1
|
Caine D, Patel V, Nguyen JC. Overuse Injury of the Epiphyseal Primary Physis. Semin Musculoskelet Radiol 2024; 28:375-383. [PMID: 39074721 DOI: 10.1055/s-0044-1785207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
Year-round participation in youth sport that involves high levels of repetitive movement fosters an environment in which overuse injuries are likely to occur. Epiphyseal primary physeal stress injuries (PSIs), unique to skeletally immature athletes, are a particular concern, given their potential for growth disturbance. Initially observed in Little League baseball players, these injuries are now known to affect the long bones around the shoulder, elbow, wrist, hand, knee, ankle, and foot of skeletally immature athletes involved in a variety of sport activities.This article offers an epidemiological and radiologic perspective on the extent and distribution of epiphyseal PSIs in youth sport. We also review a novel framework for understanding the pathophysiologic mechanisms causing these injuries. This information is essential for the early identification of epiphyseal PSIs and devising preventive measures that can reduce a delayed diagnosis and long-term morbidity. Preventing and reducing injury to the epiphyseal growth plates is essential because impairment and dysfunction can result in lifelong morbidity and a risk of premature osteoarthritis.
Collapse
Affiliation(s)
- Dennis Caine
- Division of Education, Health and Behavior Studies, Kinesiology and Public Health Education, University of North Dakota, Grand Forks, North Dakota
| | - Vandan Patel
- Department of Radiology, Section of Musculoskeletal Imaging, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jie C Nguyen
- Department of Radiology, Section of Musculoskeletal Imaging, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
2
|
Sekiguchi T, Saito S, Ogura T, Tsuchiya A, Shiratsuchi H. Abnormal Wrist Sagittal Kinematics in Gymnasts With Dorsal Wrist Pain: A New Syndrome. Am J Sports Med 2024; 52:232-241. [PMID: 38164673 DOI: 10.1177/03635465231204361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND The pathology of dorsal wrist pain in gymnasts without abnormal radiographic findings remains unclear. PURPOSE/HYPOTHESIS The purpose of this study was to identify abnormal wrist sagittal kinematics in gymnasts with dorsal wrist pain. It was hypothesized that gymnasts with dorsal wrist pain would show abnormal sagittal kinematics with reversible hypermobility of the intercarpal joint. STUDY DESIGN Controlled laboratory study. METHODS Participants included 19 wrists in male gymnasts with dorsal wrist pain, 18 wrist in male gymnasts without wrist pain, and 20 adult men without a history of wrist pain. Magnetic resonance imaging (T2-weighted sagittal images) findings at 0°, 30°, 60°, and 90° of wrist extension were used in kinematic analysis. The angles and translations of the radiolunate, capitolunate, and third carpometacarpal joint were measured and compared between the 3 groups. RESULTS At 90° of wrist extension, gymnasts with dorsal wrist pain had a significantly lower radiolunate joint angle (28.70°± 6.28° vs 36.19°± 7.81°; P = .020) and a significantly higher capitolunate joint angle (57.99°± 6.15° vs 50.50°± 6.98°; P = .004) and distal translation (1.17 ± 0.50 mm vs 0.46 ± 0.62 mm; P = .002) than gymnasts without dorsal wrist pain. CONCLUSION Gymnasts with dorsal wrist pain showed abnormal wrist sagittal kinematics. These novel findings may facilitate understanding of dorsal wrist pain, which can be recognized as a new syndrome termed "gymnast's lunate dyskinesia."
Collapse
Affiliation(s)
- Takahiro Sekiguchi
- Department of Rehabilitation, Funabashi Orthopaedic Clinic, Funabashi, Chiba, Japan
| | - Shinobu Saito
- Japan Community Health care Organization (JCHO) Tokyo Joto Hospital, Koto-ku, Tokyo, Japan
| | - Takahiro Ogura
- Sports Medicine Center, Funabashi Orthopaedic Hospital, Funabashi, Chiba, Japan
| | - Akihiro Tsuchiya
- Sports Medicine Center, Funabashi Orthopaedic Hospital, Funabashi, Chiba, Japan
| | | |
Collapse
|
3
|
Watson A, Eckersley R, Horwitz MD, Tolerton SK, Zlotolow DA. Adolescent Wrist Pain. J Hand Surg Am 2022; 47:1108-1114. [PMID: 36207227 DOI: 10.1016/j.jhsa.2022.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 11/05/2022]
Abstract
Adolescence is a difficult time, both physically and emotionally. Rapid growth coupled with physical changes in the background of high levels of activity can be overwhelming. Meanwhile, unfamiliar life stressors coupled with undeveloped compensatory mechanisms can lead to overwhelming anxiety and emotional distress. Emotional factors can make injuries and overuse syndromes feel more catastrophic. Occasionally, an adolescent's emotional distress can manifest physically, without antecedent injury or physiologic cause. Understanding the psychological milieu is as important as understanding the disease processes that can affect adolescents if one hopes to manage these patients effectively.
