Article Text

Prevalence, incidence and risk factors for overuse injuries of the wrist in young athletes: a systematic review
  1. Laura S Kox1,2,3,
  2. P Paul F M Kuijer4,
  3. Gino M M J Kerkhoffs2,3,5,
  4. Mario Maas1,2,3,
  5. Monique H W Frings-Dresen2,4
  1. 1Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
  2. 2Academic Center for Evidence based Sports medicine (ACES), Amsterdam, The Netherlands
  3. 3Amsterdam Collaboration for Health and Safety in Sports (ACHSS), The Netherlands
  4. 4Coronel Institute of Occupational Health, Academic Medical Centre, Amsterdam, The Netherlands
  5. 5Department of Orthopaedic Surgery, Academic Medical Centre, Amsterdam, The Netherlands
  1. Correspondence to Laura S Kox, Department of Radiology, G1-235, Academic Medical Centre, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands; l.s.kox{at}amc.uva.nl

Abstract

Background Overuse wrist injuries can cause long-term symptoms in young athletes performing wrist-loading sports. Information on the prevalence, incidence and associated risk factors is required.

Purpose We aimed to review the prevalence and incidence of overuse wrist injuries in young athletes and to identify associated risk factors. We focused on popular wrist-loading youth sports—gymnastics, tennis, field hockey, volleyball, judo and rowing.

Study design Systematic review.

Methods We conducted a literature search on athletes aged <18 years performing wrist-loading focus sports. Prevalence, incidence and/or risk factor ORs for overuse wrist injuries were extracted directly or calculated from reported data.

Results The search identified six studies on prevalence, five on incidence, and one on risk factors. Prevalence rates were 32–73% for wrist pain and 10–28% for overuse wrist injury. Incidence rates were 7–9% for wrist pain and 0.02–26% for overuse wrist injury. The three criteria associated with wrist pain were (with OR): age of 10–14 years (11.5), training intensity (1.2), and earlier onset of gymnastics training (1.97).

Conclusions Prevalence and incidence of overuse wrist injuries was high in multiple studies of gymnasts, and largely unknown in other wrist-loading focus sports. Three key risk factors for wrist pain in gymnasts were age between 10 and 14 years, earlier training commencement, and training intensity. Using ‘wrist pain’ in defining overuse, and further investigating risk factors can aid in identifying overuse wrist injuries in young athletes.

  • Wrist
  • Child
  • Sports
  • Overuse
  • Epidemiology
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Introduction

In young athletes, common overuse injuries of the wrist include radial epiphysitis, carpal stress fractures and tendon injuries.1–3 The most common injury types differ as per the sport, based on the type of training and associated loading pattern of the wrist. In gymnasts, for example, radial epiphysitis is often seen as a cause of wrist pain, whereas in tennis players, carpal stress fractures occur.4–6 Popular youth sports with high loading of the wrist, in this review termed ‘wrist-loading focus sports’, include gymnastics, tennis, field hockey, volleyball, judo and rowing (table 1). These are sports that are highly stimulated by Dutch (Olympic) sports organisations.

Table 1

Number of young athletes (<18 years old) performing wrist-loading focus sports in the Netherlands7

Conservative treatment of most overuse wrist injuries comprises temporary sport cessation,8 and possibly reduced performance with consequent loss of athletic talent. Overuse-induced degenerative changes in the wrist joint, such as scaphoid or ulnocarpal impaction syndrome, can be career-threatening.9 Early diagnosis is essential, for athletic performance and for long-term normal functioning in daily life.

Information on the long-term consequences of sport-related wrist injury is limited and mostly based on case reports on overuse wrist injuries, as prevalence and incidence have not been investigated on a large scale.10–12 To develop adequate diagnostic and preventive methods, more information on the prevalence and incidence of overuse injuries of the wrist in young athletes is needed. Additionally, information on risk factors for overuse wrist injuries is required to develop adequate preventive measures tailored to the athlete.

