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Agilis


May 24, 2011, 8:56 AM
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Need advice - Injured right ring finger - Full ROM
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Hello everyone,

I've been climbing for 2 years now & recently I injured my right ring finger - about 4 weeks ago. I was climbing a problem and climbed it too many times and ended up injuring my finger on one of the holds - If I were to guess I would say it was a 3 finger pocket hold. I didn't realize this practice, where I kept climbing the same route over and over, was bad. This is my first injury I have sustained from climbing. At the time of the injury, I never had any noticeable swelling and thought it was extremely minor and something not to worry about. When I tried to climb at my next session, I had sharp pains when I tried to climb on certain holds. This pain would extend down through the finger, and into the palm. I took that as a sign that I need to stop and a friend/experience climber recommended I take 600mgs of ibuprofen every 4 hours, 4 times a day for 3 days. During this time, I did ROM exercises but never had any ROM problems. I could move my fingers, in every direction, make a semi tight fist without any discomfort.

After 1 solid week off, I was climbing at a low level with hardly any pain with my finger taped. I could feel some pain but it was manageable. I took more & longer breaks between sends but soon as I tried to climb anything with crimps or difficult, the pain would be localized to my ring finger, and it was not manageable. I have been doing cool water baths with 55 degree ice water for 30 minutes, twice a day, but because of my schedule, I'm not able to do this nearly as often I should. I do get the 'Lewis Reaction' and my hand becomes pink so I know I am getting the blood flow needed.

Well, it's been about 4 weeks, climbing sporadically, and tried to climb last night with my finger taped, both buddy and for support, and certain jugs just caused too much pain to my finger. I'm scheduled to see my Doctor at the end of the week and would like some advice on what I could tell the doctor, etc. Since I lack any experience of this type of injury, I'm going in blind. The only place/time I feel significant pain is when I firmly squeeze on the top and bottom section between my middle knuckle and first knuckle. There is slight pain behind the middle knuckle but not nearly as noticeable as the other section. I still have full ROM and have no problems doing push-ups both - closed fist or open handed.

Thank you in advance and I apologize for the length of the post.


altelis


May 24, 2011, 1:35 PM
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Re: [Agilis] Need advice - Injured right ring finger - Full ROM [In reply to]
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It sounds like a pulley tear.

Look online here, there is a lot of information on pulley tears and treatment information.

Most people I know who've torn pulleys need to take about a month off, completely, and then come back slowly.

A couple things to think about:
1) If you aren't haven't any noticeable swelling, taking ibuprofen, especially that much, make lengthen recovery.

2) Buddy taping is not going to actually give the support your pulley needs, at all. Tape around the segment of your ring finger that hurts, only on that finger, as tight as you can without cutting off circulation.


Agilis


May 24, 2011, 1:48 PM
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Re: [altelis] Need advice - Injured right ring finger - Full ROM [In reply to]
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Thank you for your reply altelis.

Things to mention: I only took the ibuprofen for the first week that I was initially injured. I have since been off of it.

Again thanks for your advice. I will browse here looking for more information, but sometimes it's hard to find what you need when the symptoms of almost every injury read as being similar.


altelis


May 24, 2011, 1:50 PM
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Re: [Agilis] Need advice - Injured right ring finger - Full ROM [In reply to]
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I totally hear you- easier to look for info if you have an injury name rather than a list of symptoms.


onceahardman


May 24, 2011, 6:50 PM
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Re: [altelis] Need advice - Injured right ring finger - Full ROM [In reply to]
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I agree, likely pulley strain, maybe with some lumbrical involvement, given the palm pain.

These can be 1-6 months, and sometimes they never get back to truly 100%. The injury is almost unknown outside of the rockclimbing community, so you may see some frustration as you seek out doctors who are familiar with the injury.

Keep it moving. AROM.

I'd like to see a study, that compared between groups. One group doing dedicated AROM. Next doing AROM with 55 deg. Lewis reaction baths. Next group doing the baths only.

My admittedly biased opinion would be...AROM group showing faster healing than cold bath group, with a statistically insignificant difference between AROM, and AROM plus bath groups. But I'd like to see the study.


(This post was edited by onceahardman on May 24, 2011, 6:51 PM)


Agilis


May 25, 2011, 7:47 AM
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Re: [onceahardman] Need advice - Injured right ring finger - Full ROM [In reply to]
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I think the palm twinge/twang I felt was simply the fact I pulled on the A4 pulley when I first injured it not realizing the extent of the injury. This palm twinge has not been felt since and it's been 4 weeks.

I'm going to be doing AROM, just out of habit, might purchase some putty, but will be doing extremely light climbing as I back off from my climbing. I do subscribe to the theory that it's better to lightly climb then not climb at all because as logic would suggest, the new tissue needs to know it will have stress placed upon it so as the new tissue develops, it is strengthened.

When I go to the doctor's this Friday, if he cannot put me in contact with anyone who deals with climbing injuries/finger injuries I will take it upon myself to follow a strict regimen as follows:

Cool water baths as often as I can without over doing it.
AROM which will involve light climbing, to the point where after I warm up - My session is over. Still deciding on taping because the tightness I would need to achieve with the tape would no doubt cut circulation.

