Common Injuries and Evaluations in the Gymnast and Cheerleader

There is an increasing awareness of health and its benefits as it relates to sports medicine. Athletes desire to return to competition as soon as possible. This can be accomplished with a team of the athlete’s Primary Care Physician, Surgeon, Physical Therapist, Athletic Trainer, Coach and the athlete. When the athlete is injured, the rehabilitation process will be multifaceted. The musculoskeletal, psychological, nutritional, and cardiac are key areas to monitor as part of the total care of the athlete. In a preventative medicine effort, the pre-participation physical exam will help screen for any predisposing injuries or disposition to have an injury. The pre-participation physical examination as discussed in this paper will identify possible preexisting injuries that should be treated or conditioning deficiencies that should be remedied in gymnastics and dance or cheerleading. Poor conditioning leads to the overuse injuries common in cheerleaders. A conditioning program prior to participation and a gradual progression in intensity early in training can prevent many of these injuries. The pre-participation exam is also the ideal time to address non-musculoskeletal health issues. A general health history should be obtained to screen for cardiac arrhythmias, dizziness, or seizures. The presence of any of these should prevent athletes from taking part in stunts and pyramids. An aggressive workup should be done before participation is allowed. In addition, women and less commonly men, who participate in aesthetic sports such as dance, gymnastics, and cheerleading, are at increased risk of having an eating disorder. The health history should include careful evaluation of daily eating patterns and menstrual irregularities. Any athlete with a new stress fracture or overuse injury should also undergo this screening. If any abnormalities are found they should be addressed immediately with patient education or referral to a specialist in that area. Cheerleading is an athletic activity that blends the athleticism of gymnastics, the power of weight lifting, and the coordination of dance. However, the injury patterns in cheerleading mimic those seen in gymnastics and dance. The most common cause of injuries is partner stunts followed by gymnastic tumbling runs (Hutchinson, 2000) We will look at the most common injuries for these athletes, their mechanism of injury, and how to evaluate and screen for them, including a brief discussion about how the components of the female triad will affect the female athlete. As with all pre-participation exams, a complete exam is indicated. The overall evaluation includes measuring height, weight, pulse and blood pressure. A visual acuity screening exam, along with checking the athletes head, ears, nose and throat, neurological, cardiac, and musculoskeletal systems for deficiencies are indicated and may be treated prophylactically. Head and Neck- Low frequency of injury.

In general, the head and neck have one of the lowest incidences for injury, but is one of the highest for morbidity and mortality (Hutchenson, 1997). There are five important points to get out of the history with a head injury, current or previous. They are

1. was there any loss of consciousness,
2. Retrograde amnesia,
3. persistent headache,
4. nausea, and
5. blurry vision

The neuromuscular exam should be normal and the athlete should be asymptomatic before participation in their event. Cheerleaders and gymnastics will have a higher rate of concussions than some sports as the sport encompasses tumbling and tosses.

Evaluation should include looking for the posture of the athlete’s neck and should include full ROM, extension, flexion, lateral bending, and rotation. Performing an axial load test will allow the practitioner to identify a possible injury to the neck. Obtaining oblique and odontoid views for C1-C2 will help diagnose any injury that may have happened with a fall. Shoulder- Medium frequency of injury.

Shoulder injuries are more susceptible for gymnasts and cheerleaders who are in the air with a chance to fall and land on the shoulder, causing an AC sprain, or even a fractured clavicle. The glenohumeral joint is most commonly dislocated anteriorly. The shoulder will have a “squared off” look.

Impingement is an overuse condition seen with shoulder instability, and excessive overhead use.

An AC joint separation will produce a localized tenderness and a possible deformity of the clavicle. A rotator cuff tear will show as pain and/or weakness on external rotation and/or abduction. The instability of the shoulder will possibly show a consistent sign of rotator cuff weakness, a positive apprehension sign and an anterior or posterior laxity of the joint. Oblique and flexion films may be obtained to help diagnose the injury. Elbow, Wrist and Hand- Low to High frequency of injury.

