Growth in female gymnasts: should training decrease during puberty?

The gymnasts' hip and groin: a magnetic resonance imaging study in asymptomatic elite athletes

OBJECTIVE

Specific patterns of developmental adaptation of the proximal femur have been recognized in some sports. Gymnastics are characterized by repetitive axial loading and hip rotations in combination with extreme hip positions. It is unknown how and if these forces can affect an immature skeleton in the long term. We sought to evaluate this, by means of magnetic resonance imaging of the hip and groin of such elite asymptomatic athletes.

MATERIALS AND METHODS

We performed a case-control comparative MR imaging study of both hips and groin of 12 (7 male, 5 female) skeletally mature young (mean age 18.6 years) asymptomatic international level gymnasts with a minimum of 10 years' training with age-matched non-athletes. At the time of recruitment, none of the athletes had a recorded musculoskeletal complaint or injury in the anatomical area around the hip.

RESULTS

The study showed that elite gymnasts share four common morphological characteristics on MRI that deviate from normal and are considered to be the result of adaptational changes to the specific sport: high centre-column-diaphysis angle (coxa valga140° on average), ligamentum teres hypertrophy, friction of the iliotibial band with oedema surrounding the greater trochanter, and a high incidence (62.5 %) of radiological appearances of ischiofemoral impingement.

CONCLUSION

Our study showed that elite gymnasts share four common morphological characteristics on MRI that deviate from normal. These findings were in asymptomatic subjects; hence, radiologists and sports physicians should be aware of them in order to avoid unnecessary treatment.

Historical Trends in the Size of US Olympic Female Artistic Gymnasts

The lay press, scientists, and physicians appear to believe that gymnasts are continually getting smaller and that their “smallness” is a health risk.

Purpose:

To assess the historical changes in the size and age of the US women’s Olympic gymnastics teams from 1956 to 2008.

Methods:

The official records from the US Olympic Committee and USA Gymnastics of Olympic team members were assessed at 2 levels: individual height, mass, age, and body-mass index (BMI) and the team performance scores and rankings. Fourteen Olympic teams with a total of 106 team members, including the alternates, were included. Trend analyses were conducted using linear and polynomial models.

Results:

Simple linear correlations indicated that since 1956, height, mass, age, BMI, and team Olympic rank have been declining. However, second-order polynomial curve fits indicated that in the last 4 Olympic Games the members of the US women’s gymnastics teams have been getting larger.

Conclusion:

Women Olympic gymnasts were getting smaller through approximately the 1980s and early 1990s. Since then the size of these gymnasts has increased. The minimum-age rule modifications may have played a role in athlete size changes along with a shift from the near dominance of the former communist Eastern Bloc.

Adolescent growth spurts in female gymnasts

OBJECTIVES

Three questions were addressed: (1) Do female gymnasts have adolescent growth spurts in height, sitting height, and leg length? (2) Are the sequence and magnitude of spurts comparable with female adolescent non-athletes? (3) How do the data compare with other female gymnasts and with short girls?

STUDY DESIGN

Height and sitting height were measured annually on 15 Belgian gymnasts from 8.7 +/- 1.5 to 15.5 +/- 1.5 years. The gymnasts trained, on average, approximately 15 h/wk. Leg length was estimated as height minus sitting height. The Preece-Baines Model I was fitted to individual growth records to estimate ages at peak velocity and peak velocities for the three dimensions. Age at menarche and skeletal age were also assessed.

RESULTS

Gymnasts have clearly defined adolescent spurts in height, estimated leg length, and sitting height that occur approximately 1 year later and are slightly less intense than in nonathletic adolescent girls. Age at menarche and skeletal age are consistent with later somatic maturation. The pattern of adolescent growth and maturation is similar to that of other gymnasts, short normal late-maturing girls, and late-maturing girls with short parents.

CONCLUSIONS

The results emphasize a primary role for constitutional factors in the selection process of female gymnasts at relatively young ages.

