Wednesday, 26 December 2012

Pulley Injuries: updated

Flexor tendon pulley injuries occur most commonly in rock climbers, accounting for 27% of all finger injuries (Schoffl et al 2003). This post will revisit the anatomy, and look at the causes and symptoms, and then discuss treatment methods.

Please note: any finger injury sustained by anyone under the age of 18 should be seen by a professional due to the risk of more severe injury such as an epiphyseal plate injury 

Anatomy

Understanding the anatomy within the fingers is key to understanding the injuries to the pulley system, therefore, I will cover some old ground of the finger anatomy.

Firstly, the tendons involved in the fingers are the  flexor digitorum profundus (FDP) and the flexor digitorum superficialis (FDS). These are both involved in flexing the finger joints.

This is worthy of note, as the A2 pulley contains the both these tendons, whereas the A4 pulley only contains the tendon of the FDP as the FDS splits and inserts to the lateral sides of the A4 pulley (see image below).

This means more force is exerted on the A2 pulley than the A4 (hence why climbers most commonly injure the A2 pulley)
 
This image shows how the FDS splits and inserts laterally to the joints, therefore not passing through the A4 pulley
Ligaments of the finger

This means that the A2 is 1.5 - 2 times more likely to be injured than the A4 pulley.
(N.B. The A2 pulley is found near the base of your finger)


The ring finger is the predominantly injured finger, due to the middle finger being supported by relatively strong and long fingers, whereas the ring finger only has a strong, long finger on one side, and flanked by the relatively weak little finger, meaning it is more susceptible to injury.

Check this out for real-life anatomy of pulleys on a cadaver

(Note: not for the faint hearted!)

Causes

Causes of a pulley injury can be from:
  • Foot slip etc when crimping a hold
  • Dynamic pull from a small edge
  • Dynamic move to a small edge
  • One finger pockets   
  • Repetitive strain
Crimping is one of the main causes, due to the orientation of the finger joints; the proximal interphalangeal  (PIP) joint is flexed more than 90 degrees and the distal interphalangeal (DIP) is hyperextended, therefore there is a much higher force on the pulley system due to the friction caused by the tendons.

Copyright Schweizer

Copyright Schweizer

Severity of the injury

With a pulley injury, there are degrees of severity of the injury, graded from I to III:
  1. Minor sprain to the ligaments and pulley
  2. Partial tear to the pulley
  3. Complete rupture of the pulley
The degree of the damage obviously will impact on the rehab and time to heal. 
With a Grade III, you will be very limited in what you can do, whereas a Grade I there will be more flexibility.

Symptoms

video 

Symptoms of a pulley rupture may consist of:
  • A loud, audible pop (normally for a complete rupture) accompanied with pain (See above video)
  • Swelling at the base of the finger
  • Bowstringing of the tendon visible or on palpation
  • Limited mobility of the finger
If a partial tear occurs, you may find:
  • A small audible pop
  • Sudden onset of pain after grabbing a hold
  • Swelling
  • Limited mobility of the joint
However, you may not notice the injury until the next time you climb, and providing the acute swelling isn't too bad, you should find you are able to pull on holds open handed without any pain, but have acute pain on crimping of holds.  
A partial tear of a pulley could alternatively be misdiagnosed as a "flexor unit strain", also known as a lumbrical tear  (detailed in this post), or vice versa.
 

Diagnosis

The diagnosis of a pulley injury is normally based on the subjective history, and clinical examination (e.g. bowstringing). Ultrasound can be used to confirm bowstringing (bowstringing only occurs in complete ruptures).



Copyright Hauger et al 2000


MRI can show an A2 injury, but is not commonly used.


Copyright Hauger et al 2000

Sagittal T1-weighted spin-echo (400/22) MR images obtained at (a) extension, (b) flexion, and (c) forced flexion after the creation of complete lesions of the A2 and A3 pulleys. In a, obtained at full extension, no obvious gap between the tendon (arrow in all) and the bone (arrowhead in all) is shown. A small gap is noted in b and is maximized in c. (d) Sagittal cadaveric section obtained at forced flexion reveals the gap to be almost identical to that seen in c.
Copyright Hauger et al 2000

Treatment

In the past, it was encouraged for a surgical approach to repair pulley ruptures. However, nowadays, a conservative approach has been found to be equally effective.

