Injuries prevalence in elite male artistic gymnasts

http://dx.doi.org/10.1590/1807-55092016000100079 Natália Batista Albuquerque GOULART Morgana LUNARDI Jennifer Faraon WALTRICK Annelise LINK Leandro GARCIAS Mônica de Oliveira MELO João Carlos OLIVA Marco Aurélio VAZ *Colegiado de Educação Física, Universidade Federal do Vale do São Francisco, Petrolina, PE, Brasil. **Centro de Desportos, Universidade Federal de Santa Catarina, Florianópolis, RS, Brasil. ***Centro de Ciências Biológicas e da Saúde, Universidade de Caxias do Sul, Caxias do Sul, RS, Brasil. ****Escola de Educação Física, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil.


Introduction
Injuries prevalence in elite male artistic gymnasts CDD.20 Men's artistic gymnastic (AG) is featured by the executions of high complexity skills to be performed in six di erent apparatus: oor exercise, pommel horse, rings, vault, parallel bars, and horizontal bar 1 .In recent years, AG has shown great evolution due to materials and apparatus development, as well as to training methods improvement [2][3] .Such changes have increased the number of participants, due to a more attractive sport.However, improve in performance has been a result from more di cult elements created by the athletes (sometimes with the athlete's name being given to a speci c movement).In addition, a more strict scoring system has resulted from these material, technical and performance improvements.All these factors might lead to a higher injury risk [4][5] .
According to N 4 , each apparatus presents unique characteristics.Injuries are related to the movements performed on these apparatus, as well as to insu cient training, guidance and protection given to the gymnasts.However, the literature lacks a systematic study looking at the mechanisms and incidence of sports injury.Epidemiological studies in sports injuries are important strategies to identify risk factors and to set preventive measures against these injuries [6][7][8] .e literature presents a wide range of studies on the prevalence of injuries among female

Abstract
The purpose of this study was to investigate the injuries prevalence in men elite artistic gymnasts.Twenty Brazilian senior gymnasts, aged 23.1 ± 6.5 years, 13.9 ± 5.0 years of practice and 36.5 ± 4.7 hours per week training, participated in this study.The athletes answered a morbidity questionnaire, formulated according to studies from the literature, for information on the injuries' characteristics and circumstances.Information about the injury circumstances (gymnastic apparatus, overload training and physical exercises), the anatomic site injured, the affect biological tissue and the return to training after injury treatment were evaluated.Data were analyzed by descriptive statistics, absolute and relative frequencies.The training overload, and fl oor, pommel horse and vault were the events that presented higher injuries frequency.In relation to anatomic site, ankle, hands/fi ngers and shoulder were the most cited regions.The ligament, bone and articular capsule were the most affected biological tissues.In relation to gymnasts' return to their sports activities, 56% of them reported a better condition at return, 33% reported to have returned at the same fi tness level and 10% indicated that they were in a worse condition when they returned to the sports activities.The men's artistic gymnastics injuries are related to the mechanical demands of this sport.The analysis of risk factors helps in understanding the injuries mechanisms in gymnastics, and provides relevant information that can assist in effective prevention strategies.KEY WORDS: Injury; Gymnastic; Training; Questionnaire.gymnasts.However, these studies rarely address injury occurrence in males.us, the current study aims to investigate the prevalence of injuries in men's artistic

Method
Athletes had an average training time of about 14 years, with more than 35 hours of training per week (TABLE 1).
According to the event, injuries were distributed on Floor (23.4%),Pommel Horse (11.7%),A total of 20 Brazilian senior men gymnasts participated in the current study.e gymnast group consisted of high performance (elite) gymnasts at national competition level.e present investigation was approved by the Ethics Committee on Human Research from the Federal University of Rio Grande do Sul (CAAE: 1 0059712.9.0000.5347).All gymnasts and trainers (in the case of young gymnasts) signed the informed consent form to participate in the study.
e athletes answered a morbidity questionnaire used to identify the injuries prevalence.e questionnaire was formulated according to epidemiological descriptive studies on gymnastics athletes found in the literature [5][6][7][8] .Interviews were conducted at the time the injury occurred or thereafter, during artistic gymnastic competitions or training sessions.e questionnaire included personal information such as age, time of training (in years) and weekly training hours.Athletes recorded injury information about its anatomical location, circumstance of injury (gymnastic apparatus) and about their return to training activities after injury treatment.In order to better classify the collected data, injuries were separated according to gymnastics, the gymnastic apparatus at which the injury occurred, the anatomical sites and the most a ected biological tissues of these injuries.the a ected biological tissue, using the following classi cation: bone injury, cartilage injury, ligament injury, tendon injury, muscle injury and capsular injury.In addition, two events found in the training routine were added to evaluate injury prevalence at the men's apparatus: overload training (related to repetitive e ort of the musculoskeletal system due to gymnastic training) and warm up/physical preparation exercises.e participants answered the questions and the investigator, who was also in charge of making notes in the questionnaire, conducted the procedure.
On the current study, injury was considered as any gymnastics-related incident resulting from training and/or competition and able to cause the athlete's temporary suspension from the training routine or modi cation of all or part of his training as well as the need for medical treatment for at least a month 8 .Recorded data were systematically organized on Excel spreadsheets for analysis.Data on the injuries prevalence, their anatomical site, as well as the gymnastic apparatus where they occurred, were analyzed using descriptive statistics by absolute and relative frequencies distribution.

