Back Pain and Gymnastics: Necessary Nuisance, or Preventable and Problematic?
Flipping Painful: Low Back Pain in Gymnastics
As a physical therapist, one of my clinical specialties is the treatment of chronic low back pain. Many of my patients with chronic low back pain are adults, but a large percentage includes gymnasts and wrestlers as young as 9 or 10. While low back pain seems like an issue for older adults, it’s actually quite prevalent within these young athletes, and if managed incorrectly or ignored it can lead to chronic pain, avoidance of certain movements, or quitting a sport entirely.
If you’re a gymnast struggling with low back pain, or your child is a gymnast struggling with low back pain, you’ve probably heard things like:
Gymnastics is “bad for your back”
It’s probably time to quit and try a sport that’s less stressful on your body
You’re too young to be having back pain
Just stop doing the skills that are painful
Unfortunately, all of these have been said to me and my patients, and for a gymnast who wants to continue in her sport they are both tough and frustrating to hear. Often, this leads to pushing through pain, ignoring pain, or continuing with the same patterns that led to back pain in the first place. Yes, gymnastics can be stressful on your body. At the competitive/club level, even in lower levels, gymnasts are often practicing 3-4 hours a day, 5-6 days a week or even more. But, all of that time spent in the gym helps young athletes develop body awareness, strength, self-confidence, discipline, teamwork, set goals, overcome fear….and there are so many reasons for a gymnast to want to stay in her sport and work through an injury. Back pain doesn’t mean your sport is bad for you or that you need to quit your sport.
“Often, this leads to pushing through pain, ignoring pain, or continuing with the same patterns that led to back pain in the first place.”
My story as a gymnast
I started gymnastics at age 3. By age 7, I was part of the TOPS program, practicing 5-6 days a week, 3-4 hours at a time, and participating in regional and national testing. Around age 11, I started to notice some nagging, aching pain in my lower back. At first, I tried to ignore it and push through it. Icing after practice was common, and this was just one more body part to ice. Something always ached or was sore after long practices. But…. while massaging and icing my lower back felt good temporarily, it didn’t seem to stick. After a while, I noticed some trends. It hurt to do:
back walkovers
front walkovers
bridges
casts on bars
…and the pain started to last after practice. I dreaded doing certain skills because I knew they would hurt. I started trying to change my form to avoid arching. The pain wasn’t enough to stop me entirely, but it changed the way I practiced. It was starting to affect me outside the gym, too: I couldn’t sit on the floor without pain. I couldn’t stand in one place for a while without needing to change position to relieve my back pain.
“I dreaded doing certain skills because I knew they would hurt.”
I went to the doctor and got imaging (x-ray, bone scan). They couldn’t find a fracture and physical therapy wasn’t commonly prescribed at the time, so I was sent back to practice without much guidance. There wasn’t structurally anything “wrong” with my back that they could find, so I was cleared to keep practicing. I knew what hurt: back walkovers, bridges, front walkovers...but I didn’t have guidance as to why I was having pain or how to fix it. I was fortunate to be an optional-level gymnast at that time, so….I just cut those skills out of my routines. No more back bends, no more bridging, no more front walkovers, and I moved on. Eventually, I was able to practice without pain. I progressed to Level 9 at the club level and jointed the high school team, competing in gymnastics at New Trier High School for 4 years at the varsity level.
Dr. Kate at gymnastics practice at age 7
Still...I never really addressed the underlying issue. Fast forward to my 20s, and I still had:
back pain with sitting on the floor
low back pain when standing for a long period of time
pain when bending over without support
stiffness and pain sitting in the car for long drives
difficulty working for long stretches of time on my feet
Working as a physical therapist, I would get back pain from being on my feet for long hours treating patients. It wasn’t until I discovered strength training that I began to put my back pain into context and finally learned to manage my symptoms (more on that in another post….). As I started to learn more about my symptoms as an adult, I developed strategies I wish I had had earlier as a gymnast trying to navigate and overcome that constant aching in my lower back.
What I’ve Learned: Managing Low Back Pain
Here’s what I’ve learned from my own experience with back pain as a gymnast and my experience treating gymnasts as a physical therapist:
It’s common but not “normal” to have back pain as a gymnast. It shouldn’t be expected and you shouldn’t have to just work through it.
With the right training, rehab, and strengthening, it is possible to go back to arching and doing the skills you used to do.
Just because you have 6-pack abs doesn’t mean you have the core strength and stability you need to support your low back.
Avoiding movements and/or pushing through pain isn’t the answer and can lead to chronic low back pain down the road.
You don’t have to quit your sport to manage your pain!
