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Abstract

Background:

Adolescent gymnasts are at increased risk for wrist pathology due to repetitive high-impact wrist loading during the midgrowth spurt.

Purpose:

To conduct a comprehensive systematic review on the epidemiology and risk factors for wrist pain and injury in adolescent artistic gymnasts.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Under PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched MEDLINE, EMBASE, CINAHL, Cochrane, and SPORTDiscus from inception to January 2025. We included observational studies of adolescent artistic gymnasts that reported prevalence, incidence, and/or risk factors for wrist pain, acute injuries, chronic injuries (causing physeal stress or not attributable to a specific acute event), or positive ulnar variance (PUV). Where applicable, meta-analyses were conducted to estimate the pooled prevalence and proportion of new cases for each outcome using common- or random-effect models. Results from studies that were not possible to pool were also reported.

Results:

Of the 3650 records identified, 25 studies (185,107 gymnasts) were included for analysis. All evidence was deemed low to very low certainty. Nine studies suggested a pooled wrist pain prevalence of 53% (95% CI, 39%-66%), with 1 study reporting the proportion of new wrist pain cases to be 2% over 1 year. The prevalence of acute wrist injuries reported in 1 study was 34%, and the pooled proportion of new cases was 4% (n = 2 studies; 95% CI, 2%-7%) over a 2-year period. The pooled prevalence of chronic wrist injury was 36% (n = 6 studies; 95% CI, 12%-71%), and the pooled proportion of new chronic wrist injury cases was 5% (n = 2 studies; 95% CI, 3%-10%) over a 2-year period. Two studies suggested a pooled PUV prevalence of 4% (95% CI, 1%-14%), with 1 study reporting the proportion of new PUV cases to be 16% over an 18-month period in preteen gymnasts (mean ± SD age, 10 ± 2 years). Wrist pain was significantly associated with age between 10 and 14 years, increased age at training onset, training intensity, body mass index, years training, and weekly training hours.

Conclusion:

Our review demonstrated that adolescent artistic gymnasts demonstrate an alarmingly high prevalence of acute and chronic wrist pain and wrist injury. Further research on training intensity thresholds and risk reduction strategies is imperative for informing and implementing guidelines that protect the health of this vulnerable population.

Keywords

gymnastics wrist biology of bone biomechanics of bone epidemiology pediatric sports medicine

Gymnasts have a high incidence of injuries, with previous reports showing rates up to 9.22 per 1000 athlete-exposures.²⁸ Frequently employed as a weightbearing joint, the hyperextended wrist may experience loads up to twice the gymnast's body weight and at loading rates that exceed 16 times one's weight per second.³⁴ However, compared with typical weightbearing joints such as the knee, the wrist comprises bones that articulate over smaller contact areas and that contain thinner articular cartilage.^36,38,40,45 Consequently, wrist pain is a significant concern in gymnasts, with point and lifetime prevalence rates of 88% and 92%, respectively.^33,50 Wrist injuries are also prevalent, making the wrist the most frequently injured area in male gymnasts and the sixth most injured in their female counterparts.⁵⁴

Key to the success of artistic gymnasts, specifically, is the production of high forces at the hand and wrist while performing on apparatuses such as the floor and vault.²¹ However, for the artistic gymnast in the peak of one's adolescent growth spurt, repeated exposure to such loads may present several consequences to the open physis of the wrist. During this period of rapid skeletal growth, the distal radius and ulnar physes are particularly susceptible to shear and tensile forces that can result in physeal injury, disturbance in chondrocyte mineralization, and longitudinal growth disruption.¹⁵ This overuse physeal stress injury is otherwise known as the “gymnast wrist” (GW).⁴¹ GW has previously been cited among the most common causes of wrist pain or injury in gymnastics.^14,23 GW presents in 3 stages, with stage 1 characterized by wrist pain without radiographic abnormalities.²⁶ Stage 2 demonstrates radiographic findings of physeal change indicating stress (chronic) injury, and stage 3 is determined by acquired positive ulnar variance (PUV) or other growth deformity.²⁶

Although other high-risk sports have evidence-based guidelines for promoting player safety, including the pitch count in baseball,³² concussion guidelines in football,⁵² and neuromuscular training protocols in soccer,²⁷ gymnastics lacks similar injury risk reduction guidelines, including that for GW. Increasing awareness of the risk factors associated with wrist pain, injury, and growth disturbances is crucial for developing effective injury risk reduction strategies that promote the health and career longevity of young artistic gymnasts. Previous studies have narratively reported on these outcomes,^8,30 but a meta-analysis has yet to be conducted. We wanted to provide a comprehensive systematic review and meta-analysis of literature in this population to provide insights into specific wrist injury mechanisms and identify risk factors. The purpose of this study was to present the prevalence and incidence of wrist pain and other findings associated with wrist injury (including GW) in the adolescent artistic gymnast and to identify and evaluate the risk factors that may contribute to its development. We hypothesized that the prevalence and incidence of wrist pain and wrist injury would be high in adolescent artistic gymnasts and that the risk for these outcomes would be increased among gymnasts in the peak of their adolescent growth spurt.

Methods

Standards for Meta-Analysis of Observational Studies and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed.

