Nicole Ellis, DPT, BS
Performing Arts Medicine Outreach
The sport of gymnastics receives a lot of attention in the year surrounding the Olympics. The entertainment of the sport in part comes from watching seemingly small women use power and flexibility to achieve such great heights. The general public may question how gymnasts achieve such contortion-like positions and perform unique combinations of powerful and graceful skills. Gymnasts are able to perform such amazing skills because of the delicate balance of strength and flexibility they achieve with their training. Gymnastics is a sport in which specialization occurs very early in childhood. Gymnasts train several hours a day, 5-6 days per week starting at a young age. Early specialization of the sport can potentially lead to higher incidence of injury. However, in the sport of gymnastics, early specialization is a necessity. One of the more common injuries occurring in gymnasts is low back pain. Gymnastics requires athletes to repetitively load the spine in hyperextended positions putting increased force and stress through the spinal structures. Sports that require hyperextension of the spine and rotational movements have been shown to lead to higher rates of back injuries.1
The majority of back injuries occurring in gymnasts occur in the lumbar spine. The spine is divided into 4 regions; cervical, thoracic, lumbar, and sacral (see figure a). The vertebra in each region of the spine vary slightly, taking on different forces depending upon movements being performed. The spine also has curvature patterns that develop throughout early childhood. The curves of the low back spine are as follows: cervical lordotic, thoracic kyphotic, lumbar lordotic, and sacral kyphotic. These curvature patterns help to distribute forces appropriately throughout the spine. It is common for gymnasts to demonstrate a hyperlordotic curvature in their lumbar spine secondary to postural deficits, strength imbalances, and tight musculature.2 These imbalances can potentially lead to injury to the spine, and is referred to as lower cross syndrome (see figure b.).3
As young gymnasts develop, they will go through periods of growth in which their flexibility may change. During these growth periods, flexibility may be reduced secondary to bone growth being quicker than muscle lengthening. These periods of growth are critical time points for flexibility development.2 One major risk factor for lumbar spine injury is referred to as hinge theory. Hinge theory describes when a gymnast is achieving the necessary hyperextended positions at one “hinge” point in the spine. Factors leading to a gymnast developing a hinge include decreased shoulder flexibility and hip flexor flexibility. Gymnasts with restricted global extension will have to compensate by hinging at the lumbar spine. This leads to increased stress at the hinge point, which may develop into injury with high repletion and high forces.
In addition to hinge theory, there are several factors that predispose gymnasts to low back injuries. These factors include the high intensity and high repetitions completed at practice, performance of rotational and hyperextension skills, strength imbalances, and incorrect technique.1 Common back injuries sustained by gymnasts include spondylolysis, spondylolisthesis, muscle strain, and injury to the intervertebral discs. These injuries may present with slightly different symptoms. Back pain in all athletes, specifically gymnasts, should never be ignored. If a gymnast is complaining of pain for longer than 2 weeks, the athlete should be referred to a medical professional for a full evaluation. When being evaluated, the healthcare professional will take a full medical history, complete a full objective evaluation, and potentially order imaging if appropriate and necessary.
Spondylolysis is one of the most common injuries sustained by these athletes. A spondylolysis is a fatigue fracture of the vertebral arch at the pars interarticularis (see figure c.).3 This fracture occurs from repetitive hyperextension and rotational activities.1,3 A gymnast will have symptoms with skills such as back walkovers, back handsprings, bridges, rebounding skills, dismount landings, yurchenkos, and front walkover/handsprings.3 These skills require a significant amount of hyperextension and/or rotation which will stress the injured structure. A potential consequence of not treating a spondylolysis appropriately is the gymnast developing a spondylolisthesis (see figure d.). A spondylolisthesis occurs when one vertebra translates either anteriorly (forward) or posteriorly (backward) on the vertebra adjacent to it. This can occur as a result of several mechanisms, one being when a gymnast fractures the pars interarticularis on both sides of the vertebra.3 The slippage of one vertebra on another can create more extensive symptoms in addition to localized back pain because nerve and spinal cord compression is possible with this condition. Gymnasts with a spondylolisthesis may also experience numbness and tingling into one or both legs, weakness, and decreased hamstring flexibility. Gymnasts at risk for acquiring either a spondylolysis or spondylolisthesis may demonstrate increased flexibility of the lumbar spine, less mobility in the upper back or thoracic spine, and tight hip flexors.1 Other factors leading to this may be decreased shoulder flexibility and weak gluteal and abdominal muscles.
