Stretching

Ok, so in response to this article about stretching from the New York Times blog on reasons not to stretch that is making the rounds at present, I want to explain a little about stretching.

The blog post basically says static stretching during a warm up makes you weaker pre-sporting activity.

Well, of course it does! The idea of stretching is to lengthen muscles. Muscles work optimally in their mid range, so the longer the muscle, the less optimally the muscle is going to work!

This is easily demonstrated when looking at the structure of sarcomeres, the muscle fibres.

If the "H-zone", the area between the muscle fibres, is longer, then there is less overlap of the muscle fibres to connect to.
This means the muscle is not going to contract as strongly as it would, therefore be weaker.

The idea of stretching is to make muscles longer post activity. These muscles are not going to stretch very well cold, therefore they need to be warmed up first. This is why it is best to stretch as part of your cool down routine, to prevent DOMS (delayed onset of muscle soreness) and speed up recovery.

Rant over! :P

Physiological response to injury and hot/cold

So, this post originally started off as a post to review the evidence behind contrast baths, however, I realised it would be best to explain the physiological effect of hot and cold on the body, and discuss healing times while I'm at it, due to the overlap.

So, here it goes, I will begin with healing times and process.

The healing process consists of 3 different phases, and these are:

1. Inflammation (0-48 hours)
2. Proliferation (5 days – 4 weeks)
3. Maturation (4 weeks – 2 years +)

Now, I've put the time frames up here as a guide. A popular misconception is that these time frames are distinct and seperate, as shown below:

When actually, each of these areas overlap, as one area is winding down, the next is building up it's response, as shown below:

Now, here I will discuss what each area does physiologically, in as brief and simplest way possible:

Inflammation

We are all familiar with this process. This is when the injured area, swells, become red in colour, with associated warmth, pain, and loss of function. In this stage, the initial bridging of collagen fibres begins.

The normal response in this stage is to apply the POLICE principles.

Now, I must point, at this stage, we all panic about swelling, and try our best to get rid of it. Swelling is a natural part of the healing process and we should let it take it's course, as the swelling is needed to get fresh nutrients to the area, and to remove cellular debris.

Chronic swelling, so swelling that is still present maybe a week after the injury is not necessarily good, as this will start to impact on the optimisation of the healing process, and this is where we would want to remove excess inflammation.

Swelling upon exercise of the injured area, at this stage, would still be normal.

Proliferation

This stage shows the signs of inflammation beginning to decrease, and pain levels decreasing too.

Collagen fibres are being laid down at the injured site at the peak rate at this stage and will progress to orientate themselves in line with imposed stresses.

Maturation

This stage should so no signs of inflammation and a huge decrease in pain, with pain only at end range. This stage should focus on restoring function and strength, and optimising collagen alignment.

Collagen fibre deposits peak around 3 months post injury, but will continue to lay down up to 2 years after an inujry (depending on the severity of the injury).

Maturation is more focussed on return to normal, with excess collagen fibres removal, optimisation of the collagen matrix to accommodate imposed stresses, and return to normality of the vascular supply.

This video discusses the three stages of healing in much more
detail, if that interests you, and you can stand the accent!

N.B. Pain is not synonymous with healing. Pain levels will decrease quicker than structural integrity of the injured site improves, so the risk of re-injury is still high, even if the pain has subsided.

This graph shows that after the injury, the pain levels drop
below the threshold quicker than the tendon recovery

It is also worth mentioning a few stats on the temperature of tissues.

