Injury prevention for gymnast was presented at both USA gymnastics national congress and the Gymnastics Association of Texas Conference in 2011. We discuss proper loading mechanics of the wrist and how to achieve this via strength, stretching, and mechanics training.

1. Wrist Injury Prevention in the Gym Tony Retrosi Tony@atlanticgym.com Brandi Smith-Young, PT Perfect 10.0 Physical Therapy www.perfect10physicaltherapy.com perfect10pt@gmail.com

2. Tony Retrosi Owner/ head coach Atlantic Gymnastics Training Centers Director National Gymnastics Training Center summer camp Former Region 6 Elite Program Chairman USAG Educator (safety/ risk management and other stuff)

3. Brandi Smith- Young Competitive gymnast 2 time USAG Collegiate National Champions at TWU Bachelors in Kinesiology at TWU Masters in Physical Therapy at Tx St Fellowship trained in Orthopedic manual physical therapy Board certified orthopedic specialist in PT Specialize in treating gymnast

4. Coach & PT relationship Open lines of communication are important to achieve maximum recovery while maximizing time and training in the gym Speak with the PT about the reasons for modifications (tissue healing, impact, loading, immobilization, etc) Educate the PT on possible training tools or modification which meet the recovery criteria.

5. Treat each gymnast like aprize race car Fill it up with the best quality fuel. (and refuel frequently!) Make sure all the parts are running as close as possible to 100% efficiency Give it a rest some times Frequent tune ups

6. Active Recovery Allows the athlete to do as much training as possible, painfree, while still allowing for the injury to heal appropriately and efficiently. This is defined by the tissues involved, aggravating activities, and proper healing times. Modifications are arrived at by a close interaction with the coach and PT.

7. Benefits of Active Recovery Physical Benefits Continued overall fitness, strength, cardiovascular & anaerobic capacity Continued progress in strength & skill level on the non injured areas maintain body composition Mental benefits Proven benefit of maintaining team environment. Maintains structure for the athlete. Prevent/decrease development of mental blocks Return to competition sooner

8. Coach & PT relationship Together with your gymnastics and coaching knowledge and the PTs knowledge of healing time frames and biomechanics you can create a successful active recovery program. Use yourpatters relationship with the PT to improve training regimens, identify injury patterns or injury cycles which may be occurring, and develop injury prevention programs.

9. Why is this important to the Coach Healthy athletes = more reps in the gym Healthy athletes = better competitor Healthy athletes = consistent workouts Healthy athletes = outside growth Healthy athletes = easier motivation in the gym Healthy athletes = practices more FUN

10. Why is this important to the club owners Healthy athletes = Less lost revenue Healthy athletes = make team more marketable Healthy athletes = Outside growth Healthy athletes = Bragging rights over other sports Healthy athletes = Less problem parents

11. What plays a role in wrist injuries Wrist Injury can be caused by and be the cause of: Decreased joint motion (rolling and gliding) Decreased range of motion (flexibility) Decreased strength (shd blade, shd, arm, wrist, hand ) Balance and propriocetion deficits

12. Anatomy of the Wrist

13. Back Front

20. Anatomy cont’d All these muscle provide stabilization for the wrist. If these muscles are not functioning properly increased stress will eventually lead to injury.

21. Muscle imbalances Some muscles are strong While opposing muscles are weak Some muscles are stretched out While opposing muscles are too tight

22. Due to the stringent requirements placed on gymnast certain muscles tend to develop stronger than others Certain muscles get weak Other muscles develop tight Some develop loose or stretched

23. Common muscle imbalances Poor shoulder blade, arm, and wrist control Weak shoulder blade and shoulder muscles Extensor Carpi Radialus Brevis (ECRB) doing too much and the other wrist extensors not doing enough Weak hand intrinsic muscles Tight pec and lat muscles

24. Balance 3 systems make up balance: Visual System (eyes) Vestibular System (inner ear) Propriocetion system (receptors in joints)

25. Visual System Eyes give input into the system indicating the environment around us and movements we are making I have found gymnast tend to be visually dominant Any change in vision can affect balance.

26. Vestibular System The inner ear monitors the position of the head Any inner ear infection or injury (ie cold, fluid in the ear, sinus infection or ear infection) can affect balance.

27. Proprioception System The receptors in our joints give sensory input from your upper extremities to give your brain feedback about the floor Any joint injury can cause damage to these receptors and affect balance (does not have to be a major injury)

28. How it works in my gym PT comes in 3 x per week. (only because they are a parent of an athlete) 1 x per week is what we were doing before List of kids to see/ evaluate Consults with conditioning and rehab exercises by GROUP Consults with conditioning and rehab exercises for individuals

29. Triage Watches rehab exercises corrects positions and resistance Brings me coffee and the occasional Biscotti

30. Nuts and Bolts each event has specific exercises related to that event exercises are posted and changed about every 3-4 weeks ATTITUDE towards the exercises is as important as the exercises themselves explain WHY and the WHAT of each exercise

31. Demonstration Time

32. Resting position

33. Wrist Mechanics Push up position Push up When taking off or landing on the wrist it is imperative to have good mechanics.

