is
properly prepared for high force skills seen in the upper levels of gymnastics. This relates
to physical preparation, technical preparation, and keeping a close eye on training volume
over many years in a “long-term athletic development” mindset.

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 o Avoiding sudden “spikes” in training volume is very important for all injuries, but
particularly elbow injuries. As noted in the spine section, there has been some fantastic
research surfacing on training load and overuse injury risk in sports

o Definitely carve out time to read through it all, but in short what a lot of it suggests is that
sudden increases in training volume over a short amount of time can really put someone
at risk for injury and decreased performance. Tim Gabbett’s work discusses how both
too little preparation (physical/technical) as well as too much workload (elbow impact
repetitions, example: back handsprings or Yurchenkos in one day/week) may increase the
risk of an injury starting.

o Take this information with a grain of salt, because it is research not done specifically on
youth gymnasts. It is done more in adult running based sports, but the principle and theory
I find very relevant here.

o This research makes sense when you step back and consider gymnastics. We all intuitively
know gymnasts need to do a lot of strength, basic shaping, and drills to handle certain
skills. This is the “too little preparation” side.

o But we also have to consider the opposite. I would guess ninety percent of the skills in
gymnastics place stress on the elbow in some fashion through either compressive or
traction forces. As a coach, I totally understand the well-intentioned desire of coaches to
want to do a lot of skills/drills to help gymnasts reach their potential. That being said, as
a medical provider who sees the serious elbow issues that come up, we have to be really
careful about finding the optimal dose.

o Too little elbow stress, and we know that the body will never adapt appropriately to
eventually tolerate high forces. Too much elbow stress in a short amount of time, and then
we may see a gymnast’s elbow get really cranky.

o Having set numbers of vaults or beam series for gymnasts to not exceed will help track
volume. Rotating event focuses to vary the degree of elbow impact is also a useful
strategy. This combined with more formal strength programs and flexibility training can
be huge. Hopefully down the road in gymnastics, we will get better objective research on
these concepts to apply in every day training.

• There is an abundance of research emerging on how important the concepts of long term athletic
development and the avoidance of early overload are for the health and performance of young

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 athletes. 96 – 104 In short, much of the research from multiple sports outlines the need to monitor
work to rest ratios in young athletes, encourage physical preparation, delay overload through
single sport year-round training at too early of an age, and closely monitor athletes with both
growth tracking and periodization methods. I feel gymnastics could see massive changes in injury
rates, especially elbow and wrist injuries, if these guidelines were more formally applied from
early ages. Many fantastic coaches do this naturally, but I feel it must be formalized and standard
across all of gymnastics.

• Again, this is absolutely not meant to spook people into stopping gymnastics. It’s to illustrate an
important point. I also openly admit I have not coached a nationally ranked or elite level gymnast.
That being said I am fortunate to consult with coaches who do, and have treated quite a few high
level gymnasts, and the principle still remains true.

• Not monitoring and managing a young gymnast properly can quickly lead to the overuse issues in
the elbow, knee, ankle, and spine that plague gymnastics. On the other hand, if we approach this
time frame carefully, we may be able to guide a gymnast through their most at risk years and in
return get multiple years down the road.

I think the biggest areas for improvement on elbow and wrist injuries are:

• Better education on why these injuries occur.

• More focus on physical preparation of gymnasts, utilizing both body weight and external
weight lifting.

• Objectively tracking and limiting the number of upper body impacts a gymnast takes
weekly.

• Using a much more methodical and objective approach to prescribing training volume of
skills.

Technical and Biomechanical Factors

With all of this said, there are definitely some gymnastics technique related factors to consider. For
one, many coaches and medical providers understand that gymnasts who develop the habit of excessive
turning their hands out during vaulting or tumbling may cause elbow issues. More specifically, the
second hand of a round off for Yurchenko vaults or tumbling on floor, and during back handspring
portions of Yurchenko vaults or other tumbling. There have been studies recently published looking
at the loading to the wrist and elbow joint of gymnasts during roundoffs. From these studies, they
discourage excessive hand turn out with this classified as the “reverse” position. 106 -107

The reason for this is when this extreme rotated out position is used, it tends to lock out the elbow joint
and put excessive pressure through the outside of the joint. A more neutral or slightly rotated in hand
position allows unlocking of the elbow joint, and if needed offers the chance to bend and utilize the
triceps/shoulder musculature to help dissipate impact forces. 106

Another factor to consider is the amount of overhead shoulder capacity a gymnast uses during back
handspring skills. The first layer of this relates to available shoulder flexibility motion. If a gymnast
is unable to reach a full overhead shoulder position (175 – 190 degrees of elevation), it may create a

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situation where the elbow and wrist joints become more overloaded into end ranges of motion.

A recent study 94 looked at the correlation of shoulder motion used in a back handspring in relation
to impact hyperextension of the wrist and reports of injury. Although not specific to elbows or OCD,
the theory of having less shoulder motion and more elbow or wrist stress to compensate is definitely
plausible.

I regularly find gymnasts with elbow or wrist issues having a notable lack of weight bearing wrist
extension, which is typically not screened for but can cause huge issues. See this blog post I wrote a
few years back for more thoughts and explanations to this concept. (Comparing Weight Bearing Wrist
Mobility to Ankle Mobility / https://shiftmovementscience.com/comparing-weight-bearing-wrist-
mobility-to-ankle-mobility/ )

In conjunction with making sure a gymnast has full passive overhead shoulder flexibility, the next layer
to appreciate is the amount of control and strength a gymnast possesses in their shoulder joint. As I
highlighted above, limited strength of the elbow can make it challenging to buffer large forces seen
in gymnastics. With the lower body, the hip joint is extremely important in helping buffer large forces
that the knee may be subject too. I feel the same concept parallels for the upper body of a gymnast. The
shoulder is extremely important in helping buffer large forces at the elbow.

For one, the shoulder musculature must be well balanced and able to maintain the full overhead
shoulder position during skills. I have seen many gymnasts for elbow injuries who have tons of natural
passive flexibility, but do not possess the same amount of active control in their shoulder muscles to
maintain that overhead position during skills. This causes them to rapidly close their shoulder angle, and
collapse onto their elbows/wrists during tumbling, vaulting, men’s parallel bar skills, or women’s beam
skills.

With this is mind, I will reiterate the point that it is absolutely crucial we are prioritizing updated
shoulder flexibility methods and physical preparation programs. The most attentive coach looking
at proper workload doses and training volume will likely still face elbow injuries if gymnasts are not
physically prepared for the skills they are training in relation to flexibility and strength.

To summarize, elbow injuries in gymnasts are one of the most important medical issues we must
collectively face. I know that every gym has different time, staff, and financial restrains but all these
suggestions can be applied in some form. The rates of elbow injuries in gymnastics has been wildly
increasing, and there appears to be no signs of it slowing down. To save multiple months of training,
frustration for coaches/gymnasts, and reach higher levels of performance, we need to attempt to
implement some new concepts as a community. From here, we will move on to the wrist, which has very
close connections to the first previous sections.
Here are some articles on elbow injuries from SHIFT
• Elbow Injuries
o Understanding and Combatting the Elbow Injury Epidemic In Gymnastics (Part 1)
http://shiftmovementscience.com/understanding-and-combatting-the-elbow-injury-epidemic-
in-gymnastics-part-1/
o Understanding and Combatting the Elbow Injury Epidemic in Gymnastics (Part 2)
http://shiftmovementscience.com/understand-and-combatting-the-elbow-injury-in-
gymnastics-part-2/
o Understanding and Combatting the Elbow Injury Epidemic in Gymnastics (Part 3)
http://shiftmovementscience.com/understanding-and-combatting-the-elbow-injury-epidemic-
in-gymnastics-part-3/

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 Contributing Factors to Wrist Injuries

Wrist pain and wrist injuries have been present in gymnastics for many years due to the high impact
demand of the wrist joint. More so than the elbow, there has been an abundance of research published
on wrist injuries in male and female gymnasts. 92, 95, 106-116

“Gymnast Wrist” is a very vague term that most athletes are given as a diagnosis. This term is very
general, and often does not give insight into the specifics on injury mechanism, how to deal with the
problem in relation to every day training, and prevention strategies.

In the lower body, the ankle joint has been adapted over thousands of years of evolution to support body
weight and high impact forces. In gymnastics, the wrist joint serves as another ankle to help support
body weight when inverted. Just as the foot and ankle joint interacts with the ground to support upright
walking, the hand and wrist interacts with the ground or equipment to support many gymnastics skills.

Just as I highlighted with the elbow, the wrist joint also is an area not prepared for high weight bearing.
The ankle joint and feet structures are incredibly complex and were engineered through generations to
possess an incredible force absorbing capacity. The hand and wrist joints are not structurally designed
for such force absorbing duties. As a result, in similar fashion to the elbow joint, the wrist is at extremely
high risk for injury in gymnastics.

Typically, the most common presentation of pain in a gymnast’s wrist comes from the back of the wrist
joint. It most commonly comes up when being subjected to hyperextension range of motion under high
force loading, like seen in handstands or back handsprings.

The weight bearing forces of gymnastics has been researched, providing some helpful information. 41,117-
118
This research outlines that loading forces on the upper extremity may be up to 1.5x body weight on
vault (measured in front handspring, Yurchenko’s likely much higher), 2.2x body weight in round offs,
2.37x body weight during back handsprings, and some of the highest recorded forces can climb to 16x
body weight in force. 117-118

From the medical point of view, there are very sensitive growth plates located at the end of the two

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lower arm bones, the radius and ulna. When these growth plates are not fully developed, they do not
possess solid bone that can accept such high force. 107-109 They have more of a cartilage structure make
up, with a lower tolerance to loading.

There are also a series of carpal bones, ligaments, tendons, nerves, blood vessels, and other soft tissue
that can become irritated during hyperextension wrist motions. Although not as commonly injured
as the growth plate in young gymnasts, these structures too can get progressively damaged during
gymnastics training.

With repetitive weight bearing, suboptimal work to rest ratios, excessive stiffness in the forearm
musculature, and a lack of physical or technical skill preparation, it is common to see pain develop in the
growth plates, wrist, and hand structures. 107,115 Repetitive pommel horse training, vaulting, tumbling,
and handstand based skills can often trigger pain.

If the growth plate continues to become exposed t o heavy force without appropriate rest or volume
management, more serious injuries develop. I find this often happens when male gymnasts perform
large volumes of pommel horse training without objective tracking and periodization, or female
gymnasts perform large volumes of beam and vaulting without objective tracking and periodization.

This situation of excessive work without rest, recovery, or physical preparation, can lead to a pre-mature
closure of the growth plates and can cause significant levels of pain. Gymnasts quickly find they have
a limited ability to do weight bearing skills, or worse may try to push through and suffer more serious
stress fractures that remove them from training. This is when an athlete may be forced into a cast to
promote a proper healing environment, or sometimes requires surgery with metal pinning to correct the
problem.

Many of the same issues from the elbow section above related to physical preparation, volume
management, monitoring periods of rapid growth, and picking up on early warning signs of injury also
apply to the wrist. For that reason, I don’t want to repeat myself too much.

If gymnasts continuously complain about soreness in their wrists or are unable to do skills without
heavy amounts of wrist support (Tiger paws, tape, etc.), it needs to be addressed. I do believe that wrist
supports can be beneficial when properly implemented and combined with strength or injury mitigation
approaches. However, they shouldn’t be a cover up to real issues related to work load, total volume, and
physical or technical preparation.