Optimal tissue temperatures:
resting = 36.5ºC – 37.2ºC,
aim when exercising = 38ºC – 40ºC (as tendons exhibit plastic deformation at 39ºC, collagen at 40ºC)

Hot and Cold response

So, now I'll move onto the effect of hot and cold physiologically:

Hot and cold can increase or decrease symptoms of inflammation, and here's how:

Cold

Glenn ice climbing in cold conditions!
Copyright Glenn Manifold

Symptom	Response	How?	Additional info:
Pain	↓	Reduces nerve conduction velocity and increases the firing threshold	Considerations Rewarming after icing can take 3-4 hours With a muscle at 4cm depth from skin surface will have a 4ºC fall in 1hr Contraindications: Raynauds, Cold hypersensitivity, Open wound, Sensory defect, heart disease Precautions: Cardiac disease/hypertension, pelvis/groin area (bone marrow production/blood cells), left shoulder+neck area (proximity to heart)
Spasm	↓	Automatic protective response, prevents increase demand for O2
Metabolism	↓	Reduces need for O2 in surrounding tissue so less damage via hypoxia and reduces total debris. Less O2 means less secondary damage to other tissues
Blood flow	↓	Vasoconstriction of the blood vessels
Inflammation	↓
Oedema	↓	By vasoconstriction of blood vessels and increasing blood viscocity
Tissue extensibility	↓

Heat

The author bouldering in sunny,
warm Fountainebleau

Symptom	Response	How?	Additional info:
Pain	↓	By reducing the nerve conduction velocity and increasing the firing threshold	Precautions/contraindications: Diabetes mellitus Multiple sclerosis Peripheral vascular disease Spinal cord injuries Rheumatoid disease Possible side effects: skin burns
Spasm	↓	Automatic protective response, prevents increase demand for O2
Metabolism	↑	More energy to cells, increasing there productivity, plus increase in blood flow meaning more oxygen to area
Blood flow	↑	Vasodilation of the blood vessels
Inflammation	↑
Oedema	↑	By vasodilation of blood vessels and decreasing blood viscocity
Tissue extensibility	↑

I hope this post has given you a little more understanding around the healing process and the physiological effects of hot and cold, and hopefully this will aid understanding for future posts, such as the evidence behind contrast baths, that I'm currently working on.

Wrist Injuries Part 2

For basic anatomy and stats, as well as info on wrist injuries:

• Carpal Tunnel syndrome
• Stress fracture to the hook of hamate

see Wrist Injuries Part 1

This part will discuss Triangular Fibro-Cartilage Complex (TFCC) injuries, and scapholunate ligament injuries, as well as some preventative measures.

TFCC Anatomy

The Triangular Fibro-Cartilage Complex (TFCC) connects ulnar and radius, that is involved in stabilizing the ulnar-radial joint.

It is also sometimes referred to as the “wrist meniscus” as it acts like the meniscus in the knee by forming a congruent surface for the carpal bones to move more easily on the ulnar and radius

Symptoms

• Clicking
• Popping
• Pain on the little finger side
• Weakness
• Swelling
• Tenderness

Diagnosis is normally based on the area of tenderness and special provocation tests, as well as other investigations such as x-rays.

Causes

• Falls onto pronated hyperextended wrist
• Power-drill injuries in which the drill binds and rotates the wrist instead of the bit (obviously not climbing related!)
• Distraction force applied to the palm side of the forearm or wrist (for instance, when open-handing big slopers)
• Distal radius fractures
  

Treatment

Treatments obviously depend on the extent of the injury.

• POLICE principles
• Avoiding aggravating factors
• NSAIDs
• Immobilization in a cast for up to 6 weeks

This is because, like other ligaments, the TFCC has quite a poor blood supply and so this means that the healing process is slow.

If a cast is required, then remember to keep finger and thumb movements within the limits of the cast

Then, once out of the cast, normal rehab resumes, beginning with passive movements, then active assisted range of movements (ROM), active ROM (including stretches of the flexor and extensors), isometric strengthening, resistive strengthening (this includes eccentric movements)

Eccentric wrist strengthening

Wrist extension strengthening

Wrist flexion strengthening

N.B. It can take up to 12 weeks before progressing to strengthening work, so don't rush your rehab!

If a cast is not required, then the normal rehab described above can be implemented straight away, if deemed necessary by a professional.

