handinjuries_treatment.pdf

Hand Injuries in Rock Climbing: Reaching the

Right Treatment

Peter J. L. Jebson, MD; Curtis M. Steyers, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 5 - MAY 97

In Brief: Rock climbers' grip techniques may result in a variety of hand injuries. Minor injuries

such as soft-tissue damage, flexor tendon strain, tendinitis or tenosynovitis, joint contractures,

and carpal tunnel syndrome may be treated by a primary care physician. Patients who have

pulley ruptures should be referred if there is any uncertainty about the diagnosis. Because of

controversies regarding surgical management, primary care physicians should refer patients

who have a complete ligament tear. Referral is also recommended for such serious injuries as

locked digits, flexor tendon avulsions or ruptures, and severe joint contractures.

T he exhilarating sport of rock climbing has grown in popularity for both recreation and

competition. Rock climbers rely predominantly on digital and upper-extremity strength and

tactile ability to ascend shallow ledges and rock faces, using any of four grip techniques

depending on the terrain. All four of the grip techniques transmit extremely high forces through

the tissues of the digits, hand, and forearm, resulting in a variety of possible acute and chronic

injuries (1-10). Indeed, the hand is regarded by some as the most common site of injury in

mountaineers and rock climbers (1). These injuries may at times seem minor and

inconsequential, but because they can seriously compromise a climber's ability and safety,

proper recognition, treatment, rehabilitation, and prevention are essential.

Hand Anatomy

The muscles that produce wrist and digital flexion originate from the medial elbow, proximal

forearm and hand. The tendons insert on the middle and distal phalanges. The flexor digitorum

superficialis (FDS) muscles are responsible for flexion of the proximal interphalangeal (PIP)

joints, and the flexor digitorum profundus (FDP) muscles are responsible for flexion of the distal

interphalangeal joints. The FDS is the largest superficial muscle in the forearm and inserts on

the palmar surface of the middle phalanges. The FDP originates from the ulna and the

interosseous membrane and inserts on the palmar aspect of the distal phalanges.

Each finger has a single FDS and FDP tendon. Together with the median nerve, these tendons

pass from the forearm to the hand through the carpal tunnel. Within the tunnel, the tendons are

enclosed in bursal tissue and tenosynovium.

At the level of the metacarpal heads, the tendons enter into a double-walled hollow tube sealed

at both ends, known as the flexor tendon sheath (figure 1: not shown). This sheath is filled with

synovial fluid, which provides low-friction gliding and is a source of nutrition for the flexor

tendons. The sheath is supported by a series of retinacular thickenings which function as

pulleys. These pulleys prevent tendon bowstringing with flexion and are referred to as annular

or cruciform depending on their configuration. The second (A2) and fourth (A4) annular pulleys,

located at the proximal and middle phalanges respectively, are the most important for

preventing tendon bowstringing during active flexion.

Grip Techniques

With each of the four basic grips, the climber relies on tactile feedback from the index and long

fingers and strength from the ring finger.

Open grip. The open grip (figure 2) is used

when grasping wide or large handholds. This

grip frequently turns into a cling grip as the

climber pulls himself or herself upward.

Cling grip. In the cling grip (also known as the

"crimp"), the distal interphalangeal (DIP) joint

hyperextends as force is exerted downward and

the climber pulls his or her body upward (figure

3). This is a commonly used grip technique and

is regarded as the most painful. It places

significant compression and shear on the finger

tips and strain on the digital flexor tendons,

adjacent sheath, and pulleys. Climbers practice

the cling grip by doing one- or two-finger pull-

ups on doorjambs or training boards. In

moderation, this exercise can strengthen the

fingers and prevent injury, but it can also lead to

injuries if done excessively.

Pocket grip. This grip involves the placement of

one or two fingers into small holes (figure 4). It

is another particularly demanding grip because

during ascension the flexor tendons support

most, if not all, of the climber's body weight.

Pinch grip. This grip is used to grasp a

projection of rock between the thumb and

fingers.

Types of Climbing

Most rock-climbing situations fit one of the

following classifications:

Bouldering. This term refers to climbing over

large rocks, usually to develop strength and

practice difficult maneuvers. This type of

climbing results in fewer hand injuries than other

types of rock climbing.

Face climbing. This refers to the use of small edges, pockets, and knobs of rock for footholds

and handholds (2).

