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Extremity and Joint Conditions: Section Articles

Wrist Pain in Gymnasts: A Review of Common Overuse Wrist Pathology in the Gymnastics Athlete

Benjamin, Holly J. MD, FAAP, FACSM1; Engel, Sean C. MD2; Chudzik, Debra DNP, APRN, BS3

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Current Sports Medicine Reports: 9/10 2017 - Volume 16 - Issue 5 - p 322-329
doi: 10.1249/JSR.0000000000000398
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Abstract

Introduction

Competitive gymnastics is one of the most popular youth sports with the majority of participants ranging in age from 6 to 14 yr. In 2014, there were 4.62 million gymnasts in the United States. Injury rates among gymnasts are among the highest of any sport at the high school and collegiate level per athletic exposure. Recent data published by the U.S. Centers for Disease Control and Prevention in their Morbidity and Mortality Weekly Report cited an injury rate for women’s collegiate gymnastics of 10.4 (9.5–11.2) per 1000 athletic exposures, second only to wrestling (13.1 per 1000). In fact, gymnastics injury rates ranked higher than the rate found for contact sports such as football (9.2 per 1000) or women's and men's ice hockey, 6.1 and 9.5 per 1000, respectively (17). Westermann et al. (37) reported injury rates of 8.78 per 1000 male gymnasts and 9.37 per 1000 women gymnasts in their study of division 1 gymnasts. They further categorized the injuries according to body part and found the wrist and hand to be the most commonly injured body part in men, and the sixth most commonly injured body part in women. The discrepancy between female and male gymnasts' wrist injuries is likely due to the differences in the biomechanical demands for each sport event. In female gymnasts, the upper extremity is weight bearing and therefore absorbing direct force in tumbling, balance beam, uneven bars, and vault. Male gymnasts also vault and tumble, but there is almost exclusive use of the upper extremity for support in events, such as the rings, high bar, and parallel bars. Both female and male gymnasts have an overall higher rate of upper-body injuries relative to other sports. While acute injuries, such as fractures in the hand and wrist, certainly occur in the gymnastics population, the focus of this article is to highlight some of the more common wrist injuries related to overuse and overtraining. Prompt evaluation and management is necessary to avoid the negative sequelae that can often accompany these injuries. Little is known about effective sport-specific injury prevention strategies but general guidelines for overuse injury prevention including limiting excessive loading of the wrist, maintaining wrist joint flexibility, an emphasis on proper technique, and incorporating wrist and general core strengthening seem beneficial. General return to play principles are similar for all gymnast-related wrist injuries, including resolution of pain, restoration of normal wrist joint function, completion of a progressive rehabilitation program, and use of proper technique.

Distal Radial Epiphysitis “Gymnast Wrist”

Gymnast wrist injuries encompass various overuse conditions caused by chronic repetitive compressive impact and torsion forces demanded of this area of the body. The term “gymnast wrist” commonly refers to distal radial physis or growth plate injury. This condition is of particular concern in the adolescent athlete with immature, growing bone structures. In the immature skeleton, the physis is prone to injury because the joint capsule and ligamentous structures are stronger than the cartilaginous growth plate (29). Repeated axial loading and hyperextension of the wrist directs the body’s forces onto the unfused distal radius, which causes inflammation of the physis and widening of the growth plate. This can eventually lead to fragmented or fractured adjacent metaphyses. In many cases, the injury pattern can resemble a Salter Harris I or II stress fracture (4). Chronic, untreated distal radial epiphysitis can lead to premature closure of the physis, resulting in growth arrest of the radius (Fig. 1). Meanwhile, the ulna continues to grow, which leads to ulnar-positive variance (Fig. 2). True anatomic ulnar variance refers to the relative lengths of the distal articular surfaces of the radius ulna and is easily determined on wrist radiographs and should be assessed. Ulnar variance that is positive refers to the ulna projecting more distally (appears “longer”), neutral refers to both the ulnar and radial articular surfaces being at the same level, and negative refers to the ulna projecting more proximally (appears “shorter’). Positive ulnar variance as a complication of gymnast wrist can be both anatomical or functional and results in altered wrist biomechanics including an inability to dorsiflex the wrist, difficulty in achieving ulnar deviation, and altered loading of weight-bearing stress to the wrist. The progressive damage to the ulnar side of the wrist increases the risk of ulnar physeal injury, degenerative changes, triangular fibrocartilage complex (TFCC) injury, tendonitis, and/or ligament injuries, all of which can be associated with chronic wrist pain and dysfunction (3,4).

