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Low Back Pain In Rhythmic Gymnasts

A review of contributing factors and tips for prevention

Matt Swift, DPT, ATC
President of Change Sports Physical Therapy Institute

Rhythmic gymnastics is a sport which requires a high degree of strength and flexibility, while maintaining a graceful and esthetically appealing performance. Many of the skills performed are derived from classic ballet.  During the course of routines performed by these gymnasts, their bodies are required to be placed in positions of extreme ranges of motion.  Some of these motions involve hyperextension of the lumbar spine and end range hip flexion and extension. Competitive sport participation can start as early as nine years old and continue through late teenage years. 
Due to the nature of the sport and the age of the athletes, there are several factors which can contribute to low back pain. The purpose of this article is to review the possible causes of low back pain in the adolescent rhythmic gymnast and provide some tips to prevent injury.  It should be understood that participation in any kind of sport will increase the risk of injury to the participant. It is assumed that the participants are aware of the dangers involved in their sport. With this being understood, it is the role of the coach, parent, physical therapist or other medical professionals to do all they can to help prevent injury, while still allowing top performance in the desired sport.
First we will take a look at the contributing factors inherent in rhythmic gymnastics which can cause an increased risk for low back injury. Following, we will provide to anecdotal and research based suggestions to help prevent low back injury in these athletes.

Contributing Factors to Low Back Pain

If we take a look at the typical rhythmic gymnast she is an adolescent or pre-pubescent female, lean in structure and highly flexible. This alone can predispose someone to back injuries. As these athletes are going through their normal growth process there are aspects of it which can increase the chances of injury. The spine undergoes changes in its curvature during this age, as the lumbar spine becomes more lordodic (sway back). This places more stress on the posterior structures of the spine. In addition, bone growth is faster than muscle growth. Because of this there is a tendency to develop tight back extensors and tight hip flexors. This too will increase the lordodic force on the spine. 
Because of the composition of the pre-pubescent athlete, these lordodic forces tend to distress the cartilage in the spine before other structures. In the adult body, the vertebral discs are the ones who typically take the most wear. The hyper-flexibility of the athlete will also contribute to increased load being absorbed by the spine instead of by the supporting ligaments and soft tissue.
The constant drive to maintain a low body weight can contribute to low back problems if it is not addressed correctly. If the pre-pubescent female athlete has an excessive negative caloric intake, this can cause a decrease in estrogen production and subsequent amenorrhea. This then can result in lower bone density and predispose athletes to stress fractures.
If we look at the motions repeated frequently by the athletes, they tend to favor one side versus the other. One leg will become stronger than the other and one is more flexible as well. This asymmetry can also contribute to forces going through the spine which can cause low back pain.

Tips for prevention

Having an understanding of all the factors which will be pushing the athletes towards injury is key to prevention. As was stated earlier, any sport participation induces risk for injury. The goal is not to eliminate injury or eliminate optimal performance, but instead to address the issues which can be addressed and hopefully decrease the athlete’s chances for injury as well as increase their performance. Following are some ways athletes, parents and coaches can help prevent low back injuries.

1. Core stabilization

As was mentioned above, the lean, pre-pubescent, highly flexible athlete will have increased amounts of force being absorbed by the spine. In order to help alleviate this force, the “core”, or the muscles and tissue surrounding the spine, needs to be as strong and stable as possible. This is not simply doing sit-ups. The spine needs to be trained to stabilize in different positions. Some good exercises for this are plank holds and side plank holds. If the athlete has access to a sports conditioning trainer, focusing on rotational stability should be a key component.

2. Hip flexor flexibility

Due to the growth process and due to the asymmetric nature of the sport, the hip flexors can become tight. This will pull the pelvis into a more lordodic position. The asymmetric training of one leg more than the other can also lead to one hip flexor being significantly tighter than the other. It is important to try and counteract this by stretching the tighter side more than the other. You can use a ratio of 2 to 1. In other words, stretch the tighter side twice as much as the opposite side. A good stretch for this is a half-kneel hip flexor stretch.

3. Strengthen and stretch for symmetry

No only can there be asymmetry in the hip flexors, but this can also be seen in the strength and flexibility in the entire leg. Some gymnasts have the tendency to stretch the more flexible side more. It should be emphasized to gain symmetry in flexibility (again the 2 to 1 ratio should be used). Athletes will naturally have one leg on which they choose to jump from and use as their stabilizing leg during routines. Because of this, that one leg will get stronger than the other. Part of a preventative strengthening program should be to strengthen the weaker side more than the stronger side. The 2 to 1 ratio can be used here as well. 

4. Monitor calorie intake

As the athletes work hard at keeping a low body weight, it is essential to ensure that the calories they are taking in are of good nutritional value. Having a diet which will contribute to good bone density is essential. Incorporating the proper pre- and post- training snacks can greatly help the athlete in this area. A sports nutritionist, who understands the athlete’s needs, can be a great resource to monitor the athlete's nutrition.

These 4 tips for prevention can easily be incorporated into an athlete’s daily routine, and they can be powerful tools to use in the prevention of low back pain. There are other things that can be done to help prevent injuries in these athletes, but is beyond the scope of this article. Some of these include proper warm-up, incorporating stretching at the end of a training block instead of the beginning, foot stability training, mental skills training, functional movement screening and quick evaluation and treatment of injuries as they appear.

This article is not meant to advise on medical treatment or replace medical diagnosis by a medical doctor. Any pain or injury currently being experienced by an athlete should be evaluated by a medical doctor.