Ep 3: The Less Common Finger Injuries

[Music] Hi and welcome to the Climbing Injury Podcast hosted by St. Anker's Jefferson and James Walker. As our sport grows so do the injury rates and our hope is that through sharing of knowledge and experience we can understand climbing injuries better, treat them better and hopefully prevent some of them from ever happening. As we're both physiotherapists talking about injuries and injury prevention this podcast will be aimed at healthcare professionals working with climbers but hopefully there will be something here for all climbers curious about climbing injuries and injury prevention. Feel free to drop us a message with questions or subjects you would like us to address and if you like what we're doing please support us at patreon.com Hello and welcome to another episode of the Climbing Injury Podcast. I'm St. Anker and I'm sitting here with James. Hi James. Hey St. Anker, how you doing? I'm doing fine. Thanks and you? Good, yeah I'm all good, thank you. So now we spent like five hours discussing pulley injuries, pulley ruptures but there are obviously other conditions that affect the climbing finger. So we wanted to spend the next hour so discussing the lesser known finger injuries and see like the clinical signs and symptoms and what we can do if they happen. So what do you think about our James? Now I think that'll be useful for people because yeah definitely pulley injuries are the most common climbing injury but there are lots of other injuries of the finger and also into their hand that will be useful for people to understand how to identify themselves and differentiate themselves and also bits of tips and advice about how to manage injuries as well. Cool so we thought we would discuss Tino, Cino virus or Tino Vaginitis. We can come back to the semantics on that, lumbarical shifts in rooms and joint pain in general. That's what we try to cover over this next the next hour or so. So before we start, Stephen, let's I think listeners might be interested in seeing and getting update on how your finger is doing. So yeah let me just for people who haven't listened before or just to revamp people. So you ruptured your A4 pulley of your which finger was it now? My ring finger on the left hand. Ring finger and that was when you were in Fontan Blur how long ago was it now? Well today on May 25th it's been six weeks and two days so I ruptured it on May no April 11. Okay so yeah do you want to give people a bit of an update on how that is going and kind of how you've managed it and how it's progressed in the last few weeks? Yeah I can do. It's been interesting. I wanted to test sort of test my hypothesis if I could load it early and if I could progress way more aggressive than I would do with other people because it's easier to experiment on yourself. So from like day two after injury I started loading it and I've described that on on Instagram and on the previous episodes as well with an progressive increase in force production less pain more and more back to to climbing and bulging. It hasn't been hasn't been painful to the degree where I felt that I had to back off. I've never had increased swelling after sessions so even after like week three to four when I started doing more like rapid eccentric jump catch to edges and more exposure to smaller holds on a spray wall it's been behaving quite nicely afterwards and then I had one session outdoors climbing like I saw it out one of the few cliffs around also which is a bit steeper with with more incoote holds incoote crimps and I climbed on that and I felt like this even though I know that this will heal up and I know that is not dangerous I felt still quite like fair avoidant to grab to grab holds especially in like high angle crimps and and like from three crimps and when I done that move a couple of times then I knew that it was fine but I was quite like hesitant to do that at first so it felt more it became this sort of mental game that I find that many patients find themselves in as well that even though it's not directly painful you're still quite hesitant to grab stuff grab small holds quite quickly so I tried to work more on on the rate of forest development and and do things quickly from like week four and then it was almost no pain when climbing and not increased swelling after climbing but then as I told you when we message about it was that it like after week four it started to feel stiffer so it was like when I woke up in the morning it was harder to bend the finger fully in like to flex the PIP joint and it felt like stiffer when it wasn't moved or loaded but then if I did like just 10 seconds push where I could just push my push a half crimp towards my thumb and did that for 10 seconds then it would be way more flexible again afterwards so I thought myself that this might be some sort of healing process with more scar tissue formation which makes sense like after week four and then when I checked on the ultrasound and the tendon bone distance had decreased with a with a millimeter or so so not much but it sort of correlates a bit to this sensation and feeling of stiffness that I have so when I climb now I feel more or less back to normal I have the same strength like when it comes to pure forest production I can I can lift and pull the same on my left hand as my right hand the same with the one finger half-crim and I'm not very fair-o-void at all at the moment and I can still I can climb both roots and boulders on a level that I'm happy with but it's still not is is not a hundred percent it's still a bit stiffer so I don't know yet but it's