Figure 1
Figure 1:
Magnetic resonance arthrogram demonstrating bony bridging across the distal radial physis as is seen in growth arrest.
Figure 2
Figure 2:
AP wrist radiograph demonstrating positive ulnar variance in a young gymnast.

Patient history and presentation typically reveal several weeks of bilateral or unilateral wrist pain, usually with no history of acute trauma, worsened pain with load-bearing activities and relief with rest. Examination reproduces tenderness over the right volar radial region and bilateral dorsal radial regions at the wrist level while range of motion remains normal or mildly limited due to pain. Radiographic findings are most often normal, but severe cases may exhibit widening of the lateral and volar aspect of the distal radial physis. Magnetic resonance imaging (MRI) is not routinely indicated for these patients but if obtained demonstrates widening of the lateral aspect of the distal radial physis in addition to cartilage thickening of the medial aspect of the radial physis. Linear signal abnormality within the distal metaphysis also may be seen with MRI (29). Current treatment recommendation is primarily focused on cessation of the causative stress. It is essential to stop weight-bearing exercises usually for a minimum of 6 wk or until symptoms subside. During this period of rest, alternative conditioning and strengthening exercises of the core and upper body may be performed under supervision as well as wrist rehabilitation aimed at achieving full, symmetric range of motion and strength (4). Resolution of widening physis and sclerosis may lag behind clinical symptoms but improvements can be seen within a few weeks of rest. Therefore, radiographs are recommended between 6 and 12 wk postdiagnosis or when symptoms have resolved to verify proper healing but are usually not performed in those patients whose initial radiographs were normal. Distal radial physis growth arrest is the most serious complication in this patient population. Because this arrest may take months to be detected, it is recommended that patients with gymnast wrist be monitored for up to a year with serial radiographs at approximately 6 months and/or 1 yr postinjury. It is particularly important to monitor patients whose initial radiographs demonstrated significant changes to the immature physis. Complete radiographic resolution of changes, however, is not necessary to begin a return to play protocol. Once the clinical symptoms of pain have resolved, a gradual increase of training loads may be initiated if the athlete can demonstrate full range of motion and normal strength with careful attention to sport biomechanics and proper form. Prevention is an important aspect of the athlete's training and long-term health. Reducing high impact and/or physical stress loads on the wrist along with reduction of specific training repetition involving wrist usage during growth spurts may be effective in decreasing wrist injuries but further sport-specific research is needed. In addition, use of protective equipment, such as wrist guards, may prevent or diminish extreme dorsiflexion and the stresses associated with wrist injury and its long-term sequelae (4) (Fig. 3).

Figure 3
Figure 3:
Example of a brace that can be used to limit wrist dorsiflexion.

Dorsal Wrist Impingement

Dorsal wrist impingement or dorsal wrist syndrome is another common condition associated with repetitive dorsiflexion and axial loading, particularly in sports such as gymnastics. There are many proposed theories as to the source of the dorsal wrist pain seen in these athletes. Henry (13) in 2008 reported that the dorsal wrist capsule is pinched between the extensor carpi radialis brevis and the dorsal ridge of the scaphoid. Terng et al. (34) found the entrapment of soft tissue in the radiocarpal, and less frequently, the midcarpal joints, to be an additional source of dorsal wrist pain. Impingement of the extensor retinaculum also has been proposed as a mechanism for dorsal wrist pain in athletes (36). Repetitive dorsiflexion and its subsequent impingement can give rise to capsular thickening, synovitis, and development of dorsal wrist ganglia. Most diagnoses of dorsal wrist syndrome are made clinically and rarely is imaging helpful diagnostically. Rather, imaging is performed to exclude other causes of dorsal wrist pain ranging from occult fractures, degenerative disease, avascular necrosis of the proximal carpal bones, or other congenital abnormalities that may be associated with dorsal wrist pain.

