Hello, everyone. Welcome to our session. My name is Chris McMullen. I'm a physiatrist and sports medicine doctor at the University of Washington and happy to be leading this session today. Thanks to AAPMNR for allowing us to give this talk. I think it's going to be something really exciting and something people haven't heard before. So we're all really happy to be doing this. So our session today is Caring for the Rock Climber. So our objectives for the day, by the end of this talk, I'm hoping that everyone is able to describe climbing in general and climbing sub-disciplines. We hope that you can recall epidemiology of injuries in rock climbers and appreciate injuries that are specific to rock climbing. We want you to be able to clinically diagnose musculoskeletal injuries in rock climbers and describe the basic principles of diagnostic ultrasound of the hand and have a basic understanding of managing and triaging musculoskeletal injuries in rock climbers. So fortunately, I am not alone giving this talk today. I have a number of other excellent physicians who will be helping me out today. So again, I'm Chris McMullen there in the upper left, and I'll be doing the introduction to rock climbing, just kind of going over rock climbing basics. After me, I'll pass it off to Dr. Ziva Petran, who's an assistant professor in the Department of Physical Medicine and Rehabilitation at Rutgers New Jersey Medical School. And she'll be going over climbing epidemiology and injury mechanisms. After that, we'll go over to Dr. Eric Latzke, who's a colleague of mine here at the University of Washington. I'm also a clinical assistant professor in our rehab department. And he'll be going over ultrasound of the hand. Lastly, we'll be going over to Dr. Julia Iafrate, who's an assistant professor and director of dance medicine at the Department of Rehabilitation and Regenerative Medicine at Columbia University. And she'll be wrapping us up with some cases that illustrate some of the key points we're hoping you all pick up today. Just a few financial disclosures and affiliations. So Dr. Petran has been a part of the USA Climbing Adaptive Committee since 2017, and she was recently appointed to the USA Climbing Medical Committee. And Dr. Iafrate has some financial affiliations with 10X Health and Butterfly Network and affiliation with US Ski and Snowboard. Okay. So, you know, what are we talking about when we talk about rock climbing? Well, you may think of climbing as ascending to the top of a mountain, getting to the top of Everest. And certainly that is a form of climbing. We call that mountaineering, or if it involves trekking through snow, alpining. But that's not really what we'll be touching on today. Really, we're focusing on the sport of rock climbing. And so that means ascending vertical or near vertical face outdoors up a rock face or indoors on an artificial gym surface. So within rock climbing, there are a number of different sub-disciplines and categories of climbing. And so I just want to briefly go through those so we all have an understanding of kind of what we're talking about today, the sport we're talking about. So pictured here is something called free solo climbing. So this is Alex Honnold, who is an incredibly skilled elite climber who you may have seen the documentary Free Solo, which he is featured in. He is known for doing all these climbs without any safety equipment called free solo climbing. So this type of climbing is exciting. It makes for a good documentary, but it's very dangerous. The people, the major injuries that occur in this sport, when people die in this sport, it's often because safety equipment is not being used. So we don't necessarily want to promote this type of climbing because unfortunately, this is how we lose rock climbers every year. So in order to climb safely, we use protective equipment. And so this illustrates traditional climbing or trad climbing, which involves carrying a series of bolts with you as you ascend a rock face. You put the bolts in the wall and secure a rope to these fixtures as you ascend. It's obviously very technical, takes a lot of skill and equipment. So what has become more popular over the last couple of decades is transitioning to climbing that is a lot easier and sort of user-friendly. And so that brings us to indoor climbing gyms and top rope climbing. So the climbing shown here, you wear a harness, there's a rope that goes to the top of the wall and someone belaying below keeps you safe and from falling. So this is called top rope climbing. Lead climbing is a little bit of a variation on that where again, you're wearing a safety harness and there are bolts fixed into the wall that you attach the rope to as you ascend. Bouldering is becoming a very popular type of climbing as well because this can be done with relatively no equipment. This involves going up a wall of about 10 or 20 feet, so short distances and over a padded surface. So if you fall, you land on a padded surface and the risk of major injury is low because of that. Again, you can do this without any safety equipment and you can do this by yourself. So bouldering gyms have also cropped up all over the country. I want to touch on youth climbing for a bit as well. So it should be known that in rock climbing and sport climbing, a huge percent of our climbers are under the age of 18. In the 7 to 17 age group makes up about 35% of active climbers. And so youth climbers do experience injuries specific to their bodies, to being young. Things like stress fractures of the fingers would be an injury unique to this youth, to the growth plates, I should say. Stress fractures to the growth plates would be unique to this climbing age group. And so you just have to keep that in mind that there are injuries unique to this population. I wanted to show this picture as well. This illustrates what's called speed climbing and it involves ascending a 30 meter wall as fast as possible. And believe it or not, elite climbers can get up these walls in five or six seconds. It's pretty amazing to watch. I bring that up because this is one of the sub-disciplines that's going to be featured in the Olympics. And we were hoping to see this in 2020. Of course, this is now delayed until next year, but we are going to see climbing in the Olympics. So it is a single sport which will combine lead climbing, bouldering and speed climbing. And so competitors from their representative countries will have to be skilled in all three disciplines and a total score will be taken from the three disciplines to determine the ranking and who medals. I also have to mention para climbing or adaptive climbing. So this is becoming increasingly popular as well. And so climbing is not just limited to able-bodied individuals. There are people with amputations as seen on the left or with visual impairments as shown on the right there who can climb as well and compete at an elite level. So the International Federation of Sport Climbing actually holds international competitions in para climbing. And like all adaptive sports, the impairments of these athletes are rated