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Wrist overuse in young athletesExploring diagnostic
strategiesKox, L.S.
Publication date2018Document VersionOther
versionLicenseOther
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Citation for published version (APA):Kox, L. S. (2018). Wrist
overuse in young athletes: Exploring diagnostic strategies.
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Laura S. Kox, P. Paul F.M. Kuijer,
Jip Opperman, Gino M.M.J. Kerkhoffs,
Mario Maas, Monique H.W. Frings-Dresen
Journal of Sports Sciences 2018; 36(1): 86-96
CHAPTER 4Overuse wrist injuries in young athletes:
what do sports physicians consider important signals and
functional limitations?
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Abstract
ObjectivesTo collect items from experienced sports physicians,
relating to the presence and severity of overuse wrist injuries in
young athletes, for developing a measurement instrument for signals
of overuse wrist injury.
MethodsSeven Dutch elite sports physicians involved in guidance
and treatment of young athletes in wrist-loading sports
(gymnastics, tennis, judo, field hockey, volleyball and rowing)
partic-ipated in a focus group. They discussed signals and
limitations related to overuse wrist in-juries in young athletes.
Data were coded and categorised into signals and limitations with
subcategories, using an inductive approach.
ResultsOf 61 signals and limitations in nineteen
(sub)categories, twenty were considered import-ant, forming a
comprehensive item set for identifying overuse wrist injury in
young athletes. Signals such as pain, ‘click’, crepitations,
swelling and limited range of motion were marked useful for early
identification of overuse wrist injury. Limitations in movement and
perfor-mance were considered indicative of severe overuse injury,
but less relevant for initial injury identification.
ConclusionsThe focus group provided seventeen important signals
and three important limitations in-dicative of overuse wrist
injury. These provide the basis for a valid measurement instrument
for identifying overuse wrist injury in young athletes, with equal
emphasis on pain and on other symptoms.
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Overuse wrist injuries in young athletes
4
Introduction
In youth sports, early specialization and competition, combined
with increasing pressure on young athletes to excel often lead to
overuse injuries.1 The wrist is a typical injury location in these
athletes, susceptible to injuries such as radial epiphysitis or
‘gymnast wrist’, carpal stress fractures, and various tendon
inju-ries, all different in origin based on training type and
associated wrist-loading pattern.2-5 Possible long term
degenerative wrist joint changes after overuse wrist injuries
include scaphoid and ulnocarpal impaction syndrome, both associated
with invalidating symptoms and limitations.6 Treatment of overuse
wrist injuries in young athletes is preferably conservative, the
duration depending on the injury stage. For gymnast wrist,
increased severity of radiographic changes has shown to require
longer sport cessation before achieving full recovery.7 Early
diagnosis is therefore essential for preventing these
incapacitating short and long term conse-quences and for reducing
recovery times to facilitate timely return-to-play.
A recent literature study found wrist pain prevalence rates of
32-73% in young athletes, mainly gymnasts.8 We identified six
Olympic youth sports requiring spe-cific attention in the
prevention of overuse wrist injuries, here termed ‘wrist-load-ing
focus sports’: gymnastics, tennis, field hockey, volleyball, judo
and rowing.8 These sports were selected based on the fact that they
are popular and highly stimulated Olympic youth sports in the
Netherlands with high participation rates, and that all involve
substantial weight bearing or repetitive loading of the wrist.
Awareness has increased among sports physicians, whose role in
the evalua-tion of young athletes with wrist pain is crucial.
However, these athletes often fail to report symptoms or seek
timely medical attention.9 Adequate monitoring for overuse wrist
injuries is thus essential, and has been proposed as a behavioural
preventive method for overuse injuries.10 A short questionnaire may
be a valuable clinical diagnostic tool for identifying young
athletes with a (beginning) overuse wrist injury. In addition, the
use of a valid measurement instrument in future re-search could
provide more accurate information on the prevalence of overuse
wrist injuries in the young athletic population and across
different sports. However, a measurement instrument for detecting
overuse wrist injuries in this population is not yet available.
For young athletes in general and those in wrist-loading focus
sports in par-ticular, we aim to develop a measurement instrument
for signals and functional limitations related to (beginning)
overuse wrist injury. This instrument, the SOS-WRIST (Signalling
Overuse in Sports for the WRIST) should ideally consist of a short
questionnaire to aid in the identification of young athletes with
(beginning) overuse wrist injury. The construct this instrument
aims to measure is ‘overuse wrist injury’. Early injury
identification and athlete referral can then enable timely
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106
Chapter 4
diagnosis and appropriate treatment tailored to the athlete.This
study is part of the development process of the SOS-WRIST,
encompass-
ing a stepwise establishment of the instrument’s validity,
reliability and respon-siveness. Before proceeding to assessment of
reproducibility and construct and criterion validity, the content
validity is evaluated, which is defined as the degree to which the
instrument’s content adequately reflects the construct to be
mea-sured.11 This requires assembly of a preliminary list of items
to be included in the instrument. Potential items are collected
based on the literature and interviews of experts within the field
of interest.
