Table 2 Characteristics of the studies included in the literature review

Ling et al. [1]

N = 100 female gymnasts

Seven National College Athletic Association Division 1 women’s gymnastic programs in the Midwestern United States

Female 19.6 ± 1.2yrs, BMI 23.1 ± 2.0

Gymnastics Functional Measurement Tool and 10 associated items

Rope climb

Vertical jump

Hanging pikes

Shoulder flexibility angle

Agility sprint time

Over-grip pull-ups

Split sum

Push-ups

20 yard sprint time

Handstand hold time

Gymnastics-related injury “an injury that resulted from practice, competition, or conditioning that caused the athlete to modify or stop participation and required attention from a medical provider (certified athletic trainer, physical therapist, physician or chiropractor”

Previous injuries were those that occurred before participants were enrolled in the study

Current injury was an injury that occurred during a single academic year

Injury: “Any gymnastics related physical damage causing the gymnast to miss or modify one or more training sessions, competitions or both”

Injury severity

Mild: Missed ≤ 10 practices

Moderate: Missed 10–25 practices

Severe: Missed more than 25 practices and more than one competition and/or required surgery

Injuries were categorised as:

Mild: Missing 1–9 practices but no competitions

Moderate: Missing 10 to 25 practices or one competition

Severe: Missing > 1 competition

Assessment by medical provider certified athletic trainer, physical therapist, physician or chiropractor

Seventy-eight gymnasts sustained an injury (78%)

Most injuries were in the upper extremity

The most common type of injury included sprains and strains

For trunk injuries, a higher score on the vertical jump test was significantly associated with a decrease in trunk injuries (OR 0.69, 95% CI 0.52–0.91, P = 0.01)

This significant finding remained after adjusting for age, BMI, years of competition, previous injury, previous surgery and previous fracture (OR 0.69, 95% CI 0.47–1.01, P = 0.05)

Each one point increase in vertical jump score corresponding to an additional 3.4 cm in jump height reduced the risk of trunk injury by 30%

No other screening measures were associated with injury

Abalo- Núñez et al. [2]

N = 73 athletes

N = 51 experimental group (gymnasts, 45 female, 6 male)

N = 22 control group (athletes from other sports, all female)

56.86% gymnasts competed in national competitions

39.22% competed in international competitions

3.92% competed in regional competitions

45.45% of the control group competed at national level

4.55% of the control group competed at international level

Gymnasts 13.61 ± 4.59yrs, 1.50 ± 0.15 m, 45.28 ± 14.42 kg

Athletes 14.59 ± 3.93 yrs, 1.46 ± 0.10 m, 49.73 ± 11.19 kg

Q angle

Perimeter of the thigh

Injury at the end of the season (injury/no injury)

No definition of injury provided

Injury questionnaire

Twelve gymnasts reported injury in the season

Significant differences between injured and uninjured gymnasts for mean right Q angle (P = 0.005), mean left Q angle (P = 0.003), with a greater Q angle potentially predisposing to injury

Significant differences between injured and uninjured gymnasts for mean right bilateral weight-bearing on right leg (P = 0.025)

Age (P = 0.012), weight (P = 0.028) and height were significant variables for injury incidence rate. The effect of the Q angle on the probability of injury varies depending on the gymnast’s weight (P = 0.026)

An excessive Q angle may predispose to injury

Linder and Caine [4]

N = 68 females

Competitive gymnasts from 3 prominent private clubs (beginner to international level)

Comparison of 27 injured and 41 non-injured gymnasts

Low level: Canadian provincial level 1,2 and 3

High level: Canadian provincial level 4 and national elite level

Injured (whole sample)

12.3 ± 1.88 yrs, 145.29 ± 11.00 cm, 37.87 ± 8.16 kg

Non-injured (whole sample)

10.91 ± 1.60 yrs, 137.93 ± 10.01 cm, 32.43 ± 6.49 kg

Low-level injured

11.24 ± 1.57 yrs, 143.05 ± 12.13 cm, 35.80 ± 8.40 kg

Low-level non-injured

10.49 ± 1.51 yrs, 136.31 ± 10.31 cm, 31.33 ± 6.15 kg

High-level injured

13.09 ± 1.75 yrs, 147.69 ± 7.67 cm, 40.11 ± 7.59 kg

High-level non-injured

11.93 ± 1.35 yrs, 140.98 ± 10.24 cm, 35.10 ± 6.75 kg

Height

Weight

Biepicondylar femur width

Thigh circumference

Wrist circumference

Total skinfold (sum of 6 skinfolds)

