Bridget Snapp: I am here today at the Gwinnett Gymnastic Center talking with the friend of the show, Dr. David Marshall once again; Director of Sports Medicine over Children's Healthcare of Atlanta. Thanks for being back with us Dr. Marshall.
Dr. David Marshall: Thanks for having me.
Bridget Snapp: Alright, so when I was a little girl, I always wanted to do gymnastics. My parents had never let me because they said it was too dangerous. Now did they have any sense there, or they are just being mean?
Dr. David Marshall: Well it depends how they define dangerous. If you look at catastrophic injuries about -- concussions and broken collarbones and fractured ankles and things like that, not a pretty safe spot. If you defined dangerous or you like that you get on overuse injury then we see quite a few overuse injuries in gymnastics, just because the nature and the hour sometimes these young kids put in to compete.
Bridget Snapp: Now what are some of the most common injuries.
Dr. David Marshall: Probably, the two most common body parts that I see office are the low back and the wrist. The low back is very common, that's probably the most stressful. That's the one that they can sideline an athlete for 8 to 12 weeks and that's one that the parents and the athletes, and of course the coach is worried about is spine injury.
The most common spine injury is something called a spondylitis or a spondylitis and what that means is Spondy means spine; losis means to separate and it's a development of a stretch fracture back in the lower lumbar region. Now if you think of the spine, there is 30 vertebrate, from the base of your skull all the way down to your tail bone and normally it should be -- it should have these nice flowing curves in it.
You can just imagine when a gymnast does a lot of arching or a lot of back bending, or tumbling, they arch their back. Now if you look at this column, the shear forces are greatest right across L5, that's the fifth lumbar vertebrae down the lower back where the pant line is. So just overtime, repetitive loading of the spine and extension they can get stress reactions and eventually a stress fracture right through that L5 vertebrae. And that's called a spondylitis.
Bridget Snapp: And is that going to set them out for the season, is that --?
Dr. David Marshall: It's not necessarily a season ending injury there is a different ways to treat it. Different doctors and different orthopedists have different philosophies in how to treat it. My feeling is we should treat a stress fractures in the spine, just like we treat stress fractures in the shin, stress fractures in the wrist. If there is a disruption in the integrity of a bone, then motion becomes the enemy. So we need to try to stop all motion, so the body is unchallenged and trying to lay down new bone to repair that area. In the wrist and the ankle, it's very easily done with the cast, with the foot in a dancer, easily done with the cast.
Well it's tough to put a back in a cast, you can't do it. So we try to limit their activities, we really shut them down for period of 4 to 6 weeks. If we stop that pounding, that twisting, that tumbling then at least the body will have that going for it.
We also put them in the lumbar support brace, a corset type, a lumbar girdle type thing, that's going to try to keep their back in that neutral position.
Again the goal is trying to prevent motion, front, back, side-to-side and twisting. So if we can take them out of the gym, maybe let them do just some light conditioning and put them into brace 23 hours a day over about 4 to 6 weeks we should have to have ample time to allow that fracture to heal.
Bridget Snapp: Of course we don't want these girls having to be in these -- for 23 hours a day. What does it look like on the prevention side, girls and guys for that matter?
Dr. David Marshall: Yeah that's right male gymmies can certainly get this as well. For any injury, and overuse injury prevention is the key in order to prevent, an overuse injury you need to recognize, you need to recognize that early signs and symptoms of the injury, but then you also need to figure out or learn what types of activities and what things you need to do to avoid it or modify your workouts to where you are not putting so much stress on that area.
With the lower back injury, it's tumbling, it's that girls do repetitively loading of their spine with extensions. So the handspring, handspring and handspring, full-turn or full-twist and then the compressive landings that certainly increases the stresses.
So they need to realize that that these injuries can be caused by certain types of tumbling, full outs-sprints on the vault, that can definitely put increase stress on the lower back, especially if they are doing back handsprings before they get to the vault. So we need to understand the positions the body has put in, that increases the stress forces across this bone.
Bridget Snapp: And key to prevention here of course it would be the communication with the girls. Girls need to speak up, let the coach, the parent know that they are having some lower back pain.
Dr. David Marshall: That's a good point that you brought up Bridget, because a lot of these kids, they are afraid to tell their coaches that something hurts.
Bridget Snapp: Because coaches can be scary.
Dr. David Marshall: Well they can be scary, and the coach I think they mean well I know the coaches here mean well they encourage the kids, they want the kids and let them know when something hurts, because pain is your body's way of telling you there is something wrong. If we don't pay attention to it, then the pain is going to continue and the injury is going to get worsen. I saw a sign, recently, it said, pain is weakness leaving your body, and I think that's just crazy that encourage kids to say, the more pain you feel the more weakness live in your body and the strong you are, and that is absolutely not -- I think that's a bad signal or bad message to send these young athletes.
Bridget Snapp: You said the next thing that's common was the wrist injury.
Dr. David Marshall: Right.
Bridget Snapp: Tell me about this.
