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Wrist overuse in young athletesExploring diagnostic strategiesKox, L.S.

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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?

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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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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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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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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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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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.

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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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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


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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‘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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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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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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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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ers EL, Snyder AR. Recent injury and health-re-

lated quality of life in adolescent athletes. J

Athl Train 2009;44(6):603-610.

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Chapter 4

Supplement 1. Signals of overuse wrist injury derived from focus group of sports physicians

Example verbatim quotes

Sports physician code


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


4

Supplement 1. Continued



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

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Chapter 4




“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


4




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

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“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


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

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4




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.

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