Quick Overview of Shoulder Injuries in Gymnastics

Shoulder injuries are all too common in Men’s Gymnastics. Evidence suggests the rate of shoulder injury in gymnastics is very high compared to other sports, and these injuries often chronically affect gymnasts. In this overview, we look at which shoulder injuries commonly occur in gymnasts. We then discuss which mechanisms might contribute to injury along with risk factors to injury. Finally, we evaluate what gymnasts can do to prevent shoulder injury.

Prevalence: How Common Are Shoulder Injuries in Gymnastics?

In gymnastics, shoulder injuries occur quite often and account for a significant portion of total injuries.

Evidence indicates upper extremity injuries contribute upwards of 40% of all injuries in male gymnasts.^[1]A 2019 study surveyed 20 elite Brazilian Male Gymnasts and found shoulder injuries accounted for 12.9% of all injuries reported over their training career.^[2] Likewise, gymnasts reporting pain may have changes to their shoulder joints visible on X-Ray.^[2]

Anecdotally, many of my friends who primarily focused on rings had rotator cuff injuries at some point in their career, and multiple gymnasts I know of had surgeries on labrum tears sustained during training.

What Common Shoulder Injuries Occur in Gymnastics?

Labrum Tears: The labrum is the capsule that keeps the arm in the shoulder socket. When the labrum tears, it causes instability in the shoulder, where the arm will move out of the socket more than it should. Two common labrum tears occur in gymnasts:
– SLAP Tear: A superior labrum anterior to posterior (SLAP) tear is a rip in the top of the labrum – the capsule that keeps the arm in the shoulder socket.
– Bankart Tear: Another type of tear in the labrum, these tears occur on the underside of the labrum.

Rotator Cuff Injury: Either a partial tear or full rupture of one of the four muscles that rotate the shoulder. Most commonly, the injury affects the top of the rotator cuff muscles.^[3]

Bicep Injury: Either a partial tear or full rupture of the biceps tendon that connects the arm to the shoulder. Usually, this occurs were the biceps tendon inserts into the shoulder joint.

Mechanisms: How do gymnasts get shoulder injuries?

The stresses in gymnastics are similar to those seen in other overhead sport athletes. However, gymnastics is unique in that it requires moving the shoulders through particular stretched positions under high load. Let’s take a look at a few common mechanisms that contribute to shoulder injury in the sport.

High Stress to the Shoulder Joint

Research indicates that male gymnasts experience the highest concentration of stress on the top of the glenohumeral joint, where the arm joins with the shoulder.^[4] This concentration of stress on top of the shoulder joint can contribute to SLAP tears. While swinging on the rings, the shoulders experience forces up to 9.2x bodyweight.^[5] Repeat this over thousands of repetitions without adequate preparation or recovery and this can lead to overuse injury.

Laxity in Shoulder Joint

Gymnasts shoulders often exhibit a degree of flexibility that would be considered problematic in normal people.^[3] Often, instability of the shoulder often appears due to overuse related stretching of the shoulder capsule.^[4] Gymnasts frequently place there shoulders in stretched positions. Particularly on events like rings and bars, shoulders are placed into stretched and rotated positions. With the high forces experienced at the bottom of swings, many gymnast’s injuries occur when hanging and swinging through these stretched and rotated positions.^[3]

Voluntary Shoulder Dislocation

One more mechanism of shoulder injury is “Voluntary Shoulder Dislocation”.^[3] Often placing shoulders at end range extension and internal rotation, gymnasts perform high level skills at these extreme ranges of motion. For example, skills like inlocates and dislocates on rings, Moy and Tippelt on parallel bars, and most notoriously el-grip skills on high bar all involve this voluntary shoulder dislocation. This type of stress contributes to labral tears and instability of the shoulders.^[3]

Risk Factors

Gymnasts, like baseball and volleyball players, are overhead athletes. Commonly, overhead athletes exhibit a few risk factors that may predispose them to injury. These include lack of shoulder internal rotation, rotator cuff weakness, and scapular dyskinesis.

GIRD – Lack of Internal Rotation: Glenohumeral internal-rotation deficit (GIRD) is a lack of range of motion during internal rotation of the shoulder. Loss of internal rotations is a risk factor for chronic shoulder pain.^[5]

External Rotation Weakness: The external rotators do an excellent job protecting the shoulder from injury. In overhead athletes, the external rotators decelerate the arm after powerful movements.^[6] Failing to properly decelerate the arm could cause injuries such as rotator cuff strains or labral tears.

