In my opinion, gymnast are a special group of athletes that put extraordinary stresses on the body, unlike any other sport. The wrist is of particular concern in these athletes due to the repetitive weight-bearing stress many of their skills require. This post is all about a condition called Gymnast Wrist, which is technically known as distal radial epiphysitis. Basically, chronic stress injury to the growth plate in the wrist.
Why is Gymnast Wrist so Frustrating?
The treatment of gymnast wrist can be frustrating because the protocol is clear: shut the wrist down. However, as you can imagine, if a gymnast can’t use their wrist, there really isn’t a whole lot they can do in the gym. For mild to moderate pain, in a compliant athlete, I will suggest a simple velcro wrist brace for 4-6 weeks with no upper body weight bearing activity. However, for severe pain or a non-compliant athlete, I will recommend a below-elbow (short) cast for the same time frame. Herein lies the problem: you are taking a gymnast and shutting down the wrist, which can therefore make the wrist and forearm muscles weak, setting the athlete up for repeat injury.
General Understanding
In a pediatric patient, the growth plate is also referred to as the physis. As in most growth plate injuries, the distal radius growth plate is predisposed to injury due to the relatively stronger attachments of the joint capsule and ligaments that apply external forces to the open growth plate. The underlying cause is believed to be due to repeated upper-body weight-bearing exercises and hyperextension, such as handstands, tumbling and vaulting that cause stress at the distal radius growth plate. For all intents and purposes, gymnast wrist should be thought of in the category of a stress injury to the wrist.
Clinical Presentation
In general, the gymnast will complain of a vague, dull, achy pain on the dorsum (back side) of the wrist. Many times the pain will go unreported for weeks to months, due to a desire to continue participating. The condition usually will come to a healthcare providers attention once the athlete is physically unable to perform a desired skill. On exam, one will note tenderness to direct pressure at the wrist over the distal radius growth plate. The pain also can sometimes be reproduced with hyperextension of the wrist or asking the athlete to perform push-ups or handstands while in the office. Keep in mind that gymnast wrist can be confused with tendonitis of the extensor tendons of the wrist. However, usually with tendonitis, the athlete will have pain with direct palpation of the tendons as well as resisted extension of the wrist without pressure to the distal radius. The injury tends to present in ages 9 - 13 and is quite often bilateral.
Clinical Evaluation
In my opinion, if the exam is exactly as described above, further imaging is not usually needed to confirm the diagnosis. However, one may consider a plain x-ray of the wrist to determine if there is actual widening of the growth plate, an indication of a more severe condition. In this case, it may be beneficial to perform a comparison x-ray of the unaffected side as the widening can be subtle. In most instances, an MRI is not necessary, although it can clearly confirm inflammation at the wrist growth plate and rule out other possible diagnoses.
Treatment
In addition to the bracing or casting mentioned above, equally important is the physical therapy component. My treatment approach has evolved over time and is more focused on the large muscles groups further up the chain from the wrist. Specifically working on physical therapy targeted at the elbow, shoulder and spine. I generally like to see a focus on neuromuscular control of the shoulder and neck to decrease the associated poor movement patterns and stresses that may occur at the wrist. Of note, there is a product called a "Tiger Paw" that can be used to support the wrist during gymnastics, however, it is controversial in some gyms as it is believed to decrease over wrist strength. (although I do not know of any evidence to support this)