In addition to the points from above in the elbow section, here are some more specific bullet points
related to wrist injuries

• Objective volume management, dosing, and recovery periods are even more important for the
wrist joint. There are a large number of skills that place huge forces on this area, and the number
of impacts a gymnast takes on their wrists per day, week, or month can quickly sky rocket. This is
important for female gymnasts, but even more so for male gymnasts. Pommel horse, parallel bars,
floor, and vault repetitions can all quickly accumulate to cause issues in young developing male
athletes. Just as with the elbow section, we must try our best to objectively and methodically
consider how many reps the wrist joints of young male gymnasts are taking. The same approach
to reducing elbow overload can be taken to the wrist in relation to rotating event focuses,
capping the numbers of skills or routines done, and considering rest periods following heavy
amounts of work.

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• Local wrist flexibility, and the amount of range of motion a gymnast has into the “wrist up” motion
of extension, is important to consider. Just as the shoulder and hip joints will tend to get stiff if
soft tissue is overworked and not managed, the wrist joint also follows this logic. The muscles
that are responsible for gripping can over time become overworked and stiff. This adaptive
stiffness of gripping and wrist or finger flexing can directly limit the opposing range of motion
of wrist or finger extension. This range of motion must be maintained, as it serves as the base of
support for proper handstand stacking. Gymnasts who lose this motion may suddenly struggle
with handstand lines or be limited in their skill progression.

• Screening for wrist extension range of motion should be done on a regular basis. A gymnast
should be able to bend their wrist to 90 – 100+ degrees of extension in a weight bearing position
(hands and knees rocking for example) to make sure they can properly stack their center of body
mass for handstand-based skills. Regularly screening, and managing any limited range of motion
found, can be very helpful. It not only reduces the risk of overuse injury, but also maintains the
proper base for all handstand based skills. Here are two articles I have written that cover this
concept more in depth and offer some ideas for managing soft tissue stiffness in the wrist.

o Comparing Weight Bearing Wrist Mobility to Ankle Mobility

https://shiftmovementscience.com/comparing-weight-bearing-wrist-mobility-to-ankle-
mobility/

o Wrist Extension Mobility Series For Handstands

https://www.youtube.com/watch?v=DWJVN-9fTpc

• On a similar note, the amount of shoulder flexibility a gymnast has and uses during skills
may directly influence how much force is being placed on the wrist joint. During handspring
skills, tumbling, or handstands, the amount of shoulder motion a gymnast has overhead can
significantly reduce the amount of extension motion the wrist must perform. If a gymnast has
limited overhead shoulder flexibility, it may cause the wrist to hyperextend and irritate the same
structures mentioned above.

o This thought was recently investigated in a research article in the International Journal
of Sports Physical Therapy, which I mentioned in the elbow section.94 In all gymnasts I
treat for elbow or wrist pain, I do a very in depth shoulder mobility, overhead strength,
and upper body balance assessment. This is a crucial factor I see often overlooked and
subsequently the reason for ongoing pain. As another piece of information, I think this
concept also significantly limits beam and tumbling technique from developing. It can
also cause a gymnast to struggle with proper shaping or power development, and in many
cases be the root cause behind mental blocks developing if a gymnast continues to get
frustrated.

• Tying both the elbow and wrist together, I think these two sections serve as the most supportive
evidence to why gymnastics must adopt an open-minded approach to incorporating weight
lifting as part of their strength program. At a baseline level, many elbow and wrist injuries are

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 occurring from two simplistic concepts. For one, the elbow or wrist joint is not strong enough to
deal with the high forces being placed on it. Second, the amount of impact training being placed
on a gymnast is too high overall or is too rapidly increased in a short period of time. Both of these
scenarios above contribute to the massive rates of elbow and wrist injuries in gymnastics. If you
factor these two concepts together, it means using strategies to increase the weight bearing
strength of these joints or better manage the correct dose of impacts during skills is key for
prevention.

• The last point I want to make refers to the medical management of both elbow and wrist joints.
I think that gymnastics is oddly unique in relation to how specific elbow and wrist forces occur.
Medical providers must fully and completely understand the biomechanics and pathomechanics
of these wrist injuries in gymnastics. I unfortunately have treated many gymnasts who had
unsuccessful rehabilitation or surgical management of their elbow or wrist injuries because the
medical side of the fence was lacking. Many gymnasts are being discharged too early in their
rehab when their pain is gone, despite having significantly lacking flexibility, strength, power
development, or stability.

• Based on this, I have adopted the model my friends Mike Reinold and Lenny Macrina created
with baseball players slowly returning to throwing following elbow injuries, regardless is they
play recreational or as professional athletes. They base their throwing programs off the science
available on forces of throwing, and the timeline of healing from surgical research. They then
create programs that factor in distance, repetitions, total volume, and intensity.

o Whenever I work with a gymnast who is nearing the end of their elbow or wrist
rehabilitation, there are two important things that happen. One, is that I make a very
detailed return to skill program based on their entire profile across all events, the number
of hours/days they train per week, the time in the competitive season, and their long-term
goals. It calculates total number of skills done, builds in event rotations, and allots time
for the gymnast to do their home exercise program once their daily work load is created.
This gives them the slow, ramped approach back to total volume without spiking their
workload to acutely. I create it with them, and then send it to their coach or other medical
providers working with them. It not only gives the coach ease of mind, it also gives the
gymnast a roadmap to follow and allows open communication to occur.

o Please see the charts outlined in the lower back and shoulder section for more examples
of this. This is relevant to all injuries, but is of critical importance for the wrist and elbow.
A gymnast should not jump back into full upper body impact training even if they get
“cleared” from a medical tissue level point of view. They often have been away from impact
training, have not been doing upper body strength, and are deconditioned.

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 • The second thing that occurs is I educate them on the important need for maintenance care. This
refers both to their specific injury, but also general maintenance care based on the demands and
adaptations of gymnastics. Just as with the throwing program in baseball, one of the best things
I gained from Mike and Lenny who work in professional baseball every day is the complete shift
as a medical provider away from “reactive” care to injuries and instead to “proactive” care of
injuries.

• I now approach treatment with gymnastics clients not only in a rehabilitation sense, but in
an optimizing sports performance approach. I give all gymnasts a program that continues to
progress their home program into advanced maintenance care to manage soft tissue flexibility,
maintain muscle balance, and work specific weaknesses or movement pattern issues they may
have. In an ideal setting, I have the gymnast continue to come on a bi-weekly or monthly basis for
a “checkup” and hands on care. Aside from the actual soft tissue or strength care we do, it also
allows us to communicate on if the injury is still feeling okay or if anything is going wrong.

• I find that having this open communication and ongoing care leads to significantly higher level
of care and sports performance. I’m proud to say that about 30% of the gymnasts I treat at
Champion are on more of a maintenance care and Sports Performance program rather than only
rehabilitating injuries. I encourage all medical providers to become fully educated on gymnastics
biomechanics if they regularly treat gymnasts. I also encourage them to try and spend time
educating patients, parents, and coaches on the role of proactive or maintenance care rather
than solely reactive and rehabilitative care.

So, this wraps up the upper body section related to shoulders, elbows, and wrists. I will now move onto
the lower body, starting with hip injuries. I will tie it into lower back issues a bit more, and then continues
to go more towards impact based injuries of the knee and ankle.

Contributing Factors to Hip Injuries

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The topic of hip injuries in gymnastics is a complex one, as much more research and science related to
hip injuries in our sport has evolved in the last decade. However, given the importance of hip strength,
power, and flexibility in gymnastics, it must become a topic of regular discussion. The rates of hip injuries
in gymnastics also are unfortunately rapidly increasing, causing many athletes to miss months of training
or require surgery early in their career.

The large variety of forces and ranges of motion that a gymnast’s hip are subjected to during gymnastics
skills, as well as landings, is impressive. Take off forces have been measured at 4-5x body weight, with
peak ground reaction forces ranging from 8.8-14.2x body weight, and even 15x body weight during
controlled laboratory landing scenarios. 119-120 Even higher landing forces up to 18x body weight have
been measured in the ankle when uneven or asymmetrical impact occurs (which is extremely common
when you carefully watch gymnastics). 41

Gymnastics is extremely unique in the way that it demands very large flexibility demands, under high
speed, repetitively. These large flexibility ranges are often paired with very rapid kicking or leaping
motions. In parallel with this, landing forces during impact or tumbling passes are incredibly high.

We must remember that these large forces, and above average flexibility demands, are being placed on
immature skeleton structures of very young athletes who are often going through rapid growth spurts.
From a physics point of view, rapid growth spurts with the elongation of leg bones means exponentially
higher torque forces are placed upon the hip joints of gymnasts, and thus the muscles, tendons,
ligaments, and cartilage within.

It is this intersection of large forces, large range of motion demands, and the repetitive nature of
gymnastics that causes pain. When this is combined with the suboptimal flexibility techniques or limited
physical preparation in the form of resistance training, many gymnasts find themselves with chronically
injured hips.

The theme continues as many of the overuse hip injuries and performance problems often come from
mis-managed workloads. In almost every hip injury that I have treated a gymnast for (aside from purely
accidental falls), there was a common theme of suddenly increasing hip intensive skills, or the addition of
aggressive hip flexibility exercises.

Any sudden increase in training volume (jumps, leaps, and kicks, in bars, new strength of flexibility
exercises) should be approached cautiously and individualized to athletes as needed.

I can’t stress this enough, all the following information below related to biomechanics will not be
effective in reducing hip injuries if larger issues exist in not having proper work to rest ratios, or very
outdated flexibility methods are being used.

Considering skill repetitions, the rotation of hip intensive skills on different events, the use of
scientifically supported flexibility methods, and allowing proper rest between training of these skills is
key.

Background Hip Anatomy

As I touched upon with the shoulder, it is of extreme importance that everyone involved in gymnastics
has a basic understanding of hip anatomy. Without understanding some of these concepts, it can be

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very challenging to understand where performance drops and injury based issues come from. Those
who are in charge of designing strength, flexibility, or cardio programs should possess an even more in-
depth knowledge of the hip joint and core. The decisions made around hip strength or flexibility are of
paramount importance, as they directly influence both skill performance and the risk of injury.

My thoughts on hip mobility and why we choose certain exercises closely echo my thoughts on shoulder
mobility, and I again will not go into much depth as this was covered in an earlier chapter.

The research in the world of hip micro instability, labral tears, hip stress fractures, and other injuries
commonly seen in gymnasts has been rapidly developing in the last decade. 121 – 135 It has been great
to see so many great surgeons, healthcare providers, and strength coaches share their thoughts and
describe what still needs to be considered.

I encourage people to dive into the research of background hip anatomy, as well as the current thoughts
on hip injuries within the medical or strength fields. I will offer basic concepts from them in the coming
paragraphs as it relates to injuries but can’t stress enough how valuable the articles or textbooks
mentioned were to me over the past five years.

As I did with the shoulder section, here are three graphics that walk through

Layer 1 (Bony anatomy)

Layer 2 (Ligaments and capsule)

Layer 3 (Muscular examples).

Paralleled to the shoulder, the hip joint is made up of the socket (acetabulum) and the upper thigh bone
(femur), with the femoral head serving as the ball.

