SELF TEST: Can You Diagnose the 3 Most Common Wrist Pains with Climbing?



You’ve searched the internet for your wrist pain, clicking, clunking and you’ve come up with a wrist TFCC injury. All the websites point towards it. Think again. This region of fibrocartilage is the least likely pain creator in a climber. Read below to learn why. First, I show you the other more likely injuries that you can sustain in your wrist. Ligamentous tears, tendonosis, or just plain hyper mobility (without an injury or with a capsular sprain).

Here are the three most common scenarios common to climbers. Try to think through each as to what injury they might have, and if this might be you, learn more about these textbook injuries that I see commonly in my office.

Scenario One: The Aggressive Barn Door


You grab onto a vertical or past vertical overhead hold and then barn door off of it, twisting your whole body about your wrist while you attempt not to let go. Some, with the torsion and force going into the wrist itself, will feel tearing, popping and/or immediate pain. All will feel gingerly uncomfortable with using the wrist after this injury and have conflicting thoughts about trusting the wrist again in the same type of a scenario. This feels unsafe with all climbing holds and it might or might not be swollen compared to the opposing side.


Location: Center of wrist or anywhere in a focal, small or large region of the wrist. Often felt on the top (or back) of the wrist and can be near the base of the thumb, along the midline, or towards the outer side of the wrist.











Scenario Two: The Abnormal Shift or Popping Sensation


You load into a full on overhead sloper, with full wrist flexion, and you feel your wrist gap and give with or without pain or pops. This happens often, might or might not be accompanied by pain, and it feels unstable with loading. You likely have not had a major injury prior to this, and likely are very flexible in regards to joint mobility.

Location: Deep within the wrist as compared to superficial, feels more like joint than muscle or tendon, feels like gapping or shifting. Symptoms occur with loading of the wrist, not with wrist motions while unloaded.






Scenario 3: Chronic pain, clicking or snapping at the wrist.


You begin having slowly increasing and/or constantly chronic wrist pain with climbing that is focused to the underside of the wrist in the outer quadrant of your wrist in line with your 5th digit (pinkie) or in midline down the wrist. This hurts with side pulls, slopers, wide pinches, and/or underclings. You likely have a high computer use, are a guitar player and/or play computer games in your off time.

Location: Feels like it is along the surface, feels like structures rubbing/pinching or a sharp pain in a focal region along along the bone/tendon interface with wrist side to side motion or flexion extension motions. You likely feel clicks and snaps as you rotate the wrist or bend the wrist in the same region in severe cases.





SOLUTIONS:


Ok, now that you have read the above common scenarios, think back through what each of them might be and ask yourself, is this a muscle thing, a tendon thing, or is it joint. Could it be a true injury? Is it just something physiological and normal for that body? Is it something you should train through? Should you seek medical attention (or rehab it at home, and how?!)


NOTE: Though I am a medical provider, the treatments and conditions presented might not reflect your unique injury. Do not attempt any of the advice or recommendations without medical oversight unless you are comfortable working through an incorrect diagnosis. The below wrist is one that we have done imaging with additional injected dye to try to evaluate where the shifting is occurring. I sent this patient out for an additional diagnostic ultrasound as the motionless MRI (in neutral position) did not show any abnormalities. If at first you don't get the information you need, dig deeper my friend.


Above: Arthrogram of the wrist in a climber with wrist instability

Answers:



Scenario 1. This could be as minor as a capsular strain. A joint overstretch injury, if you keep it moving and try to load it again in a few weeks, it should be back to normal. Conversely, if it felt like a TRUE TEAR, it could be the more rare ligament tear. This ligamentous Instability occurs between the carpals or radioulnar joint of the wrist. I see it a few times a year (unlike the capsular strains which I see weekly) and it is accompanied by visible swelling, sometimes bruising, and always weakness. You cannot grip a hold, you cannot try to keep going on it. This is how you know.

If you tore a ligament between your carpals, depending on the location, these ligaments are repaired if they affect the stability of the wrist in a way that can cause further injury. One is visible on an X-ray (the Terry Thompson Sign, look it up) Others are less obvious. If the carpal to carpal ligament is not repaired, which can be conservatively managed without surgery in most cases, this “shift” or “clunk” you feel during climbing is completely fine. We instead conservatively manage it with positioning, rehabilitation and stability work with a physical therapist. NOTE: If you have had this injury, you need to go to a doc to have it imaged so we can decide what route to take. Doing nothing might not be your best choice at this time. This is one of the few examples that you definitely need medical advice. And soon.

