Risk+of+Pediatric+Overuse+Injury

= Risk Factors Associated with Pediatric Sports Related Overuse Injuries = Avery Clifton, Allison Corley, Jessica Ronnebaum, Carly Schmale, and Audrey Thompson [|1Kids in Sports Uniforms.jpg] = Purpose: = To understand and identify risk factors and the prognosis associated with overuse sports injuries among the pediatric population.

Inclusion Criteria:

 * Pediatric populations
 * Sport-specific injuries
 * Overuse injuries
 * Prognostic articles

Databases Consulted:

 * PubMed
 * CINAHL
 * Google Scholar
 * Google

Search Terms:

 * "Osgood Schlatter's"
 * "Stress fracture AND adolescent runners"
 * "Risk factors AND little league elbow", "little league elbow"
 * “Pediatric shoulder pain in swimmers”, “Shoulder instability AND swimming”
 * “Pediatric gymnastic(s)”, “Wrist pain”

Patient population:

 * Pediatric
 * Age range is from birth to 21 years old [1].

Inclusion Decision Process:
We searched for the highest level of evidence possible (i.e. systematic reviews and randomized control trials), but found predominantly cohort studies and a small number of systematic reviews. P value <0.05 is significant and odds ratios >1 considered significant.

Overuse injuries:
Occur due to repetitive submaximal loading of the musculoskeletal system when rest is not adequate to allow for structural adaptation to take place. Injury can involve muscle-tendon unit, bone, bursa, neurovascular structures, and the physis [2]. Classified into four stages [3]: 1. Pain after activity in the affected area 2. Pain during activity that does not hinder performance 3. Pain during activity that affects performance 4. Chronic pain that does not go away even when resting.

Risk factors:
Predictors of future adverse events [4].

Overview of why seeing an increase in some pediatric overuse injuries:

 * Pediatric sports have gained popularity in recent years [2].
 * Adolescents have increased pressure (from parents, coaches, scholarships, etc.) to specialize in one sport at earlier ages. This increased specialization has lead to an increased high intensity training at younger ages [2].
 * High intensity at earlier ages leads to overuse injuries in those not fully developed [2].

Basketball

Overview:

 * Occurs due to the patella tendon being overstressed.
 * It is called Jumper’s Knee because the stress through the patella tendon is at it’s greatest when doing jumping and landing activities.
 * When jumping, the quadriceps have to contract quickly and strongly, causing the knee to extend and the jump to occur. On the land, the quadriceps help absorb the forces, allowing some knee flexion to occur [5].
 * Both the forces from the jumping and landing can cause the stress on the patellar tendon and over time, the athlete can present with symptoms of patellar tendinitis [5].
 * Symptoms:
 * Pain and stiffness in the morning or during the night
 * Tenderness
 * Red or warm
 * Swollen
 * Pain worsening with jumping or running possibly accompanied by crunching sound or feeling

Risk Factors:

 * Poor Flexibility due to tight muscles [5]
 * Training Errors [5]
 * Lower Limb Biomechanics [5]

Prevention:

 * Stretch to maintain LE flexibility [5]
 * Eccentric strengthening program (especially for quads/patellar tendon) [5]
 * Gradually increase amount and intensity of training/activity [5]

Treatment:

 * Activity modification
 * Ice and rest
 * Gentle ROM and stretching

Prognosis:
Great when adolescent complies with activity modification and some rest.

= Osgood Schlatter’s Disease =

Overview:

 * An inflammation of the tibial tubercle where the patellar tendon attaches.
 * It occurs from repetitive pull on the tibial tubercle during strong quadriceps contraction, during running and jumping, that disrupts the immature bone. Usually occurs during the apophyseal stage of bone growth, when the bone is not able to handle extreme tensile forces [6].
 * The ages that it is seen at the most are 11-15 years for boys and 8-13 years of age for girls [6].

