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SPINE Volume 25, Number 11,
pp
1367_1372°'"",
©2000, Lippincott Williams & Wilkins, Inc.
• Scoliosis in Rhythmic Gymnasts
Panayot
I.
Tanchev,
MD,
Assen
D.
Dzherov,
MD,
Anton
D.
Parushev,
MD,
Dobrin
M.
Dikov,
MD,
and
Miroslav
B.
Todorov,
MD
Study
Design.
An
anamnestic,
clinical,
radiographic
study
of
100
girls
actively
engaged
in
rhythmic
gymnas-
tics was
performed
in an
attempt
to
explain
the
higher
incidence
and
the
specific
features
of
scoliosis
in
rhyth-
mic
gymnastic
trainees.
Objectives.
To
analyze
the
anthropometry,
the
regi-
men
of
motion
and
dieting,
the
specificity
of
training
in
rhythmic
gymnastics,
and
the
growth
and
maturing
of
the
trainees,
and
to
outline
the
characteristics
of
the
scoliotic
curves
observed.
An
etiologic
hypothesis
for
this
specific
subgroup
of
scoliosis
is
proposed.
Summary
of
Background
Data.
The
etiology
of
scoli-
osis
remains
unknown
in
most
cases
despite
extensive
research. In
the
current
classifications,
no
separate
type
of
sports-associated
scoliosis
is
suggested.
Methods.
The
examinations
included
anamnesis,
weight
and
height
measurements,
growth
and
maturing
data,
eating
regimen,
general
and
back
status,
duration,
intensity,
and
specific
elements
of
rhythmic
gymnastic
training.
Radiographs
were
taken
in
all
the
patients
with
suspected
scoliosis.
The
results
obtained
were
compared
with
the
parameters
of
normal
girls
not
involved
in
sports.
Results. A
10-fold
higher
incidence
of
scoliosis
was
found
in
rhythmic
gymnastic
trainees
(12%)
than
in
their
normal
coevals
(1.1
%).
Delay
in
menarche
and
general-
ized
joint
laxity
are
common
in
rhythmic
gymnastic
train-
ees.
The
authors
observed
a
significant
physical
loading
with
the
persistently
repeated
asymmetric
stress
on
the
growing
spine
associated
with
the
nature
of
rhythmic
gymnastics.
Some
specific
features
of
scoliosis
related
to
rhythmic
gymnastics
were
found
also.
Conclusions.
This
study
identified
a
separate
scoliotic
entity
associated
with
rhythmic
gymnastics.
The
results
strongly
suggest
the
important
etiologic
role
of
a
"dan-
gerous
triad":
generalized
joint
laxity,
delayed
maturity,
and
asymmetric
spinal
loading.
[Key
words:
asymmetric
spinal
loading,
delayed
maturity,
generalized
joint
laxity,
rhythmic
gymnastics,
scoliosis,
sportl
Spine
2000:25:1367-1372
Despite extensive research, the etiology
of
idiopathic sco-
liosis remains
unknown.
Different theories have been dis-
cussed,
but
none
of
them has been definitely proved.
Debates
concerning
the
primary
and
the
secondary
changes in the deformed spine still continue,
but
to
little
avail. This helplessness
is
reflected
in
the accepted
"mul-
tifactorial origin"
of
idiopathic scoliosis.
However, as the research advances, some "idiopathic"
forms find their primum mavens and may
be
classified
else-
From the
Gorna
Bania University
Hospital
of
Orthopaedics, Spine
Surgery
Department,
Sofia, Bulgaria.
Acknowledgment date:
November
6,1998.
First revision date:
February
4,
1999.
Acceptance date:
August
6,1999.
Device status category: 1.
Conflict
of
interest categories:
12,
14.
where. Empiric observations gave impetus to important med-
ical findings in the past,
and
could
be
useful now as well.
In Bulgaria, rhythmic gymnastics (RG)
is
a very pop-
ular
sport
among
girls
and
young
women.
Almost every
school has a training
group.
However,
the
most
talented
girls are
trained
in professional clubs
according
to
special
training
programs
(Figure 1).