We report the results of the first phase in developing the
SOS-WRIST: achieving adequate content validity. The present study’s
goal is to compose a list of relevant signals and limitations
related to overuse wrist injuries in young athletes, provid-ed by
experienced sports physicians.
Methods
Study design
This study is based on content analysis; systematic data
collection in an organised format. We used the Consolidated
Criteria for Reporting Qualitative Research (COREQ) checklist for
reporting the results.12 The study was performed according to the
Declaration of Helsinki and the Academic Medical Center’s ethics
commit-tee decided it is not subject to the Dutch Medical Research
Involving Human Sub-jects Act.
Through purposive expert sampling, we approached seven Dutch
sports physi-cians by email informing them about the study’s
purpose and content. This sample was chosen in such a way that all
six wrist-loading focus sports were represented by physicians
involved in care for professional-level young athletes, (e.g.
physician for (pre-)Olympic athletes, national sports federation’s
team physician). All physi-cians were acquainted with the
researchers, because of intensive collaboration of this research
group with the Academic Center for Evidence-based Sports medicine
(ACES). This study’s purpose within a research project on
signalling overuse wrist injuries in young athletes was explained
prior to the meeting, and participants were familiar with the
moderator’s credentials and interest in this topic. All seven
sports physicians provided written informed consent to
participate.
Data collection
Data was collected during a meeting at our hospital in January
2015. Participants
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Overuse wrist injuries in young athletes
4
were offered drinks, lunch, and reimbursement for travel
expenses. Three research-ers (LK, PK, JO) were present during the
entire meeting and two researchers (MFD, MM) were present for the
introductory part. The procedure, questions and re-searcher
characteristics are outlined in Tables 1 and 2.
Table 1. Focus group interview guide
Main study questions
1. What are the most important signals of overuse wrist injuries
in young athletes for sports physi-cians involved in wrist-loading
focus sports?
2. What are the most important limitations for young athletes in
wrist-loading focus sports due to overuse wrist injury, according
to sports physicians involved in these sports?
Prior to meeting
Participants are presented with a case and are asked to answer
questions 1 and 2 by email.
Case: A thirteen-year old girl who is a professional athlete
reports to your clinic with pain in her wrist since three
months.
1. According to you, what are the most important signals of
overuse injury of the wrist in young athletes?
2. What aspects are important for young athletes with possible
overuse injury of the wrist, when it comes to:
• Determining the severity of the problem?
• Deciding if diagnostic imaging is necessary?
• Deciding if a therapeutic intervention is necessary?
During meeting (approximate duration 2.5 hours)
Participants discuss their preferred answers to questions 3-5,
with ca. 30 minutes of discussion per question.
3. What other important signals of overuse injury of the wrist
have not yet been mentioned or need to be specified in further
detail?
4. What sport-specific limitations are important when diagnosing
overuse injury of the wrist?
5. What combinations of these signals and limitations are
important when diagnosing overuse injury of the wrist?
The items are numbered in a PowerPoint presentation and on a
white board, and participants are asked to post the numbers of the
signals they considered important on separate sticky notes onto the
board. The resulting collection of items of perceived importance
are further discussed.
Prompts that can be used upon the answers of participants to
questions 3 – 5:
• Does this apply to everybody?
• Does anybody want to add something?
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108
Chapter 4
An interview guide was composed in consensus by the research
group (Table 1). All participants first answered two questions by
email, and based on the answers a preliminary list of relevant
items was composed. This method was chosen to al-low for more
discussion time during the meeting while maintaining a reasonable
time schedule, and to reduce the risk of bias by preventing
participants from being influenced by each other’s initial answers.
Audio recordings of the meeting were made, for which written
permission was obtained from all participants. The mod-erator and
both assistant moderators made notes during the meeting.
At the end of the meeting, participants filled out an anonymous
questionnaire evaluating the session’s setup and content and rating
it on a 10-point scale (0= ‘not satisfied at all’; 10=’very
satisfied’). The audio recordings were transcribed verbatim by one
assistant moderator ( JO). The transcript was corrected and
approved by all participants.
