May and April saw the announcement of 2 more ACL tears in the gymnastics world (Gabby Jupp and Nadine Jarosch). Every time this happens, the gymnastics world begins to question why they are so common in our sport. We spoke to British physiotherapist Dominic Dentry about the unfortunate injury. He has worked as Team Great Britain Physiotherapist with six different sports in 18 different countries (to date). This has included attendance at Commonwealth Games, World University Games, Youth Olympic Games and more than 15 Gymnastics World and European Championships. He took part in Olympic Test Events for Sailing and Gymnastics and spent the Olympic Games at the O2 looking after the Gymnastics Teams from around the world as part of the Host Nation team.
Dominic writes for Full Twist:
25 years ago it is probable that few people outside of professional sport or the medical industry had even heard of the Anterior Cruciate Ligament (ACL) let alone knew where it was or what it did. Paul Gascoine, the beloved Gazza, changed that when he ruptured his live on TV during the 1990 FA Cup Final – would he be able to play again and at what level? The back (and front pages) of the press held their breath.
Nowadays it’s probable that most with even a passing interest in sports would be able to tell you what the ACL does, where it is and possibly that it normally signals the end of the football season for the person suffering the injury. You may rightly be wondering why such a football related slant on a gymnastics blog? The answer lies in revealing more information about the ligament itself, what it’s function is and what can be done about it when it is injured. Let’s start at with the basics…
The ACL lies inside the knee joint, along with its partner the PCL (posterior Cruciate ligament). Running from the bottom of the femur (thigh bone) to the top of the tibia (shin bone), they are the main stabilisers of the knee joint; controlling and limiting the amount of movement in the joint in partnership with a number of other ligaments which surround the joint. This arrangement is not unique to the knee – in all our joints which move it is the ligaments surrounding the joint which dictate the directions in which the joint can and cannot move. The cruciates (the PCL and ACL) control rotation of the tibia on the femur and the sliding movements which occur as we move our knees. The typical method of injury involves the body twisting over a foot which is fixed to the ground - the footballer who changes direction quickly will say that they felt their studs catch in the ground, the skier will say that they fell whilst turning and the ski binding did not release.
The ACL is strong and has a breaking strain of many times our body weight so it is most often injured in active sports involving fast movement and turning (hence the football slant to the start of this article) or equipment which amplifies the movement of our limbs.Gymnasts? The typical gymnastic ACL injury will occur on landing whilst twisting. The description of not quite being all the way round at the point of landing is common. Think apparatus dismount, the end of a tumbling sequence with lots of twisting or a badly timed vault. Those who rupture the ACL tend to know that something bad has happened – a pop is often felt or heard and they may struggle to put their weight on the leg afterwards.
Across all sports girls are slightly more at risk of suffering ACL rupture due to some anatomical differences between men and women in the shape of their knee joints and a greater angulation of the femur in women related to a wider pelvis.
What can we do about it?
Realistically if the desire is to return to a good level of sport the ligament must be repaired or reconstructed with the latter being the more common option. Without an ACL the knee is inherently unstable and prone to giving way, there is also a big risk of causing further damage to the rest of the knee as the normal controlled movement is lost.
A number of different techniques for reconstructing the ACL exist and the one chosen depends on the surgeon, any other injuries which are present, the age and fitness of the person undergoing surgery and the level of sport they wish to return to. Generally ACL reconstruction is now performed arthroscopically (via keyhole surgery) and the results are excellent. A successful outcome depends on a lot of hard work and rehabilitation but ACL rupture is not normally the career ending injury it once was.
What so many in gymnastics now?
The answer is not easy but factors such as advances in equipment, more challenging routines and fitter, stronger gymnasts who can perform more difficult skills all contribute. The FIG records as far as possible all injuries which occur during gymnastic competition and if it appears after analysis that gymnasts are causing themselves injury during certain moves, action can be taken to modify the code of points to remove the incentive to undertake them (think of the relative absence of single arm long swings in men’s high bar) for an example of this process in action.
Further advances in surgical techniques and the material used to make a graft for reconstruction will make for better repairs, shorter recovery times and better long term outcomes. Advances in training will also help – specific landing training has been part of the Great Britain training regime for some time now and equipment will continue to evolve to make gymnastics a safer sport for all who take part in it.