But
this spectacular
sport
has
turned
out
to
create problems. As the
only
special-
ized
department
for spinal disorders
in
Bulgaria,
the
au-
thors'
institution offers the chance
to
observe a disquiet-
ing
number
of
consecutive cases
of
scoliosis
in
girls
engaged in
RG
for a longer period
(5-10
years).
To
date,
no
existing classifications
of
spinal deformities
include a scoliotic category etiologically related to sports.
There have been some rare reports
on
scoliosis associated
with ballet
14
and some other sports such as tennis and jav-
elin throwing,8 but without etiologic implications.
The long-term observations
of
the current authors mo-
tivated them
to
plan
and
perform this study with purposes
to
establish the real incidence
of
scoliosis in
RG
trainees, to
analyze its specific features,
and
to try suggesting some eti-
ologic explanations for this specific scoliotic form.
• Materials
and
Methods
This study included
100
girls ages 10
to
16
years (average,
12.44
± 1.65 years)
who
had
been
trained
in
RG
for
more
than
5 years. Primarily, 105 rhythmic gymnasts were evaluated,
but
for the
purpose
of
selecting participants exposed only
to
effects
from practicing RG, 2 girls
with
spina bifida occulta
of
L5
were
excluded
from
this study, along
with
1 girl with isthmic spon-
dylolisthesis
at
L5-Sl.
The
3
of
them
had
undergone
previous
radiograph
examinations
for
low
back
problems.
Also ex-
cluded were 2
who
reported anamnestically
that
members
of
their families experienced some spinal disorders. As a result,
100
RG
trainees were selected
who
had
no
familial anamnesis
for spinal deformity
and
no
past
diseases
or
congenital abnor-
malities
known
to
result in secondary scoliosis.
The
evaluation included a history
of
familial
and
past
dis-
eases, weight
and
height measurements,
growth
and
maturing
(menarche), eating regimen (dieting, anorexic behavior), gen-
eral
and
back
physical examination,
radiographic
verification
of
all patients with suspected scoliosis,
duration,
intensity,
and
specific moments
of
the training process (e.g., physical over-
loading, asymmetric loading
of
the
spine).
The
anthropometric,
growth,
and
maturing
data
of
the
RG
trainees were compared with the average
data
for Bulgarian
girls
of
the same age
group
in nationwide statistical surveys.2
The
t test
was
used for statistical analysis.
• Results
Physical examination
of
the back, including the forward
bending test, revealed back asymmetry
in
16
girls subjected
to radiographic examination. Four
of
the girls
who
received
1367
1~68
Spine·
Volume
25·
Number
11 •
2000
Figure
1.
Typical body habitus of a 16-year-old rhythmic gymnast.
Exercise with a ball.
radiographs showed
no
structural scoliosis.
Of
the RG
trainees, 12
had
scoliotic curves
of
10°
or
more (range,
10-30°), thus presenting a very high incidence
of
12%
(Figure 2). A significant difference was observed when this
Figure
2.
A lumbar scoliotic curve of
20°
with right convexity in a
14-year-old girl who actively trained
in
rhythmic gymnastics for 6
years.
Table
1.
Juxtaposition
of
Anthropometric.
Growth.
and
Maturing
Data
in
Rhythmic
Gymnastics
Trainees
and
Nontrainees
Trainees Nontrainees
tTest
Age (yr)
12.44
:!:
1.65
13:!:
1.50
P>
0.05
Height (em)
151.38
:!:
9.66
155.3
:!:
6.80
P <
0.01
Weight (kg)
36.32
:!:
6.89
47
:!:
9.40
P <
0.001
Right-handed (%)
99
82
P <
0.05
Joint laxity* (%)
100
5P <
0.001
Menarehet (%)
10
90
P <
0.001
• Tests
for
generalized joint laxity according
to
Carter and Wilkinson.'
t Bulgarian girls have
their
menarche at
the
average age
of
12.30 :': 1.26 years
according
to
Damianova and Stanchev.2
percentage was compared with the percentage
of
scoliosis
in normal girls
of
the same age group (1.1 %), which was
established by the same medical team in a screening pro-
gram including
4800
school children in Sofia.9
The
current
screening results coincided
with
the
data
presented by
Winter,
who
accepted the conclusion
that
the prevalence
of
scoliosis
was
rather
constant
world-
wide
(1
%
to
3
%)
for curves
of
10°
or
more.
