Tuesday, 16 July 2013

A Climber's Best Friend, and Worst Enemy.

I've decided to rediscover my interest in writing.  This is something that has been on my mind for the past few months, and now seems like the perfect time to start.  In my day to day interactions, I often have people inquiring about different aspects of my life, many focused around my diet, my training, or my career.  This medium will allow for my brain to spill over, and hopefully help spark some interest or understanding around topics I have some knowledge on.  With that, let's dive right into the deep end with a topic that is pertinent to myself as both a sport climber, and a Massage Therapist.

Finger injuries.  I can already feel everyone flexing and extending that one nagging finger, the one that is sore after a hard climbing session.  These tend to develop over time, especially once a climber has progressed to using smaller holds, using a crimp grip.  Many fellow climbers will use terms like "torn pulley" or "tendon tear" to describe these injuries, but let's get a little more specific with our anatomy.

Anatomy

Injury a2 finger anatomy 1



In this picture, you can see a typical finger from a lateral view.  The first thing to notice are the three bones of the finger; the proximal phalanx, the middle phalanx and the distal phalanx.  Where these bones articulate are two joints, the Proximal Interphalangeal Joint, or PIP,  and the Distal Interphalangeal Joint, or DIP.
The FDP (Flexor Digitorum Profundus) and FDS (Flexor Digitorum Superficialis) tendons run along the bones in the finger, and are what attach the muscles of the forearm to your fingertips, and are responsible for generating force when you are crimping down on a hold.

Lastly, are the ligaments of the finger. These are often the culprit when it comes to a climber's finger injury.  Three different types of ligaments are shown, the first being the Collateral ligaments, which are located on the sides of your knuckles.  These are rarely injured, crack climbers notwithstanding.  The remaining ligaments are the Annular Ligaments (A1, A2, A3, A4 and A5) and the Cruciform Ligaments (C0, C1, C2, C3).  These two systems of ligaments create a makeshift tunnel for your finger tendons to run through, allowing for better mechanical leverage to be obtained from your tendons.

Anatomy lesson over.  Now that we know a bit about what structures make up the finger, let's talk about the position that usually causes the injury, and the injury itself.

Crimping.. (ain't easy).

Woody  Crimping

As our climbing progresses, we inevitably end up using smaller and smaller holds, to test our strength, power, and sometimes, our pain thresholds.  With these smaller holds comes a new grip position, known as the crimp.  This refers to hyperextension of the DIP joint, and hyper flexion of the PIP joint.  This position causes an extreme amount of force between the flexor tendons of the finger, and the A2 pulley.

Injury a2 finger anatomy 2

Over time, these forces cause micro tears, and in worst case scenarios, complete ruptures of the A2 pulley. With micro tears, there will normally be swelling at the pulley, as well as pain with direct pressure on it, and forced crimping. Stiffness and a loss of range of motion will be apparent with the joints above and below the pulley.  Complete ruptures occur very rarely, and are typically traumatic in nature, usually with a very loud, audible pop or snap.  The most common mechanism of injury for a complete rupture is when a climber is crimping on a very small hold, and that hand slips off the hold, loading an extreme amount of force onto the pulley. With a complete rupture, you will see the flexor tendon of the finger bowstring away from the proximal and middle phalanx. Not being properly warmed up increases the chance and severity of injury dramatically.  If you suspect that you have any degree of injury to one of the pulleys in your finger, it is important to seek medical attention immediately.

Treatment Plan

After you have been to a medical practitioner, it is time to decide what actions to take in order to best heal the injury. For a complete rupture, surgery may be required, and as such, we're going to focus on the more common partial tear.  I often see people ignoring these injuries, and trying to climb and train as they normally would. In most cases, this will lead to further injury, and a much longer rehab time once you do decide to fix the problem. Because ligaments are poorly vascularised, meaning they don't have many blood vessels supplying them with blood, they will typically take longer to heal than a muscular injury. The first stage of the injury we need to get through is the acute and subacute phase, which occurs right after the injury incident happens, up until around two weeks post incident. In every stage of the healing process, consulting with a Sports Medicine Doctor, Massage Therapist or Chiropractor who does A.R.T is going to help tremendously.

Acute / Subacute

The most important thing to do during this stage of the injury is to stop climbing, completely. This doesn't mean avoiding crimps, only climbing for a short session, or climbing top rope only, it means complete cessation from the activity. For the first few days, while swelling is present, ice the injured hand a few times a day, each time leaving the ice on until the finger is numb. This will help flush the inflammation out of the finger, and help make sure there is no leftover swelling. Also, over the counter NSAIDs (non steroidal anti-inflammatory drugs) such as ibuprofen can help reduce the swelling dramatically. Other than that, you should be eating well, resting, and making sure you get good sleep. All of these factors will lead to a faster recovery time.

Chronic

Once we have eliminated the swelling that occurred after the injury, and our bodies have laid down some scar tissue, our options open up with what we can do to help the healing process along.
Stretching will be a key component to rehabilitation, as well as injury prevention in the future.  Focus on stretching both the forearm and the fingers specifically. The best method for increasing elasticity and length in a muscle is to load the muscle with a low amount of tension, and holding the stretch for a longer period of time. When I'm working with clients, I suggest a 4 - 8 minute stretch to the affected area, at least once a day, to really get the results we want. The forearm stretch pictured below is one I like for this purpose, as you can sit relatively comfortably, and allow your body weight to give the tension in the stretch you need, without really having to work for it. The other stretch will be focusing on the affected finger regain it's normal range of motion.