In chronic cases of dorsal wrist impingement, the distal radius or dorsal scaphoid or lunate may show osteophyte development (30). Treatment involves several weeks to months of rest from weight-bearing or other inciting activities. Using wrist splints to align the wrist in a neutral position may help relieve the pain more rapidly. The symptoms of dorsal wrist impingement may respond to the use of nonsteroidal anti-inflammatory medications. Corticosteroid injections also may be helpful when the location of impingement can be identified. For refractory cases, excision of the affected portion of the capsule has been effective in improving pain, with or without posterior interosseous neurectomy, also known as the Blatt procedure. The guidelines for return to play are similar to those prescribed for gymnast wrist: core and upper body strengthening during interim recovery period, correction of abnormal biomechanics, and gradual reintroduction of weight-bearing. Routine follow-up imaging is rarely indicated in these patients.

Scaphoid Stress Fracture

Stress fractures of the scaphoid are rare but should be considered in a patient with pain in the anatomical snuffbox, regardless of the presence or absence of history of trauma. These injuries are thought to be secondary to repeated compression of the scaphoid by the dorsal rim of the radius during wrist dorsiflexion. It has been most frequently reported in female gymnasts, but can occur with any activity that requires repeated forceful dorsiflexion or excessive loading of the wrist. There are few case reports of bilateral scaphoid stress fractures in gymnasts (11,28). Pain is typically localized to the middle third of the scaphoid. Like other stress fractures, scaphoid stress fractures may not be identified on plain radiography, therefore, computed tomography, MRI, or bone scan may be needed to detect the suspected injury (Fig. 4). Current gold standard is MRI which is very sensitive for detecting signal change in the scaphoid in addition to radiographically negative occult fractures. In most cases, scaphoid stress fractures heal with immobilization in a thumb spica cast. Choice of cast treatment varies and includes both long arm and short arm thumb spicas. The period of casting ranges from 6 to 12 wk. In the event that conservative treatment fails, there have been successful cases of internal screw fixation (39).

Figure 4
Figure 4:
(A and B) Sequential T2 FS images demonstrating increased edema in the scaphoid. (C) Normal x-ray from the same gymnast before MRI. (D) AP radiograph demonstrating transverse scaphoid waist fracture in a 14-yr-old gymnast.

Scapholunate and Lunotriquetral Ligament Injuries

A functional wrist is dependent on multiple ligamentous connections that control the motion of the carpal bones in relation to each other. Of these, the most commonly injured in gymnasts are the scapholunate and the lunotriquetral ligaments. Scapholunate injury occurs with excessive wrist extension and ulnar deviation. This injury commonly occurs after falls on an outstretched hand, but also can occur when the gymnast loads the wrist during extension such as in vaulting. A thorough physical examination of the wrist is imperative because the biomechanics that cause scapholunate injuries also are associated with other injuries such as distal radius fractures, scaphoid fractures, or other carpal ligamentous injuries (38). Therefore, it is important to distinguish which specific wrist injury the patient presents with.

The most common physical finding will be the athlete’s report of pain localized to the scapholunate area of the dorsal wrist, accompanied by swelling and restricted range of motion. The athlete may have pain with wrist dorsiflexion as well as grasping or making a fist and usually describes clicking or popping in the dorsal wrist. Watson’s test, the application of pressure directed dorsally on the proximal pole of the scaphoid while passively ulnar and radially deviating the wrist, may elicit a palpable clunking as the scaphoid subluxes and relocates. Radiographs of the wrist in suspected scapholunate injuries should include a clenched fist view which may reveal a gap between the scaphoid and the lunate in the setting of complete tears or instability. A widening of this gap greater than 2 to 3 mm is abnormal. Comparison view of the contralateral wrist may be helpful in equivocal cases. Partial disruptions of the scapholunate ligament may not demonstrate widening on x-ray. MRI with contrast angiogram improves the sensitivity of MRI for carpal ligament injuries diagnosis (21,38). Multidetector computed tomography (MDCT) with contrast also is an effective tool for evaluation of soft tissue wrist injuries (21,38). Wrist arthroscopy is currently the most definitive method for diagnosing and staging scapholunate ligament injuries.

For complete ruptures, treatment consists of open repair. Treatment of incomplete injuries remains more controversial, ranging from conservative treatment with casting and rehabilitation to operative treatments such as debridement, thermal shrinkage, or pin fixation (18). Early primary repair performed in the first few months post-injury is associated with good outcomes (30). Chronic cases can be significantly more difficult to repair because it becomes more challenging to restore normal anatomy. Abnormal articulation between the carpal bones as a result of ligament disruption causes pain and precipitates arthritis secondary to scapholunate advanced collapse (SLAC) (38). These cases may require carpal fusion, which usually results in some degree of loss of range of motion. In cases where arthrosis is present, a carpectomy or wrist reconstruction may be necessary. These injuries are quite serious in gymnasts and are often career ending, regardless of the choice of treatment.