Collapse
Affiliation(s)
- Anna Watson
- Chelsea & Westminster Hospital, London, United Kingdom
| | | | - Maxim D Horwitz
- Chelsea & Westminster Hospital, London, United Kingdom; Imperial College London, London, United Kingdom
| | - Sarah K Tolerton
- Sydney Hospital and Prince of Wales Hospital, Randwick, Australia; University of Sydney, Camperdown, Australia
| | - Dan A Zlotolow
- Thomas Jefferson University School of Medicine, Philadelphia, PA; Hospital for Special Surgery, New York, NY; Shriners Hospital for Children Philadelphia, Philadelphia, PA.
| |
Collapse
|
4
|
Caine D, Maffulli N, Meyers R, Schöffl V, Nguyen J. Inconsistencies and Imprecision in the Nomenclature Used to Describe Primary Periphyseal Stress Injuries: Towards a Better Understanding. Sports Med 2022; 52:685-707. [PMID: 35247201 DOI: 10.1007/s40279-022-01648-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 11/26/2022]
Abstract
Stress injuries involving the epiphyseal-physeal-metaphyseal complex affecting the extremities of child and adolescent athletes were first described in the early 1950s. Initially observed in Little League baseball players, these injuries are now known to affect skeletally immature athletes in a variety of sports that involve high-impact repetitive overuse activities. Collectively known as primary periphyseal stress injuries, they may affect the long bones around the shoulder, elbow, wrist, hand, hip, knee, ankle, and foot of young athletes. These injuries respond well to timely treatment and relative rest, while non-compliance with non-operative treatment can produce skeletal growth disruption and resultant limb deformity. A major concern raised from the existing literature on primary periphyseal stress injuries is the long history of inconsistent and imprecise terminology used to describe these injuries. A variety of terms have been used to describe primary periphyseal stress injuries, including those which potentially misinform regarding who may be affected by these injuries and the true nature and pathophysiologic mechanisms involved. These imprecisions and inconsistencies arise, at least in part, from a misunderstanding or incomplete understanding of the nature and mechanism of primary periphyseal stress injuries. In this article, we examine the inconsistent and imprecise nomenclature historically used to describe primary periphyseal stress injuries. We also offer a novel framework for understanding the pathophysiologic mechanisms behind these injuries, and provide suggestions for more standard use of terminology and further research moving forward.
Collapse
Affiliation(s)
- Dennis Caine
- Kinesiology and Public Health Education, Division of Education, Health and Behavior Studies, University of North Dakota, Hyslop Sport Center, 2721 2nd Ave N Stop 8235, Grand Forks, ND, 58202-8235, USA.
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Via Salvador Allende, 43, Baronissi SA, 84081, Salerno, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, Largo Città di Ippocrate, 84131, Salerno, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E14DG, England
- School of Pharmacy and Bioengineering, Faculty of Medicine, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB, England, UK
| | - Rachel Meyers
- Department of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnatti, OH, 45229, USA
| | - Volker Schöffl
- Klinik Für Orthopädie Und Unfallchirurgie, Sozialstiftung Bamberg, Buger Straße 80, 96049, Bamberg, Germany
- Klinik für Unfallchirurgie und Orthopädische Chirurgie, Freidrich Alexander Universität Erlangen-Nürnberg, FRG, Erlangen, Germany
- School of Clinical and Applied Sciences, Leeds Becket University, Leeds, UK
- Section of Wilderness Medicine, Department of Emergency Medicine, School of Medicine, University of Colorado, Denver, USA
| | - Jie Nguyen
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
5
|
Trevithick B, Mellifont R, Sayers M. Wrist pain in gymnasts: Efficacy of a wrist brace to decrease wrist pain while performing gymnastics. J Hand Ther 2021; 33:354-360. [PMID: 30956069 DOI: 10.1016/j.jht.2019.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 02/07/2019] [Accepted: 03/03/2019] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN This was a clinical trial of prospective cohort. INTRODUCTION Wrist pain in gymnasts is a global phenomenon. Compression forces acting on wrists while performing gymnastics is a predisposing factor in the development of wrist pain and consequential injury of the distal radial physis in skeletally immature gymnasts. One approach to mitigate these forces is wrist bracing; however, studies on the efficacy of wrist braces to reduce wrist pain experienced by gymnasts are limited. PURPOSE OF THE STUDY The purpose of this study was to investigate the efficacy of an innovative design of a wrist brace to decrease gymnasts' wrist pain while performing gymnastics. METHODS A wrist brace was designed and