1

Hip Flexor Tendonitis

Epidemiology: Can occur at any age.

Mechanism of Injury/Description: Hip flexor tendonitis occurs with repetitive tugging/pulling/forces on your hip flexor muscles specifically the iliopsoas and rectus femoris muscle causing inflammation and pain. Typically this occurs from repetitive overuse of these muscles.

Signs/Symptoms: The gymnast will have pain on the front of the hip (at the iliopsoas and rectus femoris muscle), and pain with activating/flexing/using the hip flexor muscles (ex: squatting, running, jumping, splitting).

Diagnosis: The diagnosis is determined by a physical exam. There is usually pain with resisted hip flexion. Your Medical Provider may consider x-rays or an MRI to rule out other conditions or confirm the diagnosis.

Treatment: To treat this injury the gymnast should rest from all jumping/pounding/impact, consider taking NSAIDs, undergo physical therapy, and consider receiving an injection into your hip flexor tendon if conservative treatment fails.

Prevention: To prevent this injury ensure you are properly stretching and using correct landing mechanics, that you have a tight core strength while performing skills, and that you work on gluteus/hip strength.

Gymnastics Medical Provider PEARLS: There are many causes for anterior hip pain. Be sure you have a diagnosis and plan that is gymnastics and gymnast specific. If the pain is not improving with conservative treatment (ex: NSAIDs, PT, rest), consider an ultrasound diagnostic exam and/or injection.

Gymnast, Parent, and Coach PEARLS: As long as this does not cause pain, have your gymnast show her splits. Are her hips square/facing forward? If not, work with your gymnast on proper flexibility to help decrease the chance of injury.


2

Femoral Acetabular Impingement (FAI)

Epidemiology: Can occur at any age but is most common in adolescent athletes.

Mechanism of Injury/Description: Occurs when there are abnormal forces and contact between the acetabulum (pelvis) and femur which leads to injury to the labrum (cartilage ring in the hip).

  • CAM impingement: CAM impingement is more common in males and occurs when the base/neck of the femur (thigh bone) becomes too large.
  • PINCER impingement: PINCER impingement is more common in middle-aged women, and occurs when the acetabulum (pelvis) over-hangs/has over-coverage.

Signs/Symptoms: The gymnast will have deep pain within the hip, usually described as “groin pain”. There may be feelings of “catching” or “locking”, and the gymnasts usually have limited hip motion or hip flexion (bending up at the hip), and internal rotation (turning the hip in).

Diagnosis: Diagnosis is determined by physical exam when there is limited hip flexion to 90 degrees, limited motion to less than 5 degrees, and a positive FADDIR test. An x-rays which may be ordered include an AP Pelvis, false profile, and Dunn or modified Dunn. An x-ray may show pistol grip deformity-CAM, cross-over sign-PINCER, increased alpha angle-CAM, and an increased Wiberg/lateral center edge PINCER angle. An arthrogram MRI can be used to evaluate for a possible labrum tear (see more information below about labrum tears).

Treatment: The gymnast should rest from all jumping/pounding/impact, undergo physical therapy, and consider an injection. Surgery may be required in some cases and will be either arthroscopic or an open procedure if you have failed conservative treatment.

Prevention: To prevent this injury focus on proper stretching and landing mechanics, core strength and gluteus/hip strength.

Gymnastics Medical Provider PEARLS: X-rays can be very beneficial in making the diagnosis of FAI. Be sure to order the correct views/make sure these are done correctly the first time with an x-ray technician as you would not want to expose the pediatric patient to more radiation to the pelvis than is safe/necessary.

Gymnast, Parent, and Coach PEARLS: Over-splits when done incorrectly can lead to very serious hip injuries and impingement. Make sure you are always using proper technique.


2

Femoral Acetabular Impingement (FAI)

Epidemiology: Can occur at any age but is most common in adolescent athletes.

Mechanism of Injury/Description: Occurs when there are abnormal forces and contact between the acetabulum (pelvis) and femur which leads to injury to the labrum (cartilage ring in the hip).

