Wrist Pain In Gymnastics: Understanding Contributing Factors and Tips To Help

Wrist pain is one of the most common issues gymnasts and coaches deal with within the sport. The majority of the wrist problems that athletes complain about are wrist extension based (back of the hand moving upward), and are usually localized to the dorsal aspect (back of the palm/wrist) of the wrist joint. For this week, I wanted to offer some insight into the topic and offer advice on how to manage/prevent wrist pain with yourself or your athletes. Although other forms of wrist pain come up in gymnastics, due to the majority of the problems being extension/weight loading based that is what this post will mainly focus on.

This is an important topic to understand because of its high frequency in gymnastics, and potential for progressive injury when not addressed properly. Due to a variety of unique aspects to the sport (which I will go into below) and the structure of the wrist joint, many athletes develop nagging pains in their wrist. The pain is most commonly experienced during weight-bearing skills like handstands, tumbling, vaulting, and many other skills. There is some biomechanical research models to suggest that forces up to 2.5x an athletes body weight can be loaded through the wrist during some gymanstics skills, and up to 5x during heavy tumbling/vaulting. This number most likely dramatically increases when shallow tumbling angles or uneven weight bearing occurs on some skills. Coaches and athletes must be aware of the fact that if left unaddressed, overuse may progress to a variety of problems like tendonitis, bone bruising, ligamentous damage, possible growth plate irritation, scar tissue build up, and possible stress fractures. A very large number of athletes simply “push through the pain” not knowing that they may be causing some big problems down the road. I will explain some basic anatomy concepts for understanding, outline some reasons why a gymnast may develop wrist pain, and offer some techniques athletes can utilize to possibly manage/combat their problems.

Background

The wrist and lower arm is hands down (hah! cheesy joke) one of the most complex areas of the body. There are an overwhelming amount of bones, ligaments, muscles, and biomechanical interactions involved with even the simplest hand motions. A basic understanding of the wrist and it’s structure  is really all gymnastics coaches/athletes need to think about in relation to wrist pain.

One of the wrist joint connections known as the radiocarpal joint is what offers the most motion for moving the wrist up and down (extension and flexion).  You can feel the outsides of the joint when you grab just past the bumps on your wrist below where a watch would sit, and move your wrist up and down. It is formed by one of your forearm bones, known as the radius, making contact with the bones of the wrists, the carpals. Although many other joints play an important role in hand function, this is the primary joint that promotes the wrist moving up and down. The ability of this joint to move effectively allows a gymnast to bend the wrist back into a variety of important gymnastics positions like handstands, back handsprings, and many more.

Dorsal Impingement/Wrist Extension Pain in Gymnastics Reference Picture
http://www.hughston.com/hha/b_15_4_3b.jpg

On either side of the forearm are groups of different muscles that influence the wrist and hand motions. In a very broad generalization, the muscles on the front of the forearm (known as the wrist flexors) start in the elbow region, and travel to attach on various points along the wrist and hand bones. These muscles primarily function to bend the wrist forward (wrist flexion), rotate the hand from palm up to palm down (pronation), and work with other muscles of the forearm to make a fist for gripping (finger flexion/adduction).

On the other side of the forearm are the wrist extensors, which function in the opposite manner as the wrist flexors. They again start near the elbow and cross the wrist/hand joints, serving to bring the back of the palm up (wrist extension), rotate the hand from palm down to palm up (supination), assist with the forearm flexors for gripping, and straighten the fingers/wrist (wrist/finger extension).

Forearm/Wrist Anatomy Reference Picture
http://1.bp.blogspot.com/-8VRJvVrRWK4/TwW-mjqPk_I/AAAAAAAALaY/YIApfiuHj8Q/s1600/elbow-forearm-anatomy.jpg

With these basic anatomy thoughts, muscle functions, and motions in mind here are some possible contributing factors to why a gymnast may experience wrist pain.

