Skeletal Radiol (2006) 35: 503–509

DOI 10.1007/s00256-006-0083-7 SCIENTI FIC A RTICLE

D. Lee Bennett
Lawrence Nassar
Lumbar spine MRI in the elite-level female
Mark C. DeLano gymnast with low back pain

Received: 4 August 2005

Revised: 5 January 2006
Accepted: 6 January 2006
Published online: 7 March 2006
# ISS 2006
D. L. Bennett (*)
University of Iowa, Roy J. and Lucille
A. Carver College of Medicine,
Department of Radiology,
200 Hawkins Drive,
Iowa City, IA 52242, USA
e-mail: lee-bennett@uiowa.edu
Tel.: +319-356-3655
Fax: +319-356-2220
D. L. Bennett . M. C. DeLano
Michigan State University, Colleges of
Human Medicine and Osteopathic
Medicine, Department of Radiology,
East Lansing, MI 48824-1316, USA
L. Nassar
Michigan State University, College of
Osteopathic Medicine, Department of
Sports Medicine and Kinesiology,
East Lansing, MI 48824-1316, USA
Abstract Objective: Previous stud-
ies have shown increased degenera-
tive disk changes and spine injuries in
the competitive female gymnast.
However, it has also been shown that
many of these findings are found in
asymptomatic athletic people of the
same age. Previous magnetic reso-
nance imaging (MRI) studies evalu-
ating the gymnastic spine have not
made a distinction between symp-
tomatic and asymptomatic athletes.
Our hypothesis is that MRI will
demonstrate the same types of ab-
normalities in both the symptomatic
and asymptomatic gymnasts.
Design: Olympic-level female gym-
nasts received prospectively an MRI
exam of the lumbar spine. Each of the
gymnasts underwent a physical exam
by a sports medicine physician just
prior to the MRI for documentation of
low back pain. Each MRI exam was
evaluated for anterior apophyseal
ring avulsion injury, compression
deformity of the vertebral body,
spondylolysis, spondylolisthesis, de-
generative disease, focal disk protru-
sion/extrusion, muscle strain, epidural
mass, and bone-marrow edema.
Patients: Nineteen Olympic-level
female gymnasts (age 12–20 years)
were evaluated prospectively in this
study. All of these gymnasts were
evaluated while attending a specific
training camp. Results: Anterior ring
apophyseal injuries (9/19) and de-
generative disk disease (12/19) were
common. Spondylolysis (3/19) and
spondylolisthesis (3/19) were found.
Focal bone-marrow edema was found
in both L3 pedicles in one gymnast.
History and physical exam revealed
four gymnasts with current low back
pain at the time of imaging. There
were findings confined to those ath-
letes with current low back pain:
spondylolisthesis, spondylolysis, bi-
lateral pedicle bone-marrow edema,
and muscle strain. Conclusions: Our
initial hypothesis was not confirmed,
in that there were findings that were
confined to the symptomatic group of
elite-level female gymnasts.
Keywords Magnetic resonance
imaging . Elite gymnasts . Spine

