Physical Therapy in Sport 27 (2017) 38e49

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Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Case Studies

Examination and physical therapy management of a young gymnast

with bilateral wrist pain: A case report
Brenda Boucher, PT, OCS, FAAOMPT, PhD a, *, Brandi Smith-Young, PT, OCS, FAAOMPT b
a
601 University Drive, Department of Physical Therapy, Texas State University, San Marcos, TX 78666, USA
b
Perfect 10.0 Physical Therapy, 4311 Kilgore Lane, Austin, TX 78727, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: Wrist pain associated with weight-bearing gymnastic activities may be linked to muscu-
Received 4 October 2016 loskeletal impairments, faulty movement patterns, and poor training techniques. Inadequate proximal
Received in revised form control may adversely impact the loading mechanics throughout the upper extremities and contribute to
9 March 2017
a gymnast's complaint of wrist pain. The purpose of this case report is to describe the management of a
Accepted 13 March 2017
young gymnast with primary complaint of bilateral wrist pain associated with upper extremity weight-
bearing activities.
Keywords:
Case Description: A 10 year-old male gymnast presented with a 6-month history of bilateral wrist pain
Wrist pain
Movement impairment
aggravated by weight-bearing gymnastic activities. Based on the findings from a physical therapy ex-
Musculoskeletal impairment amination, a 3-stage progressive rehabilitation program was designed using an impairment-based,
Gymnast multi-modal approach to treat key musculoskeletal impairments and movement deficiencies. Consis-
tent with the principle of activity simulation, treatment targeted areas of weakness considered key to
activity performance and included a progression of exercises and techniques that simulated activities
reported by the gymnast to be painful.
Outcomes: The gymnast was treated for 11 visits over 8 weeks. He demonstrated improved strength,
motor control, and self-reported outcome scores that allowed pain-free return to all gymnastic activities.
Published by Elsevier Ltd.

1. Introduction
The wrist is distinctively susceptible to joint and soft tissue
injury during gymnastics as it undergoes considerable strain in
various positions (Daly, Bass, & Finch, 2001; McGinley, Hopgood,
Gaughan, Sadeghipour, & Kozin, 2003; Webb & Rettig, 2008). The
upper extremities function to position and control full body weight
during gymnastic activities, placing the gymnast at considerable
risk for wrist injury (Daly et al., 2001; Westermann, Giblin, Vaske,
Grosso & Wolf, 2014). Wrist pain is reported by more than 50% of
young gymnasts, and beginning-to-midlevel gymnasts experience
injury to the wrist more than any other skeletal site (DiFiori, Puffer,
Aish, & Dorey, 2002a, 2002b).
Pre-pubescent gymnasts are at particular risk for injury to the
wrist (Albanese et al., 1989; Daly et al., 2001). Several factors pre-
dispose young gymnasts to wrist pain including improper use of
equipment, poor training techniques, immature status of the
* Corresponding author.
E-mail address: BB10@txstate.edu (B. Boucher).
skeletal system and previous injury (Dworak, 2005; Kox, Kuijer,
Kerkhoffs, Maas & Frings-Dresen, 2015; Pengel, 2014). Most
commonly, pain is reported at the dorsal wrist in conjunction with
weight-bearing activities performed in a position of wrist extension
(Cornwall, 2010; DiFiori, Puffer, Mandelbaum & Mar, 1996; DiFiori
et al., 2002a, 2002b; Jones & Wolf, 2008). The mean age of gym-
nasts who experience wrist pain related to repetitive-loading
ranges between 9 and 14 years (Kox et al, 2015).
Interestingly, published data is notably lacking on physical
therapy strategies to treat musculoskeletal wrist pain in the young
gymnast. Recommendations to brace or splint are common
(Cornwall, 2010; Pengel, 2014), but little attention is given to the
treatment of key musculoskeletal impairments, correction of poor
movement strategies, and staging a rehabilitation program targeted
toward the challenge of gymnastics training and competition.
Although sparse information is available to guide the selection
of an effective strategy to treat wrist pain associated with load-
bearing athletic activities, recommendations exist for assessment
of movement impairments throughout the upper extremity (Cook,
2010; Minthorn, Fayson, Stobierski, Welch & Anderson, 2015;