in a way that they can compete with other athletes such that the competition level is fair. And so this is broken down into three classifications, three broad classifications and then subdivided further. But the three main ones are visual impairment, amputee or limited range power or stability, that last category and including sort of neurologic disorders. So this is certainly a growing sport. It will not be featured in the coming Paralympic Games but would not surprise me if it's ultimately added. So before moving on, I wanted to make sure we talked through some terminology that you may see throughout the talk. And specifically, I wanted to focus on holds, different holds that climbers encounter and the different grips involved when encountering those holds because it pertains to different injuries that might occur in climbers. So just looking across the screen here, you can see a jug grip. You see the pinch grip, crimp hold, I should say, which involves a small ledge, the sloper hold, pocket hold, which involves kind of one or two fingers and then the smaller holds such as a jib. Again, where this really matters is the grips that one might use on those different types of holds. The main ones I want to mention are the crimp grip, which is seen in the upper left there. And so this involves flexion through the PIP joints and puts a lot of force through those PIP joints. The open hand grip is seen in the upper right, which involves a relative extension at those PIP and DIP joints. Bottom left is a pocket grip, which involves one or two fingers and a small hold. And then again, the bottom right, that sloper type hold using a relative open hand grip. So I just wanted to give you an introduction to these holds and grips as it relates to certain injuries that you'll see throughout the talk. Okay, that wraps up my introduction. And so before I move on, I do want to put a caveat in here. So we call this talk Caring for the Rock Climber, but really we're going to be focusing in on those musculoskeletal injuries that you're most likely to see in your clinics, as this will probably be most relevant to you. But really, caring for the rock climber involves comprehensive management. You have to treat more than just musculoskeletal injuries. Nutrition is incredibly important. Disorders of energy deficiency certainly can occur in climbers. We have to monitor growth curves. We have to monitor mental health. And so it really takes a comprehensive approach to manage rock climbers overall. But given that we only have 60 minutes to talk to you, we just wanted to key in on those injuries that you may see most often. So with that, I'm going to transition over. We'll go to Dr. Petran, who will be talking about climbing injury epidemiology and injury mechanisms. Thanks. Great. So I'm going to continue here with climbing injury epidemiology. And so my sub-objectives here are to talk a little bit about the challenges of injury research in climbing, talk a little bit about what we actually know about it. So what's published, what do we know about these injuries, what kind of injuries occur, the types or the locations, and to briefly start talking about the mechanisms of injuries, and then to pass it on to Dr. Laska and Dr. Euphrates to talk about specific injuries in more detail later. And so I have no relevant financial disclosures. Like was said before, I've been volunteering with USA Climbing for some time now. And so I'm pretty passionate about this topic. To start, we need to know a little bit more about the culture of climbing as it relates to injuries. And so like Dr. McMullen already mentioned, this is a lifelong participation sport. And so even though we have a lot of these competitive youth climbers, we're also seeing that it's something that people want to do as they get older. It's something that is pretty inclusive. So we see adaptive athletes. And we're also, especially in the sport climbing world, so gym climbing, we're seeing a lot of females taking up the sport. So if we compare the membership data, for example, American Alpine Club that involves more mountaineering, there's definitely less females. But specifically in the U.S. for sport climbing, we're seeing quite a lot of interest from both genders. And so that's really wonderful. Now, in terms of research limitations, it still is a little bit of a niche sport. So even though it's expanding and there's lots of people who want to do it, and there's lots of gyms popping up all over, it still sort of comes down to those 1960s origins in Yosemite, sort of this idea of the dirtback climber or the guy that lives in a van and maybe scrounges for food, does not have a job or health insurance. And so injuries have become a little bit part of the culture. And there's definitely a lack of occasionally wanting to spend money on treating injuries because you can do it yourself. But there are also beliefs regarding health care in this sport. So, for example, if we look at Norway, where people don't have any sort of insurance limitations, right, socialized health care, we still see that climbers tend not to want to seek out help. And a nice little recent study looked at why that is. And there's not just an assumption that these injuries are not that serious, but also this idea that health professionals don't really know too much about this. And so they're not going to be able to help. And I think that's definitely something we're hoping to change. Now, the data that we do have about injuries and climbing come from a couple of main sources. So it is a niche sport. It's hard to study these populations. A large prospective study is really not out there. So what we have is data from different online surveys, so self-reported data. We do see data from different emergency room settings, so where people really get hurt and have to go to the ER. And there's different ways to collect that data. And then what we also see are these sort of small case series of very specific injuries. And there's a couple of very prolific climbing research groups that will see some selective groups. For example, the German national team is very well studied. And so we have a lot of data from these small uniform groups. And so we're really just seeing that tip of the iceberg. We're seeing the most severe injuries. We're seeing injuries in very elite climbers. And then injuries in these small specific populations that we're gathering in different case reports or case series. And so what is really important to remember, that even though climbing is a very specific sport, it's still sort of that what's common is common. It's what you see, right? So if you treat climbers, you're going to see a lot of back pain and neck pain and ankle sprains and things like that, just because those are common musculoskeletal problems in all types of sports. And then in master's athletes, you're going to see a lot of arthritis problems or tendon problems. And in youth athletes, you'll see more growth plate injuries or apoptositis. And so what's probably more interesting are what are the common, uncommon injuries. And so we'll talk about those