I don't mind taking a couple months off because it gives me a chance to weight train instead - Doing pull-ups and push-ups among other exercises yields no pain in my finger. As long as I can do that, my hopes are up.

Quick note: The 55 degrees was the temperature I found to work the best. After some research on the Lewis Reaction, it was said that the skin needs to be at 15 degrees Celsius, 59 degrees Fahrenheit in order for the Lewis Reaction to occur. So to achieve this, I'm filling a bucket up with tap water set to the coldest, which comes out at an even 60 degrees Fahrenheit and toss in about 10-12 ice cubes until the water drops to about 55-57. I believe I'm achieving the Lewis Reaction because my right hand becomes very pink, and the water no longer feels as cold as it was when it started, even though the water temp is still the same. My hand doesn't feel flush, then again I don't know what that even feels like.


Partner cracklover


May 25, 2011, 10:03 AM
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Re: [Agilis] Need advice - Injured right ring finger - Full ROM [In reply to]
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I had a partial pulley tear, and I'm sorry to say, the medical establishment was entirely useless in diagnosis and treatment.

I wound up having to do all the research and treatment myself. The most useful single element was a book called "One Move Too Many". I cannot recommend it enough. By itself it was not everything, but it had tons of useful info and contained all I needed to search for further data on the internet.

I was in my mid 30s when it happened, so if you are younger, you may heal a lot faster. For me, it took a full year to be back to 100% of where I was before the tear, and a few years more before I could stop taping entirely.

Get the book, and stop climbing for now, or if you do climb, don't use that finger at all. (At the beginning, the only time I would climb would be if I taped my bad finger to my palm and dropped six number grades).

I'm not saying you shouldn't see a doctor. It's worth it just to rule out something like a stress fracture or tumor or something. And if you have access to a doctor with experience with climbing injuries, definitely make the extra effort to see that person.

GO


Agilis


May 25, 2011, 10:19 AM
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Re: [cracklover] Need advice - Injured right ring finger - Full ROM [In reply to]
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I'm 30 and in good health and hoping I'll heal fast enough where I can climb at the level before I got injured. I don't want to be out a year because of a pulley strain.

If I go to a doctor and he recommends an MRI, will the MRI be able show the difference between a tear and a strain?

What were the treatments you ended up following?


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May 25, 2011, 10:48 AM
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Re: [Agilis] Need advice - Injured right ring finger - Full ROM [In reply to]
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Agilis wrote:
I'm 30 and in good health and hoping I'll heal fast enough where I can climb at the level before I got injured. I don't want to be out a year because of a pulley strain.

If I go to a doctor and he recommends an MRI, will the MRI be able show the difference between a tear and a strain?

What were the treatments you ended up following?

I didn't say I was out for a year. I said it was a year before I was back to 100% of where I was pre-injury. You can't force your body to heal faster than it does.

An MRI will clearly show a full rupture of either pulley or tendon, but that would be fairly clear through other diagnostics. For less than a full rupture, OAH could say better than me, I'm sure, but my guess is that it depends on a lot of factors, including the degree of damage, how long between the initial injury and when the MRI is done, and who's looking at the images. In my case, by the time the MRI was done, the doctors saw nothing.

My treatment was first to back off climbing for a while and consult doctors. Then, once I had self-diagnosed myself, I stopped climbing entirely. Then I returned to climbing but did not put any weight on that finger. I gradually brought it back into climbing, while using less and less pulley-supportive taping methods. Oh, and I'll add that I also did some mild massage of the area.

GO


(This post was edited by cracklover on May 25, 2011, 2:33 PM)


onceahardman


May 25, 2011, 2:23 PM
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Agilis, what I say might be construed as insulting. I assure you, I don't mean it that way.

First, a strain IS a tear. By definition. A grade III strain is a complete tear.

Next, what you said above regarding AROM and climbing, and continuing climbing as your AROM. This really shows you don't know what AROM means. No offense, you just don't know.

There are two types of ROM...Active (AROM), and Passive (PROM)

Passive Range Of Motion (for fingers) is using the other hand, or another person, to move the joint(s) within the available range. The purpose is to maintain health of joint surfaces, and to maintain health of soft tissue around the joint. The purpose is NOT to increase range of motion, since you only move the joint within the available range.

STRETCHING is moving a joint beyond the available physiological range. It's purpose is to increase ROM.

Active Range Of Motion- is using one's own muscles to move a joint within the available range. It does everything that PROM does, but adds on active muscular contraction, so it will increase blood flow to muscles (etc.) much more than PROM will.

Resistive exercise- is adding resistance to normal physiological motions so as to provide a strengthening effect.

Climbing easy routes is therefore resistive exercise (as far as your finger tendons are concerned), not AROM. AROM is a safer option for early rehab of this injury. Once you are pain free, and not inflamed, you can start very gentle resistive work. You can do this however you want, but if you were my patient, I'd have you proceed in a more controlled fashion than even easy climbing.


(This post was edited by onceahardman on May 25, 2011, 2:26 PM)


Partner cracklover


May 25, 2011, 2:49 PM
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onceahardman wrote:
Once you are pain free, and not inflamed, you can start very gentle resistive work. You can do this however you want, but if you were my patient, I'd have you proceed in a more controlled fashion than even easy climbing.