Literature Search and Study Selection

A literature search was conducted in collaboration with a librarian using MEDLINE, EMBASE, CINAHL, Cochrane, and SPORTDiscus (Appendix Table A1, A -E). All databases were searched from inception to January 2025 and no limits were applied. Reference lists of eligible studies and related reviews were reviewed for additional articles. The finalized reference list was imported to an online screening platform (Covidence 2024). Two authors (S.D.F.D, E.D.) independently screened the title and abstract to assess studies’ eligibility for inclusion. These 2 authors then independently screened the eligible studies according to their full text. Conflicts present at either stage were resolved by a third author (A.N.).

Eligibility Criteria

We included observational studies that enrolled an adolescent (≤19 years) artistic gymnast population and reported ≥1 of the following outcomes: prevalence, incidence, and/or risk factors for wrist pain, acute and/or chronic injuries, or PUV in gymnasts. To distinctly evaluate the prevalence and incidence of wrist pathology, studies that reported pain or injury attributed to both the wrist and the hand together or combined acute and chronic types of injuries were excluded. We excluded studies examining adult gymnasts only (>19 years), randomized controlled trials, small case series (N < 20), laboratory-based studies, reviews, posters, or abstracts. We also excluded studies that observed other gymnastic disciplines only (ie, rhythmic, aerobic, acrobatic, or trampoline).

Data Extraction and Risk-of-Bias Assessment

Two reviewers (S.D.F.D. and E.D.) independently extracted study characteristics, gymnasts’ information (competitive level, start age, weekly training hours, total years training, whether pain/injury affected training, apparatuses causing pain/injury), and reported outcomes among eligible studies. If prevalence rates were not reported directly, the number of gymnasts reported to have pain, injury, or PUV was divided by the total number of gymnasts. The proportion of new cases of wrist injury was collected per total number of gymnasts. Studies that reported the outcomes per total number of injuries were reported separately. Wrist pain was defined as the presence of any type of pain in the wrist not attributed to a specific traumatic event or diagnosed injury at the time of data collection. This definition captured overuse-related or idiopathic pain and was considered distinct from wrist injury, which was defined as a discrete diagnosis. Injuries were categorized as acute or chronic based on the definition provided in the respective study. Acute injuries were those described as either sudden onset injuries resulting in time lost from sport or medical treatment or reports of acute wrist sprain, strain, and/or fracture. Chronic injuries were those described as either overuse physeal stress injuries (ie, GW) or diagnosed injuries not attributable to a specific acute event (with or without time lost from sport). For the second objective, we extracted data related to significant risk factors identified via a regression model.

We evaluated the risk of bias in the eligible studies using the following criteria¹¹: (1) the representativeness of the study population—considered high risk if participant recruitment was inadequately described or convenience sampling was used; (2) the validity of the outcome assessment—considered high risk if unvalidated/unreliable instruments (eg, self-report questionnaires) were used; and (3) the amount of missing data—considered high risk if >20% of data were missing at follow-up. For studies that reported risk factors, we also assessed the risk of bias using the following criteria¹¹: the control of confounding variables—considered high risk if the study did not adjust for ≥3 potential covariates and the method of statistical analysis—considered high risk if the study did not use a standard method of analysis to reduce bias. The same 2 independent reviewers assessed the risk of bias and discussed with a senior author (A.N.) if discrepancies were raised. The overall risk of bias for each study was summarized as high if any one of the criteria was determined to be high risk.

Statistical Analysis

We conducted a meta-analysis for each outcome that was reported from 2 studies using the common-effects model (RStudio 2024, Boston, Massachusetts). Outcomes reported from more than two studies were meta-analyzed using the random-effects model. We quantified the pooled prevalence or pooled proportion of new cases along with the associated 95% CI. We conducted the meta-analysis with prevalence estimates that were transformed using the double arcsine method⁶ to avoid the overestimation of weights for studies with estimates toward 100%. We also reported the results of studies that were not possible to pool.

Subgroup Analysis

We defined the following a priori subgroup hypotheses to explain heterogeneity, assuming higher rates of wrist pain/injury with (1) female versus male gymnasts; (2) smaller (<60) versus larger (≥60) studies; (3) competitive- versus noncompetitive-level gymnasts (differentiated based on whether gymnasts participated in competitions); and (4) high versus low risk of bias on a criterion-by-criterion basis. Subgroup analyses were conducted if there were ≥2 studies within each category. For all subgroup differences, significance was set at an alpha of .05.

Certainty of Evidence

We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach framework to assess the certainty of evidence.⁴⁴ GRADE classifies evidence as high, moderate, low, or very low based on considerations of risk of bias, indirectness, imprecision, inconsistency, and publication bias. We examined heterogeneity for all pooled estimates through visual inspection of forest plots and the I². For subgroup analyses based on the risk-of-bias components, if no significant association was found, we included all studies and did not rate down for risk of bias. We assessed the small-study effects using Egger test when ≥10 studies contributed to a meta-analysis. One reviewer (S.D.F.D.) assessed all evaluations, and the final assessment was confirmed by the senior author (A.N.).

