Return to Gymnastics After Injury. Return to Gymnastics Begins as Soon as the Injury Occurs

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1 Return to Gymnastics After Injury Larry Nassar, DO, ATC, F.A.O.A.S.M. USAG National Medical Coordinator USAG National Women s s Artistic Team Physician Michigan State University Women s s Gymnastics Team Physician Geddert s Twistars USA Gymnastics Club Team Physician Holt High School Team Physician Return to Gymnastics Begins as Soon as the Injury Occurs The road to recover starts with the initial treatment of the injury. Initial Goals: reduce swelling reduce muscle atrophy reduce pain inhibition of the muscles Rest Ice Heat Ultrasound EMS - stim Massage Accupunture Stretch Exercises Nutrition Tape/Brace Iontophoresis Medication/creams Rehabilitation Modalities Take the time to find sports oriented physicians/therapists/atletic atletic trainers in your area Appropriate Credentials are Vital St. Vincent s s Hospital Indianapolis 1

2 Injury Recover Takes Precedent No Matter What The Circumstance At competitions/camps treatment continues during break times Learn to multi-task task Proper rest to allow the body to recover Nutrition The body needs proper nutrients to help: enhance performance prevent injury promote tissue healing 2

3 Nutrition in and out of Training Whole Body Approach to Treatment Look above and below the injury site for anything that may be out of alignment and restore balance to the body Find a good therapist that can do a complete biomechanical eval Increased Function with Whole Body Approach to Treatment Accupuncture to decrease pain and swelling 3

4 Proper Tape and Brace McConnel/Kinesio Tape Beam Bite Pressure Wrap 4

5 Beam Bite Pressure Wrap Beam Bite after pressure wrap General Rehabilitation Techniques Strength with body weight, bands, weights, towels, machines, bird seed bucket, rhythmic stabilization, etc Lower Extremity Rehabilitation 5

6 Balance Training is Vital Static Balance Drills Start simply by standing on one foot with your eyes closed. Your goal is to balance on your leg for 60 seconds. Practice this for r 5 minutes. Progress to using a wobble board. Add tubing kicks. Standing on your injured leg while doing quick, rapid battements/kicks with theraband attached to your non - injured leg. This will make you work harder to control your injured leg balance. Do 3 sets of 10 kicks in each direction. This T will help to strengthen your leg also. Repeat for each leg. Dynamic Balance Drills Progress down the line. Start with the single leg hops and her goal is to get to the 5 point star. She should hop up on her injured leg and hold her balance before hopping again. Once able to do 2 sets of 10, progress to the next drill. The 5 point star is only done 3 times once you progress that far. You should do the drills with eyes open and you can try them with your eyes closed once you feel strong enough and stable enough. Extend through the toes and push off the ground fully. I want her to be rock solid with the landings. Grab the ground with the toes. Tighten the trunk hard. Fight for a solid landing from the hop. Once she can jog, then start the Jump Progression if the physician/therapist approves of starting jumps I like to have the gymnast start by working the jump in two parts. Focus on technique and jump up both forwards and backwards. Push all the way through the toes equally on both feet. When leaving the ground the toes should be in position 3d shown here. Jump off the mats forwards s working on landing equally on both feet and proper knee toe alignment with landing. Perform 3 sets of 10 reps at each height Jump Progression The purpose of the jump program is to insure the gymnast re-learns to push off the ground with full power from the foot/ankle and to learn how to land with good form and strength through the legs and trunk. By working one foot at a time, it also helps prevent compensation due to the prior injury. The jumping exercises are vital to ensure complete rehabilitation and improved form. It is vital for her to extend fully through the toes to punch off the ground. The trunk is to remain tight by squeezing buttocks and abdominal muscles. The alignment of the knee cap between the 1 st and 2 nd toe with all landings is crucial to ensure appropriate strength and control of the body from the trunk down to the feet. PAY ATTENTION TO THE DETAIL!! THIS IS THE MOST IMPORTANT PART OF THE REHABILITATION PROCESS!! 6