15
In
what
way
do
the
RG
trainees differ
from
their
normal
coevals,
and
how
can
the
appearance
of
this endemic focus
of
scoliosis be explained?
Table
1 presents the general
data
(anthropometry,
growth,
menarche)
obtained
in the cur-
rent
study as
compared
with
the
same
data
for
nontrain-
ees
of
the same average age.
Rhythmic
gymnasts are very elegant, thin,
and
grace-
ful.
Their
height
and
weight are significantly
lower
than
those
of
nontrainees.
The
RG
trainees manifest
an
obvi-
ous delay in the
growth
and
maturing.
The
training
of
the
rhythmic
gymnasts
in
this study
started
before adolescence, usually
at
the age
of
5 years,
and
continued
up
to
the
moment
of
this
study
(an aver-
age
of
6.63 ± 2 years).
The
most
important
criteria for
the
primary
selection were flexibility
and
leanness. This
can
explain the
100%
prevalence
of
generalized joint
laxity in
the
participants.
Everyday
control
of
body
weight
was obviously
compulsory,
and
probably
the
strict dieting (although
not
mentioned by the trainers
and
trainees), because
of
the absolute requirement
of
conformity
to
the
thin
image
of
an
elite rhythmic gym-
nast. This
is
the reason
why
it is
not
surprising
that
the
average body weight
of
the
participants
was
found
to
be
10
kg
lower
than
that
of
normal
coevals. Dieting
and
physical training
are
known
to
delay
menarche
in girls
who
begin active
sports
or
ballet
at
an
earlyage.
13
,14
This
is
typical for rhythmic gymnasts also.
Some specific traits
in
the training
and
exercising
of
rhythmic gymnasts were found.
It
was
observed
that
all
RG
trainees have a flat
back
posture.
This
posture
con-
forms
to
the elegance
and
outer
appearance
required
for
the girls practicing
RG.
It
is
maintained
persistently in
such activities as walking, standing,
running,
and
jump-
ing.
The
flat back posture
is
the
constant
body
status
of
RG
trainees,
and
the tendency
to
thoracic
hypokyphosis
and
lumbar
hypo
lordosis
is
evident (Figure 3).
Scoliosis in Rhythmic Gymnasts • Tanchev
et
al 1369
Figure
3.
Lateral standing radiograph of a 12-year-old gymnast
showing the typical flat back posture with a lack of any physio-
logic sagittal curvatures of the spine.
The
intensity
of
trammg
is
extraordinarily
high:
28.4
:±:
12.16
hours
a week.
The
training
is
carried
out
6
days weekly, nearly 5
hours
a day. This results in a sig-
nificant
overloading
for juvenile
and
adolescent girls,
considering
that
most
girls begin active training in
RG
at
the age
of
5 years.
A very typical feature
of
RG
is
playing
with
different
implements
(hoop,
ball, rope,
ribbon,
and
clubs). Playing
technique, figures, exercises,
and
the like were observed,
directly
during
training
and
competitions
or
in
video-
films.
It
was found
that
during
approximately
75%
of
the playing time, the rhythmic gymnasts play
with
their
"strong"
hand
to
ensure better
control
in using the im-
plements.
This
one-hand
playing leads
to
an
asymmetric
loading
of
the spine, pelvis,
and
lower
limbs.
It
was
in-
teresting
to
find
that
99%
of
the
rhythmic
gymnasts in
this study were right-handed, a prevalence significantly
higher
than
in the
normal
population
(82%).2
No
rea-
sonable
explanation
could be
found
for this observation,
but
it could have
some
significance in defining the side
of
asymmetric spinal loading.
