A Plague Tale Complete The Aiming Training

[Sullivan Maurer]

Hippain is extremely common in gymnasts. Despite the research saying that only 3.1-5.7% of all injuries in gymnastics occur in the hip, the reality is that it is much more common. Injuries like hamstring growth plate inflammation (ischial apophysitis), hip flexor strains, and labral tears can plague gymnasts for years.

It is crucial that a gymnast get the proper evaluation, and accurate diagnosis, for their hip pain. A common misunderstanding in the medical and gymnastics world is that gymnasts just need to do more flexibility and glute exercises like clamshells to fix their hip injury. This is very misguided. It is true that soft tissue mobility and glute strength are important parts to hip health and performance in gymnastics. But, there are many other factors that I will cover below that are crucial to understanding. I have treated 1000s of gymnasts for hip pain in my career and can tell you that only focusing on stretching and low-level glute exercises is not enough to make substantial progress for hip injuries.

After this short introduction, I will start by outlining how common hip pain is in gymnastics. I will then review some of the biggest factors that might be most important to understand as to why these injuries occur. Following this, I will break down the basic anatomy of the hip joint and the most common injuries we see frequently in gymnasts.

Then, I will walk people through the 4 main phases of injury rehabilitation, share the exact exercises/approaches I use with gymnasts, and talk about returning to sports safely. To conclude things, I will discuss some ways that we can work together to reduce the risk of back injuries in gymnastics and offer help for people who may be really struggling with ongoing pain.

If you are a gymnastics coach, I have 40+ of webinars, handouts, and discussion boards inside our online gymnastics education group The Hero Lab. We cover everything from flexibility, to strength, to culture, and more while getting access to live Q&A.

At the biggest picture level, gymnastics is an extremely unique sport that has athletes using their arms as legs. The hip joint is not inherently built for these very large ranges of motion like the shoulder is, and expriences very high forces at end ranges of motion. Skills like switch leaps, ring leaps, stalders, and others can be very taxing on the hip joint structures and musculature.

The anatomy of the hip joint is very much designed for stability, not mobility. It has a deeper socket than the shoulder, allowing it to be what we put thousands of miles of walking on. It helps us handle the forces of running, jumping, and landing. But, the trade-off is that it does not allow for very large ranges of motion. For these reasons and more, we must be more cautious with extreme high-level gymnastics skills so we do not negatively stress the hip joint.

While the repetitions of skills are by far one of the biggest factors for why a gymnast may develop hip pain, we can not deny the reality that the forces that gymnastics puts on the hip of a gymnast are enormous. In an effort to help condense some of the research around this (mor in this book here and here), here is a list of forces that have been recorded.

One of the clearest factors for hip injuries in gymnastics is the massive amount of flexibility required for skills. While these large ranges of motion definitely make gymnastics one of the most impressive sports in the world, it often comes at a cost. As mentioned above, when elite ballet dancers had x-rays taken of their hips in a straddle split, there was a notable amount of hip joint subluxation that had to occur for full a 180-degree angle to be reached. There is also other X-ray evidence that this occurs in gymnasts during oversplits.

What this tells us is that in order to reach these extreme ranges of motion for splits/oversplits, jumps, leaps, stalders, and other skills, many things must go right. Not only does someone need to have the underlying boney structure that supports it, they also need significant joint capsule hypermobility and soft tissue flexibility. The reality is that not every gymnast will have these things. As a result, not every gymnast is going to fit the mold of a very hypermobile athlete who can reach full splits and perform skills that have these massive ranges of motion requirements.

On top of that, contrary to what many inside gymnastics believe, regular stretching does likely not make muscles truly longer. As this paper and this paper suggest, it is likely more of a desensitization process through receptors called nociceptors. While there is some evidence that over time the passive elements of tendons and muscles can increase their compliance, it likely is not the main reason long-term changes stick.

In order to change the actual muscle tissue itself, we likely need to be incorporating things like loaded eccentrics and science-based strength and conditioning methods that utilize weight training (more below). We also need to make sure that the muscular tissue itself, and no the ligaments or joint capsules, are the things being biased. For this, we need to study the hip anatomy in-depth and make sure we adjust certain flexibility stretches. This may not look as aesthetically impressive, but it will be better for both gymnastics performance and hip health.