Introduction athletes during the 2003–2004 season. Women’s gymnas-

In the United States of America (USA), organized women’s
gymnastics programs involve approximately 20 million
young women, with at least 2 million participating in
competitive gymnastics [1]. Some of the most recent injury
data on women’s gymnastics are for USA collegiate
tics is one of the sixteen sports currently monitored by the
National Collegiate Athletic Association (NCAA) Injury
Surveillance System. Women’s gymnastics at the collegiate
level now has the highest percentage injury rate of any
NCAA sanctioned and monitored sport [2]. In previous
studies, injury rates (per 1000 hours of exposure) of
504
American female gymnasts have ranged from 3.7 to 22.7
[3–5]. Lower back (spine) injuries account for approxi-
mately 12% of injuries in women’s gymnastics, with injury
being defined as any damage that would interfere with
training [3]. These above, referenced epidemiological
studies indicate that performance-inhibiting back injuries
are not a rare event in women’s gymnastics.
Previous imaging studies in the medical literature have
shown that degenerative disk disease and spine injuries are
more common in the competitive female gymnast than in
asymptomatic non-athletic people of the same age [6–9].
Although these findings are more common in the com-
petitive gymnast, prior studies suggest that they may not be
clinically significant [7]. Previous studies evaluating the
spines of gymnasts have not made a distinction between
symptomatic and asymptomatic gymnasts in regard to
spine abnormalities found on imaging studies [6–8].
Given the high prevalence of back injuries among elite-
level female gymnasts and the paucity of magnetic
resonance imaging (MRI) data on such conditions, it is
important to document MRI findings that are present in
asymptomatic versus symptomatic elite-level female gym-
nasts, so that an MRI finding is not inappropriately
assumed to be the source of the symptomatic gymnast’s
back pain. Therefore, we undertook a prospective con-
trolled study to evaluate the lumbar spine with MRI in
elite-level female gymnasts (both symptomatic and asymp-
tomatic) while they were attending a specific national
training camp. Our hypothesis was that MRI would
demonstrate the same types of abnormalities in both the
symptomatic and asymptomatic elite/Olympic-level female
gymnasts, since it has been previously reported that
asymptomatic athletic people can have findings of degen-
erative disk disease, spondylolysis, and other spine injuries
[6–8].
Materials and methods
Internal review board approval was obtained for this
prospective controlled study. The informed consent forms
used for this study were also reviewed and approved by our
institution’s internal review board. Written informed
consent appropriate for age was obtained for all partici-
pants after the nature of the procedure had been fully
explained and understood.
Clinical
Nineteen Olympic-level female gymnasts (ages 12 to 20
years, average age 16 years) who were invited to attend a
specific weeklong national training camp were studied.
Only these 19 gymnasts attended this camp. All 19 of these
gymnasts received an MRI exam of the lumbar spine,
regardless of the presence or absence of low back pain.
Each of the gymnasts underwent a history & physical exam
by a primary care sports medicine physician (LGN). For
purposes of this study, the presence or absence of current
low back pain was documented in the history portion of the
physical exam note prior to the MRI. Any previous history
of low back pain was also documented. Current low back
pain was defined as any low back pain currently limiting
training to any degree. A history of low back pain was
defined as any prior (but not current) low back pain that
previously compromised training.
Imaging
All MRI spine exams were performed on a 1.5 T GE Signa
MRI system (GE Medical Systems, Milwaukee, WI, USA).
The lumbar spine MRI protocol consisted of a sagittal spin
echo T1-weighted sequence with 600/17 (TR/TE), a
sagittal fast spin echo proton density sequence with
2500/10 (TR/TE) with an echo train length (ETL) of 24,
a sagittal fast spin echo T2-weighted sequence with
4000/98 (TR/TE) with an ETL of 24, a sagittal fast spin
echo inversion recovery sequence with 4000/42/150 (TR/
TE/TI) with an ETL of 8, an axial spin echo T1-weighted
sequence with 600/9 (TR/TE), and an axial fast spin echo
T2-weighted sequence with 4000/105 (TR/TE) with an
ETL of 24. The field of view was 28 cm×14 cm on the
sagittal sequences and 20 cm×20 cm on the axial
sequences. The slice thickness was 3.0 mm, with a slice
gap of 0.8 mm, on the sagittal sequences, and the slice
thickness was 4.0 mm, with a slice gap of 0.8 mm, on the
axial images.
Two board-certified radiologists (DLB, MCD) evaluated
each of the lumbar spine MRI exams independently.
Discrepancies were resolved by consensus opinion. Both
radiologists were blind as to the current physical/symp-
tomatic status and prior clinical history of the subjects.
Each MRI exam was evaluated for the presence of
anterior apophyseal ring avulsion (AARA) injury, com-
pression deformity of the vertebral body, spondylolysis,
spondylolisthesis, degenerative disk disease, focal disk
protrusion/extrusion, muscle strain, epidural mass, and
traumatic bone-marrow contusion/edema. Each of these
entities was diagnosed based on previously published
criteria [9–14].
An anterior apophyseal ring avulsion injury (AARA)
was defined as excavation of the anterior apophyseal
region with or without a persistent ring apophysis [9]. A
compression deformity of the vertebral body was defined
as an acute or chronic compression fracture involving only
the anterior column of the spine [10].
Spondylolysis was defined as disruption of the pars
interarticularis [11]. Spondylolisthesis at a disk space level
was defined as anterior slippage of the superior vertebral
body on the inferior one. Spondylolisthesis was also graded
(grades 1 to 5). Grade 1 spondylolisthesis at a disk space
 505

