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thegrassr00ts
Dec 22, 2008, 6:05 PM
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So I know I've posted here 1,000 times trying to describe to everyone what is going on with my finger. I finally got ahold of a digital camera and the pictures are attached. I'm posting this on a few different sites because I would really love some sort of diagnosis before I drive 7 hours to an orthapedist and pay him huge amounts of money becaue I don't have insurance and don't feel like paying 700 dollars for an office visit for him to say, "Hmm, that's weird, never seen that before" or "I'm sure it'll heal up, it's nothing, don't worry about it." Any and all opinions are welcome.
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thegrassr00ts
Dec 22, 2008, 6:07 PM
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So the first and second pictures are of the injured finger, the third and fourth are of the uninjured finger on my other hand for comparison. You can see the swelling on the thumb side of the middle knuckle. Some deformity, pain when crimping, and it's been about 2 months. Have done the contrast baths, friction massage, cold water therapy, and endless hours of AROM. Again, all suggestions are welcome.
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mturner
Dec 22, 2008, 6:50 PM
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Ok save us the time of looking at your other posts and tell us how the injury happened.
Also, you need to learn how to use your focus on your digital camera...yikes. Those pictures offer little to no help as far as I'm concerned.
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GeneralZon
Dec 22, 2008, 6:55 PM
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What do you do for a living? The more we know the better.
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thegrassr00ts
Dec 22, 2008, 7:03 PM
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Yea, of course the only camera I had was a serious digital camera with a massive zoom which I didn't know how to focus on anything closer than 300 yard away, although I think the first picture offers a pretty clear view of what I'm talking about. As for how it happened, I'm not really sure. There was not traumatic injury, no audible "pop" typical of a pulley injury. I'm pretty sure it just happened from overuse because I noticed the swelling and pain about a month after I started a pretty serious hangboard routine. I'm a law student for a living, so in addition to the lack of health insurance, I have next to no money for a few years...at least my job doesn't force to me to use my hands though I guess. Just because of where the majority of the swelling is I have been thinking it's a collateral ligament or a stress fracture although, I don't know if a swollen middle knuckle is typical of a pulley tear and it seems without years of medical school and some expensive, fancy pictures, I'm not going to be able to determine if there's any bowstringing.
(This post was edited by thegrassr00ts on Dec 22, 2008, 7:06 PM)
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Yosemite1976
Dec 22, 2008, 7:09 PM
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I have had a similar looking injury to my middle finger. And it took almost a year to stop hurting. I still have the knot on the side of the finger . Much smaller then it was last year but will more then likely always be there . Be careful with it . ( Sister tape it when you climb ).Protect it as best you can or it may never heal . My doc told me surgery was not a good option .
Hope you get some good answers .when you see your doc . Yes you go see a Doc.
Danielle
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onceahardman
Dec 22, 2008, 8:04 PM
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Hi Grassroots...
We've already spoken quite a bit about this.
There is a limited number of possibilities:
1) Torn ligament (collateral, or maybe capsule, or pulley, non contractile restraint)
2) Torn tendon- unlikely, due to location, and pretty good strength.
3) Torn lumbrical extensor slip- tough to diagnose in this format.
4) Infection
5) Cancer- very rare in a finger joint.
6) Fracture
Similarly, there are limited treatments:
1) Surgery- most surgeons (wisely IMO) wouldn't be in a hurry to cut here. (unless it's #5 above) Considerable risk of poor outcome.
2) Non-surgical (conservative) treatment. Two basic types here:
a) Splinting or casting- move the joint less, allowing it to scar down maximally (in theory). 4-8 weeks without moving the joint, then see what happens. You may never regain full ROM.
b) AROM- keep moving the joint, the theory being to maximize blood flow, and minimize problems which occur from immobilization, like atrophy, arthrofibrosis, etc.
Let me ask you something. Since you started doing daily AROM as I suggested, is the finger:
1) EXACTLY the same- same pain, same motion, pain occurs at the same amount of flexion or extension?
2) WORSE- More pain, more swelling, more disability, pain occurs closer to mid-range of ROM than it used to?
3) BETTER-(even slightly better)- Same pain, but pain occurs now closer to end-range, decreased swelling?
This kind of problem can certainly take a year to resolve, and I think you'll see that answer reflected in many posts here. I think the fastest resolution comes when you protect the joint (by not climbing or strength training without a splint) but move the joint quite a bit during the day.
I know it's hard to be patient.
Let me provide an example. Lets say you broke your femur. Would you seek out a million opinions, or would you get X-rays, and get it put in a cast, so you could begin healing? Would you look for quick fixes, or would you have more contentment regarding realizing it might be six months before you could walk with only a minimal limp?