Dr. David Marshall: Yeah, the wrist injuries, they are very common. Again because of the nature of tumbling, whether they believe in evaluation your creation or not, I don't care, but I think we evolve with the wrist not being weight bearing bone. Once we became biped animals, the feet and the ankles were designed to bear weight, but the wrists were not. The wrist kind of evolve to build fires and to make tools and to pick berries but now we have this gymnast that think their wrists or weight bearing bones again with all the tumbling and the handstands that they do.
So I think the increased stress we put on the wrist and the wrists were poorly designed for that, eventually they develop an overuse injury. With these young athletes, between the ages of 6 and 15 they still have open growth plates. Growth plates are found at the ends of all the long bones and the growth plates at the ends of the wrist bones are vulnerable.
So when you continue to load and compress and bear weight on those bones, eventually the growth plates get injured. If they continue to get injured without recognition, they can actually close prematurely. So now if you have your growth plates closed before they are ready to now your arms are going to be shorter. Well worse off, if one growth plate closer before the other one, then the two bones in your forearm go out different lengths and then your hands start to deviate, and that's the surgical problem.
So clearly prevention and early recognition of wrist injuries in a gymnast is paramount of preventing long term problems.
Bridget Snapp: What's going to happen if somebody comes to you and they say, I am having wrists problems?
Dr. David Marshall: The first thing we do is to read the history to check what they have done recently with their tumbling, see if they have changed levels, if they have increased their workouts, if they are working on a certain skill, and maybe loading the wrists a little too much more than they probably should, so if we look at modifying the workouts then of course the physical exam determine exactly where they hurt. If they hurt over the bone, it might be a fracture. If they hurt over the growth plate it might be just that. So it's important to go to your doctor that understands the sports understands anatomy and determines exactly where the injury is, and then the next thing is X-ray.
X-ray can definitely give us a picture as to what those bones and what the health of those growth plates look like, and then based on all three of those things we determine, what's best and what's safest for this athlete.
Bridget Snapp: If they have actually done some damage to their growth plates, would they be able to continue practicing a sport after some rehabilitation or is that --?
Dr. David Marshall: If there is clearly abnormal X-rays, if we do one side compare to the other and there is a difference then we recognize, hey this growth plate is suffering, it needs rest and again, like any other fracture, any other growth plate stress injury, immobilization is the way to go. So sometime these kids require cast, we put them in a cast for short period of time, 2 to 3 weeks, just to give that body a chance to heal without any challenges.
In the meantime, the kid still finds remarkably ways to still go to gym. Of course, they can tumble, they can do everything, but they can still condition, they still might be able to do some balance stuff, some leap, some twist, some turns on the beam, so we can always keep them in the gym doing something.
Bridget Snapp: And I often see the girls walking around with some kind of wrist guard on. Is that protective measure? What is that?
Dr. David Marshall: It is a preventive thing, those risk guards are common name for the tiger pose and those are designed to help protect the wrist. When they tumble it might prevent the wrist from bending all the way back which unloads the joint and the growth plates a little bit. It has also designed to redistribute the load evenly over both bones, so you are not getting 80% of the stress on the thumb side, bunk all the radius, it redistributes it evenly. I think every gymnast whether they start having wrist pain or not, needs to be worrying, when they get into the option levels, levels 7,8,9 where the kids are spendings, puts up 16 to 30 hours a week in the gym, they need to be encouraged to wear those risks guards.
I also recommend the level 7 get their wrist X-rays every single year, just part of their regular check that they need to have the wrist X-ray just to make sure we pick up early signs of wear and tear to stop that and prevent it and treat it and before it gets too bad. But rarely does it cause long term complications. The growth plates typically close, they mature, they heal and then when the kids are 13 or 14 and those growth plates turn to bone then the condition is resolved, so they usually don't cause long term problems.
Bridget Snapp: So these kids are resolving though?
Dr. David Marshall: They are I mean that the younger the kids are, their bone seem to be like rubber, they certainly bend along before they breaks, so these kids they are athletes, they generally tolerates aches and pains and overuse injuries very well.
Sometimes that gets in the way. I like it when the kid has a high pain tolerance, that means they don't complain any grumble about every ache and pain but when they have an overuse injury you don't want them to be so tough, you want them to let somebody know that their heel hurts, their back hurts, their wrist hurts, that's how we recognize these things early and get them treated properly.
Bridget Snapp: So is it just too much though, the gymnast going hours and hours a week, is this too much on them?
Dr. David Marshall: Well, it depends. Just a couple of months ago, we watch the Olympics and clearly those kids to get to that level, get that recognition, they have to start to somewhere and they start in gyms just like this year GGC they start when they are young and they train in order to develop those skills at that level, you have to put in the hours. Some kids can handle, some kids can't. So everybody is different.
Bridget Snapp: And that's important, they have to have a good doctor like you taking care of them and watching of them.
Dr. David Marshall: I appreciate that.
Bridget Snapp: Thanks for teaching us how they can prevent these and take care of these injuries.
Dr. David Marshall: Thank you.
Bridget Snapp: Thank you for watching this edition of ClubHouse Gas. We'll see you next time.
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