Results

We identified 3650 records after removing duplicates, of which 25 articles met the eligibility criteria (Appendix Figure A1). Two studies^5,19 were published by the same group of authors and both involved participants from the Junior European Gymnastics Championships. As the study population overlapped, we included the most recent publication⁵ only. The majority of included studies implemented a cross-sectional design (n = 14),^†† followed by a retrospective design (n = 5),^{1,20,37,49,55} prospective design (n = 5),^2,7,16,31,35 and case series (n = 1).⁴¹

Most studies (n = 20)^‡‡ included competitive-level gymnasts. Two studies^10,46 included members of a Chinese opera school who performed gymnastics-like training and three^1,49,55 did not report gymnasts’ competitive level (Table 1). Seven studies^{3,15,16,18,22,41,50} reported the apparatuses on which gymnasts experienced pain or injury. Among the included studies, the sample size ranged from 19 to 183,139 participants and the mean female proportion was 76%. The median age of gymnasts was 12 years (IQR, 11-14). Among the 8 studies in which it was recorded,^{2-4,15-17,20,43} the median body mass index (BMI) was 17 kg/m² (IQR, 17-18). Across studies, the median age at which gymnasts commenced training was 6 years (IQR, 5-7), the median hours of training per week was 17 hours (IQR, 12-22), and the median total years of training was 6 years (IQR, 5-8). Across 6 studies,^{3,15,16,18,22,50} wrist pain and/or injury affected training (ie, limited performance or caused time lost) for 30% to 63% of gymnasts. The method of assessing wrist pain or injury and the time that either was observed varied among the included studies (Appendix Table A2).

Table 1

Characteristics of Included Studies^a

General Information						Gymnastics-Related Information
Author (y)	Study Design (country)	N	Age, y	Female, %	BMI	Competition Level	Start Age, y	Training Hours, h/Week	Total Training Time, y	WP/Injury Affected Training, %	Apparatus Causing WP/Injury
Albright et al (2023)¹	Retrospective (USA)	183,139	12	86
Amaral et al (2015)³	Cross-sectional (Portugal)	23	11 ± 3	0	17 ± 2	Competitive	6 ± 2	18 ± 4	5 ± 3	30	Pommel horse
Amaral et al (2014)²	Prospective (Portugal)	25	10 ± 2	64	17 ± 2	Competitive	5 ± 2	17 ± 3	5 ± 2
Amaral et al (2012)⁴	Cross-sectional (Portugal)	33	11 ± 2	100	17 ± 2	Competitive	5 ± 1	17 ± 4	6 ± 2
Aubergé et al (1984)^{5 b}	Cross-sectional (France)	98		58		Competitive
Caine et al. (1992)⁷	Prospective (USA)	60	13	65		Competitive
Chang et al (1995)¹⁰	Cross-sectional (Taiwan)	261	14 ± 2	55		Gymnastics-like training
DeSmet et al (1994)¹²	Cross-sectional (Belgium)	191	16	100		Competitive	7	27
DiFiori et al (2002)¹⁶	Prospective (USA)	47	10 ± 2	45	17	Competitive	5 ± 2	8 ± 4	4 ± 2	42	Beam, floor, pommel horse
DiFiori et al (2002)¹⁵	Cross-sectional (USA)	59	9 ±2	47	17	Competitive	5 ± 2	7 ± 4	4 ± 2	36	Beam, floor, pommel horse
DiFiori et al (1997)¹⁷	Cross-sectional (USA)	44	12 ± 3	61	18	Competitive	6 ± 2	12 ± 6	5 ± 2
DiFiori et al (1996)¹⁸	Cross-sectional (USA)	52	12	62		Competitive	7 ± 2	12 ± 5	5 ± 3	63	Vault, floor, pommel horse, parallel bars
Fari et al (2021)²⁰	Retrospective (Italy)	79	14 ± 3	99	18 ± 2	Competitive			7 ± 3
Guerra et al (2016)²²	Cross-sectional (Brazil)	19	13	0		Competitive	6	26	8	47	Floor, pommel horse, parallel bars
Konrad and Pförringer (1997)²⁹	Cross-sectional (Germany)	289				Competitive		11	9
Lindner and Caine (1990)³¹	Prospective (Canada)	178		100		Competitive
McLaren et al (2015)³⁵	Prospective (USA)	50	13	100		Competitive			8
O’Kane et al (2011)³⁷	Retrospective (USA)	96	11 ± 2	100		Competitive
Roy et al (1985)⁴¹	Case series (USA)	21	12	90		Competitive		27			Beam, vault, floor, uneven bars
Sastre-Munar et al (2022)⁴³	Cross-sectional (Spain)	59	17 ± 4	85	21 ± 2	Competitive	7	21 ± 15	10 ± 5
Shih et al (1995)⁴⁶	Cross-sectional (Taiwan)	47		21		Gymnastics-like training
Swenson et al (2012)⁴⁸	Cross-sectional (USA)			100		Competitive
Tisano et al (2022)⁴⁹	Retrospective (USA)
Trevithick et al. (2018)⁵⁰	Cross-sectional(Australia)	237	15 ± 3	80		Competitive				35	All apparatuses
Wood et al (2010)⁵⁵	Retrospective (Scotland)
Median(IQR)			12 (11-14)		17 (17-18)		6(5-7)	17(12-22)	6(5-8)

Data are presented as mean ± SD where available unless otherwise indicated. BMI, body mass index; WP, wrist pain.

