This week I wanted to share an injury situation that recently came up with one of our gymnasts, and touch on some areas I’ve been thinking on the last few months. I really think people in gymnastics would benefit from hearing and thinking about her story. Don’t worry, both her mother and her said it was okay if I posted about it. After discussing it with them they agreed it was important information to share for other gymnasts and coaches out there. The situation is certainly a bummer as I will talk about, but I think there are some larger concepts behind the story that a lot of coaches/gymnasts/parents/medical professionals could learn from to help other gymnasts out there. I had another post lined up for this week but I thought this one was more important to get out. So, I did a little late night 2 am writing session (thank you Dunkin Donuts) and put this together for and early post this week.
His the story I keep referring to. One of my level 8 gymnasts unfortunately injured her back about a month ago tumbling on floor. She was doing a back 1 1/2, and landed in quite the awkward position. She told me (I wasn’t at the meet) she landed with upper body and upper spine forward (made the whole 1 1/2) her lower back and legs slightly behind her in the twist (made 1 1/4 ish). This caused her to be in a really funky position with her lower back torqued, and she ended up giving her left lower back a pretty good tweak. From what she told me it appeared to just an awkward landing and nothing more. But she noticed that while waiting for the next event in the meet her back continued to get increasingly stiff/sore. When she tried running down runway for her next vault touch she noticed more stiffness and pain in her back.Due to these pain levels, it was decided that she should just call it a day for the meet and ice.
Keep in mind that up until this point where she landed wrong on floor, she had not complaining any pain in her lower back during training or practice. She was training 5 days a week just like the rest of our team going through routines, conditioning, and practice for season like normal prepping for the big meets. She was, however, showing signs of the chronic anterior tilting that many gymnasts have and that I have talked about on the site. We were stressing that she had to start learning to use her shoulders and hips more than her back during her skill work because the hyper mobility of her back was noticeable. We were also harping on the need for core stability work to stress working in a neutral spine position. She did have a lot of the components commonly seen in gymnasts contributing to this type of posturing problem, and the associated movement pattern problems like hip flexor mobility/tone issues, improper firing patterns, the noted core stability issues, and some thoracic/shoulder blade stability issues. She has been following the built-in pre-hab program proactively as the rest of our girls do since the summer. Over the course of the next few days following the meet she noticed it was hard to get in and out of bed, sit/walk at school, and she was still feeling a good amount of pain.
Due to the ongoing pain it was time for a doctors visit to make sure nothing too serious had happened. The doctor ended up suggesting she start physical therapy and also scheduled her for an MRI, due to the xray showing possible spine issues. She obviously stopped gymnastics practice, and ended up starting Physical Therapy with me in the clinic. Things were kept to the basics in PT until we heard back from the MRI results. What the MRI ended up showing was that she had pretty involved loss of disc height at L4/L5, with a mild/moderate disc bulge, and a stress fracture in her middle lumbar spine from one of her spine segments being pressed forward (spondylolysis). With these findings, she was prescribed a rigid brace to be worn for 24 hours per day except when she showered or was in the clinic getting PT with me. After this 6 weeks, they will be doing another xray/MRI of her back to see what it looks like then if all looks good wean her down for long she has to wear the brace each day. From here the doctors will look at the possibility of using a soft brace, then eventually when all is healed to not wean off a brace down the road. Only after this will she be able to consider going through more rigorous PT to get her back to where she can back up to speed for her activity level. At 15 years old this is certainly a lot to have going on in her spine. Needless to say, unfortunately this is going to be a bit of time before she is even allowed to go back to the gym and start doing basics.
Why This Story Is Important
Let me be very clear…this absolutely, 100 percent, in no way is intended to be a story that scares gymnasts and coaches. If you’re a gymnast please don’t take this post as a reason to never to another back handspring. If you’re a coach don’t take it as a reason to put the brakes on all gymnastics that may be dangerous. If you’re a parent don’t go kicking in your gym’s door waving a print out of this article in some poor coaches face, or demand your doctor order and MRI for every gymnast. I love the sport of gymnastics and love being a coach, and think that it’s one of the most amazing sports in the world. It has taught me more than I could ever ask for and honestly has got me to be in the position I am today. I am very grateful for all I had in the sport, the teammates and coaches I met that helped me out, and I wouldn’t change my decision to do gymnastics if I went back and did it again. Actually it is quite the opposite of what people might take this post as. I enjoy coaching and seeing people succeed in gymnastics so much it’s part of the reason I chose Physical Therapy as a career, it’s the reason I chose to keep coaching as a part of my life, and honestly it’s why I decided to start this blog. It’s all driven to find out ways to help gymnasts reduce their injuries, increase their performance, and get everything out of the sport they want.