Rest
Climbing should be stopped only for the period in which the joint is inflamed, and it is recommended this period should be around 1-3 weeks.
Obviously this depends on the level of injury, as a complete rupture will require longer time off, whereas a partial tear will require less.
Once the joint can be moved through it's full range of movement pain-free, then this is a good indication that you may be able to start gently climbing again.

Rest also includes sleeping well and having a healthy diet, as these often aid the recovery process.

I generally find this “rest” period can be used to train other areas, such as those antagonists you've never got round to training, or that core strength that you just don't have time for at the wall.....!


Ice/Cold Water Therapy
Again, a principle from a previous post on acute injury management, icing the affected area will help promote healing and reduce inflammation
Within this is also the idea of contrast baths. However, there is limited research that they work, and no set prescribed pattern of time frame or temperatures.Google them, try them, make your own decision!

You can also try and use this clever device by BananaFinger to ice the finger. 

Stretching and massage
Stretching the affected joint helps optimise the alignment of the healing fibres. A stretch needs to maintained for at least 30 seconds to have any affect. Warming up prior to stretching is recommended.
Massaging the affected area can also optimise fibre alignment and break down any scar tissue forming, but needs to be quite vigorous and can be quite painful in order to have any effect.

Recovery Aids 

Metolius Grip Saver

Exercise Balls (e.g. Theraband)
These aids shown can help slowly regain strength to the injured finger without requiring to climb on it, and are useful in the early stages of rehab.
They are also useful tools for warming up
I am particular keen on the Metolius Grip Saver as you can use the ball to work the extensors to your fingers as well as flexing them, ensuring an equal work out to the muscle groups. (See this post on hand and finger exercises)
Within these aids is "TheraPutty", or glorified PlayDough. Use it in the same way you use the hand exercise ball.
Some people also use those Chinese stress balls, the heavy metal ones you rotate in your hands. These are good too.
It's about finding what best works for you. 


Taping
Several techniques can be utilised for taping of pulley injuries. The idea of taping is to reduce the acute angle of the flexor tendons, as shown in one of the images below. 
The tape takes approximately 10% of the strain from the pulley system, and can allow climbing with support to the injured finger, but remember it doesn't cure the injury, and only lasts a short period of time before the tape slackens off.

Tape will also not prevent pulley injuries, nor support the injury once nearly healed (however is not going to harm the finger in any way, apart from giving you a false sense of security that the injury has healed when it may not have, or be stronger than it is).

There are two techniques, the main one being H-tape, shown below:

H-Tape

Watch the video below, or here's a link to a picture guide of how to H-tape
 

The shape of the H-Tape
Other technique:

This technique is offered by Schwiezer 2012
(However, personally, I think the H-Tape has a better practical use and changes the angle of the tendons more effectively and limits the finger movement less)
Showing a different taping method, and how the tape is designed to re-orientate the flexor tendons




.
Copyright Schweizer

Schweizer tested two kinds of taping on 16 fingers during the typical crimp grip position. Taping over the A2 pulley decreased bowstringing by 2.8% and absorbed 11% of the force of bowstringing. Taping over the distal end of the proximal phalanx decreased bowstringing by 22% and absorbed 12% of the total force. Circular taping is minimally effective in relieving force on the A2 pulley.
 
Drugs
As with any injury, the use of anti-inflammatories and pain killers may help, however remember that in the initial stages of the injury, the inflammation is part of the natural healing process, and pain killers stop pain. Pain means something isn't right and to stop, so if yo can't feel the pain, it removes the ability for you to listen to your body. 

This list is by no means exhaustive of all the techniques out there to aid recovery from a pulley injury.

Returning to Climbing

When returning to rock or plastic, it is advised to start off easy, and slowly and gradually build up your sessions, intensity and grade until you know the injury has returned to the optimal strength.
You may find it easier to climb with open hand grips at this stage, and therefore climb harder than otherwise thought, but it only takes one hold for you to have to crimp to succeed, and you're back to square one.
It's important to listen to your body, especially during these phase, as it is so easy to re-injure when that amazing looking problem entices you in, just for a quick go. We are all guilty of this one!
 
