Abstract
Background:
Distal radial physeal stress syndrome, or ‘gymnast’s wrist’ (GW), refers to an overuse condition of the distal radial physis, resulting from repetitive compressive loading and shear forces on an extended wrist. As the distal radius (DR) bears nearly the entire axial load imparted on the extended wrist, the DR is at increased risk. Affected gymnasts often present with chronic wrist pain in the absence of discreet trauma. Physical examination will generally show tenderness to palpation along the DR physis and pain with hyperextension and axial loading. The condition, most commonly diagnosed radiographically, will include abnormalities at the DR such as widening distal radial physis and can lead to more debilitating conditions (e.g. distal physeal growth disturbance). Previous literature has been limited to small populations of elite level gymnasts. The primary aim of the current study was to assess a larger and more varied population of gymnasts at different ages and levels to better elucidate the descriptive epidemiology, presenting clinical and radiologic findings, treatment, and outcomes in a cohort treated at a tertiary care pediatric hospital over a 14 year period.
Methods:
A word search query was performed on a departmental database for records from January 1, 2003 thru January 1, 2017 using a series of words or phrases inclusive of GW. A subsequent retrospective medical record and radiologic review was conducted on all patients diagnosed with ‘GW’, as reported in clinical or radiologic documentation, which was then confirmed by the senior authors. Data that was collected and analyzed included demographic features, presenting signs and symptoms, imaging modalities pursued, and treatment methods for each patient. The clinical course for each patient was followed, based upon clinic notes and any subsequent imaging. The natural history, recurrence rates, and potential sequellae of this overuse condition were recorded, with special attention towards the details of physeal growth disturbance and surgeries required to address symptomatic ulnar impaction syndrome.
Results:
100 study subjects were identified with GW over the study period. Demographic features of the population included a mean age of 11.7 years (range: 6-17) at the age of diagnosis, with a strong female preponderance (F = 95, M = 5), and a different mean age between males (12.4y) and females (11.6y). The mean level of gymnasts was 4.5 (range: level 1 –10). The mean hours of gymnastics practice was 13.4 hours per week (range: 1–30), with over 90% of patients reporting that gymnastics was their primary sport. All of the patients reported pain about the DR with activities involving wrist impact, and about 75% of patients reported that they have been practicing though the pain prior to clinical presentation. The condition was shown to present on either the left (37%), the right (27%), or bilaterally (35%); where the location of pain was present mostly on the radial side (52%) or both the radial and ulnar side (38%) versus only the ulnar side (5%). The average duration of symptoms before presentation or diagnosis was about 98.7 days (range: 0-730) and resolution of symptoms occurred after an average of 3.5 subsequent visits (range: 1-14). The sequence of imaging modalities pursued and providing definitive diagnosis can be seen below in Image 1 and Table 1. Treatment most commonly consisted of cessation of all upper extremity impact activity, but was formally recommended to only 89% of patients. Other treatment strategies included physical therapy (49%) and gymnast-specific braces (46%). The mean time of complete rest pursued was 68 days, the mean time of from initial clinical evaluation to symptom resolution was 208 days, and mean time from initial onset of pain to resolution was about 351 days (due to frequent delays in presentation or diagnosis). 12 patients (12%) developed recurrence of GW, and 10 (10%) developed radial or ulnar growth disturbance (or both), with 3% undergoing corrective surgery.
Conclusions/discussion:
In a large series of skeletally immature gymnasts who developed GW, the vast majority of patients were female, though 5% of the population were males who developed the condition at a relatively older age than their female counterparts. The mean level of gymnast activity (4.5) and hours practicing (13) suggests that even lower level gymnasts can develop this overuse injury. Around 75% of patients were still practicing despite pain, greater than 3 months prior to presentation, which may reflect a poor understanding of the condition by the athletes, their coaches/trainers, and their families. The majority (71%) of cases were diagnosed by XR, but sometimes required advanced imaging (5%) to definitively diagnose or corroborate radiographically suspicious cases. Perhaps most importantly, alarmingly high rates of recurrence (12%), growth disturbance (10%) and surgical intervention were seen associated with the condition, underscoring the notion that delays in diagnosis or inadequate treatment may have lasting adverse impacts on these young athletes, and that strict adherence to prolonged periods of rest are critical to avoiding debilitating sequellae of GW.
Tables and Figures:
Rad. Findings
| Imaging Finding | Total n | n | % |
|---|---|---|---|
| Normal | 91 | 10 | 11.0 |
| Radial growth plate widening | 91 | 53 | 63.7 |
| Ulnar growth plate widening | 91 | 2 | 2.2 |
| Ulnar negative variance | 91 | 8 | 8.8 |
| Ulnar neurtral variance | 91 | 2 | 2.2 |
| Ulnat positive variance | 91 | 11 | 12.1 |
| Concomitant Radial Fx | 91 | 10 | 11.0 |
| Concomitant Ulna Fx | 91 | 2 | 2.2 |
| Sclerosis | 91 | 42 | 46.2 |
Age Distribution of GW (female vs male)