Rehab to Performance is Dr. Joey's experience with different patients on the clinical side of Engineered Per4mance. In this context he will walk you through common issues he is seeing in the clinic and how to fix it in a case study format.
Rehab to performance: Gymnast with wrist pain
This week I saw a high level gymnast presenting with wrist pain in extension. She is a young, naturally hyper mobile athlete. I'm talking hands on the floor with multi-segmented flexion and able to touch her thumb to her forearm (Bighton score of 9/9). She presents with lots of pain when doing handstands and especially with dynamic hand compression moments like pushing off the floor during tumbling routines.
Upon functional exam she had limited overhead and horizontal adduction shoulder mobility. Diving into local testing revealed a lack of soft tissue mobility in the lats, teres major, and pec minor pulling her shoulder in an anterior and internally rotated position. She is able to express full scapular upward rotation with shoulder abduction but lacks thoracic extension. She can express full wrist dorsiflexion mobility, getting to about 70° actively and 80° passively. This is hyper-extension in the general population but in gymnastics the book is re-written.
You can see that without full overhead mobility landing in a handstand is impossible, so she makes up for the lack of movement at the shoulder with excessive movement in the wrist. She lands in a handstand or pushes off the floor, cranking that wrist into hyper-extension causing dorsal impingement, pain, and rebound tightness in the flexor mass.
1. Stop aggravating the injury. Our first step in any process of rehab is education the athlete about what exactly is causing the issue and how to avoid it for the time being. This particular athlete needs to avoid excessive wrist extension for the following couple of days while the inflamed tissue heals and recovers. She is also advised to stop doing stretches for the shoulders that are by passing the tight structures and simply cranking on the joint capsule, remember she has excessive ligamentous hyper mobility so we are really just perpetuating the issue with stretches like these and setting the athlete up for chronic joint instability and worst case dislocations compromising the labrum and other supporting structures.
2. Introduce soft tissue mobility to the indicated structures, in this case the lats, teres minor, pec minor, and wrist flexor mass. My favorite techniques include simple pin and stretch and instrument assisted work. The skilled manual therapy should be left to the clinician but the session should get at those indicated structures and create measurable, immediate change.
The patient is sent home with with self myofascial homework, a few of which are shown below. Not shown are wrist flexor mass mobs on a ball (video coming).
3. Address joint restriction in the thoracic spine. The lack of thoracic extension with full shoulder flexion is addressed using joint manipulation. My favorite technique for thoracic extension manipulation is an anterior adjustment but the goal can be achieved a million different ways.
4. Add baseline strength and dynamic stability training. Immediate increases in joint and soft tissue mobility will be lost relatively quickly if not followed with stability and strength training to teach the body how to use and control the new found range. Without this essential step I have seen the patient walk out of the door feeling great only to find tightness creep back up by the time they get home. Remind you of your last chiropractic or massage therapy appointment? Increasing rotator cuff strength to help control the capsular hyper mobility is achieved with an innumerable amount of instruments but I like simple so I often start with tubing. EMG studies have shown standing external rotation with thoracic rotation to be highly effective at activating the posterior cuff so we tend to start here then progress to TRX face pulls, Y's, and T's. I finish our sessions with rhythmic stabilization exercises starting with the patient supine and the shoulder at 90° flexion, progressing about 10° further into flexion after the patient can demonstrate competency, strength, and stability in each position. After approximately 110° I progress the patient to half kneeling at 110° and continue up to 180° and finally to standing. At this point the patient can demonstrate full overhead mobility and dynamic stability in a standing position. The last step would be to get the patient inverted (as she will do in her sport) and assure full overhead shoulder mobility is achieved with no wrist pain.
In conclusion I will see this patient once per week for the next month working on the above outlined treatment plan and expect her to be able to achieve a pain free handstand within the month assuming we avoid all insulting behavior along the way, which is often a tall order with this population and emphases the importance of PREhabilitation. If you are a gymnast and experiencing wrist pain reach out to us. If you are clinician and have questions or comments please drop them below or shoot me an email.