The Twisties : The Physiology, Anatomy, and Explanation Behind What Gymnast Simone Biles is Facing at the Tokyo Olympics
By Gina Pongetti Angeletti
Owner of MedGym, LLC and Achieve Physical Therapy and Sports Medicine Institute
Medical Contributor and Correspondent, Inside Gymnastics Magazine

Let's start here. After explaining this nearly a hundred times in the last 72 hours to friends, peers, coaches from other sports, medical professionals and even news stations, I think it is important to explain, or at least touch on, the physiological aspect of stress on the body. 

For a preparatory read, please visit these two articles, it will also help you a lot in understanding. 
The Physics of Simone
The Layer of Fear: The Sport of Gymnastics, The Tokyo Olympics and Simone Biles
After reading these, you will be 1) in awe of the movement and p physics behind the sport and 2) catch up on what has been happening here in Tokyo, ICYMI, though it is- literally- everywhere.

During the qualifying rounds in Tokyo, the world witnessed something they rarely, if ever have seen from Simone Biles: a major mistake on vault, an event she has owned for years on the world and Olympic stage. 
Instead of completing a vault with a two and a half twist (called an Amanar after Simona Amanar of Romania - the first gymnast who performed it in an official International Gymnastics Federation (FIG) competition), Biles lost her air awareness, opened mid-skill and landed hard after “only” completing a one and half. It was shocking. 
Later, Biles explained she was challenged by a condition in gymnastics called the “twisties.” What are they? The “twisties” are the sudden inability for a gymnast to make the requisite spins — or sometimes any spins — for a particular maneuver. Or for some people, the opposite - the desire to twist on a skill that doesn’t actually have a twist to it.
Though the concept of dizziness isn’t what is the focus here (some people are equating in conversation and on the internet) we touch on the system that controls that as well. Even astronauts – those that should handle g-forces beyond the lay person- get dizzy sometimes. It has to do with regulation of their vestibular system. This system controls how you feel – adapting to changes in your surroundings. Think cruise ship. Amusement Park. Your sight (and how you adapt), your ear (and how your body computes and filters the sound coming in) all get processed in the brain and together with your CNS, decisions about whereyou are and howyou are existing in your space can happen. 
Though this is important in gymnastics, what is even more important is how the athlete deals with input and response. In a normal day, or workout, when everything is right (no inner ear or sinus infection, good sleep, vision adapted with proper eyewear if needed) this process takes ridiculous amounts of training. Now, have any one of these be “off” a bit, and trying to correct it is a scary feat.  Why?  Because the person who is already ‘off’ has this same body that will be trying to over or under correct with a computer system malfunction. 
What are Proprioception and Kinesthesia
The simplest way to explain it is actually knowing where your body is in space.  
Kinesthesia is one step further than this. Knowing the speed at which you are traveling (spin, flip, up and down, swinging, etc).  This is influenced by motion, visual input, hearing sounds move, feeling air on the skin and more. A multisensory barrage of non-stop feedback. 
You know if you are upright or leaning to the left. Even with your eyes closed, this is proprioception. You can tell in a car if you are turning, slowing down or getting faster, and how fast to move your arm to catch a ball. That is kinesthesia. 
The central nervous system talks to the tissues in the body. Muscles, tendons, ligaments and joint response is important, and the communication both down the chain and up matters. 
When the body wants to send messages to the brain, the reverse happens. Mechanoreceptors and neuromuscular spindles (middle of a muscle) can tell whether there has been a change in muscle length. They, then, tell the body something shortened (position change, muscle tightened) or lengthened (something stretched, position change, outside force made it happen). 
On vault, for example, an athlete can tell if they are high on the table by how much their wrist flexor muscles and ligaments stretch on impact that the hands make with the table. If the athlete is high, the impact through the shoulders is much less. 
On beam, if an athlete visually sees that the beam is not in centered vision, or if her body is not square to the beam, adjustments can be made. 
If you lead forward, your spine muscles stretch. If you roll your ankle in, your outer muscles stretch. Golgi tendon organs are located where the muscle (stretchy part) meets the tendon (part that attaches to the bone) sense stretch and pressure, send signals to process, and then a message is sent in response. This all happens in hundredths of seconds - traveling at 70-120 meters per second.  Clearly not slow like morse code in the army, for example. Heck, thousands of times faster than verbally asking a question and getting an answer. 
This is important because it all happens without thought. It happens while an athlete can be thinking about something else, like not landing with your chest down, etc. 
The appropriate response, however, is key. This is called neuromuscular control. Not overresponding or overcorrecting position as well as not under correcting. On floor exercise, for example, if a gymnast’s first tumbling pass may have landed short (underrotated, crunched ankles, takes steps forward), the athlete may correct this by trying to rotate with a small percentage more speed the next pass to make up for what may be a perception error (being ‘off’) or muscle fatigue, and needing to step up the perceived effort. 
A phenomenon called ‘presetting’ can also be done. This is where the athlete, after performing numerous repetitions, can anticipate needing a certain muscle group to be tight and yet possibly another close by to allow for some motion. An example of this is the front leg of a switch leap- where the hip flexor and quad have to work hard, but the hamstring has to first allow the stretch to happen, and then instantly work to pull the leg back down on which to land. 
What is Air Sense?
A form of proprioception, air sense is the ability to know where you are relative to twist speed, height in tumbling or off the vault, turnover rate for release moves and even the verticality of a handstand. Knowing that you cast was too hard, going too fast, and that most likely you will have to responsively control it at the top (or tip over), is an example. Knowing when to prepare for the ground when dismounting is also an example. 
Gymnasts learn how fast the body goes up in the air after setting, or bouncing, before tumbling. At the same time, how fast your body comes down.  It is at first a learning curve, and then in the end, a prediction that you can make from the minute you leave the carpet. 
When learning skills and wanting to just perform them, athletes use trampolines or bouncier floors (such as TumblTrak, air floor, rod floor, etc). At times even going into a loose foam pit to allow for more room for error. This gives more heigh and ‘time’ in the air to learn double and triple twists, how hard to twist vs flip (when they are done at the same time) and when to open and prepare to land.  Knowing up from down and when they are goingup, stalling at the top, and going down is important in anticipating time left in the air and whether to pull out of a skill safely or not. 
“Literally cannot tell up from down. It’s the craziest feeling ever. Not having an inch of control over your body. What’s even scarier since I have no idea where I am in the air, I also have NO idea how I’m going to land. Or what I’m going to hand on…head/hands/feet/back.”
We see this in divers often who hit the water horizontal, which can cause everything from blackouts to concussions, chest injury and more. For figure skaters, we see blade slips on landing and sliding out to land on their bodies or hands, risking hip and wrist and shoulder injuries and in severe cases, concussions. Think gymnasts get high off the ground? Watch an aerial skier. 
Athletes still do this even here at the Olympics.  Standing single back tucks. A high layout on floor. Just to test their air awareness. 
So what then are the ‘twisties?’
It is all about a combination of knowing where you are in the air, how high you are, the confidence in committing to the skill and the mental state to perform. 