Age
Training time Weekly hours Mean ± SD 23.1 ± 6.5 13.9 ± 5.0 36.5 ± 4.7  AG is associated with intensive movement repetition to achieve a precise execution of the different exercises.Moreover, in recent years, complexity increased in their implementation and motor demand, fact that determined an increase in daily training hours 2,6 .In this study, injuries caused by overload training presented the highest percentage of reports.D et al. 9 reported that fatigue was a major factor contribution to injury in elite gymnasts.ey are more often found at the shoulders and in the lower back.M and A 10 reported that lower back injuries are usually related to acute microtrauma (single traumatic event) or successive microtrauma events (overuse).Such events result from repetitive exions and extensions due to spine rotation in gymnastics movements.AG, just as other sports, works with an intense calendar of important competitions.Sometimes the athlete does not have time to physically recover for the next competition, as it is required.
In addition to overload training, oor, pommel horse and vault also lead to high injury occurrence, respectively.Floor is the most complex AG apparatus and it is composed of acrobatic elements combined with gymnastic strength and balance exercises 11 .Floor exercise demands are linked to strength (muscle power in the lower and upper limbs), exibility, and muscular anaerobic endurance.It may be noticed that injuries caused by this device are found in di erent joints due to its complexity and the injuries are mostly concentrated in the lower limbs 4,6 .On the other hand, the pommel horse predominantly uses the strength of the upper limbs, since the athlete's weight is fully supported on the hand 11 .

Discussion
Gymnasts must execute all elements without interruptions, which demands high anaerobic and muscular endurance, rhythm and balance on the upper limbs 6,11 .ese exercises may be associated with the high percentage of injuries in wrists, hands and ngers.As for the vault exercise, each vault begins with the preparatory running (25 meters), continues with a take-o from both feet to the springboard, a support phase on the table with two hands ( rst phase), and the second ight phase involves the pushing o from the table up to landing in a standing position 12 .us, vault leads to high rates of injuries located in the ankle, especially caused by the landing movements 6,13 .
In relation to anatomic site, ankle, hands/ ngers and shoulder were the most cited regions.By analyzing the movements performed on each men's artistic gymnastics unit, it was possible to conclude that the ankle is the most demanded joint in landing, mainly on the oor and vault apparatus 6,14 .N 4 reports that most ankle injuries occur due to unsuccessful landing.e gymnast must be able to control the ground reaction force, using biomechanical and neuromuscular strategies (biarticular muscle activation) during the landing procedure [13][14][15] .According to the literature, teaching the correct and controlled movement, and using exercises for the lower limbs are important strategies to prevent and minimize injuries [15][16][17] .
In addition, hands and ngers also present high injury incidence since much of the exercises in men's devices involve suspension and body support on these structures.According to literature 4,8 , the hand and nger injuries go from acute events, such as blisters and abrasions, to the most complex ones, such as dislocations and fractures, as it was herein mentioned.
Finally, the shoulder joint is also often injured, mainly due to movements performed in the rings.According to C and M

