Thumbs vs Shoulders

What a good boy!

Those therapists that have written pages of trivia about the instability of the shoulder joint need to take some time out, breathe a little less of their own self-importance, and have a look at the humble thumb. True thumb opposition is a movement unique to humans, and if that's not enough evidence as to why its' stability should rate more highly, it can also take credit for allowing Jack Horner to stuff his face with the best bit of his Christmas pie. Try doing that with your shoulder! 

The thumb carpometacarpal (CMC) joint is a saddle joint. It is capable of 360 degrees of circumduction, as well as abduction, adduction, extension and flexion. It is crucial to good grasp, and essential to pinch. Like the shoulder, it is not solely dependent upon bony congruity for stability, relying significantly upon a network of soft tissue structures. When these structures fail, the stability of the thumb's base is threatened and daily function, let alone sporting function, is significantly impacted.

Not Ivy, but can you see how the downward pressure
 of the bar could force the metacarpal anteriorly?

I see this most usually in older patients who have degenerative osteoarthritis of that CMC joint. Today I saw it in a young, female elite power lifter. At the top of the snatch move apparently, good form combined with normal shoulder bio-mechanics, dictates that the bar with all its weight, rest not in the palm transferring weight down through the arm, but across the first web space. 

For a woman with naturally hyper-mobile joints, this is not ideal. Ivy (not her real name) had developed a subtle palmar instability at the CMC joint in one hand. When under load at the top of the snatch, with the bar's pressure over the distal end of the metacarpal, the joint would feel as if it were about to dislocate anteriorly. It had become painful, and clicky with circumduction. It was perfectly stable with pinch and grip, and her global strength was unaffected, but crucially abductor pollicis longus (APL), extensor pollicis longus and brevis (EPL/B), and extensor carpi radialis brevis (ECRB) were all weak compared to the contra-lateral hand. And surprise, surprise, a national competition was two weeks away.

I did two things, well three really. The first was that I let Ivy educate me in the technique she uses to lift. We then broke down the mechanics of that, and I applied my understanding of anatomy. Based on that, I could explain to Ivy exactly what I felt was happening and why.

The second thing I did was to splint and tape the hand to provide the CMC with the support it was currently lacking. I didn't want a rigid material, so I used a flexible thermoplastic promoted with the potential to enhance joint proprioception. Whether it does or not, an impressive sentence like that is worthy of its' own blog! I then taped in such a way that the CMC had solid AP pressure. Immediately Ivy had relief.

Needs dynamic stability training ASAP.
Might need an opposable thumb first.

Finally, I set Ivy up with a strengthening program which concentrated on the thumb extensors in an attempt to rebuild some of the lost stability. I do think that a lot of why Ivy is having this difficulty is because she is a young woman whose joints are still immature and hypermobile. The problem is that the stresses of her sport have meant that abnormal stress has been placed across a joint that is no longer able to tolerate it. My theory is simple (FYI it's not really my theory. I've borrowed it from Virginia. See the reference below re dynamic stability training for thumbs). If Ivy can strengthen and tighten the muscles that provide her CMC joint with secondary stability, then she can regain control over that joint at the top of the snatch. Then she can take over the world, marry Jack Horner, and become a shoulder physio. 

Look after those fingers,

H

Ref
O'Brien, V., Giveans, M. Effects of a dynamic stability approach in conservative intervention
of the carpometacarpal joint of the thumb: A retrospective study. Journal of Hand therapy (26) 2013 44-52.

My Little Bit

The Australian Rules Football team I work for won the premiership on Saturday. Until last year I'd never been involved consistently in elite sport. I am now a very small part of one of the most successful teams in the history of this sport. Please understand, I know that my contribution to Hawthorn's success amounts to 0.0000005% and a couple of dozen custom neoprene finger stalls. I am not looking for, nor do I expect praise. Rather, I want to recognise, and thank the club and the other medical staff for their excellence and especially for including me as part of that team.

My 0.000005%

I'm about to head off to Malaysia for the International Society for Sports Traumatology of the Hand meeting. I can't recall ever being so motivated about a conference. I look forward to learning as much as I can, so that when the season starts again, I can bring new skills and help the boys go back to back to back! 

