Radial Epiphyseal Stress Reaction

Original Editor - Trista Chan
Top Contributors - Trista Chan and Carina Therese Magtibay

Introduction[edit | edit source]

Radial epiphyseal stress reaction is a common overuse injury affecting skeletally immature athletes engaged in high-impact sports[1]. It is particularly common among gymnasts, thus it is also known as the ‘gymnast’s wrist’. It is found that up to 32-73% of youth athletes are affected by wrist pain from overuse injuries[2], and 15% of which involves the growth plate[3].


Clinically Relevant Anatomy[edit | edit source]

 Radial epiphyseal stress reaction involves the distal radial physes (also called growth plates)[1], which is located at the end of the long bone where secondary ossification centres for growth and development occur [5]. The growth plates are especially susceptible to injuries in children and adolescents[6], but most commonly in children between 10-14 years old[3]. <be>

Mechanism of Injury / Pathological Process[edit | edit source]

Activities that put repetitive compressive, shearing, distraction and torsional forces through the distal radial growth plates[2], such as handstands, cartwheels and handsprings, increase the risk of growth arrest in this population[1].


Clinical Presentation[edit | edit source]

Gymnast wrist often presents as pain, swelling, tenderness, limited range of motion and wrist instability during physical examination. Palpation along the distal radius growth plate and over dorsal rim radius often reproduce pain. Patients often report symptoms being aggravated by weight-bearing activities or impact-related activities.

Diagnostic Procedures[edit | edit source]

Diagnostic procedures for gymnast wrist typically involve a combination of clinical reasoning and imaging findings. Clinical assessment includes comprehensive medial history, patient-reported symptoms and physical examination. The athlete is then often referred for a radiographic or MRI scan if injury to the growth plate is suspected. Diagnostic criteria[2] include:

  • widening of the growth plate in the palmar and radial side.
  • cystic changes in the metaphysis
  • beaked appearance of the distal palmer and radial parts of the growth plate,
  • blurry appearance within the growth plate



Outcome Measures[edit | edit source]

Management / Interventions[edit | edit source]

Management of the gymnast wrist often involves a multidisciplinary team including orthosurgeons, peadiatricians, physiotherapists, and coaches. Patients with epiphyseal injury may be managed conservatively or surgically, depending on severity of the imaging findings, individual factors and goals[10].

Conservative management[edit | edit source]

Physiotherapists play an important role in conservative management which includes rest and immobilization with splints or casts[3].


Advice and education regarding activity modification is also important to maintain function[3]. When pain and symptoms subside, exercise should be implemented in their management plan to help improve strength, range of motion and motor control[3]. This generally takes 4-6 weeks but can also last up to 3-5 months, until the athlete can gradually return to training if their symptoms continue[3].


Physiotherapist should work closely with the patient, their coaches and other members of the multidisciplinary team to ensure early goal setting and safe return to sports, as well as providing guidance in self-management[1].

Medical management[edit | edit source]

The patients should be referred for medical consults if a fracture is suspected. Orthopedic surgeons are responsible in assess the severity of the wrist injury, order appropriate imaging tests such as, X-rays, CT, MRI[13]. Based on the imaging findings, individual factors, and goals, they may recommend whether conservative management or surgical intervention is necessary. If surgery is required, orthopedic surgeons perform procedures such as arthroscopy, osteotomy, or fixation to address the injury[13]. They may also provide guidance on post-operative care and rehabilitation protocols.

Differential Diagnosis[edit | edit source]

Reference[edit | edit source]

  1. 1.0 1.1 1.2 1.3 Brukner P, Khan K, Cook J, Cools A, Crossley K, Hutchinson M, et al. ebook Brukner and Khan's Clinical Sports medicine Sydney: McGraw-Hill Education (Australia) Pty Limited; 2016. ‌
  2. 2.0 2.1 2.2 Mauck B, Kelly D, Sheffer B, Rambo A, Calandruccio JH. Gymnast’s Wrist (Distal Radial Physeal Stress Syndrome). Orthopedic Clinics of North America. 2020 Oct;51(4):493–7. ‌
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Arnold A, Thigpen CA, Beattie PF, Kissenberth MJ, Shanley E. Overuse Physeal Injuries in Youth Athletes. Sports Health: A Multidisciplinary Approach [Internet]. 2017 Feb 6;9(2):139–47. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349397/ ‌
  4. www.youtube.com. (n.d.). Gymnast Wrist 4. [online] Available at: https://youtu.be/ywfE4gGgSKk [Accessed 27 Jun. 2023]. ‌
  5. Gray’s Atlas Of Anatomy. S.L.: Elsevier; 2020. ‌
  6. 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. European Journal of Sport Science. 2020 Jan 12;20(9):1197–205. ‌
  7. www.youtube.com. (n.d.). Growth plate injuries. [online] Available at: https://www.youtube.com/watch?v=YSjwphWU2LA [Accessed 27 Jun. 2023]. ‌
  8. www.youtube.com. (n.d.). Gymnast wrist (Radiopaedia.org) Cases in Radiology. [online] Available at: https://www.youtube.com/watch?v=lP5Jj4VBgsY [Accessed 27 Jun. 2023]. ‌
  9. www.youtube.com. (n.d.). Pediatric MSK MRI Case Review - Gymnast Wrist. [online] Available at: https://www.youtube.com/watch?v=I16uESf8CIw [Accessed 27 Jun. 2023]. ‌
  10. Nguyen JC, Markhardt BK, Merrow AC, Dwek JR. Imaging of Pediatric Growth Plate Disturbances. RadioGraphics. 2017 Oct;37(6):1791–812. ‌
  11. www.youtube.com. (n.d.). Occupational therapy: Custom splints. [online] Available at: https://www.youtube.com/watch?v=8XY2WVyDiiU [Accessed 28 Jun. 2023]. ‌
  12. www.youtube.com. (n.d.). Exercises to Relieve Wrist Pain | Gymnastics Rehabilitation Series. [online] Available at: https://www.youtube.com/watch?v=P9FmsUDY8fE [Accessed 28 Jun. 2023]. ‌
  13. 13.0 13.1 Beck, B. and Drysdale, L. (2021). Risk Factors, Diagnosis and Management of Bone Stress Injuries in Adolescent Athletes: A Narrative Review. Sports, 9(4), p.52. doi:https://doi.org/10.3390/sports9040052. ‌