You may remember the shoulder joint has a very shallow socket, which allows for lots of motion but then
creates a situation where stability is needed. The hip is a bit opposite of this, having a deeper socket with
more joint congruency. This allows for more inherent weight bearing stability but may limit the natural
mobility the hip can achieve. 135-136

Some naturally flexible gymnasts have a bony alignment where the hip socket is not as deep. This
creates a situation where the femoral head has more access to move in larger ranges of motion, creating
significantly more hip mobility in all planes. These gymnasts typically don’t have to work on flexibility
too much to achieve full splits. They also tend to have excessively mobile hip capsules, similar to the
shoulder.

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The hip socket being overly shallow is referred to as “dysplasia.” Some gymnasts with dysplasia or
hypermobile hip capsules never have pain, but some are so far on the continuum of too excessive
mobility that it leads to instability and injury.

These gymnasts were born this way. This is usually why they were noticed as a good candidate for
competitive gymnastics, as they naturally had full splits and bridges. Like in the shoulder, natural
mobility of the hip allows them to move through a greater motion. As mentioned we have to be cautious
not to overtax their already hypermobile hip capsules and ligaments during flexibility training.

With this mobility comes the huge need to be strong, have very good technique, and have exceptional
muscular stability. This shallower hip socket, and natural hypermobility, creates a situation where the
gymnast cannot afford to have limited dynamic structures for protection.

This is where the third layer of dynamic stabilizers and muscles comes into play. The glute muscles, deep
hip rotators, other surrounding hip muscles, and core are essential for hip safety and performance.

An important note is that some athletes may have different bony morphology of their hips in which

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their femur or hip socket is more rotated forward (anteverted) or backward (retroverted). 135-136 In one
situation, the gymnast may have lots of hip and toe rotation “out” but may not have any motion of “toes
in.”

In another, the gymnast may naturally have lots of hip and toe rotation “in” but not have any moving
“toes out.” A full movement evaluation and something known as a Craig’s test is the best way to
practically assess if a gymnast may fall into one of these categories. Adjunctive radiographic X-Rays or
advanced medical imaging can also be helpful to see a boney congruency. Some may have a combination
of dysplasia, hip socket rotations, femur rotation, and different pelvic alignments.

It is way beyond the scope of this text to breakdown all these different anatomical variants, but the
reader must be aware of the simple fact that not all gymnast’s hips are the same. The gymnasts who are
naturally mobile with very flexible hips are almost always the ones we see used as demonstrators for
speaking presentations, clinics, videos online, and during other flexibility talks.

What is likely easy for that gymnast to do in a flexibility video online is because she has unique hips. That
same drill may cause significant pain and limited motion in another gymnast who has a very retroverted
or less shallow hip joints.

Many gymnasts may be limited by their bony alignment, differently shaped hips, or less mobile capsule/
ligaments. It’s not always because they are not trying hard enough. Attempting to apply one general
stretching exercise that a naturally mobile gymnast showed in a presentation may cause some serious
problems for such a gymnast. Trying to aggressively push through that bony or ligamentous limitation
will only lead to pain and headaches for all involved. If someone is continuing to struggle with hip
mobility, rather than just pushing more take a step back and consider this concept. Take them to a
qualified medical professional for an assessment.

How this Background Anatomy Applies to Hip Injuries in Gymnasts

This has been covered within the flexibility chapter, but some of it bears repeating as it relates to
medical injuries. Early in my Physical Therapy career, I spent a lot of my time treating gymnasts with
shoulder instability. I was fortunate that some of the great literature works of James Andrews, Kevin
Wilk, Mike Reinold, and Lenny Macrina were available to me. As I worked with more gymnasts for hip
issues and studied the works of hip surgeons, I started to see very similar patterns develop between
these two joints.

The same ideas related to over-stressing passive structures of the hip (capsule, ligaments, bony
alignment) versus properly addressing the soft tissue (hip flexors, quads, groin, hamstrings) were a major
contributing problem, just as with the shoulder.

Gymnast after gymnast came to me in the clinic with hip pain due to over stretching their passive
structures, not managing their soft tissue adaptations, failing to do full range control drills, and having
limited strength in their deep hip rotators and glutes compared to their hip flexors, quads, and inner
thighs.

When we took a step back to modify most provocative skills, educated them on proper stretching
approaches based on available science, taught them to manage soft tissue stiffness, and put them
through a formal strength and conditioning program for the under developed areas, many gymnasts
were able to safely return to gymnastics with no hip pain. Some cases were unfortunately too far

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advanced and ended up needing surgery to repair damaged tissue or resulted in the gymnasts choosing
to quit gymnastics due to ongoing pain when training.

I found that many of the gymnasts I treated from beginner all the way to elite level gymnasts showed
these similar patterns. Excessively overworked and stiff soft tissue, excessive strain on hip ligaments
when doing flexibility, weakness in specific hip muscles, and mismanaged workloads were at the
foundation of their issues.

Also, many of them showed great control or strength at mid-range of motion but had notable deficits in
control or strength at their end ranges of motion. The end range of motion (think 180 degrees split leap,
full sprint, or in bar skills) tended to be where most of their symptoms were reproduced, so it was crucial
that we addressed this limitation.

These athletes were coming to me in the last five years with a mis-diagnosis of “hip flexor strains”, “groin
strains” or “tight hips”. In reality, I felt they were having serious joint, ligament, and labral tissue irritation
as well as recurrent hip micro instability. I felt their “tight hips” were just protective muscular guarding
over time to prevent instability. It was my opinion that the muscular guarding was likely the bodies
attempt to prevent injury to the deeper ligaments and labral tissue.

Just as with the shoulder, I continued to read and try out new treatment concepts with both the
gymnasts I coached and treated. I was happy to see some great progress in their skill performance, with
reduced symptoms of hip pain or “popping” sensations.

The first key here is getting to the bottom of the issue, and whether it is something able to be changed
(soft tissue management, strength deficits, workloads) or not (bony alignment). A full medical evaluation
of the hip joint is crucial. 137 -138I have worked with too many gymnasts who did not get evaluated for their
hip mobility limitation, and the ongoing flexibility methods used lead to significant hip injury, sometimes
career-ending. Along with injury risk, not having an assessment and individualized approach prior to
creating a plan will likely lead to wasted time and lack of progress in hip mobility.

Readers must either assess the athlete for their individual hip mobility restrictions themselves (if within
your scope), or work with a skilled healthcare provider who can do this for you. This is absolutely key.
As in many parts of gymnastics, there are different ways to gain skills and have high-level performance.
There is no one-size-fits-all approach. The same thing goes for improving hip and shoulder mobility. If
a coach or athlete is dedicated to their mobility program but still sees limited progress, seek out some
collaboration to address the issue.

The next step following proper assessment and flexibility work, is to make sure that the dynamic
muscular structures are aiding in supporting the new-found flexibility motion. Just because a gymnast
has full splits on the floor does not mean they have great active hip motion during skills. Please see the
chapter on flexibility for more on the current research and thoughts on this.

If an athlete has lots of passive flexibility, it doesn’t mean they have the needed control or strength to
access the hip range of motion, or the ability to use it in the movement of dynamic skills. It just means
they have the potential to reach the desired hip movements or hip angles.

To achieve these large ranges actively and consistently in skills, athletes must have full control, strength,
power, and muscular endurance. Dr. Bill Sands had a great quote that sums this concept up well. He
writes,

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 “The most flexible athletes are not necessarily the most successful; flexibility for athletes may be an
optimization rather than a maximization problem

(McNeal and Sands, 2006).”

Dr. Sands has a full guest chapter on flexibility that can be found in Strength and Conditioning: Biological
Principles and Practical Applications by Cardinale, Newton, and Nosaka. I highly suggest people check out
that text, as well as all of Dr. Sand’s work in gymnastics research.

I feel it is accurate to say some hip injuries may stem from the overuse based muscular stiffness in
certain muscle groups. The most obvious is the muscular overuse that comes from the need to have
proper lower body form for both scoring and technique optimization.

To have proper form, gymnasts must constantly keep their legs together, straight, and maintain pointed
toes. This alone will cause the muscles of the front of the thigh (quadriceps), inner thigh (groin or
adductors), and lower leg muscles (calves) to become overworked and stiff.

More importantly, the muscle groups that oppose the front of the thigh and inner thigh need an extra
amount of attention to be developed. I have found that in many of the gymnasts I treat for lower
back or hip injuries, the glutes, hamstrings, deep hip rotators, and deeper core muscles are largely
underdeveloped in comparison to the quads, hip flexors, inner thigh, and more superficial core muscles.

Along with being important for injury prevention, these overlooked posterior chain muscles are crucial
for increasing sprinting speed, power generation, and amplitude in shape changing needed for higher
level skills. Large imbalances around the hip joint like these can lead to both hip pain as well as limited
hip power.

The traditional model of gymnastics strength and conditioning tends to place a high focus on the quads,
hip flexors, and front/side core musculature. Many jumping strength exercises, as well as exercises
like leg lifts, rope climbs, and common core exercises, all have overlap in these areas. If you combine
the adaptations of constantly working these muscles for proper form, along with tendency for many
gymnastics strength programs to overwork these muscle groups, it often can set up the stage for an
overuse injury situation at the hip.

I personally feel that many gymnastics strength programs, as well as medical rehabilitation programs,
are missing out on training high-level hip strength needed to reverse these large areas of muscular
imbalance and enhance power

Exercises such as weighted hip lifts, deadlift or Romanian dead lift variations, loaded carries, side
planking exercises, clamshells or lateral leg raises with resistance bands all have very good support in
research to recruit the glute and hip rotator muscles. 139-147

Due to their importance in both performance and lower body injury prevention, these exercises should
be of equal importance in gymnastics strength programs as compared to many traditionally used lower
body strength exercises.

I completely understand it is important we develop the quadriceps, adductors, and hip flexors for
success in gymnastics skills, as well as performance and injury prevention against landing forces. I
program many of the same exercises other gyms do for these muscle groups on a weekly basis.

However, many studies related to optimal sprinting or jumping performance, as well as hip and knee
injuries, have outlined the crucial role the core, deep hip rotators, glutes, and hamstrings play. 96-98, 150 - 160

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There are even some great studies that outline the role of hip, posterior chain, and other global strength
programs to increased jumping performance as well as injury prevention in gymnastics populations. 161-
163

Due to the abundance of research, and expert opinion of many high-level gymnastics coaches, I feel
we must make sure glute and hamstring specific exercises are utilized. This is best done through body
weight and formal resistance training approaches that use external load appropriately.

Going along with this concept of hip imbalances, how an athlete reaches an overall split pattern
passively also needs a quality monitoring approach. Coaches and gymnasts tend to be very keen on
correcting turned out knees, flexed feet, and hips that are skewed. However, we tend to let them all get
away with a huge overextended back and big tilt in their pelvis.

Some of this is going to happen with a split pattern, but generally speaking the gymnast shouldn’t be
getting a full split down by hyperextending their back and rotating their pelvis forward. If they are
simply relying on their lower back joints to make up for a lack of true hip mobility, we are not building
optimal patterns that we want to show up in skills. It’s not that a gymnast shouldn’t extend their back,
it’s just that we need to make sure that their lower back isn’t the only thing being used to get the desired
split angle.

For those curious about those exercises, be sure to check out these articles I have written over the last
few years.