Photo on 13 07 15 at 9 38 AM 
Photo on 13 07 15 at 9 39 AM

Massaging the area of the injured pulley will also help, by bringing more blood flow to the area, as well as loosening up some of the scar tissue that develops around the pulley, allowing for a more mobile, functional scar. After warming up the finger with some light massage, try placing your thumb right over the A2 pulley and massaging horizontally across the finger for a couple minutes a day.  Breaking down the scar tissue will cause some inflammation, so after massaging the pulley, stretch the finger for 30 seconds, and then apply ice. This process helps your body with the development of functional scar tissue.

Photo on 13 07 15 at 10 46 AM  2

Strengthening the opposing tendons in your finger will bring more balance to your hand, and will help with the strength in your open hand positions (open hand crimp, slopers, pinches). There are many different options for this, but the one i will explain requires only one piece of equipment; a strong rubber band. Typically people will use rubber bands that you find on broccoli or asparagus. Place the rubber band around your fingers and thumb, as pictured below, and proceed to open your hand and extend your fingers as wide as you can. Try to find a rubber band that allows you to get almost full range of motion, while still giving enough tension that it isn't easy to open your hand. Do 10 - 15 repetitions of this exercise, with 3 - 4 sets, a few times a week. This will help give you more balanced hand strength, and prevent future injuries. Balance is key!

Photo on 13 07 15 at 10 55 AM 
Photo on 13 07 15 at 10 56 AM

The last thing we will address is the position that caused the injury in the first place. It is important to recognize the danger of overusing a position, especially one that puts so much stress on our precious tendons and ligaments. At first, when you start climbing after a pulley injury, it is important to avoid that closed crimp position. If you are on a route or bloc which requires you to crimp, try to use an open hand grip, as opposed to closed hand (the difference is shown below). More than anything, look at this injury as a chance to get better with other hold types. What better time to develop strength and technique on those dreaded slopers or pinches!

Photo on 13 07 15 at 9 55 AM 
Photo on 13 07 15 at 9 55 AM  2

Always make sure to take injuries for what they usually are, which is an imbalance we have in the body which needs to be remedied. In my next post, I will show you how to properly tape your finger, to reinforce that ligament and prevent future injury.

Until then, if you have found this post helpful, feel free to share it with someone you know who might benefit from it. Thanks!

5 comments:

  1. Photos that include your gorgeous face would be much appreciated :)

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  2. Hi James. Great Blog!

    This is very valuable info for climbers and health professionals dealing with Flexor Pulley injuries (aka: climbers' finger).

    Just a few comments and clarifications:

    1) Regarding surgery, we rarely operate on these injuries, even for complete pulley ruptures. Surgery is indicated for complete, combined ruptures (e.g. A2 and A4) with tendon bowstringing, or in the case of a complete single pulley rupture that has healed but with chronic pain or stiffness. We reconstruct the pulley with a tendon graft and remove scar tissue to improve motion.

    2) In the acute inflammatory phase, I would add oral NSAIDs to your regimen of anti-inflammatory measures (consult an MD first). Medications such as ibubrofen are invaluable for controlling inflammation, particularly in the immediate 72hrs post injury. Other effective methods, many of which you mentioned, are ice (or hot, then ice cold contrast baths for the whole hand), massage, stretching and ROM exercises, laser, TENS and U/S.

    3) Rehab for these injuries is slow and can be frustrating if you try to climb hard too early. I usually recommend 2 weeks completely off of climbing, followed by very gradual return to climbing, starting with low intensity and big holds, and absolutely NO CRIMPING for at least 6 weeks, usually more like 2-4 months.

    4) Lastly, just a minor correction: your second photo of the hand hold is not an "open crimp", it is an "open grip". Open crimp or half crimp is like the full crimp grip, but without hyperextension at the DIP joints and without use of the thumb.

    5) I have written and researched extensively on pulley injuries in climbing, but I would refer you to articles by Dr. Volker Schoeffl (for health professionals) and his book "One Move Too Many" (for climbers), for anything you want to know about biomechanics, prevention and treatment of these injuries. Volker is the international guru on this subject.

    Enjoy!
    Yasser El-Sheikh

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    Replies
    1. Hey Yasser,

      Thanks so much for the amazing reply!

      I knew there were very specific indications for surgery when it comes to complete ruptures, but did not know what they were specifically coming from an Ortho Surgeon specializing in hands. Now i know!

      I'm not sure how I didn't mention NSAIDs, as that is usually my first suggestion along with ice and ROM exercises, but I will add that in, as I also believe it is invaluable to speeding up that acute and subactue phase.

      I also recommend that people take those first two weeks off of climbing all together, while they deal with the processes happening in the acute phase. In my experience, after those two weeks, I like climbers to be back to climbing in the gym, as it is more predictable, and they can focus on using large holds.

      Lastly, I will change out the "open crimp" terms. I think that I've just always called that position an open crimp, which has been false. Thanks for the clarification!

      If you can refer me to any of your articles you have written, I would gladly add them to my reading list along with Dr. Schoeffl's papers.

      Thanks again for all the input Yasser,
      James

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  3. Just add to this, nandrolone will increase collagen III indicators by 270% ( at 3mg/kg and Equipoise will increase it by 340% ( 3mg/Kg) , over normal body collagen repair rates. This will not repair a full tear but any stage I and II issue is treatable.

    ReplyDelete
    Replies
    1. Hey,

      I know very little about pharmaceuticals, and it is out of my scope to prescribe them, but I just read a little into this and it looks interesting!

      If you have any articles for this, please send them my way.

      James

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