level was defined as anterior slippage of the superior
vertebral body by less than or equal to 25% of the
anteroposterior dimension of the inferior vertebral body.
The grade increases by one with every quartile of the
anteroposterior dimension of the inferior vertebral body
uncovered. In addition, grade 5 was defined as complete
displacement of the superior vertebral body, with it resting
anterior to the inferior vertebral body [11].
Degenerative disk disease was classified as mild,
moderate, or severe. The findings of mild degenerative
disk disease consisted of osteophyte formation, vertebral
endplate marrow (Modic) changes [12], and/or abnormal
decreased signal on the T2-weighted sequences within the
nucleus pulposis; however, the disk space height had to be
preserved. Moderate degenerative disk disease consisted of
the above criteria with the exception that disk space
narrowing had to be present. Severe degenerative disk
disease was defined as loss of the normal disk space with
bone-on-bone articulation of the vertebral bodies.
Focal disk protrusion and extrusion were defined based
on previous research [13]. A focal disk protrusion was
defined as focal extension of disk material beyond the
interspace, with the base against the disk of origin broader
than any other dimension of the protrusion. A focal disk
extrusion was defined as focal more extreme extension of
the disk beyond the interspace, with the base against the
disk of origin narrower than the diameter of the extruding
material itself.
A muscle strain was defined as edema and/or hemor-
rhage at the myotendinous junction with or without
macroscopic tearing of the muscle [14]. Traumatic bone-
marrow edema/contusion was defined as abnormal in-
creased signal within the marrow on T2-weighted and
STIR sequences, without associated causal arthritis, mass,
or infection.
Statistics
Statistical analysis was performed to determine if the
distribution of any findings was statistically significant
between the elite/Olympic-level gymnasts with current
back pain versus those without current back pain (control
group). Comparison of the MRI findings between the two
groups was done using Fisher’s exact test, since the groups
were unpaired, the group sizes were small (less than 30
subjects and with some observational findings being less
than 5), and the data were nominal [15, 16]. The p-value
calculated from Fisher’s exact test was the double-sided p-
value, since our hypothesis (before the data were collected)
was that both groups would have similar MRI findings
[17]. A p-value ≤0.05 was considered statistically signif-
icant. Comparison of the mean age between the two groups

Table 1 History and MRI results

AGE PAIN AARA LYSIS LISTH DDD HERN STRAIN EDEMA

Gymnast 1 17 Current S1 L5 5/1 5/1(mod) 5/1(cent ext) 3/4,4/5 (rt rot) 0

Gymnast 2 15 Current L5,S1 L3 3/4 4/5,5/1 (both mod) 0 0 L3 ped (bil)
Gymnast 3 17 Current L5 0 0 4/5 (mod) 0 0 0
Gymnast 4 17 Current 0 L5 5/1 4/5(mild) 5/1(mod) 0 0 L5 ped (left)
Gymnast 5 20 Prior history 0 0 0 1/2(mod) 0 0 0
Gymnast 6 17 Prior history L2,L5 0 0 1/2,5/1 (both mod) 5/1(cent ext) 0 0
Gymnast 7 13 Prior history L5 0 0 4/5(mod) 4/5(cent pro) 0 0
Gymnast 8 18 Prior history 0 0 0 4/5(mild) 0 0 L3 ped (left)
Gymnast 9 14 Prior history 0 0 0 0 0 0 0
Gymnast 10 15 Prior history L2 0 0 1/2(mod) 0 0 0
Gymnast 11 17 Prior history L4 0 0 3/4(mild) 0 0 0
Gymnast 12 15 No pain T12 0 0 12/1(mod) 0 0 0
Gymnast 13 12 No pain S1 0 0 5/1(mod) 0 0 0
Gymnast 14 15 No pain 0 0 0 0 5/1(cent pro) 0 0
Gymnast 15 14 No pain 0 0 0 0 0 0 0
Gymnast 16 18 No pain 0 0 0 0 0 0 0
Gymnast 17 20 No pain 0 0 0 0 0 0 0
Gymnast 18 12 No pain 0 0 0 0 0 0 0
Gymnast 19 14 No pain 0 0 0 0 0 0 0
AGE = age of gymnast given in years, PAIN = low back pain, AARA = anterior apophyseal ring injury, LYSIS = spondylolysis, LISTH =
spondylolisthesis,
DDD = degenerative disk disease, HERN = disk herniation with cent referring to central, pro referring to protrusion, and ext referring to
extrusion, STRAIN = muscle strain with rot referring to the rotatores muscle, EDEMA = bone marrow edema, and #/# = disk space
level (please note that 12/1 refers to T12/L1 and 5/1 refers to L5/S1)
506