Onset of puberty, menstrual frequency, and body fat in elite rhythmic gymnasts compared with normal controls

OBJECTIVES

To assess the prevalence of delayed menarche and abnormal menstrual patterns, as well as the association of menstrual status with physical training in elite rhythmic gymnasts from Greece and Canada.

METHODS

Fifteen Greek (mean (SEM) age 14.5 (0.2) years) and 30 Canadian (mean (SEM) age 14.7 (0.4) years) rhythmic gymnasts were surveyed for age at menarche, menstrual frequency, and training profile, and measured for height, weight, and percentage body fat (%BF). Seventy eight healthy adolescents served as country specific non-active controls: 38 Greek non-athletes (mean (SEM) age 14.5 (0.1) years) and 40 Canadian non-athletes (mean (SEM) 14.2 (0.1) years).

RESULTS

Of the Greek gymnasts, 79% had not yet menstruated compared with 34% of the Canadian gymnasts. Menarche was significantly (p<0.01) delayed in the rhythmic gymnasts (composite mean 13.8 (0.3) years, n = 45) compared with the controls (composite mean 12.5 (0.1) years, n = 78). There was no significant difference between Greek and Canadian gymnasts for the age at menarche (14.2 (0.3) v 13.6 (1.2) years respectively). Menstrual irregularities were reported in 78% (61% oligomenorrhoeic and 17% amenorrhoeic) of the menarcheal athletes. Menarcheal gymnasts were found to be significantly (p<0.05) taller and heavier, with a higher %BF and a lower training frequency and training duration (p<0.05) than the premenarcheal gymnasts. Overall, the mean %BF of the gymnasts was significantly lower (p<0.05) than that of the control subjects. The Canadian controls exhibited a significantly (p<0.05) greater %BF than the Greek controls of the same age.

CONCLUSION

Delayed menarche, menstrual irregularities, and low body fat are common in elite rhythmic gymnasts. Premenarcheal gymnasts train more often and for longer, and have a lower body mass index and less body fat, than menarcheal gymnasts. Prospective studies are needed to explore further these and other factors associated with delayed menarche and menstrual irregularities in female athletes.

Eating disorders

Anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified remain a significant cause of morbidity and mortality in girls and young women. Management of eating disorders typically requires a multidisciplinary team approach, often spear-headed by the clinician initially detecting the illness. This article addresses the definitions and prevalence of eating disorders, tips on recognition and management of medical complications, and reproductive health concerns for these young women. Issues surrounding care of the patient with the female athlete triad, or amenorrhea, osteopenia, and eating disorders, are also discussed.

Premenarchal athletic injury to the breast bud as the cause for asymmetry: prevention and treatment

Some variation in breast size is normal and is common in most women. When this variation becomes large and appreciable asymmetry develops--greater than a one-cup size difference--the asymmetry often disrupts the patient's life. The etiology of most breast asymmetries is unknown; however, current theories on causes include endocrine, iatrogenic, and traumatic injury. The Tulane University Plastic Surgery Service recently evaluated two cases of breast asymmetries that developed after traumatic injury to the breast bud while the body was under increased physical stress. Both girls sustained injuries at approximately 10 to 11 years old (Tanner Stages I-II) while participating in gymnastics.

Does gymnastics training inhibit growth of females?

OBJECTIVE

The increasingly dominant performance of smaller-sized female gymnasts and increased magnitude of training beginning at an early age have prompted public and medical concerns, especially from an auxological perspective. The objective of this review is to determine if gymnastics training inhibits growth of females.

DATA SOURCES

An extensive research of MedLine (PubMed interface) along with cross-referencing was conducted using the Text and MeSH words "gymnastics" in combination with "growth," "maturation," "body height," "body weight," and "growth plate." Our analysis is limited to English articles only.

STUDY SELECTION

All published studies that included data related to the research questions were included.

