Larry Nassar, DO is the USAG National Medical Coordinator working out of Michigan State University Sports Medicine.
This is a guest post by the good Doctor.
Return to gymnastics after a gymnast has a stress fracture in their back: Spondylolysis
(use this program at your own risk)
My treatment plan for spondylolysis is very complex because it is customized to the individual gymnast.
First, I conduct a biomechanical evaluation of the gymnast to determine what the predisposing risk factors may be that created the stress fracture. I review all of their skills on each event to determine if there is a skill set that contributed to their stress fracture. The goal I set is to correct any of the risk factors found so that when they return to gymnastics they have a better body then what they had prior to the injury. I explain to them that they either need to change their body or change the activity or the back pain may return. If they only rest from activity until the pain resolves and then take the same body and return them to the same activity, chances are the same problem will return.
If the gymnast does not have pain with normal life (activities of daily living) then I do not place them in a brace for their back. If the gymnast has pain with normal life then I place them in a Criss Cross Warm and Form back brace. The goal is to relieve them from pain with normal life activities. This then allows the fracture to heal quicker since the gymnast is not irritating the fracture site. It also helps prevent muscle spasms. Most gymnasts do not want to be in the brace, but after they use it to sit in school and they notice that they can sit much better with less pain, and then they are more compliant with wearing the brace. If after 2-3 weeks in the back brace and they still have pain with normal life, then I place them in an Aspen Contour LSO to try and relieve their pain with normal life. This is a more rigid and motion restricting brace. They wear the brace 24 hours a day. They may remove it to shower and do therapeutic exercises.
Once in the Aspen Contour LSO, they remain in that brace until they can arch without pain. They now can remove the Aspen brace and return to the smaller more flexible warm and form brace.
After 4 weeks I reassess them. If their exam is significantly better and they have full pain free range of motion, then I place them on the fast track and they wear the warm and form brace only 12 hours a day for the next 2 weeks. At 6 weeks I recheck them and if doing well, the brace is then only used in the gym. At 8 weeks the hard plastic is removed from the back pouch of the warm and form brace and then by 10-12 weeks they progress to full gymnastics. The brace is completely removed once they have been able to return to full gymnastics.
After 4 weeks if their exam is improved but they still have pain with trunk extension then they are on the standard track. They then use the back brace for 12 hours per day for the next 4 weeks and I do not recheck them again until week 8. If they are then able to arch fully pain free then they wear the brace only while in the gym. If at 8 weeks they still have pain with full extension then they stay in the brace 12 hours a day and I recheck them again at 12 weeks. If they are able to arch pain free then they only wear the brace in the gym. By week 14 they then remove the hard plastic back out of the warm and form brace in the gym and when they are back to full gymnastics then they remove the brace completely. By wearing the Warm and Form brace without the hard plastic insert, the soft elastic corset helps to remind the gymnast to keep their core muscles engaged.
Physical Therapy protocol:
As soon as the gymnast is diagnosed with spondylolysis, I place the gymnast in physical therapy to correct all the imbalances found and improve their overall core stability and function. The first 4 weeks they work with neutral trunk to trunk flexion bias. If they are on the fast track then by week 6 they start working into trunk extension in PT. If they are on the standard track, they start working trunk extension somewhere between 8-12 weeks. If they are placed into the Aspen Contour LSO then in general they are not able to start extension work until about 12 weeks. They must be pain free with normal life before starting to work into extension in PT. They gradually increase their trunk strength in extension. It may be easier to start to challenge the spine in extension by working the hips into extension first, then add trunk extension and finally add trunk and hip extension combined at the same time. They must be able to arch first In PT with their exercises before they are allowed to do arching in the gym.
The key generic points in physical therapy to be addressed:
1. Shoulder flexibility restrictions – If their shoulders are tight, then they over arch their back to compensate for the lack of the shoulder flexibility.
2. Hip flexor/quad/IT band/erector spinae flexibility.
3. Normal gluteus maximus firing pattern needs to be restored.
4. Gluteus medious strength, gluteus maximus inferior fibers strength, pelvic floor strength, and abdominal strength along with proper coordination of the muscle firing need to be restored.
5. Overall, the therapist needs to correct all the musculoskeletal imbalances that are risk factors for low back pain to prevent reoccurrence of the injury.
Gymnastics Training Protocol:
The first 4 weeks they only can do some simple dance moves on the floor, low beam dance and conditioning exercises that do not over stress the back. The key point is to avoid all impact activity and arching of the back. At week 4 if they are on the standard of fast track they are allowed to start some jumps on tramp and light jogging as part of a warm up in practice. At week 6 if they are on the fast track and week 8 if they are on the standard track, and they can arch with the therapy exercises without pain, then they can start some tumbling on the tumble track and bridging over a ball or barrel mat. If on the fast track between 8-10 weeks and at 10-12 weeks if on the standard track, they are able to do all gymnastics except for the more stressful activities to the back. The last things that are added back are those that create the most stress to the back: BWO/FWO, limbers, sheep jumps, ring leaps. Sometimes I have them stop these skills altogether. Some of the other skills that may stress the back and should be approached with more caution is piked landings (double pikes are tough on the back). Reverse hechts, hand front vaults, standing back handsprings on beam (it is easier to have them start with RO BHSP then to do Standing BHSP). Beam is always harder then floor since beam does not have the same lift as they get on floor and since the skills do not have the same run into the approach to get more power. Bar skills like casting, kips and tap swings can be more stressful to the back. Straddle back to handstand can create stress to the back if they do not hit the hand stand and over arch the back to save the skill. The skills are so varied over the spectrum of levels that I try to customize the skill progression per gymnast.
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