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Journal of Back and Musculoskeletal Rehabilitation 16 (2002) 1–7 BMR79 1

IOS Press

Injuries in artistic gymnastic elite adolescents

male and female athletes
P. Kirialanis, P. Malliou∗ , A. Beneka, V. Gourgoulis, A. Giofstidou and G. Godolias
Democritus University of Thrace (DUTH), Komotini, Greece

Abstract: Objectives: The purpose of this study was to record the incidence of Sport Injuries (acute and overuse syndromes) in
Greek artistic gymnasts in relation to sex, age, event and exercise phase.
Methods: 187 Greek elite artistic gymnastic athletes (100 male and 87 female athletes) participating in Greek artistic gymnastic
championship involving all age-related categories, were observed on a weekly basis for a year. The athletes consisted of the
pre-national team that was chosen to prepare for the next Olympic games.
Results: 147 (61.5%)acute injuries and 93 (38.5%) overuse syndromes were recorded. The most common anatomical location of
injury was the ankle (110 cases, 46%), followed by the knee (63 cases, 26.2%). According to the results, the rate which involved
mild injuries was 26.8% (64 cases, 34 males, 30 females) moderate injuries was 44% (106 cases, 59 males, 48 females), major
injuries was 29% (70 cases, 38 males, 31 females). For the total sport injuries recorded, the injury incid on the “floor” and
especially during “landing phase”, were statistically significant.
Conclusions: Artistic gymnastics predisposes to acute injuries, by its nature, but up to 70% are mild and moderate. Special
attention needs to be given during “floor exercises”, especially on landing phase.

Keywords: Artistic gymnastics, muscular and skeletal injuries

1. Introduction Since the mid 1970s, competitive gymnastics has

The sport of gymnastics began with the ancient
Greeks and Egyptians, where it was used as a means
of discipline and physical conditioning for young men
being trained for warfare [38]. Today, it is both a recre-
ational and organized sporting activity, in which there
are six major disciplines: men’s artistic gymnastics,
women’s artistic gymnastics, rhythmic sportive gym-
nastics, sport aerobics, trampoline sports, and general
gymnastics [6]. Within each of these disciplines, there
are three main levels of gymnastics activity: recre-
ational, competitive, and elite [6].
Epidemiological studies relating to injuries different
information that are gathered from athletes teams, are
used to define which are the factors that predispose the
athletes to the appearance of the injuries [13,33].
∗ Address for correspondence: Malliou Paraskevi, Assistant Pro-
fessor, Democritus University of Thrace, Dept. Physical Education
and Sport Science, 69100 Komotini – Greece. Tel.: +30 5310 39662;
Fax: +30 5310 39623, E-mail: malliou2002@yahoo.gr.
undergone a dramatic transformation with respect to
the complexity of manoeuvres performed and the age
at which gymnasts start training [25]. Both coaches
and gymnasts have become more ambitious and cre-
ative, and consequently, the range and number of risk
elements incorporated into gymnastics routines. More
children are starting gymnastics from an earlier age
and maintaining an extremely high level of training
throughout the years of growth and development. Con-
sequently, it has been suggested that the increased in-
volvement and difficulty of skills practiced from an
early age may be associated with an increased risk of
injury [24]. Most elite gymnasts do not pass through
childhood and adolescence without injury, and the risk
of injury increases with longer practice time and the
degree of difficulty of the routines [36].
There is a general admission referring to the risk
factors for injuries according to they can be classified
into two categories: Internal (personal) and external
(environment) ones [37].