MAIN RESULTS

Although data from three historical cohort studies indicate that female gymnasts are short even before they begin training, clinical reports and cohort studies do suggest that some female gymnasts experience attenuated growth during training followed by catch-up growth during periods of reduced training or retirement. There is conflicting evidence whether the "catch-up" is complete. There were no studies reporting prevalence or incidence of inadequate growth. Three cohort studies provide evidence of reduced growth but training was not partitioned from other confounding factors in the gymnastics environment. Although there is a paucity of studies examining the link of dietary practices with diminished growth in female gymnasts, a review of related dietary literature indicates the potential for insufficient energy and nutrient intake among female gymnasts.

CONCLUSIONS

Elite level or heavily involved female gymnasts may experience attenuated growth during their years of training and competition followed by catch-up growth during reduced training schedules or the months following retirement. However, a cause-effect relation between gymnastics training and inadequate growth of females has not been demonstrated.

Injury prevention in women's gymnastics

The most serious problem faced by contemporary gymnasts is injury. Given that prevention is superior to treatment, can the gymnastics community and the scientific and medical community do a better job at injury prevention? Most research in gymnastics has been descriptive in nature. Injury prevention ultimately requires that one can predict the outcome of certain activities and their injurious nature. Making such predictions requires a knowledge of the scientific and medical aspects of injury, but more than that, one must have an intimate knowledge of the sport. Injury prevention efforts must be firmly grounded in science and medicine while making pragmatic linkages to gymnastics as it exists and is practiced. This article attempts to bridge the gap between the scientific and medical community and what actually happens in gymnastics.

Short stature in competitive prepubertal and early pubertal male gymnasts: the result of selection bias or intense training?

OBJECTIVES

To determine whether high-volume, high-impact physical training in prepubertal and early pubertal male gymnasts is associated with reduced statural and segmental growth and reduced serum insulin-like growth factor-I (IGF-I) and increased cortisol (C) levels.

STUDY DESIGN

Height, sitting height, leg length, and segmental lengths (humerus, radius, femur, and tibia) and breadths (biacromial and bi-iliac), diet, serum IGF-I, testosterone, and C were measured in competitive male gymnasts and normoactive children (Tanner stage < or = 2) every 3 to 4 months over an 18-month period.

RESULTS

At baseline, gymnasts (n = 31) were 0.7 years older than members of the control group (P <.05, n = 50) but were no different in terms of biologic maturity. Age-adjusted z scores showed that the gymnasts were shorter than members of the control group (-0.5 +/- 0.2 SD, P <.05) because of reduced leg length (-0.8 +/- 0.2 SD, P <.001) but not sitting height. Segmental lengths and bi-iliac breadth age-adjusted z scores were also reduced in the gymnasts (P ranging <.05 to <.001). No difference was detected for serum IGF-I or C. After 18 months of follow-up, no differences were found for rates of change in height, sitting height or leg length, segmental lengths, IGF-I, or C between those gymnasts and control subjects who remained prepubertal and early pubertal (gymnasts n = 18; control group n = 35). However, the magnitudes of baseline differences in anthropometric measures (z scores) persisted throughout the study.

CONCLUSION

Short stature in these competitive male gymnasts was due to a reduced leg length but not sitting height. The lack of a difference in growth rates, IGF-I, and diet over the 18-month period indicates that the short stature reported in male gymnasts is due to selection bias rather than gymnastics training.

Is prepubertal growth adversely affected by sport?

PURPOSE

To study the effect of genetic factors, birth weight, early childhood growth, sport, hours of training, and pubertal status on the stature and body mass index (BMI) of children aged 9-13 participating in sports at a competitive level.

METHODS

A total of 184 children (96 girls, 88 boys), competing in swimming, tennis, team handball, and gymnastics, were investigated, assessing their height, weight, pubertal development, and BMI. Of these, 137 (76 girls, 61 boys) returned a questionnaire, which enabled us to determine height and BMI at age 2-4, birth weight, and parental heights.

RESULTS

Significant differences in standard deviation scores (SDS) for actual height and for height at age 2-4 were found in both sexes between the four sports. In girls, BMI SDS was significantly different between the four sports, whereas no difference was found in boys. Each sport investigated separately showed no change in height SDS and BMI SDS between ages 2-4 and 9-13. A regression analysis showed that target height, height at age 2-4, and pubertal status had a significant impact on actual height. Interestingly, the type of sport and hours of training per week had no effect on height SDS. In boys, BMI at age 2-4 and pubertal status had a significant effect on actual BMI, whereas in girls, only BMI at age 2-4 was significant.