Look after those fingers, and GO HAWKS!!

Hamish

What's the matter with Jason?

Don't worry mate, we'll get this sorted

Jason Day, one of the best and most successful golfers Australia has ever produced, has a problem with his thumb. I don't know much else. I could possibly find out, but to be honest, I probably still wouldn't understand what the issue was unless I was to actually have a look at him myself. If he did come down to Melbourne, here's what I'd do. 

1. I'd get a decent history. I'd find out when the symptoms started. Did he hit a rock or a tree as suggested somewhere on the net. Has he changed his swing around that time? Did he play more around that time? Did he trial new gear around that time? There is always a reason, things don't just happen. 

   

   Seriously, don't stress. You're on the right track now!

2. I wouldn't look at any scans.
3. What has he done so far to manage it? What has helped to manage it? What has been of no use at all? What does he need to do and when?
4. I still wouldn't look at any scans.
5. I'd start assessing his hand, wrist, and arm. Sensation, strength, pain, stability, provocative manoeuvres etc. Probably look at his cervical spine and shoulder girdle too.
6. I might look at scans now. 

   

   A scan

7. I'd find out when he gets the pain. Is it at rest? Is it during his swing? His downswing? At impact? At follow through? In the middle of a round? At the start or end of training? Putting vs chipping vs driving? Fades vs power? During any non-golfing activity?
8. We might go to the range so I could watch him hit a few balls. I might video this.
9. I'd reassess his hand and wrist based on what I had seen and based on what Jase (we're mates now) had told me.
10. I would remember at all times that Jason is the golf expert and I am the hand expert. 

    

    The plan would be unlikely to include this bloke!
11. We would then develop a plan based on a thorough understanding of the injury and a complete understanding of what Jason needs his thumb to do.
12. The plan might be a period of rest, it might be splinting, it almost definitely would include strengthening, it might be surgery, it might need advice from others including swing guru's like Ryan Lumsden. It would be a plan that Jason would have to buy into completely. 

There has to be an answer. There has to be a way to getting my new mate Jase back to playing quality golf. It's all starts with asking the right questions.

Look after those fingers,

Hamish

"Tis the Season

When I worked at the public hospital, it was an unwritten rule that we shouldn't be away around Father's Day. This wasn't some Plastics / Hand therapy department scheme to downgrade the importance of this particular "Hallmark" holiday; but rather a recognition that we were about to get busy. 

Father's Day means new toys for the boys. Chainsaw's, circular saws, drop saws, hammer drills. In short, power tools with a particular ability to cut and maim would soon be in the hands of a particular demographic that has no ability to read instructions. It doesn't matter how many sticker's those Dad's had to remove that said "Don't touch blade while it is spinning", they would always find a way to touch that blade, and lose those fingers. 

Guess what happens next...

It was the same at the end of tomato season, when the Italian women would come into the hospital having lost fingertips to a blender that jammed whilst they were making bottles of spaghetti sauce. Funny how I never ate any of the sauce given to me as a thank you present. 

Right now, it's the end of the footy season. That means lots of thumb and wrist reconstructions are coming through. Cricket is about to begin, so soon, I'll be up to my neck in mallet fingers. That, and ulnar sided wrist pain in tennis players and golfers.

One particular golfer is the inspiration for this short piece. The Shark, Greg Norman. Shame it wasn't a shark that cut into his left hand; the chainsaw story just isn't as interesting. Still, it's no surprise. Next time Greg, pay someone to cut down that palm tree that is obstructing your ocean view. Oh, and if you need someone to help you get those fingers curling around a golf club again, give me a call.

Look after those fingers,

Hamish

Goth on a Rock

Me climbing.

   I really like rock climbers. I’d have to say, I have never treated a rock climber I didn’t envy to some degree. Their sport is graceful, but inherently dangerous. It demands strength, but also flexibility. For my son’s birthday recently, we spent the day at an indoor climbing gym. The kids went up and down the walls like rats up drainpipes. I was more like a turtle on a wheelchair access ramp. 