Out of curiosity, and in case I ever get another pulley tear...

2 questions:

1 - How do you define the point where you are pain free and the swelling has gone down? In my case, IIRC, I had very little swelling, and the pain was mostly present with climbing or direct pressure.

2 - Until that point, would you recommend trying to brace/immobilize that finger?

Thanks,

GO


Agilis


May 25, 2011, 3:00 PM
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Thanks for your reply.

No, not insulting at all. Like you said I simply do not know.

Now if light climbing is not the way to go, why do so many sources I've read say that taking long lay offs from climbing can actually do more harm than good. Reason being, the new tissue is not put under any stress and injuring the new tissue once healed will be even easier?

Thanks for your advice and look forward to your reply.


onceahardman


May 25, 2011, 3:10 PM
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Re: [cracklover] Need advice - Injured right ring finger - Full ROM [In reply to]
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cracklover wrote:
onceahardman wrote:
Once you are pain free, and not inflamed, you can start very gentle resistive work. You can do this however you want, but if you were my patient, I'd have you proceed in a more controlled fashion than even easy climbing.

Out of curiosity, and in case I ever get another pulley tear...

2 questions:

1 - How do you define the point where you are pain free and the swelling has gone down? In my case, IIRC, I had very little swelling, and the pain was mostly present with climbing or direct pressure.

2 - Until that point, would you recommend trying to brace/immobilize that finger?

Thanks,

GO

Good questions.

For really active, acute inflammation, pain at rest is a reliable indicator. Once you reach the subacute phase, pain which occurs at loads below the normal pain threshold would be a good, but less reliable, indicator. If you are generally healthy, and don't continue injuring yourself, this subacute phase should gradually decline over time.

Swelling can be measured with a tape measure, or more accurately, by measuring the volume of water displaced by (say) a finger. Again, this should improve over time.

Bracing or immobilizing can be good for certain injuries. Fractures, severe strains (ligament tears resulting in instability). I don't like immobilizing for pulley injuries UNLESS (a) you work a job where you need to use your hands a lot, and you would otherwise keep injuring it,, so you immoobilize only at work, or (b), you have tried relative rest with AROM, then PROM, and you still have pain at rest, indicating an injury so severe it shouldn't be moved for a while.


onceahardman


May 25, 2011, 3:31 PM
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Agilis wrote:
Thanks for your reply.

No, not insulting at all. Like you said I simply do not know.

Now if light climbing is not the way to go, why do so many sources I've read say that taking long lay offs from climbing can actually do more harm than good. Reason being, the new tissue is not put under any stress and injuring the new tissue once healed will be even easier?

Thanks for your advice and look forward to your reply.

I really can't speak as to why other sources say anything. I'd like to read one or two of these sources, so I can understand better.

In general though, yes, first scar tissue forms, and then this scar tissue needs to be remodeled into a strong, extensible scar that more closely resembles the original tissue. Otherwise it will be weak.

I am of the opinion that for severe injuries, this tissue remodeling needs to be done in a well-controlled fashion, or else you risk re-injury. Start with gentle manual resistance, progress to putty and resistance bands, and finally, begin some easy climbing on comfy holds.

And, learn to use the open grip. Pulley injuries are more frequent when crimping.


(This post was edited by onceahardman on May 25, 2011, 3:34 PM)


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May 25, 2011, 3:35 PM
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onceahardman wrote:
cracklover wrote:
onceahardman wrote:
Once you are pain free, and not inflamed, you can start very gentle resistive work. You can do this however you want, but if you were my patient, I'd have you proceed in a more controlled fashion than even easy climbing.

Out of curiosity, and in case I ever get another pulley tear...

2 questions:

1 - How do you define the point where you are pain free and the swelling has gone down? In my case, IIRC, I had very little swelling, and the pain was mostly present with climbing or direct pressure.

2 - Until that point, would you recommend trying to brace/immobilize that finger?

Thanks,

GO

Good questions.

For really active, acute inflammation, pain at rest is a reliable indicator. Once you reach the subacute phase, pain which occurs at loads below the normal pain threshold would be a good, but less reliable, indicator. If you are generally healthy, and don't continue injuring yourself, this subacute phase should gradually decline over time.

Swelling can be measured with a tape measure, or more accurately, by measuring the volume of water displaced by (say) a finger. Again, this should improve over time.

Bracing or immobilizing can be good for certain injuries. Fractures, severe strains (ligament tears resulting in instability). I don't like immobilizing for pulley injuries UNLESS (a) you work a job where you need to use your hands a lot, and you would otherwise keep injuring it,, so you immoobilize only at work, or (b), you have tried relative rest with AROM, then PROM, and you still have pain at rest, indicating an injury so severe it shouldn't be moved for a while.

That answers question 2 - your answer would be a clear NO, if I understand you correctly (for a partial pulley tear).

For question 1 - Sorry if I wasn't clear with my question. I wasn't asking how you can tell what "phase" of pain\inflammation you're in, or how it is measured, but what exactly you mean when you say "pain free, and not inflamed". That sounds like neither acute nor sub-acute.

I mean, in an absolute sense, it took years before there was zero pain associated with the injury site, and there is still some "swelling" in the sense that the sheath/pulley is much thicker on that finger now (presumably due to scar tissue).