CONCLUSIONS

The results suggest that prepubertal growth is not adversely affected by sport at a competitive level and that constitutional factors are of importance for choice of sport in children.

Growth, dietary intake, and trace element status in pubescent athletes and schoolchildren

PURPOSE

To examine interactions between club-level sports training, dietary intake, and nutritional status during puberty.

METHODS

A 2-yr prospective study was undertaken with 64 boys (40 ice hockey players, 24 controls) and 71 girls (28 gymnasts, figure skaters, and runners, 43 controls). The boys' age in the beginning of the study was 12-13 yr, whereas the girls were 11-12 yr. The following variables were measured in the beginning, and after 1 and 2 yr: physical activity level (record), dietary intake (record), blood hemoglobin concentration, serum ferritin, zinc and copper concentration, anthropometric indices (height, weight, skinfolds, upper arm muscle girth), and biological maturation (self-report).

RESULTS AND CONCLUSIONS

The changes in the anthropometric variables throughout the study period were not different between the athletes and controls (P = 0.09). The athlete boys had higher mean energy, iron and zinc intakes, and higher mean serum zinc concentration than the controls (P < or = 0.003). The athlete and control girls' dietary intakes and biochemical indices of trace element status were not different from each other (P < or = 0.13). Moreover, sports participation was not associated with the longitudinal changes in trace element status (P > or = 0.08). These data suggest that club-level sports training does not affect growth, maturation or nutritional status during puberty.

Short stature and delayed puberty in gymnasts: influence of selection bias on leg length and the duration of training on trunk length

BACKGROUND

Delays in bone age, the onset of puberty, and skeletal growth in gymnasts could be, in part, the reason for an interest in gymnastics, rather than being the result of vigorous exercise. We hypothesized that short stature and delayed bone age are present at the start of gymnastics, and training delays growth, producing short stature, even after retirement.

METHODS

Sitting height and leg length were measured in 83 active female gymnasts, 42 retired gymnasts, and 154 healthy control subjects. Results were expressed as age-specific SD scores (mean +/- SEM).

RESULTS

In the cross-sectional data, active gymnasts had delayed bone age (1.3 +/- 0.1 years), reduced height -1.32 +/- 0.08 SD, sitting height -1.24 +/- 0.09 SD, and leg length, -1.25 +/- 0.08 SD (all P <.001). However, in those training for less than 2 years, the deficit was confined to leg length (-0.8 +/- 0.2 SD). During 2 years of follow-up of 21 gymnasts, only the deficit in sitting height worsened (by 0.4 +/- 0.1 SD). In 13 gymnasts followed up in the immediate 12 months after retirement, sitting height accelerated, resulting in a lessening of the deficit in sitting height by 0.46 +/- 0.14 SD (P <.01). Adult gymnasts who had been retired for 8 years had no deficit in sitting height, leg length, or menstrual dysfunction.

CONCLUSIONS

Short stature in active gymnasts is partly due to selection of individuals with reduced leg length. Reduced sitting height is likely to be acquired but is reversible with cessation of gymnastics. A history of gymnastic training does not appear to result in reduced stature or menstrual dysfunction in adulthood.