7 Jump Progression Jump up 18 inches 2 legged forward Jump up 24 inches 2 legged Forward and Backward Jump down36 Inches 2 legged forward Jump down24 Inches 2 legged forward Once able to jog painfree, then start this jump progression Jump up 12 inches with both legs forward Jump down18 inches 2 legged forward Jump down12 inches 2 legged forward Jump up 12 inches 1 legged forward Jump down 1 legged 12 inches forward For xxxxx Jump up 18 inches 1 legged forward Jump up 6 inches 1 legged forward Sample Progression Back to Gymnastics Using the Jump Progression as Your Guideline To stay in shape, and with the progression back, I would use the Tumble Trak aids that you have in the gym. Once able to do 18 inch double leg jump ups, 12 inch double leg jump down and 6 inch single leg jump up, she should be able to do d leaps and jumps on a tramp. Once able to do 24 inch double leg jump ups and 18 inch double leg l jump downs then start tumble on the Tumble Trak and Tumble Trak vault and start leaps and jumps on the Tumble Trak Air Floor. Progress the leaps and jumps to the real floor and then to the low l beam and finally the high beam. Progress from the Tumble Trak to the Tumble Trak Air Floor and then to the regular floor with a sting mat. Once able to do a layout l on the floor then add back vault into the pit and tumbling on beam. Start with handspring vaults and vault drills. Progress the difficulty iculty as her skill and strength returns. Dismounts off beam and bars are added last. Start with pit landings ngs and then progress to harder surfaces. Jump down48 Inches 2 legged forward Jump down1 legged 18 inches forward Punching Progression For Full Twisting Saltos in the Laid Out Position These are a progression to work the twisting form without landing, so these drills can be done as a progression prior to doing the twist on the floor. Once she progresses to tumbling on the floor, I would like to see the same progression. She should start with a ½, then 1½, 1, 2, 2 ½,, and then triple twist. This type of progression should be done as part of her floor warm up so she does not loose her technique for twisting. She needs to become the role model on how to twist properly. She has not needed surgery yet and I would like to keep it that way. Technique, Technique, Technique, Drills, Drills, Drills!!! Floor, Half twist up onto resi Floor, Full Twist up onto resi Floor, One and a half twist onto resi Floor, Double twist onto resi These videos were made for a gymnast to stay in form while rehabilitating from an elbow injury. They can be easily applied for the knee injury as well. Punching Progression For Full Twisting Saltos in the Laid Out Position (con( con t) This is another drill to help with the twisting technique, working the puch off the floor and the ability to twist. The landing is ignored, so these can be done as a progression prior to doing the twist on the floor. Floor, Jump full twist to a mat- Stand on mat, jump up and then perform full twist and land on back. The first retired gymnast has a tendency to twist too early. The second retired gymnast (1996 Olympic Team Alternate) performs the skill with improved technique. Be very strict with requiring proper technique form the shoulders to the trunk to the legs. These videos were made for a gymnast to stay in form while rehabilitating from an elbow injury. They can be easily applied for the knee injury as well. 7

8 Basic Sticking Drills These are the beginning of sticking drills working the landing phase. She needs to focus on having a tight trunk/core and knee toe alignment with the landing. Be very strict with executing the landing of the drills. Tramp, Back drop fall Tramp, Back drop twist Back Tuck Salto Sticking Drill This is more aggressive and should not be started unless approved by your therapist/physician Increase difficulty of sticking drills as she improves her strength and form These videos were made for a gymnast to stay in form while rehabilitating from an elbow injury. They can be easily applied for the knee injury as well. Jump Rope Jumping rope is another excellent activity. (speed turns per minute) Push through the toes fully, use good trunk control and form. Be explosive and nimble. This is meant to enhance your agility and coordination. The videos could have better form, but the models were retired from gymnastics and not in their best condition. 1. Start with double leg in place. 2. Double leg travel forward 3. High knee march forward 4. Single leg in place 5. Single leg travel forward 6. To improve agility for dance attempt to pony step and perform a grapevine traveling to right side and then to the left side 7. Jump rope on the balance beam. Plyometrics Use the plyometrics as the final step as you return to full tumbling and vaulting. If there is no immediate urgency for her to have full routines, I would encourage you to do the plyometrics, prior to her return to performing full passes on the floor exercise mat. Once she has her power and form back, then return to floor. Plyometrics should be done at the beginning of practice while the body is not fatigued. They should only be done 2 times per week. Allow for adequate rest (2-3 3 minutes) in between plyometric drills. Use this time to do some gentle stretches. Progress through the plyometric exercises in a logical order from least to most difficult. Plyometric Exercises (con( con t) Double leg hops for distance Double leg hops for height Double leg hops for height and distance 8

