Gymnast's Wrist

Gymnastics is a unique sport in that it requires weight-bearing on the hands. Because of that, injuries to the upper extremity is very common especially in elbow and wrist. Even though the most of the injuries are chronic in nature, acute injuries are also common such as ankle sprain. They start the sport really early and training can be extensive and long, which causes overuse.

Gymnast's wrist is an injury to the growth plate in the wrist. Radius is the main weight-bearing bone at the wrist and prone to injury from repetitive stress placed on it from tumbling and other weight bearing activities. Salter-Harris classification is often used to classify the severity of the injury with I being the least severe and V being the most serious. Athletes with this injury may complain of pain, swelling, loss of range of motion/strength, inability to weight-bear, etc. This condition should be treated with eliminating stress to the wrist, activity modification, rest, ice, NSAIDs, and sometimes physical therapy. She may return to sport when x-ray is normal and she is symptom-free. 

X-ray film of gymnast's wrist



Rehabilitation after ACL Tear: 4-6 Weeks Post-Op

1) ROM
It is important to regain full ROM by 4-6 weeks post-operatively. Most protocols agree with this. In some cases, ROM may be limited early depending on physician's protocol. But it is important to establish full motion especially into extension by 4-6 weeks post-operatively. ROM exercise may include heel prop, heel slide, wall slide, etc. Stretching calf and hamstring muscles will help to regain knee extension.

2) Quadriceps Straightening
Quadriceps strengthening can be initiated as soon as inflammation is controlled. Initially quad sets with or without NMES(neuromuscular electrical stimulation) is a good way to start firing quad muscle and it can be progressed to straight leg raises (only if knee extension is maintained during exercise). Strengthening exercises for other muscles can also be initiated. It is important to follow physician's protocol and to protect reconstructed graft. 

3) Gait
Normal gait should be established as the injured athlete can tolerate. If he/she can't walk normally, they should be placed on the crutches. Weight shift exercise and gait training on treadmill can help to re-establish normal gait as well as walking in a pool. 

4) Strengthening (closed kinetic chain)/balance exercise
CKC strengthening exercise can be initiated later in this phase of rehab. It includes partial squat, wall squats, leg press, single leg balance, TKE, etc. Again each physician has their own protocol, so it is important to follow it.

The goals of this phase of rehab will be 1) regain full ROM, 2) establish normal gait, 3) start strengthening exercises that include CKC exercise and balance training. Also, strengthening training should be pain-free and inflammation should be under control.

Rehabilitation after ACL Tear: Immediately Post-Op

Immediately after surgery, the knee will be swollen and inflamed. For the first 10 - 14 days after surgery, the main focus is on reducing the inflammation. Depending on the surgeon, formal rehabilitation will be held for the first 2 weeks. The injured athlete should be careful with the woulds from the portal even though they might not be large. There is still a risk of surface infection at the portal sites. The knee might be placed in a rigid knee brace to protect the reconstructed knee. Or the athlete may not even wear any type of brace depending on the surgeon's preference. CPM (continuous passive motion) and PROM (passive range of motion) exercise can be initiated immediately after surgery. However, it is dependent on surgeon's protocol. Ice and NSAIDs are used to reduce and control inflammation. Elevating the knee above the heart may also help to reduce swelling.

Rehabilitation after ACL Tear: Pre-Operative

Anterior cruciate ligament (ACL) tear can be devastating to athletes. However, with advanced surgical technique and more research based knowledge about rehabilitation, the injured athlete can return to sport relatively quickly after reconstructive surgery. Rehabilitation starts right after the injury occurs. Usually, swelling is immediate and causes pain and loss of range of motion (ROM). The athlete may not be able to walk right after injury or even bear weight. It is important to control inflammation and regain inflammation as soon as possible.

1) Reducing inflammation
Pain and swelling should be controlled with ice and/or NSAIDs. Compression wrap and elevating the limb may also help to reduce swelling. Most surgeons will not even operate until inflammation is controlled.

2) Regaining range of motion (ROM)
The athlete will lose knee ROM due to swelling and muscle guarding after the injury. Regaining lost ROM is very important especially in extension. Again, surgery may be delayed until optimal ROM is regained.

3) Regaining quadriceps strength
Swelling/effusion in the knee shuts down quad activity and the muscle gets weak after knee injury. The stronger the quad muscle is before surgery, the easier post-operative rehabilitation will be, because regaining the quad strength is one of the focus during the rehab period.

4) Gait
The injured athlete may not be able to put weight on the injured limb after surgery or walk. Being able to ambulate with or without crutches is important. If the athlete can't walk normally or without symptoms such as pain or knee giving out, crutches should be used. A knee brace may or may not be worn.

Pre-op rehab after ACL tear should focus on controlling inflammation, regaining ROM, and regaining quad strength. However, when treating an athlete, they can stay active while protecting the injured limb using upper arm stationary bike or even walking in the pool.

Asymptomatic Loss of Range of Motion in Junior Athletes

Loss of range of motion (ROM) after acute injury is very common primarily due to swelling and pain. And it usually returns back to normal when inflammation is relieved. For instance, an athlete with acute ankle sprain may display swelling and loss of immediate ROM and it will be to where it was before injury when swelling and pain are gone. However, loss of ROM due to chronic conditions such as frozen shoulder may be more difficult to relieve. One of the reason is that it is developed over a long time and there may be some changes in structure and properties of sift tissue.

But some athletes may display loss of ROM and may not have any symptoms. So, it this bad?? It is not necessarily bad if they do not complain any symptoms which may include pain, decreased performance level, stiffness, etc. However, some research has shown that loss of ROM in certain joint may be linked to possible risk of injury. In overhead athletes such as baseball, softball, and tennis, it is very common to have loss of range of shoulder internal rotation in the dominant shoulder. Instead, usually those athletes will have increased shoulder external rotation compared to the other shoulder. Looking at the total ROM from internal to external rotation end range, if one side has more than 15 degrees less motion than the other side, it is called GIRD (glenohumeral internal rotation deficit) and some research has shown that those athletes may be more prone to an shoulder injury.

Overhead athletes and some athletes like gymnasts may also display loss range of elbow extension compared to the other side. Elbow extension in the dominant arm in overhead athletes may be less than that of non-dominant arm. This may be due to joint capsule tightness and/or forearm muscle tightness (pronator-flexor mass) as a result of repetitive use of the elbow, which can be relieved by stretching exercise. At the same time, it could be as result of early stage of OCD, Panner's disease, bone spur in the olecranon (back of the elbow) which could develop from repetitive stress placed in the joint during overhead motion. Some gymnasts may display loss of elbow ROM without any symptoms probably from repetitive weight-bearing, which puts compressive stress on the outside of the elbow, distraction forces on the inside of the elbow, and overloads between olecranon and humerus. Loss of ROM without any symptoms may not mean that they will need an immediate medical attention but it may be something that needs an eye kept on especially loss of motion is significantly less than the other side. When it is symptomatic in young athletes or elbow does not fully extend (extension is less than 0), they should be seen by a health care provider to find out what is causing it and correct it. Symptomatic loss motion likely indicate some type of injury or condition that needs an attention.

Asymptomatic loss ROM is often ignored until it becomes symptomatic. This may not need an immediate attention as long as it is asymptomatic, however, some literature shows that ROM loss in certain joint may be linked to risk of injury. Loss of ROM in young athletes is certainly something that we need to keep an eye on even when it is asymptomatic.