Common upper extremity gymnastics injuries and gymnastic specific return to play protocols

Abstract

Young gymnasts use their upper extremities as weight-bearing joints, imparting high repetitive loads onto the growing upper limb. The purpose of this review is to provide orthopaedic and sports medicine clinicians practical information on the etiology, presentation, and treatment of 5 common upper extremity injuries in the young gymnast: (1) “gymnast wrist” (distal radial physeal injury); (2) grip lock (acute radius and ulna fracture); (3) osteochondritis dissecans of the capitellum; (4) medial tensile injuries of the elbow (medial epicondylar apophysitis, medial epicondyle fractures, and partial or full ulnar collateral ligament tears); and (5) glenohumeral instability (including labrum tears). Specific return to gymnastics protocols are provided to guide providers and athletes through safe return to participation following these injuries.

Key Concepts

• 1)Gymnastics is a unique sport in which the arms are used as weight-bearing limbs resulting in distinct injuries.
• 2)Orthopaedic and sports medicine providers should understand these five diagnoses: Gymnast Wrist (distal radial physeal injury and the sequela), Grip Lock (acute radius and ulna fracture), elbow osteochondritis dissecans (OCD), Medial tensile injuries (medial epicondylar apophysitis, medial epicondyle fractures, and partial or full UCL tears), and shoulder instability (including labrum tears) if they will be evaluating gymnasts in their clinic.
• 3)Pre-determined “return-to-gymnastics” protocols may aid successful progression back to training and competition after upper limb injury.

Introduction

Gymnastics is one of the only sports in which the hand and upper limb are weight-bearing and subject to high-energy, repetitive axial loads. The functional demands of gymnastic training and competition predispose the upper limb to characteristic injury patterns, ranging from skeletal trauma to muscular and/or ligamentous injuries. Given the relatively early age of participation, these conditions often affect skeletally immature athletes, raising additional concerns about future growth and longer-term sequelae. The purpose of this review is to provide orthopaedic and sports medicine clinicians background and sport-specific information about the etiology, clinical presentation, and treatment of characteristic upper extremity injuries in the young gymnast. Specific “return to gymnastics” protocols will be provided to aid both patient-athletes and providers for safe and successful return to participation (Appendix B-E).

It is estimated that 4.6 million children participate in artistic gymnastics worldwide, with 746 000 participants in the United States alone [1], [2]. Participation has increased in recent years; in 2021, the number of participants increased 10% compared to the prior year [1]. Generally, gymnasts tend to be young at both novice and elite levels; indeed, the median age of all U.S. Olympic gymnasts prior to the Tokyo Olympics was 16 years [2]. The combination of intense physical demands with a young age of participation leads to a high risk of gymnastic-related injury. It is estimated that 1 in 4 Olympic-level gymnasts will experience a career-ending injury [2].

While the International Federation of Gymnastics recognizes 8 different gymnastic disciplines, the focus of this review will be on men’s and women’s artistic gymnastics. Men participate in 6 events, including vault, pommel horse, still rings, parallel bars, high bar, and floor exercise (Table 1). Women's artistic gymnastics has 4 events: vault, uneven bars, balance beam, and floor exercise (Table 1). As gymnasts develop, they typically progress through levels 1 through 10 of the Developmental Program (previously called Junior Olympics) (Appendix A). In women’s artistic gymnastics, athletes at levels 1 through 5 compete in compulsory routines, meaning that each gymnast performs the same routine for each event per level. In levels 6 to 10, routines are optional; athletes need to meet the requirements of each event at each level according to the “Code of Points” (Appendix A). Beyond level 10 are the Junior and Senior Elite levels, comprised of athletes who represent the United States at international competitions and the Olympics (Appendix A). In addition to developmental and elite programs, the Xcel program allows participation at a more recreational level; levels of Xcel participation include bronze, silver, gold, platinum, diamond, and sapphire, in order of increasing difficulty (Appendix A). While male gymnastic skills and levels are more restricted to athletes of a certain age, female gymnasts do not have these stringent restrictions (Appendix A and Table 2). Training is demanding, and young gymnasts commonly practice 12 to 40+ hours per week depending on their level. Many high-level gymnasts forgo traditional school in favor of home school programs to be able to train 2 or more times per day.

Table 1.

Artistic gymnastics events and training equipment for both women and men.

