Gymnast's Wrist (Distal Radial Physeal Stress Syndrome): One Cause of Wrist Pain in Young Gymnasts

Gymnast’s wrist is a common overuse injury in adolescent gymnasts. When the upper limb has to bear body weight for prolonged periods, the distal radial physis (growth plate) is one of the most vulnerable sites, because it takes high axial load together with repetitive compressive, torsional, and traction forces.

Epidemiology

• Roughly 46% to 88% of adolescent gymnasts have experienced wrist pain.
• Among gymnasts aged 10 to 14, 83% have had wrist pain, and as many as 51% show grade 2 or higher physeal stress injury.
• About 45% of patients have pain that lasts longer than six months.

Cause and pathophysiology

• Causes include axial compression, traction, and torsional forces acting repeatedly on the immature growth plate.
• Limited blood supply to the growth plate can also lead to abnormal endochondral ossification.
• Premature closure of the growth plate causes a mismatch in radial and ulnar length, producing positive ulnar variance and functional impairment.
• High-intensity training and doing high-load activities while the bone is still immature are important risk factors.

Risk factors

• Prolonged gymnastics training (for example, more than 35 hours per week).
• High-intensity weight bearing (such as vault, rings, and handstands).
• Rapid growth phase (on average 13.5 years in boys and 11.5 years in girls).
• Poor technique, unsuitable equipment, or a history of prior wrist injury.

History

• The usual complaint is chronic wrist pain, most often on the dorsal side and related to activity.
• Pain frequently worsens during training, and some gymnasts do not report symptoms on their own.

Physical examination

• There is clear tenderness over the distal radius, limited range of motion, and possibly swelling.
• Exercise, or loading the palm on the ground and doing push-ups, can provoke pain.
• It should be distinguished from tendinitis (tender point, and whether active wrist extension is painful).

Differential diagnosis

• Tendinitis
• Scaphoid fracture
• Ulnar impaction syndrome
• TFCC tear, congenital deformities (such as Madelung deformity)
• Physeal or diaphyseal fracture

Diagnostic tools

• X-ray: check for signs such as physeal widening, haziness, cystic changes, and beaking of the distal physis.
• MRI: assess edema around the physis, early bridging, and radial bone-marrow edema, which helps with diagnosis and surgical planning. 3D MRI can evaluate the size and location of a bone bridge to decide whether to proceed with surgical resection.

Initial treatment

• Rest immediately and avoid loading movements for at least 3 to 6 weeks.
• If there is no tenderness and no imaging abnormality, training can be resumed progressively.
• Anti-inflammatory painkillers (NSAIDs) and protective bracing help relieve inflammation and pain.

Other treatment and training

• A wrist brace or supporting device may ease pain in the acute phase, but has no clear protective effect against chronic stress.

• Rehabilitation modalities relieve minor pain.

• Exercise training can improve wrist stability and strength and help avoid recurrence.

  • The goal of wrist rehabilitation is to restore symmetric wrist range of motion and strength.
  • Improve shoulder flexibility and thoracic-spine mobility.
  • Do alternative training and conditioning, focusing on strengthening the upper body and core, to reduce the load on the wrist joint when returning to gymnastics.

  Staged rehabilitation strategy

  • Phase 1:
    • Correct mobility restrictions in the spine, shoulder, and upper-limb joints.
    • Address deficits in muscle length and neuromuscular control.
  • Phase 2:
    • Continue manual therapy to correct functional deficits.
    • Strengthen neuromuscular control exercises.
    • Begin sport-specific training in limited weight-bearing positions.
  • Phase 3:
    • Continue manual therapy as needed.
    • Further increase the intensity of neuromuscular control exercises.
    • Progress sport-specific training to full weight-bearing positions.

Surgery

• Reserved only for cases of premature physeal closure or a marked mismatch in ulnar and radial length.
• Surgical options include bone-bridge resection, ulnar shortening or radial lengthening osteotomy, and wedge resection of the distal radius.
• The choice depends on the size and location of the bone bridge and whether the physis has already closed.

Follow-up

• Regular imaging to confirm changes at the growth plate and the ulnar and radial lengths.
• Assess whether pain has eased and how much athletic function has recovered.
• Pay particular attention to whether ulnar variance recurs after surgery.

Prognosis

• If detected early and rested, recovery is good, and most gymnasts can return to sport.
• If not managed properly, it may lead to premature physeal closure, wrist deformity, and permanent functional impairment.
• In the long term, it may affect joint range of motion and strength, and even everyday activities.

References

• https://www.orthobullets.com/hand/6052/gymnasts-wrist-distal-radial-physeal-stress-syndrome
• J Am Acad Orthop Surg. 2019 Jul 1;27(13):459-467.
• Orthop Clin North Am. 2020 Oct;51(4):493-497.

Further reading

• Sports injury overview
• PRP prolotherapy
• Rehabilitation exercise prescription
• Pain management