• Hip Injuries

o From Clinic To Practice 6: Chronic “Hip Flexor Strains” in Gymnasts

http://shiftmovementscience.com/from-clinic-to-practice-6-chronic-hip-flexor-strains-in-
gymnasts/

o Treating Gymnasts with “Chronic Hip Flexor Strains” – From Clinic To Practice #6b
http://shiftmovementscience.com/treating-gymnasts-with-chronic-hip-flexor-strains-
from-clinic-to-practice-6b/

o Are Oversplits Bad for Gymnasts? Combining Science and Real Life in the Gym For
Safe, But Effective, Split Flexibility Methods

http://shiftmovementscience.com/are-oversplits-bad-for-gymnasts/

o Why I Don’t Use Ankle Weights With My Gymnasts

http://shiftmovementscience.com/why-i-dont-use-ankle-weights-with-my-gymnasts/

o From Clinic To Practice #4: Gymnast With Chronic Hamstring Injury and
“Tightness” Due To Core Control Issues
http://shiftmovementscience.com/from-clinic-to-practice-4-gymnast-with-chronic-
hamstring-injury-and-tightness-due-to-core-control-issues/

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 Hip Flexor / Groin Strains and Labral Injuries

True hip flexor and groin strains, as well as the more serious progression to ligament and labral damage
are extremely common in sports and gymnastics. 121, 123-124, 130, 164-166 Most times gymnasts will,

Have sudden onset of hip pain in the front or groin area that hurts to touch or move and causes
notable limping or altered walking pattern.

Have pain that was made worse by extending their hip or rotating it out, splits, leaps, running,
kipping, beam series, and pulling into flip shapes.

Struggle to return to gymnastics fully due to flexibility, skill, and excessive training volume.

Remember that hip injuries are a beast of a topic, with hundreds of possible overlapping factors behind
it. I think these hip flexor pains may actually (not always) be much more serious issues such as the
deeper hip layers of the ligament, capsule, and labrum micro damage occurring over time. It may feel like
it is on the surface as muscular strain, or that muscle could be irritated as a secondary reason, but deep
problems likely exist.

The end range of hip motions backwards and out (think back leg of split leap) tends to be where a lot
of these issues occur. As some research has outlined, this end range of motion can potentially put
significant stress on the front of hip joint and ligaments.

I personally feel that dynamic end ranges of motion without appropriate strength and control, may
be sparking irritation in gymnasts’ hips over time. The same concept can apply to straddling and front
kicking.

This ligament, capsule, and sometimes labrum area is even more taxed when reaching end range of
motion, due to the leg bone possibly bumping into the back of hip socket.

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I outlined this in the picture above, but it exists with both end range straddle, backward, and frontward
kicking. The two bones may essentially fulcrum on each other at all end ranges, causing increased stress.
It may create a pinching type feeling on one side, with a painful stretch or pull sensation on the other.
This is why I feel the hip flexor or groin muscles gets overstretched from behind and reflexively tighten
up to protect when sliding may occur. There can sometimes be true muscular strains of the groin or hip
flexors, as they get over stretched and may become inflamed. These injuries tend to resolve with a few
days or weeks of rest and activity modification.

There are many times when these areas get repetitively strained, and along with the soft tissue
becoming injured, the deeper hip joint itself can start to have problems. This is when injuries are falsely
labelled as “hip flexor strains” or “groin strains” as a main diagnosis.

It may be a much more serious issue like a labral tear, or ligament micro tear, which needs to be
respected for the amount of long-term problems that may follow. I have seen many gymnasts continue
to train despite having deeper hip issues, causing them to lose the entire season or need hip surgeries.

It is challenging to train large flexibility ranges with high force for gymnastics skills, but I think it can be
done if you take time to think about the concepts covered so far. 

Hip Flexor, Groin, and Labral Strain Treatment and Rehab Concepts

Here are some baseline principles that I apply during the rehabilitation process for these gymnasts. The
concepts also directly influence what I chose to do during gymnastics training to help develop the hips of
our gymnasts, and reduce the risk of injuries starting.

1. Restore Soft Tissue Mobility and Range of Motion – (If Applicable)

Not every case of hip microinstability is a super lax or more “gumby” type athlete. Gymnasts (any many
other athletes) can have capsular laxity with soft tissue mobility restrictions still being present from
overuse in training. Also remember, gymnasts may be stretching out their capsular and ligamentous
static stabilizers through years of gymnastics skills.

Despite it still being theoretical, I tend to believe that when the passive tissue is stressed it leads to
protective guarding from the dynamic stabilizers. This is especially after a recent bout of sudden
irritation. Through years of sports, certain soft tissue adaptations can occur if the athlete has not been
doing regular maintenance care for themselves.

If someone shows soft tissue limitations upon exam, it’s really important we address them. This usually
comes with manual therapy, light self-soft tissue work to modulate tone, and teaching about correct
active soft tissue vs. capsular stretching.

2. Increase Baseline Hip and Correct Strength Imbalances

A huge staple in the rehabilitation program for gymnasts who come to see us at Champion is periodized
strength programs for their glutes, hamstrings, deeper and often overlooked hip stabilizer muscles. I
tend to program their rehabilitation with basic strength exercises first, then progress it to power or rate
of force development exercises, then higher level compound strength movements, and then finally
gymnastics specific patterns. We first work from the mid non-painful range of motion as the hip calms
down, and then progress to end ranges of motion with more demand that is gymnastics specific.

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People are quick to knock isolated and “nonfunctional” training methods, but I think this is a really big
mistake. Obviously, we won’t be doing sidelying leg lifts and clamshells for a month, but half the reason
many hypermobile athletes develop pain is due to their lack of underlying strength in these smaller
muscle groups.

Remember the hip is subject to huge force under sporting conditions. It’s crucial that we have strength
of all the muscles involved around the hip acting as dynamic stabilizers to buffer these huge forces. I’m
all about half kneeling chops and crawling exercises as one part of the dynamic stability piece, but
at a fundamental level, the lack of strength needs to be addressed. On that note, as rehabilitation
specialists we must follow the available strength and conditioning literature to write programs that
actually foster hypertrophy adaptation. I think going back to master the basics was one of the key
components to these gymnasts getting back to training later on. Here are some exercises I commonly
use, (videos can be found in the articles I will provide URL links to)

• Weighted Hip Lifts / Kettle Bell Swing Progressions–

o Weighted hip lifts are something I think should be fundamental in a gymnast’s strength
program. It has enormous benefit for glute and posterior chain development when utilized
properly. Achieving end range glute control is something that will not only promote
power, but also theoretically helps to create better joint stability during loaded and more
dynamic gymnastics skills.

• Manual Eccentric Hip and Adductor Strength 

o Manual table versions of hip eccentrics can also be a fantastic way to increase the
challenge for athletes, while also applying some intermittent rhythmic stabilization’s at
their end ranges. The end range of motion tends to be the most problematic for these
athletes, as passive tissue strain tends to occur, or it may be where bony intraarticular
“fulcrum” based approximation takes place. For this reason, I feel it is crucial they are
strong and controlled through full ranges.

It’s also worth noting that a study by Jensen et al (find it by clicking here) noted eccentric strengthening
of the hip adductors assisted in reducing groin strain risk for soccer players. Despite being largely
different sports, there may be a lot of carry over to gymnastics that is worth considering. I know of many
coaches who do “active flexibility” or eccentric strength with sliders, which I think is valuable in the right
dosage. From here, things progress to more complex hip strength exercises, more loading, rate of force
development emphasis, and eventually gymnastics specific.

3. Train High Level Dynamic Stability

• Manual Hip Rhythmic Stabilizations –

o Just as with the shoulder, it’s important the hip stabilizers work in both closed and
open chain to mimic sporting demands seen in gymnastics. I have studied shoulder
instability literature extensively thanks to the work of Mike Reinold, Lenny Macrina, and
others who I am fortunate to work with closely. By combining their concepts, the current
hip instability and anatomical research, and my thoughts as a gymnastics coach, similar
treatment styles have emerged that have been extremely helpful. One of these is using
rhythmic stabilizations.

Beyond this as many people know, there are oodles of great 1/2 and tall kneeling progressions and then

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progressions to kettle bell work that force single leg hip control in a weight bearing situation.

4. Progression To Sport Specific Demands

o Curled Up Hip Series – (video here https://www.youtube.com/watch?v=5Tp10cGnnd8)

o Just as any other sport would progress rehab to higher level demands, the same
goes for gymnastics and other aesthetic sports. These curled up hip exercises bias the
end range of motion to help prevent end range stress and build up control that will
eventually transfer to skills.

From here there are hundreds of other great jumping, leaping, and active flexion drills that can be added
to the program.

5. Objective Return to Sports Plan

Just as with the spine and upper body, I always create objective return to sport plans following hip
injuries for gymnasts. The best strength, stability, and skill specific rehab can quickly be thrown out the
window if we don’t respect the basic principle of adaptation.

Once injury occurs, we must progressively stress and recover tissues, promoting the tissue to adapt
back above its prior level of capacity. We can then take the numbers of jumps, leaps, in bar skills, and
create interval programming with continued home exercise programs. I feel this is one step we often
miss in many sports, despite it being so present in many sports like baseball and running.

It’s also worth noting that hip flexor strains, groin strains, or labral irritation are not the only things that
can occur with these types of underlying principles. I have seen a huge bandwidth of injuries occur in the
hip region based off of the principles above.

I have treated other injuries such as growth plate stress fractures, avulsion tendon tears of various
muscles, abdominal strains or micro tears, hip ligament strains or micro tears, hip subluxations, and
nerve traction injuries all from the same concepts.

Every gymnast is different in their movement patterns, and how their body handles the stress of
gymnastics. With that being said, I do feel there is a huge amount of progress that can be made in this
area of hip pain. By combining medical science, expert coaching I feel many gymnasts can see large
progress for their performance and injury risks.

Hamstring Strains and Growth Plate Fractures (Ischial Apophysitis)

Next to hip flexor and groin strains noted above, the hamstring muscle and its attachment to the
growth plate in the pelvis (ischial apophysis) are both very commonly injured sites in a gymnast. 167 - 171
The hamstrings are a large muscle group that bend the knee and extend the hip, but very commonly in
gymnastics they are subject to high eccentric force during leaping, jumping, sprinting, and other skills.

The very large hamstring group converges into to a common tendon, which then attaches to the pelvis

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bone (more specifically called the “ischium” or “ischial tuberosity”). In young gymnasts, the open growth
plate is present just above where the hamstring tendons attach. 67-68 When this growth plate is not fully
developed, it may not be able to handle such high force, due to it not being a fully fused mature bone.

In gymnastics the hamstring attachment is subject to incredibly high forces. It requires extreme
flexibility and rapid contractions during aggressive eccentric lengthening. This type of contraction
occurs when the hamstring must act as a braking force to slow the leg down and control speed or high
velocity. This is often seen in sprinting, leaps or jumps, and various step ins skills on bars. Despite being
more common in female gymnasts, this can also occur in males.

Another large contributing factor to hamstring injuries is overly aggressive stretching exercises for the
hamstring, which may put significant strain on the growth plate and attachment site of the hamstring. 172
- 173

Most gymnasts will over time develop hamstring pain which begins as a small strain, and often does
not get the appropriate rest or rehabilitation it requires. A gymnast will usually rest a few days, modify
the most painful skills, and then continuing to train once they have less pain. More often than not, the
gymnast continues to train or resumes training too quickly, and the hamstring tendon or growth plate
continues to take high amounts of stress.