http://dx.doi.org/10.1016/j.ptsp.2017.03.002
1466-853X/Published by Elsevier Ltd.
 B. Boucher, B. Smith-Young / Physical Therapy in Sport 27 (2017) 38e49
Sahrmann, 2011). Identification of musculoskeletal impairments
and movement deficiencies during symptom-producing activities
is key to the examination of an injured gymnast. Likewise, use of a
staged rehabilitation program that provides progression towards
more demanding activities required of the sport is recommended
(Daly et al., 2001; Karandikar & Vargas, 2011).
Several key elements are recommended specific to examination
and treatment of the wrist and hand (Sahrmann, 2011). First is to
identify alignment and movement impairments in the proximal
upper extremity and relate any impairments to symptoms experi-
enced in distal joints (Sahrmann, 2011). Programs that emphasize
proximal control and stability are recommended to develop the
ability of tissues to accept and dissipate forces from the small joints
of the extremities to the core during weight-bearing activities
(Colston, 2012; Cosio-Lima, Reynolds, Winter, Paolone & Jones,
2003). Second, identify specific joint and muscle impairments that
contribute to dysfunction of the involved joints (Pengel, 2014;
Sahrmann, 2011). Joints that lack mobility should be mobilized,
whereas joints with increased mobility benefit from strategies that
focus on neuromuscular control (Sahrmann, 2011). Next, restore
precise patterns of movement using methods to train both isolated
movements and patterns of movement during specific exercises
(Colston, 2012; Sahrmann, 2011). Finally, gradually introduce
increased stresses to facilitate tissue adaptation to more
demanding activities (Karandikar & Vargas, 2011; Mueller & Maluf,
2002). Programs that include activities simulating specific de-
mands of the sport are recommended (Kalantari & Ardestani, 2014;
Kirkendall, 1985).
Whilst chronic musculoskeletal-related wrist pain commonly
occurs in isolation with young athletes, consideration should be
given to differentiation of other conditions affecting the wrist.
Chronic wrist pain that worsens with weight bearing in an
extended wrist position can be attributed to diagnoses that may
require additional diagnostics such as distal radial physeal stress
injury, scaphoid impaction syndrome, dorsal impingement syn-
drome, carpal instability and triangular fibro-cartilage complex
dysfunction (Avery, Rodner, & Edgar, 2016; Bak & Boeckstyns, 1997;
Cornwall, 2010; Daly et al., 2001; Kox et al., 2015; Webb & Rettig,
2008). Treatment for these conditions vary, with a trial of rest
and avoidance of impact producing gymnastic activities routinely
recommended (Caine, Roy, Singer, & Broekhoff, 1992; Cornwall,
2010; Daly et al., 2001; Pengel, 2014; Webb & Rettig, 2008).
Beyond that, commonly reported interventions include conserva-
tive methods such as bracing and cast immobilization to more
invasive techniques such as steroid injection and surgery (Daly
et al., 2001; Pengel, 2014; Webb & Rettig, 2008).
This case report uses an impairment-based examination and
multi-modal approach to treat a pre-pubescent gymnast with
chronic, bilateral wrist pain. The clinical presentation of the gym-
nast is described in relation to the functional demands of his sport.
Evaluation included assessment of his training technique and use of
equipment he routinely used and, importantly, with which he
experienced pain-related symptoms. A 3-stage, progressive reha-
bilitation program was designed with key clinical markers required
for progression. Specifically, demonstration of correct, independent
performance of isolated movements and exercises in non-to-
limited weight-bearing positions, without pain, were key clinical
markers required for progression beyond stage-1. Maintenance of
spine and upper extremity joint alignment and control of move-
ment patterns performed in limited weight-bearing positions were
requisite criteria to progress beyond stage-2. Demonstration of
correct, pain-free, sport-specific activities related to neuromuscular
control in full weight-bearing positions was key during stage-3. The
aims of this case report, therefore, are to: 1) describe the exami-
nation of a young gymnast with chronic, bilateral wrist pain and 2)
39
outline a 3-stage progressive rehabilitation program for return to
competitive gymnastic training.
2. Case description
The gymnast was a 10 year-old, right-handed male competing at
level 7 with a training intensity of 16 hours per week. Level 7 is
midlevel progression through the USA Gymnastics Men's Junior
Olympic program, which consists of levels 4e10. His level of
training was considered within range of training hours for the
competition level (Level 7 averages 10e20 h/week). He presented
to outpatient physical therapy with complaint and diagnosis of
bilateral wrist pain and a referral from his primary care physician
for evaluation and treatment. The patient described a gradual onset
of symptoms six months prior. He could not recall any specific
incident of injury, but associated his pain with load-bearing gym-
nastic activities. Pain was described as “stabbing” at the dorsal-
radial and dorsal-ulnar aspects of the wrist with occasional
popping. He did not describe any numbness or tingling sensations.
He recalled neither previous musculoskeletal injury nor wrist pain
prior to his current onset. Symptoms were experienced only when
performing gymnastic exercises and routines, specifically activities
performed in upper extremity weight-bearing positions. There was
no pain described at rest or with non-weight-bearing activities. He
had not received any prior therapeutic intervention. Written
informed consent was obtained from the gymnast and his parents
to document his status and track progress with photographs
throughout his physical therapy management. Patient rights were
protected according to the established policies of the Texas State
University Institutional Review Board Committee.
2.1. Examination and clinical reasoning
Outcome Measures The patient's self-reported pain and func-
tional status were the two primary outcome measures. Function
was measured using the Patient Specific Functional Scale (PSFS)
and pain was measured using a 10 cm visual analog scale (VAS).
Both measures have been shown to have a high level of reliability
and responsiveness (Jensen, Turner,Romano, & Fisher, 1999; Kelly,
2001; Westaway, Stratford, & Binkley, 1998). A 3-item Patient-
Specific Functional Scale (PSFS) was used to identify activities
that were painful and/or difficult to perform due to reproduction of
his wrist pain. Using the PSFS, the gymnast identified three weight-
bearing activities and assigned a rating of 5 to each: 1) perform a
push-up, 2) perform a hand-stand, and 3) activities on the mush-
room, a training device used for advanced gymnastics training. On
the PSFS, a rating of 0 indicates complete inability to perform an
activity and 10 represents the ability to perform the activity at pre-
injury level. All three activities involved weight-bearing through
the upper extremities, but provided different challenges. The push-
up and hand-stand required relatively static weight to be balanced
between the upper extremities, whereas the mushroom required
the gymnast to respond quickly to dynamic shifts in both base of
support and position of body in space. The patient rated his current
pain at 6.0 on the VAS for each of the three activities identified on
the PSFS (0 representing no pain and 10 the worst pain imaginable).
Standing Posture Examination Visual assessment of postural
alignment and movement patterns were used to provide clues to
impairments associated with joint alignment, muscle resting
length, and muscle performance. Visual observation of the gym-
nast's standing posture and active motion of the shoulder complex,
as described by Sahrmann (Sahrmann, 2001), were qualitatively
assessed. When viewed from the side, the gymnast demonstrated a
posture of slight forward head and rounded shoulders. (Fig. 1). This
posture suggested further assessment of cervical spine and
40 B. Boucher, B. Smith-Young / Physical Therapy in Sport 27 (2017) 38e49
Fig. 1. Day 1: Side view of standing posture. (Intended for color reproduction). (For
interpretation of the references to colour in this figure legend, the reader is referred to
the web version of this article.)
shoulder girdle joint mobility and muscle strength. In posterior
observation, both scapulae were observed to rest in a position of
abduction, which has been described as the vertebral border of the
scapula positioned greater than three inches lateral to the spinal
