Ask Dr J – Issue 193 – Practitioner Love

What’s All the F.U.S. About?

I jumped down from a boulder problem in the gym and felt a sharp pain in the middle of my right knee. The MRI reads: “There is a chondral injury of the lateral tibial plateau which is most likely a chondral flap/fracture with underlying bone reactive edema. The cortex is intact and no evidence for meniscal tear.” Is there anything I should do (or not do) to get myself back on the rock faster and keep myself there?

Molly | Rock and Ice Forum


Molly, Molly, Molly, what are we to do with you? I fear might be some practitioner love thing happening here. I may have to advise you to consult with someone else. I trust your bum is feeling better and your hamstring is back to full strength since our last exchange?

The MRI report basically says that when you hit the ground, the end of your femur impacted the top of the tibia and gouged up a flap of the shiny synovial cartilage that covers the end of the bone in the joint.

The scalpel is your friend. A chondral flap often breaks free and floats around the joint causing anatomical mischief. Your knee will lock randomly and before too long you’ll face plant. Your partner will not want to walk near you for fear of being taken down as well. He may meet another woman as a result. It’s just a feeling I get.

The fracture site will possibly need some cartilage grafting, whereby the scalpel guy will harvest some cartilage and graft it back on. Fancy!

You are out of climbing for a few months, and out of bouldering for quite a bit longer. A good surgeon will make all the difference. And then find a knee-rehab specialist who is highly recommended.




Recently, I was pulling on a three-finger pocket and heard/felt a small pop in my right hand. I thought that I had torn my A2 pulley. Within seconds I realized that my precious fingers were OK, but my palm was in pain, about an inch below my ring finger, and shooting about halfway down my forearm. Even though there was slight pain in my hand, I could still move my fingers and make a fist. But as soon as I take my pinky out of the equation and try anything with three fingers, the pain is there. Is it a flexor-unit strain?

Gunks76 | Rock and Ice Forum


Flexor-unit strain? WTF is that? I have seen the term bandied around a few forums but, call me stupid, can someone please define “flexor-unit strain” and explain how that constitutes a diagnosis?

Ideally, a diagnosis has the breadth of a pinpoint. Since the “flexor unit” is not an anatomical site per se, my guess is that the term refers to the whole kit and caboodle, from the muscle origin to the tendon insertion. You might as well say you strained your arm for all the detail that provides.

The mechanism and symptoms you describe are quite common, and extremely specific to climbers. I have described this injury in Rock and Ice several times in recent years, but the truth is no one has been able to truly define, to a pinpoint, what you have injured. When you drop your little finger off, you are effectively doing the “Dr. J Test” whereby you tuck a finger into your palm and flex both it and its neighbor, which is in an open-hand position. Typically you’ll feel pain in either the ring or little finger because climbers rarely isolate and load the first finger.

Two sites can potentially cause the associated pain. The first is in one of the two muscles in the forearm that control finger flexion. Each has four functionally differentiated sections with a tendon extending from each part. The second is in the palm in a group of small muscles called lumbricals that control both flexion and extension of the fingers.

Place the back of your hand on the table with your fingers extended and slightly splayed. Now raise your middle finger. That is for whoever coined the diagnosis flexor unit strain.

Now for the test: Imagine your fingers are the four tendons of one of the forearm muscles and the webbing between your fingers is where each tendon merges to become muscle. On your good hand, tuck your little finger tightly into the palm, keep the others open, and pull. The stress you can feel in the webbing between the little and ring finger is akin to that occurring where the tendons for those two fingers fuse with the muscle belly. My theory is that this junction tears when the relative length of the neighboring tendons are at extremes and under load. Hence your observation that if you don’t split your fingers there is minimal pain. That’s because the damaged tissue is not particularly loaded.

The remaining potential site is in your palm. In a recent study, diagnostic ultrasound was used to locate the source of pain that you have noted. In some patients inflammation and hematoma formation were observed in a lumbrical. So there is probably some damage here, and possibly some between the tendonous junctions at the muscle belly.

Solution: don’t split your fingers at all for a month and climb as much as you want.


The Dr. J Test:

Pull on all four fingers individually in an open-hand and crimp position, making sure to keep all fingers roughly the same length. This should be relatively painless. Now pull on each finger separately while forcefully flexing one of the neighboring fingers into the palm. Typically the test will be positive when pulling on the ring finger and curling the little finger, as this is the most common finger to be dropped from a hold. Think about the hold you were pulling on. Which fingers were curled into your palm? Replicate this using the Dr. J test and wince with the confirming