A very typical pose
is
one-leg
standing
when
a rhyth-
mic gymnast
throws
or
catches the different implements,
Figure
4.
Enlargement of the anteroposterior radiograph of gym-
nast from Figure
2.
In
this figure, it
is
more easily seen
that
the
structural changes
in
this very short curve engage only
two
vertebrae
(11
and
L2)
with a tendency to a degenerative molding
(left edges of the upper end plates). These very mobile segments
probably are impaired
by
the persistent asymmetric spinal loading
in
rhythmic gymnastics.
especially the ball
and
the
ribbon.
Some
other
typical
figures
and
exercises observed give sufficient evidence for
the conclusion
that
persistently
repeated
asymmetric
ax-
ial
loads
are
placed
on
the spine.
For
example,
during the
so-called "scales"
or
"balance"
when
the
right
arm
is
lifted
upward
in
throwing,
catching,
or
holding the ball
or
ribbon,
the
rhythmic
gymnast
jumps
and
lands
on
the
right leg
with
the
back
in hyperlordosis, the pelvis
is
tilted
to
the right,
and
the
lumbar
spine
is
bent
with
convexity
to
the
same
side.
Also, some specific features
of
the scoliosis perceived
in
rhythmic
gymnasts: flat
back
in
100%
of
the partici-
pants;
mild curves (average
Cobb
angle, 16°; range,
10-
30°); low curves engaging the
most
mobile segments
of
the spine
(thoracolumbar
in
58%
and
lumbar
in
42%
of
the participants);
no
thoracic
or
double
major
curves;
short
curves
(predominantly
4
to
6 segments
or
fewer);
and
prevalence
of
the right convexity (in
67%
of
the
participants) over the left convexity (in
33%
of
the
par-
ticipants), which
is
uncommon
for
distal curve
patterns
(Figures 2
and
4).
•
Discussion
The
pathogenesis
of
scoliosis seems
to
be well defined.
Matzen?
assumed
that
the
primum
mavens
for
appear-
ance
of
scoliosis can differ,
but
when
the scoliotic
curve
l..370
Spine'
Volume
25·
Number
11
•
2000
has once appeared, it develops according
to
its internal
laws
and
"the
scoliosis emancipates from its etiology."
According
to
the widely accepted concept
of
biplanar
asymmetry, the thoracic hypokyphosis
and
the
lumbar
hypolordosis
may
play
an
important
role in the develop-
ment
of
scoliotic deformities.4
,6
The
current
authors
share this opinion
of
scoliotic pathogenesis entirely.
However, the etiology in
most
cases
of
idiopathic sco-
liosis remains
unknown.
In search
of
implications for the
causes
of
idiopathic scoliosis,
Harrington
5 postulated
that
"the growing scoliotic spine essentially represents
structural living
matter
reacting to
abnormal
physical
forces, resulting in an increasingly deformed state. Dys-
funcrion
of
the
growth
process ultimately leads to mal-
formation
of
the
discretely
articulated
segmental
spine."
rIO
Harrington.\" assumed
that
multiple factors
contribute to the etiology
of
idiopathic scoliosis. These
factors considered
to
be
of
major
importance are the
mechanics
of
spine, nutrition,
hormonal
influence,
and
genetic tendency.
Concerning the mechanics
of
the spine, Harrington.\"
referred
to
the
Hueter-
Volkmann
principle, which claims
that
abnormal
pressures placed
on
the facets
and
the
vertebral bodies over a
period
of
time affect the vertebral
bodies, the facets,
and
the
growth
endochondral
plates.
Actually,
Volkmann
11
developed the
theory
of
bone
and
joint deformities caused by overloading
of
the growing
skeleton, postulating
that
abnormal
pressure
hampers
the
growth
of
the
epiphyseal
plates
in
adolescents,
whereas stretching stimulates it.