Most of the elbow injuries are going to be from overuse. Where the wrist and hand are the opposite of the elbow and most of the injuries will be from trauma rather than overuse. Elbows are less prone to be injured than wrist. Elbows may be injured when a tumbler in gymnastics tends to ulnar deviate their wrists when tumbling. This puts an added amount of stress on the joint, which can cause a dislocation or fracture to occur. Thus, the biomechanics of gymnastics are important to reduce the chance for injury.

The wrist and hand are not weight bearing joints. The joint will become a weight bearing one when a gymnast falls on an outstretched hand or does repetitive movements involving hyperextension of the wrist with an axial load compressing the joint. For example handstands, transition support throughout flips, and propulsion with vaulting. These loads that a gymnast put on their wrists will result in a higher frequency of injury to the wrist. Osteophyte formation, avascular necrosis, tendon and ligament damage, and fractures of the scaphoid, the most commonly injured carpal of the wrist, are some of the differential diagnosis’ a practitioner may make when evaluating a gymnast’s wrist. Palpation of the wrist may reveal small nodular swellings especially on the dorsal surface. These often represent ganglions and are more common in gymnasts. Tenderness in the anatomical snuffbox may indicate a possible fracture of the scaphoid, scaphoid-lunate joint, or a fracture of the distal radius. X-rays may be negative even with a positive tender snuff box sign. Stress fractures and micro trauma from the repeated loading of the joint in hyperextension can affect the growth plate of the radius and can result in decreased growth or length. Technically, this could cause the radius and ulnar to grow to different lengths. Therefore, it is important to have the injury evaluated when the pain is first felt. Postponing an evaluation can lead to a more serious injury. Oblique and navicular views will help get the best images for diagnosing the injury. When evaluating the wrist and other joints for instability, it is important to keep in mind that many joints pop and click. When checking for instability, a definitive positive for these tests is painful popping or clunking. Here are some of the tests to help evaluate for specific injuries of the wrist: Watson’s test for scapholunate stability — The examiner presses the scaphoid from anterior (volar) to posterior (dorsal) with the wrist first in ulnar deviation. Moving it passively into radial direction, a painful clunk or pop may be produced indicating that the proximal pole of the scaphoid subluxated over the posterior rim of the radius. Lunotriquetral ballottement test — The examiner stabilizes the lunate between a thumb and index finger and does the same with the triquetrum. A shearing between the bones is accomplished by moving the bones in opposite directions (i.e., lunate forced posterior while triquetrum is forced anterior). A painful clunk or pop is indicative of lunotriquetral joint instability. Midcarpal instability — By either having the patient actively or examiner passively pronate and ulnar deviate the wrist, a painful pop is felt on the ulnar aspect of the wrist. This indicates midcarpal instability (Souza, 1997) Lumbar Spine- High frequency of injury

Lumbar injuries are frequently diagnosed as muscle strains. It is true that a strain has occurred but it is important to look for other causes of the pain. Scoliosis, excessive lateral curvature and spondylolysis, a stress fracture of the pars interarticularis could be some of the other causes of back pain. A study of gymnast’s shows that 112 of 673 or 16%, showed signs of spondylolysis (Rossi and Dragoni, 2001). Physical findings to indicate a lumbar injury include pain to the area on extension of the back, pain with a single leg lift, lumbar rotation, or during palpation over the affected area.

Treating these injuries is often difficult and depends on what the patient wants to do. Radiographic studies will show and confirm a defect in the pars interarticularis as seen on an oblique view, also known as the “Scotty Dog” view. A broken neck of the dog is a positive sign for a broken pars of the vertebrae. A lumbosacral spot also helps to diagnose for lumbar spine injuries. Knee- Medium to High Frequency of injury

Athletes will more often one time or another in their career will deal with some kind of injury to a knee. It could be an ACL, PCL, MCL, LCL, and cartilage or meniscal injury. Instability to the ligaments, joint line pain, a positive Lachmans, Pivot shift, Posterior drawer, McMurray’s or effusion all indicate a possible knee injury.

