Rehabilitation of an elite gymnast with a type II manubriosternal dislocation.

Manubriosternal dislocations can occur from either direct k or indirect trauma and are classified as type I or type II dislocations. Type I dislocations are more common, occur secondary to direct trauma, and displace the sternal body dorsally. Type II dislocations can occur from either direct or indirect trauma, resulting in displacement of the sternal body ventral to the manubrium. (1) Type II dislocations are associated with upper thoracic hyperflexion and compression injuries. Indirect forces transmitted to the sternum through the clavicles and upper ribs cause backward displacement of the manubrium. (2)

There is evidence to suggest that this mechanism of injury, or controlled failure of the sternum, actually protects other soft-tissue structures, such as the myocardial and pulmonary systems. A retrospective study of 28 patients with sternal fractures showed that the sternal fractures prevented greater damage by absorbing a substantial part of the energy transfer. (3) The fractures in that study were treated with rest and analgesic agents.

In a prospective study of patients with blunt chest trauma, (4) the data were analyzed to determine the significance of sternal fractures and possible associated injuries. The investigators found that people with sternal fractures had less injury overall. The results indicated that fractures may help to reduce other associated injuries by absorbing mechanical energy and that patients whose sole injury is a sternal fracture without significant pain may be treated conservatively. (4) In a case report by Woo, (5) the conservative treatment of manubriosternal dislocation was reported to be manipulative hyperflexion reduction and rest. No prognosis for this method of treatment was provided.

The skeletal system of a young gymnast undergoes pronounced adaptive changes secondary to intensive sports training. (6,7) Bone stiffness tends to increase in response to this training. Although the bones are stronger, failure can occur when they are subjected to sudden overloads or impulse loads. It has been shown that in subjects with skeletal immaturity, fractures that initially mend with some deformity can completely remodel and appear normal later in life. (8)

Limited evidence exists for the rehabilitation of manubriosternal dislocations for youths in general, and a literature search revealed only 2 case reports for this population. The first case report described a 14-year-old male patient who reportedly sustained the injury when lifting a load equal to his body weight (BW). (9) No prognosis or follow-up information was provided. The second case report described a 17-year-old male patient who sustained a manubriosternal dislocation in a similar flexion-compression-type injury during a rugby game. (10) Rehabilitation consisted of rest, with no prognosis for a return to the sport. There also was no follow-up information.

Because the therapeutic approach and interventions for the treatment of a manubriosternal dislocation in an elite gynmast were not previously studied, the purpose of this case report is to describe the treatment of an elite gymnast who underwent 13 weeks of physical therapy after a nonreduced type II manubriosternal dislocation.

Case Description

A 15-year-old elite female gymnast sustained a type II manubriosternal dislocation while attempting a Tkatchev drill on the uneven parallel bars. The precipitating event occurred when she released the high bar prematurely and made contact with the low bar in a chest-first fashion. The vertical distance between the bars was 0.8 m. There was 180 degrees of forward rotation before impact, resulting in a sagittal-plane impact angle of approximately 40 degrees relative to horizontal. Figure 1 illustrates this sequence of events.

[FIGURE 1 OMITTED]

All deceleration forces occurred through bar contact at the level of the xiphoid process with the arms overhead in 180 degrees of shoulder flexion. Rapid deceleration caused cervical flexion, shoulder extension, thoracic flexion, and hip flexion. Bar rebound resulted in a feet-first landing on an approximately 10-cm (4-in) matted surface, with an immediate roll to her back. After the fall, the gymnast experienced pain at the sternal impact site. There was no visible structural defect. After a 10-minute recovery period, she returned to upper-extremity (UE) weight-bearing activities before a scheduled break.

Upon return from the break, she attempted to perform a chin-up maneuver that resulted in a popping sound and subsequent anterior chest pain. A visible "step-off" at the superior sternal margin was evident, and the gymnast was having difficulty breathing. She was transported to the hospital, where a computed tomography scan revealed a type II manubriosternal dislocation, a superior sternal margin fracture, and an inferior overlap of superior components by approximately 1 cm (Fig. 2). It is likely that the type II dislocation was facilitated by the posteriorly directed force of the bar at the xiphoid process.