ISSN 1053-8127/02/$8.00  2002 – IOS Press. All rights reserved

Galley Proof 29/04/2003; 14:33
2 P. Kirialanis et al. / Injuries in artistic gymnastic elite adolescents male and female athletes
The internal (personal) factors are characteristics of
the athlete, some of which are impossible to change,
the age, for instance, and the sex. Some, of the internal
factors though, are characteristics that can be changed,
like the strength of the lower limbs, the flexibility of
the thighs, the balance skillfulness and other natural or
moving skills.
The external factors that can affect the injuries are the
characteristics of the environment in which the athlete
acts, like the type of the sport, the weather conditions,
the way in which the sport is practiced and other factors.
Especially, for the artistic gymnastics, some of the ex-
ternal factors, which possibly affect the injuries, are the
instruments, the exercises they perform, the hours of
training, the apparatus and the training plan in general.
According to Dzioba [9] there are two great cate-
gories of athletic injuries. Those, which are a direct re-
sult of a wounding incident and those which, are caused
because of overuse (overuse syndromes). Overuse syn-
dromes occur as a result of training methods rather than
participation in competition events (acute injuries) [30].
Chronic problems (overuse syndromes) are often more
difficult to handle than acute pathology, which puts the
physicians and therapist at a disadvantage and is a key
factor usually overlooked by the coach and athlete [30].
Having listed the lower limb injuries in the Athletic
Center of Northern Greece, it was announced that dur-
ing the years 1988–1998, the over-use injuries were
54.2%, of the total referred injuries in Greek track and
field and gymnastics athlete [18].
The typical approach to training consists of the fol-
lowing phases: preparatory phase (general and spe-
cific), precompetitive period and competitive period [6,
34]. Petrone and Ricciardelli [27] divided the train-
ing in three different periods. These are the prepara-
tory period (preparatory and precompetitive phases),
the competitive period and the transitional period. Ac-
cording to them [27] 80% of the injuries happen dur-
ing the preparation period (pre season), 28.1% during
the contending period (season) and 14.05% during the
transitional period (post-season). It is not uncommon
for elite gymnasts to start training from as early as five
or six years of age, and to train for between 20 to 40
hours a week all year round [6]. This is the reason that
most of the injuries happen during the training.
Artistic gymnastics is among the sports with par-
ticular high injury percentages [13,14,37] and most of
them are also found in the lower limbs. According to
McAuley et al. [21], the majority of the injuries (47–
58%) have to do with joint ruptures and sprains [4].
The opinion that female athletes have more possibil-
ity of getting injured is supported by most of the re-
File: bmr79.tex; BOKCTP/wyy p. 2
searchers [1,5]. According Maffuli et al. [19], the effect
of the sex factor is related to the increase of the prob-
ability of injury appearance during artistic gymnastics,
since women are more often injured [3,22].
Concerning the recovering period after injury Petrone
and Ricciardelli [27] found that for 71% of the cases the
recovering time was less than 3 weeks, for 29% more
than 3 weeks and for 16% it was more than 6 weeks,
staing that in their majority they were mild injuries. On
the contrary, according to Bak et al. [1], 55% of the
injuries recovered in a time period of less than 30 days
and 45% after 6 months.
The different competitive events, which last from
only a few seconds (the vault) to about 90 seconds (the
floor routine), require a combination of speed, strength,
endurance, agility, flexibility, and power. Previous re-
search has estimated that gymnasts obtain up to 80–
90% of their energy needs from anaerobic sources, with
minimal energy from aerobic pathways [6].
Most of the injuries that happen to artistic gymnas-
tic happen on the “floor” [5,11,21]. Caine et al. [5]
found out that for female athletes 35.4% of the injuries
happen on the floor, 23.1% on balance beam, 20% on
asymmetric bars and the 13.8% on the pommel horse.
According to Linder and Caine 17, 40% of the injuries
also happen on the floor. Bale and Goodway [2], men-
tioned that most of the injuries in women happen on the
floor, followed by injuries on asymmetric bars, balance
beam and vault. On the contrary, Weiker [38] supports
that most injuries happen on beam.
More important with regard to injury risk is the fact
that both the upper and lower extremities of gymnasts
are subjected to frequent, high impact, weight-bearing
activities.
Despite the comparatively large number of re-
searchers for the injuries during artistic gymnastic there
is a gap concerning the importance of influence of the
factors that affect the appearance of the injuries. In
Greece, moreover, there is a total lack of research data.
The aim of the present study was the registration of
the injuries and the influence of, mainly, the exter-
nal factors on the appearance of the injuries of artistic