Symptoms [6]:

 * Pain, swelling, tenderness over tibial tubercle
 * Pain during exercise and with direct contact (kneeling)
 * Pain with squats and stairs
 * Enlarged tibial tubercle
 * Possible quadriceps weakness

Risk Factors [6]:

 * Weak or tight LE musculature
 * Biomechanics
 * Repetitive, strong quadriceps contraction

Prevention [6]:

 * Stretch to maintain LE flexibility
 * Eccentric strengthening program (especially for quads/patellar tendon)
 * Gradually increase amount and intensity of training/activity

Treatment [6,7]:

 * Conservative treatment for ‘acute’ phase
 * Ice, stretching, limit activity (possibly no activity)
 * Surgical treatment for ‘chronic’ phase
 * Surgical excision of ossicles
 * Possibly accompanied by thinning of the tibial tubercle
 * No corticosteroid injections
 * Atrophies the muscles
 * Research shows it doesn’t work

Prognosis:
Great when adolescent complies with activity modification and some rest.

Case Series One:

 * 261 patients
 * Followed course of injury for 12-24 months
 * Conservative treatment first
 * Sport/activity restriction and NSAIDs
 * 237 patients (90.8%) responded well
 * Rest of the patients (24), that didn’t respond well, had surgical excision of ossicles and responded well
 * Returned to normal activity (mean of 4.5 weeks)

Case Series Two:

 * 118 patients
 * Conservative treatment of limited activity – 88% responded well
 * 14 patients didn’t improve with conservative treatment, therefore underwent surgical excision of an ossicle (some also had thinning of tibial tubercle)
 * All but 1 had complete relief and returned to full activity by 6 weeks

Retrospective survey:

 * 68 young athletes with Osgood Schlatter disease
 * Average of 3.2 months with no activity
 * 7.3 months of restricted activity
 * 22 adolescent athletes with Osgood Schlatter disease
 * 20 managed symptoms with activity modification, ice and aspirin
 * 2 had to cut out activity completely for a short period of time to decrease symptoms
 * One needed surgery

= Running = http://ks.milesplit.com/articles/34065/avery-clifton-named-gatorade-kansas-girls-xc-runner-of-the-year

Overview:

 * Usually we have the right balance between osteoclasts and osteoblasts and bone keeps up and remodels adequately during weight bearing exercise (Wolff’s law) [8]
 * Sometimes bone can’t keep up with the overload of stress and breaking down occurs faster than building up. This is when a stress fracture can develop [8].
 * A stress fracture is a small crack in a bone [8].

Symptoms:

 * Localized pain and tenderness at the site of the stress fracture [8]
 * Jumping/hopping on affected leg reproduces pain [8]
 * Pain during activity, feels better with rest [8]

Risk Factors:

 * Sudden increase in training volume, intensity, duration [9]
 * Inadequate rest between activity [8]
 * Sleep deprivation [8]
 * Female gender [8]
 * Amenorrhea/menstrual irregularities
 * Nutritional deficiencies [8]

Prevention:

 * Correct training errors [8]
 * Educate female athletes and their coaches and parents on the importance of regaining menstrual regularity and hormonal balance. [8]
 * Cross train [9]
 * Ensure adequate energy intake for amount of energy being expended [9]

Treatment:
[|bilat+sfx.jpg]
 * Limited to no weight bearing for 1-6 weeks, then progress slowly back into activity [8].
 * If athlete is concerned about losing fitness during rest period, he or she can swim or bike during non-weight bearing period [8].

Prognosis:

 * With adequate rest period and gradual increase back into activity, prognosis is good for return to sport.

