Wednesday, 19 March 2014

Fingers: Ganglion Cysts

So, I've noticed a few posts on certain climbing websites discussing ganglion cysts within the fingers, and so decided that I would write a post about them, considering there were one problem I omitted from the original finger injuries post.

What is a ganglion cyst?


A ganglion cyst is a liquid filled area within a joint capsule or tendon sheath that has bulged out to a particular side.
These cysts are caused by a congenitally weaker part of the capsule or sheath that cannot handle the extra pressure of over-creation of synovial fluid, which is created by over use and chronic stressing of joints. 
They can vary in size from pea to golf ball sized, and can occur anywhere in the body but most commonly in wrists and fingers. The size is often related to the amount of stress placed on the joint, therefore more stress = larger cyst, and this is why they most commonly occur in flexor tendon sheaths of climbers, just before the first finger joint.
Ganglions are normally harmless but can cause pain, especially if they irritate a nerve. 


Symptoms

  • Pain
  • Visible swelling of a lump
  • Decrease in mobility around the joint



Treatment

The old adage of "smack it with a book" doesn't really work for cysts, no matter how much someone encourages you! As, even if it works and gets rid of the cyst for a little while, it will only refill.

Common treatments involve aspiration, steroid injection, or surgical removal of the cyst, however, some have suggested ultrasound as a treatment for the pain caused by the cyst.


Some people have steroid injections into/around the cyst to relieve the pain, however it is worth noting that steroids have been known to weaken tendons and tissues and so could cause further problems with the cyst. 
Varley et al (1997) found that there was equal success rate of removing a ganglion cyst (33%) with aspiration (insertion of a needle and draining the fluid, as depicted above) compared with aspiration and injection of steroid.

The other option is to have the cyst surgically removed, which has a re-occurrence rate of the cyst of only about 5%.



Prevention

Unfortunately, there is no current way of preventing a ganglion cyst, however they could be caused by unnecessary stresses on your joints, so avoiding or adapting the effect of these stresses could help, for instance, adapting / changing your climbing style, climbing more efficiently.

Ensuring full range of movements within your joints will also reduce the stresses put on the joint.
 
As usual, ensuring proper warm up/cool downs and eating well will aid the prevention of injuries.


References

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

NHS Choices

Varley GW,  Needoff M, Davis TRC, Clay NR 1997 Conservative management of wrist ganglia: Aspiration versus steroid infiltration. Journal of Hand Surgery 22(5): 636-637

Wednesday, 19 February 2014

Compartment Syndrome

So we all get pumped when we are out climbing, in our forearms. This is natural, but we expect this pump to ease after the route, or at the very most the next day.
So what happens when it doesn't go the next day, our even gets worse? Then it's quite possible that you're suffering from functional compartment syndrome of the flexor muscles, otherwise known as chronic exertional comparment syndrome (CECS).

Chronic exertional / functional compartment syndrome is much more common in the tibialis anterior muscle compartment in runners and walkers, but has recently been reported in the forearms of those requiring strong grip, such as climbers, motocross riders and rowers.

Physiology and Anatomy


Within the forearm, all the muscles are surrounded by a thin sheet of fibrous tissue called fascia, which holds all the muscle fibres together in their bundle.


CECS occurs when there is an increase in muscle mass but not in fascia that envelops the muscle tissue, which happens with high intensity training resulting in hypertrophy of the muscles) i.e. muscles grow quicker than the surrounding fascia).
The only space left is veins and arteries and so the vessels become constricted by the muscle mass and creates a back flow of blood and an "instant pump" The muscle still creates lactic acid, but the blood supply cannot remove it, resulting in the pump/burn, that can take days to recover. 

This process can also occur after infectious disease compromises an athletes immune system, but much less common.


Acute compartment syndrome normally occurs post fracture or crush injury, and requires urgent medical attention. This is not the focus of this post.

Symptoms

Pain in forearms during and after stress
Pumped sensation that does not decrease in the usual time frame
Pump reached way lower than your normal peak levels

Diagnosis

Diagnosis of CECS is using inter-compartmental pressure measurement during the sport specific stress (i.e. climbing) using the devices similar to below.




Schoffl et al (2004) set an algorithm as below for diagnostic of CECS dependant on the pressure found within the muscle compartments.




Differential diagnosis for the symptoms of CECS could be ulnar stress fracture or nerve entrapment

Treatment

  • stress reduction i.e. cease to perform the activity, but I know climbers, and they won't stop climbing!
  • stretching
  • massage
  • ice
  • anti-inflammatories
  • activity modification - analyse your climbing, change your climbing style, crimp less etc.
  • surgical procedure - fasciotomy



Fasciotomy



A fasciotomy is one of the surgical options to reduce CECS. It consists of two incisions into each of the different forearm compartments to reduce the pressure within the compartments. They may require a skin graft if the muscle bulk is still too large to close the skin around it.

Outcomes

Painful sensations in the forearm were reduced from 53 to 7 VAS, and more than 95% (23/24) of the motocross patients were satisfied with the postoperative result of a fasciotomy after 5  follow-up. (Winkes et al 2011)

Post fasciotomy of 12 patients reported percentage improvement after surgery was 88%. Median time to return to full activity was 9 weeks.
(Brown et al 2011)

In 8 post fasciectomy patients, all had resumed their sport in the 6 weeks after the surgery, and 3 returned to their previous level, 5 improved their level. No complications and no recurrences were reported during an average 2-year follow-up. (Croutzet et al 2009)

Physiotherapy post operatively would be to follow the post op guidelines to regain range of movement and strength.

Although surgery is highly effective for most people, it's not without risk. Complications of the surgery can include infection, permanent nerve damage, numbness and scarring.


Pre and post fasciotomy


Prevention

Unfortunately, there is no real prevention for CECS except to remember that it is really important to build up training and intensity slowly and steadily to ensure all structures within your body adapt to the changes at the same rate, as muscle bulk grows quicker than tendon strength, fascia; and this can lead to problems, imbalances and injuries.

This doesn't mean that all the usual advice doesn't apply, such as warming up and cooling down properly, keeping well fed and hydrated, and "no pain, no gain" is a myth, if your in pain, stop!



References

Am J Sports Med. 2012 Feb;40(2):452-8. doi: 10.1177/0363546511425647. Epub 2011 Oct 26.
Long-term results of surgical decompression of chronic exertional compartment syndrome of the forearm in motocross racers.
Winkes MB, Luiten EJ, van Zoest WJ, Sala HA, Hoogeveen AR, Scheltinga MR. 


Br J Sports Med. 2004 August; 38(4): 422–425.
doi:  10.1136/bjsm.2002.003996
PMCID: PMC1724897
Evaluation of physiological standard pressures of the forearm flexor muscles during sport specific ergometry in sport climbers
V Schoeffl, S Klee, and W Strecker


J Hand Surg Eur Vol. 2011 Jun;36(5):413-9. doi: 10.1177/1753193410397900. Epub 2011 Feb 21.
Chronic exertional compartment syndrome of the forearm: a case series of 12 patients treated with fasciotomy.
Brown JS, Wheeler PC, Boyd KT, Barnes MR, Allen MJ.


Tech Hand Up Extrem Surg. 2009 Sep;13(3):137-40. doi: 10.1097/BTH.0b013e3181aa9193.
Mini-invasive surgery for chronic exertional compartment syndrome of the forearm: a new technique.
Croutzet P, Chassat R, Masmejean EH.