(See below, clips from Simone Biles' Instagram post and Q and A session)

How Stress and Hormones Play a Role
For most athletes, nothing is more stressful than the Olympic Games. Well, maybe the trials to make the team, but you get my point. Stress raises cortisol 
Taking a closer watch to Simone’s uneven bar practice and dismount this AM here in Japan over a mat in a loose-foam pit, what looks like it starts out amazing ends in a half of a rotation too few. She is trying to do a double twisting, double flipping somersault after two giant swings in order to land facing the same way she started, away from the high bar, on her feet on the mat. She ends on her back, facing toward the bar. Not having twisted enough times or fast enough before the ground comes. 
“My mind and body are simply not in sync. I don’t think you realize how dangerous this is on hard/competition surface. It’s petrifying trying to do a skill but not having your mind and body in sync. 10/10 do not recommend.”
“[By the way], it’s never transferred to bars and beam before for me,” as she has experienced this on floor and vault. “But this time it’s literally on every event. Which sucks…bad.”
There is often confusion at various points in a gymnasts’ training because of the various entries and directions of rotation and flipping happen in the same practice and at times, the same tumbling pass. For example, an age-group athlete who is trying to learn their full twisting back flip often then has a difficult time going back to simply flipping without twisting. The body gets used to what we call ‘paired sequences.’ This means that the athlete thinks set-twist-flip instead of just set-flip. 
Another time is when high-level athletes learn a new skill that is simply a slight variation. For instance, many of the world’s top do double twisting double back flip on floor in a layed out position. It is considered one of the most difficult. American  Jade Carey has submitted the triple-double to be named after her, if she competes it in FIG competition. Adding one more twist and keeping two flips. Then, having a double-double later in the routine, can be, well, confusing. Just an example. 
The issue with simply trying to push through it is that for actual competition, though there are mats present, they are not as forgiving as practice in softness, absorption and overall safety. 
“It only looks ‘safe’ because I’m on soft surface. If I was on competition surface it wouldn’t look so adorable,” in response to someone telling her that even her “crashes” look adorable. 
Physically, no one wants to see catastrophic orthopedic injuries such as spine, broken bones, concussions and more. Coaches pushing, thinking that athletes need a small ‘shove’ to just try  harder, because they as well fear  not making a skill, that’s not the answer. Safety first. 
Concepts such as “perfectionism” are seen often in high-achieving athletes. The concept that there isa perfect, and that it can be achieved, and nothing else. Not only does this often continue to stress in the athlete, but when the athlete is then faced with dealing with this same stress, they get easily frustrated and angry that they cannot ‘fix’ everything. And that makes it worse.  As Brazil’s Silver Medalist stated, “People need to understand that we are not robots.”
How To Get Through Them
This is by no means an all-inclusive list, but suggestions based on numerous conversations with elite gymnasts, trampolinists, tumblers, skaters and more that I have treated as well as feedback from coaching. 