Gymnastics event and training equipment	Description:	Women’s and/or men’s gymnastics event:
Vault	Components: run, jump on board, strike the vault/table with hands, flip/twist, and landingEquipment: runway, tape measure, springboard, vault table, landing mats	Women’s and Men’s Event
Uneven Bars	Components: mount, skills, dismountEquipment: uneven bars, springboard, landing mats	Women’s Event
Balance Beam	Components: mount, skills, and dismountEquipment: balance beam 4″ wide and raised above the ground pending level, and landing mats	Women’s Event
Floor Exercise	Components: Tumble passes, and in women’s gymnastics dance: leaps, jumps, turns, and choreography and in men’s gymnastics stationary strength skills Equipment: 40 × 40 carpet with a spring floor underneath	Women’s and Men’s Event
Horizontal Bar	Components: mount, skills, and dismountEquipment: metal horizontal bar, and landing mats	Men’s Event
Parallel Bars	Components: mount, skills, and dismountEquipment: fiber glass parallel bars, springboard, landing mats	Men’s Event
Still Rings	Components: mount, skills, and dismountEquipment: rings tower and landing mats	Men’s Event
Pommel Horse	Components: mount, skills, and dismountEquipment: mushroom, pommel horse without pommels, pommel horse with pommels, and landing mats	Men’s Event
Trampoline	Equipment: spring bed, springs, can be inground or above ground, can have a woven or a solid bed, and can be used for training but in other disciplines of gymnastics this is a competitive event	Women and men both use this for training
Tumbl Trak	Equipment/description: a runwaylike trampoline used for training purposes to create less load on the body, has a spring bed/springs, and different lengths/sizes are available based off of the gym’s space, and landing areas are in a foam pit or on a softer mat	Women and men both use this for training
Mats	Description: a landing surface, typically filled with a foam inside to assist with landings to decrease the forces. Mats can vary in width and length.	Women and men both use this
Spotting Block	Description: a large mat that a coach can stand onto elevate themselves anywhere from 1 to 6 feet in the air	Women and men both use this for training

Table 2.

Gymnastics Skills: Each skill is explained further by the event performed on, a description of the skill, the level of difficulty*, and where this can be found in the video.