Bone is one type of connective tissue, chemically its really pretty similar to cartilage, tendon, ligament, etc, a glycoprotein matrix. It need time to heal. There is no magical stretch, supplement, surgery, etc, that will cut the time in half. Be careful, don't re-injure it.
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thegrassr00ts
Dec 22, 2008, 8:14 PM
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Hey OAH,
I'm hoping since my knowledge of anatomy is poor the pictures helped show what I was trying to explain. I would say the pain is generally the same, although it does get better after use, either stretching the forearms or after AROM. I haven't loaded the finger with my full body weight (like hanging from a crimp) in 2 months, but when I put my finger in a crimp position and push down, there is definite pain. I guess what I needed to hear is that there is a good possibility that this could take a year to heal. I've just never experienced an injury that wasn't traumatic, i.e. torn ACL, that would take so long to heal. I have full range of motion with the finger which makes me think splinting it is not the answer because I get no pain in normal every day activity. It's limited to a crimp grip, even open-handed on a little tiny hold feels perfectly normal, but if I even crimp slightly, there is definite pain localized on the knuckle. In other words, it doesn't shoot down my forearm, it just feels painful in that middle knuckle. Again, I know that my limited knowledge is not going to allow me to detect bowstringing of the tendons without a doctor and an MRI, but is a swollen middle knuckle a symptom of a pulley tear? Can I rule out a pulley tear based on the location of the swelling or is the location of the swelling inconclusive?
And in answer to your question, I would say the pain is not any better, however it seems to lessen after the joint is moved around a bit either with AROM or stretching.
(This post was edited by thegrassr00ts on Dec 22, 2008, 8:17 PM)
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esoteric1
Dec 22, 2008, 8:21 PM
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screw the finger, you need to go check the eye doctor, those pics are blurry as hell
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onceahardman
Dec 22, 2008, 8:28 PM
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A couple things...
How do you stretch forearms? I hope you don't pull your fingers back into extension, with your wrists extended. There is probably no good reason to stretch your forearms.
Stretching has a particular meaning, and use, as a therapeutic exercise. It is used to increase ROM. You probably already have too much ROM, since you have probably damaged connective tissue. You probably should not be stretching, at least not your fingers and wrists.
Please don't keep testing your crimp, to see if it still hurts.
A painful crimp is a pretty good indicator of a pulley strain, but it is not definitive. Perhaps you only strained it on the lateral side, and that's where you are getting the inflammation, swelling, and pain.
Surgery or not, crimping just isn't the greatest thing, biomechanically, for your pulleys. You could have it surgically repaired, go through the same 6-12 months of rehab, and then tear it again first time out.
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thegrassr00ts
Dec 22, 2008, 8:39 PM
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I don't stretch my fingers, I do a yoga pose called prayer position. Fairly self-explanatory, put your hands as if you were praying and lift your elbows up while pushing your hands together, it really helps to loosen up the forearms. One of my friends recommended theraputty from when he injured a finger, so thats where I've been testing it, no dead-hangs or any serious load bearing, but I'll try to resist the temptation. Trust me, if there's one thing I've learned from this whole experience, it's not to crimp, and from now on, if I can't do it open-handed, I can't do it at all. I think a lateral pulley strain sounds accurate, because there's no instability in the finger which I've read is indicative of a pulley strain and from my understanding a stress fracture would be causing me a lot more pain, not just crimp specific pain. Anyways, after the criticism on my photography I'm going to try and take some less blurry pictures. Thanks for all your help OAH, I know your in a weird spot trying to give medical advice over the internet through poor descriptions and blurry pictures. I think the hardest part of this diagnosis is just to accept that I may not be ready for spring...I'll try to get those pictures up soon.
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thegrassr00ts
Dec 22, 2008, 9:24 PM
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So they're still blurry as hell for sure, but the first two you can see the swelling on the middle knuckle of my ring finger, and the next three are the uninjured finger and you can the swelling in comparison.
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mturner
Dec 23, 2008, 7:19 AM
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rockforlife wrote: thegrassr00ts wrote: So they're still blurry as hell for sure, but the first two you can see the swelling on the middle knuckle of my ring finger, and the next three are the uninjured finger and you can the swelling in comparison. Sorry man but you SUUUUUCK at taking pic's, you should stick to climbing, or maybe not 
Seriously, we even gave you a second chance.