Preventative measures

Taping, however, to prevent a pulley injury doesn't work, as it has been shown that the tape is not strong enough to absorb the forces involved in causing injuries. (Warme and Brooks 2000)
Check out Chockstone.org for some more advise and info on taping.

The usual basis of a proper warm up and easy climbing is an obvious, yet poorly practiced, preventative measure. 

If it doesn't feel good, don't do it!
 
Changing your technique and style, and having a greater awareness of where your body is in space will mean you are less likely to have a foot slip, or need for dynamic moves to holds, therefore reducing the likelihood of injury.

Avoid projects way beyond your current capabilities

Variety is the spice of life - vary the duration, intensity, holds, style, angle and training tools used when climbing.

Also, change your technique to utilise open handed grip instead of over-crimping every hold will reduce the force placed on the pulley system

Diagram to represent the forces exerted using crimp vs open handed
Copyright Schweizer

As a beginner, remember that your muscles will adapt very quickily to an increase in workload, but the ligaments, tendons and pulleys take much longer to adapt, therefore making them more prone to injury. The key to this - progress your climbing in a sensible, progressive manner.

And finally, ensuring you've had enough sleep, food, water etc to ensure a productive climbing experience!

Hope this helps! Any question, feel free to ask!

Obviously every case is individual, and this is merely for reference and information. If you have an injury - get it checked out by a professional!

Check out ClimbingStrong.com for an interesting DIY method of rehab

References

Hochholzer T, Schoffl VR 2006 One Move Too Many. Lochner-Verlag, Germany

Schwiezer A 2012 Sport climbing from a medical point of view. Swiss Medical Weekly 142: w13688

Schoffl V, Hochholzer T, Winkelmann HP, Strecker W 2003 Pulley injuries in rock climbers. Wilderness and Environmental Medicine 14: 94-100 

Chapman G 2008 Finger injuries and treatment . Rock and Run

Macleod D 2010 Pulley injuries article. Online Climbing Coach

Schweizer A 2001 Biomechanical Properties of the Crimp Grip Position in Rock Climbers. Journal of Biomechanics 34:217 - 223

Schoffl VR, Schoffl I 2007 Finger pain in rock climbers: reaching the right differential diagnosis and therapy. Journal of Sports Medicine Physical Fitness 47:70-78

Hauger O, Chung CB, Lektrakul N, Botte MJ, Trudell D, Boutin RD, Resnick D 2000 Pulley System in the Fingers: Normal Anatomy and Simulated Lesions in Cadavers at MR Imaging, CT, and US with and without Contrast Material Distention of the Tendon Sheath. Radiology 217(1): 201-21 


Schwiezer A 2000 Biomechanical effectiveness of taping the A2 pulley in rock climbers. The Journal of Hand Surgery: British & European Volume 25(1): 102-107

Warme WJ, Brooks D  2000 The effect of circumferential taping on flexor tendon pulley failure in rock climbers. American Journal Sports Medicine 28(5): 674-678

Eric Horst's article on finger tendon injury 

Wednesday, 19 December 2012

Finger Injuries, Symptoms and Management

Injuries to the fingers and hands consist of:
Overuse syndromes:
  • Tendovaginitis
  • Trigger finger 
  • Dupuytrens
Injuries:
  • Pulley injuries - (click here for more information on pulley injuries)
  • Lumbrical Tears
  • Collateral ligament and Capsular injuries
  • Wearing of rings when climbing

    Please note, for all injuries, treatment for the acute phases (first 24-72 hours) is always to follow the POLICE guidelines (see previous blog post)

Tendovaginitis
  
Anatomy


Tendovaginitis isn't just a dirty sounding word, it's what climbers commonly refer to as tendonitis. Tendonitis is actually the inflammation of a tendon, whereas tendovaginitis is inflammation of the tendon sheath.
A stress exerted to the tendon sheath via increased friction to the tendon results in inflammation.
This inflammation restricts the tendon moving through the sheath which impairs movement of the tendon and in turn causes more irritation. The body responds by increasing the fibrin to the area to aid lubrication of the joint, which only increases the inflammation and irritation and causes a vicious circle.
This scenario over a lengthy period can cause adhesions to the tendon sheath and narrowing of the space in the tendon sheath, meaning that the tendovaginitis becomes inflammed easily and so creates a reproduction of symptoms.
Tendovaginitis for climbers can occur in the fingers, or forearm  

