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johnr9q
Dec 12, 2008, 5:15 PM
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I sustained an injury to the metacarpophalangeal (MCP) joint of my index finger (This is at the base of the finger where the finger joins the hand) on my left hand. This occurred in August of 2008. There was no point, I can recall, where I sustained a specific injury but after climbing at Calaveras Dome on finger cracks the finger was hurting. I continued to climb and the injury would flare up after a few hours of climbing. I mostly sport climb and after climbing a few hours the finger would start swelling and hurting causing me not to be able to maintain maximum grip. I iced it and started Buddy taping it (Taping the injured finger to the adjacent finger) but the problem wouldn't go away. I have had many other finger injuries, even rupturing a tendon in one finger accompanied by a loud popping sound, but all have healed by resting, taping and anti-inflammatory. I decided I needed to see a specialist so on November 11, I went to the University of California Davis Medical Center and saw an orthopedic surgeon who is a hand specialist. (I checked and he is probably the best in the Sacramento area) The Doctor did an exam and took an x-ray. His conclusion was “likely has capsulitis of his MCP joint, possibly with minor sagittal band injury”. The Doctor injected 0.5 cc of dexamethasone and 0.5 cc of 1% lidocaine in the joint. He was surprised that the lidocaine didn’t immediately take the pain away but there was still pain in adduction. There was less pain in normal extension of the finger (I had just been climbing at Owens for four days and the finger was hurting in adduction as well as extension and making a fist) He told me to stop climbing and have physical therapy once a week for the next six weeks and come back to see him on Dec 30. It hurts when I bend all the joints on my index finger at a forty five degree angle and place the pad of my thumb on the side on my index finger and put even slight pressure on the index finger (adduction of the index finger). I have full range of motion with the finger except I can’t make as tight a fist with the left index finger as I can with the right. My current status (December 12 ) is swelling in the morning which doesn’t allow me to make as tight a fist as later in the day and pain in abduction. I have been buddy taping it but on Dec 11, without tape, I accidentally swiped my finger across my shirt and the finger hurt so I can tell It isn’t healing very well or at least very slowly. The physical therapist (a Certified Hand Therapist) does Iontophoresis Pads with steroids for approximately 10 minutes on each side, message, and ultrasound once a week. My Physical Therapist said she rarely sees an injury like this, maybe one a year. She said it is not a finger pulley injury. She is not sure what would be done if it doesn’t heal. Also check out Climbinginjuries.com where I also posted. That is hosted by a couple of Physical Therapists.
(This post was edited by johnr9q on Jan 27, 2009, 3:34 PM)
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onceahardman
Dec 12, 2008, 7:14 PM
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Hi John...
Very good objective information.
You are taking good steps in general toward solving this problem, seeing experts, and paying attention. I have only a couple of insights.
1) It's apparent (to me) that this is more than one injury. I base this on the surgeon injecting lidocaine (presumably) into the joint space, and then being surprised by the lack of total pain relief. Had this been a pure, inflammatory capsulitis (= synovitis), the local anaesthetic would have provided total relief. Nonetheless, you appear to have gotten some relief from the injection. So, some of the injury is inside the capsule, and some is outside.
2) You talked about abduction of the injured finger, and your description describes a test of, specifically, resisted abduction of the index finger, which you describe as painful. This implicates an intrinsic muscle strain, plausibly the first interosseous. This, of course, lies outside the capsule, so it fits.
3) You have had a fairly extensive course of steroid treatment to this area, between the DMSO injection and the ionto pads. While valuable as an antiinflammatory, there is some (and growing) evidence that steroids can interfere with healing of connective tissue.
4) I'd recommend doing some research regarding steroid use, and in a non-threatening way, discuss the research with your therapist and doctor. Don't come off as a pain in the ass, or they are likely to just get defensive, and boot you. But from a long distance, it seems like a good idea to get off the 'roids, and let it rest. If you keep climbing on it, and it keeps getting sore, you are probably keeping it hanging around longer. You are probably continuing to re-injure, every time you climb. Let the scar tissue form.
