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Jnclk


Dec 13, 2011, 5:17 AM
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A3 pulley
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I'm posting up an exchange between OAHM and myself regarding a pulley injury.

I've read the forums and web articles and was hoping you could provide some additional insight.

I sustained an injury to what I suspect is my A3 pulley on my ring finger this past weekend. A3 is at the PIP joint, right? Limited, but some swelling, no pain at rest, and it didn't hurt when it happened. However, I heard a pop which was about as loud as 'normal' cracking of the fingers (not that loud, but certainly audible). It is sensitive to firm pressure, no problem with extension, can make a fist (but not tight), and I'm avoiding resisted flexion as this produces discomfort. Passive ROM is okay, active ROM to a tight fist is not.

After all that, my question is in determining the grade/severity of injury. Is bowstringing the determing factor in diagnosing a grade III rupture or is it the presence of the 'pop' noise, or both? I've seen pictures of bowstringing and as far as I can tell I do not have any.

I'm icing and resting for now. Seems like the protocol for the first 1-2 weeks?

As always, your replies are greatly appreciated. If I've butchered any medical terminology I apologize.

-Jon

To which OAHM replied;

There is no reliable way to differentiate A2 from A3 tears without imaging. Bowstringing is much more reliable than hearing a pop. Lots of reasons for popping joints, but really, only one reason for bowstringing.

Keep in mind, the amount of bowstringing is VERY small. You are looking for 1mm of motion occurring under perhaps 5 mm of soft tissue. It is slight. Have a look at this article:

http://radiology.rsna.org/content/222/3/755.full


Jnclk


Dec 13, 2011, 6:11 AM
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Re: [Jnclk] A3 pulley [In reply to]
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Isn't the A3 above the PIP (second knuckle) and the A2 below the PIP and closer to the base of the finger? My sensitivity is above the PIP. It would seem to point to A3, no?


(This post was edited by Jnclk on Dec 13, 2011, 7:50 AM)


Partner cracklover


Dec 13, 2011, 8:52 AM
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Re: [Jnclk] A3 pulley [In reply to]
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What's where -> http://www.wheelessonline.com/image2/phl3.jpg

What you need -> http://www.amazon.com/...323794944&sr=1-1

My experience and what I learned from it -> http://www.rockclimbing.com/...4;page=unread#unread

Good luck!

GO


Jnclk


Dec 13, 2011, 10:09 AM
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Re: [cracklover] A3 pulley [In reply to]
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I've already got that book. Having previously read the section on pulley injuries, I had a good idea of what happened as soon as it happened. I've also read Macleod's postings on the topic. At this point, I'm resting and moving forward with the idea that a pulley injury is the problem.

What I'm having some difficulty with is in determining the severity of the rupture. With your most recent pulley injury, you mentioned that bowstringing was visible. How obvious was it? Did you have to go into flexion against resistance to see it or could you see it simply by flexing your finger? I'd rather not put my finger into flexion against resistance at this point since the injury is only a few days old. However, aside from some minor swelling above the the PIP joint I don't see much difference from my other fingers when in the flexed position.

Thanks for the reply.

-Jon


Partner cracklover


Dec 13, 2011, 10:25 AM
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Re: [Jnclk] A3 pulley [In reply to]
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Jnclk wrote:
I've already got that book. Having previously read the section on pulley injuries, I had a good idea of what happened as soon as it happened. I've also read Macleod's postings on the topic. At this point, I'm resting and moving forward with the idea that a pulley injury is the problem.

Then you should know that your course of action is the same, whether you had a full or partial rupture.

In reply to:
What I'm having some difficulty with is in determining the severity of the rupture. With your most recent pulley injury, you mentioned that bowstringing was visible. How obvious was it? Did you have to go into flexion against resistance to see it or could you see it simply by flexing your finger? I'd rather not put my finger into flexion against resistance at this point since the injury is only a few days old. However, aside from some minor swelling above the the PIP joint I don't see much difference from my other fingers when in the flexed position.

The only way I could see the bowstringing was by flexing under tension, yes. I could also feel that the tendon bowstringed more than the same finger on the other hand. But it was pretty subtle. And I only did it a few times within the first few days, for obvious reasons.

In reply to:
Thanks for the reply.

-Jon

Happy to provide whatever help I can.

