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.

Keywords: Gymnastics; Gymnastics injuries; Return to gymnastics protocols; Return to play protocols; Upper extremity; Upper extremity injuries.

Video 1

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.

Figure 2

Gymnastics grips.

Figure 3

Grip lock X-ray.

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.

Figure 5

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

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.

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.

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).