Longitudinal bone mineral density changes in female child artistic gymnasts

Changes in bone mineral density (BMD), and related factors, in female child artistic gymnasts (n = 9) and their age- (+/-0.3 years), height- (+/-2.8 cm), and weight- (+/-1.7 kg) matched controls (n = 9) were prospectively examined. It was hypothesized that gymnasts would possess higher BMD at baseline, 6, and 12 months later and have greater gains in BMD over 1 year compared with controls. BMD (g/cm2) of the total proximal femur (TPF), Ward's triangle (WT), trochanter (Troch), femoral neck (FN), lumbar spine (LS, L1-L4), and total body (TB) were measured by dual-energy X-ray absorptiometry. Physical activity was measured by a 7-day recall; daily dietary intakes of energy and nutrients were estimated from 3-day records. Serum osteocalcin and urinary pyridinium cross-links were measured by radioimmunoassay and high performance liquid chromatography, respectively. Gymnasts versus controls possessed significantly higher BMD at all sites measured. Although not significantly different (p > 0.05), gymnasts compared with controls had moderately larger percentage changes in Troch (% Delta = 8.6 +/- 3.0 vs. 3.8 +/- 5.1%, d = 0.41), FN (% Delta = 6.1 +/- 1.2 vs. 3.9 +/- 1.6%, d = 0.55), LS (% Delta = 7.8 +/- 1.1 vs. 6.8 +/- 1.6%, d = 0.26), and TB BMD (% Delta = 5.6 +/- 0.8 vs. 3.4 +/- 0.7%, d = 0.98) as evidenced by the magnitude of the effect sizes (d). Gymnasts versus controls possessed a lower percentage body fat (p < 0.01) and engaged in more hours of very hard activity (p < 0.0001). Calcium, as a percentage of adequate intake, decreased over 12 months (p < 0.01), and urinary cross-links significantly decreased over 6 months in both groups. Female child gymnasts possess higher BMD at the TPF and related sites, LS, and TB compared with nongymnast controls, and 1 year of gymnastics training moderately increases Troch, FN, LS, and TB BMD for gymnasts compared with controls. These findings lend support to the idea that gymnastics training in childhood helps maximize peak BMD.

Skeletal effects of menstrual disturbances in athletes

This article reviews the skeletal effects and clinical implications of menstrual disturbances in active women. At the lumbar spine, menstrual disturbances are associated with premature bone loss or failure to reach peak bone mass, while appendicular sites are less affected. This suggests that trabecular bone is more sensitive to hormonal stimuli and less responsive to mechanical loading than cortical bone. Although the mechanisms responsible for the detrimental effects of menstrual disturbances are likely to be multifactorial, low circulating levels of oestrogen are thought to be the main cause. The clinical significance of menstrual disturbances depends upon a number of factors, including type of sport, genetic background, body composition and calcium intake. Not all athletes who present with menstrual disturbances will develop osteopenia. Nevertheless, the risk of stress fracture does seem to be increased in athletes with menstrual disturbances and with lower bone density. Whether athletes with menstrual disturbances are at a greater risk for osteoporosis in later life is not yet known. Bone loss can be at least partially reversed, especially with the spontaneous resumption of menses. This may serve to offset any previous increased risk of osteoporosis. Furthermore, other factors, apart from low bone mass, act to determine the likelihood of osteoporotic fractures. Therefore, the clinical significance of menstrual disturbances associated with exercise participation needs to be established for each individual athlete. Bone densitometry may guide the clinician in this respect and assist in the formulation of appropriate management strategies.

Gymnastic training and bone density in pre-adolescent females

Bone mineral density (BMD) was compared between 7-11-yr-old female gymnasts (GYM: N = 16) with a history of high volume impact loading (minimum of 15 h.wk-1 for past 2 yr) and healthy nonathletic controls (CON: N = 16). Whole body (WB) and regional areal BMD measures were determined by dual energy x-ray absorptiometry (DXA) normalized for height and body mass and also converted to bone mineral apparent density (BMAD). Volumetric BMD and bone cross-sectional areas were also measured by peripheral QCT (pQCT) at the left distal radius. GYM were significantly (P < 0.01) shorter (129.3 +/- 5.7 vs 136.7 +/- 4.4 cm; means +/- SD) and leaner (15.1 +/- 1.9 vs 19.6 +/- 4.3% body fat from DXA), and had significantly (P < 0.05) greater femoral neck (0.698 +/- 0.058 vs 0.648 +/- 0.064 g.cm-2) and trochanter (0.616 +/- 0.060 vs 0.530 +/- 0.084 g.cm-2) areal BMD than CON. GYM also had significantly higher whole body (0.101 +/- 0.009 vs 0.094 +/- 0.007 g.cm-3), femoral neck (0.245 +/- 0.060 vs 0.205 +/- 0.049 g.cm-3) and lumbar spine (0.227 +/- 0.014 vs 0.210 +/- 0.026 g.cm-3) BMAD compared with CON. Height normalized areal BMD measures were also significantly higher at all sites in GYM. Radial total (367.7 +/- 51.6 vs 307.4 +/- 27.6 mg.cm-3), trabecular (207.9 +/- 45.3 vs 163.8 +/- 31.4 mg.cm-3), and cortical (496.9 +/- 67.5 vs 429.8 +/- 33.8 mg.cm-3) BMD were also significantly greater in the GYM compared with the CON. In conclusion, high volume impact loading was associated with greater (compared with controls) whole body and regional bone mineral density in pre-adolescent female gymnasts.