I do, however, think this touches on a very important concept for the gymnastics world to spend some time thinking about. The point of this post and the only major thing I hope readers to take away from it is that she really was experiencing no lower back pain in the months before this awkward floor landing. She was showing signs of many mechanical and skill related issues that are linked to lower back pain in gymnastics. But, she was going about her training and doing skills like the rest of our team. As the title says, just because there is no pain does not mean that there is not a problem. After thinking a lot about her situation and also hearing about what her doctor thought about this injury, it likely that her underlying stress fracture and disc problems were definitely present well before she fell on that floor pass, and well before the summer when pre-hab started to be part of our daily training. There is however a possibility that an underlying stress issue was pushed over the edge by the fall. Although it can’t be proven looking back on it, I would be hard pressed to believe that one wrong tumbling pass landing caused and instant stress fracture, and the disc problems. We’ll never know, but the more likely explanation is that these issues were the result of many complex problems that existed as she trained through the years even though she wasn’t having pain. 
Without going into it now, there is quite a bit of good evidence from Stuart McGill’s work that supports the notion that most back injuries (always exceptions) occur from repetitive sub maximal loading and prolonged low-level stress on spine structures. Overtime with repetitive motions, lacking core stability/control, and prolonged stress it can set someone up for something to become an issue. More on this interesting stuff as it relates to gymnastics down in posts to come. It is definitely plausible that the awkward fall absolutely caused her lower back to get strained, abnormally load the spine joints, cause some tissue damage, send muscles into spasm, and made those issues a bit worse creating such high pain levels the following days. This would definitely explain some of her acute pain. The disc problems and stress fractures that were likely flying under the radar however, that’s more the relevant part. Those are more the concerning issues that possibly developed over time from training, and is what most lead to the doctors to choose bracing and such a long recovery timeline (my thought, I don’t want to speak for them). In a way it is almost a blessing in disguise that made her be able to get the MRI, showing the problems in her lower back. Her, her mother, and I spent a lot of time discussing in the clinic the possible outcomes if this hadn’t been caught.
I personally feel as a former gymnast, a coach, and a physical therapist who helps take care of these problems, this concept is absolutely huge to be thinking about. I think this concept echoes through many other overuse and progressive issues we see commonly in gymnastics like shoulder pain, wrist pain, knee pain, and foot/ankle/Achilles pain. Gymnasts may be showing signs associated with Achilles damage with short landings, flat feet, and poor calf mobility that may be flying under the radar to an Achilles injury. The same situation with different variables could be argued for the knee, shoulder, wrist, and other situations. The need to look at some of these factors and build in more preventative measures is one of many ways to try to stay ahead of issues that may be lurking over time.
Examples like this are why I spend so much time reading, research, learning, thinking, talking with other professionals/coaches, breaking down, and trying to apply concepts of injury prevention to be imbedded in our training as a pre-hab program. From what I have read and learned from other people working in the field of gymnastics/medical area so far, there seems to be common ground on this thinking (although again I don’t want to speak for them).
A Few Things to Remember
I wanted to make sure I touched on a few important things related to trying to stay ahead of injuries in the sport . First off being a former gymnast and being a coach I completely understand that there is an inherent risk to doing gymnastics (let alone any sport). By choosing to participate in the sport of gymnastics and especially with high level competition, we sign the dotted line knowing a certain risk of injury is present. Second, I understand the area of investigating and trying to prevent injuries in the sport of gymnastics is a monstrously complex idea. In the last 6 months as I have really put a lot of time into the website to help gymnasts with injuries they may be facing. I have encountered quite the “Pandora’s Box” effect in the process. It seems that every time I learn more, talk with other people, or put the pieces together to help a gymnast out with their problem I always have the feeling of my head buzzing. The sport, breaking down the movements, trying to figure out the problems, and trying to create preventative strategies is all extremely complicated that requires a consistent team effort. This simply points to the fact that I know there is a lot going on, and it is hard to say that anything less than a very multidimensional approach working all at once will help (pre-hab programs, quality coaching, quality progressions, proper mental/physical preparation, and so on). Third, I by no means have all the answers to dealing with all the issues that come up within the sport. In many cases it is hard to know exactly what all the factors to a problem is, and its also really hard to prevent due to how gymnastics is.