9 Plyometric Exercises (con( con t) Double leg hops for variable height and distance. Double leg hops with punch front. Flexibility - Triplane Stretches Perform these stretches times per day. Everyday! Hip and Quad Stretches arms can be place overhead and rotate the trunk away from the hip being stretched to increase the affect of the stretch. Dynamic Flexibility 3 sets of 10 quick kicks These stretches should be done at the beginning of every practice. 9

10 Upper Extremity Rehabilitation Phase 2: Closed Chain Weight Bearing Progression The gymnast can add Phase 2 exercises once the physician/trainer/therapist has cleared her to progress to weight bearing exercises. In general after weeks of Phase 1 exercises, the phase 2 exercises may be added. Progress through these exercises from 1 through 8. Once able to accomplish 3 sets of 15 reps without pain/swelling while doing the exercise and without any increased pain/swelling the next day then it is safe to progress to the next exercise. Always wait to the next day to see how the injured elbow feels before progressing.. If swelling/pain develops then either decrease the reps or drop back to the prior exercise you were doing (i.e. stop exercises 3 and go back to exercise 2). The gymnast should continue the phase 1 exercises during this phase. Phase 2: Closed Chain Weight Bearing Progression 1. Wall Press Out Place hands flat on a wall, shoulder width apart and elbows extended. Using the muscles in your shoulders, push your body away from the wall by pressing arms forward into the wall as your shoulder blades separated from each other. Your hands should stay in contact with the wall and elbows remain extended throughout this drill. Perform 3 sets of reps. 2. Wall Pushup with a Press Out- Place hands flat on a wall shoulder width apart and elbows extended. Perform a push-up up against the wall and finish with a press out. Perform 3 sets of reps. Phase 2: Closed Chain Weight Bearing Progression 3. Bent Over Press Out Place hands flat on a table or top of a mat. Hands should be shoulder width apart and elbows extended. Perform a press-out action as described earlier. 3 sets of reps. 4a. Press Up in a Push Up Position Position In the push up position, place your hands shoulder width apart with elbows extended. Perform a press-out action as described earlier. 3 sets of reps. 4b. Doggy Rock- Position yourself on the floor with your hands shoulder width apart and your knees hip width apart. Rock back and forth. Perform 3 sets of reps. 10

11 Phase 2: Closed Chain Weight Bearing Progression 5a. Dips Reclined-Lean back onto a spotting block or platform table. Keep feet on the floor. Perform a dip action within a pain free range of motion. Perform 3 sets of reps. 5b. L- Seat (sitting press-up) Using floor parrallette bars or just using a firm mat, press down with your arms to lift your body up in a pike position. Your elbows should remain straight throughout the exercise. Perform 3 sets of reps. Phase 2: Closed Chain Weight Bearing Progression 6a. Push Up with a Press Up - Perform a push-up up with hands shoulder width apart. Include a floor press-up at the end of the push-up. up. 3 sets of reps. 6b. Pull-ups ups - Perform pull-ups ups on the uneven bars with your feet resting on the low bar and your body in an incline position so you lift only partial body weight up to the high bar (straight body pull). Next add regular pull-ups. ups. As you become stronger you can change grip positions to make the push-ups ups more difficult. 3 sets of reps. 7. Elevated Push Up with a Press Up- Place feet up on an inch spotting block and perform a pushup with hands shoulder width apart. Include a press-up at the end of the push-up. up. 3 sets of reps 8. Piked Handstand Push Up with a Press Up- Place feet up on a spotting block to position the body in a piked handstand position with hands shoulder width apart. Include a press-up at the end of the push-up. up. 3 sets of reps Balance Training The Proprioception/Balance training phase is the most difficult phase for the injured gymnast to perform. However, this phase is extremely helpful for prevention of re-injury. When a gymnast injures her elbow she damages the receptors in the muscles, ligaments and joints that help the gymnast control their elbow motion and balance on their arms. This is similar to having your computer crash. You need to re-boot the system to get it to work properly again. These exercises allow you to re-boot the computer that controls the function of your elbow. These are excellent exercises that coaches can incorporate into a challenging injury prevention program. Phase 3: Proprioception - Balance Training (Mini Tramp) This set of exercises are very similar to the Phase 2 exercises. You can start this progression after the comparable Phase 2 exercise has been successfully completed. For example, the Mini Tramp on Knees Push up should not be done until the phase 2, Press Up in a Push Up Position,, is completed. The Mini Tramp exercises should always be one to two steps behind in the progression as compared to the Phase 2 exercises. This allows for proper strength before starting the more challenging Phase 3 exercises. The Mini Tramp creates an unstable surface for the gymnast to have to work off of. This enhances the gymnast s s proprioception and balance. Progress from 1 through 4. 11