processes of the associated vertebrae (Sahrmann, 2001). Addi-
tionally, the inferior angles of the scapulae protruded in a posterior
direction from the rib cage, which is consistent with a position of
anterior scapular tilt. (Fig. 2). This posture was more evident on the
right. These findings suggested further assessment of scap-
ulothoracic muscle function, specifically the middle trapezius,
lower trapezius, and serratus anterior. Both humerii appeared in a
position of medial rotation as evidenced by the olecranon processes
facing posterior-laterally. When the patient was instructed to
adduct the scapulae, the position of the humerii moved such that
the olecranon processes of both elbows faced posteriorly. This po-
sition suggested the initial position of humeral medial rotation was
a result of excessive scapular abduction. The rhomboid and trape-
zius muscles function to adduct the scapula, thus resting posture of
the scapulae suggested further assessment of these muscles. When
asked to actively elevate both arms to full shoulder flexion, a
compensatory motion of upper cervical spine extension was
observed. In addition, the gymnast demonstrated decreased
extension at the cervical-thoracic junction and upper thoracic spine
during arm elevation. In the position of end-range shoulder flexion,
both scapulae failed to reach a position equal to that of the mid-
axillary line, which is considered the appropriate position at
completion of shoulder elevation (Sahrmann, 2001). Additionally,
diminished skin creases at the location of the superior humeral
heads were observed at end-range shoulder flexion. This observa-
tion suggested a restriction of arthrokinematic inferior glide of the
Fig. 2. Day 1: Posterior view of standing posture. (Intended for color reproduction).
(For interpretation of the references to colour in this figure legend, the reader is
referred to the web version of this article.)
humeral head on the glenoid fossa, which is needed for full
shoulder elevation (Sahrmann, 2001). Findings observed during
active and end-range position of bilateral arm elevation indicated
further assessment of spine and shoulder joint accessory mobility.
Sports-specific Movement and Position Examination The
movements and positions of push-up and handstand were assessed
to examine segmental alignment of postures specific to activities
that reproduced the gymnast's pain. Observation of his push-up
position revealed several deviations from preferred alignment
(Fig. 3). The gymnast's scapulae demonstrated excessive protrusion
of the vertebral borders from the posteriomedial aspect of the
thorax. The elbows were positioned in full extension with
concomitant hyper-supination of the forearms. Preferred align-
ment at the end of the push-up position would include adduction of
the scapulae against the thorax, extension of the elbows a few
degrees short of end-range, and neutral forearm position such that
the cubital fossae face medially. In the push-up position, the
gymnast's hands were laterally rotated and both wrists were
excessively loaded in an extended, radial direction. The preferred
position would be neutral rotation of the hands with superin-
cumbent weight distributed equally across the wrist joints.
Observation of the gymnast's hands and digits revealed full
extension of the digits with the palmar arches flattened against the
floor. Preferred position would be slightly flexed digits bearing
weight in conjunction with arched palms.
In the handstand position, vertical alignment was shifted to the
right causing excessive loading throughout the right upper ex-
tremity (Fig. 4). The gymnast reported reproduction of his wrist
pain in both the push-up and handstand positions using the VAS.
Pain on the right was rated 6/10, and pain on the left was rated 5/10.
 B. Boucher, B. Smith-Young / Physical Therapy in Sport 27 (2017) 38e49
Fig. 3. Day 1: View of pushup position. (Intended for color reproduction). (For inter-
pretation of the references to colour in this figure legend, the reader is referred to the
web version of this article.)
Fig. 4. Day 1: View of handstand position. (Intended for color reproduction). (For
interpretation of the references to colour in this figure legend, the reader is referred to
the web version of this article.)
When manual assistance was provided to correct position of the
scapulae, the gymnast reported a reduction of his symptoms,
41
bilaterally (4/10 VAS pain rating). When manual assistance and
verbal cues were added to correct the position of his elbows, wrists
and hands, the gymnast reported a greater reduction of his symp-
toms, bilaterally (2/10 VAS pain rating). He was unable to maintain
the final corrected position independently due to loss of multi-joint
position and reported difficulty generating muscular control to
hold the position.
Cervical Spine and Shoulder Complex Examination Assess-
ments of the cervical spine and shoulder complex were performed
to identify impairments suggested during postural observation and
weight-bearing positions. Active range of motion, joint accessory
mobility, muscle strength and length were performed with positive
findings described as follows. Joint accessory mobility testing of the
cervical and thoracic spine was performed in the prone position.
Findings revealed decreased posterior to anterior glide mobility
from C7-T7, most notably at the cervicothoracic junction (C7-T2).
Joint accessory mobility assessment of the glenohumeral joint,
performed in supine position, found decreased posterior and
inferior glides of the humerus on the glenoid, bilaterally. In side-
lying position, scapulothoracic mobility assessment found
increased tissue resistance with passive upward rotation of the
scapula on the thorax, bilaterally. Muscle strength testing of cer-
vical musculature was performed following protocol described by
Kendall et al (Kendall, Provance, & McCreary, 1993). A muscle grade
strength of 3-/5 was assigned to the deep cervical flexors (longus
colli, longus capitis, and rectus capitus anterior). Strength testing of
the scapulothoracic muscles was performed in the prone position
following protocol described by Sahrmann (Sahrmann, 2001).
Findings included bilateral weakness of the middle and lower
trapezius muscles. Specifically, when the scapula was passively
positioned to place each muscle in its shortened position, the
inability of the tested muscle to support the extremity against
gravity was evidenced by an immediate loss of scapular position.
Although the tested muscle could tolerate moderate pressure after
being allowed to lengthen slightly into a few degrees of scapular
abduction, the tension-generating capacity of the muscle in its
shortened position was considered impaired, thus rendering a
muscle grade of 3-/5 (Sahrmann, 2001). Similarly, the tension-
generating capacity of both serratus anterior muscles was consid-
ered impaired in their shortened positions. This was demonstrated
by failure of the scapulae to maintain position on the thorax against
gravity following passive placement of the shoulder in 130 degrees
of forward flexion, scapular protraction and upward rotation. A
corresponding muscle strength grade of 3-/5 was assigned
(Sahrmann, 2001). Length assessment of the scapulothoracic
muscles, as described by Sahrmann (Sahrmann, 2001), found a
moderate restriction of the right latissimus dorsi and right pec-
toralis minor. There was minimal length restriction of the left
pectoralis minor and no length restriction of the left latissimus
dorsi.
Elbow, Forearm, Wrist and Hand Examination Assessments of
elbow, forearm, wrist and hand active range of motion, joint
accessory mobility, muscle strength and length were performed
with positive findings described as follows. Active range of motion,
measured using a standard 12 inch goniometer and following
protocol by Norkin and White (Norkin & White, 2009), showed
limitations in right wrist flexion, extension and radial deviation
compared to the left. In addition, forearm pronation was limited
bilaterally. Joint accessory mobility testing of the wrist, following
protocol described by Kisner and Colby (Kisner & Colby, 2002),
found bilateral hypomobility of the proximal and distal radio-ulnar
joints. Additionally, the humeroradial, the radiocarpal, and the
intercarpal joints of the proximal carpal row were found to be
hypomobile, bilaterally. Joint mobility restrictions produced the
gymnast's report of local stiffness, but did not reproduce his
42 B. Boucher, B. Smith-Young / Physical Therapy in Sport 27 (2017) 38e49

