Finger and Hand Anatomy, and Grip

Now, I thought I'd provide some information on the most commonly injured part of a climber - fingers! (As Logan et al 2004 report that of 545 climbers, 28% has sustained an injury to the wrist or hand - the highest percentage of injuries)

What I will discuss is the finger anatomy, grips commonly used in climbing and then I will follow it with a second post regarding injuries and their management.

So, to begin:

Anatomy

Now, not only am I going to discuss the anatomy of the fingers, but also the wrist and forearm, as some of the muscles involved in the movement of the fingers originate in the forearm.


The bones in the hand are shown here:

All relatively straight forward and not much to worry about there (apart from epiphyseal plates - but I will come onto that when I discuss injuries of fingers). The ligaments, on the other hand, are a bit more complex.

 
The finger flexor tendons are held in place by pulleys (A1-4 shown in the diagram). These pulleys ensure the action of the flexor muscle contracting bends the finger all the way to the tip across each different joint. This means that a lot of force and friction can be exerted on these tendons when a large load is put through the finger tips.

One thing worth noting is that the A2 pulley contains the tendons of both the flexor digitorum profundus (FDP) and the flexor digitorum superficialis (FDS), 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)

 

The carpal tunnel is worth mentioning briefly. This is the area in which the tendons to the fingers, blood vessels and nerves pass through from the wrist to the palm of the hand, between the carpal bones and flexor retinaculum (a ligament). It is quite a compact area and so any increase in pressure in the area, such as dramatic increase in blood supply, or inflammation of tendons etc can cause tingling etc of the hand, from compression of the other structures in the carpal tunnel such as the nerves or vessels.
 

 Now, the muscles. The muscles that flex or extend the hand/fingers originate at the medial epicondyle (for flexing) and lateral epicondyle (for extension). The epicondyles are the corners of your elbow, if you like (see pictures).

 

 

There are a few other muscles within the hand to be aware of. Have a look at the palm of your hand. Notice the fleshy parts of your hand around the base of the thumb and little finger? Good (I hope you can see them!), these are the areas where the muscles that move your thumb and little finger are hidden away, and, as you can see, they have more movement than the other digits in the hand beause of these muscles. 

Finally, the last group of muscles in the hand are the lumbricals and interossei.

• Lumbricals - (shown in the picture above) are responsible for flexion only at the metacarpophalangeal joint
• Interossei - are responsible for abduction and adduction of your fingers (see below)

 

Now, all this hand anatomy will be useful when we discuss injuries to the fingers and hand (in a later post).
Next, I will briefly discuss the significance of grip. 
 
Grips

When gripping any object, the optimum gripping position is when your wrist is at approximately 10 degrees of extension. 

This applies even with the common climbing grips displayed below.

When a climber becomes tired, they tend to lose this 10 degrees of extension and rely on the passive structures of the upper limb. 
This creates strain on these passive structures and puts them at a higher risk of injury. 
This can often be seen when climbers start sticking their elbows out like chicken wings, as they are tiring and resorting to use of passive structures.


To prevent this passive gripping and chicken winging: pure and simple, train the active structures, and when tired, try and keep some control over your positioning, as otherwise you'll never change this. 

References

Logan AJ, Makwana N, Mason G, Dias J 2004 Acute hand and wrist injuries in experienced rock climbers. British Journal of Sports Medicine 38: 545-548 

Drake, Vogl, Mitchell 2009 Gray's Anatomy for Students. Elvesier, Philadelphia


 Coming soon: Finger Injuries: Symptoms and Treatment

Importance of the hip joint in rock climbing

So, this post started as a request by my old man, who is an "older" climber!

However, he didn't elaborate on what he wanted me to discuss with regards to the hips, so I'm going to explain some anatomy, the function, the relevance of the hips to climbers, potential pathologies you may come across, treatment/preventative measures that can be taken, and any other relevant information I encounter along the way!

Anatomy

The hip joint is a basic ball and socket joint that has a large range of movement. It is also a very stable joint due to the majority of the head of femur being encapsulated by the acetabulum of the pelvis

I won't bore you with naming them individually, but the primary role of the muscles of the hip are to flex and extend the hip, as well as adduct and abduct it. A combination of these movements bring about rotational movements about the joint.