  • Wait it out.Sometimes, you just need time. Keep trying or stay home. But it works differently for different people

  • Check your stress levels.Hormones, bloodwork, sleep patterns, self-regulation, heart rate variability. B12 levels. All of it. Most world-class athletes keep track of this anyway. This is when it matters: having something as a baseline to know when you are, indeed, off. Without a baseline (just like concussion testing), there is no comparative physiologic norm. 

  • Talk Therapy.Sit with a Sports Psychologist, counselor, therapist. Make sure they are educated and certified.  It helps that they have experience in yoursport specifically, and with high-level athletes. At times, this can be someone different from your day-to-day mental health professional.  A different view and a fresh set of eyes sometimes helps. 

  • Assess the vestibular system.Balance checks, vision testing (in short or actual exams), inner ear (sneaky fluid) and more. 

  • Seek deeper trauma or PTSD assessment. Often life issues- whether dealt with or not- can have a large effect on the limbic, vestibular, CNS and body regulation systems. Trauma at home. Pressure. Relationships. So many things. Visual signs can be triggers (seeing the Olympic rings, being back in a stadium that you skated or competed in years ago when something else was going on in your life at that time). Techniques such as meditation, EMDR (Eye Movement Desensitization and Reprocessing) etc. EMDR, for example, will literally go back in time to traumatic events or moments and re-wire your body’s system response to this stress. Control – or a lack thereof – is often at the heart of this. Very parallel often to OCD, overexercising and disordered eating as well. 

  • Physically, back to basics.  Begin- for days or weeks- to re-establish the literal basics. Single flips. Handstands. Simple back tucks. Work your way up with matting and/or spotting. Convince the brain that the build-up ladder and the process work.

  • Force or don’t force the issue.For some, getting back in the gym after a good night’s sleep is a good idea. For others, as long as safety is a calculated and low concern, athletes may get right back up and try again, not wanting the “off” turns to imprint the mind. This is a process between the coach and the athlete as to whether this works. Other times, not forcing it is best. Don’t talk about it. Don’t scroll social and read about it. Don’t do interviews about it (easier said than done). Focusing on it can actually create more anxiety, an elevation in serotonin and cortisol levels. Tell your parents to not ask about it every second, every day. And if you are a parent, trust the method.  Focus on art or music for a few days. Anything to truly break the conscious and unconscious. 

  • Visualization.Gymnasts use this countless times a practice. Close your eyes, tune out the environment, and do your routine in your head. It is what you see them doing between events, or right before, when they look, they are doing some odd dance, or avoiding laser beams!

  • Take a break.This can be daunting at times.  However, there sometimes is a body relief in a break from routine. Allowing the systems to reset themselves. Allowing the brain to focus on other things. With breaks come, always, the potential of not returning, which is a risk.  However, resetting your computer is also a potential benefit. 

  • Change your routines.With the help of coaches, national team coordinators, medical staff and more, rewinding time can also be helpful, if  it was indeed a certain skill that triggered. For instance, maybe a Yurchnko double flip, and how quickly the flipping has to happen, messed with the Amanar, or something similar. Looking at training schedule, when certain skills were placed in the mix and how it potentially affected stress in the gym (even subconsciously) is an option. 

  • Find YOUR way!There are many more techniques used by qualified health care professionals. What works for YOU is truly all that matters!
In the end, it is amazing to see the support from coaches, fans, teammates, former athletes from around the world and fans for what Biles is facing. I head sighs of relief from around the world through the typed word that has been posted. A “me, too” moment for yet another culture subset. For anyone guilty about having left their sport because of it, nothing to feel bad about. For those going through it now-even writer’s block or a researcher blanking out, we feel you.
 For parents and coaches – push the wrong way, and not only will success be fleeting, but what scary alternatives there are. Treat this tenderly and the athlete can be better for it, through the process, in the long run. 
Best to you, Simone, on your journey.

FOR MORE on Olympics and Gymnastics, please visit and these articles below!
For information on individual or team consultation for your sports medicine needs, please reach out to us on 

Tokyo Olympics- The Entire Reporter’s Daily Blog

The Layer of Fear: The Sport of Gymnastics, The Tokyo Olympics and Simone Biles

Rise. And Fall. And Rise Again. The Olympic Games: Pressure, Perseverance and Passion of Suni Lee
The Amazing Aging Athlete
Artur and the Achilles
The Physics of Simone
Time Change and the Effects on the Body: Traveling to Tokyo
Making the Team: The Weight of the List
Individual vs. Team Spot: Where is the Reward
The Mental Side of the Mat
Making the Team: Selection Procedures for Olympics and USA Gymnastics Simplified

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