This injury then progresses to what is known as an “ischial apophysitis” which in lay terms means the
growth plate and bone itself starts to become inflamed or painful. If left untreated this can become a full
stress fracture of the growth plate and pelvic bone. These injuries are extremely painful due to the bone
itself and larger nerves being inflamed in the area.

Core Control and “Tight Hamstrings”

Another important topic to touch on is how lacking core control effects spinal position and can directly
impact hamstring mobility and risk of injury. The lower back, pelvis and hip joints are inseparable and
function as one large complex. The position of the lower spine and core will directly influence the pelvic
position, which in turn directly influences hamstring mobility.

Given the anatomy of the hamstrings, the position of the spine and pelvis will directly influence
apparent hamstring length. If a gymnast hyperextends their back and tips their pelvis forward, they will
be pre-stretching and lengthening their hamstrings. As a result, a gymnast who has a very overextended
lower back position may display limited hamstring mobility or a split that doesn’t goes down.

Frequently, a gymnast rapidly gains hamstring mobility by correcting their spine position. This means
they have a core control problem, not a hamstring flexibility deficit. When you are performing hip flexor,
hamstring, or other hip mobility screens, always keep an eye on their lower back position. You can also
test the difference by creating more posterior tilting and flattening of the spine to pull them out of
hyperextension.

There are other important structures in the back of the leg that may be contributing. There is a very
large nerve, the sciatic nerve, that courses along this path as well. It originates from the lower back
and travels down the entire leg to branch out into different areas in the lower leg and foot. Generally
speaking, nerves aren’t happy when they are excessively stretched. If a gymnast is put in a pike stretch
and is trying to pull themselves down, the “tightness” they feel as an intense burning in the back of their
knees or thighs might actually be sciatic nerve tension.

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This is something we certainly do not want. You may notice the stretching sensation changes depending
on if the gymnast points or flexes their toes. It could be the calf muscle influencing the sensation, but
this is typically felt in the muscle belly not behind the knees. When statically holding a pike stretch and
changing the ankle position, we are not affecting hamstring length but rather gliding the nerve back and
forth. Rather than jumping to push the knees or trunk of an athlete down, and further stretching the
sciatic nerve, we must pause and think critically. We have to consider if core position or the sciatic nerve
is limiting the pike motion, so we do not cause more harm than good.

The main reason I comment on this is because I feel it is an overlooked aspect to hamstring and other
hip injuries in gymnasts. There have been many gymnasts I work with that appear to show limitations
in their hip mobility. To address this limitation they choose to do excessive passive stretching when
ultimately core control is the root of their problem.

Issues like chronic hip joint irritation, high hamstring pain (ischial apophysitis), “hip flexor strains”
(possible labral irritation or pelvic stress reactions/greater trochanteric stress reaction) and lower back
pain all have common roots in this idea.

For these cases, I almost always take away their aggressive passive splits and overstretching, educate
them on proper core control and soft tissue work, and then look to add full range control to create
optimal hip mobility. With this approach and communication with their coach, many gymnasts I are able
to finally get over multiyear injuries and actually see improvements in split or leap performance within a
few months.

Now that I have provided background to how hamstring injuries occur, here are a few summary and
overview bullet points regarding addressing this issue.

• Going back to the flexibility chapter, this is one of the most important areas to apply more
scientific based concepts. Understanding hamstring anatomy, how the spine and core influences
someone with “tight hamstrings” and knowing how to approach flexibility in a complex type
circuit is incredibly important. Often times, stretching alone is not the answer to increase
hamstring mobility or increase a pike stretch.

• Early detection is one of the most important aspects to growth plate and overuse injuries in
youth athletes. Being able to recognize the difference between growth plate irritation and
expected stretch based discomfort is crucial. The normal expected stretch-based discomfort is
more vague and typically not described as sharp, fades upon stopping stretching, and does not
tend to last longer than 24 hours. Tendon or growth plate pain tends to be more intense and is
reported as “sharp” pain high in the buttock area by the bone. It will often surface following a long
bout of stretching or rapid kicking/jumping/leaping skills. It usually is associated with lingering
pain following the conclusion of training. It sometimes creates physical changes in movement like
small limps or inability to contract the muscle.

• We have to remember that frequently hamstring injuries occur secondary to overuse, and too
many repetitions being done in a short period of time. If a gymnast is subject to 1-2 practices
that have a very large spike in their jumps, dance, sprinting, or in bars, it may be the catalyst for
hamstring pain starting. Progressive accumulation over a month or season may also be a reason
behind issues starting.

• In contrast to this, adequate physical preparation and strength work is one of the most impactful

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 ways to reduce the risk of hamstring injury. At a very root level, these types of injuries occur
because the tendon and growth plate are being loaded with gymnastics skills at a higher level
than they are prepared to handle.

• We must be sure that we are doing eccentric type strength work for the hamstrings. I feel this
is how we can make a very large dent in how often these injuries occur. Along with monitoring
overuse, this has been very supported in the research to help with hamstring flexibility as well
as reduced risk of strain injuries.174 -179 This is one of the biggest reasons I am such a fan of
adjunctive weight lifting being added to gymnastics in a more hybrid model. Exercises like single
leg weighted deadlifts, slider drills, loaded hip lifts, and other posterior chain drills can help build
the load bearing capacity of the hamstrings. It may not completely eliminate the risk of issues, but
I have found this to be very beneficial when prescribed in the right dosage.

• The last important point is the influence of core and spine position on hamstring strain. A
gymnast with a very over extended lower back position, and an anteriorly tilted pelvis, will
typically pre-stress their hamstrings much earlier in their leg raising range of motion. This may
not only appear as “tight hamstrings” with discomfort, but may also prematurely stretch the
hamstrings, the tendon, and the growth plate of athletes. This applies to flexibility or strength
drills, but also to all the skills a gymnast performs.

• There are many reasons for an over extended lower back position. It could be soft tissue
flexibility issues in the groin, hip flexors, or lower back muscles. It could also be strength
deficits in the glutes, core, or hip rotator muscles. A gymnast could have no issues in flexibility
or strength, yet lack the technical development or physical capacity to handle high force skill
situations. The important point is that we recognize these factors exist, and work with medical
providers to narrow in exactly on what is causing the overextended spine position.

That concludes the overview of hip injuries in gymnastics based on my experiences. There are many
more complex avenues that can be investigated related to training, medical treatment, and sports
performance, but in an effort to not lose readers that is all I will cover. Now let’s move on to the last
section of this chapter, knee and ankle injuries.

Contributing Factors to Knee/Ankle Injuries

Across all epidemiological studies that have been done to investigate gymnastics injuries, it is quite clear
that the knee, ankle, and foot, (usually defined as the “lower extremity”) have astronomically high injury
rates. 1-3 ,7, 9, 13, 26-27,30,31-35 I’m going to briefly discuss some common themes related to the entire lower
body, but then address some separate factors related to the knee and ankle independently.

Due to gymnastics being largely a jumping and landing sport, it is not unusual to see a higher proportion
of knee joint strains or sprains, ankle sprains, and other accidental injuries. There is no doubt that
despite the best strength, injury prevention, or workload prescription program, accidents will happen.

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In my honest opinion, these accidental types of injuries are not the real issue that needs to be addressed.
Anecdotally, in my five years treating many gymnast’s lower body injuries, I can say confidently that
the rates of overuse injuries in the knee, foot, and ankle outpace the rates of accidental injuries about 6
injuries to 1

The more serious problem is the insanely high occurrence of;

• Knee, ankle, and foot stress fractures across all age groups in gymnastics and competition
levels. 2, 32, 34, 37, 60, 118, 180

• Growth plate injuries and overuse tendinopathies in younger gymnasts (Severs Diesease,
Osgood Schlatters, Sinding Laresen Johansson Syndrome, etc). 114,172

• Progressive tendon breakdown seen commonly in mature athletes like patellar tendinopathy
or Achilles tendinopathy. 7,9,34, 59

• Progressive tendon breakdown that has turned into a terrifyingly high rate of Achilles tears
and ACL tears in older gymnasts. 32, 34

• The unbelievable number of gymnasts who struggle with progressive and chronic bone
bruises, meniscus damage, or cartilage breakdown within the knee and ankle joint. 7, 9, 59

Next to lower back pain, lower extremity injuries are clearly represented as problems in the research,
and evident in every day training. Significant changes are required to combat this predicament. It is very
sad for me to realize how many gymnasts are told to “push through” serious issues like stress fractures,
growth plate injuries, and bone or cartilage break down in the lower body.

As I have mentioned, I completely understand that some soreness and small irritations will come with
gymnastics, and all sports, as training brings high force and the need for repetition. I know all too well
what this feels like, as I had many lower body injuries as a gymnast.

However, this is not what is happening in current gymnastics culture. I regularly talk with people in the
gymnastics community who see athletes being told to “just be tough” or stop complaining about their
knee or ankle pain. Worse is stories of gymnasts being told not go to the doctor for x rays or MRI’s,
ignore medical advice, and to just tape their ankles up so they can train or compete. Before you assume
it’s only gymnastics coaches saying this to gymnasts, it’s not.

I have seen gymnasts not speak up about their own leg injuries, only to later lose entire seasons when
they are diagnosed with a fracture or require surgery. I have seen parents push gymnasts to compete at
championship meets with stress fractures or cartilage damage, again only to lose the entire summer or
following year of training.

I also have witnessed coaches step well beyond their scope of practice to combat medical advice about
these types of knee or ankle injuries.

It is also worth noting, there are situations where medical providers are uninformed about gymnastics,
and the type of training performed. Rather than seek out help or more knowledge on gymnastics, they
just “clear” a gymnast for training with no set program for impact or landing progression.

Before someone drafts an email my way about pointing fingers, the only reason I know these things
so well is because I have made the majority of these mistakes myself. In looking back, I regret a few
decisions about managing knee and ankle injuries that now serve as fuel to become a better practitioner.

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The real question is, why over 10-20 years of progressive gymnastics knowledge and medical care, have
we only seen these types of injuries increase in prevalence.

I feel the main reasons are;

• A lack of objective monitoring for the number of hard landings or impacts gymnasts take per
day, week, and month in training. In parallel to this, not slowly ramping up the surface and
height of impact dismounts or tumbling to ground level prior to competition.

o A growing body of research in workload and periodization has emerged outlining the
importance of planning training, using modulation of intensity, avoiding sudden spikes
in volume (tumbling or dismount impacts in this case), and monitoring the acute (1
week) to chronic (3 week) workload ratios to reduce injury risk. 52 – 58

o Remember that ground reaction landing forces on a gymnast’s lower body have been
measured at 14.2 – 15 times body weight 119-120, with bone on bone forces at the ankle
joint recorded as high as 23 times body weight. 187 That is insane.

• An inappropriate cultural acceptance of letting gymnasts “land short” multiple times on a skill,
rather than stopping and going back to fix lacking technique, or simply holding training of that
skill for that day due to accumulated fatigue

• A cultural misunderstanding related to the scientific benefits of lower body resistance

training in gymnasts, to help increase the lower bodies capacity to handle insanely high loads.