Includes overlapping data with Duvallet et al.¹⁹ Only the results of the most recent publication (Aubergé et al⁵) were included.

Risk of Bias

Among the eligible studies, 80% (20 out of 25)^§§ were considered to have a high risk of bias in ≥1 criterion. Sixteen studies^‖‖ failed to recruit a representative population, 11 studies^¶¶ did not use a valid tool for assessing outcomes, and 5 studies^{20,29,31,37,50} reported a high rate of missing data (Appendix Table A3). Among studies that reported risk factors, 50% (2 out of 4)^20,22 were considered to have a high risk of bias, with both demonstrating high risk in each of the criteria used (Appendix Table A4).

Wrist Pain

Very low certainty of evidence from 9 studies^## (n = 839 adolescent gymnasts) suggested a pooled prevalence of wrist pain of 53% (95% CI, 39%-66%; I² = 91%) (Table 2, Appendix Figure A2). No subgroup analyses were significant (Appendix Figure A3). Only 1 study¹⁶ reported the proportion of new cases of wrist pain, which was 2% (1/47 gymnasts) over the 1-year study period.

Table 2

GRADE Evidence Profile With Summary of Findings^a

Outcome	Studies, n	Gymnasts, n	ROB	Inconsistency	Indirectness	Imprecision	Publication Bias	Effect Estimate, % (95%CI)	Overall Certainty of Evidence
Prevalence of wrist pain	9	839	Not serious^b	Serious^c	Not serious	Serious	Not detected	53 (39-66)	Very low
Prevalence of chronic wrist injury	6	433	Serious	Serious^c	Not serious	Serious	Not detected	36 (12-71)	Very low
Proportion of new cases of acute wrist injury	2	274	Serious	Not serious	Not serious	Not serious	Not detected	4 (2-7)	Low
Proportion of new cases of chronic wrist injury	2	274	Serious	Serious^c	Not serious	Serious	Not detected	5 (3-10)	Very low
Prevalence of PUV	2	56	Serious	Not serious	Not serious	Serious	Not detected	4 (1-14)	Very low

GRADE, Grading of Recommendations Assessment, Development and Evaluation; PUV, positive ulnar variance; ROB, risk of bias.

Certainty of evidence was not rated down on the basis of ROB because the subgroup analyses did not show a significant difference between each ROB component and the estimation (Appendix Figure A3, B-D).

Serious unexplained inconsistency (I² = 75%-100%).

Acute Wrist Injury

Only 1 study⁴⁶ reported the prevalence of acute wrist injury per total number of gymnasts, which was 34% (16/47 gymnasts). Data from 3 studies^29,48,55 reported that acute wrist injury accounted for between 22% and 46% of the total number of injuries.

Low certainty of evidence from 2 studies^31,37 (n = 274 adolescent gymnasts) suggested a pooled proportion of new cases of acute wrist injuries over a median 2-year period of 4% (95% CI, 2%-7%; I² = 39%) (Table 2, Appendix Figure A4A). Additionally, 2 studies not included in the meta-analysis because of insufficient data reported the proportion of new cases of acute injury as 5% over an 8-year period¹ and 10% over a 7-year period.⁴⁹

Chronic Wrist Injury

Very low certainty of evidence from 6 studies^{5,7,12,17,22,41} (n = 433 adolescent gymnasts) suggested the pooled prevalence of chronic wrist injury was 36% (95% CI, 12%-71%; I² = 96%) (Table 2, Appendix Figure A5). No subgroup analyses were significant (Appendix Figure A6).

Very low certainty of evidence from 2 studies^31,37 (n = 274 adolescent gymnasts) suggested a pooled proportion of new cases of chronic wrist injuries over a median 2-year period of 5% (95% CI, 3%-10%; I² = 83%) (Table 2, Appendix Figure A4B).

Positive Ulnar Variance

Very low certainty of evidence from 2 studies^3,4 that employed the Hafner Method for skeletally immature patients (n = 56 adolescent gymnasts) suggested a pooled prevalence of PUV of 4% (95% CI, 1%-14%; I² = 0%) (Table 2, Appendix Figure A7). Across all gymnasts in these studies, the mean age was 11 ± 0.05 years, and the mean ulnar variance (UV) was −3 ± 2 mm. The remaining studies employed the method of perpendiculars¹⁰ or the concentric circle technique,¹² both of which are more appropriate for skeletally mature individuals. Respectively, these studies reported PUV prevalence rates of 46% (mean age, 14 ± 2 years; mean UV, +0.5 ± 2 mm) and 71% (mean age, 16 years [SD not reported]; mean UV, +2 ± 1 mm). A single study among 25 gymnasts aged 10 ± 2 years reported that 16% acquired PUV after 18 months.²

Wrist Pain Risk Factors

Four studies^16,18,20,22 reported the risk factors associated with wrist pain in adolescent gymnasts (Table 3); however, their findings could not be meta-analyzed due to insufficient data. Multiple factors related to wrist pain were investigated including age, age at training onset, training intensity, BMI, years of training, and weekly training hours. Risk factors related to the chronological age of gymnasts were cited most frequently.^16,18,20 Only 1 study¹⁸ reported the adjusted odds ratio (AOR) for significant risk factors among gymnasts including age >10 years (AOR, 16.28), age <14 years (AOR, 208.51), older age at training onset (AOR, 1.97), and increased intensity of training (AOR, 1.19) (defined as the product of training hours per week and competitive level grouping). Based on these findings, the risk for wrist pain was suggested to be significantly increased in gymnasts between 10 and 14 years old.¹⁸ Another study also reported increased BMI (OR, 1.72) and increased number of years training (OR, 1.02) as significant risk factors.²⁰