Name of skill	Event performed on	Description	*Level of difficulty	Time in video:
Nonflight Skills:	Floor, and balance beam	A skill where the gymnast does not have any flight or height off the ground. It would be considered a static element. Examples of a nonflight skills include but are not limited to handstands, cartwheels, forward rolls, backward rolls, bridge, back walkover, and front walkovers to name a few.	Easy	Floor: 52 s to 1 min 37 secBeam: 4 min 55 s
Handstand	Floor, balance beam, uneven bars, parallel bars, high bar, rings, pommel horse	Nonflight skill; a holding position where the gymnast puts all of her/his weight on her/his hands and goes upside down.	Easy-medium	Floor: 51 secBeam: 4 min 36 s
Cartwheel	Floor, Beam	Nonflight skill; a skill where the gymnast the gymnast puts his/her hands down and kicks his/her feet over his/her head	Easy	Floor: 58 secBeam:4 min 40 s
Forward roll	Floor, Beam	Nonflight skill; a skill where the gymnast bends down and tucks and rolls over her/his body.	Easy	Floor: 1 min 2 secBeam: 4 min 45 s
Backward roll	Floor, Beam	Nonflight skill; same as a forward roll but backwards	Easy	Floor: 1 min 6 s
Bridge	Floor	Nonflight skill; an extension-based skill used for stretching	Easy-medium	Floor: 1 min 10 s
Back walk over	Floor, Beam	Nonflight skill, an extension-based skill involving a bridge and kicking over	Medium	Floor: 1 min 13 secBeam: 4 min 55 s
Front walk over	Floor, Beam	Nonflight skill; same as a back walkover only a forward motion	Medium	Floor: 1 min 17 secBeam: 4 min 49 s
Flight skills	Floor or beam	A skill where the gymnast has flight or leaves the ground. It would be considered a dynamic element. Examples of flight skills include but are not limited to back handsprings, front handsprings, and roundoffs, to name a few.		Floor: 1 min 39 s to 2 min 36 secBeam: 5 min 5 s to 5 min 27 s
Round off	Floor, Beam, vault	Flight skill; a cartwheel but with flight and landing with feet together	Medium	Floor: 1 min 39 secBeam: 5 min 5 s
Back Handspring	Floor, Beam, vault	Flight skill; a skill where the gymnast jumps backwards, extends from their spine, has their hands hit the ground and flips their body over to land on their feet	Medium	Floor: 1 min 42 secBeam: 5 min 8 s
Front Handspring	Floor, Beam, vault	Flight skill; same as a back handspring only a forward motion and you take off 1 foot instead of 2	Medium	Floor: 1 min 55 secVault: 5 min 40 s
Flip/salto	Floor, balance beam, uneven bars, parallel bars, high bar, pommel horse, rings	Flight skill; a jump and rotation of the body where the hands do not touch the ground and the gymnast lands on their feet.	medium-hard	Floor: 2 min 7 s to 2 min 10 secBeam: 5 min 12 s
Kip	Uneven bars, high bars, parallel bars, rings	Entry level skill which is used as a building block for other skills	Easy-medium	2 min 40 s
Cast	Uneven bars, high bars, parallel bars	Entry level skill which is used as a building block for other skills	Easy	2 min 45 s
Back hip circle	Uneven bars, high bars, parallel bars	Entry level skill teaching gymnasts how to shift their wrists/hands, backward rotation around the bar	Easy	2 min 50 s
Front hip circle	Uneven bars, high bars	Same as above only a forward circle element	Easy	2 min 56 s
Tap swing	Uneven bars, high bars, parallel bars, rings	Entry level skill to learn how to swing	Easy	3 min 2 s
Giant	Uneven bars, high bars, parallel bars, rings	Encircling element with the body in a mostly straight position	Medium	3 min 26 s
Pirouette	Uneven bars, high bars, parallel bars	Turning your body by changing the position of your hand. This can be a 180° or 360° turn	Medium-hard	3 min 20 s
Release element	Uneven bars, high bars, parallel bars	Letting go of the bar “release” and re-grabbing the bar (same or different depending on the skill/event)	Hard	3 min 8 s
Dismount	Floor, balance beam, uneven bars, parallel bars, high bar, pommel horse, rings	Occurs at the end of the routine and gymnasts try to “stick” the landing.	Easy-medium-hard	Bars: 3 min 34 s to 3 min 47 s
Mount	Bars, Beam, High bar, parallel bars, high bar, and rings	Occurs as the beginning of a routine/the start of the routine.	Easy-medium-hard	Beam: 3 min 51 s to 4 min
Beam Series	Beam	Typically, two skills in a row on balance beam that can be flight or nonflight skills	Easy-medium-hard	5 min 17 s to 5 min 27 s
Jump	Beam and floor	There are many jumps that are in the Gymnastics Code of Points	Easy-medium-hard	Floor: 0.6 to 26 s Beam: 4 min to 4.21
Leap	Beam and floor	There are many leaps in the Gymnastics Code of Points	Easy-medium-hard	Floor: 26 to 40 secBeam: 4 min 21 s to 4 min 27 s
Turn	Beam and floor	There are many turns in the Gymnastics Code of Points	Easy-medium-hard	Floor: 40 to 51 secBeam:4 min 28 s to 4 min 35 s
Tsukahara	Vault	Higher level vault where the gymnast jumps on the spring board, does a round off on the vault table and then flips/twists off the vault	Hard	Timer: 5 min 30 secFlip: 5 min 36 s
Yurchenko	Vault	Higher level vault where the gymnast does a round off with his/her feet landing on the springboard, jumps into a back handspring with his/her hands landing on the vault, and then flips/twists in the air.	Hard	5 min 49 s
Front handspring front tuck	Vault	Higher level vault where the gymnast jumps on the springboard and does a front handspring with his/her hands hitting the vault and then flips his/her body in the air before landing.	Hard	Timer: 5 min 40 secFlip: 5 min 45 s

*Level of difficulty was broken into 3 groups: easy (levels 1-4, Xcel bronze, silver, gold, platinum and considered a “basic skill”), medium (levels 5-8, Xcel diamond), hard (levels 9-10, Hopes, Junior and Senior Elite, Collegiate, and Xcel Sapphire). Please also see the video which shows each skill.