primary complaint of wrist pain. Muscle strength measurements, as
described by Kendall (Kendall et al., 1993) revealed bilateral
weakness of the ulnar wrist extensors. These muscles were tested
in the shortened position of full wrist extension and ulnar devia-
tion. Additionally, muscle strength assessment of the hand revealed
bilateral weakness of the lumbricals (4/5). Muscle length restriction
was found in the supinator muscles, bilaterally.
Clinical Reasoning The anatomic relationship between the
cervicothoracic spine, shoulder girdle, and distal joints of the upper
extremity creates a functional unit through the upper extremity
during weight-bearing activities (Colston, 2012; Kalantari &
Ardestani, 2014). In such positions, proximal stability is essential
for acceptance and dissipation of forces from the core to the ex-
tremities and vice versa (Colston, 2012). When the center of mass is
maneuvered over the upper extremities, distal segments respond
with concomitant motion and multi-joint, neuromuscular control
strategies to maintain balance (Kalantari & Ardestani, 2014;
Karandikar & Vargas, 2011). Muscles of the spine and shoulder
girdle function to maintain balanced stability of the trunk when
bearing weight through the upper extremities. To that end, deficits
anywhere along the kinetic chain may adversely impact distal
segment function (Kalantari & Ardestani, 2014). Dysfunction of
distal segments can lead to microtrauma of joints and supporting
structures (Kalantari & Ardestani, 2014), and a growing body of
evidence exists linking core musculature deficits to distal segment
dysfunction (Colston, 2012; Hammill, Beazell & Hart, 2008;
Kalantari & Ardestani, 2014; Kibler, Press & Sciascia, 2006;
Willson, Dougherty, Ireland & Davis 2005).
In the case of the gymnast, multi-joint impairments and poor
neuromuscular control were considered relevant to his wrist pain.
Faulty movement patterns, musculoskeletal impairments, and poor
training techniques were postulated to lead to compensatory
movement patterns. Deficits in joint mobility, muscle strength,
length and neuromuscular control were noted throughout both
upper extremities. A treatment plan was designed to correct key
impairments of the spine and upper extremity joints, improve
faulty movement patterns and enhance proximal stability. Inter-
vention was designed to promote ability of the gymnast to accept
and dissipate forces from the core to the extremities during weight-
bearing activities.
2.2. Treatment plan
The patient was seen for treatment either once or twice a week
for a total of 11 visits over 8 weeks as he continued his gymnastic
training. On the initial visit, the therapist explained the findings of
the clinical examination to the gymnast and his mother and
described the proposed 3-stage progressive treatment program. In
addition to correcting impairments identified at the elbow, wrist
and hand, a treatment plan was designed to restore movement and
control of targeted segments of the spine and shoulder girdle. A
goal of treatment was to enable a strong, proximal base to support
distal segments, especially in loading-bearing activities. Treatment
was progressed through 3 stages, each designed to gain neuro-
muscular control of targeted segments.
Stage 1: (Visits 1e4) The primary goal of stage-1 was to initiate
correction of key impairments found with joint mobility, muscle
length, and neuromuscular control, in the spine, shoulder girdle
and upper extremity joints. Demonstrations of correct, indepen-
dent performance of isolated movements and exercises of the
spine, shoulder girdle, elbow, wrist and hand, without pain, were
used as key clinical markers. Demonstrated performance was
required for the gymnast to be progressed beyond stage-1.
Manual techniques were used to increase mobility of the spine
and shoulder complex using joint mobilization and thrust manip-
ulation (Table 1). Joint thrust manipulation has been shown to
positively impact motion restrictions of the spine and shoulder
(Cleland et al., 2007; Dunning et al., 2015; Fernandez-de-las-Penas,
Palomeque-del-Cerro, Rodriguez-Blanco, Gomez-Conesa, &
Miangolarra-Page, 2007; Karas & Hunt, 2014; Krauss, Creighton, Ely
& Podlewska-Ely, 2008). These treatment techniques were there-
fore incorporated into the management strategy. Mobility impair-
ments of the forearm and wrist were treated with joint
mobilization and muscle energy techniques to improve motion.
Muscle energy techniques have been found effective to reduce
motion restrictions in various regions of the body (Fryer &
Ruszkowski, 2004; Moore, Laudner, McLoda & Shaffer, 2011;
Lenehan, Fryer & McLaughlin, 2003; Selkow, 2009), including the
forearm (Kucuksen, Yilmaz, Salli & Ugurlu, 2013). All manual
techniques were followed with strength and neuromuscular
training exercises to facilitate preferred movement patterns. The
patient was taught self-stretch and functional movement pattern
techniques to increase forearm pronation, wrist extension, and
control of digit motion. Strength and neuromuscular control of the
deep neck flexors followed the protocol of Jull (Jull, O'Leary, & Falla,
2008) using a blood pressure cuff for biofeedback. The patient
performed strength and neuromuscular training exercises for spine
and scapulothoracic musculature in the quadruped, prone and
standing positions. These were performed to gain strength and
improve movement patterns of proximal structures in pain-free
poistions.
During stage 1, verbal, tactile and visual-imagery techniques
were used to facilitate activation and sequencing of involved
musculature during a variety of upper extremity movements. The
gymnast required moderate verbal cues to activate the deep neck
flexors during activities that required elevation of the arms to
control his compensatory motion of upper cervical extension. He
was instructed to perform upper cervical flexion to activate the