was done using the two-tailed unpaired t-test, since the

groups were unpaired and the data were interval [15, 16]. A
p-value ≤0.05 was considered statistically significant.

Results

Imaging and clinical results

The results for each female gymnast are presented in

Table 1. The most common MRI findings among all the
gymnasts were AARA injuries (Fig. 1) and moderate
degenerative disk disease. MRI findings that occurred only
in the gymnasts with current low back pain were spondy-
lolisthesis, spondylolysis (Fig. 2), muscle strain, and
bilateral pedicle bone-marrow edema (Fig. 3).
Evaluation by the primary care sports medicine physi-
cian revealed four gymnasts with current low back pain
affecting their training at the time of the MRI exam. Two of
these four gymnasts felt the pain had a significant effect on
their current training, whilst the other two felt the pain had
only a mild effect on their current training.
There were 15 gymnasts without current back pain Fig. 2 Seventeen-year-old elite-level female gymnast with current
(control group). Seven of these 15 asymptomatic gymnasts low back pain and with bilateral L5 spondylolysis. The sagittally
oriented STIR MRI image readily shows L5 spondylolysis (black
had a history of previous low back pain with no current arrow) as well as adjacent bone marrow edema extending into the
back pain and a currently normal training regimen, whilst posterior elements (white arrows), including the left L5 pedicle.
eight of these gymnasts had no history of previous low Degenerative disk disease is present at L4-5 and L5-S1 (arrow-
back pain or findings of current back pain. heads)
Other findings included only one gymnast with a past
history of low back pain who had a normal MRI. All other Statistical results
gymnasts with a history of past (not current) low back pain
had evidence of either degenerative disk disease or an The ages between the pain group and the no-pain (control)
anterior apophyseal ring injury. group were compared using the two-tailed unpaired t-test.
The pain group contained four gymnasts with a mean age
of 16.5 years and a standard deviation of 1.0 year. The no-
pain group contained 15 gymnasts with a mean age of 15.6

Fig. 1 Fifteen-year-old elite-

level female gymnast without
current low back pain and with
an anterior apophyseal ring
avulsion injury at L5. a Sagit-
tally oriented fast spin echo
proton density weighted MRI
image demonstrating the injury
(black arrows). The avulsed
apophyseal ring can also be seen
(white arrow). Moderate degen-
erative disk disease is present at
L4-5 and L5-S1 (black arrow-
heads). b Sagittally oriented
STIR MRI image demonstrating
mildly increased signal intensity
adjacent to the avulsion injury
(white arrows). Moderate de-
generative disk disease is pres-
ent at L4-5 and L5-S1 (black
arrowheads)
 507

spondylolysis. The pain group contained 3/4 gymnasts

(75%) with spondylolysis, and the no-pain group contained
0/15 gymnasts (0%) with spondylolysis. Results of Fisher’s
exact test gave a subject population of 19, a smallest
value=0, a smallest marginal value=3, and a double-sided
p-value of p=0.0004. The p-values obtained using Fisher’s
exact test for the findings of AARA, spondylolysis,
spondylolisthesis, degenerative disk disease, disk hernia-
tion, and bone-marrow edema are given in Table 2. The p-
value results indicate that the findings of spondylolysis and
spondylolisthesis being confined to the symptomatic group
were statistically significant.
The bone-marrow edema p-value of 0.09 indicates that
the finding of bone-marrow edema may or may not be
statistically significant between the two groups (pain vs no-
pain). That is, more data need to be collected to determine
if there is a statistically significant difference. This would
also hold true for muscle strains, since this finding was seen
in only one gymnast.
Statistical analysis of the rest of the MRI findings
(AARA, degenerative disk disease, and disk herniation)
indicated that there was no statistically significant dif-
ference in their distributions between the two groups.

