I got a lot of great feedback from the first installment of this series, which was related to a gymnast with recurring lower back pain following a healed stress fracture.  I recently had another evaluation for a gymnast who started getting pretty intense ankle pain with high impact tumbling during training. She told me that due to competition season being in full swing, and also hopes of moving to level 9 she has been doing a lot of volume for new skills. More specifically double backs on floor and beam dismounts, which is when she first noticed the pain. She told me that it was mainly on the outside/front of her left ankle, but also on her Achilles for her right foot. At first it only hurt if she landed short on skills, but within a few weeks more landings at practice and motions during her daily like going down stairs gave her pain. A lot of gymnasts struggle with this kind of pain and I have also seen a few gymnasts with similar types of movement issues/training habits. Due to this, I wanted to share 10 take away tips from her case that might help other coaches, gymnasts, and healthcare with this type of problem.

IMG_0155

tcjoint

 

1. She Had A Notable Loss of Ankle Dorsiflexion

The sport of gymnastics inherently creates a situation where gymnasts are prone to lose dorsiflexion (toes up motion). The nature of a constant toe point, high volume and forces during jumping, being on toe for dance, and other factors create lots of calf use into plantar flexion. We clearly want gymnasts to have strong powerful calves and a good toe point, but we don’t it to become so overdeveloped that it causes a huge loss of dorsiflexion motion that may alter movement. These graphics below with lines aren’t her foot but I see this commonly with gymnasts during screening.

Ankle PF AROM Ankle DF AROM and PROM

Having a good amount of ankle dorsiflexion is essential for gymnastics skill power and movements such as proper jumping, squatting, and landings. This shift in total arc of motion can create global movement issues, but it also can have a profound effect on ankle joint mechanics and local force distribution. It throws off the normal alignment of the ankle joint to be non centrated, which can then lead to abnormal force going through certain aspects of the joint. When you stack hundreds of high impact landings per week on faulty alignment, things can get dicey fast. From this picture below you can see her having a loss of dorsiflexion in her squat, and she has to spin her feet out as a compensation (more below).

Note lack of ankle dorsiflexion and toe out compensation

I forgot to grab picture, but when she did a closed chain dorsiflexion test at a wall she was only able to reach the wall from 3″ on her right foot, and 3.5″ on her left. Anything more than this she would get stuck and then collapse her knee in to get farther. Here’s a video from an article I posted last month related to screening gymnast’s ankle mobility. I like to see gymnasts safely in the 4.5″- 5″ area knowing that many are often subject to aggressive dorsiflexion angles during training. Don’t mind my attempt at a beard during No Shave November, yikes.

For her case, I think this was one major factor for the pain she complained of on her left foot. I think this problem contributed to her right Achilles getting beat up as it was forcefully being stretched past its extensibility limit repetitively under high load. This is why I feel daily ankle mobility drills and regular screening of ankle dorsiflexion needs to be part of every gymnastics program.

As a side note, anyone interested in the more clinical aspect to dealing with dorsiflexion losses should check out Dr. Erson Religioso’s 5 Things To Address for Ankle Dorsiflexion That Are Not The Talocrural Joint. The ankle joint may be one piece of the puzzle but there may also much more too it, which have a lot of relevance to this gymnast’s case like…

 

2. She Had A Huge Imbalance for Tibial Internal/External Rotation

This is a less known factor related to mobility but it can have a huge effect on movement, ankle pain, and proper squatting abilities. I have found this issue comes commonly in gymnasts with the a loss of dorsiflexion and gymnastics demanding lots of hip mobility. Many gymnasts I have looked at have a huge increase in tibial external a rotation (spinning movement outwards towards pinky toes), and lack quite a bit of tibial internal rotation (spinning movement inward towards the big toes).

Tibial External Rotation

Tibial External Rotation

Tibial Internal Rotation

Tibial Internal Rotation

That second picture is her trying hard to rotate her big toes inward and when I tried to do the motion for her it wouldn’t budge. It’s hard to know if it’s a cause of issues or a compensation that results from other problems, as ruling out issues like congenital hip rotations is also important. Spending most of your time in this externally rotated position, especially under high impact load like tumbling and landing, can cause lots of overload to the ankle joint.

My opinion is that for many gymnasts the epicenter of the problem is the loss of soft tissue mobility in the calf and a change in the alignment of the ankle joint from above. This missing ankle dorsiflexion may then create a compensation where the gymnast is forced to rotate their feet outward into tibial external rotation motion during tumblings and landings. This cycle is perpetuated during tumbling and gymnastics skills when screening doesn’t catch it early, regular mobility work isn’t done to combat it, or the tumbling/landing form isn’t corrected. Many gymnasts show this “duck foot” type of tumbling and landings that is a tough habit to break. It takes a detailed movement exam to rule in this as a main factor, but it’s something I find regularly as something to address.