Table 1
Phase 1 (Visits 1e4): Interventions by region.

Region Treatment

Cervical spine CT: Gr V thrust manip prone, FMP: cervical rot with stabilization at CT, DNF neuromuscular training with BP cuff (Jull protocol)
Thoracic spine Grade V thrust manip supine
Scapulothoracic PNF in functional movement patterns (side-lying), quadruped SA protraction push, mid trap ph I prone lift (Sahrmann protocol), low trap ph I prone lift
joint (Sahrmann protocol), shoulder IR against T-band (Sahrmann protocol), UE elevation with T-band, doorway arm lift (focus on scapular upward rotation)
Glenohumeral Gr IV mob: posterior & inferior glides
joint
Forearm joint MET to increase pronation
Wrist joint Gr IV mob: proximal carpal row radial & ulnar glides, FMP: wrist extension with radial/ulnar deviation
Hand FMP: “arch & splay” (concentric wrist ext with MCP flex/digit ext e “arch”, followed by eccentric wrist ext with digit ext & abd e “splay”)

Abbreviations: CT, cervicothoracic; Gr, grade; manip, manipulation; FMP, functional movement pattern; rot, rotation; DNF, deep neck flexor; BP, blood pressure; PNF, pro-
prioceptive neuromuscular facilitation; SA, serratus anterior; mid trap, middle trapezius; ph, phase; low trap, lower trapezius; IR, internal rotation; T-band, therapeutic band;
UE, upper extremity; MET, muscle energy technique; mob, mobilization; ext, extension; flex, flexion; abd, abduction.
 B. Boucher, B. Smith-Young / Physical Therapy in Sport 27 (2017) 38e49 43

deep neck flexors and maintain this position when performing

exercises that involved overhead elevation of the arms. Likewise,
moderate tactile and verbal cues were needed to activate the upper
and lower trapezius muscles and the serratus anterior. Cues were
used to facilitate appropriate movement of the scapulae during
neuromuscular training exercises and movement patterns
involving overhead elevation. Specifically, he was instructed to
visualize the inferior angle of the scapula moving to a position
equal to that of the mid-axillary line during arm elevation, thereby
facilitating scapular protraction and upward rotation. The gymnast
was also given verbal and visual imagery cues to activate both the
scapulothoracic and rotator cuff muscles. These cues were given for
the purpose of promoting appropriate glenohumeral position while
performing active shoulder internal rotation against resistance of
light theraband. In the supine position with the arm positioned at
90 degrees of shoulder abduction and elbow flexion, he was
instructed to gently adduct the scapula to promote scapular stabi-
lization on the thorax. While maintaining the position of scapular
adduction, he was instructed to visualize an axis through the gle-
nohumeral joint upon which he was to precisely rotate the hu- Fig. 5. Concentric activation of the wrist extensors with concomitant metacarpo-
merus into internal rotation. phalangeal flexion/interphalangeal extension (“arch”). (Intended for color reproduc-
Similar to techniques directed proximally, manual techniques tion). (For interpretation of the references to colour in this figure legend, the reader is
referred to the web version of this article.)
and neuromuscular training exercises were used to improve
mobility and movement patterns of the forearm, wrist and hand.
Strength training exercises for hand musculature were incorpo-
rated in early treatment sessions in preparation for the preferred
“arch” position of the palm during weight-bearing activities. The
curvature of an arched palm potentiates a higher level of resistance
to weight-bearing loads by dissipating forces across multiple joints
of the hand rather than aggregating forces at a focal point within
the wrist (Vaidyanathan, 2004, p. 127). Left unaddressed, the
gymnast's default posture when weight-bearing through the hands
was a position of wrist extension, lateral rotation and excessive
radial deviation. This faulty position resulted in an accumulation of
compressive stresses localized to the dorso-radial wrist. The goal of
neuromuscular training was to instruct the gymnast to weight-bear
through the hands in a position of wrist extension without rotation
or deviation and to maintain an arched palm. To facilitate neuro-
muscular control of appropriate muscles, the “arch & splay” exer-
cise was performed. The exercise facilitated activation of the
lumbrical and interossei muscles during active wrist motion to
promote neuromuscular control of conjoint wrist and digit move-
ment (Figs. 5 and 6). Specifically, with the forearm, wrist and hand
supported on a flat surface, the exercise was performed by first,
concentric activation of the wrist extensors with concomitant
metacarpo-phalangeal flexion/interphalangeal extension (“arch”).
This was followed by eccentric wrist extension combined with digit
extension and abduction (“splay”). The overall focus of exercises
during stage-1 was to facilitate cognitive awareness of joint posi-
tion and muscle activation during specific movement patterns in Fig. 6. Eccentric wrist extension combined with digit extension and abduction
(“splay”). (Intended for color reproduction). (For interpretation of the references to
preparation to more challenging activities. colour in this figure legend, the reader is referred to the web version of this article.)
Stage 2: (Visits 5e8) The primary goals of stage-2 were to
continue manual techniques to correct impairments of the spine,
shoulder girdle and upper extremity joints, to progress exercises
related to neuromuscular control of these segments, and introduce activities with the clinician providing support and facilitation cues
sport-specific activities in limited weight-bearing positions for muscle activation and postural alignment in full weight-bearing
(Table 2). Maintenance of spine and upper extremity joint align- position (Fig. 8). Each staged progression enabled the gymnast to
ment and control of movement patterns performed in limited focus on posture, alignment, and activation of appropriate muscle
weight-bearing positions were used as key clinical markers. contractions to gain control of position and movement patterns.
Demonstrated performance was required for the gymnast to be Repetitions and timed performance measures were used to prog-
progressed beyond stage-2. ress his performance.
Proprioceptive and sport-specific training exercises were Manual and muscle energy techniques were used less
introduced. The gymnast first performed upper extremity weight- frequently, but as needed, to address joint mobility restrictions.
bearing activities in limited weight-bearing positions using the Strength and neuromuscular training exercises were progressed by
assistance of a chair or low mat (Fig. 7). Next, he performed similar increasing repetitions, resistance or position. Maintenance of joint
44 B. Boucher, B. Smith-Young / Physical Therapy in Sport 27 (2017) 38e49