Function

The main function of the hip is to provide a strong, weight bearing joint in which provides enough movement to walk, stand, and other functional movements.

Relevance to climbers

The relevance of the hips to rock climbers is bigger than you might think. 
A lot of climbers focus on the upper limb - getting stronger shoulders or fingers, and some may contemplate the feet, for example their shoes and how tight they are, however, not many think about anything else in the lower limb region. 
This is because much of the strength built up in the legs is from weight bearing exercises such as....walking, sit to stand, climbing stairs etc etc, but aren't nessecarily transferable strengths to climbing.

Copyright Seve Graepel

The hips are key in climbing, for example, being able to actively extend the hips to bring your body closer to the wall, so your centre of gravity is in line with your feet. This is in order to take some of the weight off the arms. 
Also, the range of movement about the hip is key, and can be a hinderance in many an older climber, as the infamous rock over move requires a high step with the hip joint flexed excessively than would be done in normal, everyday activities.
This high step then has the weight of the climber transferred across to it, then the climber has to stand on the rocked-over leg with all the weight of the climber being supported on that leg (with or without some holds for the arms). 
This means the hip has been flexed to it's end range, and then has to extend from this end-range position.

Copyright BMC

This can be quite a difficult move, and in reality, the best exercises for this is the movement itself: to practice rock-overs; but starting from a lesser degree of flexion and gradually building it up. 
Single leg squats and other such weight bearing exercises will build up muscles around the hip and knee that aid this movement, but does not cover the same range of movement a rock-over requires.

Pathologies

So, pathologies of the hip. There are no real hip pathologies that are common, or more likely in climbers, unlike other joints such as fingers. Therefore, hip problems are usually similar issues found with Joe non-climber Bloggs out there. 
So, generally, pain around your hip could be caused by a tightness in the hip stabilizers, such as the piriformis. A deep rub with an elbow in the buttocks region, at the midpoint between the head of femur and PSIS (posterior superior iliac spine) will often resolve the pain, minus the pain you will experience from the deep rub initially!

A lot of people I know rave about yoga as a great adjunct to most therapies, and for the hip it seems to be in a league of it's own. This is a good preventative measure for injuries.
Other hip pain could be referred from elsewhere, such as the lumbar spine, and needs checking out further by an expert.
Finally, issues related to older climbers and the hips would be that of osteoarthritis of the joint.

 So, osteoarthritis is a disease that normally occurs for the over 50's and is a degenerative joint disease that causes break down of the cartiledge of joints and produces bony spurs, both of which cause pain upon movement of the joint, along with swelling and inflammation.
There is no "cure", as it were, for osteoarthritis, but can be managed with exercise and medication, however, some do require surgical intervention (which will be saved for a later post)

Treatment and Preventative Measures

I've already discussed treatment and preventative measures along the way, but here I will summarise them:

• Build up hip strength for exercises such as rockovers by gradually building up the exercise from a lower level and working up
• Hip issues can come from other areas such as the spine - work on your core to prevent this
• Explore other options to maintaining your strength and flexibility such as yoga
• Tight piriformis and other hip stabilizers can be solved via stretches or soft tissue release (deep rub!)
• Exercise and medication can aid reduce the pain caused by osteoarthritis

Reflection: simplicity and change

So, I'm going to detour from the climbing-related posts, albeit only briefly.I am going to defer to my 9-5 NHS work, at a community hospital on the wards.

During this week, the Occupational Therapist (OT) I normally work with on the wards has been off, and so I have been working with several different OT's all week.
During this week, I have picked up 3 key points:

1. That change is good - it has kept me on my toes this week, and reassured me that I have been doing the right thing with my patients
2. That all the OT's I've worked with work in a similar way - while everyone is unique and has their own way of working, it's refreshing to see that people have similar traits running through the way they work, such as proactiveness, clinical reasoning and prioritising
3. That simplicity is often the best, and easiest way -  on this, I will elaborate further:
   As community rehab wards, patient's often get admitted for "confidence building" with regards to their mobility, and I had one such gentleman. I'd never figured out how to quantify "confidence" until an OT this week suggested just using a scale of 1-10 and he can rate his confidence that way - and there you have it, simple yet effective, and best of all, patient-centred!