Discussion
Fig. 3 Fifteen-year-old elite-level female gymnast with current low The most common abnormalities were moderate degener-
back pain and with bilateral L3 pedicle bone marrow edema. ative disk disease and AARA injuries. In our study, these
Sagittally oriented STIR MRI images of the left L3 pedicle
demonstrating very intensely increased signal consistent with findings were present in 10 of 19 gymnasts (53%). These
bone-marrow edema (arrow) two findings (degenerative disk disease and AARA
injuries) were coexistent at the same spinal level in eight
out of nine gymnasts (89%) with an AARA injury. This
years and a standard deviation of 2.6 years. The test would imply a relationship between AARA injuries and
statistic (t) was 0.6641. The degrees of freedom were 17. eventual development of mild to moderate degenerative
The p-value obtained was p=0.516. Therefore, there was no disk disease at the same level. Since previous work has
statistically significant difference between the ages of the shown that radiographs are initially normal at the time of an
two groups. AARA injury (with the classic radiographic sign of a
The two-tailed unpaired t-test was also used to determine lucency undercutting the anterior apophyseal ring not
if there was a statistically significant age difference for each becoming apparent until a few weeks to months after the
of the MRI findings (regardless of symptoms). For injury), then the AARA injuries occur prior to the
example, are older elite/Olympic-level gymnasts more development of the degenerative disk disease at the level
likely to have degenerative disk disease than younger elite/
Olympic-level gymnasts? All comparisons of age for each Table 2 Results of fisher’s exact test comparing the pain versus
of the MRI findings yielded p-values much greater than no-pain (control) groups
0.05, indicating no statistically significant difference in age
MRI finding P-value
between those with a particular finding and those without
that finding. AARA 0.3
The presence of AARA, spondylolysis, spondylolisthe- Spondylolysis 0.004
sis, degenerative disk disease, disk herniation (focal disk Spondylolisthesis 0.004
extrusions and protrusions), muscle strain, and bone- Degenerative disk disease 0.2
marrow edema in the pain group versus the no-pain Disk herniation 1.0
(control) group was compared using Fisher’s exact test Muscle strain 0.4
(since the groups were unpaired, the group sizes were Bone-marrow edema 0.09
small, and the data were nominal). For example, the
following evaluation was done for the MRI finding of Please see the legend for Table 1
508
of the AARA injury [10]. These avulsion injuries (AARA
injuries) are fairly common in the elite-level female
gymnast. Since degenerative disk disease develops in
nearly all gymnasts who have sustained an AARA injury,
the MRI finding of an AARA injury would usually be an
important predictor of future degenerative disk disease,
though the clinical relevance of mild-to-moderate degen-
erative disk disease in elite-level female gymnasts remains
uncertain.
Does early mild to moderate degenerative disk disease in
the elite female gymnast lead to increased back pain or
other back problems as an adult? A recent study found that
top-level athletes did not have increased low back pain
relative to age-matched non-athletes over an 11–16 year
follow-up period [18]. However, this study was not
confined to female gymnasts, and did not compare female
gymnasts with initially normal versus initially abnormal
imaging studies. Therefore, an area of potential future
research would be to perform a long-term follow-up study
containing two cohorts of elite female gymnasts, one
cohort with initially normal MRI exams, and a second
cohort of gymnasts with initially abnormal MRI exams.
The long-term follow-up studies could include evaluation
for continued or new low back pain, other back problems,
and a repeat MRI to examine for progression and/or
interval development of degenerative disk disease. A
project such as this might help answer the question of
clinical significance of early mild-to-moderate degenera-
tive disk disease in the elite female gymnast.
A major limitation of our study was the small number of
gymnasts available for this study. Unfortunately, at any
given time within any given country, there are only a few
female gymnasts who are at the caliber of Olympic
competition. This does not mean that research of these
athletes should be avoided (due to low numbers); however,
the results should be taken with some caution given the low
number of gymnasts available for evaluation.
Since this was not a randomized study, another limitation
was selection bias. Only elite/Olympic level female gym-
nasts were studied; therefore, our results may not be
applicable to the general population or even to an age-
matched general population.