Table 2. Characteristics of researchers and focus group
participants
Researchers Role Tasks
Female medical doctor working as a full-time researcher (LK)
Moderator, trained for this task by two co-authors (MFD and
PK).
Leading discussion
Male human movement scientist and PhD working as an assistant
profes-sor (PK)
Assistant-moderator with sub-stantial experience in super-vising
focus group meetings
Note-taking and assisting moderator by asking addi-tional
questions
Female medical student (JO) Assistant-moderator Transcribing
discussion and assisting moderator by asking additional
questions
Focus group participants Male Female
Sex 4 3
Median Range
Age 48 years 36 – 56 years
Work experience as a sports physi-cian
15 years 2 – 25 years
Number of athletes ≤ 18 years treated per year
250 25 – 750
Wrist-loading sports involved Rowing, martial arts (including
judo), tennis, gymnastics, volleyball, basketball, field hockey
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109
Overuse wrist injuries in young athletes
4
Data analysisOne author (LK) coded the transcript using
specialised software (MAXQDA, V11, Udo Kuckartz, Berlin). Three
authors (PK, MFD, MM) checked the coded transcript against the
original audio recording for appropriate coding. Each checked a
ran-dom sample of transcript pages and coding discrepancies were
discussed until 100% agreement was achieved. Transcript coding and
analysis were performed us-ing an inductive approach: identifying
items that could be grouped under themes. These themes were derived
directly from the raw data. The two research questions were used as
a framework for grouping these themes and items.
Results
Meeting summary
All participants indicated satisfaction with the meeting’s
structure and content (median rating 9; range 7-10). Participant
characteristics are shown in Table 2. In total 61 items were
collected (49 signals and 12 limitations related to overuse wrist
injury; Figure 1, Supplement 1-2):
1. 18 items collected by email prior to the meeting;2. 15 items
added by participants during the meeting;3. 28 items identified
during coding of the meeting transcript.
Twenty signals and limitations were marked as important by one
or more partic-ipants (Figure 1, Table 3). The signals ‘previous
wrist injury’ and ‘predisposition of stiff wrists for dorsiflexion’
were considered important athlete characteristics. Most of the
important signals were related to symptomatology (Table 3). ‘Pain’
was considered the main relevant signal in the category ‘symptoms’,
although several other terms were mentioned. As participant no. 1
underlined:
“Just pain is the very first thing you need to have for it [an
injury] to bother you.”
Signals of overuse wrist injuryThe category ‘severity of
symptoms’ was discussed extensively (Supplement 1). Severity of
pain measured on a 10-point visual analogue scale (VAS; 0= ‘no
pain’; 10= ‘worst imaginable pain’) was unanimously considered an
essential feature of overuse wrist injury in young athletes, but
differences in perception of pain se-verity between athletes in
different disciplines were reported. For example, a VAS
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110
Chapter 4
score of 5 or higher was considered alarming in young gymnasts,
whereas in young judokas only a VAS score of 8 or higher was
considered serious. ‘Self-management using pain medication’ and
‘self-management using tape or brace’ were suggested as reliable
measures for severity of pain in case of uncertainty about VAS
score interpretation, or even in addition to pain scoring.
Lim
itatio
ns
Limit
ations
Signals
Lim
itation
s
in m
ovem
ent
in spor
ts
Symptoms
Pain
Athlete characteristics
Physical characteristics Sport-related characteristics
Symptom
s other than pain
Treatment
Timing Relation with sports Sev
erity
T
iming
Q
ualit
y
Location
General
Competition
Spor
t-rela
ted
Tra
ining
Sex
Age
Seco
ndar
y ph
ysic
al c
hara
cter
istic
s
Hyp
erm
obile
wris
tsPr
evio
us w
rist i
njur
y
Sti�
wris
ts fo
r dor
si�e
xion
Train
ing
loca
tion
(club
. cen
tral o
r nat
iona
l)
Tech
nique
Traini
ng in
tensit
y
Trainin
g mate
rial
Most fr
equent
movem
ents du
ring spo
rts
Change in
training l
oad
Change of tr
ainer
Change in training m
aterials
Change in technique
Timing in sports season or career
Pain
‘Aching’Tenderness
Gradual onset of painNo clear acute cause of pain
Onset of pain in relation to training
Progressive pain
Pain at night
Pain in rest
Pain score on VAS
Severity of pain in words
Location
Load
ing
of w
rist
Wei
ght-
supp
ortin
g
Laun
chin
g
Supp
ortin
g in
hyp
erdo
rsi�
exio
n
Pain
in k
eepi
ng w
ith lo
ad in
spor
ts
Sudd
en e
xace
rbat
ion
of sy
mpt
oms
Acut
e on
set
Dura
tion
of sy
mpt
oms
Redn
ess
Disco
lorati
onWarm
th
Decre
ased s
treng
th
Limited
range
of moti
onSwel
lingCrepit
ations
‘Click’
Sti�ness
Itch
Pain medication
Rest
Tape or brace
Limitations in movement in general
Limitations in judo
Limitations in tennis
Limitations in volleyball
Limitations in gymnastics
Limitations in rowing
In�uence on sports performance
Reduction of number of practices
Adaptation of parts of training
Adaptation of training program
Adaptation of competition program
In�uence on sports performance
Figure 1. Coding system for all items related to signals and
limitations related to overuse wrist injury in young athletes. The
coloured inner circles represent the themes and subcategories of
the coding system, the outer circle shows all 61 items derived from
the focus group. The items that were marked as important by the
focus group are displayed in bold text.