Crack climbing. Here, the climber ascends flat rock faces using the fingers, hands, and feet as

wedges (figure 5). When a climber pushes and twists his or her fingers until they are wedged

into a crack, torque forces on the finger joints can be very high. This type of climbing is

associated with joint dislocations and digital avulsion amputations following a sudden slip or fall

(2).

Types of Hand Injuries

In general, the incidence of hand and wrist injuries can be closely correlated with the duration

and frequency of climbing and with the climbing techniques used. A quick way to gauge the

amount of climbing a person does is to inspect the hands for abrasions and hypertrophic

scarring. With greater awareness of the causes and frequency of hand injuries, climbers have

been better able to focus on prevention by adjusting their training schedules and emphasizing

strength, conditioning, and flexibility training (3).

Most climbers' hand injuries are relatively minor and can be treated with rest, anti-inflammatory

medication, and splinting and taping. Certain injuries, however, require referral and surgical

intervention, and others, if neglected or not recognized, may have serious functional

consequences. Among these more serious injuries are flexor tendon strains, pulley strains, and

ruptures.

Soft-Tissue Injuries

Among the relatively minor hand injuries are soft-tissue injuries, including fingertip injuries;

abrasions on the dorsum of the hand and fingers, called "gobies"; and hypertrophic scarring.

Fingertip injuries are the most common hand injuries in rock climbers (2), but climbers rarely

seek evaluation or treatment for them. Fingertip injuries include maceration and splitting of the

skin on the finger pads due to prolonged pressure and abrasion. Both mechanical factors and

ischemic mechanisms cause epidermal breakdown (4).

Hypertrophic scar tissue forms on the dorsal surface of the hand in response to the repetitive

abrasion and wear that usually occurs with crack climbing.

Treatment of soft-tissue injuries includes rest, appropriate local wound care, and preventive

measures such as the use of thin rubber pads or sleeves for protection when climbing or

training. Gloves are not advised because they interfere with critical tactile feedback and do not

allow for a secure handhold (2).

Flexor Tendon Injuries

Several studies describe a spectrum of rock-climbing injuries involving the digital flexor tendons

(2,3,5-7). These injuries appear to have a common pathogenesis and similar symptoms.

Injuries to the flexor tendons include tendinitis or tenosynovitis, strains, and rupture or

avulsion. The flexor tendons are particularly susceptible to injury during the cling and pocket

grips (2,6). These maneuvers place excessive stress on the tendons and surrounding structures.

With the cling grip, the majority of the stress of weight-bearing is transferred from the

hyperextended DIP joint to the flexed proximal interphalangeal (PIP) joint along the flexor

digitorum superficialis (FDS) tendon. Because the cling grip is used most often, the FDS tendon

is the one most likely to be injured.

Flexor tendinitis and tenosynovitis. In flexor tendinitis and tenosynovitis, an inflammatory

response occurs because of repetitive stress. The patient has pain and swelling along the

palmar surface of the digit, which may extend into the palm or forearm. While the patient's

passive flexion is normal, active flexion is usually limited.

A patient who has flexor tendinitis or tenosynovitis should rest, take anti-inflammatory

medication, and do range-of-motion exercises. Corticosteroid injection is rarely used, but may

be indicated in patients who have chronic tendinitis or tenosynovitis and for whom all other

treatment modalities have failed. Injection should be performed carefully as intratendinous

injections may result in tendon rupture.

Flexor tendon strain. This injury is characterized by acute onset of pain at the FDS tendon

insertion during a difficult cling grip. It is often referred to as "climber's finger." (3) If a patient

presents acutely, tenderness at the FDS tendon insertion site is noted and pain may be

accentuated with resisted PIP joint flexion.

A patient who has flexor tendon strain should rest, take an anti-inflammatory medication for

control of digital swelling, and do range-of-motion exercises. When pain has subsided and range

of motion has been restored, a progressive strengthening program can be started, followed by a

gradual return to climbing. Digital taping may be used as a preventive measure. Many climbers

circumferentially wrap the digits to help prevent flexor tendon and sheath injuries (1,2,5).

