by Sami Gurdon
Today’s article is going to examine one of the most common and also one of the most preventable injuries we see in Gymnastics – the Lumbar Stress fracture. Gymnasts are at an increased risk of developing lumbar stress fractures due to the excessive volume of lumbar extension and rotation coupled with the repetitive nature of the sport and high volume of training required.
In most cases it is possible to fully recover and build back to full training after an initial period of rest and no impact. This does however require careful management of the athlete including assessing and rectifying any underlying muscle imbalances or movement patterning issues that lead to the injury in the first place. Furthermore, they must adhere to an adequate period of rest and no impact before beginning a slow and progressive return to impact and full training. In some cases it may also be necessary to modify any pre injury skills and routines that may increase their risk of re-injury due to excessive lumbar hyperextension required or poor technique by the gymnast.
After imaging and diagnosis, physiotherapy is always the first port of call for any athlete with a stress fracture. Through manual treatment physios will work to reduce pain levels and minimise risk of further exacerbation of the condition. They will often commence basic intrinsic core retraining early in the treatment and will aim to restore pain free range of motion.
The Return to Training Process
After an initial period of rest and manual treatment the gymnast is cleared to start re-strengthening in preparation for the return to training process. This is ideally where exercise physiologists work with the athlete to get them to a point where their coach can safely and confidently begin a progressive build back to full training.
Assessing the athlete:
To give the athlete the best chance of returning to training with a low reinjury risk it’s crucial to identify why the injury occurred in the first place. An Exercise Physiologist must perform a biomechanical assessment and analyse the training program that was in place leading up to the injury as this can give some really important cues as to how and why the injury occurred. It’s important also to review the athletes skill set as if we combine this information with what was found in the movement assessment we can identify skills that might need slight tweaking or re-training and this is where communication with the coach becomes really important to ensure the best outcome for the athlete.
There are a couple of really common postural problems that are quite specific to gymnasts that result in joint instability, muscle imbalances and poor landing mechanics. These issues can be responsible for many of the stress fractures and other common overuse syndromes seen in the sport. It’s important however to treat everyone as an individual and ensure that we don’t adopt a one size fits all approach as there are many other possible causes that could be easily missed.
Following a biomechanical assessment the gymnast will commence a staged restrengthening program. This will be slightly different for each gymnast depending on the specific factors that led to their injury but a basic outline has been provided below:
- Core: Intrinsic core retraining in static and/or isometric positions
- Pelvis: Basic pelvic awareness exercises and basic pelvic mobility
- Lower Body: Basic proprioception exercises only
- Flexibility: Auxiliary stretching and mobility work that places minimal strain on the lower back.
- Core: Advanced transverse abdominus and intrinisic core exercises (increasing complexity from stage 1), lower abdominal activation exercises and isometric oblique strengthening
- Lower Body Strength: Low impact muscle activation and re-engagement exercises of posterior chain muscles (hamstrings, glutes etc) and lower limb stabilising muscles (bodyweight only and mostly static)
- Flexibility: as per stage one with the addition of upper body stretches and trigger work (with the consideration of minimising strain on the lumbar spine).
- Pelvic Mobility: more advanced pelvic awareness and mobility exercises
- Cardio: Light work on stationary bike
- Gymnastics: Advised to complete rehabilitation program in the gym with reduced training hours in order to keep routine and avoid isolation.
- Core: Focus on building core endurance and introducing rotational and anti-rotational core control
- Lower Body Strength: more advanced stability exercises, re-introduction of more compound and complex dynamic strength exercises with a focus on correcting pelvic position, preparation for reintroduction of landing mechanics.
- Upper Body Strength: Address any shoulder stability or scap setting deficits, re-introduce basic upper body strength ensuring a neutral pelvis is maintained.
- Flexibility: continue to progress stretching and mobility work avoiding positions that strain the lower back or place the gymnast in lordotic postures
- Cardio: Light to moderate stationary bike or deep water running.
- Gymnastics: Can introduce some basic gymnastics specific low impact work such as ankle complex work on beam and small amounts of static handstand hold work.
- Core: Continue to progress elements of previous phase as well as introducing more advanced dynamic core control progressions.
- Lower Body: strengthen through full ranges of motion, improve single leg stability and introduce basic landing mechanics.
- Upper Body: Continue as per last phase progressing to more advanced exercises that are isolative to the upper body.
- Flexibility: Continue as per last phase with introduction of controlled lumbar extension mobility
- Cardio: Moderate intensity on exercise bike or elliptical, introduction of low impact jogging and jumping in water (immersed to chest height)
- Gymnastics: work with coach to reintroduce gymnast to basic training progressions (mostly non dynamic skills).
- Core: Continue progressions as per last phase with the gradual reintroduction of gymnastics specific exercises
- Lower Body: Progress to advanced landing mechanics, introduce multi-directional landings and retrain jumping and take-off mechanics
- Upper Body: Continue progressions as per last phase with the gradual reintroduction of gymnastics specific exercises and whole body exercises
- Flexibility: Continue as per last phase with reintroduction of former stretching regime.
- Gymnastics: work with coach to reintroduce basic training progressions (begin work on appropriate dynamic basic skills.
- Cardio: Moderate intensity and introduction of higher intensity intervals on exercise bike.
- Continue on with maintenance program
- Begin progressive return to full training load.
- Modification of skill set if necessary to decrease risk of re-injury.
While we can’t completely reduce the risk of one occurring due to the nature of the sport and high volume of training required we can greatly reduce the risk of injury or re-injury. By developing control through full range of movement, correcting muscle imbalances particularly anterior to posterior muscle imbalances at the pelvis, improving core control and strengthening a gymnast to optimise landing mechanics we can greatly increase outcomes for gymnasts recovering from lumbar stress fractures.
If you would like to know more or need help recovering from injury please contact Sami for more information on (07) 3356 9119 or 0408 806 209