moving in the right direction at least yes that's really really interesting and yeah I don't think it suddenly means that that's what everybody should do in terms of treating pulley injuries I think we spoke about this a lot over the last couple of episodes but it's really interesting isn't that that you've managed to get back to a perception of almost kind of normality just after six weeks and like I said really in previous episodes what's what's the kind of factor from my point of view which which needs to be questioned really is how much of that's to do with your ability of being such an experienced high-level climber and and how much is the risk versus reward of starting to load it early because it could that if we don't load it and allow it to just kind of settle and heal and then start loading it there's pretty much no risk involved whatsoever whereas if you start to load it early it could potentially trigger a cycle of irritation and making it last even longer than it needs to but it's yes it's a really interesting one it's it's really interested to see how how quickly you've managed to progress it so it's certainly a useful little experiment is that yeah it's very useful and I think that my my order regulation is good probably better than most climbers so I know what to do and I know what happens and I know how to progress and I know how when to slow down and I even though I've sort of tried to be aggressive I don't feel that I've pushed things too far in any session I haven't done anything that that I have felt that was out of control but I don't think that this necessarily is is like the way for everyone and that's that's an important disclaimer as well that I I can do this based on my experience with a lot of patients and my knowledge of of the condition and also that I kind of know how to climb and how to train and I can regulate the sessions to become a harder or easier throughout the session based on how I feel, because I've done this for so long. And I think that if you were less experienced than me, I just wanted to go all in from day two. You would probably have more swelling and more pain and you would be more insecure if you fold the right path. And but I think what it shows is also that if you are an experienced climber or an athlete, and you have some, you have a time limit, so to say. So I could, I feel that if I were at the World Cup level, which I'm unfortunately I'm not, but if I were, then I could climb World Cup this weekend without being worried of doing anything wrong to my finger. And that's like six weeks post an A4 injury and I haven't, like back to normal strength. So for some people, some climbers, some athletes, it shows that you can move quite quickly forward through this process. If you have a time frame or you have to, you have some sort of deadline on when you should be, should be back. And if there aren't any severe long term consequences of going for that, like if you were going to World Championships or Olympics or whatever, it's make or break, then I don't see if you don't, if you don't cause any long term negative effects to your finger by trying to make it, then we should try it and maybe not be as conservative. But then for other people, then we might try to slow it down a bit and then be a bit more, build it up over a longer period of time. But I do find it quite interesting also that it seems like the tendon bone distance decreases. So there is some kind of healing and discard issue formation that still pushes the tendon down, maybe to a bigger degree than what I thought it would be. Yeah, I think this tricky isn't it? Because yeah, a completely agree if you had a World Cup or World Championships or Olympics and something like that, you would just try and push things. But that's more talking about the world of the league sport. I think listeners would probably be surprised to hear about examples of other sports and you've heard about this, and then in all of us, we're talking about climbing here. But you imagine you've got, I don't know, some sort of the football World Cup final, Champions League final, something like that. Like they will do pain relief injections, free days in a row before thing. You know what I mean? They're just so high rewards of these things are so high. You hear about athletes getting to the end of their career when they're doing all sorts to keep them just going from match to match. And so it's tricky to know whether, because it works for high level athletes, whether it's the good idea to do it for the general climber. And as we well know, climbers will have, and one of the things that we're going to go on today is maybe why, especially with the joint issues that we'll talk about is any reason for a climber to keep climbing, they will take it. Do you know what I mean? Like they'll always go towards the idea of keep going, keep pushing, keep training. So it's that balance and act, like I said before, with the risk versus reward of how quickly he wants to start to push things after an injury. But yeah, this is, again, we'll go full circle. This is one of the reasons we want to start this podcast is because we are still absolutely at the stage where we don't know what the absolute best way to manage these injuries are. And yeah, your sort of experiment yourself is an interesting one. But like I said, when I text you last week, like we could do with you, you're a 2-poly because we both think that the A4 is not as important and it'd be super interesting to see what would have happened if you had done this approach for an A2-poly. But this is, that's up to you now, James. Now