Tendon nodules. Patients who have a history of repetitive flexor tendon strains may have a

palpable nodule in the digit or distal palm. The nodule is located within the tendon itself and

may cause locking or triggering of the digit. During digital extension, the nodule catches on the

first annular (A1) pulley, resulting in a triggering sensation. If the nodule becomes large

enough, eventually it may not pass beneath the pulley, resulting in a "locked" finger that cannot

be extended either actively or passively. On physical examination, if a nodule is present, it may

be palpated within the flexor tendon. Triggering may be reproduced by applying pressure over

the A1 pulley during flexion and extension of the involved digit. Treatment includes injection of

a corticosteroid and lidocaine hydrochloride preparation into the flexor tendon sheath. If

triggering continues even after two injections given a minimum of 6 weeks apart, or if a

patient's digit is locked, surgical release of the A1 pulley is indicated.

Flexor tendon avulsion and rupture. An FDS tendon rupture may occur with the cling grip,

an FDP tendon rupture with the pocket grip. Patients who have these ruptures complain of the

acute onset of pain during a grip. Findings include tenderness at the FDS or FDP tendon

insertion, digital swelling, and an absence of active flexion of the PIP joint (with an FDS tendon

rupture) or DIP joint (with an FDP tendon rupture). Frequently the end of the tendon retracts,

and consequently tenderness and swelling may also be noted more proximally in the digit or

even in the palm.

Flexor tendon rupture requires surgical reattachment or repair when recognized acutely.

Patients who present more than 3 weeks after injury may be treated with a variety of surgical

and nonsurgical methods. Referral to a surgeon familiar with contemporary methods of

treatment for flexor tendon injuries is appropriate for these patients.

Second Annular Pulley Rupture

Rupture of the A2 pulley is a relatively common injury and in one study (5) has been reported

in up to 40% of professional climbers. Rupture occurs as a result of the excessive stress on the

A2 pulley during a cling grip. The long and ring fingers are most commonly involved. Pulley

rupture can occur acutely or develop insidiously.

A patient who has acute pulley rupture complains of acute pain in the volar proximal phalanx

region. The area is tender to palpation, and visible and palpable bowstringing of the flexor

tendons is usually noted during active resisted finger flexion (figure 6: not shown). The

diagnosis may be difficult, and a limited magnetic resonance imaging scan or computed

tomography scan may be necessary to help determine the integrity of the pulley and flexor

tendons (6,8).

Minor A2 pulley injuries or partial tears with no evidence of bowstringing can be treated with

either firm circumferential taping overlying the pulley or with a ring splint, worn full-time for 2

to 3 months to permit healing. Patients should also take time off from climbing.

The management of complete tears with tendon bowstringing is controversial. Surgical options

include pulley repair or reconstruction (6,8,9). If there is any uncertainty regarding the

diagnosis of A2 pulley rupture or the management of this type of injury, referral is

recommended.

Joint Contracture

A fixed flexion deformity of the PIP joint is a common finding in rock climbers (1) The deformity

is frequently bilateral and most commonly involves the ring finger (1). The contracture is

usually mild and is thought to be the result of recurrent joint effusions and synovitis.

Treatment includes rest, stretching exercises, anti-inflammatory medication, postexercise icing,

and a dynamic PIP joint extension splint. Severe fixed contractures that compromise hand

function may require surgical correction. Consultation with a hand therapist or surgeon is

appropriate for such a patient.

Ligament Injuries

Sprain, acute rupture, and chronic attenuation of the collateral ligaments of the finger (PIP)

joint and thumb metacarpophalangeal (MCP) joints have been reported in rock climbers (2). PIP

joint collateral ligament injuries predominantly involve the long finger and occur during a

maneuver known as "dynoing," (5) meaning rapid ascension of a rock face. As the climber

ascends rapidly past a pocket in the rock in which his or her fingers are placed, a finger can

become trapped and bent, stretching the ligament awkwardly. Sprains of the ulnar collateral

ligament of the thumb MCP joint are associated with the pinch grip (1).

Examination of patients who have ligament injuries reveals mild to moderate PIP joint swelling,

tenderness, and pain with motion. To assess the integrity of the collateral ligaments, palpate

them gently and then stress the ligaments with the joint first flexed and then extended. The

joint may need to be anaesthetized. Complete rupture is suggested when the joint can be

widely deviated during stress testing.

Treatment of a patient who has a PIP joint sprain with intact collateral ligaments includes rest,

icing, edema control, continued range-of-motion exercises, and "buddy taping" to the adjacent

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