• A lack of proper squat-based landing mechanics being used, which has been clearly outlined in
the research to reduce the risk of knee injury. 181 – 186

• A global undertone within gymnastics that “more is better” and that gymnasts must simply
keep doing skills until they get it right, versus capping the number of impacts or dismounts
done per day using a scientifically supported periodized approach to training.

• A cultural change to delay the performance of highly impactful skills such as double backs or
double pikes on floor, twisting vaults, and high skill dismounts, until young gymnasts develop
the physical preparedness and leg strength to handle the impact forces, and master both skill
and landing technique to protect themselves.

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 The Injury Spectrum in Gymnastics and Ankle Injuries

In a very simplistic way, the large spectrum of overuse and acute lower body injuries tend to come up
when a gymnast is trying to absorb and disperse high amounts of force during gymnastics skills. These
impact forces range from small repetitive forces as is seen in sprinting or landing jumps and leaps, all the
way to the highest forces recorded in gymnastics under dismounting, vaulting, or tumbling conditions.

The ages of gymnasts I treat for knee and ankle injuries has widely varied. I have treated competitive
gymnasts as young at eight years old, all the way up to twenty-three years old. I have also treated a huge
amount of ex gymnasts for various lower body injuries following retirement from their competitive
career.

A very interesting pattern has emerged from treating such a wide age range of people for knee or ankle
injuries. It seems that many of the principles for why these injuries occur remain constant, despite the
type or location of their injury changing based on their stage of growth.

Take the Achilles tendon for example, the most frequently injured area due to high forces applied during
running, tumbling, bounding skills, and absorbing impacts.

In a young skeletally immature gymnast, the growth plate located in the heel is typically the most at
risk. This is because it has not yet fused to become mature bone, and instead is more cartilage based.
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This reduces its load bearing capacity, and causes it to quickly become inflamed or acquire a stress
fracture when pushed too far. 78-81 Growth plate inflammation of the heel is called “Sever’s Disease” and
is something that thousands of young gymnasts deal with.

Moving on from the very young gymnast, when this growth plate closes and is able to tolerate more
force, the issues tend to move into the Achilles tendon itself. This usually occurs in gymnasts from the
age of thirteen to seventeen (with a huge variability based on developmental ages).

As the Achilles tendon takes more than it can handle, it often gets micro tearing and becomes inflamed,
causing pain and a limited ability to run, jump or land. 185 ,188 This is usually called Achilles Tendonitis
with first time acute flare ups. Over time if tendon continues to go through micro injury, limited healing,
and repetitive trauma cycles, it may start to have degenerative changes. This is usually called Achilles
Tendinosis. 189 The same principles from above remain, but now due to the presence of closed growth
plates, issues translate into the Achilles tendon itself.

Lastly, as gymnasts progress through their career, many dream to compete in college settings. As the
Achilles tendon has taken many years of repetitive impact, and often slowly experiences degenerative
change, it is extremely at risk for more serious problems. 30, 189

As gymnasts continue to train following puberty, they often have much more muscle mass, power, and a
higher overall level of skill difficulty across more training hours. We now have a scary situation, where
a degenerative Achilles tendon (remember starting from younger years of Severs or tendinosis) may be
much less capable to tolerate force. Despite this, it is being loading multiple times per day, week, month,
and through back to back competition weekends on the collegiate calendar.

I feel this is why we see full Achilles Tendon Ruptures in collegiate gymnasts, after the tendon finally
is unable to take force from years of damage and tears. As tendon researcher Cook, Rio, and Purdam
outline, there is an extensive “continuum” to tendon injuries that must be considered in terms of chronic
degeneration and ultimate tissue failure.
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Achilles issues have become a rampant problem more now than ever with full achilles ruptures being
a huge issue in the collegiate and elite setting. Dr. William Sands has done extensive research in this
area, outlining the multiple factors that must be considered including the advancement of spring floor
technology, the increase in skill difficulty being done by gymnasts at younger ages, and training volume
considerations.

I personally think these injuries are not “out of the blue”. I think they are more the end product of a
career of repetitive injury to the Achilles growth plate, tendon, and muscle complex. This unfortunately
is just more theory based on my experiences, but science is emerging that is seeming to support these
ideas.

I encourage readers to not forget that the highest recorded force applied to the Achilles tendon in
gymnastics was in 1985 by Bruggemann, which was seen during the take-off of a double back on floor.
The force recorded was 9000N, or 15x body weight. That force is absolutely enormous by itself, not to
mention what has not been recorded in force for double layouts (common skill college gymnasts tear
Achilles on) and full ins. I can’t even wrap my head around the force on the Achilles during even higher-
level skills like Moors (laid out double double) and triple fulls that require steep take off angles.

As mentioned by Bruggemann in his chapter in injuries 41 in The Sports Medicine Handbook of Gymnastics,
the amount of “flat footed” pronation of the ankle may also increase Achilles forces. It was noted that
increased heel eversion (rolling in of the ankle to a flat foot position) increased the tensile strain at
the medial column of the Achilles tendon by more than 75%. Even more tilting angle increasing strain
by 100%. This places enormous shear strain on the already loaded Achilles, and may be a huge factor
contributing to tendon break down over time.

In summary, for Achilles injuries we must consider the number of impacts, skeletal maturity level of the
gymnast and physical, technical, and mental readiness for the level of skill difficulty.

The Injury Spectrum Concept for Knee Injuries

Continuing this concept into the knee, very similar parallels can be made. For many of the same reasons
(lacking physical preparation, too many impacts in a short period of time, improper landing mechanics,
etc.) a large amount of young gymnasts experience knee pain. Are you catching on to the trend?

There are two very commonly injured growth plates in the knee. 167 One of them is at the top of the shin
bone, where the quadriceps muscle attaches. This is called the tibial tuberosity. The second is at the base
of the knee cap, where the quad tendon anchors to the knee cap. This is called the distal patellar growth
plate.

Repeating from the Achilles section, these growth plates lack the ability to handle high force
repetitively because they are not fully developed. If the growth plate in the upper shin or kneecap
become overstressed from landing impact, excessive force exposure, or lacking physical and technical
preparation, it can easily become inflamed and cause extremely painful bone irritation. These growth
plate injuries can also turn into stress fractures, Salter Harris fractures, or other forms of growth plate
fractures that make athletes miss multiple months of training if not properly addressed. 80-82

Once growth plates are finally fused, gymnasts in their high school ages will often continue to have

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overuse knee injuries but of a different nature. Just as the heel growth plate fuses and forces shift to the
Achilles tendon, as the knee growth plates fuses the forces may then be placed on tendons, ligaments,
and other structures in the knee.

This is often where injuries like patellar tendonitis or patellar tendinopathy, 189 – 190 progressive ligament
or meniscal damage, 191-192 and more serious cartilage breakdown occurs.193-194 These injuries all
unfortunately are lumped into one vague diagnosis of “patellofemoral syndrome”, “patellar maltracking”,
or “chondromalacia”. Although these diagnoses may help point to certain structures, they rarely help to
better understand treatment and prevention strategies.

Lastly, just as with the ankle there are times when structural integrity continues to decline, or faulty
movement patterns place too high of stress on knee structures. Much more serious meniscal tears,
larger stress fractures, deeper cartilage injuries (Osteochondritis Dissecans, femoral condyle stress
fractures), and possible predisposition to massive injuries like ACL tears are often the end result of this.

As can be seen when looking at the larger picture, many injuries that simultaneously undermine
performance come from very common patterns. Just as with the hip, there is a wide variety of overuse
injuries. It all has to do with unique anatomy, individual gymnastics training, and how the body absorbs
force.

I cannot tell you how many young gymnasts come with their parents or coaches to our rehabilitation
clinic, Champion PT and Performance, very frustrated with these types of overuse knee injuries.

There are definitely some biomechanical or movement based issues that we find during an evaluation.
But I am always completely honest in telling them that the “stress” in “stress fracture” or the “overuse” in
“overuse based growth plate fracture” is there for a reason. It clearly points to a problem with numbers
of skills being done to hard surfaces per day or week, an underdevelopment of lower body strength,
and improper landing mechanics. They are often looking for quick fixes in the form of rehabilitation
exercises, stretches, or illusive medical treatments that will resolve the issue, and allow the gymnast to
train pain free or compete in their upcoming competition.

This is often a hard conversation to have, because the reality of the situation is that by the time they
seek out medical care, they have likely ignored the problem for as long as possible. They have pushed
through a large degree of pain, and the injury has progressed so far they require extended time off from
training, walking boots, or surgery.

There is no quick fix that will magically speed up growth plate fractures, bone healing, or tendon repair.
Even worse are the medical providers that are promising this with some “new treatment” just on the
market. Yes, many things we do every day at Champion or that technology has created may assist in a
faster healing rate, but nothing will replace the need to honestly look at gym culture, skill repetitions,
work to rest ratios and strength and conditioning programs.

My hope is that by honestly writing about this problem and outlining the research to support the gravity
of these overuse knee and ankle issues, more people in the gymnastics community will re-think their
workload and physical preparation programs.

Objective Workloads & Acute:Chronic Workload Ratios

I have said this in every section of this chapter so far. I know readers are sick of it by now. But the
number of impacts a gymnast is taking per event, day, week, and month is extremely important. Out of

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all the areas of injury this concept is most crucial for knee and ankle injuries which rank the highest.

Gymnastics has some of the highest impact forces recorded during tumbling, vaulting, and dismounts.
In conjunction with this, we have some of the youngest and most at risk athletes who are not skeletally
mature performing these skills. If you take a step back to look at the training culture in gymnastics, it is
very easy to see gymnasts do thousands of impacts per week . I personally think that along with ankle
mobility issues and landing/running technique, this is a major reason for shin splints as well as plantar
fasciitis being such a large issue in gymnastics.

At its foundation, the most elaborate injury prevention and strength program will not compensate for
gymnasts simple doing too much during training. Athletes who are taking hundreds of impacts per day
with forces multiple times body weight are very at risk to “suddenly” have an injury start. This has been
studied extensively in other sports, with drastic increases in training volume or high cumulative training
load being indicative of increased injury risk. 52-58,196

I am fortunate to have friends who are coaches to some of the highest-level gymnasts seen in our sport.
They range from J.O. Level 10, to Division 1, to junior elite and elite national/international. I can promise
you, the coaches and gymnasts who maintain the highest level of health in their gymnasts manage work
load and rotate the number of skills done to hard surface with surgical precision.

It is not always done by the exact method offered in the research presented, but without a doubt there
is always a degree of workload monitoring, tracking, and periodization to everything. Understanding
and implementing this concept is essential if you wish to optimize athlete health, skill progression, and
reduce knee or ankle injury risk.

I think understanding tracking and implementing objective workloads will be the gold standard in the
future of gymnastics. The risk of too many hard impacts can be mitigated by,

• Objectively tracking impacts each day per event, and giving limits per event/day

• Rotating daily event focus of hard landing impacts for tumbling passes, dismounts, or vaulting.

• Rotating the surfaces of impact (resi pits, rod strips, hard floor, etc.) to not have constant high
impact forces. This can rotate based on the intensity of the training day, the week, and the time of
season.

• Understanding which gymnasts are at high risk based on times of rapid growth, being skeletally
immature, not being physically or technically prepared, or being in a fatigued state.

To make a dent in the enormous rate of impact based knee and ankle injuries, I feel gymnastics needs
to take a very hard look at the objective workloads, as well as the work:rest ratios being placed on
gymnasts.

