A WRISTED DEVELOPMENT
A week ago I was climbing at Arapiles when I felt my wrist twinge on a hand jam. It still feels a bit tweaky and maybe slightly swollen, and it occasionally pops. I hurt it several months ago as well, though now it feels different. Most of the time, it’s just the little- finger side that feels sore and hot. If I rotate my wrist around in a circle, it clicks—not a painful popping, but definitely noticeable. Playing with it loosens it up a little. If I squeeze my wrist, the whole thing pops, and I can feel the bone on the little-finger side lift up and pop back into place. Sometimes, it feels like everything’s in line, but it always goes back to that drawn-down feeling. Climbing’s not bothering it too much, so long as I don’t do anything too hard or pull slopers.
Marisa Field Salt Lake City, Utah
Marisa, my apologies that our Aussie sandstone mistreated your wrist. I had this condition many years ago. I saw a surgeon, and he said he could fuse my wrist for me—oh joy!—and he told me to stop climbing. Imagine that! Sounds like you have wrist instability. It will probably be diagnosed as mid-carpal instability, but there are several different types. Few physicians understand the biomechanics of the wrist, let alone under chronic heavy loading. Virtually every case I have seen has been in a climber.
The instability may appear after a single traumatic event (ligament injury or bone fractures), it may be secondary to prolonged chronic overload of supporting ligaments, or it may be consequent to an underlying disease process (e.g., rheumatoid arthritis). The combination of these overlapping causes will result in a specific type of instability. In your case it will probably be that chronic repetitive forces of climbing combined with the previous injury have led you down the merry path of carpal mayhem. The most commonly damaged tissue is the triangular fibro-cartilaginous complex (TFCC) that sits between the end of your ulna and the carpal bones on that side. Damage to this, or a few neighboring ligaments, allows the ulna-side carpals to drop forward, known as ulna carpal sag. If you have to “pop” them back into place, then they are actually partially dislocating (subluxing).
The click you hear when you rotate your wrist is either TFCC damage, which is now getting in the way, or the carpals on that side, having been caught in the wrong place, suddenly repositioning. These almost always stabilize, so don’t rush to the surgeon just yet. Surgery can vary between the simple, the complex, and the experimental. Routine x-rays are typically normal, though some special views, such as with a clenched fist, may be illuminating. Cinefluoroscopy (a video x-ray) will show abnormal mechanics.
Tape is your friend. Get a professional to show you the way. The extensor exercises described in Medicine No. 156 are a good idea. Though no muscles attach to the relevant carpal bones, strength clearly plays a crucial role in stability. Slopers will be very aggravating. Crimping should be fine, but don’t overdo it. Mix up your training.
I have developed a moderate pain in the extensor tendons of the thumb: abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). The pain became intense after a bouldering session on plastic. I was diagnosed with De Quervain’s Tenosynovitis. I stopped climbing at the gym four weeks ago, and since then have only done a couple of moderate trad climbs with my hand taped to avoid any stretching of the tendons. I also avoided using my thumb. The treatment has included taking ibuprofen, and multiple sessions with the PT using a steroid gel applied with ultrasound targeting the area. I have applied ice multiple times a day and wear a removable splint often. The problem is slowly getting better, although in the morning the pain is a lot more intense. Is there anything else I can do to help speed healing? Should I not climb until all the pain in the tendons is completely gone?
Ernesto Trujillo Fort Collins, Colorado
De Quervain’s is an inflammatory disorder of the synovial sheaths that the APL and EPB tendons glide through. Ironically, the sheaths are there to reduce frictional force, but when aggravated, they become inflamed. I have to say I am not a fan of splinting for any condition unless absolutely necessary. Like U.S. foreign aid, there is much hoopla, followed by enormous problems and infrequent good outcomes. I have never splinted someone or had recovery go beyond a couple of weeks. Splinting should not be frontline, but is certainly a worthy arrow if all else fails to hit the mark.
Likewise, pharmaceutical intervention is not the vanguard of medicine for musculoskeletal disorders. That said, cortisone would be of assistance, at least in the short term. This assumes that you’ve cut out aggravating activities, and addressed musculoskeletal factors, and that it is minor aggravations that are maintaining the inflammation.
For inflammatory conditions, ultrasound is pointless. It is assumed to have thermal and mechanical effects on the target tissue, and supposedly increases local metabolism, circulation and tissue regeneration. Maybe it does, but not significantly. Certainly it does not have some mystical, difficult-to-comprehend property that you, the naïve consumer, should be happy to pay for. Ultrasound is, however, a beautifully constructed placebo, used by roughly 95 percent of physical therapists. Placebo! Cocaine would be equally helpful, more enjoyable and competitively priced depending on U.S. relations with Colombia.
De Quervain’s is usually a repetitive-strain type of injury, arising after several hours of aggravating activity. Climbing is not typically a catalyst, though it may maintain the injury. Pinches often exacerbate it; most everything else does not. Ironically, trying to guard the thumb by lifting it out of the way can cause more aggravation than using it. Gaming consoles, some computer mouses, using a wrench for hours, and other repetitive activities can initiate the pathology, but it is easily maintained by activities that would not start the process.
In De Quervain’s the extensor muscles are likely to become chronically inflamed and rather pissed (that’s a diagnostic term). A stern massage often helps, as it does for many musculoskeletal conditions. Heat on the muscle bellies in the upper forearm, and ice over the lower inflamed area can be helpful.
The good doctor has spoken, and the ill winds have been soothed. If I am wrong, at least you haven’t lost any money. If I am right, please send me an Audi. An RS4 wagon would be lovely. Thank you.