An additional limitation in the study of elite athletes is
potential underreporting of symptoms (such as perfor-
mance-inhibiting back pain), although this would have
probably decreased the differences between the symptom-
atic and asymptomatic groups, thereby supporting our
incorrect initial hypothesis (that MRI would demonstrate
the same types of abnormalities in both the symptomatic
and asymptomatic elite/Olympic-level female gymnasts). If
underreporting did occur in our study (as a systematic
error), then future studies correcting for potential under-
reporting would be expected to demonstrate more differ-
ences in MRI findings between the symptomatic and
asymptomatic populations. Finally, to our knowledge,
there is no current solid research demonstrating that female
elite gymnasts have a higher threshold of pain than any
other population that would lead to underreporting of
performance-inhibiting back pain.
In our current study, the findings isolated to symptomatic
gymnasts (current low back pain) were spondylolisthesis,
spondylolysis, bilateral pedicle bone-marrow edema, and
muscle strain. Of these, only the findings of spondy-
lolisthesis and spondylolysis in the symptomatic group
were found to be statistically significant when compared
with the control group.
In regard to spondylolysis, two previous studies have
found asymptomatic spondylolysis in athletes [7, 8].
Unfortunately, these studies are not directly comparable
to this study. One of the previous studies included one
female gymnast with asymptomatic spondylolysis; how-
ever, she was not reported to be an elite-level gymnast [7].
In another study reporting asymptomatic spondylolysis in
athletes, the paper does not report the athletes’ sports.
Perhaps gymnasts with spondylolysis were all symptom-
atic in our study, since we were evaluating only those
gymnasts at a high level of competition. At a high level of
women’s gymnastic competition, a great deal of stress and
a significant requirement for spinal stability are placed on
the spine during training and competition. Previous studies
have also shown that spondylolysis and spondylolisthesis
can be associated with back pain and that, in general, when
seen in an athlete with back pain they are significant [7, 8].
Our study indicates that this association can be specifically
extended to include elite-level female gymnasts.
In regard to this study’s findings found only in the
symptomatic gymnasts, radiographs can readily identify
most cases of spondylolysis and spondylolisthesis; how-
ever, radiographs would not have detected the bilateral
pedicle edema or muscle strain found in our study. Since
bilateral pedicle bone-marrow edema is reported to be a
precursor of spondylolysis [19], MRI would be of benefit
in detecting bilateral pedicle bone-marrow edema in the
elite-level female gymnast with back pain, so that early
appropriate treatment could be instituted in order to
possibly prevent development of spondylolysis. In addi-
tion, some authors have even recently advocated the use of
MRI as a first-line imaging modality for diagnosis of
adolescent spondylolysis (especially for early acute spon-
dylolysis, when radiography is unreliable) [20].
In comparing this study with previous studies, the only
direct comparison possible is the percentage of elite/
Olympic-level gymnasts with an abnormal MRI [6, 8].
Both this study and a previous study found that approxi-
mately two-thirds of Olympic-level gymnasts have an
abnormal MRI [6]. This does help provide some extrinsic
verification to our study.
In closing, future studies that would be of benefit are: (1)
a long-term follow-up study comparing progression of
back symptoms between gymnasts with initially normal
and initially abnormal MRI exams, with an emphasis on
those with AARA injury-related degenerative disk disease
 509

(since the prognosis of mild-to-moderate degenerative disk
disease in the elite female gymnast is not known), and (2)
future larger studies (perhaps multinational studies or meta-
analysis studies in order to gain a larger number of patients)
to identify any active elite-level female gymnasts who
might have asymptomatic spondylolysis—since this has
been reported in other sports—as well as to better evaluate
the clinical and statistical significance of bone-marrow
edema in the spine.
Finally, our initial hypothesis of similar abnormalities in
symptomatic and asymptomatic elite-level female gym-
nasts was not confirmed by this prospective controlled
study. The findings of (1) spondylolysis, (2) spondy-
lolisthesis, (3) bilateral pedicle bone-marrow edema, and
(4) muscle strain were seen only in the symptomatic elite
female gymnasts. Therefore, when any of these four
findings are found in the elite female gymnast, they should
be considered as a likely source of the gymnast’s signif-
icant back pain.

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