Tumbling Take off Technique

As I mentioned in the elbow and wrist section, there are some specific gymnastics technique factors that
might be relevant to each body part commonly injured. For one, many great coaches have outlined the
concern with very shallow take off techniques during high power tumbling skills on floor. Encouraging
gymnasts to have very steep take off angles tends to increase the force on the ankle joint into
dorsiflexion and pronation.

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It is plausible to consider as dorsiflexion increases, the load on the Achilles increases. Also depending on
the situation, increased pronation and medial shearing or rotational stress may occur. I am not aware of
any specific research studies that have definitively linked a steeper tumbling angle to increased risk of
Achilles tendon injury or eventual rupture, but logically it does make quite a bit of sense.

I have been fortunate to learn from some great coaches that a more upright take off that encourages
rapid opening of the shoulder and hip vertically may be more beneficial to ankle health and tumbling
power. I have witnessed more of this technique being used over the last few years, with changes in back
handspring mechanics as well as take-off technique being more advantageous. As time progresses, we
will need to see if this alters the frequency of Achilles tears and lower body injury rates.

Return to Impact Programs (Surfaces and Quantity)

Building off the workload concepts above, one of the time periods I see the most errors made in
advanced rehabilitation of gymnastics injuries is during the return to gymnastics phase. It is common
for a gymnast who had a knee or ankle injury to be “cleared” medically following cessation of pain to
return back into full gymnastics without considering progressive workloads and unfortunately end up
re-injuring themselves.

I have made this error as a therapist and coach myself, so I am not off the hook at all. I can tell you
from first-hand experience this rapid return to impact leads to significant levels of frustration for the
gymnast, coaches, parents and medical providers. This is also consistent with emerging International
Olympic Committee research related to return to sport that outlines concerning factors for re injury. 197

I strongly suggest that anyone working with a gymnast returning from an injury be extremely objective
on slowly progressing their workload over time. I typically have a gymnast do 2 weeks of general
strength, basics, flexibility, and technical work for their lower body before actual tumbling or dismount
skills are performed. In line with this, the type of force is slowly progressed based on difficulty of skill
and the surface they are training on (tumble trak vs. floor, line beam vs. high beam, pit vs. hard ground).

Lastly this is built into the actual number of repetitions they do during an event, day, or week. Together,
these three areas of general preparation, equipment surface, and skill repetitions plays a significant role
in successfully returning a gymnast back to full training. Here is an example of this to clarify.

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As a former gymnast and someone who still coaches, I totally understand there will be times when
we need to push the timeline surrounding important competitions. I pushed through a few knee and
ankle injuries during peak competitions in my career and have worked with some athletes as a medical
provider in similar situations.

In my experience, however, this is typically a much smaller percentage of the time. In those
circumstances, I discuss the best plan with everyone involved. In most cases I find myself trying to
educate everyone on how a few weeks worth or appropriate rehabilitation, strength, and an objective
slow return to training can give them months to years in return.

Limited Force Absorbing Capacity of the Lower Body & Muscular Strength Imbalances

With the amount of time and focus most coaches place on strength and conditioning within gymnastics,
I don’t think there is any debate about the fact that gymnasts need to be strong in their lower bodies.
However, there are various methods that are utilized to help gymnasts reach the desired level of
strength.

I touched upon this above in the strength and conditioning chapter, but we must make sure there is
appropriate general strength and power development within a gymnast. Gymnastics places a massive
demand on the quads, hip flexors, inner thighs, and calves of athletes. More traditional gymnastics
strength programs tend to bias the same muscle groups during training. Thousands of jumps, leg
lifts, loaded squats, and other more plyometric exercises tend to be prescribed. These exercises are
important and can be very beneficial when properly dosed.

We must also make sure that we are not ignoring the countering muscle groups and training them in a
similar amount of volume/intensity. The biggest overlooked muscle groups in the lower body tend to be
the glutes, deep hip rotators, the hamstrings, the lateral/rotary/anti-compressive core musculature, and
the shin muscles.

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There are many great gymnastics coaches and programs that understand the need to train these areas,
and regularly put some degree of focus on them. However, I feel that even in the best programs, the
myths and misunderstandings of certain strength exercises has prohibited people from stressing these
muscle groups to the highest level they require.

Exercises like weighted single leg or double leg dead lifts, weighted hip lifts, loaded kettlebell or
dumbbell caries, various sled dragging variations, and heavy resistance band clamshells/walking all
come to mind. When trained with proper loading protocols, technique and coaching, these exercises can
be incredibly beneficial to build the lower body’s ability to handle high impact forces.

The solutions to this come back to education on strength and conditioning science, understanding
general physical preparation, applying the science of periodization, and planning exercise selection to
balance the lower body.

Soft Tissue Stiffness Negatively Impacting Squatting Mechanics

It’s known to the gymnastics world that having good form in all skills is pretty much essential to success.
You can throw all the craziest skills in the world, but if they are sloppy, the judges almost break their
pencils trying to rack up the deductions.

I touched on this concept above, but it has special relevance to teaching proper squatting mechanics for
landing to mitigate knee and ankle injury risk. After seeing many gymnasts with knee/ankle injuries who
can’t squat well, reflection upon what “good form” requires brought me to a very interesting realization.
Having “Good Form” and “Good Squat” may work against each other.

When you think about the nature of what proper form entails, we want to see:

Feet/legs together – requires lots of inner thigh muscle (adductors) contraction

Toes pointed – requires lots of calf muscle (gastrocnemius and soleus) contraction

Knees straight – requires quad muscles (rectus femoris, vastus medialis, vastus lateralis, vastus
intermedialis) contraction

Now, if you look at a squat pattern, you may notice it requires the direct opposite of this motion

Feet/legs hip width apart – about hip width to allow hip dominated squat pattern

Toes up into dorsiflexion – requires calf muscle and ankle joint mobility

Knees Bent – requires a moderate degree of quad flexibility, especially as depth increases

A theory that I have really been considering is that over years of training, gymnasts may naturally lose
their ability to squat well as soft tissue in the muscle groups used for good form become excessively stiff.

Out of all three possible limitations I think repetitive jumping or running can create calf stiffness and
contribute to loss of ankle mobility. I have seen groin stiffness cause some issues as well, but quad
flexibility tends to not be the biggest factor.

Every sport has its unique demands that create certain adaptations or changes in movement patterns.
Baseball pitchers may gain lots of external rotation shoulder mobility or have certain areas of
muscular stiffness from throwing. Soccer players may have more groin stiffness from sprinting or
kicking. Gymnasts may have groin, quad, and calf stiffness given the demands of skills and the need

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for proper form.

We want strength and power through these muscles, but we can’t let this muscular stiffness overpower
other movements like squatting, jumping, and landing. Regular maintenance care becomes pivotal at this
point to combat this potential issue.

Landing Modifications to Increase Safety

This directly builds off the idea above. The topic of how a gymnast should land continues to be
controversial for many coaches, gymnasts, and judges. I’m not the first person to bring this up, as my
good friend Dr. Josh Eldridge and Rick McCharles have written about this before. I’m just going to weigh
in my opinion on the matter.

I feel the unfortunate reality is the typical way most gymnasts were taught to land growing up (me
included) may not be the safest or most effective way to stick landings. It seems coaches are also
unfortunately very misinformed about what the best available science suggests for proper landing
mechanics to disperse force. The concerning typical landing position that we need to move away from:

Knees and feet together

Glutes engage with the “hips tucked under” into hollow

Knee dominant landing strategy

Stiff impact with upright torso

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The pictures above may be exaggerated examples of this improper landing position, but the concept
remains true. Over the last five years across the country I continue to see gymnasts landing in a way that
is very concerning.

Even worse, I continue to see coaches telling their athletes to “tuck your hips under, put your feet
together, and use your knees.” I see hundreds of gymnasts doing strength and conditioning including
loaded squats, box jumps, and single leg squats with extremely concerning form.

I understand that much of this may come from a simple lack of education. There is a large body of
research available showing landing form is an important factor playing a role in ACL tears and knee
injuries. 181-183, 186, 187, 192,

The reality of the situation is we need to change the way gymnasts land, starting from a very young age.
The more ideal landing we should be teaching is:

Feet hip width apart

Toes, knees, hips, and shoulders generally inline in a stacked position

Core engaged in a relative neutral position (not excessively hollowed or arched)

Proper angular displacement of the hip and knee joints

Hip angle generally 30 degrees, and trunk/tibial lines close to parallel

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If you would like to read up on more nerdy medical research related to this, you can check out the
review articles on factors related to ACL tears or other knee injuries here, here, here, here, and here. 197
- 201

Remember Dr. Sand’s work has suggested the forces acting on the gymnast can be as high as 15x body
weight, and gymnasts likely take thousands of impact reps over a month of training and competitive
season. This supports why we must stress proper landing mechanics from a young age. Addressing
landing position while they are young helps build better motor patterns and reduce forces from the
start. This way as they mature they will continue to safely land.

Why a Squat Based Landing is Better for Sticking

Along with injury-based aspects, the traditionally taught gymnastics landing style is also less
effective for sticking skills. During the more ideal pattern noted above the glutes and other hip
musculature can more optimally control the forces eccentrically during landings.

There are many cases I could include for athletes sticking skills more frequently in a squat versus
being forced to take steps when their feet are together and hips are tucked under. There will always
be outliers, but this seems to be the general trend. Many of the most high-level gymnasts in the world,
doing the highest impact vaulting or dismount skills, tend to sow a trend of proper squat based landing
form.

One common issue that comes up with gymnasts I treat or when we teach seminars is that of “flipping

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shape” versus “landing position”. Coaches and athletes must understand that the ideal flip shape for tight
double backs or regular front tucks is not necessarily the best way to land and dissipate high force.

Now I am quite aware that each gymnast has different anatomy that will make their squat variable from
one athlete to another. There may not be a perfect way to land, and there are an infinite number of
variables to consider.

What I’m trying to explain is that we want the athletes to use more of a hip and muscular dominant
strategy that will dissipate high forces through angular displacement. Ideally, we want to shift the
stress away from the passive ligamentous and bony knee structures to more muscular and active based
structures across the entire kinetic chain. I feel this is crucial to make dents in both the overuse and
acute injury rates that are sadly very high in gymnastics.

I know many coaches get concerned about score deductions, but from what I have read and heard from
national judges and elite coaches is that feet hip width apart is allowed as long as it is a reasonable
distance. Beam is one situation where we clearly don’t want feet hip-width apart, but the athlete can still
use hip-based strategies for their dismounts. I also realize connected bounding tumbling is completely
different than absorbing a high force skill/dismount.

There will also inevitably be short and off landings we can’t avoid, but for me I think this is where the
role of a well-designed and periodized strength program comes into play. I think there is a way to
properly prepare tissues for low landings, and I certainly think lower extremity joints should have the
capacity to handle varying force angles, but in general I feel we need to utilize proper squatting form in
the very high load gymnastics skill scenarios.

I can tell you that for almost every gymnast I work with in the clinic with lower back or lower extremity
injury, I teach them how to land correctly using a proper glute/hip based squat pattern. I have found in
many gymnasts this is often a big key to getting their injury to calm down, and safely returning back to
training.