Endomorphy

Mesomorphy

Ectomorphy

Shoulder flexion strength

Grip strength right

Pronation/supination flexibility

Splits forward right

Sit and reach

Leg raise forward left

20 m run

Leg lifts

Standing broad jump

Bar dips

Vertical jumps

Injury rate: the number of injuries sustained during the surveillance period/estimated number of hours trained during that period × 100

Time lost: number of practice hours affected by injury estimated from the injury follow-up report and the gymnast’s competitive level/ total number of hours trained: Served as a measure of seriousness of the injury

The definition of injury referred to a previous publication; however, the actual definition was not given within the article

Method of collecting injury information and definition of injury described previously in another publication

This article does not state who collected data or how

Twenty-seven gymnasts reported an injury 14 low level and 13 high level

Injured gymnasts were significantly taller (P < 0.01) and heavier (P < 0.01) than non-injured in whole sample

Biepicondylar width higher for injured gymnasts (P < 0.01) in whole sample

Thigh circumference higher for injured gymnasts (P < 0.001) in whole sample

Wrist circumference higher for injured gymnasts (P < 0.02) in whole sample

Shoulder flexion strength higher for injured gymnasts (P < 0.05) in whole sample

Shoulder flexion strength higher for injured gymnasts (P < 0.05) in low level

Grip strength right higher for injured gymnasts (P < 0.01) in whole sample

Grip strength right higher for injured gymnasts (P < 0.05) in high level

Injured gymnasts had significantly greater splits forward right (P < 0.05) in low level

Injured gymnasts had significantly lower splits forward right (P < 0.02) in high level

Injured gymnasts had significantly better sit and reach (P < 0.05) in the whole sample

Injured gymnasts had significantly better sit and reach (P < 0.05) in the high-level sample

Injured gymnasts had significantly higher leg raise forward left (P < 0.02) in the whole sample

Injured gymnasts had significantly better leg raise forward left (P < 0.05) in the low level

Injured gymnasts had significantly greater 20 m run time (P < 0.01) in the whole sample

Injured gymnasts had significantly greater bar dips (P < 0.05) in the high level

Injured gymnasts had significantly greater vertical jump (P < 0.01) in the whole sample

Body size, strength, power and speed identified as significant discriminating variables in whole sample and twice less reliably in the competitive levels

In all three instances, the injured gymnasts had higher class means than non-injured

Higher injury rate for high-level gymnasts scoring low on balance, speed and arm flexibility/strength

Sweeney et al. [9]

N = 67 female gymnasts

6 to 18 years old

Level 3 to 10 of the USA Gymnastics Junior Olympic Programme

Participants with low back pain (N = 30): 13.7 ± 2.8 yrs, 149.1 ± 14.5 cm, 43.4 ± 12.3 kg

Participants without low back pain (N = 37): 11.7 ± 2.8 yrs, 143.2 ± 13.9 cm, 37.5 ± 11.3 kg

Active and passive shoulder flexion

Active and passive hamstring flexibility (popliteal angle)

Active and passive prone hip extension

Active and passive prone knee flexion (quadriceps flexibility)

Thomas test

No definition of injury provided

Gymnasts to report their history of low back pain within the past 12 months

If yes then the months were determined and whether they had seen a medical provider

Self-reported via questionnaire

Thirty gymnasts reported lower back pain (44.8%)

Gymnasts with lower back pain were older and heavier

Negative left Thomas Test was independently associated with low back pain (P = 0.03) and therefore gymnasts with a positive test were less likely to report lower back pain

Right passive prone hip extension was lower in the back pain group (P = 0.04)

No other flexibility measurement independently associated with increased risk of low back pain

Bukva et al. [21]

N = 24 (7 males)

Qatar National Team artistic gymnasts

Aged 11–26 yrs

Males 16.29 ± 4.88 yrs

Females 13.86 ± 2.85 yrs

Beighton score

Time lost from participation (practice and competition) during 2015/16 season

“Certified trainers were recruited to prospectively record injury data”

No correlation between hyperelasticity score and number of injuries

No correlation between training hours per week and number of injuries

Miller et al. [22]

N = 55 (28 females)

British Gymnastics Lilleshall National Sports Centre during national squad training camp