Causes
  • Crimping (due to the 90 degree angle of the finger joints resulting in the highest stress through the tendons and associated sheaths)
  • Repetitive one-sided stress (e.g. campus board)
  • Climbing tired
  • Climbing without adequate rest periods
Symptoms
  • Dull ache in the hand
  • Swelling in the affected joint area
  • Pressure sensitivity of the flexor tendons 
  • Pain and strain during motion
  • Grinding in the tendon sheath  
Treatment 
  • Rest and immobilization (POLICE principles)
  • Returning to climbing once the swelling and acute symptoms have subsided easily and gradually
  • Anti-inflammatories
  • Corticosteriod injection (depending on severity)
  • Tape
  • Acupuncture
  • Electrotherapy 
     
Trigger Finger

Anatomy


Trigger finger is nicely displayed in the picture above. It's characteristic symptom is finding the finger stopping, then snapping past a particular point. 

This nodular thickening or knot is caused by chronic overuse creating micro-tears to the tendon that has formed scar tissue excessively around the injury site. It is then this formation of scar tissue that creates a blockade when the tendon is trying to pass through a pulley and creates the distinct trigger snap.

Causes
  • Chronic overuse of fingers
  • Chronic tendovaginitis
  • Serious tendon tear that has healed with a lot of scar tissue
Symptoms
  • Distinctive snapping past a point when extending the fingers.
  • Sensitivity or pain upon pressure to the tendon
  • Palpable knot of the tendon
  • Tendovaginitis symptoms
Treatment
  • Stress reduction
  • Vigorous massage to the knot
  • Corticosteroid injection to tendon sheath
  • Surgical intervention with splinting of A1 pulley


Dupuytrens

Anatomy

Dupuytrens is a heriditary condition that causes thickening to the palmar fascia which causes the flexor tendon to be shortened. Some report it usually affects the ring, middle and little finger, sparing the thumb and index.

Initially, only nodule can be visible, but it can spread and create a contracture as shown below.






Causes

Dupuytren’s disease often starts with nodules in the palm of the hand and it can extend to a cord in the finger. The palmar fascia becomes abnormally thick due to the fact that there is a change of collagen type. Normally, the palmar fascia consists of collagen type I, but if a patient has Dupuytren’s disease, the collagen type I changes to collagen type III, which is significantly thicker than collagen type I.

However, the root cause of the condition is unknown, therefore there is no “cure”, as such.



There is some evidence that the Dupuytren's may be hereditary, but some risk factors have been identified:


  • Men higher risk than women
  • Over 40's
  • Family history (60-70% of those with Dupuytren's has a family history of the condition)
  • People with liver cirrhosis (linked with alcoholism)

Unproven but suspected is repeated micro-trauma, possibility of occupational relationship, trauma and diabetes.



No definitive evidence has been found that links dupuytren's with rock climbing specifically, although the repetitive stresses on the fingers could be a factor.
Logan et al (2005) have found that 19.5% of 550 rock climbers in the UK had developed Dupuytren's, and that those with the disease climbed at a higher intensity, and that an earlier onset of the disease was found compared to the general population. So, coincidence or not, there does seem to be a higher incidence in a rock climbing population.
 

The prevalence of Dupuytren's is also on the rise in young climbers, and in comparison, is rare in young non-climbers.



Symptoms


  • Nodular soft tissue scars in the palm
  • Tenderness over this area
  • Fixed flexed position of finger
Treatment

As previously mentioned, there is no cure for Dupuytren's, but there is treatment methods to prevent the condition getting any worse.

In it's early stages, Dupuytren's can be broken down by vigorous massage over the affected area to break down the scar tissue (anecdotal evidence only).

Radiotherapy treatment may also help.