We aimed to summarise prevalence and incidence of overuse injuries of the wrist in young athletes, in particular those who perform wrist-loading focus sports. The second objective was to identify risk factors for overuse injuries of the wrist in young athletes. These aims were formulated into two research questions:

  1. What are the prevalence and incidence rates of overuse injuries of the wrist in young athletes?

  2. What are sports-related and individual risk factors for developing overuse injuries of the wrist in young athletes?

Methods

Literature search

We conducted a comprehensive literature search using PubMed (1966 to 22 July 2014), EMBASE via OvidSP (1947 to 22 July 2014), the Cochrane Library, CINAHL Plus full text, SPORTDiscus (1985 to 22 July 2014), and Web of Science (cited reference search). The search consisted of four components: concept 1 ‘young athletes’, concept 2 ‘specific anatomic structures of the wrist’, concept 3 ‘specific overuse injuries of the wrist’, and concept 4 ‘outcomes’ (eg, ‘wrist pain’). This resulted in the following search: concept 1 AND (concept 2 OR concept 3 OR concept 4). The complete search is available in online supplementary appendix 1.

Inclusion criteria

Criteria for inclusion based on title and abstract were defined as follows:

  1. Study population: athletes younger than 18 years, performing wrist-loading focus sports (gymnastics, tennis, field hockey, volleyball, judo, or rowing) or other sports that require repetitive loading of the wrist (eg, through weight bearing or high impact to the wrist);

  2. Study design: prospective or retrospective cohort studies, case–control studies, or cross-sectional studies containing original data;

  3. Study outcomes: prevalence or incidence and/or risk factors of wrist pain or non-traumatic or overuse injuries of the wrist.

  4. Language: English, Dutch or German.

The criteria for subsequent inclusion based on full-text articles were:

  1. Study population: mainly athletes younger than 18 years, performing gymnastics, tennis, field hockey, volleyball, judo, rowing, or other sports that require repetitive loading of the wrist; with less than 10% of included athletes older than 18 years or if older athletes were included, the group of athletes younger than 18 years could be analysed apart from the older athletes;

  2. Study outcomes: include a measure of overuse wrist injuries of any kind;

  3. Reported data: incidence rates of overuse wrist injuries per year or any other defined time period, per athlete exposure or per number of training hours, or a consistent exposure rate or number of training hours to be estimated using general sports information; if incidence or prevalence rates are not reported, they can be calculated from the reported data;

  4. If risk factors are assessed, exposure to the sports that require loading or repetitive stress of the wrist is measured in frequency, duration and intensity of wrist loading.

One author (LSK) conducted the literature search. After removal of duplicate records, two of the authors (LSK and PPFMK) independently screened all records based on title and abstract. Consensus was reached on records that were considered eligible by only one of the assessors. The remaining eligible articles were then assessed based on full text.

The reference lists of the included articles were screened for relevant articles. Additionally, all included articles were entered in Web of Science to check for relevant citations after publication.

Data extraction

The data collected from each study included study design, study population, data collection method, sports type and level, definition of overuse wrist injuries, and results. Prevalence and incidence rates were extracted from included studies or calculated from the reported data by two authors (LSK and PPFMK). With respect to risk factors, an adjusted OR was calculated from the data if these were not already reported in the article.

Quality assessment

For quality assessment we used a tool adapted from Shamliyan et al,13 which is presented in online supplementary appendices 2 and 3. One of the authors (LSK) assessed all included articles for quality and three other authors (PPFMK, MM and MHWF-D), each assessed a number of these articles using the same quality assessment tool. Studies with a score of 3 were considered of sufficient quality (see online supplementary appendix 2). In case of disagreement, consensus was reached after consultation between the two assessors.

Outcome measures

For the first research question, the primary outcomes were the number of young athletes sustaining an overuse wrist injury (per athlete exposure) in a sport that requires repetitive loading of the wrist and in particular, in the six sports specified above. If direct prevalence or incidence rates were not reported, they were calculated by dividing the number of athletes with an overuse wrist injury by the total number of athletes in the study.

The primary outcomes for the second research question were all established risk factors for sustaining an overuse wrist injury. Secondary outcomes were percentages of specific overuse wrist injuries in young athletes and the severity of overuse wrist injuries, as measured in, for example, time to return to sport, duration of treatment, or adjustments in training.

Results

The search yielded 3297 results, leading to the inclusion of 11 articles on prevalence and incidence of overuse wrist injuries and 1 article on risk factors, as shown in figure 1. Screening of reference lists and searching Web of Science yielded no additional articles eligible for inclusion.

Figure 1

The process of screening and inclusion and exclusion.

The main reasons for exclusion based on full text were: authors made no clear distinction between traumatic and overuse injuries of the wrist, overuse injuries were not analysed separately for the wrist, or athletes aged younger than 18 years were not analysed separately. Of the 34 articles that were excluded based on full text, 2 studies matched the inclusion criteria, but were performed within (partially) the same population as 2 other articles eligible for inclusion. To prevent selection bias, we excluded the study with the lowest number of participants for both sets of overlapping populations.