Member of National Gymnastics Artistic Squad

Males 19.2 ± 3.5 yrs

Females 16.9 ± 3.0 yrs

Injured 18.7 ± 3.2yrs

Uninjured 17.0 ± 2.8yrs

Weight-bearing dorsiflexion was measured using a weight-bearing lunge test

Defined as injured (previous ankle injury) and non-injured (no previous ankle injury)

No current ankle injury

Self-reported via questionnaire

There were 48 injured limbs

Injured limbs had a smaller range of weight-bearing dorsiflexion with greater variability compared to uninjured (44.8° ± 6.1°, 95% CI 43.0°, 46.5°for injured and 45.4° ± 6.1, 95% CI 43.9°, 46.9°for uninjured)

Injured limbs had a smaller range of weight-bearing dorsiflexion compared to the uninjured limbs, with the injured limbs having greater variability (uninjured 47.4° ± 5.7°, 95% CI 45.0°, 49.8°; injured 45.1° ± 6.0°, 95% CI 42.6°, 47.7°; t(23) = −3.259, P = 0.03)

Cupisti et al. [23]

N = 171 females

67 rhythmic gymnasts

104 controls

19 clubs, affiliated members of the Italy Federation of Gymnastics

Rhythmic gymnasts no low back pain complaint 14.5 ± 2.1 yrs, 46.8 ± 7.6 kg, BMI 18.4 ± 1.9

Rhythmic gymnasts low back pain 15.4 ± 1.5 yrs, 51.8 ± 3.7 kg, BMI 19.5 ± 0.9

Controls no complaint 14.5 ± 1.6 yrs, 53.2 ± 9.9 kg, BMI 20.5 ± 3.1

Controls low back pain 15.4 ± 1.8 yrs, 59.7 ± 9.7 kg, BMI 22.6 ± 3.6

Four skinfold thickness measurements (triceps, biceps, inter-scapular and suprailiac taken using Holtain’s skinfold calipers to calculate body fat density

Waist circumference

“Yes-response to the question do you often have back pain? was defined as having back pain"

Self-reported by questionnaire with intensity, location and characteristic of pain defined using categorical and continuous (0 to 10 rating) items

Seven out of 67 gymnasts reported low back pain (10.4%)

Six gymnasts reported bilateral pain and one central low back pain

In both gymnasts and controls the symptom-free females demonstrated lower body weight (P < 0.05), lower BMI (P < 0.05), lower fat body mass (P < 0.05) and lower waist circumference (P < 0.01) than those complaining of low back pain

Toraman et al. [24]

N = 32 females

17 girls attending the School of Physical Education and Sports and participating in a rhythmic gymnasts course

15 girls (controls) attending the Tourism Institution of Higher Education

Ballet students attending intensive summer ballet programmes

Gymnasts 20.4 ± 1.5 yrs, 166.6 ± 5.2 cm, 55.2 ± 4.7 kg

Controls 19.7 ± 0.8 yrs, 167.3 ± 3.2 cm, 54.5 ± 3.6 kg

New York Posture Rating Test

Screens posteriorly (Scored/30):

Head

Vertebral column

Pelvis

Heels and foot bases

Screens laterally (scored/35)

Neck

Breast

Shoulders

Back

Body

Abdominal protrusion and waist

Other measurements:

Genu valgum

Genu Varum

Tibial torsion

Q angle

Feiss line

Acute injuries “sudden appearing, severe injuries”

Chronic injuries “result of repetitive low threshold forces, which decreased with activity and warm-up and where pain increased following activity”

Self-reported retrospectively via questionnaire

“Measurements and evaluations were made by two different investigators”

Four gymnasts had acute and ten chronic injuries of ankle and / or foot

Unclear regarding other injuries

Gymnasts having normal foot and ankle appearance had no injury history (P < 0.05)

79% of subjects with pes planus had an ankle injury history

Gymnasts had no knee injuries so variations in Q angle were not investigated

DiFiori et al. [25]

N = 59 (31 males)

Single gymnastic club

Precompetitive level (N = 26)

Beginning level (N = 26)

Middle level (N = 5)

Advanced level (N = 2)

Elite level (N = 0)