While there are a host of injuries that gymnasts may sustain, there are 5 characteristic upper extremity conditions commonly seen by orthopaedic and sports medicine clinicians in younger patients. These diagnoses include: (1) “gymnast wrist” (distal radial physeal injury); (2) grip lock (acute radius and ulna fracture); (3) osteochondritis dissecans (OCD) of the capitellum; (4) medial tensile injuries (medial epicondylar apophysitis, medial epicondyle fractures, and partial or full ulnar collateral ligament [UCL] tears); and (5) shoulder instability (including labrum tears).

Gymnast wrist (Distal Radial Physeal Injury and Sequela)

Wrist pain affects up to 79% of the gymnasts [4]. Repetitive axial loading on the skeletally immature wrist can lead to injury to the distal radial physis, a condition known as “gymnast wrist.” Risk factors include age between 10 and 16 years (when gymnasts are going through rapid growth), increases in training volume or transitions to higher level of participation, and specific open chain, impact skills: axial loading and forearm rotation on balance beam, wrist hyperextension and ulnar deviation during vaulting, and wrist hyperextension with use of soft mats [5]. Late presentation in more advanced stages of physeal disturbance is common, as gymnasts often believe wrist pain is a “normal” part of their training.

Video 1.

Download video file ^{(119.7MB, mp4)}

A thorough history and examination will often lead to the diagnosis of gymnast wrist. Pain is typically localized over the dorsal radial metaphysis, exacerbated by axial loading. There is reproducible tenderness with palpation or compression of the distal radial physis, worsened by wrist extension. Careful examination will often reveal limited passive and active wrist extension. In advanced cases, the resulting physeal growth disturbance and ulnar overgrowth leads to prominence of the ulnar head or ulnar-sided tenderness.

Plain radiographs are recommended, including posteroanterior view with the forearm in neutral rotation (elbow flexed 90 degrees and shoulder abducted 90 degrees). Between 8% and 85% of gymnasts will have physeal widening, cystic or sclerotic changes, or even premature physeal closure on x-rays (Fig. 1) [4]. While magnetic resonance imaging (MRI) may provide additional information, advanced imaging is not necessary for diagnosis. Ultimately, diagnosis is based upon history and physical examination, and radiographic studies may be “normal” in early stages of gymnast wrist [4], [5].

Figure 1.

Gymnast Wrist X-rays and MRI. 1: Gymnast wrist: AP radiograph depicting distal radial physeal widening with sclerotic and cystic changes consistent with “gymnast wrist”. 2: Gymnast wrist: AP radiograph of same patient taken 2 years later. While there is resolution of the physeal changes, there is concern regarding distal radial physeal arrest and ulnar positive variance. 3: MRI depicting a central arrest of the distal radial physis and concomitant ulnar positive variance; note the distal ulnar physis is open.

Treatment for gymnast wrist is variable, depending upon the severity of symptoms, radiographic findings, and patient-athlete related factors. The mainstay of early treatment is rest, followed by gradual return to activities and longitudinal follow-up. Bracing or cast immobilization for 4 to 12 weeks may be helpful, with serial examinations and radiographic imaging.

Untreated gymnast wrist can have long-term effects, including chronic wrist pain, distal radial physeal arrest, and positive ulnar variance due to ulnar overgrowth [4]. Ulnar positive variance may in turn lead to secondary problems, including but not limited to triangular fibrocartilage complex tears, ulnar impaction syndrome, extensor tendon ruptures, and continued ulnar-sided wrist pain and decreased range of motion as an adult [4].

Gymnast Wrist Return-To-Gymnastics Protocol: Previous clinicians have proposed a 75% reduction rule to guide return to gymnastics after gymnast wrist [5]. The 75% reduction rule explains that gymnasts returning to gymnastics after a wrist injury, should start with a 75% reduction in volume of gymnastics skills and elements compared with preinjury level [5]. Using this concept, the authors propose a specific return-to-gymnastics protocol for gymnast wrist, beginning with traction forces and hanging skills, progressing to nonimpact closed-chain exercises, and ultimately to open-chain exercises, including axial loading, plyometric, and “flight” skills. Appendix B provides details of the gymnast wrist return-to-gymnastics plan. The specific protocol was created from a through literature review and expert opinion, drawing from experience of other sports and applying them with specificity to gymnastics.

Prior to the start of the protocol, baseline strength and range of motion measurements should be taken. Ideally range of motion and strength should be within 50% to 75% of the unaffected side prior to starting the return-to-gymnastics protocol. Within this protocol, repetitions are initially limited, and the gradual progression also allows time to restore strength, range of motion, and stability. Of note, because vault, floor exercise and pommel horse are most commonly associated with wrist pain among gymnasts, these events are phased in later [5]. The complete return-to-gymnastics protocol for gymnast wrist is provided in Appendix B.