Lunotriquetral ligament injuries are less common than scapholunate injuries. This injury should be suspected in an athlete with ulnar-sided wrist pain after wrist hyperextension and history of axial loading with radial deviation. It also may be degenerative and result from ulnar impaction. Typically patients will have pain in the area of the lunotriquetral ligament with loading of the wrist accompanied by decreased grip strength. Provocative tests include the lunotriquetral shear test, which is performed by applying a dorsally directed force through the triquetrum via the pisiform, while applying a palmarly directed force on the lunate. A positive test is indicated by a click or clunk and reproduction of the patient’s pain. X-ray, MRI, and arthrography have diagnostically inconclusive results and are often normal. Wrist arthroscopy is the most reliable tool to confirm diagnosis. Because a majority of lunotriquetral ligament injuries improve after immobilization, arthroscopy would only be indicated for patients with persistent pain or symptoms. Immobilization with cast or splint above the elbow for 6 wk is recommended for injuries without instability (23). Surgical treatment of lunotriquetral injuries with instability is debatable (23). The ability of a gymnast to return to play following the types of procedures treating dorsal ligament wrist injuries must be evaluated on an individual basis with regard to both the underlying contributing factors, the resolution of symptoms posttreatment, as well as the preservation of normal wrist mechanics. The long-term prognosis in these athletes is unknown because no longitudinal cohort studies have been reported.

Triangular Fibrocartliage Complex Injuries

The role of the TFCC is to stabilize the ulnar side of the wrist through dynamic movement by supporting the distal radioulnar joint (DRUJ) and assisting with shock absorption at the ulnocarpal joint (22). This anatomical complex consists of multiple structures that may be indistinguishable individually, but referred to as the conglomerate, TFCC. The TFCC is composed of an articular disc, meniscus homologue, ulnar collateral ligament, dorsal radioulnar ligament, volar radioulnar ligament, ulnotriquetral and ulnolunate ligaments, and the extensor carpi ulnaris sheath (Fig. 5) (15,24).

Figure 5
Figure 5:
TFCC anatomy. T, triquetrum; L, lunate; R, radius; U, ulna; ECU, extensor carpi ulnaris tendon; UT, ulnotriquetral ligament; UL, ulnolunate ligament; PRUL, palmar radioulnar ligament; DRUL, dorsal radioulnar ligament.

Injuries to the TFCC in athletes are typically related to chronic repetitive loading, acute trauma, or a combination of both. The ulnar side of the wrist bears approximately 18% to 20% of the total load bearing burden across the entire wrist (25). Biomechanical maneuvers, such as repeated ulnar deviation, grip, and pronation, increase stress on the ulnocarpal articulation and DRUJ, which places the TFCC at risk of injury. Acute injuries also can be caused by forced dorsiflexion, such as in a fall on an outstretched hand, or a distraction force applied across the ulnar side of the wrist, as is seen in golf or baseball swings, as well as in racquet sports and gymnastics.

Patient history and examination needs to determine if the TFCC injury is acute or traumatic versus chronic and degenerative. TFCC injury should be suspected when the patient presents with either localized, vague pain, or tenderness on the ulnar side of wrist. Other reported complaints may include presence of clicking or locking with supination or pronation, decreased range of motion, and decreased strength or pain elicited with grip. Reproduction of the patient's pain with axial loading of the ulnocarpal joint, such as in the press test, has been found to be a reliable predictor of TFCC injury. This assessment is performed by having the seated patient grip the sides of the chair and press upward to stand (20). The fovea sign also is sensitive and specific for the detection of TFCC injuries, particularly foveal or ulnotriquetral ligament injuries. This test requires the patient’s wrist to be in a neutral position; the soft spot found immediately distal to the ulnar styloid and dorsal to the flexor carpi ulnaris tendon is then depressed by the examiner’s thumb. Pain elicited with this maneuver is considered a positive test (33). Physical examination should assess for DRUJ instability by translating the radius against the ulna in both the palmar and dorsal directions. This should be compared to the contralateral side for signs of laxity.