gymnasts in Greece. The knowledge and evaluation of
these factors will help discover the most ideal solutions
for restriction and avoidance of athletic injuries during
artistic gymnastics.
2. Materials and method
2.1. Study population
One hundred and eighty-seven(187) Greek elite artis-
tic gymnastic athletes (100 male and 87 female athletes)
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P. Kirialanis et al. / Injuries in artistic gymnastic elite adolescents male and female athletes
participating in Greek artistic gymnastic championship
involving all age-related categories were observed on a
weekly basis for the 2000–2001 season. The 187 ath-
letes consisted of the pre-national team that is chosen
by a Special National Committee to be prepared for the
next Olympic games. The characteristics of the sample
are presented in Table 1.
2.2. Data collection and definition of injury
An orthopaedic surgeon, a physiotherapist and a
trainer composed the “injury assessment” team. Au-
thors twice a week registered any injury occurred dur-
ing scheduled games or practices which made the ath-
lete miss the next game or practice session [7]. The
date, diagnosis, mechanism, whether occurred during
practice or game, total time (in days) lost of partici-
pation, the characteristics, the anatomical location, the
event, the exercise and exercise phase of the muscle-
skeletal injuries occurred were recorded.
The doctor or physiotherapist who attended the prac-
tices and the games recorded all the injuries. Injury
was defined as “any mishap occurring during sched-
uled games or practices that made an athlete miss a
subsequent game or practice session [4]. Injuries were
classified into three grades of severity: minor (absence
from training or games for less than 1 week), mod-
erate (absence from training or games for 1 week to
1 month), major (absence from training or games for
more than 1 month). Lots of other research adapted the
same classification [7,10,26,29].
To investigate the role that age may have played
in injury rates and severity, we divided the athletes
into four age-related categories, according to Greek
Artistic Gymnastic Federation Rules. According to the
Greek Federation, those under 10 years old consisted
the A category, those 11 to 13 years old consisted the
B category, those 14 to 16 years old consisted the C
category and those older than 17 years old consisted
the D category.
The data were statistically analysed using a X 2 anal-
ysis of SPSS statistical package to determine whether
any of the previously mentioned factors had a relation
to the incidence of injury. A p level less than 0.05
denoted statistical significance.
3. Results
3.1. Injury rate
During the period of the study (12 months) the total
sample (n = 187) reported 248 injuries. An injury rate
File: bmr79.tex; BOKCTP/wyy p. 3
3
was of 1.3 per gymnast per year. In terms of gymnastic
participation over 12 month the 187 gymnasts reported
1.4 injuries per 1000 hours of training.
Using X 2 analysis there proved to be no difference
in injury rate based on the sex of the athletes (p =
0.770). The injury rate during training sessions was
statistically related in comparison to game injury rate
(X 2 = 49.273, p < 0.05) but there were no differences
in relation to sex (Table 2).
One-way ANOVA revealed that the injured athletes
had statistical significant higher duration training time
(training session time and for total weekly training
time) in comparison with the uninjured athletes (Ta-
ble 3)
It is notable that, according to records, 62% of the
total athletes were injured: 78.9% were injured athletes
was injured once, 14.1% were injured twice, 7% three
times and 1% four time.
3.2. Time of season
Subdividing the year into three periods (preseason-
season-postseason) allowed assessing the role that each
period might have to injury occurrence. The injury rate
for the athletes (males and females) into three period
of year (preseason, season and post season) was 74.5%
for the preseason, 13.3% for the season and 6.2% for
the post season.
The injury rate in preseason period was statistically
different in comparison to season and postseason injury
rate for the total athletes (p = 0.000 < 0.05).
3.3. Type of injury and anatomic location
The total sample (n = 187) reported 240 injuries
(missing value =8) for the 12 month experimental pe-
riod. One hundred and forty-seven(147) (61.5%) were
acute injuries and 93 (38.5%) overuse syndromes. Ta-
ble 4 shows that, for the total sample, injuries were
distributed throughout the body. The most common
anatomic location of injury for the athletes was ankle
(46%), followed by knee (26.2%), wrist (9.2%), lower
back (7.5%) elbow (6.2%) and shoulder (5%).
3.4. Sexes and injury rate
According to X 2 analysis there were statistically dif-
ferent injury rate between injured and uninjured ath-
letes (p < 0.05) but there was no any relation in terms
of sex (p = 0.736) (Table 3).
There was a different injury rate for the upper limbs
between male and female athletes but it was not statis-
tically different (p = 0.091 > 0.05).
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4 P. Kirialanis et al. / Injuries in artistic gymnastic elite adolescents male and female athletes