Scapular Dyskinesis: In injured athletes, the serratus anterior and lower trapezius have the tendency to weaken. These muscles coordinate scapular movement and help align the shoulder.^[6] Scapular dyskinesis is abnormal shoulder blade movement, often associated with weakness in these muscles.^[7]

Preventing Shoulder Injuries in Gymnasts

So far we’ve discussed common shoulder injuries and how they occur, but not anything actionable yet. Knowing the risks at hand, coaches and athletes should focus on shoulder injury prevention. A large component of shoulder injury prevention for gymnasts is resolving those previously mentioned risk factors, and a few key stretches and exercises can help resolve these limitations.

Stretches and Exercises

• Sleeper Stretch:
  • Lying on your side, place your bottom arm straight forward then bend the arm 90-degrees toward the ceiling. Using your other hand, push the bent arm down toward the floor, feeling a stretch through the back of the shoulder.
  • Stretching the posterior capsule, performing the sleeper stretch improves internal rotation range of motion.^[5]
• Side-Lying Weighted External Rotation:
  • Lying on your side with your top arm by your side, bend the arm 90-degrees and hold a dumbbell in your hand. Keeping your elbow by your side, rotate your hand up towards the ceiling. Lower the weight slowly and repeat.
  • Targeting the external rotators, this exercise improves external rotation strength.^[8]
  • This exercise can easily be progressed with varying reps and weights.
• Push-Up Plus:
  • In a push up, or front support, position, let the chest sink through the shoulders while keeping the rest of the body tight and arms straight. Then, press through the floor, pushing tall, and rounding the shoulders.
  • Targets the serratus anterior, which helps scapular coordination and control.
• Handstand:
  • A handstand is a gymnastics specific way to help improve shoulder health. Handstands involve coordinating the muscles of the shoulder, including the scapular muscles, in an overhead position.
• V-Sit:
  • Another gymnastics specific movement, the V-Sit targets the muscles of the upper back and back of the shoulder. This includes the external rotators.
  • Can progress toward the Manna over time.
  • Check out our in-depth discussion of the V-Sit for more details.

Citations

1. Thomas, R. E., & Thomas, B. C. (2018). A systematic review of injuries in gymnastics. The Physician and Sportsmedicine, 47(1), 96–121. https://doi.org/10.1080/00913847.2018.1527646
2. Szot, Z., Boroń, Z., & Galaj, Z. (1985). Overloading changes in the motor system occurring in elite gymnasts. International journal of sports medicine, 6(1), 36–40. https://doi.org/10.1055/s-2008-1025810
3. Gendre P, Boileau P. The Injured Shoulder in High-Level Male Gymnasts, Part 1: Epidemiology and Pathoanatomy of Surgically Treated Lesions. Orthopaedic Journal of Sports Medicine. 2021;9(10). doi:10.1177/23259671211043449
4. Momma, D., Iwamoto, W., Endo, K., Sato, K., & Iwasaki, N. (2020). Stress Distribution Patterns Across the Shoulder Joint in Gymnasts: A Computed Tomography Osteoabsorptiometry Study. Orthopaedic journal of sports medicine, 8(11), 2325967120962103. https://doi.org/10.1177/2325967120962103
5. Tilley, Dave. “5 ‘Must Hit’ Milestone’s For Gymnastics Shoulder Rehabilitation.” SHIFT Movement Science, 21 Sept. 2024, shiftmovementscience.com/5milestonesshoulderrehab/.
6. Cools, A. M., Johansson, F. R., Borms, D., & Maenhout, A. (2015). Prevention of shoulder injuries in overhead athletes: a science-based approach. Brazilian journal of physical therapy, 19(5), 331–339. https://doi.org/10.1590/bjpt-rbf.2014.0109
7. Stanford Health Care. (n.d.). Scapular dyskinesis. Retrieved September 21, 2024, from https://stanfordhealthcare.org/medical-conditions/bones-joints-and-muscles/scapular-dyskinesis.html
8. Reinold, M. M., Wilk, K. E., Fleisig, G. S., Zheng, N., Barrentine, S. W., Chmielewski, T., Cody, R. C., Jameson, G. G., & Andrews, J. R. (2004). Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. The Journal of orthopaedic and sports physical therapy, 34(7), 385–394. https://doi.org/10.2519/jospt.2004.34.7.385