SNOWMASS, COLO. (FRONTLINE MEDICAL NEWS)Overuse injuries in young gymnasts are extremely common, and they cluster at two vulnerable anatomic sites: the wrist and lower back.

“Gymnasts have to be one of the biggest parts of my sports medicine practice. Some of them are the toughest patients I see in terms of their workouts, consistency, and dedication to their sport. And they’ll work through the pain. Gymnastics is truly a sport where it’s been driven into them that no pain is no gain,” Dr. M. Timothy Hresko observed at the Winter Rheumaltogy Symposium sponsored by the American College of Rheumatology.

With a patient mindset like this, it’s little wonder that physicians have their work cut out for them when trying to help gymnasts heal and prevent future setbacks. Gymnasts are loathe to sit back and rest. Yet rest is central to successful treatment of overuse injuries. And therein lies the basis for a frequent locking of horns, added Dr. Hresko, an orthopedic surgeon at Harvard Medical School, Boston, and Boston Children’s Hospital.

“Quite often you need to reinforce to them the rest that’s necessary for this to work,” he said. “Young gymnasts will spend 20 hours a week in the gym: 4 hours, 5 days a week. We see a lot of overuse injuries associated with that. Is that pushing somebody too much? For skill sports, that’s what’s required if you want to develop the skill.”

Gymnast’s wrist: This is a stress fracture through the radial epiphyseal plate. It results from the tremendous weight-bearing loads imposed on the arms and wrists during many hours of repeated activities including tumbling, swinging, mounting, and vaulting.

Affected patients present with a complaint of pain with weight bearing on the wrist. Physical examination reveals tenderness over the distal radial growth plate and loss of range of motion in the wrist. An x-ray will show widening of the radial growth plate and perhaps irregular bone edges.

Treatment entails cessation of all impact activities for 2-3 months to permit the stress fracture to heal, along with wearing a wrist splint for protection during normal daily activities. The patient can return to gymnastics after that rest period, provided the distal radial physis is no longer tender. The return to the sport should be gradual, with resumption of vaulting reserved for last.

“Vaulting is probably the hardest activity to do and to return to,” according to Dr. Hresko.

Spondylolysis: this is a stress fracture of a lumbar vertebra, which, in gymnasts, results from repeated hyperextension. It’s the most common cause of low back pain in adolescent athletes.

“I must see 6-10 patients per week who have some phase of spondylolysis,” the surgeon said.

The diagnostic hallmark on physical examination is lumbar back pain that worsens with lumbar extension. A straight leg raise test is often positive. The stress fracture will show up on a plain film x-ray but therein lies a quandary.

“In a normal population of adolescents without symptoms, 6% will have evidence of spondylolysis on plain film x-ray. So if you see a positive x-ray in a patient with low back pain you have to ask yourself if this is really the cause of their pain,” Dr. Hresko said.

Herniated discs are “pretty rare” in youth, but the clues are the same as in adults: radicular symptoms, burning pain, and a positive straight leg raise test, he noted.

The treatment for spondylolysis is restricted activities, usually for 2-3 months or one season.

“I personally think it’s best to immobilize them with a brace. We use a custom-made, anterior-opening Boston overlap brace to limit extension. That way they can go back to activities sooner, but they’re usually out of their sport for one season, then we try to get them back for their second season, knowing that the injury isn’t going to heal anatomically,” the sports medicine specialist said.

Gymnasts who are hyperlordotic are at increased risk for spondylolysis. For injury prevention in such individuals, he emphasizes abdominal strengthening and pelvic tilting exercises to reduce the lumbar lordosis.

“We haven’t gone quite so far as to use anatomic body markers like lordosis to suggest somebody’s at such high risk that they should not go out for that sport – sort of an East German approach to athletics – but I do think that in gymnastics there are some patients whose bodies are just not up to the stress involved in that sport,” he concluded.

Dr. Hresko serves as a consultant to DePuy Spine.