[FIGURE 2 OMITTED]

The consulting physician considered a closed reduction. This procedure was not performed because of potential damage to nearby arterial structures, including both the internal thoracic arteries and the aorta. A decision was made to monitor the defect and implement progressive physical therapy in the hope of achieving a stable union. One goal of the gymnast was a return to her previous level of activity within a 6-month time frame. It was important to initiate treatment in a timely fashion. On the basis of the clinical judgment of the physician, however, the prognosis for a return to the previous level of activity within any time frame was poor.

Preintervention Functional Status and Impairments

From the time of the injury to week 2, the physician ordered the patient to discontinue gymnastics and any activities that produced pain or a sense of instability at the site of the injury. During this time, the patient reported pain with any UE or lower-extremity (LE) functional task or movement that presented stress to the manubriosternal joint, including breathing and walking down stairs. She rated her pain as 10 of 10 ("worst pain imaginable") during any UE movement. At week 2, the patient was allowed to begin LE activities but still was limited by sternal pain. At week 4, the patient was allowed to begin UE rehabilitation. At this time, shoulder active range of motion (ROM) was limited to 90 degrees in both flexion and abduction. Shoulder passive ROM in a supine position also was limited to 90 degrees secondary to perceived movement at the manubriosternal joint and subsequent pain. Strength (force-generating capacity of a muscle) was not assessed at this time. Sensation appeared grossly intact to light touch. Table 1 shows the week-to-week treatment elements, examination findings, and guiding treatment principles.

Intervention

The patient's rehabilitation program was tailored to incorporate her goal of a return to her previous level of activity. As a result, many of the rehabilitation activities were based on gymnastics. Throughout rehabilitation, progression was based on the patient's tolerance and a biomechanical hierarchy. The intervention was not advanced if pain or manubriosternal movement was perceived. In addition, static activities were initiated before dynamic activities as ROM and strength returned. This was an unusual case in that the intervention was performed in a gymnastics venue by a licensed physical therapist with guidance from a physician. The patient was seen 4 or 5 days per week for 3 to 4 hours per day.

An LE maintenance program consisting of stationary bicycle and isometric exercises was instituted by week 2 after injury in order to maintain a base level of conditioning. Upper-extremity rehabilitation began at week 4, when a plain-film radiograph revealed sternal fracture healing but limited union of the overlapping manubriosternal regions. The patient had pain with palpation and expressed discomfort when standing in a position of bilateral shoulder protraction with the arms in 90 degrees of shoulder flexion. Rehabilitation exercises included isolated elbow flexion and extension activities and bilateral shoulder flexion active-assisted ROM activities to 90 degrees. By week 6, the patient reported no pain with palpation and no pain with bilateral shoulder protraction. Therapeutic exercises instituted at week 6 incorporated UE isometric exercises and partial wall push-ups with a Thera-Ball. * The patient reported no sternal pain or perceived movement while performing these exercises.

During weeks 7 and 8, the patient was performing all gymnastics leaps, turns, jumps, and landings without sternal symptoms (secondary to transmitted open and closed kinetic-chain forces). Lower-extremity conditioning continued, with qualitative evidence of improved core stability during the performance of gymnastics skills. The patient continued to perform partial wall push-ups with the Thera-Ball and started isometric partial UE weight-bearing activities with the shoulders in greater than 90 degrees of flexion. There were no reports of sternal pain or perceived movement. The patient also began supporting partial BW tension loads through her hands in the supine position with the shoulders in 90 degrees of flexion without sternal pain.