more later in the talk. But in climbing, those are things like finger pulley injuries or finger epithelial injuries, hamate fractures, lumbrical strains, brachialis strains. So things you don't necessarily really see very often in other sports. And that's what we're hoping to sort of present today and talk a little bit more about. Now, in terms of what we know about prospective studies, so the prospective studies that aren't self-reported, we really don't have too many large or well-powered studies on this. And what we do have is from that very prolific group, the Dr. Schoffel's. So Folker and Isabel Schoffel have published on climbing injuries just for decades. And so they run a specialized climbing clinic with an associated level one trauma ER in this very geographically high climbing area in Germany. And what they've published is interesting because it reflects two things. It reflects not just how climbing has evolved over the years, so more bouldering, more dynamic movements, but probably also reflects that they're specialists in these types of injuries. So they might be seeing a little bit more finger, shoulder, hand injuries because that's what attracts patients to their clinic. But I do think that this sort of reflects overall trends that more upper extremity chronic injuries are being found because of the way that the style of climbing is evolving. And if we look a little bit more in detail, what we see is a lot of pulley injuries, capsulitis of the fingers, slap tears, which makes a lot of sense, impingement, finger flexor tendon problems. And so very high, these high strain injuries versus a decade ago is more like back problems and knee injuries. So things are changing for sure in the patterns or trends in rock climbing. Now, when we look at sort of the self-reported data that we have available in the USA, this is sort of mimicking or reflects what we found in that other study is that lots of injuries involve the upper extremity and that the lower extremity injuries are predominantly sort of these traumatic injuries like fractures of the ankle or ankle sprains. And we also see that the injury varies depending on what type of climbing you do. So indoor climbing gym, where you really are working on these small holds and you're doing a lot of crimping, you're doing a lot of dynamic movements over boulders, like you can see here, is really involving more of the fingers. Whereas something like trad climbing that was described before, where you're sort of a little bit more slow about things, you need to clip in, you need to secure yourself, has a little bit less of that dynamic strain on the upper extremity. Now, what's more interesting to me is that about 50% of these self-reported injuries in the USA actually returned to climbing before their injury is healed. And about 50% develop chronic problems related to that injury. And so we're definitely not maybe catching these as soon as we could, or we're not treating them quite as well as we could. And so chronic injuries are a reflection of that, right? We're seeing a lot of finger, elbow, shoulder injuries, which really represents the majority of the chronic injuries in the sport. And so that from various sources, we're seeing that the upper extremity is really strained. I think what we don't maybe talk about enough is that the specialized shoe wear that people use in climbing, those really teeny tiny shoes, there are quite a few injuries or sort of small injuries of the toenails, right? So the toenails and the toes and the feet can also get chronic injuries from shoe wear. So in comparison to that upper extremity predominance, acute injuries really don't involve the upper extremity much, right? So about 14% in this study, this was a study that we did in 2016 and basing it on USAER data from the National Electronic Injury Surveillance System. And so similar studies have been done on this, looking at various time points. But they all basically have the same findings of primarily these acute lower extremity injuries, fractures, strains, sprains, and not a lot of people tend to go to the ER for a finger boo-boo. We're not definitely capturing those in the ER. And then to try to put this in perspective, comparing to other sports that are a little bit better known, if we look at the injury incidence rate compared to other sports, I kind of mapped this out here. These two blue lines reflect the minimum incidence and the maximum incidence rate that's been reported in literature for climbing. And so there's only about eight primary studies that give us this information. And they're pretty variable, right? So from very, very low to sort of high-ish. And if we compare that to NCAA sports, we can see that climbing probably falls in here in sort of an average injury incidence rate sport. But we really do need to do a little bit more research to understand more about this. And so just to summarize that, in general, chronic or strain or training error injuries really involve primarily the upper extremity, whereas your acute or traumatic fall-related injuries tend to involve the lower extremity. And so what are some of those mechanisms of how these injuries occur? And so the most obvious one, of course, is falling off. And so if you fall off, you may fall either from very high or from not that high, but you may fall onto something. You may fall on your buddies trying to help you, you may fall on rocks or pads, or you may swing and hit something just depending on how you are or what type of safety equipment you're using. And so you might fall and hit a wall or fall off and hit a tree underneath you. And so there's very variable injuries resulting from falls, but this is pretty obvious. The second sort of mechanism is the one that causes the most chronic strains, but also these acute on chronic injuries like a pulley snapping or a shoulder dislocation. And that's this hanging on mechanism, right? Clearly in climbing, you're using your upper extremities. And at times, depending on what grades you're climbing, you may be suspended really only from one or two fingers, and then all that is suspended off of your shoulder. And so a very dynamic movement, right? Leading to impingements, leading to labral tears, leading to dislocations, and these chronic strain or acute injuries in the fingers primarily. And so what we need to keep in mind is that climbing is really becoming over the years more and more dynamic. And so it's not just this chronic strain that over time overuses your body's ability to adapt. It's also these acute sort of dynamic strains on small parts of your body that lead to injuries. And then you might think that when you're standing still, you're unlikely to get hurt in climbing, but especially as we get older, belaying or making sure that you're providing safety to a partner climber. Standing still puts that typical neck hyperextension position for which there's a wide variety of belay glasses to try to help with that so that you can see your climber up there without having to strain your neck. But not only can you get sort of these neck tension injuries, but often fingers