Gymnast Archives

Understanding Hip Impingement in Teens: How it Happens and How to Prevent It

by rona@revdojo.com | Jun 17, 2024 | Sports Medicine

Also commonly referred to as hip impingement, femoroacetabular impingement is a painful condition that occurs in the hips of adolescents and young adults. Two bones fit together to make up this “ball and socket” joint including the head of the femur (ball), which is part of the thigh bone, and the acetabulum (socket), which is part of the pelvis.

Impingement, or pinching, causes pain when the bones in the hip joint pinch the labrum, the soft tissue on the perimeter/edges of the acetabulum.
There are three types of FAI:

Cam impingement occurs when the shape of the femoral head or ball is abnormal.
Pincer impingement occurs when the shape of the acetabulum or socket is abnormal.
Combined impingement occurs when both the ball and the socket are abnormal.

Pediatric orthopedic surgeon Henry B. Ellis, M.D., says, “Repetitive activities make changes in the joints. In the hip, either the soft tissues become damaged, the bone actually changes its shape or both of these occur.” The reason for abnormal bone shape is not known. It may occur during development or may be in response to activity.

Symptoms of hip impingement are more likely to occur in those who perform:

Repetitive maximal flexion (bending) of the hip, such as deep squatting or high kicking.
Repetitive movements in activities, such as running, dance, gymnastics and hockey.

What are the symptoms of femoroacetabular impingement?

Pain in the hip or groin, typically in the front.
Tenderness and/or swelling of the hip or groin area.
Stiffness or pain after sitting for long periods of time.
Aching or pain that worsens with certain activities.

How is it diagnosed?
A thorough history and physical examination are used to diagnose a hip impingement. In most cases, X-rays are used to further assess the shape and fit of the bones. If symptoms do not improve or worsen, additional imaging such as an MRI or MR arthrogram may be recommended to further evaluate the soft tissue, the acetabular labrum. An MR arthrogram uses MRI, fluoroscopy and sometimes an injected medication to show the structures inside the joint.

How is it treated?
Treatment depends upon the severity of the condition and typically begins with a nonoperative approach which typically includes resting from activities that cause pain or changing to activities that do not. Other treatment options include physical therapy, joint injections or arthroscopic surgery may be required.

In a recently published article “Risk Factors for Suboptimal Outcome of FAI Surgery in the Adolescent Patient”*, Ellis and others reported findings after reviewing 126 hips (114 patients) under the age of 18 who were being treated for symptomatic FAI. This work helps Ellis and his colleagues around the country provide better counseling to patients considering surgery for FAI.

Early recognition and treatment are important because hip impingement has been shown to be a risk factor for early development of osteoarthritis of the hip.

How can hip impingement be prevented?
Overuse injuries like hip impingement and FAI occur with a high volume of training, repetition of certain movements and early specialization in a sport.

“Hip impingement in a growing child is bad news. We need to help them monitor and modify their volume of repetitive activities to prevent the condition from worsening, or even better, developing.”

Henry B. Ellis

These suggestions can help to prevent FAI and other similar overuse conditions:

Avoid sports specialization and play multiple sports throughout high school.
Emphasize moderation with load and training.
Encourage free play and lifetime sports like cycling and hiking.
Avoid year-round participation and encourage weekly and seasonal rest from activities requiring repetitive maximal flexion of the hip.
Perform proper warm-up and conditioning for all activities.

Learn more from Ellis about Hip Injuries in Young Athletes.

*Yen, Y. M., Kim, Y. J., Ellis, H. B., Sink, E. L., Millis, M. B., Zaltz, I., Sankar, W. N., Clohisy, J. C., Nepple, J. J., & ANCHOR Group (2024). Risk Factors for Suboptimal Outcome of FAI Surgery in the Adolescent Patient. Journal of pediatric orthopedics, 44(3), 141–146.