Males 9.3 ± 2.3 yrs, 129.3 ± 13.8 cm, 29.0 ± 7.4 kg

Females 9.4 ± 2.5 yrs,129.6 ± 16.2 cm,

28.8 ± 10.0 kg

Bilateral grip strength

Quality, location and duration of wrist pain in the previous 6 months

Training sessions missed and number of days per month missed recorded

Questionnaire used to record wrist pain

Thirty-three gymnasts reported wrist pain (56%)

22 gymnasts had bilateral pain (67%)

Thirty-six per cent of those with wrist pain (12 of 33) had symptoms that interfered with training

No significant difference in grip strength for both left and right wrist between those with and without wrist pain in absolute grip strength and when adjusted for weight for both males and females

Kirby et al. [26]

N = 95 (60 female gymnasts, 35 female controls)

Competitive-level gymnasts

Age matched nonathletic girls

Gymnasts 11.8 ± 2.5 yrs

144.8 ± 13.0 cm

36.6 ± 9.8 kg

Controls 11.7 ± 2.1 yrs

148.8 ± 11.7 cm

42.2 ± 9.4 kg

Shoulder flexion

Shoulder horizontal abduction

Elbow extension

Elbow supination

Lumbar motion

Hip extension

Knee extension

Toe touching

Participants asked to describe current or past musculoskeletal symptoms including “broken bones, spasms, swelling, snaps”

Enquired regarding specific regions

Categorised severity as:

Mild: Symptoms only

Moderate: Symptoms and signs

Severe: Required physician visit

Categorised duration as:

Short: Less than 1 week

Medium: 1 week to 1 month

Long: Greater than 1 month

Reported via interview

When symptoms identified one of the investigators performed a musculoskeletal examination

Total number of injured gymnasts is not reported

No significant differences between gymnasts and controls in the severity or duration of symptoms

Average number of symptomatic areas per participant was 2.25 for controls and 6.17 for gymnasts (P < 0.001)

Gymnasts who had greater ROM on toe touching also had greater low back pain (P = 0.043)

Steele and White [27]

N = 40 females

Competitive gymnasts

Local gymnastic clubs and the zone squad of the North of England

10–21 yrs

Low injury status N = 10

10.8 ± 0.33 yrs(SE)

135.2 ± 1.62 cm(SE)

31.8 ± 1.14 kg(SE)

High injury status N = 10

14.6 ± 0.83 yrs(SE)

153.4 ± 2.65 cm(SE)

46.9 ± 3.02 kg(SE)

Hypermobility assessed using Carter and Wilkinson method modified by Beighton and Horan

Peripheral flexibility determined using a Leighton flexometer including: Shoulder flexion with elevation, shoulder abduction with elevation, elbow and wrist flexion, hip flexion with knee extension, flexion with knee flexion and abduction, knee flexion and ankle dorsiflexion with knee flexion/extension

Total peripheral flexibility score was obtained by the sum of all peripheral joint flexibility scores

Thoracic and lumbar curvatures in standing and lumbar extension in prone were measured using a Loebl hydrogoniometer

Height

Weight

Endomorphy, mesomorphy and ectomorphy determined using modified somatotype method of Heath and Carter

Injury score categorised injuries in terms of severity whereby numerical ratings were assigned from 1 to 20

No apparent injury definition

Unclear how injury was diagnosed

Significant differences between the low injury and high injury group were reported for age (P < 0.001), weight (P < 0.001), Quetelet index (P < 0.001), lumbar extension (P < 0.05) and shoulder flexion (P < 0.005)

Significant positive relationship between injury score and weight (P < 0.05), lumbar curve (P < 0.05), age (P < 0.001)

Significant negative relationship between injury score and mesomorphy (P < 0.05) and height (P < 0.05)

Weight, mesomorphy, standing lumbar curvature, age and height (R = 0.834, R² = 0.696) were significant predictors of injury score

Vanti et al. [28]

Main gymnastic clubs of Emilia-Romagna Region, Italy

Adolescents attended junior high school in 3 institutes of the Emilia-Romagna Region

N = 466 (91 club-level gymnasts, 85 females, 6 males) 12.3 ± 3.63, 144.9 ± 12.2 cm, 38.5 ± 12.1 kg, BMI 17.9 ± 2.62

375 adolescents (173 females, 202 males) 13.07 ± 0.95 yrs, 154.7 ± 16.3 cm, 49.8 ± 11.7 kg, BMI 20.3 ± 3.4

Height

Weight

BMI

Lumbar ROM (via electronic motion evaluation system) therefore not included in review analysis

No definition of injury provided

Study assessed pain via a questionnaire

Have you ever had back pain and with what frequency?