will get stuck in rope or caught on belay devices, or someone forgets that they're outdoors and takes a couple of steps back while keeping an eye on their climber, and they might sprain their ankle or fall off a ledge or something like that. So even standing still can sometimes be a little bit dangerous. And so if you're not secure enough, something like this might happen to you. And then you're dealing with acute trauma yourself. And then lastly, there are different types of on-the-wall mechanisms. And so when you're climbing, not only are you putting your arm in very interesting positions or using different holds with different finger arrangements, but also your lower extremities can get injured in various ways on the wall. And so when you are stepping up or where you are moving in specific ways, you can cause a lot of these rotational compressive forces on the menisci. So those have been described. And then specifically in heel hooking, which is a maneuver where essentially you suspend your body off of your heel, you hook your heel onto a hold, and then you pull back with your hamstrings and sort of contract your gastrocs to suspend essentially your body up the wall. And so this puts a lot of strain on those cruciate ligaments, and then of course falls. And that really involves quite a few different mechanisms of injury. And then lastly, the youth climbers, right? So the young climbers really are dominating and competitive climbing. And so they're often training really hard during periods of peak growth, which is a little bit younger for the females and a little bit older for the males, but we're seeing growth plate injuries, nutritional deficiency and problems related to lots of climbing and trying to stay lean. And so that's definitely something that we need to keep in mind. And so thanks very much for listening. And at this point, I'm going to pass it on to Dr. Eric Latscom. Hi, I'm Eric Latscom. I'll be talking to you guys today about diagnostic ultrasound of the hand. We chose to focus on the hand just because it's a unique area of injuries for rock climbers, and the diagnostic ultrasound that's used for the hand is also unique. I'm sure a lot of the physiatrists watching this are already a little familiar with some of the other upper extremity ultrasound. So here's a brief overview of some of the anatomy we'll be talking about. First we'll focus on the pulleys, specifically the A2 and A4 pulleys. Then we'll talk a little bit about the flexor tendons, the joints and growth plates of the hand and the hook of the hammock. So this is an ultrasound of a normal A2 pulley in short axis, well, short axis to the tendon, long axis to the pulley. We can see underneath the A2 pulley is the tendon, and there's an area of anisotropy, meaning of hypoechoic or darkening of the tendon, and that's because we're not really optimizing this view to see the tendon, we're optimizing it to see the overlying pulley. So this is not tendinopathy or fluid in the tendon, we're just not optimized to see it. Underneath the tendon itself we have the phalanx of bone, that's the bright line here. And if we look at a video, you can scan in short axis distally and proximally, just to the ends of those pulleys. In long axis to the tendon but short axis to the pulley, it can be a little difficult to see these pulleys, especially in non-rock climbers, but in rock climbers they tend to be a little hypertrophied. They can be easier to see with differential motion, this pulley will now stand out a little bit more. Here we have the flexor tendons underneath, the FDS and the FTP tendon. And one other key to look at is where does this tendon start to rise up off of the phalanx? You can see it's held down pretty close to the bone right here, but about at the halfway point it starts to rise up, and it's going to need to to clear the PIP joint distally. That's where we can usually find our pulley overlying the tendon. Now this is an ultrasound in long axis on the tendon comparing a ruptured versus a normal pulley. Here we see a normal one just like before, and it's pretty easy to see the difference in a fully ruptured A2 pulley. There's a large dark area underneath the tendon, that's an effusion. There's an absence of a visible pulley overlying the tendon. And then there's what we saw the tendon lift off and away from the phalanx under resisted flexion. And that is something that we try to measure, the amount of what's called bow stringing off of the tendon. And the term for that is tendon phalanx distance. So we can take a measurement of that distance at rest and also under flexion. But that isn't just measured under ultrasound, it's measured under MRI as well. So and it was measured under MRI before ultrasound really came into existence. The problems with MRI though, it's a static image, lower resolution, we don't see the pulleys as well. It requires insurance authorization. And there's, well, I guess the benefit is that there's no learning curve. One thing I forgot to mention earlier, if you look to the upper right hand corner of these slides, there is a key finger or hold that will be related to the injuries that we're talking about. So we're talking about A2 pulley injuries currently, and that's why we have a picture of a crimp grip up there. And that will change throughout the presentation. And I'll try to relate back to them as we go. Going to ultrasound, some of the benefits are that it can be done dynamically. Looking at flexion resistance, it's more sensitive for partial tears because of its better resolution. And it can be done on the day of care. So we don't have to wait for insurance authorization or go through physical therapy first. The downsides though, it has a very high learning curve. And the lack of established protocols have already led to inconsistency between studies and even within studies. So we really need some more guidance on where and how we should be measuring this tendon phalanx distance. So if we look at the studies that are out there already, there are a variety of them, and they are measuring from a variety of different locations. And those locations span from measuring at the proximal third of the phalanx to the midpoint of the phalanx to the distal third of the phalanx. And because these studies are measuring at various locations, they're getting various outcomes in their data. They are though consistent with where they measure at. So if we look at the Basimir study that takes its measurements most proximally, they get the smallest distances for their tendon phalanx distances. And if we go to Boyer, who measures at the most distal aspect, they'll get the largest tendon phalanx distances. And that is consistent in the literature, but no one's really made note of that. So Wader in 2013 did write that we need a consensus reference, but it really hadn't emphasized this difference in normative values and then the difference in diagnostic values in the literature. And it's not just an ultrasound problem. We see it on MRIs too. If these are three pictures from three different MRI studies talking about tendon phalanx distance, it's