Possible Contributing Factors:

1. Unfortunately, the hand is not inherently designed for heavy weight-bearing like the ankle joint is. The ankle has a lot more internal joint stability, ligamentous support, and musculature that allows you to stand and balance for long periods of time. However, since structures of the wrist and hand are not normally weight-bearing joints, they don’t hold up to excessive forces (body weight + gymnastics force) as well as the foot. Gymnastics is a scenario where extensive amounts of time and excessive forces are put through the wrist/hand complex. This is the nature of the sport, so the only proper way to use this to your advantage in combating pain is to keep preventative rehabilitation involved, adjust training schedules when needed, monitor skill volumes, and take the appropriate steps for rest/seek medical care when needed. More on this to come later.
2. Another huge contributor to wrist pain is how the structures above the wrist like the elbow, shoulder, scapula, and thoracic spine are functioning. Problems can arise if their is a lack of mobility, proper biomechanical alignment, static stability (for weight bearing skills that remain still like handstand), or dynamic stability (for weight bearing skills that move like handsprings and most of gymnastics skills). When the alignment of the entire chain is out of whack, the small stabilizer muscles of the shoulder blade, shoulder, and elbow can’t do their job properly and allow the bigger muscles to perform. Gray Cook is huge on this type of concept, and I think that the application to gymnastics is really important. 
3. One of the biggest contributing factors to an athlete who develops wrist pain has to deal with their available range of motion in the wrist. In simpler terms, how far the wrist joint is able to move comfortably. This, unlike gymnastics being gymnastics, is something that can possibly be worked on. In normal motion, the radiocarpal joint usually permits about 70 degrees of extension for everyday use. Gymnasts often develop hyper mobility of this joint into about 80 degrees of motion comfortably. As you can see in these pictures below, an athlete in a handstand or backwards skill is forced to go far beyond this, almost into the 90-95+ degree region. If the athlete lacks the ability to move the radiocarpal/wrist joint into the amount of hyperextension needed, the joint will get pushed past its limitations. Overtime, this may create the situation where athletes may start to complain of pain. The joint is continuously pushed into a greater range that is available, while excessive force and pressure like tumbling on top of it (literally). These factors often cause the radiocarpal joint itself may begin to “impinge” upon other bones/structures in the wrist resulting in pain.
4. Upper extremity/spine chain influence for tightness or restricted mobility is a concept that can also be considered as a piece of the puzzle. By looking at Thomas Meyers work in his book Anatomy Trains, he offers the concept that a chain of muscles and fascial connections in the front of the arm (know as the Superficial Front Arm Line) connect muscles like the pecs, lats, biceps, and forearm flexors all together. I certainly can get on board with the idea that because these structures are linked through these connections tightness up the road in some back muscles, the pecs, the lats, and the biceps can certainly all influence wrist motion gymnasts may have problems with. Although relatively new information these problems often exist together in gymnasts with wrist pain, so it’s good food for thought. 

Look at these pictures below to help understand this concept. Keep in mind that the first picture is of an athlete does have restricted range of motion, and is currently dealing with wrist pain. Note the drastic differences in wrist extension angle between her actively extending the wrist (yellow), me putting over pressure on her wrist which caused some discomfort (red), and the angle that is seen during many skills that involve hand weight-bearing causing pain(blue). Below the first picture is the wrist extension of an athlete who has more available wrist extension range, and also currently does not have experience wrist pain during practice.

Restricted Wrist Extension Range of Motion

More Normal Wrist Extension Range of Motion

Handstand With Wrist Extension

As you can see, the handstand position requires a fair amount of wrist extension mobility. If the athlete does not have this available range, the body weight will the wrist joint beyond its comfortable range often resulting in pain over time. Now look at what happens in skill based movements.

Bridge With Wrist Hyper Extension

This angle is further increased when the athlete performs tumbling and vaulting skills, and even more wrist extension is needed. This is often the time that the wrist goes well past 90 degrees, while the high force  (body weight and momentum) is placed on top of the wrist. Keep in mind that this is only a bridge, and often times the angle is increased more up to about 100-105 degrees with “shallow” block angles or elongated tumbling. These type of skills typically produce the most amount of discomfort for the athlete.

In the majority of cases, there are two limiting factors to an athlete’s ability to move into wrist extension.

1. The first factor limiting wrist extension may be excessively tight forearm flexors. Remember that these muscle are on the front of the wrist, and when tight will limit the amount of opposite motion into wrist extension. If the athlete’s wrist flexors are over developed and not being mobilized/stretched properly, it effects the ability of the wrist to move into extension.

When you pick up and object, the muscles on the front (flexors) and back (extensors) contract at the same time to allow you to produce a proper grip force. Put one hand wrapped around your forearm below your elbow, then squeeze the other hand into a fist. You will feel both sides of the arm tighten up. If they did not co-contract together, you wouldn’t be able to balance the amount of force on the object with your fingers and holding on would be really tough. So, in gymnastics this amount of grip force  is amplified quite a bit when swinging on bars. The athlete grips the bar with excessive force to hold on, the  hand and wrist flexors are in overdrive trying to keep the athlete from peeling off. These muscles often fatigue and sometimes we witness the effects as an athlete assumes the “starfish” position flying through the air after peeling off (hopefully with a safe landing and a good laugh). Overtime, the muscles become very strong and tighten up, contributing to limited wrist extension.