Putting It All Together for Knee and Ankle Injuries

In summary, think about the big picture when putting things together for a gymnast. I don’t want to
make it seem like every gymnast is going to tear their Achilles, tear their ACL, or have growth plate
factures. That is certainly a little bit farfetched. It is not my goal to scare people, but rather to raise
awareness of the reality of gymnastics injuries and forces.

I’m sure there are many other viewpoints and ideas to think about. I am constantly learning from other
smart people working in the field and I’m sure I will learn even more as the months progress. I think the
risks and occurrence rates of Achilles tears in gymnastics is an example of how coaches, gymnasts, and
medical professionals who have their hand in gymnastics need to work together to pro-actively stay
ahead of serious issues like this. Major injuries like Achilles tears, ACL tears, lower back problems, and
several others can be devastating for an athlete’s health and gymnastics career.

With this mega medical chapter completed on the specific concepts of injuries, the next chapter will
cover more general concepts about the future of gymnastics sports medicine.

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Key Take Away Points

• The rates of overuse and acute injuries in gymnastics continue to be one of the biggest issues the
sport of gymnastics faces. Even with a huge cultural presence of under reporting injury and training
while still in pain, the research clearly outlines the negative consequences of injury including; short
term loss of training, long term loss of training, reinjury risk, increased mental and emotional strain,
increased risk of burnout, and delayed long-term potential in sports.

• An injury can be defined as “any damaged body part that would interfere with training”.

• Injuries have increased rates in preseason, end of season, during new skill attempts, and following
vacation (when rapid increase in intensity of training occurs).

• The available research in gymnastics injury outlines generally that 65-70% of injuries are overuse,
while 30-35% of injuries are acute.

• Available research also outlines that gymnasts often do not speak up about their injury, and continue
to train through pain or injury, despite the clear negative long-term impact.

• High rates of stress fractures in the wrist, spine, elbow, and clavicle are serious issues in gymnastics.
Alongside this are soft tissue injuries, growth plate overuse stress fractures, cartilage damage, and
ligament tears of the ACL or Achilles tendon.

• Lower body injuries to the ankle and knee are consistently reported as the more common body part
injured, with female gymnasts also having more rates of lower back pain and male gymnasts also
having more rates of wrist/shoulder pain.

• The main practical issues that need addressing for the global reduction in injury rates include:
o The creation of healthy cultural environments that encourage communication about pain and
injury.
o Not allowing the casual attitude many people in the gymnastics community take to serious
injuries, downplaying them as “pulled hamstrings”, “growing pains”, or “tendonitis”.
o Increased awareness and proactive care for shoulder/wrist injuries in male gymnasts, and
lower back/leg injuries in female gymnasts based on what the current science outlines as
effective counter injury measurements.
o Not allowing gymnasts to continue to train through notable pain or injury, whether it is stated
outright or is through people overlooking athletes complaining of pain.
o An objective, systematic, and mandatory system of objectifying workloads must be created
and followed by everyone in gymnastics.
o A cultural change on the prescription of skill, routine, and strength workloads, with more
attention paid to proper work to rest ratios and objective tracking of training volume.
o Better medical screens, diagnostics, gymnastics specific rehabilitation, and return to sport
programs for athletes with an interdisciplinary mindset.

o Lower Back Pain

Injury rates are reported between 20% - 60% of all gymnasts.
The forces on the spines of gymnast are enormous, being recorded at 11-20x body
weight.
MRI and Imaging studies, as well as follow up subjective reports from ex elite gymnasts

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 raise serious concern about the long-term health of gymnasts’ spines.
The start of pain and injury in a young athlete needs to be taken seriously as minor
muscular strains can evolve to ligament damage, bony stress reactions, and stress
fractures rapidly.
The need for monitoring workloads, setting limits for skill repetitions, and calculation
of work to rest ratios are the most important factor to consider in gymnastics before
biomechanics or rehabilitation concepts.
No injury prevention program will counter act gymnasts doing too much
hyperextension or impact skills that put massive force on the spine.
Rotating training hyperextension and hard impact skills by event can be helpful to
reduce injury risk, along with “limits” of skill repetition, diversifying skill profiles,
teaching proper extension patterns, having robust physical preparation programs,
managing hip and shoulder flexibility, encouraging high level core control and core
strength, teaching proper landing mechanics, and regularly screening for lower back
pain.
Gymnasts must also be more attentive to take care of themselves, communicate injury,
and be dedicated to physical preparation/workload programs.

o Shoulder injuries
Shoulder injuries are much more common in male gymnasts, but also exist to a high
degree in female gymnasts.
Excessively limited shoulder flexibility, as well as excessively mobile shoulder
flexibility, can both be problematic for injury risk.
Forces on the upper body have been recorded as high as 9x body weight for male
gymnasts, and 3.9x body weight for horizontal bar.
Flexibility methods should prioritize soft tissue management over ligament and
capsular stress, and there is a large need for the gymnastics community to understand
basic shoulder anatomy.
Similar to the lower back, early injury detection as well as volume management and
proper work to rest ratios are the most important factor to prevent long term shoulder
injuries.
Physical preparation programs that prepare the upper body for loading is crucial, as
the upper body is not inherently built for weight bearing.
Delaying high-level ring strength until after puberty may assist in reducing male
shoulder injuries.
Due to the high incidence of natural hypermobility in gymnasts, regular rotator cuff,
scapular, and general shoulder strength programs must be performed weekly. There is
an abundance of science to support the role of these interventions to reduce injury risk
in overhead athletes, when paired with proper flexibility and work load management.
Proper technical progression and mastery is also key in reducing shoulder injuries in
gymnastics.
Times of rapid growth and development should be monitored

o Elbow Injuries
Elbow injuries are one of the fastest growing problems in gymnastics due to many
factors including technology of equipment advancements, increased difficulty of
skills being asked of young gymnastics, lacking physical preparation programs and
suboptimal work to rest ratios of upper body impact skills.
A range of issues in the elbow exist, with less severe injuries like muscular strains on
one side and full blown stress fractures, cartilage damage (OCD), or ligament micro

338
 tearing on the other side. Due to the severity of these issues, we must be hyper aware
of the start of injuries as surgery can put a gymnast out of training for entire seasons.
OCD and stress fractures are of the highest concern in gymnastics, due to their
severity and long-term impact on health as well as training.
Repetitive weight bearing impact as seen in Yurchenko style vaulting, tumbling, beam
impact, or pommel horse/parallel bar training is thought to be the primary risk factor in
stress fractures as well as OCD, next to a previous injury. This is because the elbow is
not built to be a weight bearing joint and thus has limited force absorbing capacity.
This repetitive weight bearing is often the cause of pain and injury due to spikes in
training volume (sudden increase in vaulting, beam series, or pommel horse), or large
increases in training cumulatively over weeks.
Too little physical preparation, as well as too much loading, are both indicative of
increased injury risk.
Technical aspects such as overturning the second hand during roundoffs, and excessive
hyperextension of the elbow joint are also stated as risk factors to elbow injuries in
gymnasts.
Times of rapid growth that intersect with elevation in levels to optional level skills, and
increases in training hours per week must be monitored in young athletes.
Other factors such as shoulder flexibility, wrist flexibility, weight bearing strength,
dynamic stability of the upper body, and mastery of technical progressions for high
force skills are also factors to consider.

o Wrist Injuries
Many of the same factors noted in the elbow section directly relate to wrist injuries.
Male gymnasts tend to have more incidences of wrist pain, due to the nature of
pommel horse and parallel bar training requiring repetitive training.
The forces on the wrist (and as a result in some degree the elbow joint) have been
shown as 1.5x body weight on vault, 2.2x body weight in roundoffs, and 2.37x body
weight during back handsprings, with the highest recorded forces at 16x body weight.
Growth plates, wrist or hand bones, ligaments, and soft tissue are all at risk for injury
due to repetitive compression in weight bearing skills of gymnastics.
Excessive stiffness of the forearm flexor and pronator muscles is something to
regularly screen for and manage due to the number of gripping skills gymnasts perform
daily.
Volume management, early detection of injury, and rotation of impact surfaces
continue to be the most important tools to reduce injury risk.
Progressive resistance training with appropriate dumbbells, kettlebells, and other
weights may assist in bridging the gap between wrist loading capacity and the force of
gymnastics skills.

o Hip Injuries
Next to elbow injuries, hip injuries are the fastest growing body part injured
in gymnastics, despite being largely under reported in the literature and often
downplayed in severity by gymnasts, coaches, and parents.
Gymnastics as a culture must move away from downplaying the severity of hip pain
as “pulled hamstrings”, “pulled hip flexors” and “tight hips” to embrace the reality
that many of these issues can be indicative of much more serious injuries like labral
tears, growth plate fractures, ligaments micro tears, and cartilage damage that when
progressed require extended time off from training and sometimes surgery.
Impact forces on the hips of gymnasts have been recorded at 8.8–14.2x body weight,

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 and even up to 18x body weight with asymmetrical landings.
A variety of hip demands occur in gymnastics (leaps and jumps, to landings, to in bar
skills) which produces a larger spectrum of hip injuries.
Next to monitoring of workloads, improper flexibility methods are regularly cited as a
start to hip injuries in gymnasts. This is especially relevant with hamstring growth plate
injuries such as ischial apophysitis, ligament and labral tears, and groin injuries.
A basic understanding of hip anatomy, as well as special attention to use flexibility
methods that bias soft tissue mobility over ligament and joint level stress is crucial.
Strength, active flexibility, control drills, and technique must be paired with more
passive forms of flexibility for injury prevention and optimal performance.
An extremely high level of physical preparation must be central to gymnastics training,
with special attention paid to the glutes, hamstrings, quads, and core of gymnasts.
Early detection and integrated medical care remain the hallmark of the prevention of
more serious hip injuries in gymnastics.

o Knee/Ankle Injuries
Above all other injuries, the knee and ankle are reported as the highest reported body
part injured in gymnastics.
Stress fractures, growth plate injuries, ankle sprains, Achilles tendon injuries, and bone
bruise/cartilage damage in the ankle joint continue to be reported as the main issue in
gymnasts across many ages and levels.
Knee and ankle pain are regularly and inappropriately overlooked by gymnasts,
coaches, and parents which over time can cause increased risk of larger more acute
ligament/bony injuries if not managed.
The forces of gymnastics landings have been recorded as high as 15x body weight
per repetition. Even more concerning is the force recorded at the ankle joint during
tumbling which has been measured at 23x body weight.
The number of impacts over a short period of time, combined with the average number
of impacts in one week compared to the previous three weeks to track acute to chronic
workload and reduce injury risk, based on other sport research.
Landings should be taught in a proper squat-based pattern, rather than the classically
seen knees/feet together and more upright landing that has been indicative of huge
injury risk.
Similarly, all possible methods to reduce landing “short” must be taken, ranging from
physical or technical preparation, as well as fatigue management.
An injury spectrum appears to exist for knee and ankle injuries, where the same factors
mentioned above may be indicated for various pathologies. This includes growth
plates being more at risk when athletes are younger, tendons being more at risk during
adolescent, and full ligament or tendon tearing more common during collegiate/elite
years.
Special attention must be paid to ACL, Meniscal, and Achilles ruptures in older
athletes, as these are being seen at an even higher rates. Equipment technology,
tumbling take off technique, rotation of impact surfaces, work load monitoring, landing
mechanics, soft tissue care, physical preparation programs, and recovery methods are
all possible factors to consider.

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