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johnr9q
Dec 12, 2008, 7:46 PM
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Thanks onceahardman for the great information. Yes, I spent alot of time and effort researching the injury so I could write something that was meaningful. Your first observation, I believe, is valid. When the Lidocaine didn't completely relieve the pain Dr Szabo seemed supprised and that is when he came up with the diagnosis of capsulitis which he said affected the boney aspect of the capsul and wouldn't be relieved by the lidocaine. This is how I understood it but it probably is a lot more involved than I am describing it but I'm not a doctor or PT. Your second observation is also valid and I was very reluntant to get steroids. Dr Szabo also expressed concern about giving steroids to a climber but considered it as the best option. I will not get a second injection. Do you think the Ionto pads really provide that much steroids internally? The PT hooks up an electronic device to the pads and it looks like a lot of hocus-pocus to me. Your forth observation: I have not climbed since I saw Dr Szabo over 3 weeks ago and don't plan to climb till at least after the 30th of Dec when I see him again. I'm addicted to climbing so it is difficult to rest. I started contrast therapy this morning. I did research and not much evidence that it is helpful but thot I'd take a chance. I figure it can't hurt. 5 min in cold, 5 min in hot repeat twice. I will also tape it more to insure I don't hurt it again. Are you a doctor or PT? As I stated, I'm not very happy with the healing and am afraid that after laying off for 6 weeks and I climb after that it will be as bad as before. I base this on the amount of pain I have in abduction and the fact that the pain hasn't reduced over the last 3 weeks. At the end of my 6 weeks treatment and laying off climbing if I don't have good results I will be willing to go anywhere in the country where there is the best finger experts. Do you have an opinion where that might be? Thanks again for your thotful advise
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onceahardman
Dec 12, 2008, 8:22 PM
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Theory of iontophoresis is, An ionic solution of corticosteroid is driven through the skin by using direct current (D.C.) The steroid definitely gets through the skin, but the "hocus pocus" comes in when you try to figure out exactly what path the drug takes to the opposite electrode. It could just penetrate 0.5 mm, and travel subcutaneously around the joint, rather than straight through. It will take the path of least resistance, rather than a straight line. But it will get through the skin.
I'm a PT, who has climbed for around 30 years. I don't know any hand therapists out west at all. I'm in western NY state, Niagara Falls/Buffalo area.
This kind of injury can be super frustrating. Improvement might be 5% per month, with easy potential for re-injury.
Let me ask you something. When you totally relax the injured finger, and use the other hand to move the finger passively into abduction (without firing the muscle(s) that move the injured finger), is the pain exactly the same, i.e. same intensity, and occurs at the same angle of abduction?
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johnr9q
Dec 12, 2008, 10:11 PM
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Again thanks: I will attempt to answer your question. The description I gave for getting the pain to present itself is really a combination of abduction and rotation. (as I under stand it, abduction is moving something away from a center line) but what I do is bend all 3 joints on my index finger at 45 degrees so I am half way to making a fist with that finger (keep the other fingers out of the way and straighter so they don't interfere with the manipulation of my index finger) and then place the pad of the thumb on the side of the of the index finger (adjacent to the fingernail) and attempt to push the index finger, with the thumb, toward the pinky finger. (It appears to me that this manipulation not only abducts but also rotates) Doing this manipulation with little effort I get pain. When I take my other hand and attempt to do the same manipulation I also get pain. Now if I hold my injured finger straight and bend the other fingers out of the way and take my other hand and attempt to do a pure abduction (no rotation as in the previous manipulation) I get no pain in either direction. Do you use iontophoresis? I think, based on your suggestion, I'll not get any more iontophoresis procedures. At 5% per month healing, that would be 20 months. Would I be out of climbing all that time?
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onceahardman
Dec 12, 2008, 10:46 PM
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OK, that helps. First, FYI, a couple definitions:
(For the fingers)
Flexion is the motion which bends the pad of the finger toward the palm, like making a fist.
Extension is the opposite, straightening the finger.
Abduction (in the hand) is moving a finger away from the midline of the hand, away from the middle finger.
Adduction is the opposite, moving your fingers toward midline.