The
current
authors
consider
the
hypothetical
ap-
proach
of
Harrington
very
appropriate
for explaining
the
appearance
of
scoliosis
among
rhythmic gymnasts. In
their study, they
found
three factors
of
major
importance
that
make
the rhythmic gymnasts different from their
coevals
not
involved
in
sports,
and
probably
increasing
very significantly the incidence
of
scoliosis
among
them:
1) generalized joint laxity as a hereditary terrain; 2) de-
layed
growth
and
maturity
caused by physical, dietary,
and
psychic stresses;
and
3) persistent asymmetric over-
loading
of
the spine. These factors
may
contribute
to
the
etiology
of
this scoliotic form.
The
authors
called the
coincidence
of
these three factors
the
"dangerous
triad."
Carter
and
Wilkinson. 1
demonstrated
persistent joint
Llxity to
be
an
important
predisposing factor in congen-
ital dislocation
of
the
hip.
They
reported
also
that
gen-
eralized joint laxity affected both axial
and
limb joints.
This
statement
suggests a possible relation
to
spinal dis-
orders also.
It
is
assumed
that
the increased range
of
motion in girls
with
generalized joint laxity could lead
to
increased pressure, impacts
on
the
growth
plates,
or
both, especially in girls
with
abnormal
physical loading.
In this way, the germinal
or
proliferative zones
may
be
impaired
and
growth
disturbed
more
or
less substan-
tially. This was suspected also in Harrington's.\"
hypoth-
esis,
and
this
probably
is
the case in
RG
trainees.
Prolonged hypoestrogenism
is
a well-recognized com-
plication
of
weight loss, dieting, and physical training in
girls
and
young women. The delay in menarche
is
com-
mon
in
most
girls
who
begin different sports
at
an
early
age.l.3 Estrogen, in particular, has essential effects
on
the
bone, which include stimulation
of
epiphyseal closure.
10
The
delayed
growth
and
maturing
cause a
prolongation
of
the "vulnerable growing years," a
term
introduced by
Harrington,s
and
this
abnormality
exposes the
growth
plates
to
the influence
of
the unfavorable mechanical fac-
tors (pressure, impacts,
microtrauma)
for a longer pe-
riod. This
is
what
probably
happens
in the
RG
trainees,
with
90%
of
them still having
no
menstruation
at
the
average age when their
normal
coevals have
had
their
menarche.
The
persistent asymmetric overloading
of
the
spine
is
typical for
RG.
It
was
very interesting
to
find
that
99%
of
the participants were
right-handed,
which
made
them
significantly different
from
their
normal
coevals,
among
whom
82%
are right-handed.2
The
right-hand
playing
predetermines right-leg
standing,
jumping,
taking
off,
and
landing,
with
the body balanced
by
bending the tho-
racolumbar
juncture
and
the
lumbar
spine
with
convex-
ity, usually
to
the right.
The mechanics
of
one-leg standing, which leads
to
a
temporary scoliotic posture with convexity
to
the ipsilateral
side, has been well studied by Wagenhauser
12
and
Debrun-
ner
and
Hepp:'
This specific mechanical situation repeats
constantly
in
RG
and probably produces overpressure in
the
most
mobile segments
of
the spine (thoracolumbar
juncture and lumbar spine), mainly affecting the left lateral
and posterior parts
of
the
growth
endochondral plates (fig-
ure 4). An important contributory effect could be ascribed
to the flat spine of the
RG
trainees, which generally
is
rec-
ognized as a risk factor in the pathogenesis
of
structural
scoliosis. An additional
proof
could
be
the presence
of
low
and short thoracolumbar
and
lumbar curves in
RG
train-
ees.
Most
of them (67%) manifested convexity
to
the right.
This curve pattern
is
the reverse
of
the usual idiopathic
forms in this spine region, which predominantly manifest
convexity
to
the left.
The
absence
of
thoracic
and
double
major
curves in
the
participants also
is
noteworthy,
giving some impor-
tant
evidence for
the
role
of
the thoracic cage as a but-
tress protecting
their
thoracic vertebrae, in
particular
their
growth
plates,
from
the
impairing
effect
of
the
asymmetric spinal
loading
in RG.