The gymnast wrist return to gymnastics protocol incorporates “soreness rules” similar to the rules used for baseball pitchers in return to throwing protocols [6]. These “rules” are in place to help a gymnast determine what to do if soreness occurs. Table 3 fully explains the soreness rules for gymnast wrist.

Table 3.

Soreness rules.

Soreness	Description:
No Pain	If there is no soreness during or after practice, the gymnast will advance gymnastics per their plan
Soreness Guidelines	If the gymnast has soreness during warm-up but the soreness is gone within the first 15 min of practice, the gymnast will repeat the previous workout/skills from last practice, and if the upper extremity injury becomes sore during this workout, the gymnast will stop and take 2 days off and upon return to gymnastics, and drop down to the previous week
	If the soreness is more than 1 h after practice, or the next day, the gymnast will take 1 day off and repeat the most recent week of their gymnastics plan
	If the soreness occurs during warm-up and soreness continues through the first 15 min of practice, the gymnast will stop gymnastics/weight-bearing skills and take 2 days off and upon return to gymnastics, drop down to the previous week.

Grip lock (Acute Radius and Ulna Fracture)

“Grip lock” is a characteristic gymnastics injury which occurs while wearing grips (Fig. 2) during swinging on high bar, rings, or uneven bars resulting in an acute radius and ulna fracture. Grips and dowels (Fig. 2) are used to decrease friction on the hand (which causes blisters and “rips”) and provide better hold on the bar. Grip lock occurs when a gymnast who has grips on (typically on high bar, rings, or uneven bars) is performing an encircling skill around the bar, and the dowel on the grip locks in place as the athlete continues to swing/rotate on the bar. This causes an acute radius and ulna fracture (Fig. 3) [7]. In these situations, the athlete remains suspended from the apparatus by the fractured limb until acute care is provided or in some cases the athlete is unexpectedly released from the bar without control. Of note, females are less likely to have grip lock compared to male gymnasts [8].

Figure 2.

Gymnastics grips.

Figure 3.

Grip lock X-ray.

All medical staff at gymnastic events should be aware of this injury pattern and an emergency action plan including available staff and equipment as well as transportation to a medical facility should be in place for grip lock. Needed equipment includes a spotting block, splinting material, bandage scissors, and sterile dressings in case of open fracture. When a grip lock occurs, the spotting block should be immediately located and the emergency action plan should be activated. The gymnast will most likely be in three potential positions: (1). Released and thrown from the bar (2). Hanging directly with their weight down and grip/hand stuck on the bar, or (3). Body weight still on top of the bar and on top of the grip lock (Table 4).

Table 4.

Grip lock management.

Grip lock situations	Description
Situation 1: Released from the bar/event	This is treated as any other catastrophic sports injury. The athlete should be stabilized on a spinal board with a cervical collar and the injured limb splinted. The grip should be removed if possible due to risk of impending swelling.
Situation 2: Hanging directly with their weight down and grip/hand stuck on the bar	Gymnasts may already be supporting their weight on the noninjured side. Medical staff should immediately put the spotting block in place and have another medical provider or coach lift the athlete so that weight and traction are not being applied to the affected/injured side. The limb should be stabilized and the grip removed if possible.
Situation 3: Body weight still on top of the bar and on top of the grip/grip lock	Again, 1 medical provider should position the spotting block while another medical provider or coach should attempt to “unwrap” the athlete from the bar. If the coach is able to help the medical provider, the medical provider should stabilize the fracture while the coach lifts up and reverse circles the athlete to release the grip
	In all three scenarios there is a potential for an open fracture. Once the gymnast has been stabilized, splinted, they should be transported via EMS to a local hospital, preferably with a pediatric orthopaedic team.

Medical treatment of grip lock should include, x-rays of the forearm (Fig. 3). Depending on the type of fracture, the treatment may include casting, closed reduction, or open reduction internal fixation. Fracture treatment is dependent upon injury pattern, displacement, and patient age, though additional consideration for soft-tissue injury and risk of compartment syndrome is warranted given the high-energy mechanism.