34. Improper mechanics lead to repetitive abnormal stress Leads to inefficient performance Leads to injury

35. Proper Loading mechanics Fingers facing fwd Maintain palmar arches Antecubitalfossa (“Smiley face”) points inward (“kiss each other) Elbows straight but not locked out Shoulder blades cinched up to the rib cage (no winging)

36. Post- Treatment Pre-Treatment

37. Post- Treatment Pre-Treatment

38. Post- Treatment Pre-Treatment

39. Poor Shoulder blade control

40. Proper wrist mechanics can be achieved by Balancing muscle imbalances Shoulder blade, shoulder, and wrist strength and flexibility Improving balance or proprioception Training proper loading mechanics

41. Strengthen Shoulder Blade muscles Cat Rocking (fig 1) Start in the Cat Pushes Once rounded, keep the upper back rounded by pushing through the heels of the hands as rock back toward heels Keep rounded as return to the start position. Repeat x15 Figure 1

42. Ts ph I (middle trap)(fig 2) Lay face down with arms in a “goal post” position Set shoulder blades down and back. Keep there. Gently, lifting from the thumbs just high enough to slide a piece of paper under the arms. Make sure to relax the upper trap and only engage the middle trap. Hold 10 sec x5 Figure 2

43. Y ph II(fig 3) Lay face down arms in a bent arm Y position Set shd blades down & back. Gently lift from thumbs enough to slide a piece of paper underneath Make sure upper traps relaxed and shd blades stay down & back. Hold 10 sec x 5 Figure 3

44. Wall Slides(upper trap) (fig 4) Standing 6” from wall, place elbows shd width apart on the wall. Raise arms up as high as possible Breath in as shrug everything up toward the ceiling. Shd blades toward ears. Hold as breath out, keeping the ribs expanded and the shd shrugged. Hold 10 sec x5 Figure 4

45. Elbow Strength Bicep curls Make sure to start with the palm facing the body. Rotate the wrist out Curl up slow and controlled Don’t lock the elbow

46. Elbow Strength Triceps pushes Make sure they keep the shoulder blade cinched to the rib cage with a straight back Straighten the elbow keeping the “smiley face” toward the body Don’t lock the elbow

47. Wrist strength Wrist Extension(fig 5) Set wrist in neutral. Actively lift wrist. Push with the other hand to the end range. Hold 10 sec x10 DO NOT let the wrist move inward. May have to start with no weight. Progress to 1-3 lbs. Figure 5

48. Basic Wrist strength Flexion (curl) (Fig 6) Supination (out) (Fig 7) Pronation (in) (Fig 8) Always keep wrist in neutral. Slow and controlled. 2x15 Figure 6 Figure 7 Figure 8

50. Wrist strength with band

51. Wrist Strength with Rockers Radial/Ulnar Deviation Supination/Prontation

52. Wrist Rolls with weight on Wobble board

53. Strengthen finger muscles Pillow pickups or foam pickups Elbow at side and bent to 90 deg. Wrist in neutral. Pickup foam with straight fingers. (fig 9) X 2-3 min Pick up foam with finger tips bent. (fig 10) X2-3 min Figure 9 Figure 10

54. Upper extremity control Push ups (on the floor or tennis balls) Create arch in wrist Elbows facing each other Bend straight down Don’t sag in shoulder blades Even weight through wrist

55. Tennis ball or Rockers Butt-up Pushups

56. Balance Training progression Pushup position weight shifting on therapy ball Weight shifting on ball Balance Board Bosu Ball

57. Rocker Handstand Holds Floor/pommel/Pbar hand position Bars hand position

58. Handstand wobble board

59. Handstand Rebound

60. Rocker Slides & Slide to Press up

61. Rockers Press ups floor hands

62. Rockers Press ups floor hands

63. Rockers Press ups Bar hands

64. These exercises can lead up to tumbling and vaulting: Make sure the gymnast’s hand is not collapsing when loaded Make sure the gymnast is not locking the elbows out May start with just fixing the position in push ups and then in handstands Progress to tumbling, etc

65. When doing pushups and other conditioning the key is for the gymnast to control their shoulder, elbow, and wrist . Do NOT allow the arch of the hand to collapse or the elbows to roll out and hyperextend.

66. Stretch Lats Robots lat stretch (fig 11) Lie with knees bent. Pull ribs toward hips with abs. Elbows close together. Keep ribs down and elbows in as reach toward the floor. Hold 10 sec repeat 5 times Figure 11

67. Stretch pec muscles Pec stretch (fig 12) Stretch as pictured or Have a partner sitting at gymnast’s head. Place heel of the hand on the front of both shoulders. Gently lean into the partner, pushing toward the floor. Hold 1 minute Figure 12

68. Stretch Pronator muscles Pronator stretch (fig 17) Place hand palm up on a wall at waist height. Straighten the elbow. Gently lean hip into the elbow, pushing toward the ceiling and wall. Hold 30 sec- 1 minute Figure 17

69. Stretch Wrist Extension Place the wrist you are stretching fingers facing straight forward. Place the other hand on top resting over the bend in the wrist Press the bottom hand flat with the top hand as you lean your body weight forward. Be sure to keep the arch of the hand

70. How to incorporate in the Gym Station at Vault or Bars Station during routines at Floor or Beam Drills during vault or conditioning During handstand holds or pushups or other conditioning make the athletes aware of proper mechanics. Stretch at the beginning or end of workout or when waiting for turns

71. THE BOTTOM LINE IT WORKS AND DOESN’T TAKE UP ANY MORE TIME THE KIDS ARE GOING TO TALK DURING WORKOUT. GIVE THEM SOMETHING TO DO WHILE THEY TALK

72. To a hammer- everything looks like a nail

73. Contact Information Atlantic Gymnastics www.atlanticgym.com tony@atlanticgym.com Follow Tony Retrosi at facebook, twitter, and google plus

74. Contact Information Perfect 10.0 Physical Therapy & Performance Training www.perfect10physicaltherapy.com perfect10pt@gmail.com 512-426-6593 Follow Perfect10PT on gymanstike, facebook, and twitter

75. All information from: The Manual Therapy Institute http://www.mtitx.com/ Shirley Sahrmann. Diagnosis and Treatment of Movement Impairment Syndrome.