Although
no
definite
consensus exists concerning
the
distribution
of
curve pat-
terns in idiopathic scoliosis, it
is
generally accepted
that
the thoracic
and
double
major
curves occur the
most
frequently
and
the
lumbar
curves the least frequently.
The
current
findings suggest the possibility
of
an
asym-
metrical
hampering
of
the
growth
of
the
most
mobile
spinal segments in
RG
trainees.
There
is
a single published
report
on
scoliosis associ-
ated
with
ballet dancing,14 in which
the
prolonged
hy-
poestrogenism
and
its effects
on
bone are
thoroughly
discussed.
No
implications for the etiologic relation be-
tween scoliosis
and
asymmetric
loading
of
the spine are
proposed.
At
this writing,
no
existing classification in-
Scoliosis
in
Rhythmic
Gymnasts·
Tanchev
et
al
1371
cludes
"sports
scoliosis"
or
"sports-associated scoliosis"
as a separate category, although
it
is
not
unusual
to
ob-
serve scoliotic deformities in adolescents
and
young peo-
ple training for tennis, javelin throwing,
or
similar sports
with asymmetrical loading
of
the spine.
The significantly higher incidence
of
scoliosis in rhyth-
mic gymnasts
and
the specificity
of
this deformity suggest
the exclusion
of
"rhythmic gymnasts' scoliosis" from the
large group
of
idiopathic scoliosis. Therefore, the au-
thors propose the separation
of
a sports-associated sco-
liosis, which
may
contribute
to
the better classification
of
this nosology. This specific scoliotic entity seems
to
have
a phenotypic origin.
The
current
study
generates
an
eti-
ologic hypothesis including the
"dangerous
triad"
of
generalized joint laxity, delayed
maturity,
and
asymmet-
ric overloading
of
the spine.
Tnc
authors
believe
that
these risk factors
may
be the
cause
of
primary
scoliosis in some adolescents
not
in-
volved in
any
sports,
who
usually are referred
to
as hav-
ing idiopathic scoliosis. An
appropriate
extension
of
the
research in this respect
would
be a
comparative
study
juxtaposing the etiologic
moments
and
the specificity
of
the deformity in
rhythmic
gymnasts
to
a
control
scoliotic
group
of
girls
with
similar
anthropometric,
growth,
and
maturing
data,
but
not
engaged in sports.
•
Key
Points
•
The
authors
found
a lO-fold higher incidence
of
scoliosis in
rhythmic
gymnasts (12
%)
than
in their
normal
coevals (1.1
%).
• This study identified a separate scoliotic
entity
related
to
sports.
•
The
results suggest the
important
etiologic role
of
a
"dangerous
triad":
generalized
joint
laxity, de-
layed maturity,
and
asymmetric spinal loading.
References
1.
Carter
C, Wilkinson J. Persistent joint laxity
and
congenital dislocation
of
the hip. J Bone Joint Surg
[Br]
1964;46:40-5.
2. Damianova
M,
Stanchev
Z.
Endokrinologia vdetskata vazrast. Sofia: Mediz-
ina i Fiskultura,
1987:228-9.
3.
Debrunner
HU,
Hepp
WR.
Onhopaedisches
Diagnostikum.
Stungan,
New
York: Georg Thieme,
1994:62-4.
4. Dickson RA, Lawton
JO,
Archer lA, er al.
The
pathogenesis of idiopathic
scoliosis: Biplanar spinal asymmetry. J Bone
Joint
Surg
[Br]
1984;66:8-15.
5.
Harrington
PRo
The etiology
of
idiopathic scoliosis. Clin
Orthop
1977;126:
17-25.
6. Leatherman KD, Dickson RA.
The
management
of
spinal deformities. Lon-
don, Boston, Singapore, Sydney,
Toronto,
Wellington: Wright,
1988:44-54.
7. Matzen PF.
Orthopaedie
fiir Studierende. Leipzig: JA Barth,
1977:286-307.
8. Peterson
L,
Renstrom P. Sports injuries:
Their
prevention
and
treatment.
Basle: Ciba Geigy,
1993:237-58.