12 Overview of the Progression PHASE 1 Continue throughout the entire rehabilitation course as a maintenance program Balance Training (Mini Tramp) RHYTHMIC STABILIZATION Continue throughout Phases 2 and 3 RHYTHMIC STABILIZATION Continue throughout Phases 2 and 3 PHASE 2 Once able to do a Press Up in a Push Up Position Start the Phase 3 exercises Continue the PHASE 2 progression PHASE 3 (Wobble Board) The Wobble Board exercises should be one step behind the mini tramp exercises PHASE 3 (Swiss Ball and Combinations Part 1) high level of difficulty PHASE 3 (Mini Tramp) The Mini Tramp exercises should always be one to two steps behind in the progression as compared to the similar Phase 2 exercises PHASE 3 (Mini Tramp) Continue with this progression as you progress into the Wobble Board 1. Mini Tramp on Knees Push Up- In a kneeling position, perform a pushup with a press out. Perform 3 sets of reps with good form. 2. Mini Tramp Push Up- Perform a pushup with a press out. Perform 3 sets of reps with good form. PHASE 3 (Combinations Part 2) Very high level of difficulty OPTIONAL Balance Training (Mini Tramp) 3. Mini Tramp Elevated Push Up- Perform a pushup with a press out. Perform 3 sets of reps with good form. 4. Mini Tramp Piked Handstand Push Up- Perform a piked pushup with a press out. Perform 3 sets of reps with good form. Balance Training (Wobble Board) The Wobble Board is more advanced than the Mini-Tramp. It can be used in substitute for the Mini-Tramp progression. I prefer to have the gymnast start with the Mini-Tramp Progression and then add the Wobble Board Progression so it lags behind by one step. For example, when the gymnast has progressed to doing the Mini-Tramp Push-up up they can start the Wobble Board on Knees. When they have started the Mini-Tramp Elevated Push-up up they can start the Wobble Board Push Up Position, etc. The Wobble Board exercises are performed by keeping the elbows straight and pushing through the arms into the board. The hands should be placed shoulder width apart. The gymnast should rock the board into clockwise and counterclockwise circles. Perform 3 sets of seconds of circles (CW and CCW). Progress through the 4 wobble board exercises. These exercises can be used as part of an injury prevention program also. 12

13 Balance Training (Wobble Board) 1. Wobble Board on Knees- Keep the elbows straight and push through the arms into the board. The hands should be placed shoulder width apart. The gymnast should rock the board into clockwise and counterclockwise circles so that the outer edge of the board makes contact with the floor throughout the circular motion. Perform 3 sets of seconds of circles (CW and CCW). 2. Wobble Board Push Up Position- Same as above except in a pushup position Balance Training (Wobble Board) 3. Wobble Board Elevated Push Up Position- Same as above, except in an elevated pushup position. 4. Wobble Board Piked Handstand Push Up Position - Same as above except in a piked handstand position. The gymnast may need a spot. (Panel mats on end were used out of quick convenience. This set up with the panel mats on end is not recommended. Use spotting blocks instead.) Balance Training (Swiss Ball) These two exercises may be started once the gymnast has completed the Wobble Board exercises. These are more difficult than the Wobble Board exercises and may require a spot. Perform sets of reps 1. Swiss Ball Push Ups- The gymnast lays her chest on the ball and then walks on her hands until the ball reaches her feet. She holds the hollow body position while doing push ups. 2. Swiss Ball Elevated Push Ups- The gymnast kneels on a spotting block or panel mat stack and places hands and chest area on a Swiss ball. She rolls the ball away from the mats. She holds the hollow body position while doing push ups. Balance Training (Combinations) These are the most difficult of the Phase 3 proprioception/balance training exercises. The gymnast may need a spot when they first attempt these exercises. The gymnast may attempt these once they have completed the Mini-Tramp and Wobble Board progressions. In general, sets of reps of these exercises may be attempted. These exercises would be very challenging as part of a injury prevention program. They also are fun for the gymnast to try since they are more challenging the typical rehabilitation exercise. Due to their difficulty, these exercises are optional to perform. 13