Table 3

Significant Wrist Pain Risk Factors^a

Author (y)	Type of Analysis Used	Risk Factor	Odds Ratio		P
Author (y)	Type of Analysis Used	Risk Factor	Crude	Adjusted	P
DiFiori et al (2002)¹⁶	Multivariable logistic regression	Age (10-14 y)	NR	NR	.03
DiFiori et al (1996)¹⁸	Multivariable logistic regression	Age (>10 y)	NR	16.28	.02
		Age (<14 y)	NR	208.51	.02
		Increased age at training onset	NR	1.97	.02
		Increased training intensity	NR	1.19	.04
Fari et al (2021)²⁰	Univariate logistic regression	Increased years of training (right wrist)	1.02	NR	.03
		Increased years of training (left wrist)	1.02	NR	.02
		Increased age (right wrist)	1.23	NR	.03
		Increased age (left wrist)	1.46	NR	.004
		Increased BMI (right wrist)	1.72	NR	.001
Guerra et al (2016)²²	Chi-square	Increased weekly training hours	NR	NR	.04

BMI, body mass index; NR, not reported.

In studies reporting on specific events,^{3,15,16,18,22,41,50} all gymnastics apparatuses (floor, pommel horse, balance beam, vault, parallel bars, horizontal bars, uneven bars, rings) were reported to cause wrist pain or injury (Table 1). However, the floor was the most reported apparatus used by both sexes to cause pain or injury among the studies.^{15,16,18,22,41,50} The pommel horse^{3,15,16,18,22,50} and balance beam^15,16,41,50 were the most reported male-only and female-only apparatuses, respectively.

Discussion

The major finding of this systematic review and meta-analysis of 25 studies was that young gymnasts demonstrated an alarmingly high prevalence of wrist pain and wrist injury. The highest risk identified was in 10- to 14-year-olds, which corresponds to the adolescent growth spurt. Wrist pain occurred in 53% of adolescent artistic gymnasts with a proportion of new cases of 2% over 1 year. Acute wrist injury occurred in 34% with a proportion of new cases of 4% over a median 2-year period, and chronic wrist injury occurred in 36% of adolescent gymnasts with a proportion of new cases of 5% over a median 2-year period. This study also found that PUV occurred in 4%, with a proportion of new cases of 16% over an 18-month period in preteen gymnasts.

While this study failed to establish a direct relationship between rates of distal radial physeal stress injury (GW) and PUV, it has previously been reported that GW can result in a 10% growth disturbance rate with 3% of those affected requiring surgical correction.²⁵ Despite the acknowledgement for such consequences in the literature, this review identified a lack of consistent and specific reporting of the GW diagnosis across included studies. This makes it impossible to determine the true pooled rates of related complications such as pain or permanent skeletal changes.

The current review demonstrated that ages between 10 and 14 years, as well as increased age at training onset, training intensity, BMI, years of training, and weekly training hours were significant risk factors for wrist pain development in adolescent gymnasts. Risk factors related to the chronological age of gymnasts were cited most frequently.^16,18,20 Only 1 study¹⁸ quantified the AOR for this variable and observed gymnasts between 10 and 14 years old to be at increased risk. This age cohort coincides with the onset of the adolescent growth period and encompasses the period of peak growth velocity (PGV), which occurs around 11 to 12 years in girls and 13 to 15 years in boys^51,53 and reflects the maximal growth during the midgrowth spurt.⁵¹ During this period, alterations in the rate of mineralization cause temporary weakness, making the distal radial physis increasingly susceptible to injury.¹⁸ Repeatedly exposing the wrist to high-impact loads during the vulnerable PGV period may explain the relationship between age and gymnasts’ increased risk for wrist pain. Microtraumatic changes to the distal radial physis that result from these repetitive, high-impact wrist loads may also explain the association of wrist pain/injury with increased training intensity, increased BMI, more years of training, and longer weekly training hours.²⁶ Furthermore, gymnasts who initiate their training at a later age may be closer to/within this vulnerable growth period, possibly increasing the risk for wrist pain/injury that is a direct result of GW.¹⁸

Future Recommendations

Adolescent gymnasts experience high-intensity training during the period of peak skeletal growth.¹³ This highlights the need for evidenced-based SafeSport guidelines that optimize long-term wrist health by minimizing injury and permanent growth disturbances. Prospective studies using validated and systematically collected outcome measures are recommended to improve the epidemiological understanding of diagnosis-specific risk factors and to clarify the influence of training volume and training intensity on pain or injury. These are necessary to inform future injury surveillance tools and establish parameters for risk reduction guidelines. Finally, studies that examine other biomechanical and morphological factors suggested to influence wrist pain and injury risk, such as wrist braces, soft mats, and joint angles,^9,24,39,41 will further aid in developing guidelines that are both relevant and informed.