you're just going some milestone, Craig. So you crimp the living shit out of it. And then you'll rough your A2. No, I think we agree on this. And I think we had some good discussions on it. And I think like this is a conservative approach in terms of that there's no medications, there's no injections. I sincerely believe that there aren't any severe long term consequences of trying this approach. But I still think that we shouldn't look to the absolute elite athletes on how they train or how they manage their injuries. Like we have downhill skiers in Norway that rupture their ACL and the knee, get a surgery and then they come back and they win the World Championships nine months later. And like that's not possible if you're not experienced, if you're not well trained, if your life isn't fully only about doing high speed on a downhill slope. So yeah, I think we can learn something from the principle so that it might be possible to load earlier and maybe be a bit more aggressive and it could work out good. But it's not necessarily like we should look to the extreme elite level athletes for how to manage these kinds of injuries. So and I'm not a very elite level athlete. I'm a father of two and have a normal life and I train like three to four times a week. So it's like if I can manage this, then a lot of, a lot more people can manage it and then you can sort of just scale it down a bit, I think. Well, that was a quick recap on the finger. So hopefully it will still keep on improving and now we can discuss some other things. So maybe we could start with Tino, Sinovirus and why that's at least the way I see it, maybe the second most common injury or stress reaction to the fingers that I see in my clinic. I don't know how about you. - Yes, potentially I think it depends what we are defining as a true Tino, Sinovirus because I think there is a crossover between what I would call Morozae pulley irritation and then a true Tino, Sinovirus where potentially the whole finger is kind of swollen and you have that morning stiffness into the finger and things like that. So yes, I think it is common. I definitely see a lot of joint issues which we'll go on to talk about as well, basically the middle joint, the PI key joint of the finger. But yeah, well first of all, let's discuss that. What is a Tino side of itus and how does it present in clinic to itself? - Well, the Tino, Sinovirus refers to a condition that affects the tendon sheet. So the tendons they run inside tendon sheets and the tendon sheet is also a part of the complex that makes up all the connective tissue inside your palm, including the pulleys. So the tendon sheet is covered with the Sinovirus membrane same as in your joints and the membrane produces some fluid so that the tendon can glide frictionless through this tendon sheet. With enough irritation, strain, compression, then the Sinovirus membrane can be irritated and produce more fluid. So there's a thickening within the tendon sheet and it's not like that fluid is varied then it gets quite thick. And especially if you haven't moved it in a while, it's even thicker and more rigorous. So not so easy for the tendon to slide through. So that's sort of like the Tino Sinovirus name and it often represents as pain over the the roller aspect of the finger so the inside of your hand over the proximal and the interfalanx. So sort of between where the finger starts of the MCP joint up to the PIP joint and up to the DIP joint. So the location is often the same as if it was a pulley rupture and that's why I think it's important that we discuss the difference between a pulley rupture and the Tino Sinovirus. - Yes and that's where, yeah, so there's a couple of things that are really obvious from a assessment point of view to differentiate between those things. So we do, as physiotherapists, we do what we call a subjective history which is basically asking people questions about when it started, how long it's been going on for, the presentation of the pain, what makes it her, is it so night, more than it's just all this sort of question. questions about history. And yes, a fully rupture will always come on in in the cute fashion, won't it? It will be from an incident, you know, most likely, you know, for crimping or or on a hold and they will have a sort of mechanism of injury. Whereas it's, you know, side of it doesn't tend to come on like that. They can come on rapidly. I've seen them where someone will have a real increase in training loads and it can come on seemingly over kind of like two or three days or it can have a gradual build up over a longer period of time. And then what we call objectively, which is again, actually physically assessing the finger, it can be a little bit harder to visually do that because, like St. Amma say, if you sort of push it to the finger or even ask where it's sore, it potentially will seem just like a A2 or an A4 pulley kind of injury. But there's a couple of things that tend to be different. So first of all, actually in a sort of what I would class it to true Tino sign about is that the actual finger itself tends to be kind of swollen, whereas often with actual pulley strains or irritations or actually even with pulley ruptures, there's not a huge amount of swelling always around the kind of the hole of the finger. And then the second thing that we can differentiate it with is an ultrasound scan. So with obviously a pulley injury or pulley rupture, we see this sort of bow stringing or the tendon coming away from the bone like a gap. Whereas we don't see it out with a Tino sign about this, but what we do see is we