“Identifying Sex-Specific Risk Factors for Stress Fractures in Adolescent Runners [10]”

 * 748 competitive high school runners
 * 442 girls
 * 306 boys
 * Method: Online surveys administered that covered the following areas:
 * Training history and performance
 * Prior injury and fracture
 * Dietary intake and eating behaviors
 * Menstrual history
 * Sports participation and cross-training
 * Runners were prospectively followed for 2.3 +/- 1.2 total seasons of cross country and track and field to identify development of stress fractures during this time.
 * Statistical Analysis:
 * Girls and boys data analyzed separately
 * The prospective results (whether or not the athlete sustained a stress fracture or not) were combined with survey results
 * The group who sustained stress fractures prospectively were compared to the group who did not sustain a stress fracture using one of the following:
 * T-tests
 * Wilcoxon rank sum tests
 * Chi squared tests
 * Fisher’s exact tests
 * Independent variables that had been identified as risk factors for stress fractures in previous studies were analyzed using univariate analysis
 * Those variables that were shown to be significant through univariate analysis were then analyzed through multivariate analysis
 * P < 0.05 significance for variables in multivariate
 * Results from prospective data of 428 girls and 273 boys:
 * 23 girls and 11 boys were diagnosed with a stress fracture during the prospective study
 * Tibia was most common place for girls, metatarsals for boys
 * Multivariate regression: 4 independent risk factors for stress fractures in girls identified:
 * Prior fracture
 * BMI < 19
 * Late menarche (≥15 yr)
 * Previous participation in gymnastics or dance
 * In boys:
 * Prior fracture
 * An increase in the number of seasons participating in sports
 * Prior participation in basketball was actually found to decrease boys’ risk of stress fractures

Clinical Recommendations:

 * Because history of a prior fracture was found to be a risk factor for both boys and girls in this study, it seems that prevention of stress fractures in the first place will give adolescent runners the best prognosis.

= Baseball =

Little League Elbow


[|d03c822f0b3b2c460a23b530aa6adcd6_article_image_36739-640.jpg]

Overview:

 * Little league elbow (LLE) is term used to describe a variety of conditions. Most commonly medial epicondyle injuries and osteochondritis dissecans of the capitellum [3].
 * LLE creates medial elbow pain due to the valgus stresses that the elbow is placed under during pitching; particularly during the cocking and acceleration phases [3].
 * The valgus stress encountered produces tension at the medial elbow, shearing at the posterior elbow, and compression at the lateral aspect of the elbow [3].
 * Pitchers that are still growing are at risk of developing LLE because of the growth cartilage that is present [3].

Risk Factors:

 * Primary is overuse [3]
 * Pitching mechanics
 * Pitch volume
 * Applies to those pitches thrown during competition
 * Muscular fatigue [3]
 * Objective measures: decreased reaction time, movement coordination, motor precision, and muscle force generation capacity
 * Pitch type
 * Some research recommends not throwing breaking pitches (curveball and slider) as youth because of the different hand, wrist, and forearm positioning and movements when compared to the fastball and change-up [3].
 * Conflicting research also states that there is no significant findings to suggest that the curveball causes increased stress to the elbow [3].
 * Overall, focus should be placed on mastering the fastball and change-up before working on the mechanics of other pitches [3].
 * Physical conditioning
 * Focus on maximizing performance and decreasing the risk of injury
 * Warm-up [3]
 * Warm-up activities serve to elevate core body temperature, enhance motor unit excitability, improve kinesthetic awareness, and maximize active ROM [3]
 * Static stretching after warm-up [3]
 * Resistance training [3]
 * Trunk strengthening [3]
 * Neuromuscular training [3]


 * Previous shoulder or elbow pain with throwing in the preceding 12 months [11]
 * Previous shoulder or elbow injury requiring medical attention [11]
 * Team training greater than or equal to four days per week [11]
 * Self-training seven days per week [11]
 * Being a regular player [11]
 * ROM of the shoulder [11]


 * Increased age [12]
 * Increased weight [12]
 * Decreased height [12]
 * Lifting weights in season [12]
 * Playing baseball in more than one league [12]
 * Decreased self-satisfaction with performance [12]
 * Throwing less than 300 pitches or more than 600 during the season [12]
 * Split-finger (e.g., forkball, sinker, splitter) [12]


