• Disciplines: acrobatic, artistic, gymnastics for all, parkour, rhythmic, tumbling, and trampoline ( Tables 90.1 to 90.5 )

    • Olympic disciplines: artistic, rhythmic, trampoline

    Table 90.1
    Acrobatic Gymnastics (Men and Women)
    Events Levels
    Women’s pairs
    Men’s pairs
    Mixed pairs
    Women’s group
    Men’s group
    Junior Olympic Elite
    Levels 1–10
    Competitive levels: 2–10
    Future Stars

    Table 90.2
    Artistic Gymnastics
    Events Women’s Programs
    Uneven bars
    Floor exercise
    Xcel Program: Competitive Recreation Tract Junior Olympic Elite
    5 Levels: Bronze–Diamond
    All levels competitive
    Levels 1–10
    Competitive levels: 2–10
    Talent Opportunity Program (TOPS 7–10 years old)
    HOPES (10–12 years old pre-elite)
    Junior Pre-Elite
    Junior and Senior International
    Events Men’s Programs
    Floor exercise
    Pommel horse
    Still rings
    Parallel bars
    High bar
    Xcel Program Junior Olympic Elite
    3 Levels: Bronze–Gold
    All levels competitive
    Levels I–X
    Competitive levels: IV–X
    Future Stars Program
    Junior National Team
    Senior Elite Team

    Table 90.3
    Rhythmic Gymnastics (Women Only)
    Events Programs
    Xcel Program Junior Olympic Elite
    Levels A–D
    Competitive levels: A–D
    Individual and group competitions
    Levels 1–8
    Competitive levels: 3–8
    Individual and group competitions
    Future Stars Program
    Individual and group competitions

    Table 90.4
    Tumbling and Trampoline (Men and Women)
    Events Levels
    Double minitrampoline
    Synchronized trampoline
    Junior Olympic Elite
    Levels 1–10
    Competitive levels: 1–10
    First competitive level: 1
    (except synchronized trampoline: level 10)

    Table 90.5
    Gymnastics for All (Men and Women) and Parkour
    Noncompetitive Competitive HUGS (Special Needs Program) Parkour
    Exhibitions and Shows Power Team: Levels 1–10
    Acrobatics and Tumbling
    USA Gym for Life
    Has both recreational and competitive options Newest discipline
    Only international-level competitions

  • Over 169,000 competitive gymnasts register yearly with USA Gymnastics, and up to 5 million recreational gymnasts in the United States.

    • USA Gymnastics current national governing board and oversees the majority of competitions within the United States.

      • New nationwide governing boards for competitive gymnastics are being founded and may change the landscape of gymnastics within the United States

  • More than 70% are female artistic gymnasts


  • Injury rates: vary greatly depending on the level of the gymnast and hours spent training

    • 0.687–2.859 injuries per 1000 hours of training

    • 6.07–9.22 injuries per 1000 athletic exposures in collegiate athletes

    • 42.6–106.2 injuries/1000 registered gymnasts in Olympic-level gymnasts (artistic, rhythmic, trampoline)

  • Higher incidence during dismounts and floor exercise in women and during vaulting in men

  • Contributing factors:

    • Poor landing technique, including landing short

    • Landing with overly upright posture, decreased knee flexion, and relative joint stiffness

  • Sprains most common, followed by strains

  • The ankle/foot is the most commonly injured body part, except in nonelite male gymnasts and acrobatics (where it is the hand/wrist)

  • Competition injury incidence approximately two times the practice incidence

  • High incidence of growth plate injuries because of an immature skeletal system

  • Injury risk factors:

    • Larger size

    • Rapid growth

    • Training for >15–20 hours/week

    • Life stress

  • Gymnasts are both lower and upper extremity weight-bearing athletes; therefore, injuries incurred during gymnastics participation are comprehensive ( Table 90.6 ).