Standard radiographic evaluation needs to include posteroanterior and lateral views of both affected and unaffected wrists. MRI has replaced arthrography for detecting TFCC injuries, yet the gold standard for diagnosing TFCC injury remains wrist arthroscopy (19). MR arthrogram performs better than standard MRI for most injuries to the TFCC, but some of this difference can be mitigated with the use of a 3 Tesla MR scanner. Multidetector computed tomograpy (MDCT) arthrography also is highly sensitive and specific for TFCC injuries in those for whom MRI is not an option (21).

Treatment recommendations for minor TFCC injuries involve use of soft bracing to immobilize the wrist and forearm, in combination with nonsteroidal anti-inflammatories and physical therapy. More significant tears should be treated for 4 to 6 wk in a long arm cast. Arthroscopic debridement or repair is an effective treatment in acute injuries but is usually reserved for athletes who fail an initial course of nonoperative treatment. Exceptions would be those with evidence of DRUJ instability or the high level athlete, in whom earlier surgical intervention might decrease time away from competition (7). Those with positive ulnar variance are predisposed to further TFCC injury and may undergo ulnar shortening osteotomy in place of, or along with TFCC repair (27). Corticosteroid injections have shown positive results in helping athletes complete their competition season. However, these injections are not recommended if the patient has significant distal radioulnar joint instability (5,19).

Ulnar Impaction

Ulnar impaction or ulnocarpal abutment syndrome is the result of repeated contact of the distal end of the ulnar with the carpal bones and TFCC. It is usually observed in the setting of ulnar-positive variance, which can be congenital, secondary to trauma, or secondary to premature closure of the radial physis, as seen with chronic distal radial epiphysitis otherwise referred to as gymnast wrist. The radiocarpal joint absorbs most of the force during axial loading of the ulnar neutral wrist. However, with an additional 2.5 mm positive ulnar variance, the amount of force transferred through ulnocarpal joint increases over twofold (25). Therefore, axial loading, pronation, and ulnar deviation may elicit pain and patients with ulnar impaction often present with ulnar-sided wrist pain after activity (32). Usually, it is in the absence of any acute trauma.

X-rays will show ulnar-positive variance (Fig. 2) but in chronic cases also may reveal sclerosis or subchondral cysts of the lunate, triquetrum, and ulnar head. However, early presentations of ulnar impaction may have subtle or no radiographic findings, in which case MRI can be useful to evaluate for marrow edema, cartilage or ligamentous damage, or cystic changes (6). Adding a pronated clenched-fist view to a standard wrist series may further expose dynamic ulna-positive variance (35). Treatment for ulnar impaction involves decreasing the load across the ulnar side of the wrist. This is accomplished surgically, though there are multiple open or arthoscopic techniques that may be utilized dependent upon the clinical presentation (6).

De Quervain’s Tenosynovitis

De Quervain’s stenosing tenosynovitis (DQST) is a common injury in racquet, golf, and gymnastics athletes, due to the mechanisms of grasping combined with repetitive ulnar deviation motion. This stenosing tenosynovitis is an inflammation of the abductor pollicis longus and extensor pollicis brevis as they pass under the tendon sheath at the radial styloid. During a clinical exam, tenderness and swelling can be detected over the distal radius at the styloid. Eichhoff’s test, pain produced when the patient’s thumb is tucked into its closed palm combined with ulnar deviation, and Finkelstein’s test, pain with examiner-applied traction and ulnar deviation of the thumb of a resting neutral wrist, are the classic assessment tests for DQST. Because of the lack of specificity of these tests, Goubau et al. (9) have proposed the Wrist Hyperflexion and Abduction of the Thumb (WHAT) test. As the name indicates, the wrist is hyperflexed and the thumb is abducted and extended at which point resistance is applied to the thumb. Pain with this maneuver indicates a positive test. In their study, the authors found this test to have much improved specificity and negative predictive value over the classic Finkelstein’s test. De Quervain’s is distinct from intersection syndrome, which occurs at the intersection of the first and second dorsal compartment tendons 4 to 8 cm proximal to the radiocarpal joint, proximal to the location of De Quervain’s. Ultrasound or MRI will reveal tenosynovial effusion and soft tissue edema, and often low-signal scar tissue from thickening of the first compartment tendons and sheath which will positively identify DQST sequelae.

