Elbow Overuse Injuries in Pediatric Female Gymnastic Athletes

Abstract

Background: Radial head stress fractures (RHSFs) and capitellar osteochondritis dissecans (COCD) are rare but may be seen in gymnasts. The purpose of this study was to compare the clinical and radiographic characteristics and the outcomes of RHSF and COCD in pediatric and adolescent gymnastic athletes.Methods: Classical gymnasts and competitive tumblers £18 years of age presenting with RHSF or COCD over a 5-year period were reviewed. Radiographic characteristics, clinical characteristics, and patient-reported outcomes were compared.Results: Fifty-eight elbows (39 with COCD and 19 with RHSF) were studied; the mean patient age was 11.6 years.Gymnastic athletes with RHSF competed at a higher level; of the athletes who competed at level ‡7, the rate was 95% of elbows in the RHSF group and 67% of elbows in the COCD group. The RHSF group presented more acutely with more valgus stress pain than those with COCD (p < 0.01) and demonstrated increased mean valgus angulation (and standard deviation) of the radial neck-shaft angle (13°± 3.8°for the RHSF group and 9.3°± 2.8°for the COCD group; p < 0.01) and decreased mean proximal radial epiphyseal height (3.7 ± 0.6 mm for the RHSF group and 4.2 ± 1.5 mm for the COCD group; p < 0.01). At a minimum of 2 years (range, 2.0 to 6.3 years), the RHSF group reported fewer symptoms; the QuickDASH (abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score was 1.75 ± 3.84 points for the RHSF group and 7.45 ± 7.54 points for the COCD group (p < 0.01). Those at a high level ( ‡7) were more likely to return to gymnastics independent of pathology, with the RHSF group reporting higher final activity levels with the mean Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) score at 26.0 ± 7.5 points compared with the COCD group at 23.6 ± 5.7 points (p < 0.05). Of the 9 patients with bilateral COCD, only 3 (33%) returned to gymnastics.Conclusions: RHSF with features similar to the more familiar COCD lesion may present in gymnastic athletes. Those with RHSF may present more acutely with a high competitive level and may have a better prognosis for return to competitive gymnastics than those with COCD.

Returning to Sport: A Level-Based Guide for Women’s Artistic Developmental Program Gymnasts

“…Elbow injuries in female gymnasts may be acute -such as an elbow dislocation -but are more often chronic and secondary to overuse -such as an osteochondritis dissecans (OCD) lesion or radial neck stress injury. [41][42][43][44][45] OCD lesions of the elbow are typically diagnosed with a history of chronic lateral elbow pain; a physical examination notable for pain to palpation of the capitellum, sometimes with abnormal elbow ROM or effusion; and either radiographic or MRI findings of an OCD. 46 Management may be non-operative or operative depending upon the stability of the lesion upon diagnosis.…”

“…The mainstay of treatment is rest. 44,45,47,48 Once the athlete has undergone appropriate treatment and is cleared to return to sport, it is important to consider that, like the wrist and shoulder, the elbow is exposed to extremely high impact forces in gymnastics. Additionally, the gymnast's elbow endures repetitive valgus stress resulting in compressive forces through the elbow's lateral structures as well as increased tensile forces through the medial structures.…”

Overuse Injury of the Epiphyseal Primary Physis

“…The most common SH-type stress fractures reported in the literature are type II, but type III fractures are also very common in climbing athletes. 11 Although SH IV stress fracture is relatively uncommon, it was reported to affect the proximal radius of gymnasts [52][53][54] and can cause premature physeal closure.…”