pretty easy to see that these distances are taken from two very different, three different locations, proximally here, near the midpoint here, and definitely near the distal phalanx, or sorry, the distal third of the proximal phalanx. And then when we take all those studies and we look at their data for diagnostic purposes, A2 ruptures at rest vary somewhere between 2.8 and 3.7 millimeters of tendon phalanx distance, where then under stress, that can increase to 4.4 to 5.1 millimeters. So how should we be measuring these tendon phalanx distances? Well, we need to be able to measure at the same point every time. And we need to be able to do that because we want to compare injured pulleys to normal pulleys. And we want to be able to compare a patient today to the same patient eight weeks from now and see if he's healed. So we need a reference landmark, whether that is the PIP joint, the MCP joint, or the pulley. But if the pulley's ruptured, we can't use it as a landmark. And if we want to do resist inflection dynamically, we can't use the PIP joint as a landmark because the patient needs to be able to flex their finger. So what I do in clinic is I measure the length of the proximal phalanx is the first thing I do. And if that's 4 centimeters, then I measure the midpoint, which would be 2 centimeters. Then I slide my probe proximally. So I no longer have the PIP joint in view, but I have the MCP joint in view. And this allows the patient to be in a position where he or she can fully flex their PIP joint. I maintain that I still have the 2 centimeter distance from the MCP joint and then have them flex under resistance. So we can make out the pulley here. And then under flexion, you can see a little bit of increase in the tendon phalanx distance. This pulley is intact. This is a climber without an injury. The same techniques can be applied for measuring the A4 pulleys. Now, in these images, the techniques are not applied because I have not seen an isolated A4 pulley injury since we really kind of fixed our protocol here at University of Washington. But using those techniques, measure at one half or the midpoint of the middle phalanx this time. Use the proximal joint, the PIP joint, as the landmark. And then depending on the size of the patient, you may be able to use a linear probe or a hockey stick probe. Going back to my last slide I forgot to mention, I would definitely use a linear probe when measuring the tendon phalanx distance because it's the only thing that's going to allow you to get your landmark in view and your midpoint of the phalanx. If you use a hockey stick, you probably won't have enough context in your image to make those consistent measurements. Also in ultrasound, we can see partial tears. This is typically seen at the distal end of the pulley. And if you imagine a short axis view on this tendon, there would be no pulley in this image and we just see fluid here and you wouldn't really be able to tell the difference between a full and partial tear. So always make sure to get two views, a short axis and a long axis view, and confirm that the tendon phalanx distance is greater than two millimeters. We also see thickened pulleys and these thickened pulleys can be just adaptive for the climbers. They are not always pathologic or causing pain, but they can also lead to stenosing tenosynovitis. In the general population, that's a problem we see at the A1 pulley with trigger finger. But in climbers, it tends to happen more at the A2 pulley. There are normative data already on the thickness for pulleys and for symptomatic pulleys. But of note, MRIs are not able to measure pulley thickness because they just do not have the pixelation that's required. Moving on to flexor tendons, this is just a normative anatomy under ultrasound. We can see the FDS tendon superficially, the FDP tendon, and the volar plate over the metacarpal head, proximal phalanx distally. In short axis, we see those same things. Here's the FDS, which as we move distally, we'll split and go down each side deep to the FDP and insert before the FDP inserts. We'll see the lumbrical muscles and the digital artery and digital nerve. I'll briefly touch on FDP tears and avulsions are also known as Jersey finger injuries. The risk here, refer to the pictures, the open hand grip. This places more stress at the FTP tendon. There are various types of FTP tendon injuries, types one through six, I believe, but types one through three are more common and we'll be focusing on those as they don't involve a frank fracture of the distal phalanx. These are not my images. These are taken from a study by LePage in 2015, but these are great ultrasound images of a type one injury where the tendon is retracted to the level of the palm. This is often seen with chronic injuries or injuries that happened a while ago and were just missed. You can see an empty tendon sheath here. You see a FDS tendon, but no FTP tendon, which is why this tendon looks a lot thinner than the normal finger next to it, which is this is just a normal uninjured finger. You can also see at the level of the palm in short axis that the FTP tendon looks thick, swollen and hypochoic. Type two injuries retract to the level of the PIP joint, often getting stuck at the A3 pulley. And the difference here is if you move to the MCP joint, you'll still see both the FDS and FTP tendons. Sometimes these injuries can occur with a concomitant avulsion injury, and here's an x-ray showing that avulsion that gets stuck at the level of the A3 pulley. The bigger the avulsion, though, the more distal it can get stuck. So if we have a really large bone fragment, that can get stuck at the A5 pulley and at the DIP joint. That's a rare injury, though. Other things we see when we're scanning climbers' fingers, sometimes we see masses. The most common mass is this flexor tendon sheath retinacular cyst, also called a ganglion cyst. It can be associated with tenosynovitis of the flexor tendons and the pulleys, but the things to know are that it's a hypochoic mass. It's usually non-compressible. It's avascular, so there's nothing about it, and its borders are well-defined, so there's nothing about it that is concerning for, say, a malignant tumor. These can be aspirated, just like any ganglion cyst, if they're large enough, and they can also be excised, which is probably the better treatment given the rate of occurrence. The next injury we'll talk about are handmaid injuries. Now, here's our key up here. This is an undercling grip, and the unique orientation with ulnar deviation of the undercling grip causes the flexor tendons to rub against the handmaid and predisposes to a handmaid stress fracture. Now, let's go back to this image. I would not be able to tell you if there's a stress fracture based on this ultrasound, and that's kind of the take-home point here. Some handmaid injuries, if there's, say, like this large cyst sitting next to the handmaid, are easy to see, and here's a cyst that compressed the branches of the ulnar nerve. But unless you have something like that, you're not going to really be able to say if there's