"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