 * Limited hip flexion and internal rotation at 90 degrees of hip flexion [13]
 * Our body is a kinetic chain, the force that our lower extremities can generate with throwing is able to be transferred up the chain to our core, shoulder, and elbow. If we have proper alignment of the plant leg, the leg contralateral to the throwing arm, it will create the most effective transfer of energy by allowing our hips, pelvis, and trunk to rotate. In addition to decrease the amount of forces and torque on the arm it is also necessary for the pelvis to be in aligned with the lead foot when it makes contact, have maximal shoulder external rotation, and proper ball release. If you don’t have sufficient range of motion with hip rotation then that can negatively affect your throwing mechanics.


 * Older than 11 years [14]
 * Taller than 5 feet [14]
 * External rotation of the shoulder below 130 degrees (measurement in forearm neutral at 90 degrees)[14]
 * External rotation muscle strength above 80 N (18 lb) [14]
 * Internal rotation muscle strength above 100 N (22.5 lb) [14]

A Preseason Checklist for Predicting Elbow Injury in Little League Baseball Players [11]
1. Condition of the elbow of the throwing arm 2. Information about the individual player’s baseball playing and practice 3. Pitching form 4. Flexibility
 * Prospective cohort study
 * Investigated effectiveness of a risk factor checklist for predicting elbow injuries in little league baseball players.
 * Parents and coaches had to answer a 20-item checklist was created based on four areas of risk:





1. Has experienced shoulder or elbow pain while throwing in the preceding 12 months 2. Has ever experienced an elbow or shoulder injury requiring medical attention 3. Team training greater than or equal to four days per week 4. Self-training seven days per week 5. Checklist item no. 5: “Are you a regular player?” 6. Checklist item no. 8: “Does your pitching arm often feel fatigued while playing baseball?”
 * Follow-up survey was done a six months.
 * Exclusion criteria: those with throwing pain in the elbow or shoulder at the beginning of the season, didn’t complete survey at the beginning and at 6 month follow-up.
 * Inclusion criteria for the 20-item checklist: whether the factors were already reported as risk factors for throwing-related elbow injury in previous studies and whether the coaches and parents could easily evaluate the factors with reliability even if they didn’t have any medical knowledge.
 * Divided players into two groups: those with occurrence of elbow injury during the season and those without injury
 * Analysis: t test was performed on the interval items of age, height, weight, and the number of months playing baseball. A chi-square test was done for the ordinal items.
 * Unpaired t test demonstrated that age, height, weight and length of time playing baseball were significantly different between the two groups
 * Chi-square test was also significantly different between the two groups.
 * Logistic regression analysis was used to establish whether the risk factors were independently related to having an elbow injury while in-season.
 * Dependent variable: presence or absence of elbow injury during the season
 * Independent variable: all items that had a P-value of < 0.1 in univariate analyses
 * Based on the p-value and odds ratio six items were found to be significant:




 * Taking these six variables an injury risk score (IRS) was calculated and the receiver operating characteristic (ROC) curve demonstrated a 0.717 sensitivity and a 0.771 specificity.
 * Total of 389 players with 53 had experienced an elbow inj; rate of 13.6%
 * This study found that the volume of baseball played was a significant risk factor that has also been demonstrated in other studies.

Prevention:
https://lehmansbaseball.files.wordpress.com/2011/02/pitcher-phases.png
 * Education
 * Identify athlete’s risk factors
 * Consult the USA Baseball Medical and Safety Advisory Committee position statement on Youth Baseball Injuries for recommendations [15]. [|Pitching Guidelines]
 * Coaches and parents need to listen to the athlete and are accountable too.
 * Fundamental movement screen (FMS) as a preparticipation screening tool to find any deficits that the athlete may have and then address those deficiencies [3].
 * FMS requires strength, flexibility, ROM, coordination, and balance
 * Assess pitching mechanics
 * Pitchers should avoid other overhead sports for at least three months out of the year [3]
 * Avoid pitching with arm pain and fatigue [3]
 * Limiting pitch count [11]
 * Strict compliance is necessary in order to avoid injury
 * Focus on those risk factors that can modify

media type="youtube" key="jRJCLs9HZEs" width="560" height="315" media type="youtube" key="uF4tFjv92DI" width="560" height="315" media type="youtube" key="D1nNYqgp2nA" width="560" height="315"