    Table 90.6
    Differential Diagnosis of Gymnastics Injuries
    Lower Extremity Injuries
    Foot Base of the fifth metatarsal avulsion fracture
    Base of the fifth metatarsal apophysitis (Iselin’s disease)
    Calcaneal apophysitis
    Calcaneal fat pad contusion
    Calcaneal stress fracture
    Lisfranc injury
    Stress fractures: navicular and metatarsals
    Toe fractures
    Turf toe
    Ankle Anterior and posterior ankle impingement
    Distal fibular Salter–Harris I fracture
    Ankle sprains: high, lateral, and medial
    Os trigonum fracture
    OCD of the talar dome
    Osteochondritis dissecans-talus
    Posterior tibialis tenosynovitis
    Knee ACL tear
    MCL/LCL sprain/tear
    Meniscal injuries
    Osgood-Schlatter syndrome
    Osteochondritis dissecans of the MFC
    Patellofemoral syndrome
    Patellar subluxation/dislocation
    Sinding–Larsen–Johansson syndrome
    Hip Acetabular labral tear
    Femoral acetabular impingement
    Femoral stress fracture
    Hip instability/hypermobility
    Upper Extremity Injuries
    Hand/Wrist Fractures related to grip lock
    Ganglion cysts
    Gymnast wrist
    Scaphoid fractures/stress fractures carpals
    Scaphoid impaction syndrome
    Scapholunate dissociation
    TFCC tears
    Ulnar impaction syndrome
    Elbow Elbow dislocations
    Medial epicondyle apophysitis
    Medial epicondyle avulsion fractures
    Osteochondritis dissecans of the capitellum
    Ulnar collateral ligament injuries
    Shoulder Proximal humeral epiphysitis (Little Leaguer’s shoulder)
    Impingement syndrome
    Labral tears
    Multidirectional instability
    Rotator cuff strain/tears
    Shoulder dislocations/subluxations
    Head Concussions
    Cervical Spine Cervical fractures
    Cervical strain
    Lumbar Spine Discogenic back pain
    Facet syndrome
    Lumbar strain
    Mechanical lower back pain
    Scheuermann disease
    ACL, Anterior cruciate ligament; LCL, lateral collateral ligament; MCL, medial collateral ligament; MFC, medial femoral condyle; OCD, osteochondritis dissecans; TFCC, triangular fibrocartilage complex.

Common Injuries and Medical Problems

Mild Traumatic Brain Injury (MTBI)

  • Mechanism of injury: Hitting the head on the mat/floor or apparatus during a fall or dismount.

  • Incidence: One study on club female gymnasts found a 30% lifelong occurrence. An additional study on elite-level male gymnasts had an incidence rate of 5.7/1000 registered gymnasts.

  • Return to play: Several activities are aerial in nature; hence, the graduated return protocol will have to be modified to meet the demands of the gymnast while maintaining their safety until the athlete has been fully cleared.

Cervical Spine Fracture, Subluxation, and Dislocation

  • Mechanism of injury: Complex aerial and acrobatic nature of gymnastics places athletes at a risk of catastrophic neck injuries. Cervical spine fractures, subluxations, and dislocations can occur through various mechanisms:

    • Landing head first in loose foam pit, on trampoline, or on mat

    • Failure to complete rotation or over-rotating on aerial or salto maneuver

    • Landing on upper back with neck in hyperflexed position

    • Landing on chin or chest with neck in hyperextended position

  • Specific consideration to standard evaluation and treatment:

    • Pediatric cervical spine collar availability

    • Loose foam pit injuries:

      • Foam blocks that fill the pit are easily disturbed, and the athlete is typically buried in the blocks.

      • Avoid jumping into pit to help an injured athlete because the disruption of foam blocks could worsen the injury and make it more difficult to remove the athlete.

      • Considering the difficulty of removing a gymnast with a cervical spine injury from a loose foam pit, physicians, trainers, coaches, and local paramedics should practice emergency removal as part of an emergency action plan.

      • Gently placing a mat into the pit and then using this as a means to reach the athlete is one method to minimize disturbing the foam blocks.