So you must have meant "when pain and swelling have dropped to ____________". I'm asking about how to fill in the blank. Is it when the pain and swelling is sub-acute? If so, then that means pretty much immediately, in my case.

Thanks again,

GO


onceahardman


May 25, 2011, 4:00 PM
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cracklover wrote:
onceahardman wrote:
cracklover wrote:
onceahardman wrote:
Once you are pain free, and not inflamed, you can start very gentle resistive work. You can do this however you want, but if you were my patient, I'd have you proceed in a more controlled fashion than even easy climbing.

Out of curiosity, and in case I ever get another pulley tear...

2 questions:

1 - How do you define the point where you are pain free and the swelling has gone down? In my case, IIRC, I had very little swelling, and the pain was mostly present with climbing or direct pressure.

2 - Until that point, would you recommend trying to brace/immobilize that finger?

Thanks,

GO

Good questions.

For really active, acute inflammation, pain at rest is a reliable indicator. Once you reach the subacute phase, pain which occurs at loads below the normal pain threshold would be a good, but less reliable, indicator. If you are generally healthy, and don't continue injuring yourself, this subacute phase should gradually decline over time.

Swelling can be measured with a tape measure, or more accurately, by measuring the volume of water displaced by (say) a finger. Again, this should improve over time.

Bracing or immobilizing can be good for certain injuries. Fractures, severe strains (ligament tears resulting in instability). I don't like immobilizing for pulley injuries UNLESS (a) you work a job where you need to use your hands a lot, and you would otherwise keep injuring it,, so you immoobilize only at work, or (b), you have tried relative rest with AROM, then PROM, and you still have pain at rest, indicating an injury so severe it shouldn't be moved for a while.

That answers question 2 - your answer would be a clear NO, if I understand you correctly (for a partial pulley tear).

For question 1 - Sorry if I wasn't clear with my question. I wasn't asking how you can tell what "phase" of pain\inflammation you're in, or how it is measured, but what exactly you mean when you say "pain free, and not inflamed". That sounds like neither acute nor sub-acute.

I mean, in an absolute sense, it took years before there was zero pain associated with the injury site, and there is still some "swelling" in the sense that the sheath/pulley is much thicker on that finger now (presumably due to scar tissue).

So you must have meant "when pain and swelling have dropped to ____________". I'm asking about how to fill in the blank. Is it when the pain and swelling is sub-acute? If so, then that means pretty much immediately, in my case.

Thanks again,

GO

I think you are really looking for a black-and-white answer to kind of a "gray" question.

Acute inflammation is characterized by pain at rest, swelling, redness, and heat. (Dolor, Tumor, Rubor, Calor, first characterized by Hippocrates) It is believed to be caused by the presence of intracellular fluids released by cellular damage into extracellular spaces, where it comes into contact with nerves, causing pain at rest.

Subacute inflammation occurs afterward, and is characterized by a decreased threshold for nerve cells to register pain, i.e., you will have pain with relatively minor forces applied to structures, which when uninjured, would not cause pain. It is indefinite in terms of how long it lasts, exactly, and perhaps could have contributed to your pain of several years.

The final phase is the chronic phase, at which point healing has pretty much ceased, although some remodeling will still occur.


There really probably isn't a satisfactory answer to your question, other than perhaps, "when the pain and swelling have dropped to the point that you can no longer tell an injury occurred". For many severe injuries, there will be permanent effects, and sometimes, permanent pain. There is such a thing as a career-ending injury.

As far as your increased thickness at the pulley, it's not really swelling, but scar tissue, as you surmise. It is probably a permanent reminder of your injury, Scar tissue is how we heal, and in the early stages of healing, scar tissue is your friend, your want to let it form.


cacalderon


May 25, 2011, 5:01 PM
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Sounds like a tear.

My advice: months of rest (rest = no climbing).


Agilis


May 25, 2011, 7:41 PM
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onceahardman wrote:
Agilis wrote:
Thanks for your reply.

No, not insulting at all. Like you said I simply do not know.

Now if light climbing is not the way to go, why do so many sources I've read say that taking long lay offs from climbing can actually do more harm than good. Reason being, the new tissue is not put under any stress and injuring the new tissue once healed will be even easier?

Thanks for your advice and look forward to your reply.

I really can't speak as to why other sources say anything. I'd like to read one or two of these sources, so I can understand better.

In general though, yes, first scar tissue forms, and then this scar tissue needs to be remodeled into a strong, extensible scar that more closely resembles the original tissue. Otherwise it will be weak.

I am of the opinion that for severe injuries, this tissue remodeling needs to be done in a well-controlled fashion, or else you risk re-injury. Start with gentle manual resistance, progress to putty and resistance bands, and finally, begin some easy climbing on comfy holds.

And, learn to use the open grip. Pulley injuries are more frequent when crimping.

Thank you everyone for your replies and advice, really appreciate it.

The source that first gave me insight is here:
http://onlineclimbingcoach.blogspot.com/2010/05/pulley-injuries-article.html

This source and another source,
http://www.climbinginjuries.com/page/fingers

Share the same opinion. These links are given so you can read them since you mentioned you were interested in them.