see something called a halo sign or a halo effect, which what that basically means is when you are using the ultrasound scanner and you are holding it, sort of sideways onto the finger. So you have what we call a transverse view of the finger. You can see the tendons running through the middle, but then you get this kind of like black halo around the tendons. And again, I think things that I read is that clinically you can actually measure that distance as well between the sort of actual tendon itself and the, I guess there would be the diomptoms, I think I would say, from the actual halo effect. And roughly it is kind of two millimeters or more that would be kind of classed as a Tino sign of it. But I think the ultrasound scan is almost part of the picture there. With a pulley rupture, it is a, you could probably not even ask anybody any questions and just scan their finger and you can just see if it is ruptured or not. Whereas the Tino sign of it is more of a build up of the whole questions and the history of it. And then yeah, like as I said just before, couple of designs that I tend to see is people talking about morning kind of symptoms being worse when they first wake up and the stiffness within the finger and the joint. Yeah, would you agree with those points? Yeah, definitely. I think it is at least a swelling and the morning stiffness and that it can often be painful to fully flex the finger. It's painful to load often, especially in a half crimp. And sort of like always in this, in our line of work that the patient is usually telling us the diagnosis. So like if they come in and they have pain over the same aspect as they would have if it was a pulley rupture and that it hasn't been an acute incident then then it's probably something something else and that something else usually is some sort of irritation of the synovial membrane. So some sort of Tino Cinemidus and then an ultrasound scan will confirm the diagnosis. But then again, if you see a lot of experience climbers, they tend to have quite a lot of fluid around the tendons nonetheless. So you always have to compare compared to the other fingers. And so like two millimeters is fine as a guide, but then you should compare it to the neighboring fingers and also the fingers on the other hand. So yeah, I agree with that. And you would just say and before we started recording, we just have a quick catch up. And you were saying that you feel that sometimes you see this from a repetitive direct pressure into the finger. You're using the example of a kiln of oil. If you want to just expand that a little bit. Yeah, you can it could be like any sort of incertjog. So if it if that's the cause, if that's where it's starting, it's I don't know, it's not always that easy to to find, but many people when they start to have some some finger pain, they tend to drop the intensity and then just figure out they're going to climb easier, easier grades and then do more moves because that's intuitively the right thing to do. But then if you do that indoors and you do it on steep walls and you will always climb on incertjogs or at least incert holds. And so you see you see this external compression from from the incert holds that they sort of just push and compress onto the tendon sheet. And that happens if you do weighted pull up on a narrow bar. If you do like, kill the boards, for instance, where you have a lot of incertjogs and you can tilt it to like 50 degrees and do quite hard hard moves on it. And so you have this repetitive compression from the hold onto the onto the palm and the inside of your finger. So I think that that can often be be a cause so that you could you could get it directly from these sessions and it could also be a worsening of the problem that you have some finger pain and then you decide to climb easier on incert holds and then it would just get worse. Yeah, I see that a lot with with climbers replacing the intensity for volume. And that's not always the the best idea is it the perception is that it's easier. Because again, what climbers want to do is sort of if they're not doing intensity, they still want to feel like they've tried kind of hard or feel like they've maybe pushed themselves a little bit and replacing that volume where they might kind of feel tired or feel pumped or whatever is something that they'll intuitively do. But because of the reasons, the end just said that's not always a solution. Sometimes it even makes it worse and again, when we go on to talk about joint issues as well, that repetitive high volume of loading of the finger and the joint is sometimes even worse than short sessions, short intense sessions. So in terms of treatment of that, what we would recommend, from my point of view, one of the big differences compared to like the pulley strains, for example, would be that I do like to try and address that sort of inflammation that you have within the finger. I think it's quite useful to do that and sometimes what happens is you get this what we call inflammatory cycle, whether the brain and the body becomes almost hypersensitive to increasing that level of swelling. So I like to do, I guess I call them sort of anti-inflammatory techniques and have a period of time where we completely modify the load. So that's looking at the persons training and climbing and volume intensity and explaining, like we've just said, how it's important to modify and reduce the overall amount of stress through the finger to kind of sometimes give a little bit of a break. But yeah, sometimes I will talk to people about what we call anti-inflammatory techniques. So that