The Injured Shoulder in High-Level Male Gymnasts, Part 1: Epidemiology and Pathoanatomy of Surgically Treated Lesions

Abstract

Background: Weightbearing and traction-suspension movements with the upper limbs put considerable demands upon the shoulder region of high-level gymnasts. The diagnosis of instability in these gymnasts may be difficult because voluntary inferior shoulder subluxation is part of their training and is needed to perform some acrobatic figures.

Purpose: To (1) assess the epidemiology of shoulder lesions requiring surgery, (2) describe the types of injuries and assess which maneuvers and equipment put the gymnast most at risk, and (3) present a pathoanatomic classification of the injured shoulder in high-level male gymnasts.

Study design: Case series; Level of evidence, 4.

Methods: Over a 20-year period (1994-2014), 26 high-level male gymnasts (30 shoulders; mean age, 22 years; range, 16-33 years) were referred to our surgical center for shoulder pain or instability. Four gymnasts underwent surgery on both shoulders. All shoulders were evaluated clinically, radiologically, and arthroscopically. An independent observer evaluated the circumstances in which these lesions occurred, including the apparatus used and the maneuvers performed.

Results: The mean duration of symptoms before surgery was 8 months (range, 6-24 months). Eighteen injured shoulders (60%) had chronic overuse injuries. In 27 shoulders (90%), the mechanism of injury was traction of the arm in forced flexion-rotation while using suspension equipment with locked hands on the bars or the rings. In the remaining 3 shoulders, the traumatic position was one of an isometric muscle contraction against gravity, sustained while performing strength-and-hold positions on the rings. Based on the main presenting symptoms (pain and/or instability) and main anatomic lesions found during arthroscopy, the injured gymnasts' shoulders were classified into 2 categories: painful shoulders (n = 13) with no clinical, radiological, or arthroscopic findings of instability (mainly superior cuff and biceps anchor lesions) and unstable shoulders (n = 17) with isolated inferior capsule labral tears or mixed lesions (tendinous and capsulolabral). Some gymnasts with inferior labral tears had no recall of having suffered a dislocation or subluxation.

Conclusion: The majority of injuries requiring surgery in this population occurred during traction in forced flexion-rotation using suspension equipment. Injured shoulders were classified as either painful or unstable shoulders.

Keywords: SLAP lesions; high-level gymnasts; instability; labral tears; partial cuff tears; shoulder arthroscopy; shoulder injury.

Figure 1.

Labral attachment was divided into 6 zones (A-F). Labrum not attached in zone B was considered physiologic. Labral tears located below the equator (zones C-E) were considered secondary to inferior traumatic instability. Labral tears in zone A were diagnosed as SLAP (superior labral anterior and posterior) lesions. Labral tears in zone A or F associated with deep rotator cuff tears (“kissing lesions”) were diagnosed as posterosuperior impingement.

Figure 2.

Number of gymnasts who underwent surgery per year.

Figure 3.

Two traumatic exercises in men’s gymnastics. (A) Forced flexion–internal rotation  of the shoulder during parallel bars exercise in suspension. (B) Isometric muscle contraction against gravity during a strength-and-hold element on rings (the “iron cross”).

Figure 4.

Posterior arthroscopic views demonstrate some of the pathologies found in the 2 categories of gymnasts’ shoulders. (A) Left shoulder shows an articular-sided supraspinatus tear with a flap of the tendon and lateral instability of the biceps tendon in a gymnast with chronic shoulder pain (painful shoulder group). (B, C) Right shoulder shows an abnormal capsular distension with a “labral crack” in zones C and D in a gymnast with chronic shoulder pain and no recall of any subluxation. LHB, long head of the biceps; SP, supraspinatus.

Figure 5.

Physiologic specifics of the gymnast’s shoulder: voluntary inferior shoulder subluxation is needed to allow complete rotation of the shoulder while the hand and wrists are locked on the bars or rings. (A) In this exercise on the horizontal bar, the gymnast who has his shoulder in extension and external rotation (RE) makes an effort to internally rotate (RI) and dislocate his shoulder inferiorly. (B) Extension and internal rotation during the “voluntary gymnast shoulder inferior subluxation.” (C) Fluoroscopic image demonstrates the inferior glenohumeral subluxation of the humeral head during the “dislocation maneuver.”