Figure 1. Coding system for all items related to signals and
limitations related to overuse wrist injury in young athletes. The
coloured inner circles represent the themes and subcategories of
the coding system, the outer circle shows all 61 items derived from
the focus group. The items that were marked as important by the
focus group are displayed in bold text.
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111
Overuse wrist injuries in young athletes
4
Regardless of sport-related discrepancies in pain perception,
most participants considered pain difficult to assess in young
elite athletes. ‘Pain upon loading of wrist (in sports)’ was
suggested as indicative of overuse wrist injury, but only if asked
directly because young elite athletes may be used to having pain
regularly, and are thus not quickly inclined to report pain. Sports
physician no. 6 illustrated:
“Young gymnasts are already used to having pain; I’ve seen a
young female gymnast […]. She did have pain, but did not let the
doctor know. When you asked her about it, she said that she did
have pain.”
Table 3. Items marked as important by the focus group of sports
physicians (n=7)
Question 1: Signals of overuse wrist injury Number of sports
physicians
Athlete characteristics
1. Previous wrist injury 3
2. Predisposition of stiff wrists for dorsiflexion 2
Symptoms – pain
3. Pain 4
4. No clear acute cause of pain 2
5. Onset of pain (before/during/after training) 2
6. Gradual onset of pain 4
7. Progressive pain 4
8. Pain score on VAS 2
9. Pain upon loading of wrist (in sports) 4
Symptoms – other than pain
10. ‘Click’ 2
11. Crepitations 1
12. Swelling 2
13. Limited range of motion 3
14. Acute onset of symptoms 3
15. Duration of symptoms 5
Symptoms – treatment
16. Self-management using tape or brace 4
17. Self-management using pain medication 3
Question 2: Limitations due to overuse wrist injury
18. Adaptation of training program 6
19. Influence on sports performance in training 4
20. Influence on sports performance in competition 4
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112
Chapter 4
‘Pain in keeping with loading in sports’ was discussed
extensively as a signal to distinguish between overuse injury and
pain considered to be normal by the ath-lete. Participant no. 2
suggested asking:
“Do you think that this [pain] fits with the exercise you have
done? Or is this more than you would expect?”(Supplement 1)
‘Complaints’, ‘bothering’ and ‘problems’ were brought up as
alternatives for ‘pain’, as well as a number of other symptoms
(crepitations, ‘click’ in the wrist, swelling, limited range of
motion) because for athletes ‘pain’ could be too specific, while
symptoms of overuse wrist injury may very well be present.
Seemingly contradictory, ‘acute onset’ was marked as important,
as well as ‘no clear acute cause of pain’ and ‘gradual onset of
pain’. Participants indicated that chronic symptoms of overuse
wrist injuries can suddenly exacerbate and thus manifest as acute
injury. When suspecting overuse wrist injury in athletes with acute
onset of symptoms, participants suggested inquiring whether any
wrist symptoms had been present earlier.
Both ‘duration of symptoms’ and ‘progressive pain’ were
considered relevant when relating to a longer period of time.
However, duration of symptoms was not found completely reliable in
distinguishing overuse from acute injury.
Limitations due to overuse wrist injury
Three limitations were considered important: ‘adaptation of
training program’ and ‘influence on sports performance’. The
consensus was that reduced training would not be informative in
identifying overuse injury because elite athletes gen-erally
continue training even when experiencing pain. Several sports
physicians suggested specific questions about training type to be
more revealing, such as changes in training program due to symptoms
(Supplement 2). They emphasised that a missed practice in many
sports is of less consequence than missing a match. Others argued
that any adaptation in sports is relevant in signalling overuse
wrist injury. Training program adaptation was considered a common
early response to overuse injury in young athletes, whereas serious
injury would more likely lead to missing parts of a competition as
well. Influence on sports performance was there-fore considered a
limitation indicative of possibly serious overuse wrist injury.