   

    If I wasn’t climbing, I was watching. One climber in particular caught my attention. She was a big woman with Goth style makeup and purple hair. There is no way that if I’d seen her on the street that I would have credited her with any athletic ability whatsoever. I don’t think I’ve ever been more wrong. Watching her focussed repetition and her rehearsed moves as she made her way up a ridiculous wall was hypnotising. And then, like I always do, I started to look at her hands. Every finger was taped.

Ruptured A2 pulley.
Note how the tendon (black line) no longer conforms to the bone.

    When rock climbers come to see me, it is usually for treatment of a finger pulley injury. Pulleys are thin bands of tissues that force the flexor tendons in the finger to glide as closely as possible to the bone, ensuring the most efficient transfer of power. When they tear, the tendon is freed, and will take a more direct path to its’ insertion. This is known as bowstringing. Depending on how bad the tear is, they do respond well to conservative management. 

Tape pre application

    In 2007, Dr Isabelle Schoffl published an article that examined the ability of several taping methods to replicate the role of a finger pulley. She was able, using ultrasound imaging, to determine that one particular method was significantly better at this than others. She called this the “H method” of taping, and I’ll try to explain it below.

• Get an 8- 10cm piece of rigid sports tape
• Split it down the middle longways, leaving a 1cm “bridge” in the middle. The tape should resemble an H now with legs of about 4cm.
• Place the “bridge”, ie the not split bit, over the palm side of the PIP joint (the middle joint of your finger.
• Wrap the ends of the tape closest to your palm around the finger below the PIP joint.
• This bit is important. Bend the finger at that PIP joint to about 30 degrees. Then wrap the remaining two legs around the finger above the PIP joint.
• This is also important. The tape needs to be firm, but not so tight that it makes your finger turn blue or go numb. If that happens, please loosen it off asap.

Finished tape

   When completed, the tape doesn't look significantly different from a circumferential tape, or a figure eight tape. Where it does differ however, is in its’ ability to provide support directly where it is required instead of simply redistributing forces. 

There are several clips on YouTube that demonstrate the technique nicely. I like the fact that the finger still bends easily with the tape on. I really like the fact that Dr Schoffl has quantified finger strength and the tendon / bone relationship with the tape on. I have now even started to adapt this method for taping PIP volar plate strains, as I find it easier than figure eight taping, whilst also being less bulky. The athletes also report that it still gives them the support they need.

Goth on a Rock

I never spoke to the Goth climber. She didn’t get my business card, nor did she get a lesson on H taping. It’s more than likely she didn’t need my help. But if she ever does need that lesson, I’ll be able to show her how to protect her pulleys, confident that science has my back. I’ll even find some purple tape to match her hair!

Look after those fingers,

H

        Refs: Schoffl, I et al. Impact of Taping After Flexor Tendon Pulley Ruptures in Rock Climbers. Journal of Applied Biomechanics 23:52-62, 2007.

It's Only a Little Finger...

An elite level breast stroke swimmer came through the rooms recently. Bart (not his real name) had had surgery to address a wrist injury that had been affecting his ability to train in the pool and in the gym. His rehab went really well, and he was able to get back into training earlier than we'd first expected. Bart's strength and weight bearing tolerance all rapidly came back to pre-injury levels. However something slipped through. 

EDM. Scarring at level of DRUJ

Bart was unable to actively extend his little finger on the affected hand beyond neutral. In fact, he had an extensor lag of that digit, along with a weakness into abduction. In focusing on the wrist, we, and he, had missed tethering of his extensor digiti minimi tendon to scar tissue. Breast strokers touch the wall with both hands at the start of a turn. Whilst there's no real power or heavy pushing required, the hands do need to be flexible enough to absorb and react to the speed with which the swimmer approaches the wall. Bart only realised he lacked this flexibility when he went to touch the wall, and his little finger was not able to actively move into the position it needed to. 

Touch The Wall!!

The lack of movement was minor. It made no difference to his grip strength, nor to his ordinary, every day activities. It didn't directly make his lap times slower. But Bart knew something was different, and that knowledge did make a difference to the activity that mattered the most. We needed to address that so that he could swim with confidence in every part of his body.