Prevention of grip lock is critical and may be facilitated by simply checking the fit of the athlete’s grips [9]. Grips that are “stretched out” or too long for the gymnast are more likely to lock the dowel in place; thus, it is recommended that gymnasts and coaches check the fit of their grips every three to six months and always have an extra pair of well-fitting grips in their gym bag.

Grip lock is an important injury that medical providers should be aware of and understand the unique aspect of treatment and emergency action plan if this were to occur.

Elbow osteochondritis dissecans (OCD): OCD of the capitellum is typically seen in gymnasts age 10 to 14 years old. Currently, OCD is believed to be caused by repetitive loading of the developing distal humeral chondroepiphysis, which in skeletally immature athletes has a relatively limited vascular supply [10]. The resulting failure of the subchondral bone and articular cartilage may lead to pain, stiffness, and ultimately mechanical symptoms due to loose body formation. In addition to the younger age and functional demands, gymnasts may be at higher risk for developing OCD due to the shearing and compressive stress on the hyperextended elbow [10].

Clinically, gymnasts with OCD may present with posterolateral elbow pain, mechanical symptoms such as “catching” or “locking,” and loss of elbow motion. Often prodromal soreness has been present for months prior to seeking medical care, due to the common belief that elbow soreness, like wrist soreness, is “normal in gymnasts”. On physical examination, there is typically tenderness to palpation of the capitellum, and decreased range of motion when compared to the contralateral elbow [9]. Crepitus may be present in more severe OCD. Plain radiographs should be obtained, including oblique views, to evaluate for characteristic cystic and sclerotic changes seen with OCD. Clinicians should perform a careful exam of both elbows and consider contralateral x-rays, as there is an approximately 10% risk of bilateral elbow OCD in gymnasts [11]. An MRI should also be obtained to stage the lesion as this will determine the treatment (Fig. 4).

Figure 4.

X-ray and MRI of elbow OCD: 1: Elbow OCD: AP radiograph depicting subtle lucency in the capitellum, consistent with early OCD. 2. Elbow OCD: sagittal T2 MRI image depicting and unstable OCD lesions. Note the fluid signal extending below the articular surface, with cartilage breech.

Treatment of OCD is predicated by severity of involvement and stability of the involved articular cartilage and underlying subchondral bone. A number of classification systems have been proposed to portend prognosis and guide treatment. Generally speaking, stable OCD lesions are treated with rest from upper extremity activities, followed by physical therapy and serial clinical and radiographic examinations. Surgery is indicated for unstable OCD lesions, and treatment options range from loose body removal, debridement, marrow stimulation, OCD drilling, fragment fixation, internal fixation, and/or osteochondral grafting [10], [11]. While the surgical indications, techniques, and anticipated outcomes fall beyond the scope of this review, all surgical treatment options entail postoperative recovery comprised of rest to allow for healing, restoration of elbow motion and strength, and gradual return to sport-specific activities [11], [12], [13], [14], [15].

Elbow OCD Return-To-Gymnastics Protocol: As with other conditions, a gradual, sport-specific protocol to guide return will facilitate safe and healthy return to gymnastics. Historically, recommendations were based upon time from injury or surgery, with little to no criteria for skills advancement. Most published reports cite clearance to gymnastics after surgery is at 6 to 8 months postoperatively [12], [16]. There is a general consensus that range of motion and strength should be between 80% and 90% of the unaffected side [16].

To provide athletes, coaches, and providers more specific guidance, a gymnastics-specific protocol is proposed (Appendix C). Lower extremity skills may begin at 2 weeks postoperatively, progressing for 6 months while the elbow heals. Gradual progression of lower extremity and core activities allow for both upper extremity protection as well as rehabilitation of lower extremity motion, strength, balance, and skills often affected from prolonged time away from gymnastics. At 6 months postoperatively following confirmation of OCD healing, upper extremity traction/hanging forces begin, with subsequent progression to nonimpact closed-chain exercises and open-chain compression, plyometric, and impact/flight skills; this sequence allows for full return to gymnastics at roughly 9 months. Limiting the number of repetitions in the early phases of recovery and avoiding axial loading and valgus stress until there is capitellar healing are key features of this protocol. The complete protocol is provided in Appendix C.

Medial tensile injuries

Medial elbow pain in gymnasts can also occur and most commonly is caused from medial epicondylar apophysitis, medial epicondyle fractures, and partial or full UCL tears.