I have adjusted my recovery regimen. It will consist of:

- Pulls ups w/ different grips and push ups
- General exercise
- Plenty of rest
- Sporadic climbing**

**Only climbing I will allow is climbing that allows virtually no stress on my right ringer finger's A4 pulley and will be once a week.

If my doctor thinks otherwise I will take his advice into consideration. It will be tough to not climb but a few months off will be good.


(This post was edited by Agilis on May 25, 2011, 8:09 PM)


onceahardman


May 26, 2011, 4:53 AM
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Agilis wrote:
onceahardman wrote:
Agilis wrote:
Thanks for your reply.

No, not insulting at all. Like you said I simply do not know.

Now if light climbing is not the way to go, why do so many sources I've read say that taking long lay offs from climbing can actually do more harm than good. Reason being, the new tissue is not put under any stress and injuring the new tissue once healed will be even easier?

Thanks for your advice and look forward to your reply.

I really can't speak as to why other sources say anything. I'd like to read one or two of these sources, so I can understand better.

In general though, yes, first scar tissue forms, and then this scar tissue needs to be remodeled into a strong, extensible scar that more closely resembles the original tissue. Otherwise it will be weak.

I am of the opinion that for severe injuries, this tissue remodeling needs to be done in a well-controlled fashion, or else you risk re-injury. Start with gentle manual resistance, progress to putty and resistance bands, and finally, begin some easy climbing on comfy holds.

And, learn to use the open grip. Pulley injuries are more frequent when crimping.

Thank you everyone for your replies and advice, really appreciate it.

The source that first gave me insight is here:
http://onlineclimbingcoach.blogspot.com/...njuries-article.html

This source and another source,
http://www.climbinginjuries.com/page/fingers

Share the same opinion. These links are given so you can read them since you mentioned you were interested in them.

I have adjusted my recovery regimen. It will consist of:

- Pulls ups w/ different grips and push ups
- General exercise
- Plenty of rest
- Sporadic climbing**

**Only climbing I will allow is climbing that allows virtually no stress on my right ringer finger's A4 pulley and will be once a week.

If my doctor thinks otherwise I will take his advice into consideration. It will be tough to not climb but a few months off will be good.

I made your links clicky. I read the McLeod article, and enjoyed it. I don't think it's inconsistent with anything I said above. 1-3 weeks of total rest from climbing (or until the acute inflammatory phase is over), Then start rehabbing, including easier climbs with open grip.

I am of the personal and professional opinion that AROM is more effective at increasing the deep blood flow necessary for healing, and that the "flushing" effect of the Lewis reaction is really more of a subcutaneous effect. I'd like to see a comparative study.

I'll read the other article later. Thanks for supplying them.

PS...I think perhaps I communicated poorly above. When I said they can be 1-6 month injuries, that does not mean no climbing for 6 months. That means you may well have pain for 6 months, or even longer. They can be very stubborn.


(This post was edited by onceahardman on May 26, 2011, 5:08 AM)


Partner cracklover


May 26, 2011, 8:47 AM
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Re: [onceahardman] Need advice - Injured right ring finger - Full ROM [In reply to]
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onceahardman wrote:
cracklover wrote:
onceahardman wrote:
cracklover wrote:
onceahardman wrote:
Once you are pain free, and not inflamed, you can start very gentle resistive work. You can do this however you want, but if you were my patient, I'd have you proceed in a more controlled fashion than even easy climbing.

Out of curiosity, and in case I ever get another pulley tear...

2 questions:

1 - How do you define the point where you are pain free and the swelling has gone down? In my case, IIRC, I had very little swelling, and the pain was mostly present with climbing or direct pressure.

2 - Until that point, would you recommend trying to brace/immobilize that finger?

Thanks,

GO

Good questions.

For really active, acute inflammation, pain at rest is a reliable indicator. Once you reach the subacute phase, pain which occurs at loads below the normal pain threshold would be a good, but less reliable, indicator. If you are generally healthy, and don't continue injuring yourself, this subacute phase should gradually decline over time.

Swelling can be measured with a tape measure, or more accurately, by measuring the volume of water displaced by (say) a finger. Again, this should improve over time.

Bracing or immobilizing can be good for certain injuries. Fractures, severe strains (ligament tears resulting in instability). I don't like immobilizing for pulley injuries UNLESS (a) you work a job where you need to use your hands a lot, and you would otherwise keep injuring it,, so you immoobilize only at work, or (b), you have tried relative rest with AROM, then PROM, and you still have pain at rest, indicating an injury so severe it shouldn't be moved for a while.

That answers question 2 - your answer would be a clear NO, if I understand you correctly (for a partial pulley tear).

For question 1 - Sorry if I wasn't clear with my question. I wasn't asking how you can tell what "phase" of pain\inflammation you're in, or how it is measured, but what exactly you mean when you say "pain free, and not inflamed". That sounds like neither acute nor sub-acute.

I mean, in an absolute sense, it took years before there was zero pain associated with the injury site, and there is still some "swelling" in the sense that the sheath/pulley is much thicker on that finger now (presumably due to scar tissue).

So you must have meant "when pain and swelling have dropped to ____________". I'm asking about how to fill in the blank. Is it when the pain and swelling is sub-acute? If so, then that means pretty much immediately, in my case.