I’m quite aware that there is most likely no amount of pre-hab in the world that would have saved her from landing wrong and tweaking her back. Maybe some more progressions and technique work during practice sure, but again that is hard to know for sure. Gymnastics is a demanding sport and with that comes quite the complex piece of trying to attack injuries that are common. In my mind however, I think this example can speak to how important integrated pre-hab and injury prevention models are for our daily training habits, along with continuing to learn and become more educated. I’ve learned and picked up more new information about gymnastics injuries in the last 6 months related to training/coaching than I think I have in the two years by talking to a lot of people.
As I have said in the past, there are plenty of awesome coaches and programs that are already handling injury prevention concepts really well. To them I give them a high-five and say keep up the good work. In the last month or so I have been sinking my teeth into as much material as I can related to the lower back and gymnastics biomechanics.
Concluding Thoughts
I’m sure people reading this have seen similar situations play out, I definitely know this story personally because it was me in high school (no one else’s fault but my own believe me). In my mind, I think that there is a solid place in training for preventative techniques that may affect a problem the lower spine some of which being addressing imbalances around the spine. Investigating core stability, thoracic mobility, hip mobility, and bridge position capabilities are a few in terms of the lower back. It’s not the coaches job to act as a medical professional, just as it’s not the medical professionals job to come in and tell your team how to do gymnastics. However it can be a team approach using all these resources to provide the best gymnastics experience for the athlete. Along with this regularly teaching basic core stability, taking time to incorporate pre-hab into training, stressing proper jumping and landing mechanics, encouraging proper strength training to tolerate the forces of gymnastics, teaching proper mechanics and progressions, managing the beginning signs or a mechanical problem/injury, addressing factors related to the sport/equipment, and many more factors can all have their important role.
Acute injuries are going to happen, believe me I know. If a grip rips in half and you are sent star fishing through the area to the mat, if you miss your hand on a stutz and wreck yourself, or if you miss your foot and eat it on beam, that’s called “the nature of the beast”. However these progressive and overuse injures that keep rearing their ugly head may have some good ways to be addressed during an integrated pre-hab model during training and in conjunction with the other important aspects I noted. There are no easy answers to the issues in the sport, nor do I have the answers to all the questions that come up. Some of it does , yes, boil down to the sport predisposing some degree of injury. I simply wanted to share this story as it made a pretty significant impact on the work that I am doing with other people in the field. More importantly I really to make people think a bit. Dr. Josh Eldridge and I did another podcast discussion for Gymnast Care last week that dove into this story and some of the other issues we both think are important. It should be out in the next month or so. Teaching the gymnasts about listening to their body, proper rest and recovery, proactive injury management, and proper progressive training are all crucial. it takes a team approach and everyone being on the same page.
Just to be sure it’s clear, this are just my opinions based off of what I have thinking the last few months and again by no means do I want to scare people out of gymnastics. I’m sure in good time this gymnast will recover from her injury and be back in the saddle doing gymnastics. Not every gymnast gets unfortunate injuries like this, and like I said I’m sure many programs are doing fantastic with injury prevention. I’m not sitting behind my desk at home shaking my fist at anyone, I’m just trying to open the door for some ways to help. I’m sure this post will generate some chatter in the gymnastics community and I may even get some cranky finger wags my way but hey comes with the territory. Just some more ways to get feedback and learn. My goal with a lot of the work I do is to look at ways for how we can keep gymnasts as safe as possible, so that they can take all the great benefits from the sport thousands of people have seen. No one is going to gain a lot of great things gymnastics can offer sitting out because of an injury. I just want to offer the situation for readers and highlight some points that have driven me to want to be more proactive injuries in the sport, as well as try to increase the performance of the athletes I work with. That’s all for now,
Dave
I'm a Physical Therapist at Bay State Physical Therapy in Salem MA, a women's optional gymnastics coach for North Shore Wildcat's in Beverly MA, and was also a competitive gymnast for the majority of my life. I received my doctorate in Physical Therapy along with my minor in Psychology in 2013, and look to obtain my Certified Strength and Conditioning title in the upcoming year. I created The Hybrid Perspective to offer my opinions/thoughts on the benefits of connecting Physical Therapy and Gymnastics. I look to address common patterns of dysfunction and injury/pain for gymnasts, educate people about gymnastics based pre-hab to possibly reduce injury, help maximize gymnast's performance, and gain knowledge myself from those involved in the sport. Feel free to share, comment, and offer your experiences through the site. 
The Hybrid Perspective : Linking Gymnastics & Physical Therapy 