If a gymnast has back pain for longer than 2 weeks, it is time to be evaluated! The patient can be screened by a physical therapist or go directly to a doctor. The doctor will take a thorough medical history and objective measurements. It is common for a gymnast to have a palpable step-off deformity if a spondylolisthesis is present.1 The physician may order imaging to confirm a diagnosis. Potential images that would be beneficial in the diagnosis of this condition includes plain radiographs (x-rays), bone scan, CT scan, and MRI.
The treatment of a spondylolysis and a spondylolisthesis will be fairly similar. The initial phase of treatment will require the patient to rest from sporting activities and any activity that increases pain. The doctor may provide the patient with a brace to wear for a period of time. The goal of the brace is to help the gymnast maintain a more neutral spine position and decrease stress on the injured structures.1 The athlete will also begin physical therapy treatment. In the situation that conservative management fails, further medical treatment may include epidural steroid injections or surgical intervention if symptoms continue to progress.1
A critical aspect of conservative management of spondylolysis, spondylolisthesis, or any other low back injury is physical therapy. There are several aspects that need to be addressed in order to eventually progress an athlete back to gymnastics. Factors that should be addressed in a rehabilitation program should include core strengthening, glute strengthening, back strengthening, shoulder flexibility, shoulder strengthening, hamstring flexibility, and hip flexor flexibility. The main goal of core strengthening is to develop the core stabilization muscles such as the transverse abdominis and multifidus in order to improve dynamic stability. Core strengthening is crucial in gymnastics in order to support the spine to maintain normal postural alignment when completing various sills. Another important area to focus on is improving shoulder flexibility and strength in order to reduce the risk of hinging at the lumbar spine. Also focusing on hip flexor and glute strengthening will be beneficial in reducing hinging and help to create a more fluid arch throughout the entire body rather than at a hinge point.
The length of time the gymnast will be required to rest will depend on the exact injury the athlete sustained. Depending on the severity of the injury, the gymnast may be out of the majority of practice for 3-6 months. The length of time held from practice will vary depending on physician recommendation and how diligent the gymnast is with following restrictions and completing the rehab program.
Once pain relief is achieved, the gymnast has been medically cleared by the physician and has developed adequate strength and flexibility, she may begin progressing back into gymnastics. The progression back to gym needs to be gradual and skills requiring significant amounts of hyperextension will be added back in last. When progressing back to gymnastics, the first skills to be incorporated will be low-level basics that do not require arching. For example, a gymnast may begin with handstand holds, relevé walks on beam, spotted together leg casts on bars, mini tap swings on bars, and jogging on the tumble track. As the gymnast begins to add new skills in at practice, she and the coach will need to ensure that she is exhibiting global extension and not hinging in the lumbar spine. If the gymnast experiences an increase in pain after a new skill is added, she should discontinue this skill and talk with the physical therapist about how to progress. The coach and physical therapist should work together with the gymnast to ensure safe progressions. Specific skills that should be added in last include back walkovers, back handsprings, bridging, front walkovers, and front handsprings. Rebounding skills and dismount landings will also put increased stress through the spine and therefore should be added in towards the end of the gymnast’s return to participation.
The gymnast should work with his/her physical therapist to develop a core stabilization maintenance program to be completed 2-3 times a week to maintain strength in core, shoulders, and glutes, as well as the flexibility of the shoulders, hip flexors and hamstrings. Depending on the severity of the injury, a gymnast may need to maintain lower repetitions of high impact and hyperextension skills and may need to make adjustments to routines to avoid skills requiring hyperextension.
It is important to remember that every gymnast and every injury is a little bit different. There is no cookie cutter recipe to successfully return a gymnast to full participation following any sort of back injury. Every injury should be taken seriously and should be treated to avoid future complications. The sport of gymnastics is beautiful and awe-inspiring. As health professionals, coaches, and athletes, we need to work to maintain a healthy spine for all of our gymnasts so they can continue to inspire us all with their grace and strength!
1. Metkar U, Shepard N, Cho W, Sharan, A. Conservative management of spondylolysis and spondylolisthesis. Semin Spine Surg. 2014(26):225-229.
2. Sands, W.A., McNeal, J.R., Penitente, G. et al. Stretching the spines of gymnasts: a review. Sports Med (2016) 46: 315-327. doi:10.1007/s40279-015-0424-6
3. Kruse D, Lemmen B. Spine injuries in the sport of gymnastics. Current Sports Med Reports. 2009;8(1):20-28.