will be things like this sort of top end of the scale that would be like actually taking anti-inflammatory, it's like taking agro-profen or even a prescribed medication called the proxet, which GP would have to prescribe. And then it would be other things like massaging the finger or massage rings, it would be icing the finger or using anti-inflammatory gels or the other thing that I think is quite useful is the compressive bandage, the cohesive bandage, which provides some compression to the finger. And sometimes I like to have a week or two, where the person will mainly be focusing on trying to reduce that sort of inflammation, visible inflammation within the finger to kind of like cut that cycle and that leaves up with a nice kind of base sort of starts to build upon. Yeah, do you think the sort of addressing the inflammation is this? as a useful thing to do? Yeah, I think it depends a bit on where people are in their pain and inflammation phase. So if they have a lot of swelling and that it doesn't take much load to aggravate it, so there's clear signs that you have an inflammation within the tendon sheet and yeah, insides or I know some recommend steroid injections directly into the tendon sheet. I don't think we have data to support the either or the other way, but I've seen too many failed cases of injections in and around tendons that I feel comfortable doing that. So I think the way you describe it, that if you want to do some medication, then do it systemically through tablets or even try with gels and see if it works, at least it doesn't do any harm in a long term. And then have a couple of weeks where you take the total load down. So I prefer to try to keep the intensity high, but the volume low and then maybe take away climbing for a week and just do finger boarding. So you have, you could still like load the finger, but not that much and you take away all these small eccentric faces and the shock loading of actually grabbing onto hold so you can do everything in a controlled way. So you get the inflammation under control, you see the swelling goes down and then you build from there. I guess that's sort of the same way as you do it. Yeah, I think so, I mean to be honest, it's a very similar approach to how we would treat pulley strains and irritations like modify the load, like you say, like really reduce that. It's all individual, so it all kind of depends on the level of the climber and where they're where they're at, but modify the load. And I'm about to think a load here, like I talk a lot about climbers of sort of changing the dials and what I mean by that is, is that they think about all of the things that they do to train for climbing. And that the person maybe just needs to take a little bit of a break of certain aspects of their climbing, sort of finger intensive stuff, but they can spend their time more time and more effort on other aspects of their training. So it's not like they have to, I think we've seen as sound devices, it isn't like they have to have like huge period of time off, I don't think. So yeah, like you're saying, modify it and be loaded, and then some of that pulley injuries kind of progressively building that load, and the sense of the volume in intensity. I often see this cycle of getting a painful finger and then taking like three weeks off and then going back into climbing, and then this one, it just comes back directly. So I think there is a lot of value in trying to have some kind of load throughout. Like in general, we're not that, like these big drops and tops in load patterns. So like if you use to climb three times a week and then you get a painful finger and it don't climb for three weeks, we have a massive drop in the loading pattern and then you come back into climbing and then everything just flares up again. And so I think we need to get like this inflammation on the control, but also find ways to continuously load the tendon so that you sort of smooth, smooth this curve out of it and avoid these big drops and tops in your loading pattern, which people tend to be quite happy to hear that they can do something instead of like tordual wrist for three weeks. Yeah and that's it. And I speak to patients about this a lot is pain is a really useful thing, but often within injuries kind of pain is king and what I mean by that is patients often don't go and see physiotherapists unless they're in pain and sometimes the patient perceives that once their pain has gone, the problem has gone. And it's really important, like it's the same with saying if you have three weeks off with any injury, your pain's probably going to go, by the way, it's going to settle quite a lot. And so the idea is saying well the pain has gone, therefore my capacity and low tolerance of that finger is now good to go and I can crack on, kind of doesn't make sense because you just have three weeks off so you've kind of got slightly deconditioned. And just because the finger isn't painful doesn't mean that those the tissue and those cells and your brain is ready for you to just go back onto the wall and crack back on. And what I'm trying to do is there a bit like let's make up for last time, I've had three weeks off so I think it feels fine now so let's sort of just get on with it. And often like you say in it, it just kind of flesks back up and it goes the same with high level rehab, you know, if you've had a polybrookcher or any kind of injury, the idea of taking it steady and progressive, say for example you get back up to, let's say 70% of your perceived ability and climate grade and training level and whatever injury you