Prognosis:

 * Determined on an individual basis
 * Return to sport once pain has subsided
 * Full ROM
 * Equal strength

= Swimming =

Swimmer's Shoulder


[|swimming.jpg]

Overview:

 * Swimmer’s shoulder is a broad term that includes overuse injuries of the shoulder due to a high volume of swimming.
 * The most common injury classified as swimmer’s shoulder is secondary impingement [16].
 * Secondary impingement has a gradual onset from repetitive trauma occurring to the shoulder, rather than any identifiable traumatic event causing it [16].
 * The cause of secondary impingement is glenohumeral laxity, and swimmers typically have excessive shoulder ROM, specifically ER. There is often failure of the rotator cuff to stabilize the humeral head resulting in increased stress on the tendons. (Hypermobility is not instability unless the secondary stabilizers do not function adequately and symptoms occur) [16]
 * The primary symptom that occurs with swimmer’s shoulder is pain, and this pain usually worsens as the swimmer fatigues, which affects their stroke mechanics [16].
 * Competitive swimmers may swim around 20-40 miles per week, which is the aerobic equivalent of running 80-160 miles per week, so it is understandable how overuse injuries occur [17].
 * It is unknown if the repetitive motion of swimming causes shoulder laxity, or if people who have more shoulder laxity are more inclined to continue swimming because the laxity makes them more efficient in the water [17].

Risk factors:
[|inge_de_bruijn_stretch.jpg] [|661070-yellow-strokemaker-paddle.jpg] [17] [17]
 * Sex [17]
 * Females have higher prevalence
 * Swimming experience [17,18]
 * Training distance [18]
 * >10,000m daily (6.2 miles), or >20 hours per week
 * Stroke choice [17,18]
 * Freestyle has highest injury prevalence
 * Workout intensity [17]
 * Lack of upper extremity weight training [17,18]
 * Stretching (especially when performed with a partner) [17]
 * Overstretching of the capsule increases instability [17]
 * Stretching of the anterior capsule should be avoided [17]
 * Buddy stretching should also be avoided because it causes swimmers to stretch past a comfortable stretch, potentially causing lasting pathologies [17].
 * Use of hand paddles in training [17]
 * Abnormal ER to IR ratio, which is usually already present when a swimmer reaches high school [17]
 * Poor stroke technique [17]
 * Crossing the arm over midline during the pull phase of freestyle
 * Lacking elbow elevation during the recovery phase of freestyle
 * Dropped elbow is very indicative of impingement because a lower elbow decreases the amount of IR needed to have the hand clear the water.
 * History of previous shoulder injury [18]
 * Serratus anterior weakness (scapular winging) [18]

Prevention:
media type="youtube" key="u77z9sDUwh4" width="560" height="315"
 * Swimming with proper technique is the best way to prevent shoulder injury. Most intermediate-level coaches do not typically know how to correct form to prevent injury [17].
 * Weight lifting regimens that strengthen the rotator cuff muscles helps aid in secondary stabilization of the shoulder [17].
 * Strengthening of the scapular retractors, low trap, external rotators, and core muscles is also important to correct strength imbalances [17].
 * Educating coaches on prevention of injuries through proper stretching, strengthening, and most importantly, stroke technique [17]

Prognosis:

 * About 95% of swimmers are able to return to sport after having swimmer’s shoulder [17].
 * The other 5% will have a surgical intervention [17].
 * The amount of time before returning to sport varies based on recovery time. The longer the swimmer is out of practice, the longer it takes to return, and typically swimmers to do not return to their same level after a prolonged injury [17].