Table 1
Age and the anthropometrical characteristics
Athletes Male (n = 100) Female (n = 87)
characteristics Mean (±SD) Mean (±SD)
Age (years) 13 (±3.2) 11,5 (±2.3)
Weight (Kg) 38.8 (±12.8) 32.4 (±9.6)
Height (cm) 144.8 (±17) 138.2 (±13.1)

Table 2
The injury rate for the athletes (males and females), in the three periods of the year and d
No cases Injury rate % Injuries in training (cases) Injuries in games (cases) Other(cases)
Athletes (187) 248 132.6 176* 52 12
Male (100) 139 139 94 35 10
Female (87) 109 125.2 80 27 2
∗ Statistically significant.

Table 3
The training session time and total weekly training time for injured and non-injured male and female athletes
Total cases Male cases (%) Female cases (%) Training session duration (h) Total training time weekly (h)
MD (±SD) MD (±SD)
Injured* 116 63 (63%) 53 (61%) 4.1 *(±1.02) 26.61 (±3.81)
Non-injured 71 37 (37%) 34 (39%) 3.42 (±0.84) 20.79 (±3.87)
∗F ∗F
1.184 = 25.173, 1.183 = 28.18
2
∗ Statistically significant.

3.5. Severity of injury 4. Discussion

According to the results, the rate which involved mild
injuries was 26.8% (64 cases, 34 males, 30 females),
moderate injuries was 44% (106 cases, 59 males, 48
females), major injuries was 29% (70 cases, 38 males,
31 females) (missing value=8). No statistical differ-
ences between severities of injury in relation to sex
(p = 0.670) were observed.
3.6. Age-related category
To analyse the role that age may play in injury out-
comes, we assigned the athletes to one of the four age–
related categories. Using X 2 analysis there proved to
be no difference in injury rate based on the athlete’s
age in relation to sex (p = 0.422).
3.7. The event
According to one-way ANOVA results the “floor” is
the equipment on which most of the athletes of artistic
gymnastic are injured, with statistical differences, than
other equipment for males (F = 5.425, p < 0.05)
and for females (F = 3.406, p < 0.05) (Table 5) and
especially on landing phase.
The artistic gymnastics injury rate is high. This find-
ing is alarming and should be considered by coaches
and sport medicine personnel in terms of developing
and implementing injury prevention programs directed
at gymnastics participants.
The injury rate for the male athletes was 139% and
for the female athletes was 125% during a certain pe-
riod, which is much greater than in most of the studies.
Moreover, other researchers as well, justify the differ-
ence as for the injury incidence due to the age-level and
time duration of the training session [1].
The different injury incidence rate could be due to
the fact that this study differed from the others in sev-
eral bases. Firstly, the higher rate in comparison with
the researches, which reveal lower injury rates [11,12]
could be due to different competitive level of the sam-
ples (elite in current research). On the contrary, the
lower injury rate that previous studies revealed in com-
parison with the studies that had higher injury rates [5,
11] could be due to lower training time duration weekly.
The training period of the artistic gymnast who took
part in the research was great enough, since the average
training time of a training unit is almost 4 hours and
the hours of training during the week are more than 24
hours. Most researchers reported that the duration time
of the training in a week was 20 hours [5,31,32]. Kirby
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P. Kirialanis et al. / Injuries in artistic gymnastic elite adolescents male and female athletes 5

Table 4
Acute and chronic injuries in terms of anatomical location
Anatomical location Acute injury cases (%) Overuse syndrome cases (%) Total injury cases (%)
Total 147 (61.5%) 93 (38.5%) 240 (100%)
Ankle-foot 76* (51.8%) 34* (36.3%) 110* (46%)
Knee-thigh 36 (24.7%) 27 (29.3%) 63* (26.2%)
Wrist-hand 19 (12.9%) 3 (3.4%) 22 (9.1%)
Elbow-forearm 8 (5.3%) 7 (6.8%) 15 (6.2%)
Shoulder 5 (3.2%) 7 (6.8%) 12 (5%)
Lower back 3 (2.1%) 15 (17.4%) 18 (7.5%)
∗ Statistically significant.