trialled over 3 weeks by 48 male gymnasts (aged 8-22 years, levels 4-7) with wrist pain. Wrist pain was recorded on a visual analog scale of 1 to 10 before and after trial. Data analysis was performed using SPSS-22 (IBM Inc). Paired t-tests were performed to compare variables before and after trial, with effect size analyses used to quantify the relative magnitude of any differences. RESULTS Paired t-tests indicated the gymnasts reported significantly reduced pain (P = .002; 53.5%) while wearing the braces for training on the pommel, floor, and parallel bars. The overall large effect size value was practically significant (d = 0.902). DISCUSSION For any wrist brace to be effective, it needs to be implemented when the gymnast experiences wrist pain before an injury occurs. This would minimize the development of pain-provoked adaptive movement patterns that perpetuate dysfunction. CONCLUSIONS The brace with the volar gel pad is recommended to be worn as an adjunct to current strategies in management of gymnasts' wrist pain or as an injury prevention device in skeletally immature gymnasts.
Collapse
Affiliation(s)
- Beverly Trevithick
- Department of Health and Sport Sciences, University of the Sunshine Coast, Queensland, Australia.
| | - Rebecca Mellifont
- Department of Health and Sport Sciences, University of the Sunshine Coast, Queensland, Australia
| | - Mark Sayers
- Department of Health and Sport Sciences, University of the Sunshine Coast, Queensland, Australia
| |
Collapse
|
6
|
Primary Periphyseal Stress Injuries in Young Athletes: A Systematic Review. Sports Med 2021; 52:741-772. [PMID: 34370212 DOI: 10.1007/s40279-021-01511-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Overuse injuries are common in sporting children and adolescents. These injuries are a particular concern when they involve the epiphyseal-physeal-metaphyseal (EPM) complex given their potential to disturb skeletal growth. Specifically, the limits of mechanical tolerance of the EPM complex to repetitive stress may be exceeded by the intense and continuous training characteristic of many youth sports today. OBJECTIVE This article describes the present status of knowledge on the occurrence and outcome of primary periphyseal stress injuries (PPSIs) affecting the EPM complex in the extremities of children and adolescents involved in youth sports. METHODS A comprehensive review of the sports medicine literature was conducted to determine the nature and extent of PPSIs affecting the EPM complex of the extremities among youth sports participants and the potential for consequent skeletal growth disturbance and resultant limb deformity associated with these injuries. RESULTS Our initial search uncovered 128 original published scientific articles reporting relevant data on PPSIs. There were 101 case reports/series, 19 cross-sectional, 1 case-control, and 7 cohort studies with relevant data. The case reports/series studies reported 448 patients with PPSIs involving the extremities. Children and adolescents representing a variety of high impact repetitive youth sports activities-including baseball, badminton, climbing, cricket, dance, gymnastics, rugby, soccer, swimming, tennis, and volleyball-may sustain PPSIs involving the shoulder, elbow, hand and wrist, knee, and ankle and foot. Although incidence data from prospective cohort studies are lacking, data arising from cross-sectional studies suggest that PPSIs may be common in select groups of youth athletes-including the shoulder in baseball players (0-36.6%), wrist in gymnasts (10-83%) and platform divers (52.6%), and fingers in rock climbers (5-58%). Notably, not all stress-related skeletal changes detected on imaging were symptomatic in these studies. When diagnosed and treated with an appropriate period of rest and rehabilitation, most patients studied were able to return to their sport activities. However, our data also show that 57/448 PPSIs (12.7%) produced growth disturbance, and that 28/448 patients (6.2%) underwent surgery for their injuries. Absence of treatment, delayed presentation and diagnosis, and non-compliance with a rest regimen were common in cases that produced growth disturbance. CONCLUSIONS PPSIs may affect the extremities of children and adolescents engaged in a variety of youth sports, especially at advanced levels of training and competition. Most skeletally immature patients with PPSIs respond well to timely treatment; however, in extreme cases, PPSIs can progress to produce skeletal growth disruption which may necessitate surgical intervention. Clearly, establishing the early diagnosis of PPSIs and providing timely treatment of these injuries are needed to ensure the skeletal health of youth sports participants. Rigorous prospective longitudinal epidemiological and imaging studies designed to provide incidence rates of PPSIs and to determine the effect of PPSIs on long-term skeletal health are also necessary.