Osteochondritis Dissecans (OCD) in the Elbow

by rona@revdojo.com | Oct 19, 2022 | Sports Medicine

Our Center for Excellence in Sports Medicine treats a wide array of sport-related injuries and conditions in young athletes. One common condition treated is osteochondritis dissecans (OCD) of the elbow. This condition can happen to anyone but is especially common in sports such as gymnastics, tumbling, and baseball.

“This condition often presents to us in very late stages because it develops without symptoms,” says pediatric orthopedic surgeon Philip L. Wilson, M.D. He advises athletes, particularly baseball players and those in weightbearing sports like gymnastics, not to ignore nagging elbow pain. “Painless loss of extension is another sign that should not be ignored,” he says. “Proper diagnosis and early treatment can make a real difference in the course of care and outcomes.”

Our pediatric sports medicine team is a national leader in caring for and studying elbow OCD in young athletes. “The more we learn about the condition and the athletes, the better we can be at treating elbow OCD and teaching others the best way to prevent and manage it,” Wilson says. Here are two examples of Scottish Rite’s work:

An ongoing study called SAFE is open to young athletes, including gymnasts and baseball players. This study is looking at movement mechanics and the causes of injuries in these populations. Check out this video about SAFE testing.

A study published in 2021, “Elbow Overuse Injuries in Pediatric Female Gymnastic Athletes: Comparative Findings and Outcomes in Radial Head Stress Fractures and Capitellar Osteochondritis Dissecans,” specifically addressed findings in 58 elbows in gymnasts (average 11 years of age) treated at Scottish Rite for Children throughout a course of five years. This study was the first to describe the differences between OCD and radial head stress fractures.

Learn more about OCD of the elbow, its causes, symptoms, treatment, and prevention below.

What is osteochondritis dissecans of the elbow?
The surfaces of the bones inside joints are covered with a smooth, gliding surface called cartilage. Osteochondritis dissecans (OCD) is a condition in which an area of cartilage and the underlying bone begin to soften, crack, or even separate. If left untreated, OCD can cause further damage to the cartilage in the joint and early arthritis.
This is a rare condition that most often affects the knee, but it can also affect the elbow, hip or ankle. In the elbow, the surface on the end of the humerus, the capitellum, is the most affected. This is typically seen in active individuals ages 8 to 19, more often boys than girls.

How does elbow OCD occur?
There are likely several factors, and the exact cause is still unclear. A common cause is a temporary loss in blood supply to an area of bone in a growing child, often combined with repetitive joint impact (overuse). There may be a genetic cause as well. Athletes at risk also often have a history of early sport specialization and year-round training. Some may report a history of a minor injury, but this is likely not the cause of the OCD lesion.

What are the signs and symptoms of OCD in the elbow?
OCD may be present even if there are not symptoms. An asymptomatic OCD lesion, one that does not cause any symptoms, may be identified when evaluating another concern. Signs and symptoms vary and may include:

Pain that worsens with activity
Popping or clicking
Swelling
Fluid inside the joint
Catching or locking with movement
Limited motion

How is elbow OCD diagnosed?
Physical examination, history, and X-rays are used to diagnose OCD in the elbow. Advanced imaging, such as an MRI, is often necessary to fully assess the condition and determine treatment options.

How is elbow OCD treated?
Properly treating and managing osteochondritis dissecans in the elbow lowers the risk of long-term damage to the joint. With diagnosis and treatment in the early stages, tissues may heal with rest and limiting activities that cause pressure on the OCD lesion.

Athletes benefit from continued training while resting their elbows. It is important for our team to help them understand what activities are safe and will not cause further problems on the elbow. Examples of activities to continue while receiving treatment for elbow OCD include:

Jogging
Stationary bike
Core strengthening
Lower body weightlifting of resistance training
Swimming
Golf putting only

These “weightbearing” activities are not allowed because they put pressure directly on the area of the OCD lesion:

Sports of any kind
Handstands
Tumbling
Push-ups, planks
Upper body weightlifting or resistance training

When may surgery for elbow OCD be needed?
Many elbow OCD lesions can improve with conservative, nonoperative treatment. However, surgery may be necessary if the:

The OCD lesion appears loose, unstable, or large.
Cartilage becomes loose in the joint.
Imaging shows an advanced or worsening condition.
Symptoms are worsening despite nonsurgical treatment.