Thanks again,

GO

I think you are really looking for a black-and-white answer to kind of a "gray" question.

No, I really am not looking for a black and white answer.

What I'm looking to do is to reconcile this:

"Once you are pain free, and not inflamed.... when the pain and swelling have dropped to the point that you can no longer tell an injury occurred.... you can start very gentle resistive work. "

with this:

"I don't think it's inconsistent with anything I said above. 1-3 weeks of total rest from climbing (or until the acute inflammatory phase is over), Then start rehabbing, including easier climbs with open grip. "

Unless I'm missing something, the first would lead to no resistive training for six months or longer, while the second would wait only a couple of weeks for the same injury. That's a factor of 12 difference.

You yourself seem to recognize the issue, when you say: "When I said they can be 1-6 month injuries, that does not mean no climbing for 6 months. That means you may well have pain for 6 months, or even longer. They can be very stubborn. "

So if it can take 6 months or longer to be pain free from an injury, and you can be climbing long before the end of that time, but you don't recommend even light resistive training until you are fully pain free...

Um... what?

GO


(This post was edited by cracklover on May 26, 2011, 8:53 AM)


onceahardman


May 26, 2011, 11:09 AM
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Re: [cracklover] Need advice - Injured right ring finger - Full ROM [In reply to]
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cracklover wrote:
onceahardman wrote:
cracklover wrote:
onceahardman wrote:
cracklover wrote:
onceahardman wrote:
Once you are pain free, and not inflamed, you can start very gentle resistive work. You can do this however you want, but if you were my patient, I'd have you proceed in a more controlled fashion than even easy climbing.

Out of curiosity, and in case I ever get another pulley tear...

2 questions:

1 - How do you define the point where you are pain free and the swelling has gone down? In my case, IIRC, I had very little swelling, and the pain was mostly present with climbing or direct pressure.

2 - Until that point, would you recommend trying to brace/immobilize that finger?

Thanks,

GO

Good questions.

For really active, acute inflammation, pain at rest is a reliable indicator. Once you reach the subacute phase, pain which occurs at loads below the normal pain threshold would be a good, but less reliable, indicator. If you are generally healthy, and don't continue injuring yourself, this subacute phase should gradually decline over time.

Swelling can be measured with a tape measure, or more accurately, by measuring the volume of water displaced by (say) a finger. Again, this should improve over time.

Bracing or immobilizing can be good for certain injuries. Fractures, severe strains (ligament tears resulting in instability). I don't like immobilizing for pulley injuries UNLESS (a) you work a job where you need to use your hands a lot, and you would otherwise keep injuring it,, so you immoobilize only at work, or (b), you have tried relative rest with AROM, then PROM, and you still have pain at rest, indicating an injury so severe it shouldn't be moved for a while.

That answers question 2 - your answer would be a clear NO, if I understand you correctly (for a partial pulley tear).

For question 1 - Sorry if I wasn't clear with my question. I wasn't asking how you can tell what "phase" of pain\inflammation you're in, or how it is measured, but what exactly you mean when you say "pain free, and not inflamed". That sounds like neither acute nor sub-acute.

I mean, in an absolute sense, it took years before there was zero pain associated with the injury site, and there is still some "swelling" in the sense that the sheath/pulley is much thicker on that finger now (presumably due to scar tissue).

So you must have meant "when pain and swelling have dropped to ____________". I'm asking about how to fill in the blank. Is it when the pain and swelling is sub-acute? If so, then that means pretty much immediately, in my case.

Thanks again,

GO

I think you are really looking for a black-and-white answer to kind of a "gray" question.

No, I really am not looking for a black and white answer.

What I'm looking to do is to reconcile this:

"Once you are pain free, and not inflamed.... when the pain and swelling have dropped to the point that you can no longer tell an injury occurred.... you can start very gentle resistive work. "

with this:

"I don't think it's inconsistent with anything I said above. 1-3 weeks of total rest from climbing (or until the acute inflammatory phase is over), Then start rehabbing, including easier climbs with open grip. "

Unless I'm missing something, the first would lead to no resistive training for six months or longer, while the second would wait only a couple of weeks for the same injury. That's a factor of 12 difference.

You yourself seem to recognize the issue, when you say: "When I said they can be 1-6 month injuries, that does not mean no climbing for 6 months. That means you may well have pain for 6 months, or even longer. They can be very stubborn. "

So if it can take 6 months or longer to be pain free from an injury, and you can be climbing long before the end of that time, but you don't recommend even light resistive training until you are fully pain free...

Um... what?

GO

When you jump around and ask a different question using quotes further downthread, it's kind of like "moving the goalposts" a bit...but I think I understand what you mean. I also answered it:

In reply to:
For really active, acute inflammation, pain at rest is a reliable indicator. Once you reach the subacute phase, pain which occurs at loads below the normal pain threshold would be a good, but less reliable, indicator.

Pain at rest is a reliable indicator of acute inflammation. Pain which comes on with very minor forces can still be an indicator of acute inflammation, but is less reliable,

Let's say you sprained your ankle. A bad sprain will be red, puffy, hot, and painful, even at rest, when not bearing any weight at all through it. It might be excruciating to bear weight.

A minor sprain might well be pain free at rest, but still quite painful when bearing weight, and very painful if you loaded the sprained ligament(s).