Participants agreed that specific limitations in sports were not
relevant in identifying overuse wrist injury. Sport-specific
movements (e.g. ‘backhand’, ‘hand-stand’) were discussed, as well
as general descriptions of movements (e.g. ‘dorsi-flexion’).
General descriptions were considered too difficult to describe to
young athletes. Sport-specific movements were said not to provide
essential information,
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113
Overuse wrist injuries in young athletes
4
and to be so numerous that it would be too time-consuming to ask
about all possi-ble movements.
Discussion
This focus group of sports physicians provided 17 important
signals and three im-portant limitations indicative of overuse
wrist injuries in young athletes, to be used in the development of
a valid measurement instrument for overuse injury of the wrist, the
SOS-WRIST. Signals such as pain and other symptoms were marked as
useful for early identification of overuse wrist injury.
Limitations in movement and performance were considered indicative
of severe overuse injury, but less relevant.
We interviewed a representative sample of prominent Dutch top
sports physi-cians with extensive experience in treating elite
youth athletes and representing all wrist-loading focus sports, who
were in agreement on the meeting’s outcomes. Considering the fact
that the total body of registered sports physicians involved in
wrist-loading sports in the Netherlands is relatively small, we
considered this an acceptable focus group size. We attempted to
further reduce potential risk of bias by ensuring the participation
of sports physicians active in different sports, so that all
wrist-loading focus sports were represented. By collecting items by
email prior to the focus group meeting, we further attempted to
reduce any risk of bias due to the presence of other participants.
One focus group was therefore considered suffi-cient. An additional
focus group of sports physicians could aid in the elimination of
this potential weakness. However, as the target population of the
SOS-WRIST instrument consists of young athletes, we aim to compose
multiple focus groups of young athletes in wrist-loading sports in
addition to sports physicians, in which the content validity will
be further assessed. The multi-stage item collection through
e-mail, focus group and final item prioritization produced a
comprehen-sive list of relevant items in a time-efficient
manner.
Many of the 61 items such as age, sex, previous injury,
technique, and training intensity are in line with the literature
on overuse injuries in young athletes.13-16 However, including this
extensive item list in a measurement instrument or a con-cise
patient history is not feasible. The twenty important items
proposed by these sports physicians form a comprehensive item set
for identifying overuse wrist in-jury in young athletes.
Additionally, several of the proposed items have not been
reported extensively in the literature: both wrist-specific
(predisposition of stiff wrists for dorsiflexion), and general
items indicating overuse wrist injury (use of pain medication, tape
or brace). Inquiring about these items could reveal overuse wrist
injury in clinical practice. With regard to use of a brace however,
it should be noted that preventive
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Chapter 4
brace usage in gymnastics may render this signal less specific
in an exclusively gymnastic population.17
Although the six wrist-loading focus sports represented here are
diverse, none of the twenty important items are clearly
sport-specific. Nevertheless, pain percep-tion was found to differ
between sports, illustrated by sports physicians reporting higher
acceptable VAS scores in judo than in gymnastics. The large
majority of female gymnasts compared to a more even sex
distribution in judo could explain the discrepancy in VAS scores,
as females have been shown to have lower pain tol-erance than
males.18 Sport-specific pain score interpretation may therefore be
nec-essary in signalling overuse wrist injury in young athletes,
with lower thresholds for gymnastics than for judo. The other 19,
non sport-specific, items can be used in all wrist-loading focus
sports.
Despite sport-dependent differences, the sports physicians
considered pain an important signal of overuse wrist injury, and
proposed a VAS as a practical man-ner of assessing pain intensity.
Similarly, while prevalence rates of overuse wrist injuries are
high, many young athletes continue to practice their sport
regardless of pain.8 In a study among gymnasts pain was described
as ‘aching’ in 88% of gym-nasts with wrist pain.17 Other authors
have stated that the term ‘pain problems’ in overuse injury
surveillance in adult athletes identified more overuse injuries
com-pared to a ‘time loss to injury’ definition.19 Clinicians
seeking to identify beginning overuse wrist injuries in young
athletes may therefore best use general terms for discomfort
instead of just ‘pain’. Alternative signals such as ‘aching’,
‘tenderness’, and ‘problems’ as proposed by this focus group, need
to be evaluated further in the young athletic target
population.