At week 9, a plain-film radiograph was taken with the patient in a handstand position. In this static orientation, the dislocation site appeared to be stable. Rehabilitation continued with increased load bearing through the sternum in a controlled but progressive manner. Exercises included press handstands, handstand pirouettes, handstand walking, handstand forward rolls, reverse push-ups (suspended from bar or beam), front supports with cast on bars (to the horizontal position), sagittal-plane supine core stability activities, and supported supine wall pushes (simulated partial weight-bearing glenohumeral joint elevation performed in the supine position on a roller with assistance, with a focus on quick repulsion). Gymnastics skills included tumble track salto and back saltos and beam side aerials to promote kinesthetic awareness. Table 2 shows the gymnastic skills included in the patient's rehabilitation program.

During weeks 10 and 11, the patient was challenged with progression to more dynamic UE skills. Controlled dynamic loading was accomplished with low-bar glides and kips without reported pain or movement. Back hip and clear hip circles on the low bar and three-quarter giants on the high bar also produced no symptoms. Progressions were determined on the basis of known loading (tension and compression) models for each skill and were performed in a controlled fashion. Tension stresses at the hand-bar interface in association with combinations of free-hips and kips typically present up to 4 times BW. (11) High-bar three-quarter giants and full giants typically present up to 2.5 times BW. (12-14)

Compressive load progressions were accomplished with gravity-reduced positions. As an example, compressive loads of less than BW can be accomplished with wall push-up and horizontal push-up positions. A static handstand would present a compressive load of BW at the hand-floor interface or the hand-bar interface. A dynamic handstand would produce compressive loads of greater than BW.

Follow-up computed tomography was performed at week 13 (Fig. 3). There was no evidence of a calcified union between adjacent sternal components. There was, however, evidence of a shelf on the superior-posterior aspect of the sternum. The alignment suggested remodeling secondary to tension and compression forces acting through the manubriosternal joint.

[FIGURE 3 OMITTED]

The rehabilitation plan of care continued to increase sternal load bearing tinder both compression and tension with gymnastics exercise elements. Activities included back handsprings on the tumble track and down a 30-degree incline wedge, rope climbing, pull-ups, kips, free-hips, giants, and saltos. All activities were performed without reported pain or sternal movement.

Outcomes

The rehabilitation process through week 13 included approximately 200 contact hours (4 or 5 days per week for 3 to 4 hours per day) and was guided by a biomechanical hierarchy. The patient's prognosis for a return to elite gymnast activities shifted from poor (at week 2) to very good (by week 13). At the conclusion of the intervention, the patient was able to perform all UE manual muscle tests with a grade of 5 of 5 and had full UE ROM. She reported her pain as 0 of 10.

During the therapeutic progression, the manubriosternal joint was subjected to compressive and tensile forces ranging from one-quarter BW to 4 times BW. Values of less than BW were accomplished with gravity-reduced positions. Values of greater than BW were achieved with centripetal loads imparted during the performance of rotational gymnastics skills. A conservative estimate of cyclical loading during a 4-hour session would be in excess of 100 cycles. If a return to the previous level of activity was used as a benchmark, then the rehabilitation process was a success. The gymnast successfully completed the season and qualified for the regional competition, at which she placed fifth on the beam in a field of 25 gymnasts.

Discussion

Although there is no direct evidence regarding the treatment of a manubriosternal dislocation in a young athlete, surgical and nonsurgical treatment strategies were compared in a prospective study of 26 patients with grade III acromioclavicular joint separations. (15) The investigators found superior results from nonsurgical treatment with respect to time to return to athletics (3.5 months) and time of immobilization (2.7 weeks). (15) The acromioclavicular joint is similar in structure to the manubriosternal joint. This research supports a nonsurgical treatment approach for traumatic joint dislocations. Supporting evidence for progressive rehabilitation included a prospective randomized clinical study on the rehabilitation of 62 patients after shoulder dislocation repair via an arthroscopic Bankart procedure. (16) That study showed that accelerated rehabilitation resulted in a more rapid return to functional ROM and functional activity.

