26 Feb 2 Comments Dave Foot and Ankle, Uncategorized , , ,

A few weeks ago in Part 1 of this article, I talked about some factors related to a gymnast I treated for impact based ankle pain. I talked about ankle dorsiflexion mobility, tibial internal/external rotation, the role of proper squatting and landing mechanics, and toe mobility influences. I wanted to keep the train rolling and offer some more concepts to think about related to gymnasts struggling with this type of issue.

Dynamic Lunge Test End

5. She Was Going Through A Growth a Spurt

This was the case with the last gymnast I posted about, but I think this is a huge factor coaches and gymnasts need to be in tune with. There are a couple reasons for this. One is that often times as bone growth occurs rapidly, the muscular structures get left behind in the adaption cascade. Rapid growth occurs from bone elongation at growth plates.  Muscles, tendons, and ligaments can undergo quite a bit of strain as bones are elongated and the soft tissue can’t keep up. For this gymnast’s case, I think her rapid growth spurt created a lot of strain on her Achilles and calf tissue that along with the factors above. I think this made a big impact on her ankle mobility restrictions.

PVH - Long Term Athletic Development

Also, during this process it’s very common for a gymnast to struggle with skills as their body has to acclimate to the new “re-calibration” changes. Gymnastics is a sport of fine tuned coordination and precision, so rapid changes in the body dimensions during development can dramatically throw off their nervous system. Becoming taller, gaining muscle muscle, developmental changes both physically and metabolically, and multiple other second effects are just a few factors.  As coaches I think knowing this important, as it has links to many types of injuries seen during training. I talked about this in a video related to breathing, leg lifts, and core stability last month.

Breathing Leg Lift Pic

There is a huge difference between someones chronological age, and their developmental age. Not all 7 year olds or all 16 year olds are the same developmentally, especially in gymnastics. Thinking about their rate of development, knowing when their growth spurt may be going on, and also being aware of it is very important. We can be understanding and educate the gymnast on why their performance may be suffering, and also possiblly make training adjustments to help stay ahead of injury problems.

 

6. She Recently Underwent A Dramatic Increase In Impact Skill Volume

A big thought train of mine is considering exposure rates of impact landings and lower back hyper extensions in training. This is based off the work of Dr. Bill Sands, and how he used to have a detailed monitoring system for his gymnast’s training programs. I think that in order to make a notable dent in both impact and in lower back injuries, we have to start being more adamant about quantitatively measuring skill volume. Although some gyms do this well, I think this piece is generally missing in gymnastics. Due to this we loose sight of just how many repetitions of impact/hyper extension our gymnasts are subject to.

Example of Compressive Forces

Example of Compressive Forces

More often than not I think we simply train for a block of time, give a certain number of skills that need to be made, or sometimes just train until we “get it”. We have to remember the forces of gymnastics are very real, and may be between 14-17x the gymnasts body weight each impact. If the gymnast is taking 20 impacts during tumbling on floor, then goes to beam and does 20 more impacts between series and dismounts, then goes to vault and takes 5 vault landings, your looking at 45 for a day. That’s an arbitrary number as an example, but looking at 4 days a week training that may take you to almost 200 per week. Then you add in other complexes, side drills, routines, meets on the weekend, and things stack up fast.

Although I very much support that we need to put in our appropriate number of reps to encourage proper motor skill learning, it’s crucial that we don’t let it continue without thinking on exactly how many times they have landed or hyperextended their spine. It’s not a perfect scenario without real data to support it, but I hope the point I’m trying to get across comes through. No pre-hab or proactive program in the world can combat over-exposure and under recovery for a gymnast.

7. She Wasn’t Dividing That Volume Across Softer Surfaces

I’m personally a fan of making sure that if a gymnast is undergoing huge volume increases for skills, they divide it up across softer surfaces. Clearly it’s important that a gymnast know and train on the competition surface.  This allows them to build proper control, understand the difference, and prepare themselves for meet situations. That being said I think lots of overuse issues and increased risk of traumatic issues start to be triggered in season by so many hard impacts. I was lucky to have a long conversation with Neil Reisnick regarding this concept at congress last year. He finds with his collegiate team that more time on softer surfaces helps to combat issues like this and get more benefit in the long term. I know many coaches share this view, but I think it bares repeating as it was a major spark for this gymnasts pain.

 

8. Her Pain Started With Short Landings

Going along with the conversation I had with Neil last year, he talked about how he pictures each of his gymnasts having a number on their leo during practice for how many short landings they can take. He mentioned how he factors in the short landings and makes sure to monitor why it’s happening, as each time the gymnast takes a low landing it can have huge repercussions on both their physical and mental health. From my point of view as a physical therapist, I find that many issues can start from accumulating short landings. Even though a gymnast may not complain of pain, we have to make sure it’s not happening often.

IMG_0673

I think non painful short landings quickly become mildly painful short landings that a gymnast “walks off” and keeps training through. I think it then becomes more painful short landings, which then become painful landings in general. I think at the first site of short landings we need to take a step back and get to the root cause of why it’s happening like premature attempts, rushing progressions, mental blocks, technique errors, and so on. Obviously fluke accidents happen and are unavoidable, but for many cases I think stepping back to address the situation early can prevent a situation like this gymnast had with her ankles pain.

 

9. She Got It Looked At Early

I can’t stress the important of this one enough. Within 3 WEEKS of the issue staying constant, the gymnast and her mother realized that it may be something that wasn’t just “part of gymnastics”. They got an appointment with a great pediatric orthopedist who knew gymnastics. He then also recommended that she see me with a temporary reduction in training to address the underlying causes of the issue. Both the orthopedic physician and myself share the idea that because she did this, it prevented the start of a small problem from becoming a full blown injury.

As a former gymnast and now coach, I know that gymnastics is demanding and comes with its share of bangs, bruises, and discomfort. However I don’t feel things like sharp ankle pain when you jump and walk, ongoing back or wrist pain with daily activity, or reoccurring injuries fall on that list. Things can quickly progress from aches to full blown injuries that keep someone out for multiple months. I think stress reactions become stress fractures and acute INFLAMMATION become much more serious tendon damage when we don’t screen and be quick to react. Don’t get me wrong I want my gymnasts to be able to train hard and be successful. But, being riddled with injuries and pain is the fastest way to take away from that. A temporary reduction in training and taking the time to address the why behind what’s causing the injury can go a long way for the gymnast. With bigger competitions and certain situations the pros and cons can be weighed out, and I get that. However I often tell my own gymnasts and patients to “see the forest beyond the trees” and consider long term considerations versus suffering through a few practices.

Concluding Thoughts

With these few articles I hope readers have been able to pick up a few things, or at least think differently about the situation. Although I am a big fan of bringing up and expanding on these thoughts, in the end I think we want ways to actually fix the problems.Coming up soon I’ll try to offer people some preventative ways they can help out with gymnasts who may have some of the issues I touched on during the last few weeks. Remember, If someone is having ongoing pain the option of pre-hab is off the table and they need a detailed movement exam to figure out whats going on. I’m happy to say that this gymnast I’m working with is actually doing really well with almost no pain now, and it has been a 4 or 5 times I have seen her. Hopefully this info will help keep people out of the same situations. Take care,

 

– Dr. Dave

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