Seal with tethered scars. Needs some silicone?

We were able to quickly reverse the tethering of the scar with aggressive massage, stretching, and isolated strengthening. Once we had, Bart said his goodbyes, and resumed his repetitive journey along that endless black line. Good luck for 2016 mate!

Look after those fingers,

H

Move It or Lose It!!

For whatever reason, hand therapists have been a bit behind the ball when it has come to recognising the influence of proprioception on the joints of the hand and wrist. Proprioception has been poorly defined by brevity in the past; now it is best understood as a word that describes the sensory, motor and processing components that help a joint maintain its' stability during functional movement (Hagert, 2012). Unfortunately that definition doesn't mean much to a lot of people, and it's importance in hand and wrist health is not appreciated. 



So rather than force a patient to sit down with a dictionary, or lecture them until their eyes glaze over, I talk about the act of doing. Because if you are "doing", you are probably involving your proprioceptive skills. And if I can convince you to do your doing in a particular manner, then you can amplify those proprioceptive skills.

Osteoarthritis of the hand joints

Why is this important? Well, take oseoarthritis (OA). The lay understanding of this disease is that it refers to the loss of the layer of cartilage over your bones at the joints. When the cartilage is gone, you have bone on bone which is painful. That's osteoarthritis. Yes... to a point. Osteoarthritis is probably a disease that starts well before the cartilage is gone and the bone is degenerate. A new classification system has recommended that OA in the joints is a direct result of OA in the ligaments (McGonagle, 2010). As the ligaments weaken, they aren't able to provide joint stability, and the joint itself becomes stressed leading to bony OA (Tan, 2006). Follow that thinking, and we're back where we started, at proprioception.

Do circus elephants have better joints than their jungle cousins?

Perhaps, if we can convince patients at risk of developing OA (pretty much everyone), to use their hands in such a way that stress is minimised but importantly maximises proprioceptive input, the ability of ligaments to do their job will be enhanced. It goes beyond strength, and movement through a prescribed range because they are only two points of the triangle. Proprioceptive tasks need to be included to ensure joint stability is maintained, and in the case of injury, rehabilitated. That's the why. The "how" is a different matter all together! 

Look after those fingers,

Hamish

Refs:
Hagert, E., Mobargha, N. The role of proprioception in osteoarthritis of the hand and wrist. Current Rheumatology Reviews 2012; 8(4) 278-284

McGonagle, D. The anatomical basis for a novel classification of osteoarthritis and allied disorders. J Anat 2010; 216(3): 279-91.

Tan, AL. Combined high resolution magnetic resonance imaging and histological examination to explore the role of ligaments and tendons in the phenotypic expression of early hand osteoarthritis. Ann Rheum Dis 2006; 65(10): 1267-72

All the answers in one little theory... perhaps not!

Simon "The Wiz" Whitlock showing how the DTM should be done!

If there’s a subject close to my hand therapy heart, it is the “Dart-thrower’s motion” or DTM. For the uninitiated, the DTM was coined in an attempt to describe a pattern of wrist movement that most limits motion between two important bones in the wrist, the scaphoid and the lunate. The reason my ears prick up when DTM is mentioned is that when hand surgeons and therapists first started talking about it in the late 2000’s, I started to integrate it into the management of my patients.

My DTM splint

I created a splint that was designed to limit movement to the DTM. I wrote a paper about it for the Australian Sports Physiotherapy magazine, and was an invited speaker at the International Hand Therapy conference in 2010. I also presented my splinting concept and some preliminary results at a couple of conferences in Australia.

I’ve had some great success with applying these principles, especially with those patients who were prepared to stick with the program I devised. The program involved wearing a splint that restricted motion to the DTM plane, and a progressive series of exercises and proprioceptive activities. One patient in particular stands out. I’ll call him Markos.

Markos "the Glassman" Moya (not his real name or picture!)

