The document discusses impact knee and ankle injuries in gymnastics. It notes that these types of overuse injuries affect thousands of gymnasts worldwide and are a major problem that is getting worse. The document outlines several contributing factors, including a lack of understanding of workload management principles, the evolving difficulty of skills and equipment, and cultural resistance to prioritizing basics over new skills. It then details some of the most common knee and ankle injuries at different age ranges. The document concludes by discussing prevention methods, including radical communication, workload management, physical preparation, proper landing and skill technique, prehab, and managing injuries when they first occur.

1. Combatting Impact Knee and Ankle
Injuries in Gymnastics
Dr. Dave Tilley DPT, SCS, CSCS
1

2. 2
Why spend a whole lecture on this?
We should spend a whole month on this!
Without a doubt one of the top 3 topics that
plagues gymnasts, coaches, and medical providers
Research Articles 1-3

3. 3
Research and every day coaching experience
is pretty clear on this
• Impact overuse knee and ankle injuries affect 1000’s of
gymnasts worldwide
• Not only is it a problem, it’s getting worse despite our
efforts
• It’s have a huge negative impact on athlete health,
training progress, and gymnasts quitting the sport
What’s Going On?
Research Articles 1-3

4. 4
Many, many factors interacting
• We do not understand and use work load
science, periodization, and formalized
strength principles well enough
• Gymnastics is hard.
• Skills + Equipment Evolves = More Force per
rep
• 8.8-14.9x Body Weight Recorded Floor
• 23x Body Weight (!?) at ankle joint
Why Is It Such An Issue?
Research Articles 1-3

5. 5
• Sport Evolves = More Reps per skill and hours
per week
• We work with KIDS! ( Yes 18 is still a kid )
• Cultural Resistance
• Basics + Technique > Throwing New Skills
• Delay Specialization
• Off Season
• Interdisciplinary Team > Coach Doing All
• Flexibility
• Strength and Conditioning
Why Is It Such An Issue?
Research Articles

6. 6
Trauma
• ACL / Meniscus Tear
• Achilles Tear
• Fractures
• Ankle Sprains or Other
Ligaments
Overuse
Knee
• Growth Plate Inflammation
• Stress Reaction / Fracture
• Knee Cartilage (OCD)
• Patellar Tendinopathy
• Meniscus & Ligament Breakdown
Overuse
Ankle
• Growth Plate Inflammation or
Stress Fracture
• Ankle Cartilage (OCD)
• Achilles Tendinopathy
• Meniscus & Ligament
Breakdown
Research Articles 4-22

7. 7
Same Song, Different Dance?
Sever’s
Achilles
Tendinopathy
Stress Rxn
ACL / Meniscus
Tear?
Stress Fracture or
OCD?
8 - 1 2 Ye a r s O l d
M o s t V u l n e r a b l e A r e a
= G r o w t h P l a t e
1 2 - 1 6 Ye a r s O l d
M o s t V u l n e r a b l e A r e a
= Te n d o n / B o n e
1 7 + Ye a r s O l d
M o s t V u l n e r a b l e A r e a
= B r o k e n D o w n
Te n d o n / B o n e / C a r t i l a g e
Research ArticlesResearch Articles 4-22

8. 8
Same Song, Different Dance?
Osgood
Schlatters
SJL Syndrome
Patellar
Tendinopathy
Stress Rxn
ACL / Meniscus
Tear?
Stress Fracture or
OCD?
8-12 Years Old
Most Vulnerable
Area = Growth
Plate
12-16 Years Old
Most Vulnerable
Area =
Tendon/Bone
17+ Years Old
Most Vulnerable Area
= Broken Down
Tendon/Bone/Cartilage
Research ArticlesResearch Articles 4-22

9. 9
What Are The Most
Common Injuries? – Knee
Osgood Schlatters – Bone Inflammation of
Growth Plate Where Quad Attaches
Sinding Jarson Lohanssen – Bone
Inflammation of Growth Plate Patella
Stress Reactions/Fractures – Bone
Inflammation progressions to cracking
Research ArticlesResearch Articles 4-22

10. 10
What Are The Most
Common Injuries? – Knee
OCD – Break Down cartilage inside knee
joint
Meniscus – damage to shock absorbers
of knee joint
ACL/Other Ligaments – failure of
supporting structures around knee
Research ArticlesResearch Articles 4-22

