Gymnasts Wrist
(Distal Radial Epiphysitis)
Introduction
Gymnast’s wrist, more appropriately termed distal radial epiphysitis, is an uncommon cause of wrist pain in most athletes but commonly seen in gymnasts. It is caused by repetitive microtrauma with axial load bearing in the wrist. It can be considered a chronic salter harris 1 fracture. Overall, it is poorly described in the literature which is mostly limited to case reports. One study estimated that it affects between 46% and 79% of gymnasts[1]DiFiori, John P. “Overuse injury and the young athlete: the case of chronic wrist pain in gymnasts.” Current sports medicine reports 5.4 (2006): 165-167
Pathophysiology
Essentially, the wrist experiences excessive loads when using the wrist as a weight bearing joint. This leads to repetitive compressive loads and shearing forces on the dorsiflexed wrist. This repetitive stress leads to inflammation of the physis. In the skeletally immature athlete, physis is weaker than the joint capsule and ligamentous structures. Microtrauma can lead to premature fusion of physis and excessive overgrowth of Ulna. This may be due to either physeal microfractures or temporary ischemia. It is most commonly seen in gymnastics, especially parallel bars, vault, balance beam and floor exercises. There are also case reports in weight lifting and rock climbing.
Widening physis with ulnar variance
Widening physis with ulnar variance
Clinical Features
The typical patient is a female gymnast between age 10 and 14. The onset is gradual over weeks to months without trauma. They will endorse dorsal radial sided wrist pain, worse in extension. It is also worse with axial stress loading (vaulting, hand-walking). On physical exam, they have tenderness and swelling to the distal radius. Range of motion may be normal or restricted. There is pain with hyperextension or axial loading. Grip strength and neurovascular exam should be normal.
Bony bridging across the distal radial physis as is seen in growth arrest.[2]Benjamin, Holly J., Sean C. Engel, and Debra Chudzik. “Wrist pain in gymnasts: a review of common overuse wrist pathology in the gymnastics athlete.” Current Sports Medicine Reports 16.5 … Continue reading
Widening of the lateral aspect of the radial physis (arrow). The linear hyperintense signal inferior to the physis (arrowhead) may represent cartilaginous rests within the metaphysis[3]Poletto, Erica D., and Avrum N. Pollock. “Radial epiphysitis (aka gymnast wrist).” Pediatric emergency care 28.5 (2012): 484-485.
Imaging
Standard radiographs of the wrist should be obtained in all patients. Findings may include widened and irregular growth plates. Metaphyseal and epiphyseal sclerosis regulatory and subchondral cyst may also be seen. In more chronic patients positive ulnar variance is often found. MRI findings include peripheral edema, bridging, bone edema and widening of the physis. MRI should be obtained in all patients with chronic or refractory symptoms and those with an unclear or uncertain diagnosis.
Management
Non operative management is indicated in most athletes. The first step is cessation of all weight bearing activity and immobilization. Immobilization can either be in a cast such as a short arm or radial gutter or preferably in a cockup wrist splint so the patient can take it on and off. The duration of immobilization varies based on the severity of symptoms but will usually be at least two to four weeks but can be up to three to six months in more refractory cases. The management team should consider serial radiographs if they’re abnormal initially to help trend them back to normal. Occasionally surgery is indicated in these patients and those would be refractory cases or very late presentation. Surgical procedures include resection of the physeal bridge or ulnar epiphysiodesis and radial osteotomy.
Wrist guards which may help prevent extreme dorsiflexion
Athletes should also have some instruction at prevention of disease and recurrence. As they begin their return to play, they should manage their load and volume, focus on strength and flexibility and proper technique. Wrist guards may also be used to help blunt or prevent extreme dorsiflexion.
Rehabilitation and Return to Play
There are no clear or evidence-based rehabilitation guidelines. During immobilization and under the supervision of a physical therapist, the athlete can begin alternative conditioning and strengthening exercises of the upper extremity. Wrist rehabilitation should be focused on full range of motion and strength in both upper extremities.
There is no clear return to play guidelines either and that will vary depending on the rate of recovery of the athlete and severity of symptoms. Once symptoms have resolved athletes can begin increasing their training loads under supervision. Athletes should demonstrate full range of motion and strength before beginning return to play. Emphasis should be on sport specific biomechanics and proper form.
In terms of prognosis, most athletes do very well if diagnosed and treated early. Some cases have a longer recovery period if they are late to seek care. Complications include ulnar variance, radial shortening and TFCC injury.
Summary
In summary, gymnast wrist is poorly described in the literature but appears to be fairly common among gymnasts. It is essentially characterized by inflammation of the growth plate of the distal radius due to using it as a weight bearing joint. The diagnosis can be made clinically and supported by X-ray and MRI. Management primarily revolves around immobilization and cessation of the offending activities. If treated early, athletes have an excellent prognosis.
– More Wrist Pain @ Sports Medicine Review: https://www.sportsmedreview.com/by-joint/wrist/
– Read More about Gymnast Wrist @ Wiki Sports Medicine: https://wikism.org/Distal_Radial_Epiphysitis
References