The data extracted from the included studies are presented in table 2 (prevalence rates), table 3 (incidence rates) and table 4 (risk factors).

Table 2

Prevalence of overuse wrist injuries and wrist pain

Table 3

Incidence of overuse wrist injuries and wrist pain

Table 4

Risk factors for wrist pain

Study populations

Of the 11 studies that were included for the first research question, 6 studies investigated prevalence rates and 5 investigated incidence rates, as is shown in tables 2 and 3. These studies were performed in the USA, Canada, China, Australia and Greece. Study population sizes varied from 50 to 398 participants, with a total of 620 participants in the 6 studies on prevalence and a total number of 909 participants in the 5 studies on incidence. Nine of these studies were performed among gymnasts of elite and subelite levels, indicated by a variety of level definitions (eg, ‘precompetitive’ or ‘recreational’).15–20 ,22–24 One study described young Chinese opera actors performing training similar to gymnastics training14 and 1 described young elite rowers.21

The mean age of the participants in the studies on prevalence varied from 9 to 14 years. In the studies on incidence, the mean age ranged from 9 to 13 years in different subgroups, with one study only reporting a median age of 18 years. The studies on prevalence contained a total of 405 girls (65%) and the studies on incidence, a total of 578 girls (64%). This corresponds with the large proportion of included studies that focused on gymnastics, a sport that is generally more popular among women compared with men.25

For the second research question, one study on risk factors for overuse wrist injuries was included, describing 52 young gymnasts in the USA.16 The study contained 32 girls (62%) and the mean ages of the included participants were 12 and 11 years for girls and boys, respectively.

Quality assessment

Prevalence was determined in six studies: five cross-sectional studies and one retrospective cohort study. The overall quality of these six studies was scored as ‘good’ in three studies, ‘sufficient’ in two and ‘low’ in one study. Of the five studies that investigated incidence, three were prospective cohort studies and two were cross-sectional studies. Two of these five studies scored ‘good’ quality and three ‘sufficient’ quality.

The one included study on risk factors scored ‘sufficient’ quality. Quality assessment subscores are shown in table 5.

Table 5

Quality assessment subscores*†

Prevalence and incidence

In reporting overuse injuries of the wrist, commonly two types of definition were used, namely ‘overuse wrist injury’ and ‘wrist pain’. We considered these definitions to be two separate entities and have reported them separately in tables 1 and 2.

Prevalence rates of wrist pain varied from 32% to 73% in four of the six included studies on prevalence. The prevalence of wrist pain was 56–67% in the studies rated as good quality14 ,17 and 73% in the study of sufficient quality.16 Two studies described the prevalence of overuse wrist injury, with rates of 28% in the study of good quality18 and 10% in the study of sufficient quality.19

Incidence rates of wrist pain were 7–9% in two studies of sufficient quality.20 ,21 The incidence of overuse wrist injury was 0.6–26% in two studies of good quality23 ,24 and 0.02% in one study of sufficient quality.22

Risk factors

In the prospective cohort study on risk factors for wrist pain in young gymnasts, multiple factors were investigated, including age, sex, height, weight, competitive level, age of initiation of training, years of training, training hours per week, and cumulative exposure hours. Of these factors, four were shown in multivariate analysis to be independently associated with wrist pain: ‘age at start of gymnastics training’, ‘age over 10 years’, ‘age under 14 years’ and ‘intensity of training’. The strongest associations were found between age over 10 and under 14 years and the presence of wrist pain. The adjusted ORs were 208.5, 16.3, 11.5, 1.97 and 1.2 for age under 14 years, age over 10 years, age 10–14 years, age at which training began, and training intensity, respectively.

Secondary outcomes

Only the study by Dixon and Fricker18 reported the distribution of overuse injuries of the wrist. The most commonly found causes of overuse wrist injuries in that study were 8 ligament sprains or strains (20%), and 31 impingement syndromes (76%). Epiphysial stress injury was reported in three girls, and stress fracture in three boys. Similarly, the severity of the overuse injuries was not reported specifically for wrist overuse injuries in many studies. DiFiori et al16 reported differences in grade of wrist pain, with grade 1 in 14 (37%) participants, grade 2 in 16 (42%), and grade 3 in 8 (21%). In 12 (36%) of the participants with wrist pain in another study by DiFiori et al,17 symptoms interfered with training.