Diagnosis: Common Types of Low Back Pain in Gymnasts
There are a few common types of lower back injuries in gymnasts. You may have gotten imaging showing a conclusive stress fracture, inconclusive imaging, or a “clear” x-ray. In general, despite the findings on an x-ray, the management of these injuries is often similar and many of these conditions can be successfully treated conservatively with physical therapy. Here are a few terms you might see on an imaging report or on a referral from a physician:
Mechanical or “non-specific” low back pain: there’s no evidence of a fracture or structural damage on an x-ray, but the gymnast is experiencing low back pain with their sport (or, often, this has carried over into their daily activities).
Spondylolysis: there is evidence of a stress fracture in the spine. This commonly takes place in the lowest lumbar vertebrae for gymnasts (L5) but may occur in other parts of the lumbar spine.
Spondylolisthesis: this is a stress fracture that has progressed. As a result of the fracture, one segment of the lumbar spine has moved slightly relative to the adjacent segments. For spondylolisthesis injuries, it’s especially important to learn to recruit muscular stabilizers to help support the spine and promote healing.
Symptoms of all of the above might include:
Pain in the lower back that might be sharp or more intense during practice and often lingers after practice and at rest
Low back pain with sitting in a desk throughout the school day
Low back pain sitting on the floor
Low back pain when leaning forward unsupported (for example: packing a suitcase on the floor; bending over to use sidewalk chalk; playing a game on the floor)
Low back pain when sleeping or lying on your stomach
Pain with arching or extension. This most often shows up in gymnastics with:
Bridges
Back and front walkovers
Scales
Front or back handsprings, especially from a standing position (vs a tumbling pass)
Cast to handstand (especially if a gymnast is still learning this skill and struggling with form)
Tumbling or landings
Why does arching hurt?
Body Mechanics and Positioning
Sometimes, the answer is simple and biomechanical. Basically, it’s related to how a gymnast is moving. Often, a gymnast arches from one segment of his or her spine more than others rather than achieving a uniform arch position and moving throughout the back. I call this the “hinge point” in the arch position— and this point is often where a gymnast will have pain. Sometimes, this is due to a mobility issue in the spine or the hips, sometimes it’s due to a lack of control in the abdominal muscles or a lack of core stability, and sometimes a gymnast just needs a little training to understand how to arch correctly.
These are the most common reasons for low back pain in the gymnasts I see, and these athletes do not necessarily have anything structurally “wrong” with their backs-- they just need to learn body awareness and control related to protecting their low backs. Often, I’ll see gymnasts with 6-pack abs who have great core strength on the surface, but are unable to recruit deeper abdominal and back muscles to really support their backs through the demands of their sport. This is where retraining and sport-specific core strengthening comes into play through PT.
Structural or Anatomical Issues (a “Spondy”)
If a gymnast is diagnosed with a “spondy”, or a stress fracture in his or her low back, arching will often be the most painful sport-specific position. This is because arching closes down the joints in the spine and puts additional stress on the injured area. If a gymnast is diagnosed with a spondy, he or she can absolutely return to arching and extension again, but it will be a monitored and gradual process that allows for the spine to heal before re-introducing the arch position.
This often means a rehabilitation program that initially removes skills like back and front walkovers, back and front handsprings, scales, high-impact landings, and Yurchenkos until the gymnast’s back has had a chance to heal. These movements are then slowly re-introduced according to the gymnast’s tolerance and once they’ve developed enough core strength and stability to support the arched position.
What does gymnastics-specific PT look like?
We’ll talk through a plan for modifying skills to allow the gymnast to continue to practice without irritating their back injury. In the case of a spondy or back pain with arching, we’ll often first remove or modify irritating movements like back or front walkovers or bridging until they can better tolerate the arch position.
We’ll begin a program to build core and hip strength to support the low back through the demands of the sport.
We’ll talk about the mechanics of the hollow and arch position and build strength in these positions. We’ll also work on avoiding “hinging” from one section of the spine.
We’ll slowly and functionally re-introduce the arch position, incorporating gymnastics skills and sport-specific movements. We’ll discuss a plan for return to sport and talk about modifications and gradual progressions to return to practice and competition.
Back pain doesn’t have to be the end of a gymnastics career. In fact, rehabbing a back injury can help you return to your sport stronger, more resilient, and with better body awareness and form than before your injury.
“My 10 year old daughter is a gymnast and suffered a back injury. She needed PT. By referral we met Dr. Kate. Dr. Kate is a former gymnast, speaks gymnast lingo, is super knowledgeable about all things gymnastics and just flat out pretty darn awesome. She had my daughter pain free and competition ready in 4 weeks. She even taught us about preventing further injury. ”
Dr. Kate Blankshain specializes in treating chronic low back pain and gymnastics injuries at Outlier Physical Therapy in Chicago and Highland Park, IL.
To schedule with Dr. Kate, email: kate@outlierphysicaltherapy.com