have over that shoulder elbow, whatever is no longer painful, it doesn't necessarily make sense then to just say, great, I'll now go to 100% because I have got no pain anymore, like all that not having pain means is that your brain has decided, again there's no longer any need for the reaction here to be a painful reaction because the current amount of stress and load is within the capacity of that tissue. That doesn't mean that you can suddenly then go back to your previous 100% because that's done a huge job. And yeah, with this Tino Sanivitis, often a period of time of reduced load and maybe do these anti-inflammatory methodologies will make it feel miles better, like or almost symptom-free quite quickly. And what's the insane there is stone and make the mistake of jumping straight back into all of your training and climbing because that's what you tend to get this recurrent cycle of this injury really. Yeah, I agree. And a lot of people also ask about taping if they should tape this, tape their finger and the way I see it is that you can always tape a body part so you can add a novel sensory input to the brain from that body part and it will feel better, but mechanically, it doesn't really make sense that you would want to wrap something around an area which is already swollen and already as sort of subject to too much compression. So I think from a mechanical point of view, then taping these Tino Sanivitis fingers aren't a very good idea, but I acknowledge the fact that it feels more stable and it could feel less painful if you tape it. So I don't know, do you have any pros or cons on taping or not taping on these kinds of issues? No, I don't see the need to tape these whatsoever. Unless it gives the person, I'll rephrase that there's not a necessity to tape it. I don't think it gives the person any mechanical advantage or it doesn't prevent anything else from happening. What if the person feels that their ability to climb and relax and psychologically move without fear, we've taped, then that's fine, and that's okay, it's not, I don't think it's massively detrimental either way. I think tape is useful in sometimes in pulley injuries just because it simply keeps you to a more open hand position. If you haven't got a really high level of awareness, like I think you have seen from your level, those things of climbing, then having a H tape on a finger will just simply prevent you from getting into a crimp and full crimp position, which helps to keep away from those levels of loads. So yeah, Tino Sanivitis, and also in joint issues, I don't think it's very useful, whereas when we go on to speak about lumbarical injuries and flex attendent injuries, I think it's extremely useful to take the finger. So yeah, stay tuned for that info, yeah. And then the podcast. Yeah. Well, I guess we can sort of wrap the Tino Sanivitis up. I'll make an attempt for a conclusion. So try to avoid the incoherd holds or bars that externally compress. into the area. Try to reduce the volume but maintain the intensity. You can have shorter sessions but they can still be harder if you don't provoke too much swelling over the next 24 hours. Most importantly manage the inflammation so get the inflammation under control and then progressively load it the way we want would have done it with a full injury. Does that wrap it up? Sort of okay. That's it, I think that could pull it up. Good, good. Then we can move over to the joint pain and we will at some point we'll do an episode on the adolescent climbers and youth climbers with more like epiphyseal stress injuries but for now we're going to stick to to the common joint pain that climbers tend to get. So you want to describe the typical climbing patient that comes into your office with joint pain in their finger? Yes, so the most common joint to get this in I think would certainly be the middle joint in your finger which is called the PIP joint, the proximal intervallungial joint. However we do see it also in the distal intervallungial joint and I actually saw a lot of that over a COVID time, over lockdown when people were doing a lot of finger boarding and small whole training and let's explain in a moment why I think that was but yeah most of the time we see it in the PIP joint. So yeah let's just explain about these joints then. So a lot of the moving joints in your body are what we call sonovial joints. The reason that we have sonovial joints is to allow sort of nutrition and lubrication of a moving joint. So let's take the PIP joint in the middle of the finger, it has what we call two ends of the bone which have a layer of something called hayland cartilage over them and then surrounding actual joint in a cell you have some called a joint capsule and what called a sonovial membrane. So the joint, the inside of the joint has sonovial fluids and the job of these sonovial fluid is to lubricate the joint but also to provide nutrition and the way we say nutrition we just mean like chemicals that help you know keep the joint healthy and climbing obviously is a spot that puts huge amounts of load through these joints and if you have a mismatch between the capacity and ability for those joints to take load and stress and the amount of load that you're putting through it and sometimes you can get a reaction and irritation either of the sonovial joint and the capsule itself or the actual surfaces of the cartilage remain the joint or both. And the typical presentation that we see is I mean you can visually see it as soon as the person almost walks in it's a sort of big sort of enlarged swollen kind of chunky joint isn't it in on