Medial Epicondyle Apophysitis: Medial epicondyle apophysitis is similar to gymnast wrist as it is a repetitive stress injury to the apophysis of the medial epicondyle. Gymnasts typically present to clinic with chronic medial sided elbow pain and x-rays (AP, Lateral, and oblique views) are typically performed show widening at the growth plate (Fig. 5). Contralateral x-rays may be helpful for comparison. Initial treatment is rest for a minimum of 6 weeks, or until there is no tenderness to palpation at the medial epicondyle apophysis. Physical therapy then commences with a guided return-to-gymnastics plan (Appendix D).

Figure 5.

X-ray of medial epicondyle apophysitis- Medial epicondyle apophyseal stress injury: note is made of asymmetric widening of the medial epicondylar physis.

Medial epicondyle fracture: A medial epicondyle fracture typically results from a fall onto an outstretched arm with a valgus moment. Physical exam will demonstrate tenderness to palpation at the medial epicondyle, swelling, decreased range of motion and strength, and potentially deformity of the affected elbow. Ulnar nerve function should be assessed given the proximity of the ulnar nerve to the zone of injury. X-rays should include AP, lateral, and external rotation oblique views to diagnose the fracture and characterize displacement (Fig. 6). Treatment of medial epicondyle fractures in gymnasts typically consists of open reduction and internal fixation, and once performed, 2 weeks of immobilization followed by 4 weeks of hinged elbow bracing to avoid valgus but regain read-only memory. After confirmation of fracture healing, physical therapy for strength and range of motion as well as a guided progression back to full gymnastics (Appendix D).

Figure 6.

X-ray of medial epicondyle fracture: AP elbow radiograph of a left elbow demonstrating a displaced medial epicondyle fracture in a 10-year-old gymnast.

Partial UCL tear: Partial UCL tears are seen in gymnasts but there are few scientific papers that describe this injury in gymnastics [17], [18]. The UCL is the main stabilizing ligament on the medial aspect of the elbow and can have partial or complete tearing with a valgus force typically with hyperextension. As reported in the literature a flexed elbow with a valgus force is more likely to produce a full UCL tear and thus a partial tear is typically suspected when the gymnast describes a hyperextended elbow with a valgus force as the UCL typically provides only 30% stability of the elbow joint in extension as compared to 50% stability with the joint in elbow flexion [17], [18]. Gymnasts presenting with a partial UCL tear will describe an acute upper extremity weight-bearing injury with a valgus force to the elbow. On exam the gymnast will locate their pain to the medial aspect of the elbow in the area of the UCL, have a positive valgus stress test indicated by the joint opening and laxity as compared to the uninjured side, acute inflammation of the elbow joint with possible ecchymosis on the medial aspect of the elbow, as well as tenderness to palpation on the UCL. In terms of diagnostic tests, typically a minimum of three x-ray views (AP, lateral, obliques) are obtained to look for any bony injury or avulsion. An MRI is then performed next and shows a partial tear of the UCL (Fig. 7). Ultrasound can also be used in the diagnosis of a UCL injury, allowing for both static and dynamic assessment. First line treatment for a partial UCL tear includes limitation of elbow motion possibly with a brace, and then progression with physical therapy, and then an eventual return to gymnastics protocol. There are several studies that have shown partial UCL tears do well with nonoperative treatment [17], [18].

Figure 7.

MRI of complete UCL tear. 1: Elbow UCL tear: proximal complete UCL avulsion injury of the right elbow in a 12 year old skeletally immature gymnast.

Complete UCL tear: A Gymnast may also experience a complete UCL tear. These tears have a similar presentation to the partial tears but can be differentiated on MRI. Treatment includes a discussion of surgical treatment, including repair or ligament reconstruction. Given the length of postoperative rehabilitation following UCL reconstruction, a candid discussion about the likelihood to return to prior level of gymnastics should be had. A through discussion should occur with the athlete and surgeon on the surgical procedure.

Medial Tensile Injury Return-To-Gymnastics Protocol: Once the athlete has clearance from their medical provider and has gained back range of motion and strength, a return to gymnastics protocol should begin. It has been stated in previous literature that certain events and skills cause more force on the elbow, and the return to gymnastic protocol must take these forces into account [18]. Using the Gymnast Wrist protocol, the authors adapted and created a return to play protocol starting with traction/hanging forces and then progressing to nonimpact closed-chain exercises to then open chain exercises, to compression, plyometric, and impact/flight exercises which would then fully progress the gymnast back to full gymnastics (Appendix D).

