Gymnastics Association of Texas 2010 conference: Presentation geared toward gymnastic coaches on preventing and addressing ankle injuries. Biomechanics of loading mechanics on the ankle. Training exercises to improve loading mechanics and prevent or address ankle injuries in gymnast.

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

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: To bring sport specific quality care to gymnast Decrease the number of injuries in gymnast Improve recovery time, decrease time lost in the gym, and improve return to sport status Enhance performance

5. Common Complaints Pain on the outside of the ankle Pain on the inside back of the ankle Pain in the midfoot; many times outside Pain in inside of shin Pain in outside of shin Pain in the Achilles

6. What plays a role in ankle injuries Ankle Injury can be caused by and cause: Decreased joint motion (rolling and gliding) Decreased range of motion (flexibility) Decreased strength (hip, knee, ankle) Balance and propriocetion deficits

7. Anatomy of the ankle

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

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

18. Due to the stringent requirements placed on gymnast certain muscles tend to develop stronger than others Certain muscles get weak Other muscles develop tighter Some develop looser or stretched

19. Common muscle imbalances Poor hip, knee, and foot control Weak hip muscles Weak posterior tibialis Posterior tibialis doing too much and the gastroc not doing enough Weak Soleus muscle (the other toe pointer) Weak foot intrinsic muscles Tight calf muscles

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

21. 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.

22. 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.

23. Proprioception System The receptors in our joints give sensory input from your lower 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).

24. Demonstration Time

25. Foot Mechanics Single leg standing Single leg ¼ squat When taking off or landing it is imperative to have good mechanics.

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

29. Foot Mechanics & Balance Single leg standing (SLS) Mechanics Eyes open hard surface Eyes closed (-visual system) (test proprioception and vestibular) Eyes closed on soft surface (- visual –proprioception) (test vestibular) Eyes closed on soft surface head back (challenge vestibular system)

30. Eyes open on hard surface

31. Eyes closed on hard surface

32. Eyes closed on soft surface

33. Eyes closed head backon 8 incher

34. Demonstrate Muscle testing Hip Ankle Foot Flexibility testing Gastroc Soleus

35. Proper foot mechanics can be achieved by Balancing muscle imbalances Hip, ankle, and foot strength and flexibility Improving balance or proprioception Training proper take-off and landing mechanics

36. Strengthen Hip muscles Clam ph I (fig 1) Sidelying, roll hip forward. Tighten abs, tighten buttock. Keep heels together and lift one knee up. Monitor hips, no motion. Hold 10 sec x5 Figure 1

37. Clam ph II (fig 2) Begin with clam ph I. Then lift from the knee straight up with heels a few inches apart. Hold 10 sec x5 Clam ph 2.5 Same as ph III Against a wall Hip rolled forward, heel touching wall. Hold 10 sec x5 Figure 2

38. Clam ph III (fig 3) Roll hip forward. Tighten abs, tighten buttock. Turn top foot out, Raise leg. Hold 10’ x5 No motion at the hips. Keep rolled forward. Figure 3

39. Hip & knee control Squatting (card pickups near wall) Both legs Create arch Hinge from hips Bend straight down Knee over second toe

40. Hip & knee control Single leg ¼ squat (fig 4) Standing on one leg, hips level Use a pen, golf ball, or card Squat to set ball down with R hand Back to start position Squat and pick up ball with L hand Continue alternating which hand picks up the ball. Knee must stay over 2nd toe and no motion at the hips. Weight evenly through the foot DO NOT let the arch of foot collapse 2x20 (can follow with balance postures) Figure 4

41. These exercises can lead up to landing drills: Make sure the gymnast’s foot is not collapsing when landing May start with just a jump to a stick. Then jumping from the beam or vault to a stick.

42. When doing plyos and other conditioning the key is for the gymnast to control their foot on push-off and landing. Do NOT allow the foot to collapse or be loose.

43. Retrain calf muscles Heel raise with knee straight (fig 5) Progress from 2 ft to 1 Raise heel up. Heel must stay in line over the 2nd toe. DO NOT let the heel move inward. 2x15 Figure 5

44. Soleus Bent knee heel raise (seated) (Fig 6) Start seated, 1 leg crossed with arms rested on knee. Slow and controlled. Raise heel over 2nd toe. 2x15 Figure 6

45. Soleus Bent knee heel raise (standing) (fig 7) Progress to standing, start both feet at same time progress to 1 foot Use beam for balance. Slow and controlled. Raise heel over 2nd toe 2x15 Figure 7

46. Strengthen foot/toe muscles Towel curls (fig 8) Place a towel on a smooth surface (tile works well) Do in standing and 1 foot at a time. Curl the towel with your toes towards you until reach the end of the towel. Start again x 5 min May add 1-8 pounds on towel. Heel must stay on the ground. Do NOT let arch collapse. Figure 8

47. Balance Training progression SLS eyes open Balance postures SLS eyes closed Balance postures SLS on 8 incher eyes open SLS on 8 incher eyes closed SLS on 8 incher head back eyes closed SLS balance postures on beam

48. Balance training Balance Postures Maintain arch in foot. Hold 20 sec-1 min Tree (Fig 9) Front Scale (Fig 10) Figure 9 Figure 10

49. Balance Training Cont’d Balance Postures Back Scale (Fig 11) Bent knee back Scale(Fig 12) Sneaky Lunge (Fig 13) Figure 11 Figure 12 Figure 13

50. Challenge balance Add 4 incher, 8 incher, BOSU ball (Fig 14) Progress from 2 feet stable surface (floor) 2 feet unstable surface Sting mat to 8 incher to BOSU ball 1 foot stable surface 1 foot unstable surface Put them on beams Stand 1 leg balancing Add ball tossing Figure 14

51. Beam ball toss

52. Stretch calf muscles Calf stretch (fig 15) Against a wall or stationary object. Place foot stretching back with toes straight forward. Create an arch. Gently lean forward DO NOT let foot collapse. Hold 1 min Figure 15

53. 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

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