Along with gripping, the forearm flexors are also needed to balance body weight and control a handstand position. They are the fine tuning muscles that help control weight in a handstand, similar to the calf muscles of the ankle when you stand upright. If the athlete’s swaying becomes too much, the wrist/hand flexors can’t manage balancing and the athlete is forced to use another strategy (walk their hands or bend from the hips to control the handstand, for example). The muscles are also needed for proper “push” like with blocking off floor of vault to create turn over. Pressing down through the wrist and fingers helps to propel the athlete from the surface to generate power. Over time the flexor muscles become very tight from all of these things. If these muscles remain bound up like cables without being mobilized (stretching,myofascial release, etc.), they will restrict the athlete’s ability to move into the opposite motion (wrist extension). As I noted above, without the available range of motion problems may start to be seen.

2. The other factor that may limit wrist extension may be a restriction in the joint itself (versus the muscles around it mentioned above). When a person moves their wrist into extension pulling up towards their head, the bones of the hand  (carpals) roll downward on the forearm bone towards the floor. Each joint has a unique joint movement, but in the radiocarpal joint the wrist bones always move in the opposite direction of the motion being performed. This concept doesn’t matter too much to the average person, but it will come up later in one of the exercises. So if an athlete has a restricted joint (from overuse, scar tissue build up, and many more factors), they may experience pain when the joint is being forced past its comfortable range when doing handstands, skills, and the other fun stuff. By increasing the joint’s range of motion it may aid in reducing the discomfort felt during skills and practice.

3. As I wrote about in a previous post regarding bridge mobility, many gymnasts possess overdeveloped latissimus dorsi muscles that may be limiting the ability to fully raise their arms overhead. This scenario can also have an impact on the wrist joint. If the athlete is unable to reach into full shoulder flexion (arms behind ears), they may be forced to make up for the range of motion with wrist hyper extension many handspring based skills. Examples include front/back handsprings on floor and beam, and yurchenko vaults. In simple terms, the athlete may have to bend the wrist more than usual to make up for their inability to reach overhead. Overtime this may lead to the repetitive build up of stress on the joint, and possible pain/injury. Below is a test to see if the athlete may have restricted overhead mobility due to the latissimus dorsi muscle, which can be read about fully in the hyper link to the bridge post above.

Improper Latissimus Dorsi Length Test – Note Lower Back Lifts Off Surface and Creates Appearance of Normal Overhead Mobility

Proper Testing Latissimus Dorsi Length Testing – Note Lower Black Flat to Surface and Arms Unable to Fully Flex Overhead

Now like I always try to remind readers, this by no means encompasses every “why” and “how” to what may cause an athlete wrist pain. The amount of force gymnastics places on the wrist can create a pretty length list of probably causes to wrist pain. This is just one scenario I have run into many times when working with athletes who complain of wrist problems. With that being said, here are some ways that you can work on the wrist/hand muscles and joint to possibly deal with a problem.

Increasing Mobility Into Wrist Extension

Myofascial Release for the Forearm Muscles:

Like I noted above, problems may arise when the athletes forearm muscles are overworked and under mobilized. With the excessive amounts of gripping, handstand balancing, and pushing motion, a gymnast has to be on top of keeping their forearm muscles from being overly tight. By reducing the tension in the forearm muscles, the athlete may gain better mobility of the wrist into extension during skills and reduce pain. An athlete can use a PVC pipe (ours got named “Petey the PVC”) to massage and roll out their forearms. A small 2 foot section costs $8 at Home Depot and can be covered with athletic tape to reduce slipping. The athlete can also use golf balls and lacrosse ball to hit localized tender points along the muscles bellies after being warmed up, or after practice/at home. Have the athlete use their body weight and free arm to find an appropriate amount of pressure (uncomfortable not through the roof). I personally feel that this type of mobilization is crucial to keeping an athlete’s forearms healthy, due to the amount of demand they are put under daily.

Wrist Flexor Myofascial Release Using lacrosse ball

Wrist Flexor Myofascial Release Using PVC Pipe

Wrist Extension Stretching With Band for Joint Mobilization:
I also noted above how the joint itself may be restricted in its range of motion. Many times people will stretch their wrists and get muscular stretch, but don’t mobilize the joint along with it. One self mobilization technique an athlete can use to work on is with an elastic resistance band or stretching strap.