an injury to the handmaid underneath it. So I have a very low threshold for anybody who comes in with pain in the area of their handmaid who's a rock climber for getting a CT or an MRI. Talking about the joints of the fingers, sure, you could scan them with an ultrasound, but to ultrasound all those joints, that would be a lot of different images. So x-ray is still the gold standard. The debate really is whether climbers have increased rates of osteoarthritis in their hands. Most studies out there say they don't, but most of those studies only use AP x-rays. The one study that used lateral x-rays, too, showed osteophytes in about 84% of PIP joints and 68% of DIP joints, and that was in climbers who had been active in climbing for about 20 years on average. So I would say it makes sense to me, given the injuries that climbers have, that they have higher rates of osteoarthritis at those joints. Then let's talk about growth plates, as Chris and Jeeva already mentioned. If you can tell me which one of these pictures is abnormal and which one's normal, more power to you. I would not be comfortable using ultrasound to say where there's a growth plate injury and where there isn't. Growth plates are just probably one of the harder things to diagnose or to rule out injuries to in kids, especially with ultrasound. So here on the left is a normal joint and on the right is a fractured growth plate. So I still rely on x-rays if I have a young kid and I'm suspicious for a growth plate injury. And there are plenty of studies out there showing that growth or epithelial fractures are pretty common in rock climbers. A shuffle study showed that of the 20 injuries in climbers under the age of 15, 14 of them were growth plate injuries. So have a high suspicion for this injury in the kids you're seeing. Take-home points though, if you suspect a pulley injury and it's the most common injury I see, use ultrasound. Find the pulleys in short axis, then in long axis. Measure the tendon phalanx distance at about the midpoint of the proximal phalanx and try to be consistent with the location you're measuring at. Remember the tendon phalanx distance cutoffs, meaning less than 2 millimeters is normal. Anywhere between 2 and 3 millimeters is likely for a partial tear and anything greater than 3 or up to 5 millimeters with stress would be consistent with a full tear. Flexor injuries though, flexor tendon injuries, ultrasound and x-rays are both useful. Especially x-rays can make it much easier to see that avulsion injury. For growth plate injuries, you definitely want an x-ray. And for hammock stress fractures, get a CT or MRI. So that's all I have today. And I guess this format doesn't allow for questions, but I'll use any occasion to throw up a reference to the Patriots. So now I'll let Julia take it away. Okay. Hey, guys. My name is Julia Iafrate. I'm one of the sports medicine physicians at Columbia University Medical Center. And now I'm going to be finishing up the hour talking about cases on rock climbing injuries. And I have no disclosures that are pertinent to this lecture today. All right. Our first case is a 28-year-old climber who's presenting to the sports medicine clinic with right index finger pain after climbing. Normally he climbs about five times a week and gets occasional swelling, but felt a pop during a full crimp hold, which is the picture that you see in the image here, followed by severe pain with swelling. On physical exam, there is swelling over the index finger and tenderness to direct pressure over the A2 pulley. There's also pain with resisted finger flexion and bow stringing appreciated. On imaging, we see some MRI and ultrasound images. So on MRI, we have T1 weighted images that show A2 and A4 as focal thickening of low signal intensity. And then there's also osseous insertion of the A2 pulley appreciated in figure A there. And then in figure B, or image B, excuse me, the tendon to bone distance is increased. And so we see a bow stringing effect here. The axial image just below that does show a vulsion of the A2 pulley at the proximal phalange holding away from the bone. On ultrasound imaging, this image is courtesy of Dr. Latska. We see a sheath effusion observed behind the flexor tendon with abnormal separation between the flexor tendons and the anterior cortex of the phalanges, which is causing that bow stringing that we just discussed. The gap increases during resisted flexion with dynamic testing. So any time they have to flex that PIP to about 40 degrees and the DIP to about 10 degrees and then push against that resisted finger. So we can see that in the video right there. So what is our diagnosis here? Well, this is an A2 pulley rupture. In terms of injury classification systems, there's a couple of them. But basically a grade one is considered less than 25% tear or strain of the pulley. A grade two is greater than 25% tear of an A2 or A3 pulley or a full thickness tear of the A4 pulley. A grade three is a complete tear of the A2 or A3 pulley. And then a grade four is a full tear of multiple pulleys or full A2 or A3 tear with other structures being involved. So pulley ruptures make up about 33% of climbing injuries and it does usually occur in the A2 or A4 pulley and the ring finger is the most commonly involved. When you think about it, the A2 pulley holds down both the FDS and the FDP tendons and so that kind of partially explains why it experiences greater forces generally than the A4 pulley does. With these ruptures, pain is quite severe, especially with direct pressure over the pulley or when trying to crimp or pull with the affected digit. ER visits generally are not required, but they should seek medical evaluation within the first three to ten days. If the pain radiates into the hand or the wrist, it's probably not a pulley injury and it could be injury to one of the flexor tendons instead. They should not have any stiffness, swelling, or tenderness along the knuckles themselves. In terms of algorithms, so there's a couple different algorithms that exist for pulley injuries. Generally, the goal though is the same. So you want to immobilize for the first few days and then gradually return to climbing with some support. Generally, treatment for a mild to moderate injury requires a balance of protection, scar mitigation, and progressive loading of the injured tissues. The literature does show that outcomes are quite excellent with conservative management up to grades three and most climbers return to their previous level of climbing. Grade four ruptures, however, do usually require surgical reconstruction and full return can take place anywhere up to 12 months after injury. This is just another algorithm that shows a similar recommendation, just in a different chart form. That TPD under grade one is that tended phalanx distance, which you heard Eric refer to earlier. And then this last one's another rehab algorithm that exists that a lot of physical therapists tend to use. Just a good way to kind of see it in a different form, but basically it goes through immobilization, physical therapies, gentle climbing, full