8 Br J Sports Med 2001;35:8–20 Br J Sports Med: first published as 10.1136/bjsm.35.1.8 on 1 February 2001. Downloaded from Review Balancing the risk of injury to gymnasts: how eVective are the counter measures? R M Daly, S L Bass, C F Finch Abstract equipment used by gymnasts, and coach- Background—To minimise injury risk and ing and the role of spotting in preventing maximise gymnastics performance, injury. coaches, parents, and health professionals (Br J Sports Med 2001;35:8–20) working with young gymnasts need to understand and practise safe gymnastics. Keywords: gymnastics; injury prevention; counter Aims—To (a) identify the various injury measures; eVectiveness; coaching; equipment counter measures specific to gymnastics, (b) critically review the literature describ- Although there is increasing evidence that chil- ing each injury prevention measure, and dren are becoming more sedentary and less fit,1 (c) assess, using available risk factor and the number of children and adolescents injury data, the weight of evidence to involved in organised sporting activities such as support each of these counter measures. gymnastics, tennis, and swimming has actually Specific recommendations for further re- increased.2 Although the long term risks search and implementation strategies to associated with involvement in organised sport prevent injury and improve safety are also during the period of growth and development given. are still obscure, concern has been expressed Methods—The relevant literature was over a potential epidemic of both acute and identified through the use of Medline chronic overuse sports injuries.34 (1966 to May 1998) and SPORT Discus (1975 to May 1998) searches, hand search- Adolescence appears to be associated with ing of journals and reference lists, and the highest incidence of injury, which may be partially due to the growth process itself induc- discussions with key Australian gymnas- http://bjsm.bmj.com/ ing an imbalance between strength and flexibil- tics organisations. 5 Results—The key gymnastics injury coun- ity. There is also evidence that the growth ter measures identified in this review plate cartilage is less resistant to repetitive include coaching (physical preparation, stress than adult articular cartilage, and that education, spotting, and performance the ligaments of children are stronger than the technique), equipment, and the health cartilage and bone to which they are at- 56 support system (medical screening, treat- tached. This may result in an increased like- lihood of injury to the open epiphysis. Gymnas- ment, and rehabilitation). Categorisation on September 25, 2021 by guest. Protected copyright. of the type of evidence for the eVectiveness tics as a potential cause of injury is of particular of each of these counter measures in concern because of participation by children preventing injury showed that most of it is and the frequent high impact loading associ- based on informal opinion/anecdotal evi- ated with both training and competition. dence, uncontrolled data based studies, Gymnastics as a sport has enjoyed a boom in and several prospective epidemiological popularity over the last 20 years, which may studies. There is no evidence from for- reflect the increased publicity and television mally controlled trials or specific evalua- coverage given to the sport at events such as the tion studies of counter measures for Olympic Games. The sport of gymnastics began gymnastics. with the ancient Greeks and Egyptians, where it School of Health Conclusions—Although gymnastics is a was used as a means of discipline and physical Sciences, Deakin sport associated with young participants conditioning for young men being trained for University, Melbourne, and frequent high volume, high impact warfare.7 Today, it is both a recreational and Australia R M Daly training, there is a paucity of information organised sporting activity, in which there are six S L Bass on injury risk factors and the eVective- major disciplines: men’s artistic gymnastics, C F Finch ness of injury practices. Further control- women’s artistic gymnastics, rhythmic sportive led trials are needed to examine the gymnastics, sport aerobics, trampoline sports, Correspondence to: extent to which injury prevention counter and general gymnastics. Within each of these Dr Daly, School of Health Sciences, 221 Burwood measures can prevent or reduce the disciplines, there are three main levels of Highway, Deakin University, occurrence of injury and re-injury. Par- gymnastics activity: recreational, competitive, Victoria, Australia 3125 ticular attention should be devoted to and elite. At present, the vast majority of [email protected] improving training facilities, the design competitive participants are children. This is Accepted 30 October 2000 and testing of apparatus and personal probably because of the widely held belief that to www.bjsportmed.com How eVective are gymnastics counter measures? 9 achieve success at the highest level, training and 1998) which were used to obtain most of the Br J Sports Med: first published as 10.1136/bjsm.35.1.8 on 1 February 2001. Downloaded from competition should begin before puberty when a information for this review. Discussions with small lean physique is likely to convey a key Australian gymnastics organisations and performance advantage. It is not uncommon for hand searching of journals and reference lists elite gymnasts to start training from as early as were also carried out. The keywords and five or six years of age, and to train for between phrases used to search the literature included 20 and 40 hours a week all year round.89 “gymnastic” and one or a combination of the Since the mid 1970s, competitive gymnastics following words: injury, training, prevention, has undergone a dramatic transformation with conditioning, strength training, flexibility, pre- respect to the complexity of manoeuvres per- participation screening, equipment, technique, formed and the age at which gymnasts start education, coaching, spotting, medical treat- training.10 Both coaches and gymnasts have ment, and rehabilitation. The literature search become more ambitious and creative, and for the relevant material did not discriminate consequently, the range and number of risk ele- between males and females or the diVerent lev- ments incorporated into gymnastics routines els of gymnastics. The material reviewed was have increased substantially.11 More children are restricted to the English language. starting gymnastics from an earlier age and Injuries in sport, such as those that occur maintaining an extremely high level of training during gymnastics, generally result from the throughout the years of growth and develop- culmination of a pre-existing condition and/or ment. Consequently, it has been suggested that a particular set of circumstances.12 A multifac- the increased involvement and difficulty of skills torial chain of events usually results in the inci- practised from an early age may be associated dent leading to an injury during sport. Three 12 with an increased risk of injury. Most elite phases are identifiable as points of interven- gymnasts do not pass through childhood and tion: before the event, the event, and after the adolescence without injury, and the risk of injury event.12 Injury counter measures are measures increases with longer practice time and the aimed at preventing or reducing the risk of 13 degree of diYculty of the routines. injury. It has been suggested that injury coun- Although a number of safety practices are ter measures can be targeted at the three phases widely adopted to prevent the occurrence and in the chain of events leading to an injury. recurrence of gymnastic injuries, the eVective- Gymnastics injury counter measures can there- ness of these preventive measures has received fore be equated to primary (before the event), little attention. Given the cost of treatment for secondary (event), and tertiary (after the event) injury rehabilitation, the loss of sports participa- prevention,14 as shown in table 1. tion time, and the risk of long term or even per- Although few counter measures specific for manent disability, it is important that injury gymnastics have been formally shown to actually counter measures be identified to reduce the prevent injury, the key counter measures identi- occurrence, recurrence, and severity of injuries fied in the literature pertain to coaching (physi- associated with sports participation. The aim of cal preparation, education, spotting, and per- this review was to (a) identify the various injury formance technique), equipment, and the health http://bjsm.bmj.com/ counter measures specific to gymnastics, (b) support system (medical screening, treatment, critically review the literature describing each and rehabilitation). The evidence for each injury prevention measure, and (c) assess, using specific counter measure in these categories will available risk factor and injury data, the weight be discussed according to the level of supportive of evidence to support each of these counter evidence. On the basis of this assessment, measures. Specific recommendations for further recommendations are made for improving the research and implementation strategies to pre- safety of gymnastics and for further counter vent injury and improve safety are also given. on September 25, 2021 by guest. Protected copyright. measure research and development. The classi- fication for the strength of the type of evidence Methods showing the eVectiveness of each counter meas- The information