  • CAM impingement: CAM impingement is more common in males and occurs when the base/neck of the femur (thigh bone) becomes too large.
  • PINCER impingement: PINCER impingement is more common in middle-aged women, and occurs when the acetabulum (pelvis) over-hangs/has over-coverage.

Signs/Symptoms: The gymnast will have deep pain within the hip, usually described as “groin pain”. There may be feelings of “catching” or “locking”, and the gymnasts usually have limited hip motion or hip flexion (bending up at the hip), and internal rotation (turning the hip in).

Diagnosis: Diagnosis is determined by physical exam when there is limited hip flexion to 90 degrees, limited motion to less than 5 degrees, and a positive FADDIR test. An x-rays which may be ordered include an AP Pelvis, false profile, and Dunn or modified Dunn. An x-ray may show pistol grip deformity-CAM, cross-over sign-PINCER, increased alpha angle-CAM, and an increased Wiberg/lateral center edge PINCER angle. An arthrogram MRI can be used to evaluate for a possible labrum tear (see more information below about labrum tears).

Treatment: The gymnast should rest from all jumping/pounding/impact, undergo physical therapy, and consider an injection. Surgery may be required in some cases and will be either arthroscopic or an open procedure if you have failed conservative treatment.

Prevention: To prevent this injury focus on proper stretching and landing mechanics, core strength and gluteus/hip strength.

Gymnastics Medical Provider PEARLS: X-rays can be very beneficial in making the diagnosis of FAI. Be sure to order the correct views/make sure these are done correctly the first time with an x-ray technician as you would not want to expose the pediatric patient to more radiation to the pelvis than is safe/necessary.

Gymnast, Parent, and Coach PEARLS: Over-splits when done incorrectly can lead to very serious hip injuries and impingement. Make sure you are always using proper technique.


3

Labral Tear

Epidemiology: This injury is seen in all age groups but more common in female athletes.

Mechanism of Injury/Description: The labrum is a cartilage horseshoe shape on the acetabulum (pelvis bone) where the femur (thigh bone) goes into the joint. The labrum helps provide stability and movement for the hip joint. An injury to the labrum can occur acutely with one quick plant and twist, or degenerative (over time) wear and tear to the labrum.

Signs/Symptoms: The gymnast will experience pain deep within the hip in a “C” shape, and snapping or feeling like your “hip is catching/locking.”

Diagnosis: The diagnosis is determined by a physical exam when there is pain within the hip going from a fully flexed, externally rotated, and abducted position to a position of extension, internal rotation, and adduction. An x-ray can also determine the diagnosis and may show FAI (femoroacetabular impingement), hip dysplasia, or arthritis. An MRI is a definitive test, and usually an arthrogram is ordered.

Treatment: The gymnast should rest from all jumping/pounding/impact, consider taking NSAIDs, undergo physical therapy, injections, and sometimes surgery is needed if conservative treatment fails.

Prevention: To prevent this injury focus on proper stretching and landing mechanics, core strength and gluteus/hip strength to absorb the forces on the labrum.

Gymnastics Medical Provider PEARLS: Always look for FAI (femoroacetabular impingement) when thinking of a labrum tear. First start with conservative treatment including rest, NSAIDs, PT and if that fails try an ultrasound guided interarticular injection. If the pain goes away with the injection then this could be the treatment. If the pain goes away but comes back then surgery could be a considered. If an interarticular injection does not help the pain at all consider other sources of pain coming from the hip (ex: hip flexor, radiating from low back, etc…).

Gymnast, Parent, and Coach PEARLS: Do not jump right to surgery. Just because there is a torn labrum in the hip, this may not be the source of pain. Consider a diagnostic ultrasound exam and/or injection to understand where the pain is coming from.


3

Labral Tear

Epidemiology: This injury is seen in all age groups but more common in female athletes.

Mechanism of Injury/Description: The labrum is a cartilage horseshoe shape on the acetabulum (pelvis bone) where the femur (thigh bone) goes into the joint. The labrum helps provide stability and movement for the hip joint. An injury to the labrum can occur acutely with one quick plant and twist, or degenerative (over time) wear and tear to the labrum.