Markos had diagnosed mid-carpal instability. He didn’t want surgery because typically the surgery restricts wrist motion. Markos had dreams of joining the world senior’s tennis tour in 18 months’ time. He wore the splint, and was religious with his exercises. Importantly, he also addressed aspects of his tennis game, hitting flatter through the ball. I just googled him to find his is now ranked just outside the top fifty in the world for his age group. He’s living the dream, and is proof the principles work… or is he? 

Classic SL dissociation. Not that easy!

It was the IFSSH scientific committee’s report on wrist biomechanics in 2007 that focussed on the DTM. Since that time, research on the DTM has succeeded spectacularly on muddying the waters. In 2013 they updated their report.  What appeared to be so clear cut, and so useful, is now confused with definitions of different planes of DTM; of functional DTM vs pure DTM, and of potential problems with the movement. We aren’t nearly as convinced now that there is any merit in using it in rehabilitation to protect a dysfunctional joint. Questions have been asked, and answers are still being sought. Memo to self; when you think you know it all, you don’t. It’s that’s simple.

Look after those fingers,

Hamish

Making Sense of Therapy

Looks better in Brown & Gold

I've been to a few of David Butler and Lorimer Moseley's talks. Whilst I am by no means a hardened disciple, I think their core message is solid. If you truly understand the nature of what it is that is causing you pain, then you have a better chance at beating it. David's latest blog discussed an article compared the results of traditional therapy for whiplash, and a brief educational intervention. There was no difference between the results. Whilst he is not discounting the usefulness of traditional hands on treatment, he is questioning the importance we place on it.

NOI Group

From a sports medicine perspective, if I think of the athletes who have recovered from something as simple as a thumb collateral ligament tear; those who sat down, and actively listened to me as I reviewed basic anatomy, healing rates, etc have been less likely to have ongoing problems. Now that opinion has no basis other than a very quick chart review of the first 8 footballers that came to mind, but there has to be merit in making a priority of giving the patient the tools to take ownership of their condition.

I'll stop there, spend your time reading David's article.  David Butler, Time for Motor Freedom

Look after those fingers,

Hamish

What would Tommy Say?

Do you think Tommy Hafey would have spent much time concerned about PIP joint volar plate injuries? Would he have given any thought to a player that complained about jarring his wrist, or spraining a collateral ligament? 

Tommy Hafey played and coached Australian Rules Football at the highest level at a time when the game really was ferocious. He was a hard man, and had high expectations of his teamates and himself. Tommy maintained a rigorous exercise regime right up into his 80's; waking a 5:20 every morning to run 7k, swim in the bay, do 250 pushups and then 700 crunches. He died yesterday aged 82.

I think Tommy Hafey the footballer and coach would have put injuries to fingers and hands pretty low down the pecking order. However, from all accounts, Tommy was a man who showed genuine interest in everyone and everything they did, not just how well they played footy.

I saw Tommy occasionally down at Sorrento when I was out running or paddling in the early morning. He always had a smile, and although he didn't know me, always asked how I was going. I think Tommy Hafey the man would not have ridiculed an athlete who complained of a sore finger as long as that athlete showed the same level of commitment to their sport and their health, that Tommy did. Thanks for the smiles mate, and rest in peace Tommy "T-shirt" Hafey.

Look after those fingers,

Hamish

Zebras and Horses and Golf

I gave up playing golf because I figured I could better spend the 4 hours it takes for a round of frustration trying to get up on a surfboard. Whilst the surfing skills have not advanced to the level I might have hoped, I still love golf. Not so much the frustrations of the game, but rather the minutiae that goes into a golf swing. The biomechanics of grip combined with wrist, elbow and shoulder movement add up to a complicated puzzle that is confused even further by injury. Sometimes however, this puzzle is most easily solved by following the "horses are more common than zebras" analogy.

I've seen a particular professional golfer a couple of times now. She too can have the now generic female patient name of Ivy. Ivy initially came in having had a three month history of left wrist and thumb pain that was worst with loaded thumb extension and wrist extension, i.e. down swing and through impact. An MRI showed bruising around the scaphoid and trapezium. Manual muscle testing indicated weakness of the ECRL and FCR, and pinch strength was reduced.

