Gymnastics Association of Texas 2010 conference: Presentation geared toward gymnastic coaches on common causes of wrist injuries in gymnast. Biomechanics of loading the wrist. Training exercises to prevent and decrease wrist injuries in gymnast.

1. Wrist Injuries in Gymnast Brandi Smith-Young, PT Perfect 10.0 Physical Therapy Fellowship trained manual therapist Board certified orthopedic specialist www.perfect10physicaltherapy.com perfect10pt@gmail.com

2. Introduction Competitive gymnast Two time USAG Collegiate National Champions at TWU Bachelors in Kinesiology at TWU Masters in Physical Therapy at Tx St

3. Practicing for 5 years Fellowship trained in Orthopedic manual physical therapy Board certified orthopedic specialist in PT One of 300 therapist in the US with these certifications

4. My passion: Bring sport specific quality care to gymnast Decrease the number of injuries in gymnast Improve performance, recovery time, decrease time lost in the gym, and improve return to sport status Performance Enhancement

5. Common Complaints Pain on the outside of the wrist Pain on the inside of the wrist Pain across the wrist Pain into the hand

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

7. Anatomy of the Wrist

8. Back Front

15. 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.

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

17. 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

18. 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

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

20. 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.

21. 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.

22. 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)

23. Demonstration Time

24. Resting position

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

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

27. Post- Treatment Pre-Treatment

29. Demonstrate Muscle testing Shoulder Blade Wrist Hand Flexibility testing Pecs Lats

30. 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

31. Strengthen Shoulder Blade muscles Cat Pushes(serratus) (fig 1) On all fours Set shd blades down and back Push through the heel of the hands. Rounding out like a cat Make sure to push till you can push no more. Keep head in. Hold 10 sec x10 Figure 1

32. Cat Rocking (fig 2) 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 2

33. Ts ph I (middle trap)(fig 3) 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 3

34. T ph II Laying face down with elbows slightly bent in a T position. Set shd blades down and back. Keep down & back as raise arms slightly off the floor 1-3” Make sure upper trap is relaxed. Hold 10 sec x5

35. T ph III (fig 4) Lay face down in a T position with elbows straigth. Set shd blades down and back. Gently lift from the thumbs 1-3 inches off the floor. Make sure upper traps relaxed. Make sure not arching, engage abs. Hold 10 sec x10 Figure 4

36. Y ph I (lower trap) (fig 5) Lay face down hands on head Set shd blades down & back. Gently lift from the elbows 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 5

37. Y ph II(fig 6) 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 6

38. Y Ph III (fig 3) Lay face down arms in a Y position. Set shd blades down & back. Gently lift from the thumbs 1-3 inches from the floor. Make sure upper traps relaxed & shd blades stay down & back. Make sure not arching. Hold 10 sec x 5 Figure 7

39. Wall Slides(upper trap) (fig 8) 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 8

40. Upper extremity control Push ups Create arch in wrist Elbows facing each other Bend straight down Don’t sag in shoulder blades Even weight through wrist

41. Balance Training progression Pushup position weight shifting Wight shifting on ball Balance Board Bosu Ball

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

43. 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.

44. Wrist strength Wrist Extension(fig 9) 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 9

45. Basic Wrist strength Flexion (curl) (Fig 10) Supination (out) (Fig 11) Pronation (in) (Fig 12) Always keep wrist in neutral. Slow and controlled. 2x15 Figure 10 Figure 11 Figure 12

46. 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 13) X 2-3 min Pick up foam with finger tips bent. (fig 14) X2-3 min Figure 13 Figure 14

47. Stretch Lats Robots lat stretch (fig 15) 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 15

48. Stretch pec muscles Pec stretch (fig 16) 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 16

49. 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

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