However, I have found via personal experience that the visible nodule of a Dupuytren's contracture is just the tip of the iceberg, as it can actually be hiding a much deeper level of scar tissue that is unseen without the use of ultrasound or other diagnostic imaging tools.

If Dupuytren's progresses too far, then the only option for regaining functional use of the hand is surgical intervention. This can remove the scar tissue formed, however can lead to a long period of no climbing, and the recurrence rate is high.

Recently, a collagenase enzyme injection has been developed, for non-surgical approach, but again, recurrence rate is very high, but reports show that the recurrence is not as severe as the original contracture. This also leads to 4 months of rehab and using of night splints. 

It must be noted that, although the lack of substantial trialled evidence is obvious, there is a great deal of anecdotal evidence that suggests that taking glucosamine supplements accelerates the contracture process associated with Dupuytren's disease (See Arthitis Research UK or Dupuytren Online)



Lumbrical Tears

Anatomy

The lumbricals are muscles that are between your metaphalangeal joints. They flex the metocarpalphalangeal joints whilst extending the interphalangeal joints, performing the motion pictured below.



Unlike most muscles, these attach to the flexor digitorum profundus tendons and and distally to the extensor expansions. They are fan shaped muscles.



The third and fourth lumbrical are the ones most susceptible to injury, due to them both being bipennate and originating from the flexor tendons.



Causes

When using a one finger pocket, normally, the other fingers not in use are flexed maximally. If using a pocket with the middle or ring finger, this causes a shift in the flexor tendons and increases the distance between the origins of the lumbrical muscle, therefore causing a disruption or tear in the muscle belly.




Symptoms

An audible snap (not too dissimilar to a pulley rupture) with severe pain and swelling in the finger and palm. Painful on palpation over the flexor tendons in the palm.

Holding a one finger pocket with the affected finger results in severe pain in the palm, yet buddying up on two finger pockets is painless.

This injury can be seen on ultrasound for accurate diagnosis

Treatment

  • Buddy taping middle and ring finger
  • Moderate stretching programme of middle finger forced to flexed, ring finger forced into extension, and vice versa
  • Preventing use of one finger pockets (at least until after 2-4 months)

Maximum strength in the injured finger may not fully return, but due to the nature of the buddying up of fingers in a painless symptom, climbing can continue for the injured party.


Further reading: Schwiezer 2003


Capsular and Collateral Ligament Injuries

Anatomy

At each finger joint, between the interphalangeal joints, there is a joint capsule that houses the synovial fluid for the joint. Also, there are ligaments on each side of the joint called the collateral ligaments.




Sometimes an osseous lesion may occur (which I believe is a tumourlike boney abnormality) and an X-ray needs to be performed to rule this out as a cause of injury to the ligaments or capsule)

Causes

When using a crack or two finger pocket and twisting, this can damage the structures mentioned above. Due to them being linked, damaging one inevitably damages the other. Damaging the ligament can be classified as a Grade I, II, or III.

They can also occur from dyno-ing and failing to remove a finger from the starting pocket and catching it in an upwards motion.




Symptoms

  • Decreased mobility around the affected joint
  • Pressure sensitivity
  • Joint instability
  • Swelling at the joint

Treatment

  • Immobilization
  • Splint
  • Buddy taping
  • Gentle stretching in the later stages

All are designed to prevent instability around the joint.


Further reading: click here

Wearing Rings When Climbing

Please do not wear rings or any jewellery when climbing. I get you're married or have a nice watch and want to show it off and are very proud of it, but please take it off when climbing.

Worse than a telling off from your wife while entail, such as incidents like this (please note, gruesome pictures below)





Sorry, I can't do it, the pictures even give me the heebie-jeebies! If you have a grotesque side, you can click here for some images (if you do wear a ring while climbing, and think I'm talking rubbish, please click the link – you need to understand the seriousness of the situation.)



What makes it worse, too, is that the damage caused by this “degloving” of the finger is very difficult to repair.

Others

There are other injuries and conditions that affect the fingers for climbers, such as ganglions, tendon strains, fractures (including epiphyseal fractures), amputation and abcesses. However, I feel these are less common and, unless there is the demand, I won't blog about them (or at least have no aims too at the moment apart from epiphyseal fractures). 
Let me know if you want me to discuss these points though. 