Physique as a risk factor for ulnar variance in elite female gymnasts

The aims of this study were: 1) to determine ulnar variance variability of elite, female gymnasts; 2) to evaluate the relationship between ulnar variance and physique, maturity status, and training characteristics of these gymnasts. All 156 skeletally immature female gymnasts were participants at the World Championships Artistic Gymnastics, Rotterdam, The Netherlands, in 1987. Chronological ages varied between 13.1 and 20.6 yr (mean = 15.9 +/- 1.3 yr). A large set of anthropometric dimensions was taken and somatotype was determined by the Heath-Carter technique. Skeletal age was assessed by the Tanner-Whitehouse II method. Menarcheal status and training data were collected by questionnaire. Ulnar variance was determined according to Hafner et al. Gymnasts differ significantly from reference girls with respect to physique and maturational status: gymnasts were smaller and delayed in skeletal maturity with about 1.5 yr. For those who had attained menarche, mean age at menarche was 15.1 +/- 1.3 yr. Ulnar variance shows a normal distribution in the gymnasts, ranging from -10.5 mm to +5.9 mm, which is somewhat more positive, i.e., an ulnar overgrowth, than reference wrists. The relationship between ulnar variance and somatic and maturational features suggests that female gymnasts who are more mature and have a physique characterized as relatively tall with a high lean body mass are at greater risk for developing a positive ulnar variance. No relationship between ulnar variance and training characteristics was evident. It is concluded that the observed positive ulnar variance in this sample of elite female gymnasts is less pronounced than originally stated in most "case reports."

Prospective study of psychological development of adolescent female athletes: initial assessment

PURPOSE

This study aimed at assessing the impact of physical training on psychological functioning at the onset of a prospective study of psychological and somatic maturation of adolescent female athletes.

METHODS

Twenty-seven highly trained gymnasts aged 12.7 +/- 1.1 year (mean +/- SD, training load = 18-26 hr/week) and 16 age-matched but moderately trained swimmers (13.0 +/- 0.9 yr, training load 4-15 hr/wk) were submitted to standardized somatic and psychiatric examinations during training camps.

RESULTS

Gymnasts were significantly shorter, lighter and thinner (p < 0.001) than swimmers. Their bone age was moderately but significantly retarded (-1.42 +/- 0.99 yr, p < 0.001) in contrast with swimmers in whom it was adequate for chronological age (+0.28 +/- 0.94 year, ns). Only 7.4% of gymnasts had already had menarche in contrast with 50% of age-matched swimmers (p = 0.003). Psychological functioning was considered as normal in all subjects. However, seven athletes including 3/27 gymnasts and 4/16 swimmers (p = 0.394) were considered as subjects "at risk" to develop a manifest mental disorder over time. Ten gymnasts (41.7%) presented with a global delay in psychological maturation, whereas no such case was observed among swimmers (p = 0.015). No correlation could be established between psychological delay and pubertal retardation (p = 0.210).

CONCLUSION

Strenuous training in gymnastics for more than 1 yr has so far no detectable interference with the normal maturational events of adolescence. The outcome of athletes at risk to develop psychopathology as well as those with a global delay in psychological maturation who presented as if they were still in the latency period, remains uncertain.