Shoulder pain in swimmers: A 12-month prospective cohort study of incidence and risk factors [19]

 * Prospective cohort study on competitive swimmers
 * Inclusion criteria:
 * 74 competitive swimmers (37 female, 37 male) in Melbourne, Australia that has competed at a state or national level
 * Practices at least 5 times a week, and will do this for at least a 12 month span
 * Exclusion criteria:
 * History of shoulder surgery
 * History of shoulder dislocation
 * Having shoulder pain the day of initial testing
 * Procedure:
 * Initial testing:
 * Questionnaire about demographics, swimming characteristics, training, and injury history
 * IR and ER ROM measurements
 * Anterior and posterior GH glides
 * Swimmers carried on their usual training for a 12 month period and kept a weekly diary to monitor injury
 * Injury was reported by the symptom duration and the number of missed or modified practices
 * Definition of significant interfering shoulder pain (SIP): significant interfering shoulder pain that interferes with competition, training, or progression caused by modification or cessation of training.
 * Definition of a significant shoulder injury (SSI): any SIP that lasted for at least 2 weeks.
 * Data Analysis
 * Variables examined:
 * ROM, GH laxity, injury history, demographics, competitive characteristics, and training in past year
 * Bivariate logistic regression analyses examined these variables.
 * A backward stepwise binary logistic regression was used to determine the independent predictors of shoulder injury.
 * A final logistic regression model was used to determine the goodness of fit, odds ratio, and confidence interval.
 * Results
 * 38% of participants reported significant interfering shoulder pain (SIP), and 23% of participants reported a significant shoulder injury (SSI)
 * 70% of these reported were new injuries
 * The incidence rate is 0.3 SIP injuries per 1000 kilometers of swimming, and 0.2 SSI injuries per 1000 kilometers
 * 90% of injuries were sustained during training particularly during the pull through phase of freestyle. The other 5% occurred during races.
 * The average duration of the injuries (both SIP and SSI) was 4±2 weeks
 * The mean age of injured swimmers was 15±3 years
 * Injury frequency was not statistically different between males and females
 * Increased ER was associated with SIP (p=0.015)
 * Previous shoulder injury was associated with both SIP and SSI (p=0.001)
 * The odds ratio showed both increased and decreased ER led to an increased prevalence of swimmer’s shoulder.
 * Swimmers with previous shoulder pain or injury were 4.1 (95%CI: 1.3, 13.3) times more likely to have an SIP, and 11.3 (95%CI: 2.6, 48.4) times more likely to have an SSI.
 * Amount of miles swam was not a significant predictor of injury

= Gymnastics =

Gymnastic's Wrist
[|3-jpg.jpg]

Overview:
Start video at 40 seconds media type="youtube" key="NW0ey4kquV8" width="560" height="315" [|622_Longitudinal_Bone_Growth.jpg]
 * Children are starting gymnastics earlier; repeated loading on the wrist can cause stress and overuse injuries [20]
 * Wrist pain is common among gymnast (70-80%) [20]
 * Activities such as tumbling, mounting, dismounting, and swinging demand large amounts of weight bearing on the upper extremities [8]
 * Certain actives such as the pommel horse in gymnastics can load the wrist up to 10X the body weight, can lead to distal radial growth plate injury in children that are still growing (age 10-14 most frequent due to growth spurt) [8,23]
 * “ In a growing child, the open growth plate in the wrist is very vulnerable to injury, and gymnasts can develop what we call “gymnast’s wrist,” or a stress fracture to the growth plate. If left untreated, overtime the continued stress can lead to early closure of the growth plate, while the other bone in the wrist continues to grow normally. The result is a condition called positive ulnar variance. This in turn predisposes the athlete to developing cartilage tears in the wrist and traumatic or stress injuries to the bones in the hand.”-Children’s Hospital Colorado [21]
 * Positive ulnar variance describes where the distal articular surface of the ulna is more distal when compared to the articular surface of the radius.
 * “Compressive loading and shearing forces cause physeal microfractures at the hypertrophic zone, the weakest zone due to the paucity of collagen matrix and lack of calcification reinforcement.”-Davis [22]