the finger and I think it probably tends to go into two categories you tend to I forget the the acute ones where the person hasn't necessarily got and this is maybe in the younger climber when I say younger one I'm talking about youth climbers but sort of people in there maybe 20s or 30s where they get an acute or what we call the acute uncronic kind of swelling and flare up with that joint but actually they don't necessarily have any adaptive changes to the joint which are kind of there more permanently and then you tend to see some climbers who are a little bit older where they do maybe have some swelling and acute kind of irritation but then even when their fingers are good you look at their fingers and you will see this kind of thickening and enlargement of the joint and even if you sort of poke into that it feels kind of sort of tough and that's what we call sort of adaptive changes of the of the of the joint so yeah in terms of the presentation of how it kind of visually looks and what if you're thinking you're listening I think and is that me that's usually the presentation um yes Ian so from your point of view why do why does this happen like what is some of the common things that you um sort of see um in in the group of climbers who will get this type of problem um I usually see it in correlation to crimping um especially high angle crimping uh which puts the the IP joint into hyper extension and the PIP joint into flexion um can't really call it hyper flexion but is I picture that you put a lot of weight on a bar and then you squat really really deep down and then just imagine what happens to your knee joint so I think what happens is that when you when you crimp hard then the PIP joint is inflection and you distribute the forces running through the joint on a very small surface so you create all these micro damages in in a cartilage and and the joint which causes this inflammation to repair those micro damages and the same thing happens in a DIP joint when you hyper extend it so you you can press the the door so side of the joint and the same reaction happens so I think that I often see it in in terms of that that the people go on to climbing on smaller holds um maybe going to especially like it's around also that you do a lot of climbing on vertical granite so you tend to crimp a lot on vertical granite and on on smaller edges like half a pad so that's one one group of climbers that I see it in and then I see it a lot in in novice climbers that just they just started climbing and they increase their volume so you just put a bit more stress to your finger joints and most people haven't really train their fingers that specifically and then you enter climbing in at the age of 25 and you just do a lot of climbing which affects the joints so I think that's like taking out the older ones that have done this for many many years and have these adaptations in their joint and then that's mainly the two two groups that I see do you agree? Yeah absolutely and um what's what's important to understand about crimping and especially uh full crimping is that not only do you get this higher angle that puts more stress on the joints but you also get a slight rotation within the joints so what happens to develop force into a full crimp and if you're listening you can try try this if you sort of um grab onto something and and full crimp especially with your form over what tends to happen if you to sort of generate more force is you deviate which means turn the wrist slightly to the size we call it ulnar deviation so the little finger um that's out of your forearm is where the ulnar bone is and you deviate your wrist slightly um to get more sort of um force as well as extending your wrist um and what that does is it puts a rotation of rotational force through the actual joint so not only are you compared to if you're in a drag or even a half-grim you start to pull a rotational force through the joint which thus the offset the load um going through the joint and can put sort of little hot spots on the areas of of college and with uh with lots of climbers the idea of training and increasing training is often to just uh push yourself i think there's a bit of a glamourisation of like you just have to try it's really hard to get stronger climbing now the problem is with finger boards is that often you kind of can't see your fingers you can't see what you're doing and people i think i really encourage people to take a picture or film themselves when they are finger-boiling on a normal finger board and i think people be really surprised by oh okay well that just looks symmetrical why is there a gap between those two uh fingers why is there a rotation on one side and not the other and and all these kind of things and i think sometimes yeah if people kind of have a sudden increase in intensity and volume then the joints can sometimes get a get a get affected um i i mentioned before that the di-peed a distal joint i saw a lot of that during lockdown. I think the reason for that is because one, there was a sudden change in the person's intensity and volume of load. They would do a lot of fingerballing because people can get out of the house. Like St. Emma saying, when you are on smaller edges and people are maybe trying to train on 15 million below edges, what happens in some people is you have this hyper extension of the distal interpellent geel joint and the difference with the DIP and the PIP side of ituses, mostly with the DIP you just tend to get most of the pain on the back of the joint, what we call the dole sole below the nail, below the top side of the