11. 11
What Are The Most Common
Injuries? – Ankle
Severs– Bone Inflammation of
Growth Plate Where Achilles
Attaches
Stress Reactions/Fractures – Bone
Inflammation progressions to
cracking
Talar Dome OCD– Cartilage break
down in ankle joint
Research ArticlesResearch Articles 4-22

12. 12
Is There Any Hope For Gymnastics? Prevention Methods
After 6 years of geeking out… here are the only things I
have seen honestly move the needle on injury rates
Research Articles 4-22

13. 13
What is the major overlapping factor?
Tissue
Capacity
Tissue
Load
Load
Load
Load
Tolerance
Tolerance
▲
Capacity
▼
Load
(For optimal adaptation)
Research ArticlesResearch Articles23-28

14. 14
Impact
Injury
Reduction
Radical
Communication
Workload
Management
Robust
Physical Prep
Proper Landing
Technique
Proper Skill
Technique /
Readiness
Weekly PreHab
(Soft Tissue and
Strength)
Research Articles

15. 15
Radical
Communication
You can not bring technical solutions to
cultural problems
Environments that do not have mutual trust,
positive role modeling, and community
support will not have success in injury rate
reduction
Research Articles

16. 16
Radical
Communication
How do you build this?
”People believe what you do, not what you say”
Daily conversations, habits, choices
Patience, work, patience, work…. Patience and work.
LISTEN when someone says pain starting and modify
If really a fear, motivation, or misalignment of goals… have
the harder conversation.
Research Articles

17. 17
Workload
Management
Remember these pictures?
Research ArticlesResearch Articles 23-28

18. 18
Robust Based
Physical Prep
Remember this lecture?
I put them in order for a
reason!
Research ArticlesResearch Articles 23-28

19. 19
Proper Landing
Technique
There’s no way around it…
We HAVE to change how gymnasts land
Not Ideal
• Knee Dominant
• Upright Torso
• Hips Tucked Under
• Knees Together
• Lack of hip angle
Research Articles 4-11

20. 20
Proper Landing
Technique
Not Torn ACL > Not “Pretty”
More Ideal
• Hip Dominant
• Angled Torso
• Spine More Neutral
• Knees Hip Width
• Hip Angle
encouraged for
glute and hamstring
deceleration
Research ArticlesResearch Articles 4-11

21. 21
Proper Landing
Technique
This is not just me suggestion this…
TONS of helpful research on this
Research Articles

22. 22
Proper Skill
Technique /
Readiness
Is this Yurchenko/Full/Dismount
REALLY ready for hard today…
Helpful guidelines we use
• Must perform 7 in mock competition setting before and during
meet weeks
• “Not happening in 3, not happening today” in practice or meets
• Health > Score, Medal, Social Media, etc. Period.
Accidents still happen and things go wrong, but much is preventable!

23. 23
Weekly PreHab
(Soft Tissue and
Strength)
Research Articles

24. 24
So What Do I Do
When Someone
Starts to Have
Pain?

25. 25
11 Steps (no pun intended)
1. Reduce Impact Volume
2. Early Medical Care
3. Patience
4. Manage Soft Tissue
Research Articles

26. 26
5. Nightly Ice and Compression
6. Land Properly
7. Rebuild Local Strength
Research Articles

27. 27
8. Rebuild Impact Volume
9. Build Leg Strength
10. Correct Technique
11. Track Growth
Research Articles