A number of other symptomatic signals such as crepitations,
‘click’, swelling and limited range of wrist motion were marked as
relevant, consistent with the lit-erature.9,15,20 The sports
physicians additionally indicated that young elite athletes are
used to experiencing pain. Similarly, a literature review has shown
that ath-letes have a higher pain tolerance than non-athletes.21
Inquiring about pain alone may therefore not identify overuse wrist
injury at an early stage, thus requiring these other symptoms to be
assessed with equal emphasis in clinical practice.
Gradual as well as acute onset of symptoms was considered
possible in overuse wrist injury. Although overuse injuries are
typically considered to be of gradual onset, the literature
increasingly focuses on overuse injuries presenting with acute
symptoms.20 Overuse wrist injury should therefore be considered in
the differen-tial diagnosis in young athletes with acute onset of
wrist symptoms. A history of previous wrist injury, as suggested by
this focus group, can be indicative of overuse wrist injury in such
cases.16 Similarly, symptoms preceding the acute event may provide
valuable information on the presence of overuse wrist injury.
This focus group considered limitations in performance less
relevant for early
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Overuse wrist injuries in young athletes
4
identification of overuse wrist injury than signals, because
they may only arise at a late injury stage. Pain during sports
activity with limited performance is common-ly considered
indicative of advanced-stage overuse injury.14,22 Minor limitations
in sports activity may not prompt young athletes to seek medical
help. For example, in a study among gymnasts as little as 13% of
young gymnasts with wrist pain con-tacted a physician because of
their symptoms, even though 42% was unable to per-form a full
training session, and 21% missed at least one training monthly due
to wrist pain.9 When the time lost to injury is significant, such
limitations can neg-atively influence young athletes’ quality of
life.23 Limitations in performance may thus indicate serious
overuse wrist injury in young athletes. In clinical practice,
targeted inquiry about partial limitations such as training program
adaptation can help identify these patients.
This study reports the results of a focus group of sports
physicians with exten-sive experience in treating young elite
athletes in wrist-loading focus sports. For a complete overview of
relevant items for early identification of overuse wrist inju-ries,
the input of the target population of young athletes is essential.
The next step in the collection of relevant items for the SOS-WRIST
will thus consist of focus group meetings with young athletes in
wrist-loading focus sports, with more in-depth assessment of items
related to athletes’ social context (e.g. role of parents). The
total collection of items derived from literature, sports
physicians and young athletes will be used to select the
appropriate combination of items, ultimately resulting in a concise
item set for the measurement instrument.
Conclusion
A focus group of sports physicians involved in treating youth
athletes in wrist-loading sports provided 17 important signals and
three limitations indicative of overuse wrist injury. The outcomes
of this study provide the basis for develop-ing a measurement
instrument for identifying overuse wrist injury in youth ath-letes,
with equal emphasis on pain and on other symptoms.
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15. Valovich McLeod TC, Decoster LC, Loud KJ,
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injuries. J Athl Train 2011;46(2):206-220.
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4
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Centre (OSTRC) overuse injury questionnaire.
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118
Chapter 4
Supplement 1. Signals of overuse wrist injury derived from focus
group of sports physicians
Example verbatim quotes
Sports physician code
Athlete characteristics
Physical characteristics
1. Sex [no quote]
2. Age “Age and sex are things that you want to know, no matter
what.”
3
3. Secondary physical charac-teristics
“If you can show that they get more wrist injuries when they do
strength training before reaching menarche or having any physical
development, then should you look not just at the age they start
doing strength training, but also at secondary physical
characteristics?”
5
4. Hypermobile wrists “Hypermobile wrists, how are you going to
measure that? That’s something we’re facing everywhere.”“If you’re
asking a child: ‘Do you have hypermobile wrists?’ it’s better to
obtain that from [physical examination] then from asking the
child.” “[Tests for hypermobility]; all expert-based.”
5
6
2
5. Previous wrist injury “Whether someone has had a wrist injury
before should definitely be added [to the list]. That is the only
thing that always comes up in risk factors.”
2
6. Predisposition of stiff wrists for dorsiflexion
[no quote]
Sport-related characteristics
7. Training at club, central institution or national
se-lection
“There is no central supervision of loading and load capacity.
When an athlete is training at mul-tiple locations, nobody looks
after the total load. Then what can happen is that he does a
ridiculous amount in one day.”“If you’re training centrally or at
the club? Then there are different types of equipment and a
different floor.”
5
4
8. Technique “It is also important whether it is the dominant or
the non-dominant hand. With a two-handed back-hand you get other
injuries than with a forehand.”“And in rowing: whether you turn
inside on the indoor rower, or outside: then you turn more.”“[In
judo] when they get older, they grasp in the neck. Children handle
the lapels more and are make different manoeuvres.”