climbing, and then making sure that you're using supportive taping because we're often recommending taping. So when it comes to taping, how do we manage this? So options include taping versus what's called a pulley ring. If you are going to tape, the H-tape method is believed to be the best one. It does create a small but significant reduction in strain on the pulley, and it is best for the A2 pulley as it best limits the tendon to bone distance. So basically how to use it, you use a broad piece of tape that you can rip in half, creating an H, which you see in the image here. Then you apply central pressure directly over the A3 pulley, which is at the PIP joint. Flex the PIP to about 60 degrees when placing the tape, and then that's going to allow for that tendon bone approximation. Then you tighten the distal strip and then the proximal strip. The pulley ring, however, which is down in the bottom corner, is thought to work even better as it provides compression along the tendon without too much pressure on the actual vessels or nerves. There are, of course, surgical options as well for some of these injuries. There's the non-encircling image in A, and then the looped reconstruction, which is in image B. These both have longer rehab protocols involved, of course. When it comes to rehabilitation, I really recommend that patients work with a PTOT who is familiar with rock climbing, because that can make a huge difference for them. Generally speaking, the goal is to work on mobility first. They need to get to full range of motion before progressing to strengthening with finger webs or bands. Then you want them to begin load testing and progressive loading program. Level one involves isometric holds. Level two involves isometric holds using resistance bands. Level three is resistance bands with climbing-specific movements. They should be doing all these resistance band exercises without pain prior to initiating the climbing plan. Level four entails beginning that return to climbing progression. Once they do begin climbing, you should make sure to protect the pulley through the use of either that pulley ring or H-tape to the finger. They should start climbing at a level well below their normal ability. They should perform a minimum of four days of climbing at each level prior to proceeding to the next difficulty level. They should only advance if their pain is not increasing and their workouts are done with minimum strain. In terms of prevention, there's a couple of things that we can consider doing. The most important one is avoiding dynamic moves from a crimp grip. Anytime you have your hand in that crimp, and then these images up here just show you the different types. There's an open hand, a half crimp, a full crimp. Then you want to make sure that the closed crimp is not the one that you're moving dynamically from, especially. Generally speaking, dragging is a safer pull angle for them. They can use those more open hand or drag holds instead of crimps when they can balance it out. Crimping does tend to put about 31 times more force on the A2 pulley than an open hand crimp. However, there is some thought that this may end up increasing risk to the A4 pulley by using so much open hand. Really, just balancing out those different grips is going to help you disperse the stress to the hand. Case number two. This is a 42-year-old female rock climber with gradual onset of pain in the palm of the left hand. Pain is most substantial with performing a pocket technique, which you can see in the image below here. This is a single finger grip while climbing. It is provoked by a shift of the deep flexor tendons of the adjacent fingers. On physical exam, a stress test does create provocation of pain with passive extension of the ring finger while the patient aims to close her fist. There is no symptoms provoked when the middle finger is extended simultaneously, which you see in that image B on the top. And then the quadragia effect of the third lumbrical muscle disappears due to non-separation of the bipennate origins of the lumbricals. These muscles obviously have two origins. If those two origins are both working together, then obviously you don't have as much stress going through the lumbrical muscle. On imaging, T1-weighted fat-saturated MRI in the axial and coronal directions show separation of the fourth lumbrical muscle tendon, which you see in the red arrows on the top there, from the musculotendons FTP origin of the ring finger, but only on the ulnar side. Also note that there is surrounding inflammation that we can appreciate just right beside those red arrows. And then on ultrasound, which we see down in image C, we see swelling and hyper-echogenic reflections representing a hematoma in the fourth lumbrical muscle. So our diagnosis here, a grade three lumbrical muscle injury. All right. So how does this happen? We know that these muscles originate from the FTP tendons and work to flex the fingers at the MCP joint and extend the fingers by pulling up on the extensor hoods. When the fingers are holding a pocket, they are extended, and so there's this relative upward pull on the tendon due to tension in that monopocket. If you are flexing your adjacent fingers, then the tendons have this downward force, which then opposes the pocketed finger. This applies a sheer force to the lumbrical and can cause a strain or tear. So when we talk about ultrasound imaging, we can see with lumbrical tears usually this hypoechoic lumbricals that look really swollen on imaging. The flexor tendon sheath may have an effusion, but should be without any tendon pathology. And there could be loss of muscle fiber pattern within the lumbricals, which you can see down in the bottom right-hand corner. That fourth lumbrical image looks quite different than the first lumbrical in the picture beside it. In terms of treatment for this, so the most common location is the third and fourth lumbricals, and again, that's because of those bipennate origins. And the main risk is the pocket technique, especially single finger. So with grade one injuries, these are microtraumas in the lumbrical muscle with a positive clinical stress test, but no pathologic findings on ultrasound. And then this usually requires about four weeks of functional therapy, and then they tend to do pretty well after that. Grade two is a lumbrical muscle fiber disruption without tendon involvement, and ultrasound tends to show edema of the lumbrical muscles with or without adjacent tenosynovitis of the flexor tendons. And this usually requires about eight weeks of therapy plus tape. And then grade three is a musculotendinous disruption of the lumbrical muscle, and MRI evidence will usually show tendon discontinuity at the FDP or FDS tendon origins. Grade three is typically diagnosed whenever lumbrical muscle tendon discontinuity is seen regardless of the extent of actual muscle edema or hematoma or any adjacent tenosynovitis. And this usually requires two weeks of immobilization with eight weeks of therapy and ten weeks of taping. In terms of prevention, this is a fantastic slide that I