Signs/Symptoms: The gymnast will experience pain deep within the hip in a “C” shape, and snapping or feeling like your “hip is catching/locking.”

Diagnosis: The diagnosis is determined by a physical exam when there is pain within the hip going from a fully flexed, externally rotated, and abducted position to a position of extension, internal rotation, and adduction. An x-ray can also determine the diagnosis and may show FAI (femoroacetabular impingement), hip dysplasia, or arthritis. An MRI is a definitive test, and usually an arthrogram is ordered.

Treatment: The gymnast should rest from all jumping/pounding/impact, consider taking NSAIDs, undergo physical therapy, injections, and sometimes surgery is needed if conservative treatment fails.

Prevention: To prevent this injury focus on proper stretching and landing mechanics, core strength and gluteus/hip strength to absorb the forces on the labrum.

Gymnastics Medical Provider PEARLS: Always look for FAI (femoroacetabular impingement) when thinking of a labrum tear. First start with conservative treatment including rest, NSAIDs, PT and if that fails try an ultrasound guided interarticular injection. If the pain goes away with the injection then this could be the treatment. If the pain goes away but comes back then surgery could be a considered. If an interarticular injection does not help the pain at all consider other sources of pain coming from the hip (ex: hip flexor, radiating from low back, etc…).

Gymnast, Parent, and Coach PEARLS: Do not jump right to surgery. Just because there is a torn labrum in the hip, this may not be the source of pain. Consider a diagnostic ultrasound exam and/or injection to understand where the pain is coming from.


4

Apophysitis/Avulsion
Ischial Tuberosity

Epidemiology: Occurs in gymnasts with open growth plates, meaning they are still growing and have not yet finished going through puberty.

Mechanism of Injury/Description: This occurs from repetitive stress and traction/pulling from the hamstring muscle on the growth plate at the ischial tuberosity (“butt bone”) causing injury, and either inflammation (apophysitis) or a fracture (avulsion). Avulsion refers to the muscle forcefully being pulled and taking a piece of bone with it causing a fracture.

Signs/Symptoms: The gymnast will complain of pain on the “butt bone.” If this is an avulsion injury the gymnast will experience a “pop” or “snap” followed by immediate pain, bruising down the leg, and inability to ambulate (walk) normally. In the case of an apophysitis injury, there will be pain with activation/using the hamstring muscles and swelling.

Diagnosis: Diagnosis is determined by physical exam when there is pain to palpate/push on ischial tuberosity. An x-ray can also determine the diagnosis. An AP supine pelvis x-ray may show widening at the growth plate (apophysitis) or an avulsion fracture (the bone has “pulled off” at the attachment of the muscle/growth plate). MRI or CT would be the definitive test to give the diagnosis.

Treatment: The gymnast should rest from all jumping/pounding/impact. Potentially the gymnast may be prescribed crutches, NSAIDs, physical therapy, and possibly surgery (if there is an avulsion fracture, displacement >3cm).

Prevention: To prevent this injury consider proper stretching of the lower extremity, focusing on safe landing mechanics, core strength, and gluteus/hip strength and listening to your body and telling an adult if you are experiencing pain.

Gymnastics Medical Provider PEARLS: This can be a very challenging diagnosis as almost every skill/event in gymnastics involves use of the hamstring (Ex: kicks, jumps, kips, tap swings, back handspring, running, etc…) and so for the first 2-6 weeks from the diagnosis gymnastics is very limited (gymnasts could do conditioning-upper body and core if given clearance by a medical provider). There have been some gymnasts who try to do uneven bars during this rest period but those who do tend to have a longer recovery as they really aren’t “resting” the hamstring completely.

Gymnast, Parent, and Coach PEARLS: If your gymnast has pain in her/his buttocks/hamstring region do not ignore this! See a medical provider as soon as you can. Focus on splits with square hips and proper stretching to avoid this.


4

Apophysitis/Avulsion
Ischial Tuberosity

Epidemiology: Occurs in gymnasts with open growth plates, meaning they are still growing and have not yet finished going through puberty.