So there you have it, a brief insight into the other side of my physiotherapy work!

UIAA MedCom grading for comparison

So, as I discussed in my blog post regarding BMC Injuries Symposium 2012, I explained that I'd learnt about converting climbing grades to a set numerical number (as apposed to one that is a combination of numbers and letters) so that it is comparable to other studies, and so that statistical packages can analyse the data.

Now, in my dissertation, I originally converted all grades to a common denominator (English Tech grade, if you were wondering) and then assigned them a numerical interger.
This is the same process using the UIAA MedCom grades with just a variation on the interger assigned.

I re-assigned my climbing grade values and still came out with the same result of average climbing grade for the population used in my sample, however with the new figures assigned, the comparison between studies becomes easier.

Just a useful nugget of information for anyone collecting data about climbers out there!

  

Management of Acute Injuries

So, this post aims to explain the best way to manage an acute injury.
The definition of an acute injury is an injury that has occurred within the last 48-72 hours.

Now, the Association of Chartered Physiotherapists in Sports Medicine (ACPSM) are the leaders in providing the articles for this topic, and had previously released the PRICE principle (1998), which stood for:

• Protection
• Rest
• Ice
• Compression
• Elevation

But this has now been superseded by the POLICE principle (2012), also released by the ACPSM, which stands for:

• Protection - protection is designed to protect the injury from any further damage. The amount of protection is dependant on the injury, but supports the joint while recovery takes place. Protection can take many forms, such as bandage, splints, tape or brace

• Optimal Loading - this is the difference from the old PRICE principles, which means that rest needs to be balanced with a incremental rehabilitation structure that slowly introduces the injury to varying degrees of stress. This will mimic the natural mechanical strains imposed on the injured structure and promote healing in a functional and optimal fashion.
  
  

This does not mean that the use of crutches or braces cannot be used (as would have been previously using the Rest principle) as they could well be key in regulating the amount of load through the injury.

• Ice - Ice has always been used traditionally, as it:
•  reduces pain (by increasing the threshold required for the nerve cells to send a pain stimuli, and by reducing the speed at which the stimuli is sent), 
• reduces spasm (which prevents further damage to tissues, and reduces the oxygen demand for the tissue), 
• reduces metabolism (therefore reducing the oxygen need in surrounding tissue so reduces damage caused by hypoxia and reduces total debris in the tissue. Also, less oxygen supplied to the tissues means less secondary damage to other tissues) ,  
• reduces blood flow (via vasoconstriction), and  
• reduces swelling (via vasoconstriction of the blood vessels and increasing the viscosity of the blood).

• Compression/Elevation - Compression and elevation is to reduce the swelling and limit blood flow to the area when not icing the affected area. This aids venous return so that fresh blood can be introduced to the area, bringing with it fresh nutrients for the healing process, and getting rid of the debris from the injured site.

Never compress and elevate simultaneously, as this can compromise blood flow to the affected area!

Notes for using ice:

• Always have a barrier between the ice and skin such as a towel or polythene bag etc to prevent ice burn
• Ice should be in contact with the site for maximum 20 minutes at a time, with around 2 hours between each administration
• While ice reduces pain, this does not mean that the site is healed
• Muscles take a lot longer to warm up than they do to cool down - take care with any exercise or activities such as driving up to 4 hours after icing a muscle
• Check sensation around the area before applying ice - reduced sensation means the person may not feel if there is problems with the area the ice is applied to i.e. ice burn etc
• Do not apply in the chest area due to cold blood around the heart
• Do not apply to someone with high blood pressure, as the vasoconstriction will cause their blood pressure to increase further   

Remember! Every injury is different, and this is by no means a "one fits all" programme, it is merely advice to guide a better recovery. Every injury, and the time it takes to heal, is unique.
 