Risk Factor:

 * Age between 10 and 14 years [23]
 * Earlier training commencement [20]
 * Training intensity [20]
 * The floor exercise, the pommel horse, and the balance beam were most frequently associated with wrist pain symptoms [23]
 * Exercises that load the wrist with excessive force [23]

Treatment:

 * Conservative [8,23]
 * Stop all painful activity [8,23]
 * Avoid extensive pressure on the wrist joint for 6 weeks [8,23]
 * Use brace or tape to help support wrist [8,23]
 * Reduce the volume of training [8,23]
 * Strength, ROM, Flexibility, Bracing [8,23]

Prognosis:
[|Arthur+Mariano+Youth+Olympics+Day+8+Gymnastics+-07lxLM8n4Il.jpg] Wrist Pain, Distal Radial Physeal Injury, and Ulnar Variance in Young Gymnasts: Does a Relationship Exist? [24]
 * Conservative treatment works well with early diagnosis and rest [22]
 * Return to activity only when pain free [22]
 * May need to continue to wear brace [22]
 * Purpose: “The purpose of the current study was to investigate the relationships among wrist pain, radiographic findings of the distal radial growth plate, and ulnar variance in a single population of nonelite young gymnasts, who represent the majority of gymnastics participants in the United States”
 * Hypothesis: “There is a relationship between wrist pain, radiographic findings of distal radial growth plate injury, and ulnar variance in skeletally immature young gymnasts.”
 * Study Design: Cross Sectional
 * Participates: 59 young gymnasts between the ages of 5 to 16 (28 girls and 31 boys). All trained at the same gymnastic club.
 * Material and Methods:
 * Questionnaire: Collected information on age, sex, age of initiation of training, training hours per week, competitive skill level, years of training, and cumulative exposure hours, and define training movements. A history and description (location, duration, quality) of pain was collect over the pervious 6 months. Which activities (ex. handsprings) and events (ex. pommel horse, floor exercises) produced pain. It also assessed if the wrist pain limited training or caused them to miss training. Same questionnaire was used in pervious studies over similar topics. Competitive gymnasts were further categorized as beginning, middle, advanced, or elite. Comparable groupings for boys and girls were based on USA Gymnastics classifications. For the purposes of statistical analysis these categories were assigned numerical values of 1 through 5.
 * Physical Examination: Each participant underwent a physical examination of the wrist and a single measurement of height and weight. The grip strength was also recorded by using a dynamometer. Each grip strength was taken 3 times and used average.
 * Radiographs: Bilateral posteroanterior and oblique radiographs of each wrist were obtained. For ulnar variance measurement, the posteroanterior radiographs were obtained and measured by using the method described by Hafner et al. for skeletally immature subjects.
 * Data Analysis: STATA statistical Software program. Wrist pain: univariate analysis with a t-test. Radiographic finding: multivariate logistic regression. Ulnar variance analysis was performed by selecting the most positive ulnar variance measurement for each subject.
 * Results: Factors significantly associated with wrist pain included higher skill level (P=0.03), older age (P=0.004), and more years of training (p=0.02). For those between 10 and 14 years of age, 83% had wrist pain, compared with 44% for those outside of that age range (P=0.004). Wrist pain prevalence was significantly related to the grade of radiographic injury (P=0.007).
 * Discussion: Radiographic findings of distal radial physeal injury are associated with wrist pain among young nonelite gymnasts.
 * Limitations: Small sample size, cross-sectional study design cannot prove a causal relationships with respect to training, wrist pain, and radiographic findings of the distal radial growth plate, nutrition, equipment, coaching, and individual technique.