What kinds of procedures are used to treat OCD in the elbow?
The choice of surgical procedure depends on the condition of the tissues at the time of surgery. Most procedures are performed using an arthroscope, a camera, and tools inserted through small incisions, but a large surgery may be needed in some cases. Our sports medicine pediatric orthopedic surgeons are experts at treating OCD and can walk you through what to expect.

Procedures that may be offered alone or in combination include:

Drilling – drilling holes into the bone to increase blood flow and healing.
Stabilizing – inserting a screw, suture, or other piece of hardware to keep loose tissue in place.
Grafting – placing biological tissue in the area.

What can be expected after surgery for elbow OCD?
Our sports medicine experts work with every patient to develop an individualized postoperative treatment plan. After surgery, closely following postoperative instructions will protect the joint while the tissue is healing. Exercise and activity recommendations will be different for every patient.

How long does OCD in the elbow last?
Each case is unique, and the timing of returning to normal activity or sports will be discussed with your sports medicine physician, surgeon, or advanced practice provider. Symptoms may last months or years. It’s very important to understand that symptoms may return if the area does not fully recover before returning to repetitive or weight-bearing activities.

How can elbow OCD be prevented?
Overuse injuries like OCD occur with a high volume of training, repetition of certain movements, and early specialization in a sport.

These suggestions can help to prevent elbow OCD and other similar conditions:

Learn how to moderate training loads and intensities.
Make time for free play and lifetime sports like tennis, golf, cycling, and hiking.
Take breaks weekly and between seasons.
Learn to properly warm up and perform conditioning for your sport.

Learn more about sport specialization and preventing overuse injuries in young athletes.

Overuse Injuries in Pediatric Female Gymnasts

by rona@revdojo.com | Feb 9, 2022 | Sports Medicine

Overuse injuries can come in many forms and remain a concern for athletes of various sports.

Many recognize the risk of overuse injuries in the elbow in baseball players, but did you know gymnasts are at risk for elbow injuries as well? In our pediatric sports medicine practice, we see two unique conditions of overuse in gymnasts’ elbows. These conditions are triggered differently than in a throwing athlete. For gymnasts, these injuries are caused by compression when the arms are repeatedly in a weight-bearing position.

Recently published in The Journal of Bone and Joint Surgery, this study from our team described the different aspects between the following elbow conditions induced by repeated activity in a group of 58 competitive gymnasts seen in our practice.

What is capitellar osteochondritis dissecans (OCD)?
A rare, painful developmental bone and cartilage injury to the capitellum on the elbow end of the humerus, the upper arm bone.

What is a radial head stress fracture?
An even less common bone injury to the radial head, the elbow end of a forearm bone, caused by repeated compressive forces in the elbow.

“Even though these are rare conditions, we see them enough that we were able to look at a large group seen over five years in our practice,” study author Chuck W. Wyatt, M.S., CPNP, says, Comparing multiple details of the images and characteristics of the gymnasts, including activity levels, the study found several key findings.

Both injuries present at a young age, 11.6 years on average in this group.
Radial head stress fracture may be more likely in a more acute (sudden) manner.
Likelihood of returning to competition seemed likelier with higher level of training and competition at the time of diagnosis.
Having capitellar OCD on both elbows was associated with the lowest rate of return. One in three returned to same or similar level of competition.

In our sports medicine practice, we will use this information to counsel gymnasts who present with these conditions and more importantly, continue to study and educate the gymnastics community about early recognition, treatment and prevention. “This population has so many unique characteristics to consider when it comes to injuries,” assistant chief of staff and lead author Philip L. Wilson, M.D., says. “We look forward to continuing to study to understand how growing and intense training affect their bones and long-term health, particularly in the elbow.”