1. Put the strap around the base of a beam or bar, then have the athlete loop the other end around their wrist.Face the fingers towards from the base (so the strap is pulling on the bottom of the arm), have the athlete kneel down.

Wrist Extension Mobilization With Band 1

2. Have the athlete placed the free hand (left hand in picture below) to brace the hand being mobilized (right hand). While keeping tension on the band and free hand on top, have the athlete  pull up slightly towards the ceiling to provide a small amount of joint distraction, and stretch into a gentle wrist extension stretch.

Wrist Extension Mobilization With Band 2

The “up” motion gaps/separates the joint and frees up space to allow more joint motion to occur. The distraction force also frees up some room so the bones and other structures don’t push on each other causing discomfort (like what happens in tumbling, vaulting, etc.). The elastic band helps to pull the joint in its natural motion during wrist extension and promote smooth joint gliding. These motions added onto the normal stretching and myofascial release may reveal larger mobility increases into wrist extension. This may transfer over to more mobility during skills/competition, and possibly less impingement based pain. I can’t take credit for this technique, it’s from a DPT  who works out in the western US with a lot of high level athletes. It seems complicated with the steps, but it isn’t. Be sure to go gently on the stretch to not cause any wrist of hand issues, the motion should be very slight. This is a good stretch because the athlete can self regulate how much pressure they put on the wrist. This is a great exercise to set up during down time of events, warm ups, or at home when time is limited.

Increasing Latissimus Dorsi Mobility for Overhead Motion

As noted above, restrictions in a gymnasts overhead motion due to overdeveloped latissimus dorsi muscles may influence the force at the wrist joint due to the connection of the entire upper extremity chain. There are various ways that you can work on the latissimus dorsi muscle to improve overhead flexibility, and possible reduce the amount of wrist hyper extension during skills. The full post for details can be read here, but here are some reference pictures.

Latissimus Dorsi Muscle

Myofascial Release for Latissimus Dorsi Using Foam Roller

Myofascial Release For Latissimus Dorsi Using Lacrosse Ball

Bilateral (Both Arms At Same Time) Latissimus Stretch

L Unilateral (One Side) Focused Latissimus Dorsi Stretch

Another way to work on overhead motion is by working on middle spine or thoracic spine extension. Often times gymnasts develop faulty posture, increased lumbar mobility during skills, and abnormal movement patterns predisposing the thoracic spine to get stiff into the extension movement. Here is a way to work on this. Have an athlete lay over a foam roller with it about shoulder blade height, and gently extend back, only moving from their middle spine. The athlete can also use a light weight to help add some pressure, be sure to go lightly and keep good form while doing this (the gymnast shouldn’t feel their lower back or head moving too much).

Thoracic Spine Extension Mobilization Using Foam Roller and Light Weight

The gymnast can also just focus on the middle spine area if they don’t use a weight (which also uses shoulder flexibility) and simply reach their arms behind their head. Many gymnasts have very flexible shoulders as a result of missing thoracic spine motion, so this option will be better to not further enhance the shoulder flexibility. We don’t want to make the gymnasts shoulders more flexible, we want to get at the stuck thoracic spine. 

Mobilizing Into Thoracic Extension/External Rotation Using Dowel and Block or Bar: For this, the athlete will hold the dowel just outside of shoulder width in a front giant/supinated grip, and place their elbows on a block. They will keep their lower spine completely neutral and tight, it should not move at all. Pressing down into their elbows, they will try to push their upper chest into the ground, and hold for a few seconds. Do this for a few sets of 10, cueing them to breathing out on the way down. The motion should only come from the middle back/shoulder blade area.

Thoracic Ext Mob Start

Thoracic Ext Mob End 2.jpg

Working On Overhead Scapular Stability and Positioning: Like I noted above, many times if the shoulder blades and shoulder aren’t doing their job to align properly the larger muscles can’t do their job to help the athlete reach over head and accept weight. Some simple exercises can help cue the athlete to engage their scapular muscles and reach overhead properly. Wall angels are one of my favorite. Have the athlete stand flat backed against a wall, engage their shoulder blades and pull them back slightly, then while keeping the back of their hands against the wall they will slowly straighten over head.

Wall Angel Starting Position

Wall Angel Ending Position

Once the gymnast understands this type of scapular engagement, have them practice handstand and stability drills overhead to apply the concept. Then the gymnast can engrain them into their overhead movements that involve handstands or weight bearing on their wrist to help get proper control, and help reduce the amount of force the wrist takes.