A TFCC injury could mean up to 3-4 months off climbing

Surgery may be required, such as an arthroscopic repair, depending on the extent of the injury.

A lot more on TFCC can be read here: http://triangularfibrocartilagecomplextear.blogspot.com

Scapho-lunate ligament tear

Anatomy

The scapholunate ligament connects the scaphoid to the lunate. It's an important stabiliser of the wrist to control the movements between the bones. If this ligament is torn there is a loss of the balance of the wrist, and causes abnormal wrist movements.

Symptoms

• pain in the center or on the thumb side of the wrist, worsened with activities such as push-ups, or other activities that load the wrist
• grip weakness,
• snapping, or popping of the wrist
• swelling
• tender and specific swelling over the gap between the scaphoid and lunate

Causes

Large stress on extension and ulnar deviation, normally a fall on an outstretched hand – e.g. falling off when bouldering, and spraining your wrist

Treatment

Initially, immobilization up to 8 weeks or more

Then progress to increasing the range of movement and gentle strengthening/loading activities

Timing and progression of the exercises depend on many factors, such as the type of injury, and the healing process.

A surgical option may be required.

Avoidance/prevention

The obvious prevention is to avoid movements that cause the issues, however, this is always not easy to do. Therefore, if a wrist injury does occur, take notice in the early stages and do something about it, rather than continue to climb on it and make it worse.

Safer bouldering:

Learning how to properly fall sideways or backwards with fingers pointing safely towards the body (thumbs to the bum) would be a beneficial technique to learn, especially for the boulderer, to try and reduce wrist injuries. It is worth emphasizing that these techniques are not instinctive and need to be learned in a safe environment

References

Bourdon M, Thompson J 2013 Safer Bouldering http://www.mec.ca/AST/ContentPrimary/Learn/Climbing/IntroToClimbing/SaferBouldering.jsp

Bissell B, Bedi A 2011 Scapholunate Ligament Tear http://www.sportsmd.com/Articles/id/14/n/scapholunate_ligament_tear_.aspx

Palmer AK, Werner FW 1981 The triangular fibrocartilage complex of the wrist--anatomy and function. J Hand Surg Am 6(2):153-62.

McNamara MG, Carino BB, Thomas R 2012 Diagnosis: TFCC Tear http://www.akhanddoc.com/TFCC.htm

http://www.shoulderelbowhand.co.uk/wrist_ligament_injuries.html

Verheyden JR 2012 Triangular Fibrocartilage Complex Injuries  http://emedicine.medscape.com/article/1240789-overview

http://triangularfibrocartilagecomplextear.blogspot.com/2010/04/how-can-physiotherapy-help.html

http://ih-voc.eznetpublish.ihealthspot.com/tabid/14407/mid/24836/ContentPubID/113/ContentClassificationGroupID/-1/Default.aspx

Roux A 2010 Scaphoid and Scapholunate Ligament Injuries: The Achilles' heel of the wrist http://occupational-therapy.advanceweb.com/Archives/Article-Archives/Scaphoid-and-Scapholunate-Ligament-Injuries.aspx

Wrist Injuries Part 1

Wrist injuries aren't as common as finger injuries (from what I've seen), but can be just as serious, if not more serious, especially as climbers often focus on fingers, elbows and shoulders and seem to forget that wrist bit in between!

I've been trying to find statistics on wrist injuries, and the most common wrist injuries, however, most articles lump wrist/finger/hand injuries all together, so after much digging, I decided to focus on 4 main wrist injuries, and these are:

• Carpal Tunnel syndrome
• Stress fracture to the hook of hamate
• TFCC (Triangular Fibrocartilage Complex) injuries
• Scapho-lunate ligament tear

The latter two will come in a follow up post, Wrist Injuries Part 2

Statistics I did manage to find:

11% of 39 rock climbers had carpal tunnel (Rooks et al 1995)

50% had hand or wrist injuries (Rooks et al 1995)

7.1% of 42 climbers had undercling wrist injury and carpal tunnel (Rohrborough et al 2000)

9 out of 115 injuries = wrist (7.8%)(Bollen 1988)

12% wrist #, 5% wrist sprain (out of 545) (Logan et al 2004)

Schwiezer (2012) has said that these injuries are frequently seen only several months after the initial trauma. A ligamentous injury is quite difficult to treat at such a late stage and the prognosis is much worse. It is recommended that you get your wrist thoroughly investigated if it has been painful for more than three weeks, to exclude such an injuries.