My thinking was that Ivy had developed a mild radial carpal instability, with micro-trauma in FCR impacting on the trapezium as it crosses it, causing the bone stress over time. I've seen this bruising around the trapezium previously in female golfers. Weakness compounds the injury, which forces patterns of the golf swing to alter in a minor way, but perhaps enough to make the pain worse. 

NOT Ivy

In Ivy's case, she knew that if she didn't extend the wrist as much during the swing, she had less discomfort. I gave Ivy a program of wrist proprioceptive exercises, leading onto muscle specific strengthening to the wrist and thumb. Ivy spent some time with her swing coach, rejoined the tour and reported by email great improvements, until that is, she hit a rock, in China.   

Ivy came back into the clinic yesterday. The wrist pain had gone, now what she had was much more specific to the thumb. Probably related, but different. It was apparent Ivy had worked hard on the wrist exercises. Strength was better, and proprioceptively her control was much better also. What she'd let slip though, were the thumb and hand strengthening exercises. 

Ivy's thumb was now feeling unstable, not clinically, but certainly to her. The left thenar eminence was soft compared with her right hand, and pinch strength was again reduced. Neurological testing was negative. This time, the MRI showed nothing. Now, I could have started looking for zebras, but horses are much more common in Australia, so I focused on the strength. If Ivy can make her thumb strong again, she will be able to keep it stable through her swing. It made sense to Ivy, it made sense to her coach, and it made sense to me. I'll let you know how it pans out.

Look after those fingers,

Hamish

How Specific is Specific?

Specific is very specific is the answer. I recently saw an elite level rower for management of a thumb extensor tendon that she had inadvertently severed on the fin of the hull of her boat. Ivy (not her real name but a nice one) had key competition trials coming up, and her rehab had to be squeezed in somehow.

All power to the thumb

I must have seen over a hundred thumb extensor injuries. It's usually not an especially tricky rehabilitation protocol, you just need to understand how to grade things. The extensor pollicis longus (EPL) is the tendon responsible for hyper-extending the tip of your thumb, and is also responsible for allowing thumb retroposition which is lifting the thumb up, up and away from a flat hand. Ivy had cut hers over the top knuckle of her thumb which meant we could get away with  a hand based splint, and an early motion protocol post surgery.

The only issue was that Ivy was very specific about what she needed the thumb to do. As an elite level rower, she had to be able to actively flex the top joint of her thumb to 70 degrees, and maintain an eccentric load through the EPL in order to control her oar accurately. But what was even more important to her, was that her life after rowing was in no way compromised by a thumb that wouldn't straighten. 

Every session for me became a study of the bio-mechanics of rowing. I have had no experience as a rower, with the few seasons I spent racing outrigger canoes counting for naught. We discussed stroke length, grip strength, grip positions, singles vs doubles, and the myriad of other factors that could affect performance at Ivy's level, right down to the specifics of thumb position.

Go "Ivy" GO!!

Ivy did well in rehab,meeting all the treatment goals we set. However she recently sent me an email after performing exceptionally in the trials. The comment that got me was this, "My thumb felt really good with normal race rowing but the confidence and coordination (ie for the final sprint) is still on the improve." Movement, tendon integrity, and strength were no longer a concern, for they were almost 100%. The specifics Ivy now needed were better proprioception and fine motor co-ordination. And not just for training or for the race, but for the final sprint.

Ivy now has additional exercises designed to help her thumb with that final sprint. No doubt they will help her with life once she steps out of the boat. They will definitely help the next person that cuts a tendon who walks up the stairs and into my clinic because even if they aren't an elite athlete, I know that their specifics will be very specific too. Thanks Ivy, and good luck.

Look after those fingers,

H

Listening to Instinctive Fingers

My dog Barney was hit by a car this morning. Completely my fault. Off the lead, busy road, we are walking to school on one side, and there's a cat on the other. What's a whippet to do but trust his speed and chase? The Mercedes was quicker unfortunately. I ran him to the vet; it looks like he's a lucky dog, and we're a lucky family.

VP protective splint without tape

The thing is, that all the time he was in the vet's rooms, as she was listening to his chest, I was testing his legs. I was stressing the joints, feeling for instability, testing the integrity of the bones. I had to do something, and as ineffectual as it was, it made me feel better.