Patients will be able to walk on the knee, with or without pain. A MRI and radiographic studies, lateral, standing AP and merchants should be ordered to help determine the cause of the injury. Ankle- High frequency of injury

The ankle is one of the most common athletic injuries. Ankle sprains occur with a twisting injury, and may involve the lateral ligaments, medial ligament or the ligaments connecting the lower tibia and fibula. An inversion of the ankle consists of the lateral ligaments of the ankle, the anterior talo-fibular ligament, the calcaneo-fibular ligament, and the posterior talo-fibular ligament. An eversion sprain is a less common sprain, which is composed of the medial ligament of the ankle, a broad fan-shaped ligament called the Deltoid ligament.

Plantar Fasciitis and Achilles tendonitis will both present as tenderness along the respective tendon in question. Pain can be sudden with activity. Therapy and rest will hopefully help the athlete overcome these injuries without having to go to surgery.

Two quick tests that can be performed are the anterior drawer test and talar tilt test. Both look for laxity of the joint. Again, X-rays will help diagnose and rule out any fracture that may have occurred.

Overuse injuries-

Many injuries can be caused by overuse. Osgood schlatters disease of the tibial tubercle, Little league elbow (Medial epicondylitis), Tennis Elbow (Lateral epicondylitis), stress fractures, spondylolysis and shin splints are all caused by overuse of the joint and muscles associated with it. Mannor states that low back pain is a common disorder in gymnasts that can arise from macro trauma or repetitive micro trauma. She also states that due to the excessive hyperextension of the low back, gymnasts will be affected in their routines that involve such motions, such as floor exercises, balance beam skills, vaulting, walkovers, and dismounts (2000). One other injury to worry about is compartment syndrome. The 4 compartments, particularly the anterior compartment, can cause pain by repetitive motions, like running. Anoxia and nerve compression can be manifested by this problem which if not treated promptly can result in surgery to relieve the symptoms.

The Female Triad-

The number of women athletes is ever increasing in numbers. The difference in anatomy between the woman and man has a substantial effect when playing sports and exercising. Women tend to have less dense bone, less lean muscle, a lower center of gravity, shorter limbs, and a gynecoid pelvis. The female pelvis’ width makes the biomechanics of the knee different than men, which leads to a greater Q angle, and has been shown to have an increased knee injury associated with it (Noble, 2001). ACL injuries occur 4 times more in women than men, (Moeller, 1997) possibly a result from a narrowing of the intercondylar notch. They also have more patellofemoral problems than men do.

Not only do females need to worry about all of the aforementioned problems, but then also have to think about nutritional considerations, like iron. Competitive gymnasts will sometimes restrict caloric intake to meet certain weight requirements or to conform to certain pressures from peers. The Female athletic triad consists of eating disorders, amenorrhea, and osteoporosis. The decreased caloric intake reduces peripheral fat. This decreased the conversion of androgens to estrogens, which helps to contribute to the amenorrhea state. If the caloric intake is inadequate then the bone density may be lower than wanted as well. All of these problems are interlinked and must be screened for to ensure the females safety in participation of their event.

Conclusion-

The primary purpose of the preparticipation exam is to screen for disease and to give the athlete a clean bill of health for participation. Discussed in this paper were ways to identify and hopefully screen for some of the more common injuries that one may see as a health care provider when evaluating these athletes. Remember this exam is not intended to be long as the neuro and musculoskeletal areas may be tested simultaneously. Checking the heart, lungs, head, eyes, ears, and musculoskeletal system will ensure the athletes can participate with a lesser degree of getting injured or killed from a disease or injury that would have other wise not been detected. Appendix Figure 1-2. Shows the injuries and the time lost from activity as it relates to the injury. (Hutchinson, 2000) References

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6. Rossi, F., Dragoni, S. (2001). The Prevelence of Spondylolysis and Spondylolisthesis in Symptomatic Elite Athletes: Radiographic Findings, Sports and Medicine www.sportmedicina.com/spondylolisthesis.htm, Accessed 7-10-04.
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