Hard to see but she's rocking the "duck foot" take off

Hard to see but she’s rocking the “duck foot” take off

 

3. She Struggled With Proper Squatting/Jumping/Landing Technique

I believe this is a resulting movement pattern issue from the two points above, but also has to do with the nature of gymnastics and a lack of teaching proper squat form for young athletes. Proper landing and squatting form is critical for gymnasts as it is a jumping and landing sport. Improper squatting and landing technique has a huge link to both overuse and traumatic spine, knee, ankle, and foot injuries. Along with this, improper jumping technique can create huge losses in power and makes sticking skills very difficult. For these reasons, I feel we have to teach our younger athletes correct mechanics so it hopefully becomes built into their brains as an automatic part of gymnastics.

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The picture at the beginning of this post shows her struggling with a double squat pattern, and single leg squatting was equally as tough for her to do correctly. Her single leg jumping tests were very unstable and showed her taking most the landing in her knees (picture above). What we want is a good hip loaded and posterior chain focused landing form, to help de-load the knees and ankles. The picture below is a great example of this hip and knee alignment during a stuck Yurchenko 1 1/2, although I would say her torso is a little too far back/upright in relation to her legs.

Photo Credit to the Pac 12 network - http://pac-12.com/videos/recap-georgia-dabritz-and-tory-wilson-power-utah-womens-gymnastics-past-asu

Photo Credit to the Pac 12 network – http://pac-12.com/videos/recap-georgia-dabritz-and-tory-wilson-power-utah-womens-gymnastics-past-asu

Lots of improper landings may create local knee stress, distal ankle and Achilles stress, and is a concern for traumatic injuries like ACL tears. I feel all of these concepts are main reason many Achilles and impact ankle issues coming about over time for gymnasts, as they impact the floor hundreds of times per week under high force. Anyone interested in my thoughts on combatting Achilles tears in gymnastics can check out there articles form last year (Part 1 and Part 2).

Lacking ankle dorsiflexion mobility may be one factor contributing to why a gymnast shows quad dominant landings with not the greatest squat form. It could also be that they just have no idea how to land the right way, or have a technical skill error. For whatever reason, it’s important to address and correct early. Also, there are a ton of ways to screen for and work proper jumping mechanics related to knee injuries, which you can read more about this in an article my good friend Dr. Joe Myhren and I put together last year.

 

4. She Had Very Stiff Plantar Fascia and 1st Toe Mobility Issues 

 The bottom of her feet were unbelievably stiff, and she reported get really sore during practice. She also has a notable loss of big toe extension in weight bearing , which is important for proper running and tumbling mechanics. It can also be a factor leading to the problems noted above, but again a “chicken or the egg” type of scenario. There is a lot going on in the bottom of the foot in terms of soft tissue structures, a variety of bones and ligaments, and also small muscles that help to stabilize the foot. Lacking great toe mobility can greatly reduce running and hurdling mechanics for tumbling/vaulting. It can also create a situation where the gymnast can’t get full hip extension during these activities, which may reduce glute use and power output during vaulting/floor. The photo below isn’t her but it can give readers and idea of the concept.

http://www.drsarahsimison.com/uploads/6/4/7/4/6474065/744504_orig.jpg

http://www.drsarahsimison.com/uploads/6/4/7/4/6474065/744504_orig.jpg

https://runsmartonline.com/articles/strength/wp-content/uploads/2014/03/first-toe-extension-running1.jpg

https://runsmartonline.com/articles/strength/wp-content/uploads/2014/03/first-toe-extension-running1.jpg

For many gymnasts I think this is inherently the nature of the beast with gymnastics, as the bottom of their feet can become very dense and stiff with so much impact pounding, then possibility influencing foot/ big toe mobility. We have to make sure that we are regularly tending to the myofascial structures of the foot with soft tissue work. The foot is extremely important for sensory feedback to the brain but also helping to create stability for the gymnast. Theres a lot of space in the brains inner mapping to pick up info from the feet, hands, and face.

Photo Sep 07, 1 58 58 PM

CKC Springboard Drill Intrinsics

That’s All For Part 1!

So that’s all I wanted to go through this week so that there isn’t too much info to digest. Anyone interested in these concepts can also check out an article I wrote last year on impact based ankle pain in gymnastics. Next week I’ll offer some more things to think about, and then I’ll try to get another video up that offers readers some mobility/control progressions they can use in the gym to work on this. Take care,

– Dave

 

References

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