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A sprained wrist is a fairly common injury seen in athletes because it usually is a result of a fall on an outstretched hand. This can occur in any number of sports in which gravity is a factor.
The wrist is composed of eight small carpal bones linked to five metacarpal bones (the long bones of the hand) on one side and the bones of the forearm (ulna and radius) on the other side. The wrist joint is also known as the radiocarpal joint because the distal radius articulates with several of the carpal bones of the wrist.
What complicates the diagnosis in a wrist injury is that there are numerous ligaments stabilizing the wrist. There are ligaments that stabilize the radius and ulna to their adjacent carpal bones, ligaments that stabilize each individual carpal bone to its adjacent carpal bone, and ligaments that stabilize the distal carpal bones to the metacarpal bones. All in all, there are a lot of ligaments located in the wrist.
Classifications of a sprained wrist
Sprains are an injury to a ligament. Ligaments hold bone to bone and provide stability in a joint. Because of the large number of ligaments located in the wrist, it is possible for an athlete to injure multiple ligaments during a significant injury.
Sprains are classified depending on the severity of the injury from mild (1st-degree sprain), moderate (2nd-degree sprain), to severe (3rd-degree sprain). Each classification has specific signs and symptoms that can be evaluated to determine the specific grade of injury.
Grade one or mild
A mild sprain is one in which the ligament is stretched, but not torn. The athlete may experience tenderness over the injured ligament, mild swelling, and some discomfort when the hand is moved through flexion and extension or moved side to side.
Dependent on the athlete’s pain tolerance, an athlete with a first-degree ligament sprain may be able to continue to compete if protective taping is applied to the wrist for support.
A second-degree sprain
Is considerably worse than a first-degree sprain. The primary difference is that a second-degree sprain includes a partial tear of the injured ligament(s) along with notable instability when the ligament is tested. A partial tear may result in increased laxity of the joint possibly making the joint unstable.
The signs and symptoms of a second degree sprained wrist include moderate swelling throughout the joint, significant discomfort upon any movement of the wrist, increased pain upon palpation, and instability when the ligament is tested. The functional ability of the wrist/hand may be significantly compromised in a second-degree sprain.
The athlete may complain of pain, “clicking”, and a feeling that something is giving away with a partial ligament tear. This type of injury may result in dynamic instability (instability of the bones when the wrist/hand is in motion).
Third-degree or grade three
The most severe type of sprain is a third-degree sprain because it is the result of a complete rupture of one or more ligaments. It would take a significant force to completely rupture one or more ligaments in the wrist, but it can occur with a fall from a height greater than the athlete (upended basketball player after jumping into the air or a “flyer” falling on an outstretched arm after being tossed into the air).
The athlete may present with significant pain and possible deformity of the wrist. Completely ruptured ligaments can result in dislocations of one or more of the carpal bones. The function of the hand/wrist would be compromised as well resulting in the athlete’s inability to use the hand (inability to grip).
Athletes suspected of either a second or third-degree sprain should have their wrist/hand immobilized and be transported to a local emergency room for further medical evaluation.
A diagnosis of a sprain is made only after other conditions have been ruled out including:
• Fracture of the distal radius/ulna (Colles fracture)
• Displaced distal radial epiphysis (separation of the bone at the epiphysial plate in young athletes)
• Scaphoid fracture (most common carpal fracture of the wrist)
• Dislocation/Instability of carpal bones
If initial medical evaluations are unsuccessful in determining a diagnosis and the athlete still complains of pain and swelling in the injured wrist, the athlete should be referred to a hand surgeon for further evaluation. Because the anatomy of the wrist is so complex, injuries can be missed on an initial evaluation and may only be picked up by a specialist.
Who gets a sprained wrist?
A sprained wrist is common in athletes competing in sports in which diving, sliding, and falling are a natural part of the sport (baseball, softball, football).