Activity Modification and Tracking Symptoms:

Remember that unfortunately with high volume/training and high forces from the sport, many times even working on these types of techniques will not fully reduce wrist pain. If this is the case, a discussion must be had about proper steps to limit gymnastics activity until the pain reduces. Initially, skills and activities that produce wrist pain in the gym should be limited to specific numbers, wrist supports or tape should be used, and the athlete must be taking proper care of their wrists at home. Often times limiting the painful activity and replacing it with a less demanding surface (tumble trak, cushioned beams) will take some pressure of the wrist while still maintaining skill performance. Adjunctive management like the mobilization, stretching, myofascial release, and icing during this time is crucial.

If wrist pain is continuing despite activity modification, if the athlete has moderate to severe pain, if the pain is constant through the day, or if the athlete is having difficulty with non gymnastics based activities (school, chore at home)  it may be time to seek out medical advice while taking some time off. If ignored and left untreated while “gritting through it”, it can develop too much more serious injuries down the road. Orthopedic specialists and Physical Therapists will be able to further analyze the problem and break down rehabilitation into a specific schedule.  Although it is never something that a gymnast wants to hear, laying off for two weeks for a flare up is much better than missing two months with an injury like a stress fracture or tissue damage. During this time there are plenty of other things the athlete can work on to maintain their conditioning and skill progressions.

Concluding Thoughts 

Granted that there is much more that goes into tackling wrist pain, I hope this small amount of information may play a role in reducing the frequency within your gymnastics activities. There are many more possible reasons for the pain, and ways of managing the problems that come up. As you can tell from all of my posts, I feel that these type of techniques for myofascial release, proper mobilization/stretching, and good biomechanical techniques is really important for programs to adopt. I personally feel that the investment of $50 dollars for lacrosse ball, golf balls, PVC’s, and foam rollers are well worth the investment for any program. Taking the time to educate your gymnasts will allow them a large toolbox of how to manage their problems through their entire career. I hope that this information can serve you as many gyms start to shift towards competition season and increased volume of training.

*January Update* – I originally wrote this post 2 months ago but had a recent update that I wanted to share.  The girl I mentioned from the first picture went through about 3 weeks of activity modification and a program from the exercises above in place of impact activities after her wrist started to get really bad. I just wanted to share a picture that I took of her wrists to show the difference.

Post Test Range of Motion

It’s the same left wrist, she is just facing the other direction from the original picture. You can see she has quite a bit more range of motion in her wrist, although not completely full it is a good amount. The gymnast didn’t have to attend formal Physical Therapy, currently has no pain and is back to being able to do full vaulting, tumbling, and beam unrestricted. She continues to do her pre-hab to make sure the problems stay away at home or before practice. I just thought this would be cool to share with people to see the difference.  Best of luck with all of this,

Dave

References

• Webb B.G, Rettig L.A. Gymnastics Wrist Injuries. Current Sports Medicine Reports: 7(5) September/October 2008.
• Bradshaw E.J., Hume P.A. Biomechanical approaches to identify and quantify injury mechanisms and risk factors in women’s artistic gymnastics. Sports Biomechanics. 2012; 11(3) 324 – 341 
• DiFiori J.P. Overuse Injury and the Young Athlete: the Case of Chronic Wrist Pain in Gymnasts. Current Sports Medicine Reports. 2006 5:165-167
• Caine D., et al. The Handbook of Sports Medicine In Gymnastics. First Edition. John Wiley and Sons, 2013
• Cook G., et al. Movement –  Functional Movement Systems: Screening, Assessment, Corrective Strategies.  First Edition. On Target Publications, 2010.
• Myers TW. Anatomy Trains: Mysofascial Meridians for Manual and Movement Therapists. Second Edition. 2009
• Page P., Frank C.C., Lardner R.. Assessment and Treatment of Muscle Imbalances: The Janda Approach. Sheridan Books; 2010
• Magee D. Orthopedic Physical Assessment. Fifth Edit. St. Louis: Saunders Elsevier; 2008.
• Wrist Pain In Gymnastics Picture Reference: http://www.hughston.com/hha/b_15_4_3b.jpg
• Wrist Muscles Reference Picture http://1.bp.blogspot.com/-8VRJvVrRWK4/TwW-mjqPk_I/AAAAAAAALaY/YIApfiuHj8Q/s1600/elbow-forearm-anatomy.jpg