28. References
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Symposium Medico-Technique (pp. 17-27). Lyss, Swizerland: International Gymnastis Fedearation.
3. Thomas RE., Thomas BC. A systematic review of injuries in gymnastics. The Physician and Sportsmedicine.
https://doi.org/10.1080/00913847.2018.1527646
4. Pappas E., Zampeli F., Xergia SA., Georgoulis AD. Lessons learned from the last 20 years of ACL – related in vivo biomechanics research
of the knee joint. Knee Surg Sports Traumatol Arthrosc. 2013 Apr; 21(4): 755 - 766
5. McaAdams TR., Mithoefer K., Scopp JM., Mandelbaum BR. Articular Cartilage Injury in Athletes. Cartilage. 2010 Jul; 1(3): 165 – 179
6. Logerstedt, D.S., et al. Knee Stability and Movement Coordination Impairments: Knee Ligament Sprain. J Ortho Sports Phys Ther. April
2010, 4(40). A3 – A37
7. Mordecai SC., Al-Hadithy N., Ware HE., Gupte CM. Treatment of meniscal tears: An evidence based approach. World J Orthop. 2014
Jul 18; 5(3): 223 – 241
8. Kramer DE., Miller PT., Berrahou IK., Yen YM., Heyworth BE. Collateral Ligament Knee Injuries in Pediatric and Adolescent Athletes. J
Pediatr Orthop. 2017. Dec [currently ahead of print]
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Orthop. 2014. Nov 18; 5(5): 677 684
10. Smith, HC., Vacek P., Johnson RJ., et al. Risk Factors for Anterior Cruciate Ligament Injury. : A Review of the Literature – Part 1:
Neuromuscualr and Anatomic Risk. Sports Health. 2012 Jan; 4(1): 69 – 78
11. Smith, HC., Vacek P., Johnson RJ., et al. Risk Factors for Anterior Cruciate Ligament Injury. : A Review of the Literature – Part 2:
Hormonal, Genetic, Cognitive Function, Previous Injury, and Extrinsic Risk Factors. Sports Health. 2012 Mar; 4(2): 155-161

29. References
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13. Arnold A. Overuse Physeal Injuries in Youth Athletes: Risk Factors, Prevention, and Treatment Strategies. Sports Health. 2017. 9 (2) 139 –
147
14. Paterno MV., et al. Prevention of Overuse Sports Injuries in the Young Athlete. Orthop Clin North Am. 2013. October 44(4) 553 – 564.
15. Chen YT, Tenforde AS, Fredericson M. Update on stress fractures in female athletes: epidemiology, treatment, and prevention. Curr Rev
Musculoskelat Med. 2013. 6:173-181
16. Behrens SB., et al. Stress Fractures of the Pelvis and Legs in Athletes: A Review. Sports Health. 5(2): 165 - 174
17. Astur DC, et al. Stress fractures: definition, diagnosis, and treatment. Revista Brasileira de Ortopedia. 2016; 51(1) Jan – Feb, 3-10
18. Yun Li, H., Hua YH., Achilles Tendinopathy: Current Concepts about the basic Science and Clinical Science. Biomed Res Int. 2016: pp. 1-9
19. Chilvers M, Donahue M, , Manoli A. “Foot and Ankle Injuries in Elite Female Gymnasts”. Foot & Ankle International, Vol 28, No.2, Pages
214-218, Feb, 2007.
20. DeLee JC , Drez D , Miller MD . Achilles tendon injuries . In: Orthopaedic. Sports Medicine: Principles and Practice . 3rd ed. Philadelphia,
PA : Saunders Elsevier ; 2010 : 2182 – 2205 .
21. Cook JL1, Purdam CR. Clin Sports Med. 2003 Oct;22(4):777-89. Rehabilitation of lower limb tendinopathies. Clin Sports Med. 2003
Oct;22(4):777-89
22. Cook JL., Rio E., Purdam CR., Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and
research? Br J Sports Med. 2016 Oct; 50(19): 1187 – 1191

30. References
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24. Bourdon PC, et al. Monitoring Athlete Training Loads: Consensus Statement. International Journal of Sports
Physiology and Performance, 2017, 12, S2-161 -S2-170
25. Lorenz D., Morrison S. Current Concepts in Periodization of Strength and Conditioning for the
Sports Physical Therapist. Int J Sports Phys Ther. 2015 Nov; 10(6): 734-747.
26. Haff GG. Periodization strategies for youth development. In Llyod RS, Oliver JL, Strength and
Conditioning for Young Athletes: Science and Application. 2014. Routledge: New York. 149-158
27. Turner A., Comfort P. (2018) Periodization. In Turner A, Comfort P; Advanced Strength and
Conditioning: An Evidenced-Based Approach. New York: Routledge, 116 - 136
28. Gabbet TJ. (2018) Workload monitoring and athlete management. In Turner A, Comfort P; Advanced Strength and
Conditioning: An Evidenced-Based Approach. New York: Routledge

31. THANK YOU!
Questions? Chime in on The Hero Lab
Facebook Page or email
dave@shiftmovementscience.com