Gymnasts tend to have a significant number of wrist injuries because of the type of skills performed and the equipment utilized in the sport. Because gymnasts spend a lot of time upside down and on their hands, the wrist has a tremendous amount of force being transferred from the forearm through the wrist and into the hand.
Closely linked to gymnasts are competitive cheerleaders. Wrist injuries are common in competitive cheer because of the advanced stunts in which “bases” (athletes who toss and catch the “flyers”) throw “flyers” into the air and then catch them after the “flyer” performs a stunt. Injuries can occur to the “flyers” if they are dropped from a significant height onto the ground or to the “bases” if they do not use proper technique when catching a “flyer”.
Specific equipment used in the sport of gymnastics also lends to wrist injuries. For example, wrist injuries can occur from stunts performed on the vault because of the amount of energy and force transferred from the sprint lead-up to the springboard and onto the vault. The pommel horse is another example of an apparatus that is linked with a high number of wrist injuries.
Divers are another group of athletes who sustain wrist injuries because of the amount of force the diver places on his/her wrists as he/she enters the water. Before hitting the water, divers will lock their elbows into extension and will hyperextend both wrists locking them tightly over their heads. This position subjects the wrists to a tremendous amount of force especially when the diver hits the water after diving from a 10 meter board (30 feet above the water).
There are several mechanisms of injury for a sprained wrist including falling on an outstretched arm, twisting of the wrist (especially if sports equipment is worn, i.e., baseball or softball glove), and hyperextension or hyperflexion of the wrist/hand.
Preventing a sprained wrist
Teaching athletes how to fall correctly by absorbing the force of the fall and rolling to dissipate the force is a good place to start in preventing wrist injuries. The body has a built-in protective extensor mechanism when a person falls. When an individual loses their balance and begins to fall, the body automatically moves the arms out in front of the body to protect the head and face. This is an unconscious reflex and one that begins very early in life.
To override this protective reflex, kids need to be taught how to fall so that they do not hurt themselves. The key to falling and not withstanding injuries to the wrist and forearm is to teach kids how to tuck their arms into their body and immediately begin to roll when they fall. The rolling motion dissipates the force of the fall throughout the torso of the body.
This technique is especially important for kids who participate in sports such as rollerblading and skateboarding because there is a high incidence of wrist injuries in these types of sports. Along with teaching kids how to fall, protective equipment should be worn when possible.
Special protective equipment for the wrist has been designed for athletes in sports that tend to have a high incidence of injuries. These braces are uniquely designed with a reinforced rigid brace that crosses the front of the wrist. If the athlete falls onto his/her wrist, this rigid piece absorbs the force of the fall protecting the bones and ligaments within the wrist.
Treatment for a sprained wrist
Treatment will depend on the severity of the injury. First degree sprains can follow sports injury treatment using the P.R.I.C.E. principle – Protection, Rest, Icing, Compression, Elevation for the first 48 hours. Depending on the size of the athlete, small ace bandages (2”, 3”, and 4”) can be used to provide initial support for the wrist until the pain diminishes.
Athletes with suspected second or third degree sprains should be immediately immobilized with a rigid splint (hand, wrist, and forearm) and then placed in a shoulder sling to immobilize the elbow and referred for medical evaluation.
Once a fracture/dislocation has been ruled out and a sprained wrist has been diagnosed, the goals of the initial rehabilitation period are to reduce pain and swelling. This can be accomplished utilizing the P.R.I.C.E. principles of initial treatment.
To assist in the healing process, the wrist should be immobilized either with an ace bandage or a brace. This immobilization allows the ligaments to begin to heal. If movement of the wrist occurs too soon (while the wrist is still painful), the new tissue that the body produces to mend the ligament can be disrupted and the healing process delayed.
As pain decreases, pain-free gentle range-of motion exercises can be started moving the wrist through flexion, extension, and side-to-side movements. These should be performed slowly by the athlete. The athlete can gradually increase the range of the motion over time.