How would you rate your usual pain from 0 to 10?

Divided into low-level low back pain frequency of “sometimes”

Medium/high-level “intensity ≥ 4/10”

Self-reported via questionnaire

Forty-two (46%) and 24 (26%) gymnasts reported low-level and high-level lower back pain respectively

No significant difference between height, weight, BMI and LBP in either the gymnasts or adolescent groups

Wright and De Crée [29]

N = 15 females

Members of the Kettering Olympic Gymnastic Club Elite Competition Squad, UK

Age range 8 to 18 years old

11.8 ± 3.5 yrs

Low injury 9.5 ± 1.3 yrs, Height 132 ± 6.8 cm, mass 28.0 ± 4.3 kg, BMI 15.8 ± 1.3

High injury 14.3 ± 3.3 yrs, Height 153.9 ± 17.3 cm, Mass 48.0 ± 12.8 kg, BMI 15.0 ± 0.5

Somatotype determined using the Heath-Carter somatotype method (categorised as endomorph, mesomorph or ectomorph)

Percentage body fat estimated from 4 subcutaneous skinfolds (triceps, subscapular, suprailiac, medial calf)

Height

Mass

Biceps muscle girth

Medial calf muscle girth

Humerus bone width

Femur bone width

Grip strength

Standing vertical jump

Muscle endurance via pull-ups and push-ups

Sit and reach

Shoulder and wrist elevation

Back extension in bridge

Ankle dorsiflexion

Ankle plantarflexion

“A gymnastics-related incident that limited participation in any of the gymnastic events”

Participants classified as having a “low” or “high” injury status based upon previously described system in [27]

Self-reported by questionnaire for injuries in the previous 4 years

Low injury N = 8, high injury N = 7

Abrasions were most common in the low injury group and sprains in the high injury group

The high injury group was significantly older (P = 0.002), taller (P = 0.006), heavier (P = 0.001)

Significant difference in BMI (P = 0.001) with the high injury group being marginally “underweight” and the low injury group had “severe protein-energy malnutrition”

High injury group scored better on the vertical jump than the low injury group (P = 0.021)

Low injury group scored better on back extension in the bridge (P = 0.013) and ankle dorsiflexion (P = 0.013)

The number of overuse injuries was significantly higher in the high injury group than in the low injury group (29.0% vs. 11.1%)

Ghasempour et al. [30]

N = 43

Elite male gymnasts in the Iranian Premier League and Division One

Age 16 to 28 years (mean 20.47 yrs)

Weight 64.33 ± 7.2 kg

Height 170 ± 0.05 cm

BMI 22.15 ± 2

Weight

Height

BMI

Endomorphy

Mesomorphy

Ectomorphy

Fat percentage

Ankle girth

Calf girth

Length of lower extremity

Small body size

Medium body size

Large body size

Total body size

Injury was defined as “any damaged body part (only the ankle in this study) that required medical attention or prevented or restricted the gymnasts from training or competing in any activity/apparatus in any way and/or length of time”

Gymnasts completed an injury questionnaire while a sports specialist was available to answer any questions

79% of gymnasts had experienced ankle injuries over the past year

Joint and ligamentous injuries were the most common

Body size had a positive relationship with ankle injuries (P = 0.002, r = 0.524)

There was no significant relationships between the presence of ankle injuries and other anthropometric characteristics

Ghasempour et al. [31]

N = 43

Elite male gymnasts in the Iranian Premier League and Division One

Weight 64.33 ± 7.2 kg

Height 170 ± 0.05 cm

BMI 22.15 ± 2

Age 16 to 28 years (mean 20.47 yrs)

Weight

Height

BMI

Endomorphy

Mesomorphy

Ectomorphy

Fat percentage

Upper extremity length

Wrist girth

Forearm girth

Small body size

Medium body size

Large body size

Total body size

Injury was defined as “any damaged body part (only the wrist in this study) that required medical attention or prevented or restricted the gymnasts from training or competing in any activity/apparatus in any way and/or length of time”

Gymnasts completed an injury questionnaire while a sports specialist was available to answer any questions

53.5% of gymnasts had experienced a wrist injury over the last year

Skin and muscular injuries were the most common

Weight was positively related to wrist injuries (P = 0.02, r = 0.34)