3
1
7
9. Training intensity “You always start with a sports history:
how long, what do you do, what is your [training] structure?”
5
Continued
-
119
Overuse wrist injuries in young athletes
4
Supplement 1. Continued
Example verbatim quotes
Sports physician code
10. Training material “But the form of the [ judo] suit changes,
it be-comes heavier, and that means grasping more strongly. The
material is different. Those are things you need to pay attention
to in athletes like judo-kas. Tennis rackets can have different
weights, too.”
7
11. Most frequent movements during sports
“[In tennis] dorsiflexion or palmar flexion, pronation.”“For us
[in judo] it is firmness, grasping.”
37
12. Change in training load “We’ve already seen that; if you
double the training intensity, you have a five times higher risk of
injuries.”“Change in training load is very generic, of course.”
5
5
13. Change of trainer “With signals of overuse, aren’t you
talking about change of trainer?”
5
14. Change in training mate-rials
“In tennis, I also think of tension [of the racket] and of
changes in technique.”
5
15. Change in technique “At some point, a strength training
component is added, and then there is nobody looking after the
implementation and the technique.”
5
16. Timing in sports season or in sports career
“And the question is: what are you up against? Is it a
qualification match for Wimbledon or a local tournament? What do
you accept, what is your goal and how important [is it], do you
need to achieve some status? Then you’ll accept more than if that
is not the case. So, what are the interests?”
5
Symptoms
Pain
Quality of pain
17. Pain “What somebody says, is being dismissed; but that’s the
most important thing: the way he describes it. That can be a word
we don’t call pain, but stiffness, or aching, it doesn’t have to be
pain. When you ask whether they have pain, they will say ‘No’. If
you for-mulate the question differently, you leave it open.”
7
18. “Aching” [no quote]
19. Tenderness [no quote]
Timing of pain
20. Gradual onset of pain [no quote]
21. No clear acute cause of pain “But you can also have overuse
that is still produc-ing acute symptoms.”
3
Continued
-
120
Chapter 4
Supplement 1. Continued
Example verbatim quotes
Sports physician code
“Somebody who falls and breaks his wrist is pretty acute, but
someone who lands badly while he already had some complaints; is
that acute or chronic?”
5
22. Onset of pain (before/during/after training)
“Some injuries are painful after loading, others during
loading.”
5
23. Progressive pain [no quote]
24. Pain at night “It is certainly always a red flag for
physiothera-pists.”
2
25. Pain in rest [no quote]
Severity of pain
26. Pain score on VAS [About a child aged 8 years:] “A child
like that should just not be having pain at all.” “We want to know
pain and the level of pain, that’s what we have the VAS for.”“In
gymnasts, you keep to zero to two, above five is painful, too
painful.”“In judo they find eight severe, and three to four is
normal.”
5
3
4
7
27. Severity of pain expressed in words
“What I’m missing here, and what they did have in the
questionnaire by Bahr et al, is that you can also ask: ‘Do you have
some pain, severe pain, or terrible pain?’“
3
Location
28. Location “That also depends on pain; if someone gets a kick
in the shin with soccer, that hurts with a pain score of 10, but I
would allow him to play if he can toler-ate it. But when it’s in a
joint or a muscle, then for example a [pain score of] 2 is already
too much.”
5
Relation with sports
29. Pain upon loading of wrist (in sports)
“In my case, they always have pain during a shot, otherwise they
won’t come to see me.”
3
30. Pain with weight-support-ing exercise
“Imagine having pain in your wrist every time you land.”
5
31. Pain with launching [no quote]
32. Pain with supporting in hyperdorsiflexion
“For gymnastics I mentioned supporting themselves in
hyperdorsiflexion, especially on the pommel horse. Then they carry
their body weight on the wrists in hyper-dorsiflexion, because the
device is very smooth and flat.”
4
Continued
-
121
Overuse wrist injuries in young athletes
4
Supplement 1. Continued
Example verbatim quotes
Sports physician code
33. Pain in keeping with load in sports
“[It’s] the distinction between pain that is normal [and pain
that isn’t]; when the athlete thinks it is in keeping with the
exercise he has done, then he will not try to find help.”“You could
ask: ‘Do you think this is in keeping with the exercise you have
done? Or is this more than you would expect?’“
2
2
Symptoms other than pain
34. Itch [no quote]
35. Stiffness [no quote]
36. “Click” “Patients sometimes indicate that there is a ‘snap’
or a ‘click’ in the wrist.”
5
37. Crepitations “I would call it creaking, crepitations. When
you’re asking young people, creaking is better than crepi-tations,
which they don’t know.”