To promote tissue remodeling in this case, the manubriosternal joint was loaded first under compression and later under tension in a controlled and progressive manner. Each week, the activities put greater loads on this system to stimulate bone growth. The technique is called "distraction osteogenesis" and has been used successfully for the treatment of fracture nonunions and mal-unions. (17) During this process, newly formed tissue typically is stretched via a mechanical fixation device. It then is exposed to compressive forces during functional activities. These forces are thought to direct the process of new bone formation through what has been referred to as the tension-stress effect. (18,19) It has been shown that the greater the distraction frequency, the better the outcome. In support of this technique is the conservative estimate of 100 cycles per day for the gymnast.

This mechanism for promoting bone formation seems to be applicable to fracture healing as well and may have facilitated the repair of the sternal fracture. (20) Additional evidence supporting the positive impact of distraction on hypertrophic nonunions was presented in a 16-patient case report. (21) Hypertrophic changes indicated that tissue at a nonunion healing site has the biologic potential to heal. What it lacks is an appropriate mechanical environment. The adolescent frame with open growth plates provides an environment conducive to continued bone growth. The sternal fracture may have stimulated bone growth in the manubriosternal area. The rehabilitation process that included cyclical and progressive loading of the manubriosternal structure provided the mechanical stimulus to remodel the tissue in this region and develop a stable joint.

Conclusion

Treatment was guided by clinical judgment, biomechanical principles, previous clinical research on similar dislocations and fractures, the patient's perceived treatment tolerance, and the patient's goals. The literature supports the decisions made during the rehabilitation process and suggests that cyclical loading may promote bone growth in this circumstance. The progressive compressive and tensile loads placed on the nonunion appear to have stimulated the recovery process. Future studies comparing rest and progressive physical therapy approaches would aid in the development of more formal treatment guidelines.

Dr Pidcoe provided concept/idea/project design, data collection and analysis, and project management. Both authors provided writing. Dr Burnet provided consultation (including review of manuscript before submission). The authors wish to thank their patient--an incredible athlete whose perseverance and presence are an inspiration to others.

This article was received September 15, 2006, and was accepted December 22, 2006.

DOI: 10.2522/ptj.20060275

References

(1) Kalicke T, Frangen TM, Muller EJ, et al. Traumatic manubriostemal dislocation. Arch Orthop Trauma Surg. 2006;6:411-416.

(2) Nikas DJ, Freeman JE, Newsome RE Jr, Fletcher JR. Late repair of chest deformity secondary to traumatic manubriosternal disruption: case report. J Trauma. 1995; 4:781-783.

(3) Roy-Shapira A, Levi I, Khoda J. Sternal fractures: a red flag or a red herring? J Trauma. 2006;1:59-61.

(4) Jackson M, Walker WS. Isolated sternal fracture: a benign injury? Injury. 1992;8: 535-536.

(5) Woo CC. Traumatic manubriosternal joint subluxations in two basketball players. J Manipulative Physiol Ther. 1988;5: 433-437.

(6) Daly RM, Rich PA, Klein R, Bass SL. Effects of high-impact exercise on ultrasonic and biochemical indices of skeletal status: a prospective study in young male gymnasts. J Bone Miner Res. 1999;7:1222-1230.

(7) Proctor KL, Adams WC, Shaffrath JD, Van Loan MD. Upper-limb bone mineral density of female collegiate gymnasts versus controls. Med Sci Sports Exerc. 2002;11: 1830-1835.

(8) Maffulli N, Baxter-Jones AD. Common skeletal injuries in young athletes. Sports Med. 1995;2:137-149.

(9) Swarup S, Bonomally K, Ansari MZ. Fracture of the sternum: an unusual case. Eur J Emerg Med. 1999;1:71-72.

(10) Smith M, Lenehan B, O'Keefe D, Martin A. Manubriosternal joint dislocation in contact sport. Emerg Med J. 2001;18: 488-489.

(11) Hay JG, Putnam CA, Wilson BD. Forces exerted during exercises on the uneven bars. Med Sci Sports Exerc. 1979;2: 123-130.