Shoulder Injuries (See Also Chapter 49: “Shoulder Injuries”)

Anterior Dislocation, Labral Tears, and Multidirectional Instability

  • Important to differentiate between instability related to anatomical abnormality vs. generalized ligamentous laxity and multidirectional instability (MDI)

  • Surgical fixation, when appropriate, should take into account the gymnast’s need for stability vs. the range of motion required in competitive gymnastics

Rotator Cuff Syndrome, Impingement, and Tears

  • More common in male gymnasts

  • Rings, high bar, and parallel bars all put substantially increased stress on the shoulder

Elbow Injuries


  • Upper extremity weight-bearing activities can be gradually introduced, once a gymnast has full range of motion (ROM) and strength in the upper extremity and is pain-free.

Ulnar Collateral Ligament Sprain

  • Mechanism of injury: Valgus stress to the medial aspect of the elbow causes traction injury to the ulnar collateral ligament (UCL); may occur acutely because of a fall on an outstretched hand or chronically because of repetitive upper extremity weight bearing.

  • History: Valgus mechanism; may be acute or chronic

  • Physical examination: Findings typical of UCL injuries; evaluate for an increased carrying angle and elbow hyperextension bilaterally, which may be a risk factor for this type of injury

  • Imaging: Radiographs for evaluation of medial epicondylar avulsion fracture or chronic changes of the apophysis. A magnetic resonance imaging (MRI) arthrogram may be needed to determine the degree of ligamentous tear.

  • Treatment: Typically, nonoperative; surgery is reserved for complete rupture of UCL and chronic instability.

Capitellar Osteochondritis Dissecans (OCD)

  • Mechanism of injury: Repetitive weight bearing causes valgus stress with medial elbow tension and lateral radiocapitellar joint compression.

  • History: Gradual onset, elbow pain with weight-bearing activities; pain relieved by rest; decreased elbow extension; in more advanced cases, mechanical symptoms of catching and locking.

  • Physical examination: Tenderness to palpation over radiocapitellar joint; effusion may be present; ROM, particularly extension, may be decreased.

  • Imaging: Radiographs: If positive will show a radiolucency or fragmentation within the capitellum, with irregular ossification and crater next to articular surface; MRI arthrogram helps determine integrity of articular cartilage or if radiographs are negative and there is a high clinical suspicion.

  • Classification and treatment of OCD lesions ( Fig. 90.1 ):

    • Type I: No displacement of lesion or fracture of the articular cartilage

      • Treatment: Nonoperative; no upper extremity weight bearing or strengthening activities until radiographs show evidence of healing and pain resolves completely; consider splint or brace if pain not relieved by discontinuing upper extremity weight-bearing activities or to improve compliance

    • Type II: Evidence of fracture of articular cartilage or partial displacement of lesion

      • Treatment: Controversial; ranges from conservative to surgical

    • Type III: Complete detachment of lesion with resulting loose body

      • Treatment: Typically, surgical

        • Osteochondral autologous transplant surgery (OATS) is showing promising outcomes in gymnasts, including improved return to sport with type III lesions

    Figure 90.1, Capitellar osteochondritis dissecans.

  • Complications: Loss of ROM, degenerative changes, chronic pain; can be career ending; imperative to identify these early in order to minimize complications; 40% of lesions in female gymnasts noted to be bilateral, highly consider bilateral evaluation given the incidence. Considering severity of outcomes in gymnasts with high-grade lesions, maintain a high index of suspicion for this entity in a gymnast who presents with chronic elbow pain even with normal x-rays.

Grip Lock

  • Mechanism of injury: When gymnast performs circling elements on uneven bars or horizontal bar, overlapping of leather grip against itself causes grip to lock or catch in place. The hand remains stationary as body continues to swing, causing forearm to “wrap around the bar” and fracture.

  • Evaluation and treatment: Appropriate for type of fracture(s)

  • Prevention: Regular replacement of grips as leather stretches out over time; routine checks to ensure that grips are not long enough to overlap around bar. Avoid sharing of grips between gymnasts. Use caution if gymnast has been training on larger-diameter bar and then switches to smaller-diameter bar.

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