There is no physiological rotation in the fingers. It would be a twisting motion, (long axis rotation), trying to turn the pad of (say) the index finger around, so it faced the same direction as the nails of the others.
You are describing a combined motion, flexion and abduction. BUT, I'm not sure of something. when you are using the thumb to push your index finger, it sounds like you are pushing the index finger toward the middle finger. This is, by definition, adduction.
Unless I'm reading you wrong.
Try this:
using your other hand, palpate (feel) along the border of the index finger, the side facing the thumb. When you get to the MCP, is most of the pain RIGHT THERE, right at the joint line?
OR, as you continue feeling down the border of the hand, toward the thumb, do you feel most of the pain in the meaty muscle attached to the metacarpal of the index finger?
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onceahardman
Dec 12, 2008, 10:55 PM
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This is probably boring as hell for everybody else, but it's cool to me...
I think I get it, from your description. It sounds like you ARE doing a long-axis rotation of the first phalanx of the index finger. You are kind of using your finger like a crank, and rotating the phalanx on the metacarpal head.
Now, try this:
Extend the PIP and DIP, but flex the MCP to about 90 degrees or so. NOW, use your thumb to push the index finger. Do you still get the pain?
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johnr9q
Dec 12, 2008, 11:04 PM
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I call this a wallet injury cause it hurts when you stick your thumb and index finger into your left rear pocket of your pants to retreive your wallet. So I keep the PIP (First joint from the end) and DIP (Second joint from the end) (or maybe visa versa) straight and push with my thumb and yes, I still get pain. (Actually I even get some pain at the MCP joint before I press with my thumb when trying to force the MCP joint to a 90 degree . I told Dr Szabo and I don't know if it's significant or not but the pain is a little more severe in all cases on the pinky side of the MCP joint.
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onceahardman
Dec 12, 2008, 11:25 PM
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In reply to: Actually I even get some pain at the MCP joint before I press with my thumb when trying to force the MCP joint to a 90 degree
Adding complexity...
This sounds (at least THIS PART) like a first lumbrical injury, another intrinsic muscle, like the first interosseous described above.
It's a toughie. Long and frustrating. Contrast baths won't hurt, but likely won't help very much. Rest (no climbing or grabbing your wallet, or testing it frequently to see if it is improved). Do some active range of motion (AROM). Just make a fist, then spead your fingers, over and over again. 3 sets of 50, daily. No resistance. Don't worry about getting to full, end-range flexion for now. Just a comfy, pain-free range.
Stay in touch, feel free to pm me if that's better for you.
edited for typo, spelling of lumbrical
(This post was edited by onceahardman on Dec 12, 2008, 11:40 PM)
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johnr9q
Dec 14, 2008, 3:25 PM
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Onceahardman. Thanks for helping me figure out my finger issues. As I said I saw Dr Szabo, who is a hand specialist, but he's not a climber and probably can't relate to what climbers experience. I'm 64 years old and keep myself in excellent shape both by climbing and working out so I'm not the typical 64 year old overweight couch potato. I expend a lot of effort and get a lot of enjoyment out of touching 5.12 in my climbing. So, altho Dr Szabo appears to care about my injury, he's probably thinking "Why doesn't this guy just leave me alone, cause at his age he should be only worried about using the remote control and then his finger injury wouldn't be an Issue. I have more improtant things to think about, like sewing on people's fingers that have cut them off". I saw a post where someone talked about Dr Mark Robinson (an orthopedic Surgeon working in Mammoth Lakes, Ca) who they considered a finger expert. I checked Mark's bio and he's mostly into knees and broken bones. But after thinking about Mark I thot it would be great if I could find a specialist who appreciates Climbers injuries and also an expert on finger injuries. Do you know anyone like that? I'd go anywhere in the country. Do you think what I am suggesting is necessary or should I just seek out the best finger expert I can find and not be concerned about their appreciation for climbers problems?
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onceahardman
Dec 14, 2008, 4:59 PM
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Hi John...
Is Dr. Mark Robinson the same Mark Robinson who climbed a lot in the Gunks, in the 70s?
Allow me to be frank. Although your fitness and skill are inspirational, the unfortunate fact is, you just don't heal as fast as you did when you were 18.