(12) Reid JG, Kopp PM. A force-torque analysis of the kip on the horizontal bar. Can J Appl Sport Sci. 1983;8:271-275.

(13) Neal RJ, Kippers V, Plooy D, Forwood MR. The influence of hand guards on forces and muscle activity during giant swings on the high bar. Med Sci Sports Exerc. 1995;11:1550-1556.

(14) Witten WA, Witten CX, Brown EW, Wells R. The back giant swing on the uneven parallel bars: a biomechanical analysis. In: United States Gymnastics Federation Sport Science Congress Proceedings. 1991;1:12-18.

(15) Press J, Zuckerman JD, Gallagher M, Cuomo F. Treatment of grade III acromioclavicular separations: operative versus nonoperative management. Bull Hosp Jt Dis. 1997;56:77-83.

(16) Kim SH, Ha KI, Jung MW, et al. Accelerated rehabilitation after arthroscopic Bankart repair for selected cases: a prospective randomized clinical study. Arthroscopy. 2003;7:722-731.

(17) Waanders NA, Richards M, Steen H, et al. Evaluation of the mechanical environment during distraction osteogenesis. Clin Orthop Relat Res. April 1998: 225-234.

(18) Ilizarov GA. The tension-stress effect on the genesis and growth of tissues, part I: the influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res. January 1989:249-281.

(19) Ilizarov GA. The tension-stress effect on the genesis and growth of tissues, part II: the influence of the rate and frequency of distraction. Clin Orthop Relat Res. February 1989:263-285.

(20) Richards M, Goulet JA, Weiss JA, et al. Bone regeneration and fracture healing: experience with distraction osteogenesis model. Clin Orthop Relat Res. October 1998;(355 suppl):S191-S204.

(21) Kocaoglu M, Eralp L, Sen C, et al. Management of stiff hypertrophic nonunions by distraction osteogenesis: a report of 16 cases. J Ortbop Trauma. 2003;8:543-548.

* The Hygenic Corp, 1245 Home Ave, Akron, OH 44310-2575.

PE Pidcoe, PT, DPT, PhD, is Associate Professor, Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA 23298 (USA). Address all correspondence to Dr Pidcoe at: [e-mail].

EN Burnet, PT, DPT, is Graduate Assistant, Department of Physical Therapy, Virginia Commonwealth University.

[Pidcoe PE, Burnet EN. Rehabilitation of an elite gymnast with a type II manubriosternal dislocation. Phys Ther. 2007;87:468-475.]

Table 1.
Treatment Highlights (a)

Week   Direction or Prescription        Examination Findings

0      Physician ordered a              CT scan revealed type II
         discontinuation of all           manubriosternal dislocation
         gymnastics activities and      Pain with any UE movement:
         any 11E activities that          difficulty breathing
         produced pain or instability

2      Physician provided               Plain-film radiograph revealed
         prescription for LE              no change in status
         rehabilitation

4      Patient was allowed to perform   Plain-film radiograph revealed
         LE landing activities and to     limited union in overlapping
         begin unrestricted UE            regions of dislocation
         rehabilitation                 Pain with palpation
                                        Discomfort with bilateral
                                          shoulder protraction with
                                          arms at 90[degrees] of
                                          shoulder flexion

6      Progress UE rehabilitation       Plain-film radiograph revealed
                                          what appeared to be
                                          initiation of union at
                                          inferior margins of
                                          overlapping areas
                                        No pain with palpation
                                        No pain with bilateral
                                          shoulder protraction with
                                          arms at 90[degrees] of
                                          shoulder flexion
7-8                                     No reported sternal pain or
                                          perceived movement with
                                          activities

9      Continue to progress load        Plain-film radiograph obtained
         bearing through the sternum      in handstand position
         in a controlled manner           revealed that dislocation
                                          site appeared to be
                                          statically stable

10

11                                      No reported pain or perceived
                                          movement in sternal area