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esoteric1
Dec 23, 2008, 7:43 AM
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i had a finger injury a long time ago, it got pinched in a sharp bottleneck, it went numb for over a week, so i came on here and someone told me to dip it in cider, repetitively.
never had a problem since, who would a thunk
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boracus
Dec 23, 2008, 6:07 PM
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G-
I'll second OaH's opinion, it's just going to take awhile to heal. I've personally delt w/ finger injuries that took a year to heal and have been dealing w/ one for about 5 months now.
For my 2 cents worth, I seriously doubt that it's one of the pulleys (either the annular or cruciate ligaments) I would go w/ a collateral lig injury or a strain of the either the lumbrical or dorsal interossei muscles.
I have no proof, this is only a theory from personal experience and observation. I believe that some climbers are more prone to injuring their PIP joint region (any of the following structures: PIP joint capsule and collateral ligs, the tendinous slips of the dorsal or palmar interossei or lumbrical muscles) because of the structure (length of bones and general configuration of their hands) of their hands.
A lot of times when we climb were not simply pulling straight down on a hold. Especially in a traversing situation we use our hands to pull and push us sideways. It may not seem like much but you're putting a significant amount of stress on the PIP joint at these times. It creates a slight torquing effect on the PIP joint as the fingertips are "anchored" on the hold and the rest of the hand is being either pulled or pushed away from the stationary point of the fingertips. So when you're in the crimp position you get somewhere around a 90deg angle at the PIP joint which creates a nice levering effect on that joint putting significant torsional stress on the PIP joint structures.
So that's my theory on how climbers end up w/ these seemingly bizzare, nagging finger pains at the PIP joint that take forever to heal up... I guess what you'd like now are some suggestions on what the hell you can do about it?
I definitely agree w/ Once here, you've got to back off enough to not re-injure the affected area. It sounds like you can do most of your daily routine and even climb in some hand positions w/ out causing it to hurt. You're going to have to stay w/ this routine until you feel like you can move on to the next step in the progression of getting back to where you can start using a non stressful crimp position. This might be using large crimps to start w/. I'd be curious to know, if you're game for a little experiment, if it's not so much the size of the crimp but more whether you have to pull or push sideways on a crimp that causes the most pain.
Like I said this is only my own theory and I can't say that I would really advise you to try crimping at all until you're damned sure that you can crimp w/ out causing a re-injury. If you can climb on other holds w/ out pain than I'd say stay there and enjoy being able to climb at all and focus on some other aspect of your climbing (like different footwork techniques such as bicycle moves, heel hooks, inside/outside flags...etc.) I'd also be a little wary of pinch grip holds since these can also be taxing on the PIP joints.
As far as therapy it sounds like you've got a good routine. If you're looking for some specific hand stretching ideas there are some good ones listed in "One Move Too Many" but be careful when stretching injured tissue, getting full ROM back is necessary but will take time, the stretches might feel a litte stiff or uncomfortable but shouldn't cause pain.
The only other suggestion I would throw out there for you to try is some strengthening of the hand. Again this might be too much right now and you may be risking pronlonging the injury, however, if you want to get back to being able to crimp at your pre-injury ability level you'll have to strengthen that fnger at some point.
For lack of a better description I use the term Submersion Exercises: basically the old school technique of filling a container w/ dried beans, rice, sand etc and submerging your hand in the container and simply moving your hand and fingers through a full ROM while the substance provides resistance. Just to give you an idea of difficulty, if you have a container that you can get your forearm submerged to the wrist and fill it w/ rice it provides a substantial amount of resistance. Depending on how well your hand is doing you may want to start w/ something like pinto beans instead.
Hopefully you've got some ideas on where you stand and what the rehab/recovery process ahead looks like. As far as the concern on the swelling: even a little adema in the fingers can create an obvious deformity. Also if you've caused some damage to the structures surrounding the PIP joint you may have some fascial thickening/ scar tissue that may be remodeled and taken care of or may remain permanently as a result of the initial injury. If it's not causing problems after you've completely recovered and have your ROM and strength back there's nothing to be concerned about, it may look different but shouldn't be anything more than that.
Good luck and I hope that you find the patience to let your finger heal up so you can get back to where you want to be.
cheers, BA
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thegrassr00ts
Dec 23, 2008, 6:31 PM
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So to put an end to the speculation for those of you who care, after hearing the multiple opinions I got on a few different websites and talking to Dr. J from Rock and Ice, I got some fancy pictures taken (MRI) and went to the orthopedist. He a very interesting explanation as to why my symptoms (Swollen knuckle) didn't really match up with the location of the pain. Well, he informed me, that I severely strained, although did not tear my collateral ligament. Since, the injury occurred about three months ago, the reason for the swelling is scar tissue and there is no pain there. However, he then also told me I had a full rupture of the A2 pulley, so the swelling was from a different injury than what was causing me the pain. Either way its going to be a long, hard road before I get back onto the rock. Thanks to everyone who tried to help and for putting up with my atrocious pictures. A note to anyone who is looking for injury advice and is reading this post, do yourself a favor and just climb open-handed. This injury is not worth the small percentage of strength you gain from crimping. Anyways, the doc told me climbing open handed should be fine, and to stay off anything I couldn't climb completely open-handed for a while, and with six months of what he called "climbing rehab," that is climbing nice juggy or slopey routes with my pulley nice and taped, I should be alright.