Getting second and third and fourth opinions is a good idea, but it doesn't guarantee you will get an answer you like better. In fact, if you keep asking surgeons what can be done, sooner or later one or more will start recommending surgery.
Szabo is probably doing the right thing by leaving it alone. What else can a doctor do? Cut it open, inject it, or give you pills.
A PT or OT or CHT can build you a brace, and give you exercises.
Being a climber might help with empathy, but it doesn't change the principles.
NO one really knows how long it might take. My guess of 5%/month improvement is little more than an educated guess.
My recommendation is rest, AROM, and stop messing with it. Keep up your nutrition, and your overall fitness. Try hard to avoid reinjury.
You can't really speed healing, you can only optimize the conditions at which it will happen.
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thegrassr00ts
Dec 14, 2008, 8:12 PM
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Hey OAH,
You gave me similar advice a few weeks back for what I think is a collateral ligament injury. While the AROM really seems to help, the finger feels fine after an AROM session and I get no pain when crimping, but if I don't do the AROM I still get some pain/weakness in that finger. My question is what does that really mean? Does that mean that if I do a proper warm-up and can climb with no pain that I should, or is this just an indicator that its healing and I should keep increasing the blood flow to the area?
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johnr9q
Dec 14, 2008, 9:59 PM
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OAH: Yes, it's the same Mark Robinson. Again, thanks for very thotful advise. I am doing just as you told me two days ago and haven't allowed the joint to experience any pain since. I guess I'm not very patient. However some of the manipilutations you asked me to do and questions you asked seemed to be more insightful than Dr Szabo exam. I am continuing to do the Hot/cold therapy with unknow results.
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onceahardman
Dec 14, 2008, 11:09 PM
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grassroots, warmed up soft tissue usually hurts less. Why? Maybe increased extensibility just from being warmer, maybe just moving scar tissue around a bit. Also, moving the joint supplies nutrition to the joint surfaces.
clearly, though. you are still healing. How do you know crimping doesn't hurt if you aren't climbing?
Keep up the good work. It will continue improving.
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onceahardman
Dec 14, 2008, 11:16 PM
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In reply to: I guess I'm not very patient. However some of the manipilutations you asked me to do and questions you asked seemed to be more insightful than Dr Szabo exam.
My personal opinion is, often times, doctors rely on the technology available to them, things like MRI and diagnostic injections.
PTs need to rely only on their brain, eyes, and hands.
In your case, I can only read and think, which makes it even tougher.
Ask your own PT about adding some active range of motion to your program. I know it seems stupid, like you aren't doing anything. But it's highly under-rated. Joints are built to move. Give them what they want.
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boracus
Dec 16, 2008, 2:21 AM
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J-
Sorry to hear about the tweaked finger but from reading the posts I'd agree w/ Once that it's a lumbrical strain and could have some involvement of the collateral ligaments and maybe joint capsule. Unfortunately ligaments are veeerrrryyy slow to heal and they take a long time to remodel even once they've healed. I damaged a collateral ligament in my hand and although I was climbing on it again @ 100% and pushing myself 4months out I could still feel it being a little achey after a session a full 8 months post injury.
I wanted to chime in w/ a suggestion that may help. Again Once is correct on the healing front, unfortunately @ 64 you're simply not going to recover as fast as you did 30yrs ago. One reason for that is the fact that as men age the amount of testosterone available to the body is up to 50% less than what it is until about the age of 40. Testosterone is not only instrumental in building muscle as a steroid it has far reaching affects on metabolism and tissue maintenance and consequently on how quickly you can repair damaged tissue.
Now this is not a silver bullet for your injury but by naturally boosting your serum testosterone levels you'll be more likely to maximize your body's ability to repair this injury. My suggestion is to try Tribulus Terrestris extract, it's been shown to cause a mild increase in testosterone. It is not a hormone or even a precursor, the proposed mechanism of action is that Trib causes an increase in LH (luteinizing hormone) which causes the Testes to produce more testosterone. The typical dosage of Trib is to take apprx 3 grams/day broken into two dosages, one in the am and one before bed. Taking dosages beyond 4 grams is of only minimal value.