12                                      Plain film radiograph was
                                          unclear, patient was
                                          referred for CT

13     Patient was discharged from      All activities were performed
         physician's care and             without reported pain or
         returned to gymnastics           movement in sternal area
         activities without             CT revealed evidence of
         restriction                      remodeling along load lines

Week   Guiding Blomechanics and         Intervention Examples
       Treatment Principles
0      Rest                             Not applicable

2      Maintain UE stability during     LE: isometric and resisted
         activities                       hip, knee, and ankle
                                          exercises; stationary
                                          bicycle exercises

4      Progress LE landing activities   LE: leaps and jumps up to
         and initiate UE open             ~61-cm (2-ft) heights
         kinetic-chain activities         (limited UE motion)
                                        UE: isolated active ROM for
                                          biceps and triceps muscles
                                          against resistance;
                                          active-assisted
                                        ROM for bilateral shoulder
                                          flexion to 90[degrees]

6      Initiate LJE compressive         UE: isometric exercises in
         loading                          positions of up to
                                          90[degrees] of shoulder
                                          flexion and abduction;
                                          partial wall push-ups with
                                          Thera-Ball

7-8    Progress to UE tensile loading   LE: perform all leaps, turns,
                                          and landings without
                                          restriction
                                        UE: continue wall push-ups
                                          with Thera Ball; begin
                                          tensile loading in the
                                          supine position

9      Begin saltos (aerial flipping)   UP press handstands, handstand
         front, back, band side to        walking, handstand
         promote kinesthetic sense        pirouettes, and handstand
       Increase LE dynamic loading        forward rolls; bar casts to
                                          horizontal; reverse push-ups
                                          (supine with shoulders at
                                          90[degrees] of flexion, pull
                                          up to bar or beam)

10     Increase UE dynamic loading      UE: reverse push-ups in more
         (tension and compression)        vertical position (more body
                                          weight on LIES); bar glides,
                                          kips, back hip circles, and
                                          three-quarter giants
11                                      UE: progression to full giants
                                          on bars

12

13     Increase IA,, and LE load        UE: back handsprings on
         bearing under both tension       trampoline surface and down
         and compression                  a 30[degrees] incline,
                                          Thera-Ball push- ups, bar
                                          kips, free hips, giants, and
                                          dismounts

(a) CT = computed tomography, LE = lower extremity, ROM = range of
motion, UE = upper extremity.

Table 2.
Gymnastic Skills Included in Patient's Rehabilitation Program

Gymnastic Skill   Description

Cast              A bar skill in which the gymnast supports body
                    weight through the hands with the hands on the bar
                    at waist level. The gymnast then swings the legs
                    forward (hip flexion) and then backward (hip
                    extension) in a pendular motion, pushing down on
                    the bar to elevate the body and legs to a position
                    that is horizontal to the ground. This position
                    requires shoulder flexion from 0[degrees] to
                    approximately 90[degrees]. This position may
                    increase to the handstand position (180[degrees]
                    of shoulder flexion) in more advanced athletes.

Salto             A flip or airborne single-rotation skill in the
                    sagittal plane around a medial/lateral axis.

Kip               A bar skill that begins with a pendular long-body
                    swing under the bar. At the end of the forward
                    swing, hip flexion brings the legs to the bar and
                    shortens the radius of gyration, resulting in a
                    faster backward swing. During this backward swing,
                    the gymnast re-extends the hips and extends the
                    shoulders from 180[degrees] to 0[degrees] of
                    shoulder flexion, ending in an upright support
                    position on the bar.

Giant             A circling bar skill that begins in a handstand
                    position, rotates 360[degrees] in the sagittal
                    plane, and ends back in a handstand position. The
                    hands and bar are the axis for the rotation.

Free-hip          A circling bar skill that starts from a cast
                    position, rotates 360[degrees] backward (sagittal
                    plane), and ends in a support position. It is
                    performed without the hips in contact with the
                    bar.