A sprained pulley would be similar. A complete tear can be quite painful, even at rest, for several days. As it begins to heal, macrophages clean up cellular debris, and lymph carries away inflammatory chemicals, and the pain at rest goes away, but you still have pain with minor loading (either compressive or tensile). And you could be in considerable pain if you specifically load the pulley by crimping.

So, in general, when you have no pain at rest, you can start ROM. Try AROM. If AROM is painful, back off. Try PROM. If that is still painful, Continue resting.

When you have full, pain free AROM, start gentle tensile loading. Be careful you do not do this too aggressively. You do not want to make it worse, and return to an earlier inflammatory stage, characterized by pain at rest, or pain with AROM. It's OK if it hurts a bit with the loading, as long as the pain does not remain worse as a result of that loading.

Continue to prgress the intensity of the loading exercises, as long as you can do so without making it worse. remembering you need rest between sessions.

I hope that's better.


Partner cracklover


May 26, 2011, 12:11 PM
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Re: [onceahardman] Need advice - Injured right ring finger - Full ROM [In reply to]
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onceahardman wrote:
cracklover wrote:
onceahardman wrote:
cracklover wrote:
onceahardman wrote:
cracklover wrote:
onceahardman wrote:
Once you are pain free, and not inflamed, you can start very gentle resistive work. You can do this however you want, but if you were my patient, I'd have you proceed in a more controlled fashion than even easy climbing.

Out of curiosity, and in case I ever get another pulley tear...

2 questions:

1 - How do you define the point where you are pain free and the swelling has gone down? In my case, IIRC, I had very little swelling, and the pain was mostly present with climbing or direct pressure.

2 - Until that point, would you recommend trying to brace/immobilize that finger?

Thanks,

GO

Good questions.

For really active, acute inflammation, pain at rest is a reliable indicator. Once you reach the subacute phase, pain which occurs at loads below the normal pain threshold would be a good, but less reliable, indicator. If you are generally healthy, and don't continue injuring yourself, this subacute phase should gradually decline over time.

Swelling can be measured with a tape measure, or more accurately, by measuring the volume of water displaced by (say) a finger. Again, this should improve over time.

Bracing or immobilizing can be good for certain injuries. Fractures, severe strains (ligament tears resulting in instability). I don't like immobilizing for pulley injuries UNLESS (a) you work a job where you need to use your hands a lot, and you would otherwise keep injuring it,, so you immoobilize only at work, or (b), you have tried relative rest with AROM, then PROM, and you still have pain at rest, indicating an injury so severe it shouldn't be moved for a while.

That answers question 2 - your answer would be a clear NO, if I understand you correctly (for a partial pulley tear).

For question 1 - Sorry if I wasn't clear with my question. I wasn't asking how you can tell what "phase" of pain\inflammation you're in, or how it is measured, but what exactly you mean when you say "pain free, and not inflamed". That sounds like neither acute nor sub-acute.

I mean, in an absolute sense, it took years before there was zero pain associated with the injury site, and there is still some "swelling" in the sense that the sheath/pulley is much thicker on that finger now (presumably due to scar tissue).

So you must have meant "when pain and swelling have dropped to ____________". I'm asking about how to fill in the blank. Is it when the pain and swelling is sub-acute? If so, then that means pretty much immediately, in my case.

Thanks again,

GO

I think you are really looking for a black-and-white answer to kind of a "gray" question.

No, I really am not looking for a black and white answer.

What I'm looking to do is to reconcile this:

"Once you are pain free, and not inflamed.... when the pain and swelling have dropped to the point that you can no longer tell an injury occurred.... you can start very gentle resistive work. "

with this:

"I don't think it's inconsistent with anything I said above. 1-3 weeks of total rest from climbing (or until the acute inflammatory phase is over), Then start rehabbing, including easier climbs with open grip. "

Unless I'm missing something, the first would lead to no resistive training for six months or longer, while the second would wait only a couple of weeks for the same injury. That's a factor of 12 difference.

You yourself seem to recognize the issue, when you say: "When I said they can be 1-6 month injuries, that does not mean no climbing for 6 months. That means you may well have pain for 6 months, or even longer. They can be very stubborn. "

So if it can take 6 months or longer to be pain free from an injury, and you can be climbing long before the end of that time, but you don't recommend even light resistive training until you are fully pain free...

Um... what?

GO

When you jump around and ask a different question using quotes further downthread, it's kind of like "moving the goalposts" a bit...but I think I understand what you mean. I also answered it:

In reply to:
For really active, acute inflammation, pain at rest is a reliable indicator. Once you reach the subacute phase, pain which occurs at loads below the normal pain threshold would be a good, but less reliable, indicator.

Pain at rest is a reliable indicator of acute inflammation. Pain which comes on with very minor forces can still be an indicator of acute inflammation, but is less reliable,

Let's say you sprained your ankle. A bad sprain will be red, puffy, hot, and painful, even at rest, when not bearing any weight at all through it. It might be excruciating to bear weight.

A minor sprain might well be pain free at rest, but still quite painful when bearing weight, and very painful if you loaded the sprained ligament(s).