Strengths and Limitations

The main strengths of this study include the conducting of a comprehensive search and applying of explicit eligibility criteria, which allowed for inclusion of more studies in the current review compared with previous related reviews,^8,30 as well as pooling of key outcomes. This review, however, was limited by the inclusion of studies with high risk of bias, as well as by heterogeneous definitions of pain/injury, study designs, and reported outcomes. Many studies reporting risk factors failed to present odds ratios or report on other athlete-specific and external factors previously suggested to influence GW risk.⁵³ Last, the failure to discriminate among specific wrist injury diagnoses including GW, as well as a general tendency for gymnasts to underreport wrist pain or injury^42,47 and overconformity to sport ethics, may all contribute to an underrepresentation of the true prevalence and incidence of the reported outcomes included in this study.

Conclusion

Footnotes

Appendix

The following searches were conducted on February 2, 2024, and January 14, 2025.

Final revision submitted August 15, 2025; accepted September 18, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: This study is supported by the Tanenbaum Institute for Science in Sport (TISS) Research Accelerator Grant. The TISS grant has supported conference fee reimbursement to present this research at the Annual TISS conference and supports the umbrella research program under which this project falls. S.D.F.D. has received funding from the Canada Graduate Scholarships–master’s program and partial funding under the TISS Research Accelerator Grant. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

ORCID iDs

Stefania D.F. DiLeo

Atefeh Noori

Erin Day

Timothy A. Burkhart

Andrea H.W. Chan

††

References 3 -5, 10, 12, 15, 17, 18, 22, 29, 43, 46, 48, .

‡‡

References 2 -5, 7, 12, 15 -18, 20, 22, 29, 31, 35, 37, 41, 43, 48, .

§§

References 2, 3, 5, 7, 10, 12, 15 -18, 20, 22, 29, 31, 35, 37, 41, 46, 48, .

‖‖

References 2, 5, 7, 10, 12, 15 -18, 20, 22, 31, 35, 41, 46, .

¶¶

References 3, 10, 15, 16, 18, 20, 29, 31, 35, 37, .

##

References 3, 10, 15, 18, 20, 22, 35, 43, .

References

Albright

Meghani

Lemme

Owens

Tabaddor

Characterization of musculoskeletal injuries in gymnastics participants from 2013 to 2020. Sports Health. 2023;15(3):443-451. doi:10.1177/19417381221099005

Amaral

Claessens

Ferreirinha

Maia

Santos

Does ulnar variance change with age and what is the influence of training and biological characteristics in this change? A short-term longitudinal study in Portuguese artistic gymnasts. Clin J Sport Med. 2014;24(5):429-434.

Amaral

Claessens

Ferreirinha

Santos

Ulnar variance related to biological and training characteristics, pain and handgrip strength in Portuguese skeletally immature male gymnasts. J Sport Health Sci. 2015;4(2):174-181. doi:10.1016/j.jshs.2013.04.004

Amaral

Claessens

Ferreirinha

Santos

PJ.

Ulnar variance related to biological and training characteristics and handgrip strength in Portuguese skeletally immature female gymnasts. J Sports Med Phys Fitness. 2012;52(4):393-404.

Aubergé

Zenny

Duvallet

Godefroy

Horreard

Chevrot

Study of bone maturation and osteo-articular lesions in top level sportsmen. J Radiol. 1984;65(8-9):555-561.

Barendregt

Doi

Lee

Norman

Vos

. Meta-analysis of prevalence. J Epidemiol Community Health (1978). 2013;67(11):974-978. doi:10.1136/jech-2013-203104

Caine

Roy

Singer

Broekhoff

Stress changes of the distal radial growth plate. Am J Sports Med. 1992;20(3):290-298. doi:10.1177/036354659202000310

Campbell

Bradshaw

Ball

Pease

Spratford

Injury epidemiology and risk factors in competitive artistic gymnasts: a systematic review. Br J Sports Med. 2019;53(17):1056-1069. doi:10.1136/bjsports-2018-099547

Carter

Aldridge

Fitzgerald

Davies

AM.

Stress changes of the wrist in adolescent gymnasts. Br J Radiol. 1988;61(722):109-112. doi:10.1259/0007-1285-61-722-109

10.

Chang

Shih

Penn

Tiu

Chang

JJ.

Wrist injuries in adolescent gymnasts of a Chinese opera school: radiographic survey. Radiology. 1995;195(3):861-864.

11.

CLARITY Group. Tool to Assess Risk of Bias in Cohort Studies. Accessed February 25, 2025. https://www.distillersr.com/resources/methodological-resources/tool-to-assess-risk-of-bias-in-cohort-studies-distillersr

12.

DeSmet

Claessens

Lefevre

Beunen

Gymnast wrist: an epidemiologic survey of ulnar variance and stress changes of the radial physis in elite female gymnasts. Am J Sports Med. 1994;22(6):846-850. doi:10.1177/036354659402200618

13.

DiFiori

JP.

Overuse injury and the young athlete. Curr Sports Med Rep. 2006;5(4):165-167. doi:10.1097/01.CSMR.0000306500.48234.cd

14.

DiFiori

Caine

Malina

RM.

Wrist pain, distal radial physeal injury, and ulnar variance in the young gymnast. Am J Sports Med. 2006;34(5):840-849. doi:10.1177/0363546505284848

15.