Gymnastics is a very unique sport where very young kids ages 8-12 are asked to perform very high force skills, in high amounts, and are training 20+ hours per week in some situations. In some areas of the sport, particularly those trying to get on the pre-elite/elite or NCAA track, it can create a difficult time period where pre-pubertal athletes are training high force skills, in high repetition, well before their bodies are physically or mentally capable of handling it. This is where expert coaching, training plans, and pacing comes must be a priority.

Based on great literature (more here, here, and here), it is clear that a properly done, properly coached, and properly progressed strength and conditioning program is beneficial for performance and reducing the risk of injuries. This includes a combination of both external weight lifting and bodyweight strength work. This type of training is huge to help build the core and glute muscles, and the other dynamic stabilizers, to protect the ligaments, tendons, and joint capsules in the hip.

As a result of this cultural barrier, many gymnasts do not get the adequate core/leg strength and capacity needed to handle the high-impact forces going through their hip joints. Not to mention, they are putting a huge bottleneck on their potential to train and compete for high-level skills. Gymnastics is a sport based on explosive bodyweight power. The same thing that helps improve this power will also help mitigate the risk of back injuries, both overuse and acute. For more information about this topic check out this popular blog post I wrote in 2016.

This is in contrast to the suggested landing pattern, supported by enormous amounts of data, of a squat-based landing that has the feet hip-width apart, knees tracking in line with the hip and feet, and the allowance of squatting to parallel depth so various musculature can be recruited to buffer forces.

Until this becomes the gold standard for teaching gymnasts how to land in practice and competition, we may continue to see high back pain rates. I recently gave big presentations to the coaches and judges in the NCAA about this topic that you can check out here.

There is great evidence that this is concerning for increasing the risk of burnout, overuse injuries from repetitive movement patterns, and that it may negatively impact their overall athletic potential long term. The majority of the literature suggests that 14 or 15 years old is ideal for specialization. With that in mind, I think that may be unrealistic for many gymnasts, and that 10-11 might be a better target.

But hearing about gymnasts specializing at 8 years old, as studies including one in the NCAA I was part of have suggested, is definitely concerning for all injuries. This is something our sport desperately needs to talk about and change to protect young at-risk gymnasts. While there is a large range of movements in gymnastics, the repetitive impact of only doing gymnastics from a young age might be a big reason so many lower back injuries are so common.

I strongly feel that creating relative off-seasons, using periodization, and utilizing cross-training are crucial for reducing back injury risk and optimizing performance. The reality of our sport is that there has never been a time when gymnasts followed evidence-based guidelines around recovery, offseasons, and science-based work to rest ratios.

Workload, athlete monitoring, and periodization are all areas of research that have become very popular in sports around the world. It is very common to hear about sports like soccer, basketball, and baseball utilizing specific workload tools to help plan and manage training volumes in athletes.

This is particularly true for the lower levels, where proper tumbling, vaulting, and bar technique is crucial. Gymnasts must be put through the proper technical progressions skills and events to make sure they are equipped to handle the high forces of skills. If these foundations are not set from an early age, and a constant focus as the gymnast progresses in level, it might create high-risk situations. Making changes here comes down to better coaching and education systems throughout the world, to share. the optimal technique and progressions to keep gymnasts as safe as possible.

Lastly, there is no denying that the sport of gymnastics has become exponentially harder in the last 10 years as equipment technology progresses. The spring floor, the vaulting table, the trampoline beds, and other advancements have helped skyrocket the level of skills being performed. The double-edged sword here is that this also increases the average force the body takes.

I by no means am here to bore people with a dissertation in anatomy. But if we wish to make a change in the rates of back injuries, we must first understand the anatomy that contributes to those injuries. This helps to understand the nature of common injuries and leads us down the road of helpful strategies to reduce risk. To best do this, I will mirror the available literature studies that describe layers of the hip. Keep in mind I have modified the terminology and layout slightly the lean into the less medical diagnostic organization.

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