Table 2
Phase 2 (Visits 5e8): Interventions by region.

Region Treatment

Cervical spine CT: Gr V thrust manip prone, FMP: cervical rot with stabilization at CT, DNF neuromuscular training progression with BP cuff (Jull protocol)
Thoracic spine Grade V thrust manip supine
Scapulothoracic PNF in functional movement patterns (side-lying), quadruped SA protraction push, mid trap ph II prone lift (Sahrmann protocol), low trap ph II prone
joint lift (Sahrmann protocol), supine active lat stretch, upper trap wall slides with shrug, BAPS board ant-post/side-to-side pushup position, balance board
ant-post-side-to-side pushup position, pushup position hold on knees and progress to toes, progress to “butt-up” pushup position (feet on low table),
progress to “butt-up pushup position (feet on plinth)
Glenohumeral Gr IV mob: posterior & inferior glides
joint
Forearm joint MET to increase pronation (as needed), pronation wall stretch
Wrist joint Gr IV mob: proximal carpal row radial & ulnar glides (as needed), wrist stretch against wall, FMP: wrist extension with radial/ulnar deviation
Hand FMP: “arch & splay” (concentric wrist ext with MCP flex/digit ext e “arch”, followed by eccentric wrist ext with digit ext & abd e “splay”)

Abbreviations: CT, cervicothoracic; Gr, grade; manip, manipulation; FMP, functional movement pattern; rot, rotation; DNF, deep neck flexor; BP, blood pressure; PNF, pro-
prioceptive neuromuscular facilitation; SA, serratus anterior; mid trap, middle trapezius; ph, phase; low trap, lower trapezius; lat, latissimus dorsi; ant-post, anterior-pos-
terior; MET; muscle energy technique; mob, mobilization.

Fig. 7. Patient performs a handstand in a reduced weight-bearing position with the
assistance of a mat. (Intended for color reproduction). (For interpretation of the ref-
erences to colour in this figure legend, the reader is referred to the web version of this
article.)
Fig. 8. Patient performs a handstand in full weight-bearing position with the assis-
tance of a clinician. (Intended for color reproduction). (For interpretation of the ref-
erences to colour in this figure legend, the reader is referred to the web version of this
article.)

related to neuromuscular control in full weight-bearing positions

alignment and control of movement and position patterns were
requisite criteria for exercises performed in weight-bearing posi-
tions. Once the gymnast demonstrated the ability to control
segmental alignment and movement patterns with minimal
external support, treatment progressed to stage-3, performance in
full weight bearing.
Stage 3: (Visits 9e11) The primary goals of stage-3 were to
address key impairments with manual techniques as needed,
advance exercises related to neuromuscular control, and progress
to sport-specific activities in full weight-bearing positions (Table 3).
Demonstrations of correct, pain-free, sport-specific activities
were used as key clinical markers.
Sport-specific training activities were progressed to full weight-
bearing positions (Table 3). Handstands were progressed from full
weight-bearing against a wall (Fig. 9), full weight-bearing with
weight shift challenges (Figs. 10 and 11), to finally, full weight-
bearing without assistance (Fig. 12). He was instructed to use
self-check cues to facilitate correct performance. During this final
stage of treatment, the gymnast was instructed to incorporate his
physical therapy training strategies as he returned to gymnastic
training without restrictions.
Use of manual techniques was limited primarily to enhance
 B. Boucher, B. Smith-Young / Physical Therapy in Sport 27 (2017) 38e49 45

Table 3
Phase 3 (Visits 9e11): Interventions by region.