Beginning exercises to help strengthen the wrist
Start with ball squeezes
The athlete can use either a tennis ball or racquetball. If these are not readily available, a rolled sock works just as well. The athlete places the object in his/her hand and squeezes the object as hard as he/she can without going into pain. This can be performed multiple times throughout the day and early during the rehabilitation process because this exercise can be performed while the athlete’s wrist is immobilized.
Advanced strengthening exercises
Once the athlete has pain-free full range of flexion and extension of the wrist, advanced strengthening exercises can be started. The purpose of advanced strengthening exercises is to provide resistance to the muscles of the wrist and forearm through the normal motions of the wrist.
Resistance band exercises
Resistance bands or tubing can be used to provide resistance to strengthen the wrist muscles. While the athlete is sitting, one end of the band can be wrapped under the foot while the other is wrapped around the hand and held tightly. The tension of the band can be adjusted by either tightening or loosening the band. Several wrist exercises can be done with resistance bands. All the athlete needs to do is change the position of the wrist/hand for each exercise. The athlete can begin with the palm of the hand facing up. The athlete starts by adjusting the band so that the band is somewhat tight between the foot and hand.
The athlete starts the exercise with the wrist in full extension (knuckles towards the ground) and then pulls the band up until the wrist is fully flexed. This can be repeated for 10 repetitions.
Once the athlete has completed one set of exercises, the athlete can rotate the hand/wrist until the palm is facing towards the floor. The athlete can then perform a second set or 10 repetitions beginning with the palm down and moving the wrist upwards into full extension.
Last the athlete rotates the hand and wrist to a position where the thumb is facing the ceiling. This works the muscles on the thumb side of the wrist and hand.
Once the athlete has performed a complete set of 30 repetitions (10 for each position), the athlete can start at the beginning and repeat the sets two more times for each wrist position.
Recovery – Getting back to Sport
The final component in any rehabilitation program is the addition of sport specific exercises. These are exercises specifically designed to put the athlete through the skills and demands of his/her sport in a progressive fashion so as to ensure that the wrist has completed healed and that the athlete has the confidence necessary to return to sport.
The athlete’s sport is analyzed for a breakdown of fundamental skills. The athlete is then asked to perform these skills beginning at 50% intensity. As the athlete continues through the list of basic skills, the intensity is gradually increased incrementally over time until the athlete performs the skills full out. Depending on the classification of the injury, this phase may take anywhere from several days to several weeks.
When Can I Return to Play?
The athlete can return to sports when he/she has been released by a sports medicine professional and when the athlete has cleared the following return-to-sports criteria:
• Pain free full range of motion of the wrist
• Pain free full strength equal to the uninjured wrist
• Completion of sport-specific functional training
• Protective wrist taping if appropriate
Taping sprained wrist
Taping with KT Tape
Getting a Second Opinion
A second opinion should be considered when deciding on a high-risk procedure like surgery or you want another opinion on your treatment options. It will also provide you with peace of mind. Multiple studies make a case for getting additional medical opinions.
In 2017, a Mayo Clinic study showed that 21% of patients who sought a second opinion left with a completely new diagnosis, and 66% were deemed partly correct, but refined or redefined by the second doctor.
You can ask your primary care doctor for another doctor to consider for a second opinion or ask your family and friends for suggestions. Another option is to use a Telemedicine Second Opinion service from a local health center or a Virtual Care Service.
SportsMD’s Second Opinion and Telehealth Service
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- Anderson, M.K., Hall, S. & Martin, M. (2005). Foundations of Athletic Training: Prevention, Assessment, and Management. (3rd Ed.). Lippincott Williams and Wilkins: Philadelphia, PA.
- Bahr, R. & Maehlum, S. (2004). Clinical Guide to Sports Injuries. Human Kinetics: Champaign, IL.
- Irvin, R., Iversen, D. & Roy, S. (1998). Sports Medicine: Prevention, Assessment, Management, and Rehabilitation of Athletic Injuries. (2nd Ed.). Allyn and Bacon: Needham heights, MA.