The majority of patients respond well to initial treatment with thumb spica wrist splinting to maintain a neutral position, along with rest from activity that causes symptoms and nonsteroidal anti-inflammatory medications. This conservative treatment is typical initial protocol. However, meta-analyses have reported corticosteroid injection as the most effective and preferred treatment (Fig. 6). In fact, injection therapy is the recommended first-line treatment in severe cases of DQST (2,31). In some anatomic variants, the extensor pollicis brevis is contained within its own separate sheath, which often leads to refractory DQST, but surgical release of this sheath has provided excellent results. Musculoskeletal ultrasound is being used with increasing frequency to detect the presence of the additional sheath and help guide injections in these refractory cases. Further research is needed to evaluate the clinical outcomes of US guided injections in the gymnastics population. Surgical release of the De Quervain’s compartment can be curative, but experts concur that no less than 3 months of nonoperative treatment, including steroid injection, should be trialed prior to surgical consideration (14).

Figure 6
Figure 6:
Demonstration of approach for injection of De Quervain's tenosynovitis.

Intersection Syndrome

A relatively uncommon injury, intersection syndrome is an overuse syndrome of the forearm associated with repetitive wrist dorsiflexion and radial deviation (1). The injury pathophysiology consists of inflammation and peritendinous edema at the point approximately 4 to 6 cm proximal to Lister’s tubercle, where the first dorsal compartment tendons cross over the second dorsal compartment (16,30). The syndrome is most often seen in activities requiring repetitive wrist extension such as rowing, racket sports, and skiing, as well as in gymnastics.

Patient will typically present with localized pain, swelling, and tenderness in the dorsal radial aspect of the distal forearm. With repeated wrist flexion and extension, a palpable, and occasional audible crepitus can be elicited, giving rise to the term squeaker’s wrist. Finkelstein’s test may be negative; however, pain may be elicited at the site of tendon crossover (16). Besides history of repeated flexion-extension demands placed on the wrist, intersection syndrome often develops after a new biomechanical modification in a sport, unusually strenuous training periods, or acute incident which precipitates symptoms. Understanding the mechanism of injury is key to diagnosing any wrist injury, as well as assessing thorough history of events that may have contributing factors to the patient’s clinical symptoms.

MRI or ultrasound will reveal edema or fluid surrounding the first and second extensor compartments, tendinosis, muscle edema, tendon thickening or loss of the normal comma shape of the tendon, and/or juxtacortical edema (8). Treatment recommendations consist of activity modification while symptoms persist, nonsteroidal anti-inflammatories, and splinting in slight extension at rest and with aggravating activities (10,12,26). Corticosteroid injection into the painful area of the second dorsal compartment is an effective therapy, though this injury typically responds well to conservative treatment and has a 60% to 100% success rate to full recovery (10,26). Rarely, surgical treatment may be needed in refractory cases to decompress the extensor tendons at area of intersection (10).

Conclusions

The biomechanical and physiologic demands of gymnastics require highly functioning upper extremity joints, which are not generally accustomed to or necessarily designed for repetitive forceful impact and weight bearing. For this reason, overuse injuries in the upper extremities are more commonly seen in gymnasts than in other sports. Because of the repeated forceful loading of the wrist and the use of the wrist and hand to support the entire body, wrist injuries are seen frequently. Fortunately, many of these injuries are treatable with activity modification, correction of improper biomechanics, soft bracing, and physical therapy. In addition to directed therapy for the injured wrist, physical therapy should incorporate core stabilization exercises as well as mobility and stabilization exercises of the shoulder and elbow as this is felt to potentially minimize the load on the wrists during upper extremity activities. In some severe or refractory cases of chronic wrist pain, corticosteroid injections and/or surgical intervention may be indicated and has shown therapeutic benefit. It is essential that practitioners who provide care for gymnasts have a thorough understanding of the unique biomechanical demands of the sport on the wrist joint and the variety of significant overuse injuries associated with gymnastic participation. Finally, it is critical to provide education and implement injury prevention strategies to aid in early diagnosis and management of wrist pain in the gymnastic population. Further research is needed to explore the effectiveness of commonly employed strategies of joint strengthening and stability in the upper extremity coupled with core strengthening and improvement in sport-specific biomechanic techniques in this youth-dominated sport.

The authors declare no conflict of interest and do not have any financial disclosures.

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