This study, “Elbow Overuse Injuries in Pediatric Female Gymnastic Athletes” was published in a highly rated, peer-reviewed journal, The Journal of Bone and Joint Surgery. Authors include Scottish Rite for Children Sports Medicine medical staff and former research coordinators who have gone on to pursue post-graduate degrees in the field.

Read the full article here.

Learn more about Osteochondritis Dissecans (OCD) in the Elbow.

Rising Elite Gymnast

by rona@revdojo.com | Feb 4, 2021 | Sports Medicine

When 12-year-old Julia began gymnastics eight years ago, her coaches immediately recognized her strength, focused attention and determination. They knew she could be great. Julia continues to prove them right and has earned her spot on the Hopes team at Plano’s World Olympic Gymnastics Academy (WOGA). Hopes is a pre-elite program for gymnasts under the age of 14 to begin their journey through the Elite Program, where National Team coaches look to find the next generation of Olympians.

While preparing for the Hopes Competition season, Julia was practicing new gymnastic skills progressions, which required her to land on her left leg repeatedly. She began experiencing soreness in her hip, and her coach could tell that something was wrong by the way she was moving. She suggested that Julia get it checked out to prevent further injury. Her mom, Heather, brought Julia to the Scottish Rite for Children Orthopedic and Sports Medicine Center in Frisco, Texas. She was seen by sports medicine physician Shane M. Miller, M.D., who is very familiar with the demands of gymnastics.

Miller recognized that Julia had an injury to a growth center where the hamstring tendon attaches to the pelvis, called the apophysis. The apophysis is made of soft cells called cartilage that will later be replaced by bone. In growing athletes Iike Julia, the apophysis is vulnerable to injury from repetitive activity. Until Julia finishes growing, this activity-related inflammation called pelvic apophysitis could continue to be a problem.

Fortunately, surgery is not required to treat the condition, so the Scottish Rite team developed a care plan focused on physical therapy to get Julia back in the gym for the USA Gymnastics (USAG) Development Camp. Physical therapist Lorenzo Vite, who frequently works with elite and pre-elite gymnasts, worked closely with Julia to help her achieve her goal. “We began by assessing musculoskeletal dysfunctions. Once dysfunctions were identified, we started low-impact movement skills and then we put her into our brand new Hydroworx® underwater treadmill to allow the muscles to work without too much stress,” says Vite. “From there, we progressed her to strengthening programs, monitoring her all the time to make sure that we didn’t exacerbate the hip pain.”

Julia enjoyed the variety of exercises that she did with Lorenzo. “At first, physical therapy was hard, but after a little bit, it all started getting easier,” she says. Over the course of eight sessions, Vite carefully managed and monitored Julia’s progress until they believed that she was able to perform. After she passed a rigorous functional test with flying colors, they knew that she was ready. Julia performed well in the USAG Development Camp in October and is continuing to compete pain-free!

Although COVID-19 slowed everything down for a while, it did show young athletes how taking time off can be beneficial. “In the gymnastics culture, people always think that you shouldn’t take any time off, but the pandemic showed us that if you miss some time and if you do it right, you can come right back and avoid injury,” says Heather. “In some cases, girls came back stronger in their core, which made them stronger gymnasts.”

Young athletes often feel like they have to play through the pain, so they don’t let their team or coaches down. Both Julia and Heather encourage other young athletes to speak up when something doesn’t feel right. “Talk to your coaches about it and tell them what’s happening,” says Julia. “Make sure that they know, so they don’t push too hard because you don’t want to hurt yourself.” Injuries may be treated quickly early on, but if athletes continue to practice and compete at a high level, it may become much worse, taking them out of their sport much longer. “Missing practice to go to Physical Therapy, does not mean you are falling behind or not getting stronger,” says Heather. “You are actually getting even stronger by going through physical therapy.”

Today, Julia continues her exercises to help prevent future injuries, and she is using everything that she has learned through this experience to help her fulfill her dream of competing in the Olympics!