DiFiori

Puffer

Aish

Dorey

Wrist pain, distal radial physeal injury, and ulnar variance in young gymnasts: does a relationship exist?

Am J Sports Med. 2002;30(6):879-885.

16.

DiFiori

Puffer

Aish

Dorey

Wrist pain in young gymnasts: frequency and effects upon training over 1 year. Clin J Sport Med. 2002;12(6):348-353. doi:10.1097/00042752-200211000-00005

17.

DiFiori

Puffer

Mandelbaum

Dorey

Distal radial growth plate injury and positive ulnar variance in nonelite gymnasts. Am J Sports Med. 1997;25(6):763-768. doi:10.1177/036354659702500607

18.

DiFiori

Puffer

Mandelbaum

Mar

Factors associated with wrist pain in the young gymnast. Am J Sports Med. 1996;24(1):9-14.

19.

Duvallet

Leglise

Auberge

Zenny

Radiological study of bone lesions of the athlete's wrist. Kinesiology. 1983;21(89):157-162.

20.

Farì

Fischetti

Zonno

, et al. Musculoskeletal pain in gymnasts: a retrospective analysis on a cohort of professional athletes. Int J Environ Res Public Health. 2021;18(10):5460. doi:10.3390/ijerph18105460

21.

Fernandes

SMB

Carrara

Serrão

Amadio

Mochizuki

. Kinematic variables of table vault on artistic gymnastics. Rev Bras Educ Fis Esporte. 2016;30(1):97-107. doi:10.1590/1807-55092016000100097

22.

Guerra

MRV

Estelles

JRD

Abdouni

Falcochio

Rosa

JRP

Catani

. Frequency of wrist growth plate injury in young gymnasts at a training center. Acta Ortop Bras. 2016;24(4):204-207. doi:10.1590/1413-785220162404157422

23.

Hart

Meehan

Bae

d’Hemecourt

Stracciolini

. The young injured gymnast: a literature review and discussion. Curr Sports Med Rep. 2018;17(11):366-375. doi:10.1249/JSR.0000000000000536

24.

Hart

Whited

Bae

Bauer

Sugimoto

Wrist guards/supports in gymnastics: are they helping or hurting you?

Am J Sports Med. 2023;51(13):3426-3433. doi:10.1177/03635465231199683

25.

Heyworth

Sullivan

Hart

Bauer

Bae

Gymnast wrist: a retrospective analysis of descriptive epidemiology, clinical & radiologic features, treatment & outcomes. Orthop J Sports Med. 2019;7(3)(suppl):2325967119S00064. doi:10.1177/2325967119S00064

26.

Hoang

Mortazavi

Pediatric overuse injuries in sports. Adv Pediatr. 2012;59(1):359-383. doi:10.1016/j.yapd.2012.04.005

27.

Inside FIFA. Injury Prevention and Health Promotion. Accessed December 21, 2024. https://inside.fifa.com/about-fifa/medical/injury-prevention

28.

Kerr

Hayden

Barr

Klossner

Dompier

TP.

Epidemiology of National Collegiate Athletic Association women's gymnastics injuries, 2009–2010 through 2013–2014. J Athl Train. 2015;50(8):870-878. doi:10.4085/1062-6050-50.7.02

29.

Konrad

Pförringer

[Sports medicine aspects of artistic gymnastics.] Article in German. Sportverletz Sportschaden. 1997;11(1):35-37. doi:10.1055/s-2007-993362

30.

Kox

Kuijer

PPFM

Kerkhoffs

GMMJ

Maas

Frings-Dresen

MHW

. Prevalence, incidence and risk factors for overuse injuries of the wrist in young athletes: a systematic review. Br J Sports Med. 2015;49(18):1189-1196. doi:10.1136/bjsports-2014-094492

31.

Lindner

Caine

Injury patterns of female competitive club gymnasts. Can J Sport Sci. 1990;15(4):254-261.

32.

Major League Baseball. Guidelines for Youth and Adolescent Pitchers. Accessed December 21, 2024. https://www.mlb.com/pitch-smart/pitching-guidelines

33.

Mandelbaum

Bartolozzi

Davis

Teurlings

Bragonier

Wrist pain syndrome in the gymnast. Am J Sports Med. 1989;17(3):305-317. doi:10.1177/036354658901700301

34.

Markolf

Shapiro

Mandelbaum

Teurlings

Wrist loading patterns during pommel horse exercises. J Biomech. 1990;23(10):1001-1011. doi:10.1016/0021-9290(90)90315-T

35.

McLaren

Byrd

Herzog

Polikandriotis

Willimon

SC.

Impact shoulder angles correlate with impact wrist angles in standing back handsprings in preadolescent and adolescent female gymnasts. Int J Sports Phys Ther. 2015;10(3):341-346.

36.

Morimoto

Ferretti

Ekdahl

Smolinski

FH.

Tibiofemoral joint contact area and pressure after single- and double-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2009;25(1):62-69. doi:10.1016/j.arthro.2008.08.014

37.

O’Kane

Levy

Pietila

Caine

Schiff

MA.

Survey of injuries in Seattle area levels 4 to 10 female club gymnasts. Clin J Sport Med. 2011;21(6):486-492. doi:10.1097/JSM.0b013e31822e89a8

38.