14 Balance Training (Combinations( Part 1 1. Wobble Board on Knees with Cut Foam Roller- Just like the prior Wobble Board on Knees exercise except the gymnast kneels on a cut foam roller to increase the difficulty. Keep the elbows straight and push through the arms into the board. The hands should be placed shoulder width apart. The gymnast should rock the board into clockwise and counterclockwise circles so that the outer edge of the board makes contact with the floor throughout the circular motion. Perform 3 sets of seconds of circles (CW and CCW). 2. Wobble Board on Knees with Foam Roller- Same as above except she kneels on a circular foam roller. Combinations Part 1) Balance Training (Combinations( Part 2 1.Wobble Wobble Board with Swiss Ball- This is an advancement from the Swiss Ball Push Up exercise. Instead of placing her hands on the floor, the gymnast places her hands on a wobble board and performs circles CW and CCW. Perform sets of seconds of circles (CW and CCW). 2. Swiss Ball Push Ups with Cut Foam Roller- This is an advancement from the Swiss Ball Push Up exercise. Instead of placing her hands on the floor, the gymnast places her hands on 2 cut foam rollers and performs push-ups. ups. Perform 1-31 sets of reps. Combinations Part 2) Balance Training (Combinations( Part 2 3. Swiss Ball Push Ups with Foam Roller- This is a progression from the Swiss Ball Push Ups with Cut Foam Roller exercise. The gymnast now uses a full foam roller instead of one that is cut. Perform sets of reps. 4. Swiss Ball Push Ups with Hands on Balls- This is a progression from the Swiss Ball Push Ups with Foam Roller. Now the gymnast is using two volleyballs to support the hands instead of a foam roller while doing pushups. Perform 1-21 sets of reps. Combinations Part 2) Upper Extremity Plyometrics Plyometrics are designed to transition the strength that the gymnast has regained in the rehabilitation process into power. There is no value in doing these exercises if the athlete has not regained her strength. Plyometrics should be done at the beginning of practice while the gymnast is rested. These exercises should not be done if the gymnast is fatigued. The gymnast must be explosive with their action when doing these exercises. Rotate through the 4 exercises in a circuit style. It is advised to rest from minutes in between each exercise. During the rest time the gymnast may stretch. Plyometrics should be done only twice a week (i.e. Monday and Thursday). 14

15 Upper Extremity Plyometrics Plyometric Wall Push Away- Lean forward and fall toward a wall. Catch yourself with your hands against the wall and then quickly push away from the wall and repeat. Allow your elbows to bend close to 90.. Perform 3 sets of 10 reps. Plyometric Pushup with a Blocking Action- Start in the push-up up position, then quickly snap arms over head and return to the push-up up position. Maintain a tight and stable trunk. Perform 3 sets of 10 reps. Upper Extremity Plyometrics Plyometric Hops with Feet on Blocks- Start in a piked position. Place feet up on a spotting block or locked into a stall bar. Perform 5 short quick hops forward and then back again. Repeat 3 sets This exercise can be done in a pushup position also. It is called a Wheelbarrow exercise. Have a partner hold the feet and travel forward with the gymnast as she blocks the floor performing 10 short, very quick forward hops forward. Try not to bend your elbows greater than 45 and maintain your trunk in a hollow body push up position. Repeat 3 sets. This is my favorite stretch for the shoulders. Keep the trunk flat. Flat ribs and flat hips. This gives the best overall stretch with good form. In post surgical situations, all stretches should be over seen by the physician, therapist, trainer. Stretching Example of Progression Back to Gymnastics I have developed some generalized guidelines to help coaches make a more informed choice on how to progress the injured gymnast back to gymnastics. This is just a generalized guideline. You should try and customize this based upon your gymnast s s skill level. I have tried to relate the strength needed to perform the exercises with gymnastics skills. In this manner, the gymnast should regain confidence in their injured shoulder and the coach can assess the gymnast s s ability to support their own body weight again. 15