Collapse
|
7
|
Abstract
The distal radial physis is a common site for injury in gymnasts because of the significant amount of load applied during upper extremity weight-bearing. Wrist pain has been reported in up to 88% of gymnasts. The long-term consequences of overuse wrist injuries, such as distal radial physeal arrest, include degenerative conditions that often cause pain and functional limitations. In the more immediate stage of many overuse injuries, early diagnosis can promote quicker care and recovery and thus faster return to play. Less time lost to injury can be very important in maintaining an athlete's quality of life.
Collapse
|
8
|
Kraan RBJ, Kox LS, Oostra RJ, Kuijer PPFM, Maas M. The distal radial physis: Exploring normal anatomy on MRI enables interpretation of stress related changes in young gymnasts. Eur J Sport Sci 2020; 20:1197-1205. [PMID: 31928133 DOI: 10.1080/17461391.2019.1710263] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Rationale: Explore the MRI-appearance of the healthy distal radial physis and the distribution of stress-related changes in physeal thickness in young gymnasts to aid in the understanding of the pathophysiological process of stress-related physeal injury. Methods: Symptomatic gymnasts with clinically suspected overuse injury of the distal radial physis and age and gender-matched asymptomatic gymnasts and healthy non-gymnasts underwent an MRI-scan of the wrist. A cartilage-specific sequence was used to obtain three-dimensional reconstructions of the distal radial physis. Heat maps and line charts of these reconstructions visualised distribution of physeal thickness per study group and were used to explore differences between study groups. Symptomatic gymnasts displaying the most profound physeal widening (n = 10) were analysed separately. Results: Twenty-seven symptomatic - (skeletal age 12.9 ± 1.5 years), 16 asymptomatic - (skeletal age 12.8 ± 1.9 years) and 23 non-gymnasts (skeletal age 13.6 ± 1.9 years) were included for analysis. Physes of healthy non-gymnasts had a thin centre and increased in thickness towards the borders. Gymnasts demonstrated an increase in thickness of the entire physeal surface. In symptomatic gymnasts increase in physeal thickness was most prominent at the volar side when compared to asymptomatic gymnasts and non-gymnasts. Conclusion: The healthy distal radial physis is characterised by a thin centre surrounded by thicker borders. Stress applied to the wrist during gymnastics causes an overall increase in physeal thickness. Profound thickness increase is present at the volar side of the physis mainly in symptomatic gymnasts. These results can help unravel the pathophysiological mechanism of stress-related physeal injury in gymnasts and aid early injury identification.
Collapse
Affiliation(s)
- R B J Kraan
- Department of Radiology & Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands.,Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, Netherlands
| | - L S Kox
- Department of Radiology & Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands.,Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, Netherlands
| | - R J Oostra
- Department of Medical Biology, Section Clinical Anatomy and Embryology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
| | - P P F M Kuijer
- Coronel Institute of Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
| | - M Maas
- Department of Radiology & Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands.,Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, Netherlands.,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center AMC/VUmc, Amsterdam, Netherlands
| |
Collapse
|
9
|
Ashwell ZR, Richardson ML. Gymnast's wrist in a 12-year-old female with MRI correlation. Radiol Case Rep 2019; 14:360-364. [PMID: 30581523 PMCID: PMC6297268 DOI: 10.1016/j.radcr.2018.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 09/02/2018] [Accepted: 09/11/2018] [Indexed: 11/22/2022] Open
Abstract
We describe a case of chronic overuse injury of the distal radial physis (gymnast's wrist). While the radiographic appearance of this entity has been reported, there are limited studies highlighting the MR appearance of this entity. This lesion is being seen with increasing frequency in young, elite gymnasts. If this injury goes unrecognized, there is potential for abnormal osseous development, with premature physeal fusion, abnormal joint inclination and even Madelung deformity.
Collapse
Affiliation(s)
- Zachary R. Ashwell
- University of Washington, Department of Radiology, Musculoskeletal Radiology Division, UW Medical Center – Roosevelt, 4245 Roosevelt Way NE Box 354755, Seattle, WA 98109, USA
| | | |
Collapse
|