Table 5
Number of cases of injured male and female athletes in relation to event and
exercise phase
Event Landing * Take off Tumbling
Male Female Male Female Male Female
Floor * 64 39 – 10 9 3
Beam X 10 X 10 X 3
Asymmetric bars X 10 X – X –
Vault 6 14 – – – –
Bars, horizontal 9 X 6 X 3 X
Bars, parallel 34 X – X – X
Others 3 4 – 2 3 4
∗ Statistically significant.

and Kolt 16 referred higher duration time of training
in week base and Bernard et al. [4] reported that the
artists gymnasts of higher level are trained for almost
27.5 hours a week.
In the present study, the time of weekly training
between the injured and non- injured athletes is was
ascertained that the injured athletes are being trained
for more hours a week than the non injured ones. It
also came out that there is a relation between the time
of training in a unit and the incidence of injuries
The above results are in agreement only in part with
the results of other researchers [1,16] who found out
the relation of the injuries in general to the duration of
training.
The lower limb was the injury site most often re-
ported by the gymnasts. The supremacy of the lower
limb injuries of female artistic gymnasts goes together
with the data of most searching studies in which the
great participation of the lower limbs in the injuries is
reported. This greater incidence is reported in the data
of Steel and White 34 with 69%, and lower in the find-
ings of Garrick and Requa [11] with 48%. This is most
probably due to the differences that can be found at
some important factors in the different like the specifi-
cation/determination of the injuries, the level of the ath-
letes, the size/number of the sample and the planning
of the research in general [23].
The ascertainment that the injuries of the ankle joint
prevail is also justified by the findings of Pfister et
al. [28]. Kolt and Kirkby [15] in contrast supported that
the knee possesses the greater incidence of injuries.
The ascertainment that there are no important dif-
ferences for the incidence of the injuries and the sex,
comes in contrast to most of the findings of the interna-
tional bibliography, where it is supported that women
have more possibilities to present injuries [1,19]. From
the results of the present study it was ascertained that
sex does not influence the injury incidence
In addition, the present findings are in agreement
with the findings of Bak et al. [1] as for the fact that the
male athletes present more injuries at the upper limbs in
contrast with the female athletes. This result is justified
by the fact that men accept more burdening at the upper
limbs in most of the equipment like rings, horizontal
bar and parallel bars. This opinion supports the fact
of the lack of injuries at the shoulder joint for women
in the present study and the existence of more injuries
at the wrists for the men. Moreover, the fact that the
women presented greater incidence of injuries at the
elbows is justified by the fact of the different equipment
between men and women, since for women at the three
out the four equipment should engage hand movement.
From the results it is ascertained that there is no sta-
tistically important relation between injuries and age.
Despite the lack of statistically important differences
it is ascertained that at age up to 10 years for male as
well as female athletes, a lower incidence of injuries
Galley Proof 29/04/2003; 14:33
6 P. Kirialanis et al. / Injuries in artistic gymnastic elite adolescents male and female athletes
appears and there is a tendency to find greater incidence
of injuries as age increases for male athletes.
The reported results, which have to do with the in-
juries according to the equipment, agree entirely with
most of the researchers [1,5] who support the fact that
the floor is the equipment on which most of the injuries
happen.
These results are related to the fact that the
time/duration of the training on the floor is greater in
comparison to other events [1]. The present findings are
in contrast with three other research findings. Specif-
ically, Weiker [39] supported that most injuries hap-
pen on balance beam and asymmetric bars. Steel and
White [34] reported greater incidence of injuries for the
female athletes on the horse vault. Finally, Lowry and
LeVeau [18] supported that most injuries happen on the
parallel bars for male athletes.
Although the injury rate in this sport is high, ac-
cording to severity assessments only 29% of the cases
involved major injuries.
The ascertainment that there is a total lack of seri-
ous injuries is in correspondence with the findings of
Dixon [8]. It would be difficult of course to support
that artistic gymnastics is a risky sport. According to
Dr. L. Eglise, who is responsible for the medical team
of FIG, artistic gymnastics is not a dangerous sport but
a risky one.
5. Conclusion
The present study supports that a higher injury rate
occurred on the floor exercises (boys and girls) espe-
cially on landing (girls). This high incidence, which is
due to large resistance amount placed on lower limbs
joints, especially on the knee and ankle ligaments, in-
creased the risk acute injury factor.
These findings are alarming and should be consid-
ered by coaches and sport medicine personnel in the
light of developing and implementing injury preven-
tion programs on floor exercises (especially landing),
directed at gymnastic participants.
6. Recommendations
Learning of safety and proper technique (especially
on floor exercises and during landing phase) in order
to assist gymnasts in learning skills, to correct body
position and to develop confidence.
Use of safety devices and protective equipment (mat-
ting, sprung floors, hand guards, etc.) in order to reduce
the magnitude of impact and frictional forces imposed
on the musculoskeletal system.
File: bmr79.tex; BOKCTP/wyy p. 6
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