Anatomy of wrist

Bones

Ligaments

Carpal Tunnel anatomy

Carpal Tunnel 

Cause

Carpal tunnel symptoms arise from compression of the median nerve as enters through the carpal tunnel and into the hand.

The median nerve controls the movement of the thumb, as well as sensation in the thumb and the next two-and-a-half fingers.

This compression can be caused by swelling within the carpal tunnel, or changing the orientation of the structures around the carpal tunnel, that could be caused from:

• Damage to the flexor tendons usually occurs due to overuse of the forearm flexors.
• Injury to wrist – sprain, fractures, crush injuries
• RSI -from strenuous grip, repetitive wrist flexion
• Sudden increase in activities leading to strenuous grip

Symptoms

The main symptoms of carpal tunnel are:

• Numbness
• Tingling
• Pain

...within the affected hand

Normally in a specific pattern of the thumb and first two and a half fingers (as this is where the median nerve supplies within the hand)

However, other symptoms can include:

• a dull ache and discomfort in the hand, forearm or upper arm
• a burning, prickling sensation
• dry skin, swelling or changes in the skin colour of the hand
• becoming much less sensitive to touch (hypoaesthesia)
• weakness in the thumb when trying to bend it at a right angle, away from the palm (abduction)
• weakness and wasting away (atrophy) of the muscles in the thumb
• weakness to the hand and fingers, meaning it becomes difficult to perform dexterous tasks, such as typing or fastening buttons.

The symptoms of carpal tunnel are often worse after using the affected hand. Any repetitive actions of the hand or wrist can aggravate the symptoms, as can keeping your arm or hand in the same position for a prolonged period of time.

The symptoms of carpal tunnel tend to develop gradually and usually start off being worse at night or early in the morning.

Treatment

Initial treatment of carpal tunnel should consist of the POLICE principles. This will mean resting the wrist, ceasing all aggravating activities (yes, this means climbing), avoid ports that requires a large amount of stress on the forearm flexors (yes, this also means climbing!), as well as racquet sports, gripping activities, opening jars, cans or doors, carrying or lifting.

This rest is to ensure that the body can begin the healing process and prevent causing any further damage.

Only once these activities can be performed pain free, can you gradually build up the stresses applied to the wrist and return to activities.

“No pain, no gain” attitude will cause the problem to become chronic, which then becomes a lot harder to treat and will take much longer to resolve.

If your carpal tunnel syndrome is caused by an underlying health condition such as rheumatoid arthritis, treating the condition should improve your symptoms.

• Wrist splints
• Physiotherapy
• Corticosteroid injections
• Carpal Tunnel Release surgery

I will discuss the first two

Wrist splints

A wrist splint can be worn at night to keep it in the same position and aid the rest required. A wrist splint prevents the bending of the wrist and further compression of the carpal tunnel.

Wrist splints are widely available, but you must follow the other advice to ensure the problem resolves. If there is no change within your symptoms after 4 weeks, definitely seek professional help.

Physiotherapy

The cause for your carpal tunnel could be due to:

• excessive training or activity
• muscle weakness
• muscle tightness
• joint tightness
• poor sporting technique or equipment
• inadequate warm-up
• Injury to the neck, upper back and nerves

Exercises to target muscle tightness and weakness would be extensor and flexor stretches, and extensor/flexor stengthening (see medial epicondylitis post and the images below). 

