Aka: Radial Physeal Stress Syndrome”
A 6 year old girl came in to the clinic two weeks ago. Confidently, she jumped up when I called her name in the waiting room, and sat proudly on the treatment table. When I asked her what was hurting, she said happily, and with a big smile on her face, “nothing!”
After a few more questions, some help from mum, and a phone call to her coach, we came to discover that this pre-elite gymnast, training 18 hours per week, had started complaining of pain in her right wrist during press to handstands and tumbling, about 3 weeks ago.
I know this pain. Soreness at the joint line, grabbing and rolling my wrists as I line up for my turn on the floor, asking my coach if I can switch to forwards tumbling instead, because then I won’t have to put my hands down. Lots of gymnasts know this pain.
We start training on our hands as soon as we can, because building up strength and endurance in our upper bodies is vital in gymnastics. The handstand is the basis of most tumbling and vaulting skills, and the majority of time spent on the parallel bars, uneven bars, and rings is inverted, bearing the whole body weight through the wrists.
There are two issues to consider here. One - intense, repetitive loading on an immature musculoskeletal system. Two - an immature communication system to alert us when something is wrong. Both can be addressed with some background knowledge.
Towards the end of every long bone in our body, is a growth plate or “physis” made up of softer cartilage tissue. In the arm, the radius bone bears weight at the wrist joint. The radial physis does not fuse until the age of 12-16 in girls, and 14-18 in boys. Until this age, this area is more prone to injury as these cells are more active. In chronic cases, repetitive loading can lead to stress reactions in the surrounding bone, a widening of the growth plate and early bone fusion, leading to deformities and persistent pain.
So, how can we pick it up?
Young gymnasts train a great number of hours, including strength training and flexibility conditioning. They are used to experiencing pain. However, their coaches are still teaching them the difference between muscle adaptation and tissue damage. Young gymnasts may not report wrist pain until it is quite severe, or has been persistent for many weeks.
It then follows that we need to be on the lookout for these signs. We can do this in a number of ways.
- Physiotherapists can track growth rate, and identify periods of increased risk. Screening for movement control is a good way to keep on top of changes.
- Young athletes can be asked directly how they are feeling on a regular basis. Rather than describing “pain”, asking if their wrists are “tender” or “aching”, if they are having “problems” with their wrist, or if it is “bothering them” may help to identify an issue. Symptoms to keep an eye out for can include clicking, grinding, and swelling. Irritated growth plates will be tender to touch, however the wrist won’t tend to lose any range of movement.
- Gymnastics coaches and parents can check for nonverbal signs, including holding or cradling the wrist, missing sessions, using strapping tape, or particular avoidance of certain skills - eg. backward walkovers, tumbling, handstand holds in a strength circuit. Coaches need to be careful here, as the gymnasts' pain that may be stopping them from performing a movement may be wrongly misinterpreted as fear or “cheating”.
Once identified, the Gymnast’s Wrist has an excellent prognosis. Focused on load management and joint strengthening, rehabilitation is straightforward, and a reminder that it is important to listen to your body at any age.
So how did she go?
After designing a short “rehab recipe” and opening up communication channels between the parent, gymnast, coach and physio, this diligent little gymnast was painfree and starting to get back into her tumbling within the fortnight.
Laura S. Kox, P. Paul F. M. Kuijer, Jip Opperman, Gino M. M. J. Kerkhoffs, Mario Maas & Monique H. W. Frings-Dresen (2018) Overuse wrist injuries in young athletes: What do sports physicians consider important signals and functional limitations?, Journal of Sports Sciences, 36:1, 86-96
Frush, T. J., & Lindenfeld, T. N. (2009). Peri-epiphyseal and Overuse Injuries in Adolescent Athletes. Sports Health, 1(3), 201–211.