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boracus
Dec 23, 2008, 6:42 PM
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G-
Sorry to hear that the damage is a little more extensive than it seemed. Glad to hear that you're getting taken care of and thanks so much for following up and posting the MR results. I woudn't have guessed a complete A2 rupture but I'm certainly not always right.
Good luck w/ the road back to being 100% and it's good to hear that your ortho has you climbing during the recovery.
cheers, BA
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onceahardman
Dec 23, 2008, 8:22 PM
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Hi grassroots...
Well, I'm glad you had the MRI done, at least you have the diagnosis you were seeking.
A couple things:
1) In your second post above, yesterday 12/22, you said it was about two months since the injury occurred. Today, 12/23, its 3 months. Assuming 3 months is correct, 3+6 = 9 months from injury date to crimping again, according to the MD, (assuming no re-injury). Hopefully that is fairly accurate.
2) This thread is another good illustration of a general concept. It is not always necessary to have a super-accurate diagnosis to design a suitable treatment plan. The treatment plan I recommended, for example, would remain exactly the same today as yesterday. As it begins to improve I'd add strengthening exercises, but IMO it's not appropriate yet.
It helps to determine a few things-
-Stage of healing- acute, sub-acute, or chronic.
-Type of tissue involved- contractile (tendon/muscle);
passive restraint (ligament/capsule/pulley/);
Bone;
nerve;
joint component (articular cartilage, also, I and some others consider bursa in this category).
BTW, you mentioned doing friction massage. My opinion is, it's too soon for that. You need more scar tissue first.
I wish you well, grassroots. Please stay in touch, and feel free to ask me anything you want. Thanks for making the effort at learning.
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thegrassr00ts
Dec 23, 2008, 8:55 PM
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3 months since the injru occured, 2 months since I realized the injury was serious and stopped climbing completely.
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gunkiemike
Dec 27, 2008, 11:47 PM
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Totally anecdotal $0.02 here... I had similar swelling on the knuckles closer to the fingertips. Too much small hold play in the gym. Just overuse strain, and after my consult with the Dr., I told myself to stick with bigger holds and steeper terrain, and the prob has never returned. For me, an "interesting" characteristic was that wiggling the fingertip sideways (within the plane of a flat hand) would be very painful. Zipping a jacket zipper was out of the question for a while.
The swelling is still there but pain is gone and function is 100%. There's plenty of time to test myself on thin crimps outdoors in the summer; "training crimps" in the gym was, for me, a bad idea.
Data point, look at that pic of Hans Kraus. Dude's knuckles look like an oak tree.
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thegrassr00ts
Dec 30, 2008, 9:58 PM
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Hey OAH,
Had a couple of questions for ya. After the injury when I would push my fingers to full extension, the injured finger kind of pointed at a weird angle, and just didn't follow the same path of extension as the uninjured finger. Now, the finger feels "tighter" for a lack of a better term, and when both the injured finger and uninjured one are in full extension, they look identical. I'm wondering if this is a result of some tendons and/or pulleys healing, as in they've reattached themselves and now the finger is behaving more like a normal finger? Just wondering.
Next, the collateral ligament injury I sustained is still really swollen, and the doc said not to really worry about it, it's just a lot of scar tissue. Well I'm wondering if I should be worried, and what I can do to reduce the inflammation. Finally, I was wondering what experience you have with Power Putty. I picked some up at EMS a few days back and it seems to working miracles. I use it resist extension and flexion, as well simply squeezing it to keep the blood flowing to the finger. Wondering what your experience with it has been.
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onceahardman
Dec 30, 2008, 10:56 PM
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grassroots,
Healing is a wonderful thing. It's expected that joints will track better as the passive restraints heal.
I agree, don't worry about the scar tissue lump, unless you are a hand model or something. Scar tissue is your friend at this point.
If you were in my clinic, I'd have had you strengthening with putty, rubber balls, etc. I'm glad it is going so well for you.
(This post was edited by onceahardman on Dec 30, 2008, 10:58 PM)
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