9. Tanchev
P,
Dikov
D,
Dzherov
A,
er al. School screening for scoliosis in Sofia:
An analysis
of
screening results
of
4800
studems.
Orthop
Trauma
(Bul) 1996;
33:69-73.
10. Underwood LE, Van
Wyk
11.
Hormones
in normal
and
aberrant
growth. In:
Williams
RH,
cd.
Texrbook
of
Endocrinology.
6th
ed. Philadelphia: WB Saun-
del's,
1981:1149-91.
1 I. von
Volkmann
R. Chirurgische Erfahrungen iiber Knochenverbiegungen
und
Knochenwachstum. Virchows Arch Pathol Anal'
1862;24:512-22.
12.
Wagenhauser
FJ.
Das
Problem der
Halrung.
Orthopiide
1973;2:128-39.
13.
Warren
MP.
The
effects
of
exercise
on
pubertal
progression
and
reproductive
function
in
girls. J
C1in
Endocrinol
Metab
1980;51:1150-7.
14.
Warren
MP,
Brooks-Gunn J,
Hamilton
LH,
et al. Scoliosis
and
fractures in
young ballet dancers. N
EngJ
Med
1986;314:1348-53.
15.
Winter
RB.
Natural
history
of
spinal deformity. In:
Bradford
DS, Lonstein
JE,
MoeJH,
Ogilvie
JW,
Winter
RB, eds.
Moe's
Textbook
of
Scoliosis
and
Other
Spinal Deformities.
2nd
ed. Philadelphia,
London,
Toronto,
Sydney,
Tokyo,
Hong
Kong: WB Saunders,
1987:89-95.
Address reprint /'equests to
Panayot
1.
Tanchev,
MD
Spine Surgery Department
Coma
Bania University Hospital
of
Orthopaedics
56, N. Petkov Street
Sofia
1614,
Bulgaria
Point
of
View
Roger
P.
Jackson,
MD
North
Kansas
City
Hospital
North
Kansas
City,
Missouri
The authors have published
an
interesting, stimulating,
and
provocative article. They report their observations
of
risk
factors in adolescent female athletes involved in rhythmic
gymnastics
who
develop scoliosis with specific features.
The risk factors involve a "dangerous triad": generalized
joint laxity, delayed maturity,
and
asymmetric spinal load-
ing. The specific features for the type
of
"sports-associated
scoliosis"
that
the authors describe include lumbar
and
tho-
racolumbar curves with
no
thoracic
or
double major curve
patterns,
and
short
curves with prevalence
of
convexity
to
the right. The authors
put
forth a strong argument for a
category
of
so-called "sports scoliosis."
In their article, the
authors
have
compared
their
re-
sults with the average
data
for Bulgarian girls
of
the
same
mean age from a previous nationwide statistical survey.
Although this appears to
be
appropriate, I
do
not
think it
allows them to make such strong claims
that
prolonged
asymmetric loading
on
the growth plates
of
the vertebral
1372
Spine'
Volume
25'
Number 11 • 2000
..
bodies was a contributory factor, in
and
of
itself, to the
development of the specific type
of
scoliosis they describe in
their article.
To
more completely prove this point
or
hy-
pothesis, the authors would need to compare the rhythmic
gymnastic trainees studied directly to a subgroup
of
right-
handed nontrainees with joint laxity and delayed menarche
from the previous nationwide survey they quoted. Gener-
alized joint laxity with delayed menses and maturity can be
common features for many young women, whether they
are involved
in
sports
or
not,
and
especially if they are en-
gaged in sports
at
an early age.
The
authors
stated
at
the end
of
the discussion section
that
more research is needed in this area. I believe
that
more studies
are
needed
to
help
support
the
authors'
eloquent
arguments for a
"dangerous
triad"
leading to
"sports-associated scoliosis." Also, additional research
is
needed
to
answer
the
obvious question: Does such a
specific scoliotic entity associated
with
sports exist for
boys?
The
authors
have
made
a significant contribution
to
our
literature,
but
at
the same time have created
many
questions. I encourage
them
to
continue
on
with
their
excellent clinical research.
