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

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