References:
 
 Bleakley CM, Glasgow P, MacAuley DC 2012 PRICE needs updating, should we call the POLICE? British Journal Sports Medicine 46:220-221 (See below)

MacKenzie, B. (2000) Cryotherapy 

http://www.njdsportsinjuries.co.uk/education_2_2826422889.pdf 

ACPSM, (1998). Guidelines for the management of soft tissue injury with protection, rest, ice, compression and elevation (PRICE) during the first 72 hours: The Chartered Society of Physiotherapy.
 

     

BMC Climbing Injuries Symposium 2012

So I returned from the hectic yet informative weekend at the Showroom Cinema in Sheffield in one piece!

Now that I have had time to reflect and digest all the information taken in, I'm now (hopefully) ready to give you some nuggets of useful information taken from the weekend.

The weekend consisted of fantastic talks from speakers such as Volker (German Orthopaedic surgeon and medic from the German National Team) and Isa Schoffl (Paediatrician and finger expert), Audry Morrison (Nutritionist), Waqar Bhatti (Consultant Radiologist), Stewart Watson and Charlie McCall (Physiotherapists), Tim Budd (Sports and Remedial Massage Therapist), Gary Gibson and Robert Bradshaw-Hilditch (Podiatrists).

Waqar ultrasounding fingers and exploring the movement of tendons within the joint space

 Lectures ranged from common shoulder injuries: both conservative and surgical management to soft tissue therapy and hydration.

The biggest things I took out of it for impacting my future practice were:
With regards to movement on rock:

• To assess a climber, assess them climbing
• Balance is the key to provide locomotion
• Mistakes in climbing techniques cause ineffieciencies
• Reduce the load on passive structures, and train actively for this
• To move each body part in order, starting at the feet and move upwards - not forgetting hip position
• Use both hands when moving - one can be used in a stabilising fashion when other limbs are being moved
• Don't compete when training - it's supposed to be a safe environment!
• Climbing technique issues won't become apparent until the climber is climbing at their limit

Klauss explaining the effect of stretching on muscles using sweet snakes to demonstrate

With shoulder injuries:

• Surgical decision is based on biological age of the muscles, not of the chorological age of the patient
• Long head of biceps adds approx 5-7% of your overall over-head strength
• A SLAP tear can be caused from chronic repeated twisting of the biceps tendon from repeated shoulder extension, abduction and forearm pronation
• Scapulohumeral rhythym should be approximately 2:1, whereas in climbers, research has found, it is in the region of 3.7:1
• When assessing the shoulder, look proximally to distally to identify whether the issue is coming from the shoulder, or more proximally from the spine
• Any rehab needs to be functional, but also broken down into smaller component parts

With climbing related statistics:

• to use the UIAA MedCom table to convert climbing grades to be comparable to other studies
• that climbing has a very low injury rate per 1000 hours of sport, as rugby = approx 260, climbing = 3.1 or less
• of 604 injuries in climbers, 122 were pulley injuries (20%)

Gary and Rob's preliminary data on the forces exerted through a climber's foot - notice alot goes through the first ray, which can cause problems with the foot arch

Other information found:

• Balled theraband is good for rehabilitation of a finger injury/operation
• Fascia adds muscle power through the matrix of fascia
• 168 hours in a week - seeing a physio for 1 hour is  less than 1% of your week - learn to self manage your diagnosis
• Inflammation is an integral part of the healing process - only need to do something about it if it is out of control
• That very often, the visible sign of an injury can be just the tip of the iceberg for what lies beneath the surface
• To try and modify climbing style/technique/behaviour rather than stop climbing altogether due to an injury
• Finally - if you have a problem/injury and your not sure what to do, go and see an expert!

From this, the next stage for myself, personally, is create a legible record of the notes I made from this symposium, endeavor to get my work published, and keep learning all I can!
For any information on what I have talked about on here, don't hesitate to ask - it's all about sharing of information and preventing injuries!

 

I leave you with the sound of an A2 pulley tendon tear, and the audience's reaction at the symposium! 

Further reading: "One Move Too Many" by Hochholzer and Schoffl for the climbing injuries bible

"Waterlogged" by Tim Noakes for more on hydration and overhydration

"Anatomy Trains" by Tim Myers for more on fascia