Answer Scenario 2: This client has symptoms that parallel joint laxity. Often genetic and not earned, there are now 24 types of collagen (at the time of writing this, it could be higher now!) which make up the tissue that decidedly make your joints either tight and rigid, or stretchy and flexible. There is a whole spectrum of tissue types that make us different. Mine are flexible and prone to injury, yours might be overly tight (and prone to a whole different array of injuries). Some climbers have to work on wrist stability and load homework to keep their wrists from gapping. Luckily for you, if you are young, it is likely to tighten up with age!

Answer Scenario 3: This client has tendonitis (likely tendonosis) of the wrist flexors secondary to chronic overload. If we could only get this client to unload their wrist in their daily activities and training, it should heal nicely. But keep in mind, the previous damage is now a risk factor for future flareups. This is a management case as we cannot repair the past damage, but we can keep it from getting worse. As this injury is a case of cumulative damage, quick action is needed to unload it and to help it to heal. These efforts will be rewarded with many more years of enjoying your favorite sport (and your job) without pain and disability. As I have seen many climbers be forced to stop climbing or to change their job due to pain created with tendonitis, it is my medical opinion that this is an injury that is a very important watch zone. You don’t want to ignore it and pull through it. The approach on this is two pronged, focus where the injury is and also on the factors that have caused it in the first place. This will help it to heal and then more importantly, keep it from coming back.

So in discussion, none of these three cases above are specifically or only TFCC injuries. Climbers who feel their TFCC is torn are often unhappy with rehab and care (and bracing) if this diagnosis is incorrect. For correct diagnosis of a TFCC tear, we can do a diagnostic ultrasound to visualize any nearby tendon abnormalities (tendonosis), we can look within the wrist to look for ligamentous tears, and we can look at the TFCC itself to look for abnormalities in regards to blood flow with Doppler. But you need to get in sooner than later, because if it heals, the doppler does not show abnormal blood flow any more. I HATE that wrist widget says this on their website:



This is incorrect in SO many ways, and doesn't come with a medical disclaimer either. NOR do they back up their claim with any research. Capsular injuries such as sprains respond nicely to taping, so do a few others, so please keep thinking for yourself and asking questions :-)


So What about the TFCC?



Wrists are complicated. A 3 joint line, the wrist consists of the line of joints that connects the forearm to the hand, and then the lines of joints that allow the hand to bend and flex as you pinch, grasp and load in your favorite sport. Many of you have questions regarding the wrist widget, TFCC cartilage injuries and returning to climbing after a nasty wrist injury. I hit the big 3 above that I see constantly in my office so you can see the difference. Conversely, TFCC injuries involve a load into the wrist (such as dropping down into a pushup) with a side-bend load into the outer aspect of the wrist. Imagine shaking someone’s hand and they grab your hand, bend it toward the ground, and jam it together. This is the mechanism of a TFCC injury.


Other mechanisms of TFCC injuries include hyperextension of the wrist with load such as in weight lifting, or doing hand stands (and your arm accidentally gives way and you fall onto the wrist at an angle). Luckily, climbing is at the opposing angle, it opens the joint instead of jamming it, it is likely flexion instead of extension, AND we do get into side pulls however there is rarely a smack into the wrist into this angle unless you have a big whipper on a rope or land wrong onto the pad. These two mechanisms would lead me to do advanced imaging of your wrist for a possible TFCC diagnosis. Weight lifters, baseball/tennis, gymnasts and parkour clients are much more likely to have this injury than climbers.

With this said, I order imaging often on the wrist to evaluate tendonitis, tendonosis, hypermobilty, ligamentous instability and joint damage. My clients can go to a local imaging center for this evaluation in conjunction with my care. Don’t feel like you are lost, wherever you live. All of these scenarios I give are clients that we got back to climbing at 100%. The first scenario did need surgery, she did tear the ligaments that hold the wrist to the ulna. She was back to bouldering at 100% within 14 months. And then we saw her for a shoulder ;-)

Life is long. Go live it!! And if you need help along the way, I am here.

Dr. Lisa

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