Padmore

Chan

AHW

Langohr

GDG

Johnson

Suh

The effect of forearm position on wrist joint biomechanics. J Hand Surg Am. 2021;46(5):425.e1-425.e10. doi:10.1016/j.jhsa.2020.10.017

39.

Poletto

Pollock

AN.

Radial epiphysitis (aka gymnast wrist). Pediatr Emerg Care. 2012;28(5):484-485. doi:10.1097/PEC.0b013e318259a5cc

40.

Pollock

O’Toole

Nowicki

Eglseder

WA.

Articular cartilage thickness at the distal radius: a cadaveric study. J Hand Surg Am. 2013;38(8):1477-1481. doi:10.1016/j.jhsa.2013.04.037

41.

Roy

Caine

Singer

KM.

Stress changes of the distal radial epiphysis in young gymnasts. Am J Sports Med. 1985;13(5):301-308. doi:10.1177/036354658501300503

42.

Ryan

Little Girls in Pretty Boxes: The Making and Breaking of Elite Gymnasts and Figure Skaters. Warner Books; 2000.

43.

Sastre-Munar

Pades-Jiménez

García-Coll

Molina-Mula

Romero-Franco

Injuries, pain, and catastrophizing level in gymnasts: a retrospective analysis of a cohort of Spanish athletes. Healthcare. 2022;10(5):890. doi:10.3390/healthcare10050890

44.

Schünemann

Brożek

Guyatt

Oxman

GRADE Handbook. Published 2013. Accessed December 21, 2024. https://gdt.gradepro.org/app/handbook/handbook.html#h.svwngs6pm0f2

45.

Shepherd

DET

Seedhom

BB.

Thickness of human articular cartilage in joints of the lower limb. Ann Rheum Dis. 1999;58(1):27-34. doi:10.1136/ard.58.1.27

46.

Shih

Chang

Penn

Tiu

Chang

Chronically stressed wrists in adolescent gymnasts: MR imaging appearance. Radiology. 1995;195(3):855-859.

47.

Smits

Jacobs

Knoppers

“Everything revolves around gymnastics”: athletes and parents make sense of elite youth sport. Sport Soc. 2017;20(1):66-83. doi:10.1080/17430437.2015.1124564

48.

Swenson

Henke

Collins

Fields

Comstock

RD.

Epidemiology of United States high school sports-related fractures, 2008-09 to 2010-11. Am J Sports Med. 2012;40(9):2078-2084. doi:10.1177/0363546512453304

49.

Tisano

Zynda

Ellis

Wilson

PL.

Epidemiology of pediatric gymnastics injuries reported in US emergency departments: sex- and age-based injury patterns. Orthop J Sports Med. 2022;10(6):23259671221102478.

50.

Trevithick

Stuelcken

Mellifont

Sayers

Epidemiology of wrist pain in Australian gymnasts. Sci Gymnast J. 2018;10(2):179-188.

51.

Tsutsui

Iizuka

Sakamaki

Maemichi

Torii

Growth until peak height velocity occurs rapidly in early maturing adolescent boys. Children. 2022;9(10):1570. doi:10.3390/children9101570

52.

USA Football. Concussion Recognition and Response. Accessed December 21, 2024. https://usafootball.com/health-safety/concussion-recognition-return-to-play

53.

Webb

Rettig

LA.

Gymnastic wrist injuries. Curr Sports Med Rep. 2008;7(5):289-295. doi:10.1249/JSR.0b013e3181870471

54.

Westermann

Giblin

Vaske

Grosso

Wolf

BR.

Evaluation of men's and women's gymnastics injuries. Sports Health. 2015;7(2):161-165. doi:10.1177/1941738114559705

55.

Wood

Robertson

Rennie

Caesar

Court-Brown

. The epidemiology of sports-related fractures in adolescents. Injury. 2010;41(8):834-838. doi:10.1016/j.injury.2010.04.008

56.

Hafner

Poznanski

Donovan

JM.

Ulnar variance in children? Standard measurements for evaluation of ulnar shortening in juvenile rheumatoid arthritis, hereditary multiple exostosis and other bone or joint disorders in childhood. Skeletal Radiol. 1989;18(7):513-516.

57.

Coleman

Blair

Shurr

Resection of the radial head for fracture of the radial head. Long-term follow-up of seventeen cases. J Bone Joint Surg Am. 1987;69(3):385-392.

58.

Palmer

Glisson

Werner

FW.

Ulnar variance determination. J Hand Surg Am. 1982;7(4):376-379. doi:10.1016/S0363-5023(82)80147-0

Epidemiology and Risk Factors of Wrist Pain and Injury in Adolescent Artistic Gymnasts: A Systematic Review and Meta-analysis

Abstract

Background:

Purpose:

Study Design:

Methods:

Results:

Conclusion:

Keywords

Methods

Literature Search and Study Selection

Eligibility Criteria

Data Extraction and Risk-of-Bias Assessment

Statistical Analysis

Subgroup Analysis

Certainty of Evidence

Results

Risk of Bias

Wrist Pain

Acute Wrist Injury

Chronic Wrist Injury

Positive Ulnar Variance

Wrist Pain Risk Factors

Discussion

Future Recommendations

Strengths and Limitations

Conclusion

Footnotes

Appendix

ORCID iDs

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References