Now, I'm trying not to prostitute my dog's injuries for the sake of this blog, and it is a long bow to draw I know, but when bad things happen, we so often revert back to what we instinctively know. I've had three people through in the past few days with volar plate injuries to one of their fingers. Two went to someone else first. One listened to herself. 

VP protective splint without tape lateral

The former two came in with fingers that were swollen and angry. One finger was ramrod straight attached to an icypole stick, the other had been splinted in a flexed position for too long. They were both in pain and could barely move their fingers. The third had let her finger rest in the position it wanted to sit in, in about 40 degrees of flexion. She'd iced it, and lightly massaged the joint. There was still swelling, and there was some discomfort, but she was in a much better place because she had listened, albeit subconsciously to her injury. 

I manage all volar plate PIP joint injuries in a similar way. I splint in flexion initially, gradually extending the finger out into extension. Active flexion is encouraged within the limits of the splint. There's plenty of oedema control, and plenty of education. Sure there's a risk of flexion contracture, but with guided splinting the significance of this can be mitigated.

Two of the patients were high level sportswomen. They needed splints to play in, but also protect the injury. I used a product called Cobra Cast, and made volar splints that would limit extension but allow enough to shot a basketball, and permit enough flexion to hold a cricket bat, but still protect the avulsion fracture from impact. I can't claim either had a great game, however I am convinced that by letting the finger heal in a controlled manner, natural and instinctive recovery will occur. Just as it will with Barney.

Look after those fingers,

Hamish

Those that can do...

Stuart Canavan is a physiotherapist that started his private practice around the same time as I started mine. We've stayed in touch over the years, as he and Kathryn Leggo morphed Rowville Physiotherapy into a giant sports medicine hub for the south eastern suburbs. 

They asked me in to chat with their physios about wrist injuries. I could have talked for days, but got an hour. Essentially my message became one of if you understand what goes where, and what does what, you can help the wrist regain the stability lost through injury. Ultimately, it is stability that is essential to the wrist above and beyond strength .

For too long, therapists and rehab professionals have been guilty of handing out static wrist curls and the like, building strength at the expense of stability; even as they prescribe exercises to maximise ankle or shoulder proprioception. In the hand therapy world, that's changing rapidly. Outside of that, the concept remains unusual, and challenging.

Ligaments need stress to be able to do their job. Their job is to tell the wrist what to do, when to relax, and when to tighten up. If they have a lay off, if they are locked up for a period of time, then they need re-education, much as the muscles do. So challenge them.

Do exercises for the wrist in unusual planes incorporating shoulders and elbows. Use balls, bouncing, rolling and catching. Swap a static weight for a dynamic one like a slosh pipe. Take the activities your patient likes to do, and include it as therapy. I had a fly-fisherman come in recently. On his first visit we got the basics under control. The second time he came by, he brought his rod and we fished for gravel in the car park. 

Anderson Hand Therapy may not have morphed into a hand therapy treatment centre megalopolis, but over the past 12 years, it has certainly allowed the part of my brain that devotes itself to hand rehab to morph into more than a one trick pony. And it all starts with what goes where.

Look after those fingers, Hamish

Hands 0, Cannons 0

A game of AFL 9's last night proved fruitless for both my business and my ego. No hand injuries, the Camberwell South Cannons got smashed, and I only bagged the one goal from two attempts. First goal for the season, so I shouldn't be too upset.

To date, I've seen about 6 of the boys on the team and one of the WAG's. Three mallet fingers, two collateral ligament sprains, an arthritic thumb, and one scapho-lunate ligament sprain. All responded brillantly to a bit of reassurance, some thermo-plastic, time and the right exercises.

Oh that it should be that easy all the time. The difference with the Cannons is that they are my mates, they know what I do, and they know I take little injuries seriously. So that then, is the aim of this blog. To spread the word about hand and upper limb injury in sport, and to let people know that if they don't treat a sore hand with respect, it will usually continue to be sore. Which is where I can help.

Look after those fingers,

Hamish