Region Treatment

Cervical spine DNF neuromuscular training progression with BP cuff (Jull protocol), DNF activation with cervical rot/UE elevation (BP cuff biofeedback)
Thoracic spine Grade V thrust manip supine
Scapulothoracic joint PNF in functional movement patterns (standing), quadruped SA protraction push with rock-back to heels, mid trap ph III prone lift (Sahrmann
protocol), low trap ph III prone lift (Sahrmann protocol), BAPS board ant-post-side-to-side pushup position for endurance, balance board ant-
post-side-to-side pushup position for endurance, “butt-up” pushup position for endurance (feet on plinth), walk-outs: “butt-up” pushup position
(feet on low table) with progression to small weight-shifts; handstand hold with progression to handstand shoulder taps against wall or spotted,
progress to handstand hip taps against wall or spotted; handstand slide board spotted
Glenohumeral joint MET to increase shoulder IR, supine pec stretch with partner, doorway pec stretch
Forearm joint pronation wall stretch
Wrist joint wrist stretch against wall, FMP: wrist extension with radial/ulnar deviation
Final Home Exercise Open chain: standing UE elevations against wall, standing UT wall slides, supine UE elevation with black T-band, quadruped SA protraction push
Program with rock-back to heels, prone ph II-III mid trap & low trap lifts
Closed chain: walk-outs in “butt-up” pushup position (feet on low table) with progression to small weight-shifts, handstand hold with shoulder
taps against wall, handstand hold with hip taps against wall

Abbreviations: MET; muscle energy technique; FMP, functional movement pattern; rot, rotation; DNF, deep neck flexor; BP, blood pressure; PNF, proprioceptive neuro-
muscular facilitation; SA, serratus anterior; mid trap, middle trapezius; ph, phase; low trap, lower trapezius; UE, upper extremity; ant-post, anterior-posterior; pec, pectoralis.

Fig. 10. Patient performs a handstand in full weight-bearing position with weight shift
challenges (BAPS board). (Intended for color reproduction). (For interpretation of the
references to colour in this figure legend, the reader is referred to the web version of
this article.)