A sprained pulley would be similar. A complete tear can be quite painful, even at rest, for several days. As it begins to heal, macrophages clean up cellular debris, and lymph carries away inflammatory chemicals, and the pain at rest goes away, but you still have pain with minor loading (either compressive or tensile). And you could be in considerable pain if you specifically load the pulley by crimping.

So, in general, when you have no pain at rest, you can start ROM. Try AROM. If AROM is painful, back off. Try PROM. If that is still painful, Continue resting.

When you have full, pain free AROM, start gentle tensile loading. Be careful you do not do this too aggressively. You do not want to make it worse, and return to an earlier inflammatory stage, characterized by pain at rest, or pain with AROM. It's OK if it hurts a bit with the loading, as long as the pain does not remain worse as a result of that loading.

Continue to prgress the intensity of the loading exercises, as long as you can do so without making it worse. remembering you need rest between sessions.

I hope that's better.

Better? Hell, it's superb! Clarifies the situation, more than I thought possible. Thanks very much, I appreciate it.

GO


altelis


May 26, 2011, 5:28 PM
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Re: [Agilis] Need advice - Injured right ring finger - Full ROM [In reply to]
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Couple of random thoughts, seeing a lot's gone on since I last checked in...

1) Diagnosis. Current literature shows that ultrasound is equally sensitive as MRI for diagnosis of A4 pulley tears. HOWEVER, the caveat here is that if there isn't a pulley tear on ultrasound, the specificity is too low to be able to rule a pulley injury out. And usually the ultrasound won't be able to give any more information.

MRI is better able to rule out a tear as well as rule in or out other possible concomitant injuries as well. There are, of course, some caveats.

It needs to be a 3 tesla MRI. A "normal" MRI doesn't give enough detail for a proper diagnosis. Also, the radiologist really needs to be an orthopedic specialist. This is borne out in the literature, and my own injury is a good example. MRI initially came back clean, but my orthopedist (a hand specialist) had enough suspicion that he had a second read of the films done by a radiologist who specializes in orthopedic imaging. Sure enough, found the tear as well as a strain in the extensor tendon, both missed originally.

There's the "short" answer about imaging.

2) Something to think about with pull-ups: light climbing as a recovery method involves putting as little weight on your finger as possible. Especially in the beginning- slabby climbs, climbs with very positive feet, etc. While you don't think about pull-ups as climbing, they are, in essence, full on climbing. They are fully weight-bearing. They don't have to be full weight on the injured finger, but you'll need to be deliberate on how you hold the bar/hang-board. Don't forget that part...


Agilis


May 26, 2011, 6:04 PM
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Re: [cracklover] Need advice - Injured right ring finger - Full ROM [In reply to]
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cracklover wrote:
Better? Hell, it's superb! Clarifies the situation, more than I thought possible. Thanks very much, I appreciate it.

I agree. Judging from my own injury and what OnceAHardMan said, I have zero pain at rest, and I am at the AROM stage. I will still take a month off from any real climbing just tonbe on the safe side.

Thanks again.


Agilis


May 26, 2011, 6:14 PM
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Re: [altelis] Need advice - Injured right ring finger - Full ROM [In reply to]
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altelis wrote:
Couple of random thoughts, seeing a lot's gone on since I last checked in...

1) Diagnosis. Current literature shows that ultrasound is equally sensitive as MRI for diagnosis of A4 pulley tears. HOWEVER, the caveat here is that if there isn't a pulley tear on ultrasound, the specificity is too low to be able to rule a pulley injury out. And usually the ultrasound won't be able to give any more information.

MRI is better able to rule out a tear as well as rule in or out other possible concomitant injuries as well. There are, of course, some caveats.

It needs to be a 3 tesla MRI. A "normal" MRI doesn't give enough detail for a proper diagnosis. Also, the radiologist really needs to be an orthopedic specialist. This is borne out in the literature, and my own injury is a good example. MRI initially came back clean, but my orthopedist (a hand specialist) had enough suspicion that he had a second read of the films done by a radiologist who specializes in orthopedic imaging. Sure enough, found the tear as well as a strain in the extensor tendon, both missed originally.

There's the "short" answer about imaging.

2) Something to think about with pull-ups: light climbing as a recovery method involves putting as little weight on your finger as possible. Especially in the beginning- slabby climbs, climbs with very positive feet, etc. While you don't think about pull-ups as climbing, they are, in essence, full on climbing. They are fully weight-bearing. They don't have to be full weight on the injured finger, but you'll need to be deliberate on how you hold the bar/hang-board. Don't forget that part...

Hello there... Sure has. This topic blew up thanks to both the intelligent questions and answers posted.

1. That is kind of scary to think that if a climber experiences an injury more severe than mine, and really needs
propper diagnosis, that they might not get the correct diagnosis due ton he obscurity of these types of pulley injuries.

2. I agree with you which is why my pull-ups are being done on a bar instead of holds. The bar is always perpendicular to my grip/forearm. The contours of a lot of jugs I found irritated my A4 pulley not by pulling on it, but by the pressure being applied to it.

I appreciate the advice. I would not be doing my pull ups if I were in pain.

Thanks for your input. Tomorrow is my doctors visit and I'm armed with a wealth of knowledge thanks to everyone who participated in this thread and will reply tomorrow with a status update on how the visit went.

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