Discussion

The aim of this literature review was to determine prevalence and incidence of overuse injuries of the wrist in young athletes and to determine possible risk factors for these injuries. We found prevalence rates of 32–73% for wrist pain and 10–28% for overuse wrist injury, as well as incidences of 7–9% for wrist pain and 0.02–26% for overuse wrist injury in a total number of 11 studies. We found one study on risk factors for wrist pain identifying age between 10 and 14 years as an important possible risk factor.

Wrist-loading sports

Nine of the studies in this literature review described overuse wrist injuries in young gymnasts. Possible reasons for this gymnastics dominance can be the obvious repetitive stress to the wrist that is involved in gymnastics exercises, combined with the fact that overuse wrist injuries in gymnasts have been described in multiple case reports. Apart from gymnastics, many other popular youth sports, such as tennis, field hockey, volleyball, judo and rowing, require repetitive loading of the wrist and could thus put young athletes at risk for overuse wrist injury. However, our extensive search brought up only one article on overuse wrist injuries in rowing and no literature on the prevalence, incidence or risk factors for overuse wrist injuries in other sports. Studies that did report overuse injuries in other sports often only distinguished between traumatic and overuse injuries in general, instead of evaluating overuse injuries by body part.

In the studies on gymnastics, the level of practice varied from beginning level to elite, and the different level definitions used limited comparisons between studies. Overall, based on the numerous definitions of non-elite gymnastics, more lower level gymnasts than elite gymnasts were included. This can be explained in part by the relatively smaller number of elite athletes in any sport compared with recreational or lower level athletes. However, this heterogeneity in level could have caused an underestimation of prevalence and incidence rates, as rates of overuse injuries would be expected to be highest in elite athletes because of their higher exposure to wrist loading in training and competition.

Prevalence and incidence

The large variation in prevalence and incidence rates can be explained in part by the differences in methodology of the included studies. The most reliable manner to obtain information on this subject would be through a prospective cohort study, but unfortunately only three of the included studies were set up using this methodology. This variation, combined with the small number of studies and limited quality of some studies, made comparison between these studies and interpretation of their results difficult. This process was further complicated because of the use of two outcome measures. Five of the included studies used a definition of overuse wrist injury, whereas the remaining six studies investigated wrist pain as the main outcome measure.

Importantly, the term ‘overuse wrist injury’ was defined in multiple ways: for example, wrist pain in the past 6 months versus the past 12 months, or overuse injury diagnosed by a physician versus overuse injury defined as any musculoskeletal symptom of the wrist. Other authors have suggested that using a definition of overuse based on time loss to injury can underestimate the true prevalence or incidence of overuse injuries because for many athletes, the presence of an overuse injury does not immediately lead to time loss to injury.26–28 The presence of pain may be a more accurate measure of overuse injury in the athletic population. This could in part explain the higher prevalence rates for wrist pain than for overuse wrist injury that were reported by the 11 articles in this literature review.

Risk factors

With respect to risk factors for overuse injuries of the wrist, we found only one study that investigated this subject and reported sufficient information on exposure and statistical analysis of risk factors. Our conclusion can thus only provide an indication of possible risk factors for wrist pain in gymnasts. As the article provided only the separate components of the regression model used, we calculated an adjusted OR from the data presented for the assessed risk factors. Age between 10 and 14 years correlated most strongly with wrist pain, with an OR of 11.5, indicating a possibly higher risk of overuse wrist injury in young athletes during their growth spurt. DiFiori et al29 also found this age range to be significantly associated with the presence of wrist pain in young gymnasts.

Strengths and limitations

We applied several methods in order to optimise the overall quality of this literature review. First of all, we used an extensive and broad search consisting of sensitive search strings in six databases to minimise the amount of valuable articles that could be overlooked. Second, two authors independently selected eligible articles based on the inclusion criteria. We applied the PRISMA method for items that should be included in a systematic review.30 While extracting data and interpreting the results, we took into account the quality and risk of bias of each study, based on the quality assessment we performed using a previously used checklist.13

Our study also has limitations. In spite of the broad search, we found only 11 articles that fit the inclusion criteria. We have, therefore, taken the number and heterogeneity of these articles into account while drawing only tentative conclusions.

Additionally, the quality score of the included articles on prevalence and incidence was good in five studies, sufficient in five studies and low in one study. The quality score of the study on risk factors was sufficient. Nevertheless, we decided to include all 11 studies because of the limited amount of overall evidence on the subject of overuse injuries of the wrist in young athletes and took the quality scores into account in the interpretation of the results.