7
38. Swelling “It used to be: swelling, warmth, redness.” 3
39. Limited range of motion [no quote]
40. Decreased strength “Often, it is difficult to assess; they
frequently stop doing some things because they have pain, is that a
true decrease in strength?”
2
41. Warmth [no quote]
42. Discoloration “Not always, but sometimes in a severe
inflamma-tory reaction. I recently saw a girl at the national
championships, and her wrist really had a blue colour.”“But with
blue, you really think of an injury.”
3
6
43. Redness [no quote]
Timing
44. Acute onset of symptoms “If it arose acutely, that doesn’t
mean that it’s not the consequence of chronic loading.”“If there
was an acute moment of onset, you should have a sub question: ‘Did
you have com-plaints about your wrist before this?’”
3
5
45. Sudden exacerbation of symptoms
“What often happens is that people already have symptoms, then
something happens and after-wards those symptoms are much
worse.”
5
46. Duration of symptoms “When it’s been bothering somebody for
two months.”
1
Continued
-
122
Chapter 4
Supplement 1. Continued
Example verbatim quotes
Sports physician code
“If it [the pain] arose today and it is severe, and five days
later it is still severe, then it [the injury] is more serious than
when the pain is completely gone after one day.”“That doesn’t
really differentiate between acute and chronic.”
3
6
Treatment
47. Self-management using tape or brace
“A signal can also be that he has some tape on his wrist.”
3
48. Self-management using pain medication
“In principle, children shouldn’t be using pain
medication.”“[They may say:] ‘I can do everything, but I do take
acetaminophen before practice.’““Is that an important signal of
overuse injury? Any-body can take medication.”
5
2
7
49. Rest [no quote]
For items added to the list prior to the meeting that were not
discussed in further detail during the meeting itself, no verbatim
quote is presented.
Supplement 2. Limitations due to wrist overuse injury derived
from focus group of sports physicians
Limitations Example verbatim quotes
Sports physician code
Limitations in movement
General
1. Limitations in movement – general
“Are there movements that limit you in your sport?” 7
“Not being able to [do something], that doesn’t exist,
especially not for gymnasts. They just keep going. Especially with
World Championships com-ing up, they want to keep going.”
6
“If you really can’t do something, that is a legitimate signal.”
2
“Actually, this is not a very relevant question. Be-cause you
are already asking about everything; there are not a lot of
sport-specific limitations.”
5
Sports
2. Limitations in volleyball “In basketball or volleyball it is
hitting a ball, the service or smash.”
5
3. Limitations in tennis “In tennis it is either the forehand,
or the backhand, that is often a different injury, or the
service.”
3
4. Limitations in judo “For us it is steadiness, grasping.”
7
Continued
-
123
Overuse wrist injuries in young athletes
4
Supplement 2. Continued
Example verbatim quotes
Sports physician code
5. Limitations in gymnastics “In gymnastics, you ask about
supporting and hanging.” 6
“If for example they do less on the bars, less push-ing, no
acrobatic series.”
4
6. Limitations in rowing “[I would ask:] ‘Is it with turning or
pulling the oar?’“ 1
Limitations in performance
Training
7. Adaptation of training pro-gram
“If [an athlete] tells you that he is adapting something
[practice or competition], then it is relevant to see him, because
he is unable to do what he wants to do.”
2
“When somebody can do only 20% of what he nor-mally does, I
consider the problem to be bigger.”
1
“[I try to] find out if they have symptoms, they some-time don’t
tell or they don’t have symptoms because they don’t do a complete
training program.”
4
“[You could ask:] ‘Do you do the same as the rest of your team?
Or do you skip things?’“
2
8. Adaptation of parts of the training
“They can continue, but then they support them-selves on their
fingers and forehand when they have wrist complaints.”
4
9. Reduction of number of practices
“You can start training less and keep playing the same number of
matches, or you can reduce both, less training and a fixed number
of matches.”
7
“You see this especially in overuse injuries; they have an
injury, but they don’t miss any training sessions.”
5
“They never miss a complete practice, but [they do miss] a part
of it.”
4
10. Influence on sports performance “[You can ask:] ‘Has it
influenced your performance?’“ 3
Competition
11. Adaptation of competition program
“They will always reduce [the number of] practices and still
keep on going to matches.”
2
“But if you practice less and fully participate in all matches,
then the problem is less serious than when you practice only half
and participate in half of the matches. You are injured and showing
that you cannot do everything.”
1
12. Influence on sports performance [no quote, see item 59]
For items added to the list prior to the meeting that were not
discussed in further detail during the meeting itself, no verbatim
quote is presented.