control of the scapulae during activities performed in full elevation

and protraction. Both motions were integral to performance of the
gymnast's weight-bearing activities, and treatment focused on
improving position and control of the scapula on the thorax, with
precision and endurance to promote proper loading mechanics.
Fig. 9. Patient performs a handstand in full weight-bearing position with the assis- The gymnast was discharged from physical therapy with a final
tance of a wall. (Intended for color reproduction). (For interpretation of the references
to colour in this figure legend, the reader is referred to the web version of this article.)
home exercise program to include 5 open chain and 3 closed chain
46 B. Boucher, B. Smith-Young / Physical Therapy in Sport 27 (2017) 38e49
Fig. 11. Patient performs a handstand in full weight-bearing position with weight shift
challenges (Hip taps). (Intended for color reproduction). (For interpretation of the
references to colour in this figure legend, the reader is referred to the web version of
this article.)
exercises. All exercises were designed to promote neuromuscular
control of the upper extremities during sport-specific activities
(Table 4).
3. Outcomes
In addition to outcome measures throughout the treatment
period, a complete set of patient self-report measures was taken at
baseline, 4 weeks, end of treatment (8 weeks), and at a 6-month
post-treatment follow-up (Table 5). After 2 weeks performing
stage-1 treatment, the patient demonstrated improved neuro-
muscular control of scapulothoracic and upper extremity move-
ment patterns during open chain activities performed in a variety of
positions. By the fifth visit (week 4), the patient reported his ability
to perform a handstand at 8 (PSFS) and ability to perform on the
mushroom at 7 (PSFS). At this time, he demonstrated difficulty
maintaining sustained scapular control in weight-bearing
Fig. 12. Patient performs a handstand in full weight-bearing position without assis-
tance. (Intended for color reproduction). (For interpretation of the references to colour
in this figure legend, the reader is referred to the web version of this article.)
positions. His ability to control static posture and movement of the
cervical spine, glenohumeral, and elbow joints during weight-
bearing and non-weight-bearing positions was notably improved.
Neuromuscular training to improve wrist and hand control during
loaded and unloaded activities was introduced, and the patient was
given specific verbal and visual cues to assist with self-
reinforcement. By visit 11, the patient reported no wrist pain and
demonstrated ability to perform all gymnastic activities at pre-
injury level. At a six-month follow-up visit, the patient reported
no recurrence of wrist pain and the ability to perform all gymnastic
activities. The patient selected a score of þ7 on the Global Rating of
Change (Kamper, Maher, & Mackay, 2009) scale indicating he
considered himself a “very great deal better.”
4. Discussion
Wrist injuries often result in lost training time for the young,
 B. Boucher, B. Smith-Young / Physical Therapy in Sport 27 (2017) 38e49
Table 4
Home exercise program.
Final Home Exercise Open chain: standing UE elevations against wall, standing UT wall slides, supine UE elevation with black T-band, quadruped SA “cat rocking,”
Program prone ph II-III mid trap & low trap lifts
Closed chain: walk-outs in “butt-up” pushup position (feet on low table) with progression to small weight-shifts, handstand hold with shoulder
taps against wall, handstand hold with hip taps against wall
Table 5
Scores on Visual Analog Scale for current pain and Patient-Specific Functional Scale items.
Current Pain* Ability to perform a push-upa
Session 1 (day 1) 6 5
Session 5 (week 4) 0 10
Session 11 (week 8) 0 10
6 month post-treatment 0 10
*Current pain was based on a 10-cm horizontal visual analog scale, where 0 indicated no pain and 10 indicated maximum pain.
a
Assessment of function was based on a 10-cm horizontal visual analog scale, where 0 indicated unable to perform the skill and 10 indicated ability to perform the skill at a
level similar to pre-injury.
aspiring gymnast (Caine et al., 1992; Cornwall, 2010; DiFiori &
Mandelbaum, 1996; Kox et al., 2015). Rather than refrain from
training, the athlete may modify position and performance with
compensatory strategies in an attempt to accommodate symptoms
during load-bearing maneuvers. Faulty position and improper
techniques can lead to altered movement patterns, musculoskeletal
impairments and resultant pain (Daly et al., 2001; Sahrmann,
2001).
This case report describes an impairment-based, multi-modal
approach to treat a 10-year old gymnast with primary complaint of
chronic, bilateral wrist pain associated with load-bearing activities.
It was the authors' opinion that intervention designed to address
musculoskeletal and motor control impairments throughout the
upper kinetic chain would yield better results than limiting treat-
ment to local areas of complaint. During gymnastics, safe execution
of upper extremity weight-bearing maneuvers requires strict
neuromuscular control of the spine, shoulder girdle and segments
of the upper extremity (Farana, Jandacka, & Irwin, 2013; Gittoes,
Irwin, Mullineaux & Kerwin, 2011; Koh, Grabiner, & Weiker, 1992;
McNitt-Gray, Hester, Mathiyakom & Munkasy, 2001). Although
wrist and hand strategies are considered important to manage
upper limb stability under conditions of axial load, shoulder and
periscapular muscles are fundamental to maintaining controlled
balance and stability (Kalantari & Ardestani, 2014). Lack of proximal
strength and motor control potentiates injury to distal segments
(Sahrmann, 2011). In the authors' opinion, correction of impair-
ments throughout the proximal chain was important to reduce the
gymnast's local symptoms of wrist pain and restore proper move-
ment mechanics.
Our management strategy to facilitate multi-joint neuromus-
cular control during upper extremity weight-bearing activities
followed the principle of gradual introduction to more demanding
activities (Kalantari & Ardestani, 2014; Lindner & Caine, 1990).
Consistent with recommendations to correct key musculoskeletal
impairments and faulty movement patterns before introducing
load-bearing tasks (Daly et al., 2001), intervention during stage-1
focused on techniques to increase mobility and control motion in
symptom-free positions. Demonstrations of correct, independent
performance of isolated movements and exercises of the spine,
shoulder girdle, elbow, wrist and hand, without pain, were used as
clinical markers. Manual techniques were used most frequently
during this stage to correct impairments throughout the spine and
upper extremity. In keeping with recommendations to improve
performance using non-weight-bearing conditions before pro-
gressing to weight-bearing activities, (Karandikar & Vargas, 2011)
47
Ability to perform a hand-standa Ability to perform on mushrooma
5 5
8 7
10 10
10 10
our program included many open kinetic chain exercises during
stage-1.
In stage-2, treatment strategies were directed towards main-
taining spine and upper extremity joint alignment and control of
movement patterns performed in limited weight-bearing positions.
Manual techniques were needed less frequently to address joint
and soft tissue restrictions. Exercises related to neuromuscular
control during sport-related activities were introduced. Coordina-
tion between sensorimotor input and musculoskeletal response is
proposed to promote functional stability, (Vaseghi, Jaberzadeh,
Kalantari & Naimi , 2012) and activities performed in a closed-
kinetic chain are suggested to improve dynamic stability by way
of joint approximation and co-contraction (Goldbeck and Davies,
2000). Compression during weight-bearing activity is considered
important to stimulate mechanoreceptors and enhance proprio-
ception, (Goldbeck and Davies, 2000) therefore, stage-2 exercises
introduced limited weight-bearing, sport-related activities.
Reduced weight-bearing activities provided joint compression
while enabling the gymnast better ability to control his movement
patterns. Muscles of the spine and proximal limb girdle function to
maintain proximal stability, which is believed critical for the
transfer of energy from the core to the distal body segments
(Colston, 2012), therefore, importance was given during stage-2
intervention to include exercises designed to promote spine and
shoulder girdle stability.
During stage-3, treatment progressed to sport-specific activities
in full weight-bearing positions. Demonstrations of correct, pain-
free, sport-specific activities related to neuromuscular control
were considered key. Supporting literature describes improvement
of joint stability by challenging balance in load-bearing functional
positions (de Oliveira, de Morais Carvalho, & de Brum, 2008). For
the gymnast, functional positions included weight-bearing activ-
ities such as the push-up and handstand. During stage-3, chal-
lenges to the gymnast's balance and load occurred with various
activities that required transfer of weight and balance, both on
stable and unstable surfaces. The gymnast responded positively to
the stage program described in this document, with observed
improvement in motor control and movement patterns. Subjective
pain ratings further supported this progression.
5. Conclusion
This case report describes a progressive rehabilitation program
using an impairment-based, multi-modal approach to treat key
musculoskeletal impairments and movement deficiencies
48 B. Boucher, B. Smith-Young / Physical Therapy in Sport 27 (2017) 38e49
identified from the clinical assessment. Consistent with the prin-
ciple of training for activity simulation, a rehabilitation program
was designed to include a 3-stage progression of exercises that
mirrored activities reported by the gymnast to be painful. Muscu-
loskeletal impairments and faulty movement patterns that corre-
sponded to symptom-producing activities were addressed, and a
program to restore neuromuscular control towards full weight-
bearing activities was completed. The gymnast reported resolu-
tion of symptoms and ability to perform load-bearing maneuvers at
pre-injury level within 11 treatment sessions. These outcomes were
maintained six months post rehabilitation.
Conflict of Interest
None declared.
Ethical Approval
This study met criteria and was granted status of exemption by
the Texas State University Internal Review Board.
Funding
None declared.
Acknowledgements
The authors thank the Alicia Shugart and Kristin Dugan for their
assistance as research assistants.
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