One nice thing about Trib is that it's relatively inexpensive. You can get a one month supply of good quality supplement for about $15. I just wanted to throw this out there since there is a very real decrease in the amount of free testosterone as men age. Obiviously if you are already doing some kind of hormone replacement/anti-aging therapy or have gone beyond supplements such as Trib than disregard this info.
I also wanted to apologize if through your ethical perspective you find this suggestion/avenue offensive. I respect each individuals decision to play/train/climb as they see fit and by their own rules. I simply wanted to give you information that you may not have had and that could help in getting you back to doing what you love.
Good luck w/ the injury and I hope you heal quickly,
BA
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johnr9q
Dec 16, 2008, 2:54 PM
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Thanks Broacus for your help. I will definately purchase some Trib. As they say "It certainly can't hurt".
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johnr9q
Dec 16, 2008, 5:19 PM
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Onceahardman: You asked the following and I didn't answer: "using your other hand, palpate (feel) along the border of the index finger, the side facing the thumb. When you get to the MCP, is most of the pain RIGHT THERE, right at the joint line?
OR, as you continue feeling down the border of the hand, toward the thumb, do you feel most of the pain in the meaty muscle attached to the metacarpal of the index finger?" The following image shows where the most significant pain is
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johnr9q
Dec 16, 2008, 5:22 PM
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The attached image shows the manipulation that I described previously where I can, with very little pressure, push my thumb against my index finger to cause pain. This is, I believe, adduction and it is also attempting to rotate the finger.
(This post was edited by johnr9q on Dec 16, 2008, 5:25 PM)
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johnr9q
Dec 28, 2008, 4:45 PM
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Additional development on index finger injury. On 12/25 My 2 year old grandson leaped across me on the couch and I didn’t see him till the last second as he was heading headfirst toward the floor. I caught him with my hand with the sore finger and hurt it. After this incident I could cause the tendon running across the top of the MCP joint to pop causing a sensation similar to popping a knuckle. (probably the tendon moving out of its normal path) I can make this pop by spreading all my fingers as far apart as possible (abduction) and keep the index finger straight except bend it at the MCP joint. At a point near full bending the tendon pops
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johnr9q
Dec 31, 2008, 5:20 AM
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Today I say Dr Szabo, hand surgeon for my 6 week follow up visit. He basically said he didn't know what the problem was and I may have to learn to live with it. It is still hurting and still not climbing. He didn't think the popping I experienced on 12/25 was significant. (In his office, I was able to get the index finger on the other hand to do the same popping) I have arranged for a second opinion from Stanford on the 8th of Jan so will keep all posted
(This post was edited by johnr9q on Dec 31, 2008, 3:34 PM)
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onceahardman
Dec 31, 2008, 12:41 PM
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John...
The lumbricals specifically extend the PIPs and flex the MCPs, so So it's likely the lumbrical that is "popping" over something when you do that motion.
Doesn't help it heal any faster, though. Sorry.
My opinion is, it's a good sign Szabo didn't offer to cut it. If he's not sure he can improve it, he'll leave it alone. Good ethics there. After all, he makes his living cutting people open.
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johnr9q
Jan 8, 2009, 8:29 PM
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Follow up on my continuing saga: Today I went to the Stanford Hand Clinic and saw a lady Plastic Surgeon. She believes my pain is from a soft tissue sprain. She said when I initially hurt my finger, if I would have not used it for a month or so, it would have healed on it’s own. But now it has become a chronic injury and probably won’t heal. She wants me to get an MRI to see if there are any “hot spots” identifiable. She believes that surgery may be able to correct the problem. She says there probably isn’t anything to repair because the damaged tissue has probably atrophied and retracted. She said surgery would clean up and remove the scar tissue and provide fresh tissue that could heal properly if immobilized for a month or so. She considered giving me another steroid injection but thought it best not to cause I will get an MRI soon and a steroid may give false information on the MRI.
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onceahardman
Jan 8, 2009, 8:50 PM
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Good luck John, if you decide to have the surgery, I hope it goes perfectly well for you. Please stay in touch.
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