PHYS THER
Vol. 87, No. 4, April 2007, pp. 468-475
DOI: 10.2522/ptj.20060275
Rehabilitation of an Elite Gymnast With a Type II Manubriosternal Dislocation
Peter E Pidcoe and
Evie N Burnet
PE Pidcoe, PT, DPT, PhD, is Associate Professor, Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA 23298 (USA)
EN Burnet, PT, DPT, is Graduate Assistant, Department of Physical Therapy, Virginia Commonwealth University
Address all correspondence to Dr Pidcoe at: pepidcoe{at}vcu.edu
Submitted September 15, 2006;
Accepted December 22, 2006
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Abstract
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Background and Purpose: This case report describes the rehabilitation of an elite, 15-year-old gymnast after a nonreduced type II manubriosternal dislocation. The rehabilitation took place in a gymnastics venue but was guided by a physician and a licensed physical therapist.
Case Description: The gymnast participated in a 13-week rehabilitation program for range of motion and strengthening that was based on a biomechanical hierarchy. Rehabilitation began at week 2 after injury for the lower extremities and at week 4 for the upper extremities.
Outcomes: By week 4, the patient began upper-extremity strengthening, and by week 6, the patient had no pain with palpation and tolerated light sternal loading. At week 9, a plain-film radiograph revealed a stable manubriosternal joint, and by week 13, the patient returned to gymnastics pain-free.
Discussion: This case report shows that, after a 13-week regimen of progressive and repetitive, cyclical tensile and compressive loading, the manubriosternal joint was stable, and the elite gymnast was able to return to the sport, successfully competing in a regional competition.
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Introduction
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Manubriosternal dislocations can occur from either direct 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 gymnast 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.
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Case Description
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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.
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Figure 1. Illustration of the Tkatchev drill from a sagittal perspective. Note that approximately 180 degrees of forward rotation occurred from frames C to H before impact with the low bar. The angle of the trunk at impact was approximately 40 degrees relative to horizontal.
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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.
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 gravityreduced 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.
The rehabilitation plan of care continued to increase sternal load bearing under 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.
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Outcomes
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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.
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Discussion
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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 malunions.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.
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Conclusion
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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.
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Footnotes
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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.
* The Hygenic Corp, 1245 Home Ave, Akron, OH 44310-2575. 
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References
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Copyright © 2007 by the American Physical Therapy Association.
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Introduction
Case Description