As with all exercises, these should be performed pain-free. They are generic wrist flexibility and strengthening exercises for the wrist.

A physiotherapist may use other modalities and treatment techniques to resolve your carpal tunnel

Prognosis can be more than 6 months for a carpal tunnel problem to resolve

Climbing technique and carpal tunnel

Changes in climbing pattern may reduce the recurrence of carpal tunnel, especially if it was climbing that caused the carpal tunnel in the first place.

This may involve:

• training planning with warming up and cooling down
• stretching exercises,
• longer rest periods,
• use of different hand positions,
• appropriate climbing shoes

(Peters 2001)

Differential Diagnosis

Please bear in mind that although your symptoms are portrayed as carpal tunnel syndrome, there may be a different cause to your symptoms, such as

• radial nerve at the elbow and proximal forearm may be an origin of pain (supinator tunnel syndrome). Since this is purely a motor nerve, only weakness of the wrist and finger extensors and a dull pain are perceived. Stretching exercises and deep friction massage of the supinator muscle are usually helpful and surgery is rarely necessary.
• median nerve at its passage through the pronator teres and the ulnar nerve at the elbow (cubital tunnel syndrome) and at the hypothenar, but this is rare.
• Digital nerves may also be compressed but rather acutely (neuropraxia) when squeezed into cracks or holes, activating a sharp electrifying pain directly over the nerve with a hyposensitivity and numbness below the injury. These symptoms usually disappear after a few weeks. (Schwiezer 2012)

Hook of hamate stress fracture

Cause

A hook of hamate fracture is quite rare, but is quite a climbing-specific injury (can occur in golfers too) that has been observed during a repeated attempt of an under-cling-grip on a difficult boulder.

The fracture was caused by the climber holding his wrist in an ulnar-abduction where the FDP-tendons of the small and ring-finger are deflected by the hamate hook. The high forces at the hamulus finally led to a basal-fracture of the hamate (indirect fracture type).

Similar to the scaphoid, hamate fractures cannot be picked up on normal x-rays. This means this type of injury is rarely diagnosed

Symptoms

• Ulnar nerve symptoms such as:

1. Numbness or tingling (‘pins and needles’) in the little and ring fingers
2. Numbness or tingling in the heel of the hand
3. Weakness in the hand when performing fine motor movements, straightening the ring and little fingers, and spreading the fingers
4. Muscle atrophy

• localisation of tenderness over the hook of hamate
• pain on movement of the ring and/or little finger due to the proximity of the flexor tendons to the hook (Barton )

Treatment

The fracture can be treated successfully with a special splint in ulnar and radial deviation of the wrist if picked up early enough. (Schwiezer 2012 and Barton )

Otherwise, an excision of the fragment, but this is quite a delicate operation, with mixed results.

References

 

Bayer T, Schweizer A. 2009 Stress fracture of the hook of the hamate as a result of intensive climbing. J Hand Surg Eur Vol. 34:276–7.

Peters P. 2001 Nerve compression syndromes in sport climbers. Int J Sports Med 22:611–7.

Rooks MD, Johnston RB , Ensor CD, McIntosh B, James S. 1995 Injury patterns in recreational rock climbers. Am J Sports Med  23(6): 683-685

Barton N 1997 Sports injuries of the hand and wrist. Br J Sports Med 31: 191-196

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

Rohrbough, J. T., M. K. Mudge, R. C. Schilling 2000 Overuse injuries in the elite rock climber. Med. Sci. Sports Exerc., 32(8):1369–1372.

Logan AJ, Makwana N, Mason G, Dias J. 2004 Acute hand and wrist injuries in experienced rock climbers.Br J Sports Med. 38(5):545-8.

Bollen 1988 Soft tissue injury in extreme rock climbers. British Journal of Sports Medicine 22(4): 145-147

 Next post: Wrist injuries part 2: Scapholunate injuries and instability and TFCC Injuries