stole from Eric because it's really excellent. Please excuse the middle finger that's up, though. That is just as a way of showing you the differences here. So there's the Spider-Man grip, which we see on the left-hand side here. The fingers that are not actively squeezing the web shooters, which is analogous to the climbers' fingers that are not in the pocket, are neutral and extended, neutral, sorry, or extended and not completely flexed. Only when climbing, all your proximal phalanges should be in line with each other. And then the Ice-T grip, which we see on the right-hand side, basically you want the fingers that aren't in the pocket to be in neutral extension as opposed to fully flexed. So this bottom image is fully flexed, and you can see that's causing a lot more strain on the finger that is in the pocket versus the picture that's up and to the right does have all the proximal phalanges in a row. All right. Case number three. So this is a 30-year-old male right-hand dominant intermediate climber who presented with gradual worsening pain in the right index finger after a 10-day vacation. The pain was described as initially dull and diffuse and as only occurring during climbing activities. As the trip progressed, the pain became more focal and intense and was noted to be exacerbated with holds that were requiring higher percentage of body weight to be supported by his right hand. Initially, pain occurred with finger jams and finger locks. However, over time, the pain did worsen and also occurred with fist jams, hand jams, and eventually with grip-type hand holds. The climber denied any violent traumatic falls, and the pain did resolve with rest after that initial trip. However, he did note that he had been training for several months prior to the trip and had been asymptomatic during that training period. But after a second weekend trip, the pain became more intermittent and then occurred with certain activities of daily living, for example, when typing, whenever a key struck that second finger. On physical exam, there was no bruising. Passive range of motion was painless. No pain with active motion. He was, however, point tender over the distal ulnar aspect of the proximal phalanx and had mild tenderness to radial stress. On imaging, plain x-rays did show a periosteal change at the ulnar aspect of the junction of the distal third and medial third of the proximal phalanx. So our diagnosis here, a stress fracture. So the use of finger jams, finger locks, hand jams, fist jams, and grip hand holds, which are some of these images you see here, all place repetitive, compressive, and tensile stress on the fingers. So these repetitive forces place climbers at risk for stress fractures just like any other injury can do. So always be aware of this risk in our climbers. In terms of management, you treat these like you would basically any other stress fracture in the upper extremity. So you'll initially want to unload the affected tissue, then regain mobility in and around the tissue, and finally strengthen the tissue. Then you really need to utilize movement strategies to change old movement patterns and create newer, healthier ones to avoid these injuries in the future. Climbing can start about nine weeks later if they're not having any symptoms. And finally, our last case. So this is a 24-year-old male experienced rock climber who sustained a right knee injury while attempting a heel hook maneuver at an indoor climbing gym. He experienced posterior knee pain and heard a pop. And he was unable to finish climbing because his knee became quite swollen. So Dr. Petrin did mention this earlier on, but just a reminder of the heel hook maneuver and what it is. So basically, this maneuver allows for high foot placement and aids in ascent. So at initiation of the maneuver, the leg is abducted as it swings upward. And then that knee is hyperextended as the heel is locked into place. The hamstrings are then contracted, and this is used to lever the body in an upward direction. There is a substantial amount of force created through the leg as the whole body weight is lifted upwards. On physical exam in the ER, x-rays did reveal that there was no fracture, but there was a soft tissue injury that was suspected. So the climber was given crutches and soft knee support and told to follow up in sports medicine clinic two weeks later. In the sports medicine clinic, there was an effusion present and reduced range of motion appreciated. There was also tenderness at the medial and lateral joint lines. There was laxity and a soft end point in the PCL. However, the ACL, MCL, and LCL were all noted to be intact. On MRI imaging, there was a complete tear of the anterior lateral bundle and a partial tear of the posterior medial bundle of the PCL. And so our diagnosis here is a tear of the PCL. So in terms of management, we recommended extension brace and crutches. And the patient then started PT at about four weeks, working on range of motion and strengthening. And then at about a year later, his PCL laxity had stabilized with a solid end point and his pain had basically resolved. However, even though he was able to return to climbing, his ability to perform the heel hook remained impaired. So that's all the time we have, but that was just a couple of cases that hopefully you were able to think through after these lectures. And here's Chris just to finish up. And also, I just would like to recommend that you all give climbing a try at some point in time, probably not in flip-flops like I sometimes do. Thanks. Thanks so much, everyone. Thank you for tuning in and thanks to our speakers for all that wonderful information. I do just want to kind of wrap this up real quick with a few take home points. So the key things here, rock climbing is becoming more mainstream. You're going to see this in your clinic and a basic understanding of climbing disciplines and terminology will serve you well. Chronic injuries, think about the upper extremities, acute injuries, lower extremities. Injuries can occur falling off, hanging on, and even standing still. Special consideration for youth climbers, remember the growth plates. That has to be on your differential when a kid has finger pain. An ultrasound can be incredibly valuable for diagnosing hand and finger injuries. When you're looking for those pulleys, find them in short axis, then long axis, and be consistent when you're measuring your tendon phalanx distance. Rock climbers present with unique injuries, pulley ruptures, lumbrical tears, finger stress fractures, et cetera. And so having some understanding of this is very helpful. We have a long way to go when it comes to climbing research. If this is a field you're interested in, help us out. There's a lot of work to be done. Thank you all. Hopefully you enjoyed this talk and hopefully this helps you treat climbers in the future.

rock climbing injuries

sub-disciplines of rock climbing

indoor climbing gyms

epidemiology of climbing injuries

mechanisms of climbing injuries

diagnostic ultrasound

hand imaging

pulleys

tendon phalanx distance

treatment options