18
, most movements in the rings require shoulder abduction and consequent capsular compression in order to keep joint stability.us, many injuries su ered in this unit are due to in ammation in the shoulder joint capsule.
e current study also aimed to evaluate the tissues presenting the highest injury prevalence in men's AG.e ligament tissue presented the biggest number of cases, usually due to sprains.According to the report of the athletes themselves, these injuries are mostly caused by the oor apparatus, and they often occur after successive jumps or incorrect landings 6,8 .Ligaments, despite being adaptable and exible, allow natural movement of the bones they are connected to.ey do not present major force resistance under sprain loads 19 .
us, it results in the partial rupture of this tissue and in the longer overall time required to treat it.
In addition to the ligament tissue, bone tissue injuries were also quite cited by the athletes.According to the results, they occur due to fractures in the feet, toes as well as in the hands and ngers.Bone tissue is a specialized structural tissue and its solid composition adapts to the support functions and to its protection 20 .According to the literature, bone injuries have a ected athletes due to the strong impact of the exercises required by the artistic gymnastics 6,20 .erefore, it is worth teaching right landing technique, since the movement must be done on both feet or on both hands in order to dissipate power impact on the structures 13,16 .
Finally, the injuries in the articular capsule are also among the three most cited tissues and it is due to the overload training and, in some cases, to speci c ring exercises, as it was previously mentioned.Among this group of injuries, it is worth highlighting those located in the anterosuperior top and on the posterosuperior shoulder labrum (SLAP).ese injuries usually occur in the insertion zone, over the biceps tendon, due to the biomechanical overload exerted by the shoulders rotation and abduction movements [21][22] .C and M 18 report that many athletes present shoulder instability, thus training sessions should involve strengthening of shoulder muscles that are related to dynamic stabilization of this joint, especially the rotator cu .
Biological tissue response is in uenced by tissue age, tissue fatigue, mechanical tissue properties, and other factors 19 .erefore, athletes and coaches must know some clinical aspects that occur in skeletal tissues following trauma, as well as the fact that the a ected tissue requires di erent treatment modalities (immobilization, surgical treatments, in ltrations) to keep the segment from any other injuries.In this study, the athletes reported that some injuries severely a ected more than one tissue.
The injuries in AG show complex etiology; however, N 4 points out that the role played by health professionals such as physical educators, physiotherapists and medical doctors may reduce injury risks and allow faster recovery and the gymnasts' safe return to sports practice.Besides the basic precautions involving injuries, the biomechanical studies have provided theoretical data in such extent that the skills needed to prevent injury and prolong the athlete's career in sport are more properly applied.
Regarding the conditions required to the gymnasts' return to sports practice after treatment, 56% of them have reported better return, 33% reported to have returned at the same tness level as pre-injury and 10% have reported to be worse tted when they returned to sports practice.During the rehabilitation period, after the injury was healed, the athletes must change their training habits and improve their skeletal tissues conditioning in order to enable their e cient recovery 23 .According to the current study, most athletes reported better conditioning after the recovery period.Such result is linked to the strengthening exercises used in rehabilitation and to reduced training load, as well as to training and improved strengthening techniques.
In the current study, the athletes had di culty remembering previous injuries.On the other hand, they reported that it was easier to remember the latest events or those that have marked their careers.In addition, the di culty athletes have to be properly diagnosed for certain injuries by clinical professionals was also shown in the current study.erefore, it is also important to have the participation of these health professionals (such as physiotherapist or coach) to answer information regarding athletes' injuries.
The current study presents the following conclusions: -Most injuries in men's artistic gymnastics are due to overload training and to moves on oor, pommel horse and vault;
-The anatomical sites with highest injury prevalence in men's artistic gymnastics are: ankle, hands, ngers and shoulders; -Biological tissues presenting higher injury prevalence in men's artistic gymnastics are: ligament tissue, bone and articular capsule of the shoulder joint.
us, studies focused on analyzing risk factors associated with injuries are critical for a better understanding on the occurrence mechanisms as well as to boost the development of more speci c prevention programs for AG.Data in the current study showed that injuries in AG mostly occur because of physical stress due to training and/ or overtraining.Therefore, 1) a good physical preparation, including valences such as strength, speed, power, exibility and resistance of all muscle groups associated with the training; 2) a thorough multidisciplinary physical/clinical examination prior to competition season involving the coach, the physiotherapist, the medical doctor, the nutritionist and the psychologist; and 3) the study of injury mechanisms and the development of prevention programs, especially for the apparatus that involves landing and body support, may all lead to signi cant results regarding injury prevention and performance improvement.

TABLE 1 -
Gymnasts' age, training experience and training time variables.

TABLE 2 -
Absolute (n) and relative (%) injuries distribution regarding their anatomical site.

TABLE 3 -
Absolute (n) and relative (%) injuries distribution according to the event.

TABLE 4 -
Events related to artistic gymnastic training and the affected biological tissue.