References

Schoffl VR, Schoffl I 2007 Finger pain in rock climbers: reaching the right differential diagnosis and therapy. Journal of Sports Medicine Physical Fitness 47:70-78

Schwiezer A 2012 Sport climbing from a medical point of view. Swiss Medical Weekly 142: w13688

Schwiezer A 2003 Lumbrical tears in rock climbers. Journal of hand surgery 28B(2): 187-189

Logan AJ, Mason G, Dias J, Makwana N 2005 Can rock climbing lead to Dupuytren's disease? Br J Sports Med. 39(9):639-44.

Hochholzer T, Schoffl VR 2006 One Move Too Many. Lochner-Verlag, Germany

Arthitis Research UK 

Dupuytren Online

Monday, 10 December 2012

Attitudes Towards Recovering From Injury

This post was spurred by an article I read in the most recent Summit magazine, published by the BMC (Winter 2012 edition) by Hazel Findley, about bouncing back after a fall, whether it injures you mentally, or physically, or both.

Now, I went away to do some reading about this, to come back with some links to journals etc, but with climbing psychology, there are three aspects to discuss:
  1. Risk taking and associated behaviours within rock climbing (encompassed in this is fear behaviours)
  2. Climbing technique and behaviours towards training ("head in the game")
  3. Recovery from injury
Now, the first is well researched, and continues to be well researched. The coaching aspect of both climbing and other sports covers the second element.
However, it was the third I was most interested in, and the most pertinent to this blog. And this was the most difficult to find any climbing related evidence for. 
A lot of the evidence out there is related to whiplash / workplace / low back pain injuries, which is understandable as these are the most common type of issues, especially psychologically as it can come down to compensation disputes etc. when another party is involved.

Therefore, I will have to resort to generic guides around injury recovery. 
There are many theoretical models out there to read about, such as the health belief model and transtheoretical model of change (stages of change model). 
However, I'm going to keep it simple and use a common sense approach. 

If you are injured, then motivation will be lost. There is a link between motivation and functional outcomes during rehab - if you start losing positive functional gains with rehab, due to plateauing or other issue, then motivation will decrease, causing a further reduction in rehab gains. Like I said, common sense.
However, sometimes, as climbers, we have an urge to get back on rock as soon as possible - highly motivated, but not always channelled in the correct way. Sometimes, rest and relaxation is positive therapy - both for the body, and the mind. 

Within physiotherapy, my aim and approach is very much to educate the patient, both in the injury and ways in which the self management can be performed. This then empowers the patient in their own rehab, and letting the therapist guide the patient towards their goals. This way, the patient can fully understand the injury and aims of treatment, and therefore can be more motivated in recovery.

Goal setting is also a method used in physiotherapy, and can lead to an "increase in self efficacy and/or self-confidence as a result of accomplishing a set goal during the rehabilitation process."
I find this very useful too, as, for any patient, the end goal is open and known to all parties. Often, it can become difficult to discharge a patient, but if you identify realistic, timely goals in the first place, this conversation needn't be a difficult, and then everyone is singing from the same hymn sheet. 
It also means a common goal that is aimed for by both the therapist and patient, meaning it is patient orientated, therefore, no-ones time gets wasted! 

That is all I'm going to touch on the matter. I will leave you with the original article I read, and one last nugget of information.

Brukner and Khan (2006) have said that, to "market" treatment, the SUCCESS anacronym can be used - simple, unexpected, concrete, credible, emotional, stories - e.g. someones personal account of recovery rather than words in a book. With that in mind, here's Dave Macleod's personal recovery from foot surgery








References

BMC Summit Winter Edition 2012 

Brukner P, Khan K (eds) 2012 Clinical sports medicine 4th ed. Sydney: McGraw Hill pgs 267-268



Reese LMS, Pittsinger R, Yang J 2012 Effectiveness of psychological intervention following sport injury.  Journal of Sport and Health Science 1(2): 71-79


Sutherland AG, Alexander DA, Hutchison JD 2006 The mind does matter: Psychological and physical recovery after musculoskeletal trauma. J Trauma 61(6):1408-14.