GO


Jnclk


Dec 13, 2011, 1:21 PM
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Re: [cracklover] A3 pulley [In reply to]
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After seeing a knowledgable doc today and armed with my own research it looks like it's my A4 (and not A3) on my left ring finger. He saw no bowstringing during resisted flexion. No suspected A2 and/or A3 involvement. It's either a full or partial tear. Imaging would be the only way to know for sure. However, imaging doesn't change the recovery protocol. Looks like it's time for some house projects.


Partner cracklover


Dec 13, 2011, 1:52 PM
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Re: [Jnclk] A3 pulley [In reply to]
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Jnclk wrote:
After seeing a knowledgable doc today and armed with my own research it looks like it's my A4 (and not A3) on my left ring finger. He saw no bowstringing during resisted flexion. No suspected A2 and/or A3 involvement. It's either a full or partial tear. Imaging would be the only way to know for sure. However, imaging doesn't change the recovery protocol. Looks like it's time for some house projects.

Good luck. I know how it goes. You'll be back.

One other thing - since you mentioned house projects. I'd suggest using some kind of splint that supports/protects those pulleys whenever you're doing anything that could either stress or impact them, like swinging a hammer or picking up a heavy object. Lemme know if you want, and I can send you pics of what I fashioned. Although I'm sure you could buy a much fancier version.

Cheers,

GO


onceahardman


Dec 13, 2011, 2:34 PM
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Re: [Jnclk] A3 pulley [In reply to]
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Look at the second picture in this article:


http://emedicine.medscape.com/...6-overview#aw2aab6b5

If anybody could blow that picture up, and put it on here, that would be great. I've had it on here before (in various forms) and have suggested it be made a "sticky" for future research purposes.

Ultimately, though, as you have found out, it doesn't matter. All conservative (ie non-surgical) treatment will be the same, regardless of which pulley is injured.

Good luck, read the article too. Keep the fingers moving, to maintain motion and supply nutrition.


Partner cracklover


Dec 13, 2011, 3:41 PM
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Cheers,

GO


onceahardman


Dec 13, 2011, 6:47 PM
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Re: [cracklover] A3 pulley [In reply to]
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Thank you. I wonder if any mods would consider making this sticky?


Jnclk


Dec 14, 2011, 5:11 AM
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cracklover wrote:
Good luck. I know how it goes. You'll be back.

One other thing - since you mentioned house projects. I'd suggest using some kind of splint that supports/protects those pulleys whenever you're doing anything that could either stress or impact them, like swinging a hammer or picking up a heavy object. Lemme know if you want, and I can send you pics of what I fashioned. Although I'm sure you could buy a much fancier version.

Cheers,

GO

I've got a aluminum-foam splint which I've been wearing while working on the house. The injury is on my non-dominant hand. I've also been wearing it while sleeping.

As far as injuries go, this isn't that big of a deal. It doesn't hurt at rest. I can start climbing easy stuff in about a month. So aside from a break from climbing which the rest of my body will appreciate it's not all that bad.

As far as climbing easy, last year I had a RC strain from a skiing accident. Instead of not climbing at all, I just TR'd stuff while only using my good arm. Obviously overhanging routes were out, but I was climbing 5.10 slab to vert clean. It made the transition back to harder (for me) climbing pretty smooth.

By the way, the anatomical pic below as well as the one in the link you provided above are excellent. It makes it very clear what is where. What I'd been looking at previously led me to believe it was my A3.


Partner cracklover


Dec 14, 2011, 8:45 AM
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Out of curiosity, do you know what you did that caused the injury?

GO


Jnclk


Dec 14, 2011, 9:55 AM
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cracklover wrote:
Out of curiosity, do you know what you did that caused the injury?

GO

I was crimping (big surprise) on a fingery route and heard a pop. I was pretty surprised because my foot didn't slip, but I was in a tenuous and awkward position and it was cold out.


Jnclk


Dec 15, 2011, 8:03 AM
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When it was time for the therapy stage what did you do? The "One Move..." book doesn't detail what to do. From what I've gathered elsewhere it seems to be squeezing putty, massage, and gentle stretching.. At what point did you start, two weeks out?


Partner cracklover


Dec 15, 2011, 9:00 AM
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3 phases for me:

1st -Assisted range of motion stretches,
2nd - stretching out and in (full open hand to fist (or as close to a fist as I could get without pain)) unassisted by the other hand,
3rd - Finally - resisted range of motion, via H-Taping and a Grip Master Hand-exerciser.

I was able to start phase 3 about a month post-injury.

At first I couldn't use the last phalanx of the injured finger with the grip-master thing. That took another month or more, IIRC.

Here's what OAHM suggested:

onceahardman wrote:
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.


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