A 15-year-old male adolescent presenting with right wrist pain and swelling for short duration. The patient is physically active and part of gymnast team. X-ray of both wrists and MRI exam of the right wrist were requested.
The X-ray revealed widening of the right distal ulnar and both distal radial physeal plates with irregularity and sclerotic changes more pronounced along the left distal radial metaphysis (Fig.1).
MRI showed widening of the right ulnar distal physis and mildly elevated signal pattern associated with mild irregularity of the distal metaphysis and minimal sub-periosteal fluid. Minimal irregularities of the distal radius metaphysis with no significant diastases of its physeal plate or related manifest marrow oedema were also noted (Fig.2).
Gymnast’s Wrist comprises a spectrum of chronic overuse injuries afflicting the skeletally immature wrist secondary to physeal plates repetitive compressive insults applied in stressing sports like gymnastics -hence the etymology- and manifesting as chronic Salter-Harris type I injury [1].
The distal radius is mostly involved because it bears the primary stressful forces at wrist joint, with less frequent distal ulnar involvement. Patients usually present with pain of gradual onset exaggerated by weight-bearing/compressive activities while the wrist is in extension position [2].
The characteristic radiographic diagnostic criteria include widening of the physis, especially volary and radially, with peri-physeal pseudo cystic as well as sclerotic changes. On MRI, the physeal changes can also be appreciated with peri-physeal marrow oedema depicted in some cases [3].
Clinically there are three stages; an early stage characterized by chronic wrist pain (no radiographic abnormalities), decreased range of motion in the middle stage (radiographic features start to ensue) and osseous deformity in the form of disrupted radial growth with relatively lengthened ulna (positive ulnar variance and related morbidities such as TFCC tears and ulnar impaction) in the late stage [4]. The radiologic features along with typical history are sufficient to make the diagnosis.
The treatment depends on the affliction stage. Rest with ice packs and anti-inflammatory drugs are the mainstay at early stage. Application of splint/cast immobilization is sometimes required, with surgical reduction of the ulna reserved for the late stages. Recovery also is variable and takes anywhere from one to six months according to the stage [2].
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Distal ulnar and radial physeal stress syndrome “Gymnast’s Wrist”
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1. From the anteroposterior (AP) and oblique X-ray of the right wrist:
• The epiphyseal plate between the distal radius epiphysis and metaphysis shows mild irregularities in some areas, with partial widening.
• Changes in bone density can also be seen on the radial and volar (anterior) sides of the distal radius, suggesting stress-related changes in the growth plate region.
• Overall joint alignment and trabecular structure appear acceptable; no obvious signs of acute fracture are noted.
• No significant large-area edema is observed in the soft tissues, but mild localized swelling may be present.
2. MRI (primarily coronal view) demonstrates:
• Slightly abnormal signal near the epiphysis, with increased signal intensity around the distal radius growth plate and adjacent bone marrow, indicating edema or inflammatory response due to chronic stress.
• No clear fracture line or collapse of the articular surface is observed.
• Surrounding soft tissues show mild signs of edema without evident ligament ruptures or joint effusion.
Considering the patient’s age, type of physical activity (gymnastics), symptoms (wrist pain, short-term swelling), and imaging findings (widening of the distal radius growth plate region and surrounding bone changes), the most likely diagnosis is: “Gymnast’s Wrist,” i.e., stress-related injury of the distal radial epiphysis.
1. Treatment Strategy:
• Early conservative treatment: Reduce or temporarily discontinue weight-bearing wrist movements, apply ice packs (cold therapy), and consider NSAIDs to relieve local pain and inflammation.
• Use of a wrist brace or cast immobilization may be necessary to lessen the ongoing stress on the growth plate, promoting recovery of inflamed or stressed tissues.
• If later stages present marked radial-ulnar deviation (limited radial growth) or severe joint instability, surgical intervention (e.g., corrective osteotomy or ulnar shortening procedure) may be considered, but such cases are relatively rare.
• Rehabilitation duration varies among individuals, ranging from several weeks to several months.
2. Rehabilitation Exercise Prescription (FITT-VP Principle):
• Frequency (F): Begin with low-intensity wrist exercises 2–3 times per week, increasing to 3–4 times per week as pain improves and weight-bearing capacity increases.
• Intensity (I): Exercise at a level that does not significantly exacerbate pain. Initially focus on simple wrist range-of-motion (ROM) exercises, gradually increasing difficulty and loading over time.
• Time (T): Start with 10–15 minutes per session, increasing to 20–30 minutes as tolerated. Short sessions can be performed 2–3 times per day to distribute stress.
• Type (T): Begin with non-weight-bearing passive/active ROM movements such as wrist flexion/extension, pronation/supination, and radial/ulnar deviation. In later stages, add resistance bands or light weights to strengthen forearm muscles and enhance joint stability.
• Volume (V): Adjust total exercise volume based on pain levels and joint stability. Increase gradually on a weekly basis without overloading the joint.
• Progression (P): Once pain and swelling subside, progressively introduce weight-bearing exercises like planks or handstands. Monitor symptoms closely; if pain recurs, reduce loading and revert to lower-intensity activities.
3. Special Considerations:
• In adolescents, pay special attention to the growth plates to avoid permanent deformities or joint injury from repeated excessive loading.
• If ligamentous laxity or improper gymnastics techniques are present, focus on correcting movement patterns, enhancing core stability, and strengthening the forearm musculature during rehabilitation.
This report is a reference analysis based on the current imaging and medical history and should not replace a face-to-face clinical diagnosis or recommendations from a professional physician. The specific treatment plan must be determined by a specialist after a comprehensive clinical evaluation.
Distal ulnar and radial physeal stress syndrome “Gymnast’s Wrist”