Clinical implications

Clinicians and training staff should be aware that gymnasts aged 10–14 years are at risk of developing wrist pain. A dreaded cause of wrist pain in these athletes is radial epiphysitis—a stress injury to the radial growth plate which is also known as ‘gymnast wrist’.31 Continuing loading of a stress-injured wrist can cause irreversible damage and debilitating long-term symptoms.32 However, DiFiori et al16 found that only 13% of participants with wrist pain contacted a physician. Second, gymnasts with wrist pain can continue training, sometimes with only adjustments in training intensity.31 In one study, as many as 64% of gymnasts with wrist pain did not report that their symptoms interfered with training.17 Close medical supervision, for example, by directly inquiring about the presence of wrist pain on a regular basis, is therefore essential to monitor overuse wrist injuries in young athletes in order to prevent long-term degenerative joint changes.

In the clinical management of young athletes with overuse wrist injuries, assessment of pain level, for example, on a visual analogue scale, may be a more reliable measure for injury severity than evaluation of limitations in sports performance. This further implies that consensus is needed on the injury definition for clinical monitoring as well as for future epidemiological studies on this topic, because using a ‘time loss’ or ‘medical attention’ definition may result in under-reporting. We suggest the use of ‘wrist pain’ instead of ‘overuse wrist injury’ when monitoring overuse injuries of the wrist, which is analogous to statements on overuse injuries in general.26 ,27

Moreover, overuse injury is generally considered to be of gradual onset, while the provoking moment of certain overuse-induced injuries, such as stress fractures, can be sudden, mimicking acute injury.26 When longitudinally monitoring overuse injuries using wrist pain as a measure for wrist overuse injury, documenting both the moment of onset and injury history as a possible risk factor for reinjury is essential.

Finally, the limited number of studies underlines the need for information on prevalence, incidence and risk factors of overuse injuries of the wrist in young athletes. Especially in wrist-loading sports other than gymnastics, the wrist-loading pattern suggests these athletes are at risk of overuse wrist injuries. Small case series of overuse wrist injuries support this hypothesis. In the expanding young population at risk for overuse injury due to the increase in youth sports’ participation, overuse wrist injuries may become a major concern that requires alertness on the part of the clinicians and thus, further knowledge on case definitions, occurrence and risk factors. A structured methodology, including exposure measurements and risk factor analysis, is fundamental value for future studies on this subject to improve study quality, reliable results and clinical applicability.

Conclusions

Prevalence and incidence of overuse wrist injuries are diverse among gymnasts, with high peaks in multiple studies. Clinicians should be aware that gymnasts aged 10–14 years, with high-training intensity and earlier onset of training are possibly at risk for wrist pain. In other wrist-loading youth sports, such as those popular in the Netherlands, the occurrence of overuse wrist injuries is unknown despite numerous case series addressing this problem in young athletes. We recommend risk factor evaluation using wrist pain as a definition for overuse to identify overuse wrist injuries in young athletes earlier with a view to superior management of overuse wrist injuries and prevention of complications.

What are the new findings of this study?

  • The literature on prevalence, incidence and risk factors for overuse wrist injuries in young athletes focuses mainly on young gymnasts.

  • There is a lack of information on the occurrence and risk factors of overuse wrist injuries in young athletes performing wrist-loading sports other than gymnastics.

  • Clinicians should be aware that an age between 10 and 14 years is a high-risk period for wrist overuse injuries in gymnasts; this may warrant screening for wrist injuries.

  • Wrist pain is a suitable definition to detect overuse injuries of the wrist in young athletes performing wrist-loading sports.

  • Young gymnasts often continue to train with wrist pain without seeking timely medical attention, thus close medical supervision is recommended to mitigate the potential for irreversible damage to the growing wrist.

Acknowledgments

The authors would like to acknowledge Joost G Daams who assisted in performing the extensive literature search.

References

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Supplementary materials

  • Supplementary Data

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Footnotes

  • Contributors All five authors contributed to formulation of the study design and inclusion criteria. LSK performed the literature search together with JGD; LSK and PPFMK performed article screening and inclusion. LSK performed data extraction from the included articles. Quality assessment of included articles was performed by LSK, PPFMK, MM and MHWF-D. All five authors contributed to drafting and revising of the article, and approved of the final article before submission. MM and MHWF-D contributed equally as last authors of this paper.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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