Mechanism of Injury/Description: This occurs from repetitive stress and traction/pulling from the hamstring muscle on the growth plate at the ischial tuberosity (“butt bone”) causing injury, and either inflammation (apophysitis) or a fracture (avulsion). Avulsion refers to the muscle forcefully being pulled and taking a piece of bone with it causing a fracture.

Signs/Symptoms: The gymnast will complain of pain on the “butt bone.” If this is an avulsion injury the gymnast will experience a “pop” or “snap” followed by immediate pain, bruising down the leg, and inability to ambulate (walk) normally. In the case of an apophysitis injury, there will be pain with activation/using the hamstring muscles and swelling.

Diagnosis: Diagnosis is determined by physical exam when there is pain to palpate/push on ischial tuberosity. An x-ray can also determine the diagnosis. An AP supine pelvis x-ray may show widening at the growth plate (apophysitis) or an avulsion fracture (the bone has “pulled off” at the attachment of the muscle/growth plate). MRI or CT would be the definitive test to give the diagnosis.

Treatment: The gymnast should rest from all jumping/pounding/impact. Potentially the gymnast may be prescribed crutches, NSAIDs, physical therapy, and possibly surgery (if there is an avulsion fracture, displacement >3cm).

Prevention: To prevent this injury consider proper stretching of the lower extremity, focusing on safe landing mechanics, core strength, and gluteus/hip strength and listening to your body and telling an adult if you are experiencing pain.

Gymnastics Medical Provider PEARLS: This can be a very challenging diagnosis as almost every skill/event in gymnastics involves use of the hamstring (Ex: kicks, jumps, kips, tap swings, back handspring, running, etc…) and so for the first 2-6 weeks from the diagnosis gymnastics is very limited (gymnasts could do conditioning-upper body and core if given clearance by a medical provider). There have been some gymnasts who try to do uneven bars during this rest period but those who do tend to have a longer recovery as they really aren’t “resting” the hamstring completely.

Gymnast, Parent, and Coach PEARLS: If your gymnast has pain in her/his buttocks/hamstring region do not ignore this! See a medical provider as soon as you can. Focus on splits with square hips and proper stretching to avoid this.


5

Apophysitis/Avulsion

Anterior Superior Iliac Spine (ASIS)

Epidemiology: Occurs in gymnasts with open growth plates, meaning they are still growing and have not yet finished going through puberty.

Mechanism of Injury/Description: This occurs from repetitive stress and traction/pulling from the Sartorius and tensor fascia lata muscle on the growth plate at the ASIS causing injury, and either inflammation (apophysitis) or a fracture (avulsion). Avulsion refers to the muscle forcefully being pulled and taking a piece of bone with it causing a fracture.

Signs/Symptoms: The gymnast will complain of pain on the “hip bone.” If this is an avulsion injury the gymnast will experience a “pop” or “snap” followed by immediate pain, bruising down the leg, and inability to ambulate (walk) normally. In the case of an apophysitis injury, there will be pain with activation/using the Sartorius and tensor fascia lata muscles and swelling.

Diagnosis: Determined by physical exam when there is pain to palpate/push on ASIS. An x-ray can also determine the diagnosis. An AP supine pelvis x-ray may show widening at the growth plate (apophysitis) or an avulsion fracture (the bone has “pulled off” at the attachment of the muscle/growth plate). MRI or CT would be the definitive test to give the diagnosis.

Treatment: The gymnast should rest from all jumping/pounding/impact. They may be prescribed crutches, physical therapy, and possibly surgery (if there is an avulsion fracture, displacement >3cm).

Prevention: To prevent this injury consider proper stretching of the lower extremity, focusing on safe landing mechanics, core strength, and gluteus/hip strength and listening to your body and telling an adult if you are experiencing pain.

Gymnastics Medical Provider PEARLS: It is rare to have an avulsion injury but if the gymnast does not truly rest, he/she is at high risk for having an avulsion occur.

Gymnast, Parent, and Coach PEARLS: If your gymnast has pain in her/his hip region do not ignore this! See a medical provider as soon as you can. Focus on splits with square hips and proper stretching to avoid this.