Glenohumeral instability (Including Labrum Tears)

Gymnasts require both flexibility and strength to successfully perform high-level skills. Given the glenohumeral joint’s range of motion and lack of bony constraint, these demands may lead to shoulder instability [19]. Shoulder injuries in gymnasts have been reported in 20% to 86.9% of gymnasts [20]. Like other weight-bearing and overhead athletes, shoulder instability may be unidirectional and post-traumatic or multidirectional in the setting of generalized ligamentous laxity. Multidirectional shoulder instability (MDI) is commonly seen in gymnasts [20]. Underlying hyperlaxity, as seen with increased Beighton scores in gymnasts, may predispose athletes to MDI [19].

During high-intensity, repetitive training, the rotator cuff muscles may fatigue and lose their dynamic stabilizing effect, leading to subluxation or dislocation of the humeral head, glenoid labral tears and/or increased capsular laxity [19]. Labral pathology is seen particularly after acute trauma. Anterior labral tears (Bankart lesions), humeral avulsions of glenohumeral ligaments (lesions), anterior labral periosteal sleeve avulsions (lesions), and concomitant bony injuries of both the glenoid rim (bony Bankart lesion) and posterior superior humeral head (Hill-Sachs defect) have all been described in gymnasts [21].

While gymnasts with acute instability events will present with pain, swelling, and limited shoulder motion after an acute injury, patients with MDI may present with insidious onset discomfort and subjective complaints of “looseness” or subluxation with repetitive activities. Careful history and physical examination will help discern between acute labral tears and more subtle instability due to ligamentous laxity. Radiographs of the shoulder, including anteroposterior, scapular Y, and axillary views, should be obtained, particularly after acute trauma, to assess glenohumeral reduction and associated bony lesions (Fig. 8). Advanced imaging, including MRI with or without intra-articular contrast, may help confirm the diagnosis (Fig. 8).

Figure 8.

X-rays of a shoulder dislocation and MRI of a labrum tear. 1: Shoulder dislocation: AP radiograph depicting an anteroinferior glenohumeral dislocation. 2: Axial MRI arthrogram of same patient, depicting an anteroinferior labral tear (arrow).

While nonoperative treatment remains the first line treatment for young athletes, recurrent instability may be seen in up to 95% in individuals under 25 years old and can be as high as 100% in skeletally immature athletes [21]. Surgical stabilization may be considered for symptomatic patients with functionally limiting instability failing nonoperative physical therapy and activity modification.

Shoulder Instability (including labrum tears) Return-to-Gymnastics Protocol: Similar to other progressions along with surgical timing considerations a week by week return to gymnastics progression was created for a gymnast who underwent shoulder arthroscopy and labral repair (Appendix E). Within this protocol, repetitions are initially limited, and the gradual progression also allows time to restore strength, range of motion, and stability.

Summary

Given the unique functional demands and characteristic upper extremity injuries seen in young gymnasts, sport- and condition-specific return-to-gymnastic protocols are critically important. In addition to timely diagnosis and appropriate surgical management, specific,guidelines regarding return to gymnastics may facilitate communication and shared expectations among patients, providers, therapists, and coaches. These protocols presented here were developed from review of the existing literature and expert opinion of orthopaedic and sports medicine providers, former gymnasts, and gymnastics coaches. Some protocols are presented in phases of recovery based upon symptoms and subjective metrics; other protocols are presented as week-by-week guidelines following surgical intervention. Appendix B-E go into specific details for upper extremity injuries and return to gymnastics protocols.

Author contributions

Hart Elspeth: Conceptualization, Investigation, Project administration, Resources, Writing – original draft, Writing – review & editing. Bauer Andrea: Writing – original draft, Writing – review & editing. Bae Donald: Writing – original draft, Writing – review & editing.

Declaration of competing interests

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests.

Dr. Donald Bae reports Royalties, Lippincott Williams and Wilkins. Board member, Foundation for Advancing Pediatric Orthopaedic. Board member, Pediatric Orthopaedic Society of North America.

Elspeth Hart is the founder of the nonprofit Gymnastics Medicine: Education and Research (GymnasticsMedicine.org) and also works as medical staff for USA Gymnastics.

Dr. Andrea Bauer has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary material

Supplementary material

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