16 Example of Progression Back to Gymnastics 1. Once the gymnast has enough strength to perform a press-up in a push-up up position,, then the gymnast may try to hold a handstand against the wall (10-60seconds). The gymnast may also try hanging from the high bar at this time also. 2. Once able to hold a handstand then progress to front and back walkovers on the floor mat. This helps to make sure they have enough arm strength so that their shoulder will not collapse as they do the BWO/FWO. 3. Cartwheels (CW) on the floor mat may be started during the next practice session after 3 sets of 10 BWO/FWO are performed. Cartwheels do require single arm loading so this may be difficult to do. Therefore, it is recommended that she be able to perform a push-up up with a press-up before doing the CW. She needs enough strength so the arm will not collapse on her during the CW. Example of Progression Back to Gymnastics 4. Once 3 sets of 10 cartwheels have been completed then Round Offs (RO), Back and Front Handsprings (BHSP/FHSP) may be attempted on the tumble trak at the next practice. If the injured shoulder is on the lead arm for the RO then they may have more difficulty and may have to start with BHSP/FHSP before the RO. The gymnast should have enough strength to perform a piked handstand pushup with a press up before attempting the FHSP/BHSP on the tumble trak. Example of Progression Back to Gymnastics 5. Once 10 RO, 10 BHSP, and 10 FHSP are accomplished on the tumble trak with good form and strength, then combinations may be started (i.e. RO BHSP) on the tumble trak. The gymnast should be increasing the force of the tumbling and once the coach and athlete feel they have proper technique, the gymnast may start back tucks/layouts on tumble trak into a pit. At the same time individual skills may be added on floor (RO, BHSP,FHSP) and BWO/FWO/CW may be started on a line, then progressed to low beam. It may be possible to start tap swings on bars now also. Example of Progression Back to Gymnastics 6. Once the gymnast is able to do tumble passes into the pit off tumble track, she should be able to start combinations on the floor. Remember that if the injured shoulder is the lead arm for a round off that it will be torque more and may be more difficult to do as opposed to BHSP/FHSP. 7. Once the gymnast is able to do 2 sets of 10 combinations on the floor with good technique and good power then they can finish the passes with back tuck saltos/layouts. During this time they are increasing the difficulty of their tumbling passes on tumble trak. During this same phase they can start individual skills (i.e.. RO, BHSP, FHSP) on a line, then on low beam, then on high beam. They should at least be able to do 10 of each skill before progressing from low to high beam. The gymnast may be able to do floor rail work during this phase. Caution, do not overload the gymnast with to many new skills/drills on the same day. Try to stager the addition of new skills and drills d so that not too much is being added at one time. 16

17 Example of Progression Back to Gymnastics 8. Once the gymnast is able to do back tucked saltos/layouts on the floor they should be ready to start vault drills. Start with handstand pop drills and progress to simple handspring vaults. I like to see 10 good handspring vaults with power and good technique before progressing to more difficult skills. Remember, if the lead arm for round-offs offs if the injured arm, it may take longer before Yurchenko vaults can be started. 9. Bars is usually the most difficult event to add back. Therefore, e, I like to get the gymnast going on the other three events first before adding the event that may cause the most problems. So far the gymnast has only hanged from the bar, tap swings, and done floor rail work. 10. Finally, the gymnast should be progressing as her skill level dictates on floor, beam, vault. She should be starting single rail work on bars now and then add transitions between bars. The last thing to add a back is straddle back to handstand, pirouette skills if she pirouettes on the injured side, release moves and skills with difficult grip positions. Summary of Upper Extremity Progression Back to Gymnastics The key to a successful return to gymnastics if for the gymnast to first regain their full range of motion. Next they must regain their strength, power and proprioception. Then the addition of skills in a logical order progressing from tumble trak to floor to beam. Some gymnasts recovering from an injury may actually be able to vault before they can tumble. The gymnast may be able to hang from the high bar and do some tap swings earlier in the progression, but more difficult grip positions and pirouettes, etc should not be added until the end of the progression. That is why it is important for the coach to critically look at the skill progression and be willing to change the progression if the gymnast encounters problems with the original plan. Conclusion I hope you found this program helpful. Remember, do not focus on what you can not do, but instead, focus on that which you can do and that which you can do, give it 110%. Good Luck 17