finger because that's a real compressive spot. Whereas in the PIP joint, I think the person tends to feel pain all around the joint, don't they? So that can be a difference but yeah, I thought that's useful to explain the mechanism of full crimping. But yeah, like St. Emma was saying that again, the volume and intensity going through fingers can be a big factor. Now in terms of the, they're sort of looking at these in the diagnosis, I don't know what you think about this, but the actual, in my opinion, the actual ultrasound scan in this type of injury is not hugely useful. I don't think it tells you a huge amount or actually you don't tend to see that much of it, then you can actually just visibly see on looking at the person's finger, would you agree with that? Yeah, I sometimes you see a bit more fluid within the joint, especially within the PIP joint, but then again, like with the Tino-Sanavitis, then you would have to check the other joints as well because at least experienced climbers tend to have a bit more fluid within their joints, without that being pathological finding, whereas it's more an adaptation to stress and load. So I think ultrasound could be good to exclude any ruptures or anything else, but it's not, I don't rely on an ultrasound scan with these, with these St. Emma-Sanavitis fingers. And I agree with you that the PIP joint seems to affect by the whole of the joint, so it's more painful also on the side, maybe even within the palm side of the hand, as well as on the top. So like if you sort of knock on a table or knock on a door, then it used to be, usually it's quite sore on the on the dorsal side, whereas the DIP joint can be quite specific, like if you go onto a bit a deeper edge size, for instance, then it's not that painful anymore and you can manage fine. So I see more PIP joints than I do DIP joints, but that I think that's because a lot of people climb a lot indoors. And like I said, one thing is the rotational forces on the full crimp, but also like if you climb steep on incoge crimp, then you have a lot of rotational forces on the PIP joints, which I think also seems to cause this irritation of the of the sinomial membrane and then the increase in fluid, which then affects the mobility and the joint and also be painful. So what do you recommend? What do we do with this? What do we do? So I would guess that there'll be a lot of people listening to this podcast to have, I've got this problem or had this problem for a long time and it feels like it's very difficult to get rid of it. Unlike the Tino Sanivitis, which I think is kind of straightforward, I think it can resolve quite quickly. I'll be honest, these are tricky ones. There's some of them that are really, really stubborn aren't they? In terms of, yeah, people can have it for these issues with these middle joints for a long, long time. There are definitely some older climbers. There's a lot of the older, when I say older, 50 and over, sort of sport climbers in the UK and climb on the limestone, who, yeah, that you look at their joints and their super, sort of, nobily and thickened and enlarged and their range of movement is really quite poor and they've just kind of had some level of pain in these joints for a long, long time. Now, whether that's because the mentality of that generation is just to kind of get on with it and just keep climbing regardless and they've just pulled on small lines that crimson for a long time. That's a different conversation, but yes, what I'm trying to get out here is these problems of something that can re-accur and can go off for a long time, but there are definitely ways that they can be resolved and managed. But I think with these ones, often it has to be a good conversation with the patient where they really accept and realise that they have to sort of commit to a change and modification in the way that they approach their climbing and training for an extended period of time to really allow this joint to settle down and not to re-accur. So that's the first thing to say is these can be tricky issues really. So in terms of the things that I like to recommend and do, the first one would be, again, looking at how irritable and how inflamed and sore the joint is and again looking at methods that we can use to reduce inflammation. These problems are are problems that I have sent a couple of people for steroid injections, but that will be in people who have really just tried lots of things and they've gotten to this really chronic cycle of irritation and effort analysis just kind of not really work and that can sometimes be a good method to reduce that sort of chronic cycle of irritation, but it's not very common that that will happen. But again, definitely going back to those kind of anti-inflammatory techniques of potentially a period of time taking anti-inflammatories and icing the joint and using the cohesive compressive bandage I think works quite well. I quite like to pretty much always with these ones, there's an element of reduced range of movement with them, so people will find that they can't fully straighten it and can't fully bend it. Now I'm not a massive fan of tendon glides, just kind of aimlessly opening and closing the hand a hundred times a day within the range of movement that you've currently got. I think climbers like to do it because it feels like just doing something. I'm not sure how useful that is because you move your hands like that all the time, just joint day. So movement of joints that are sore is useful in the same way that some load of joints is useful, but when I took a range of movement, I'm talking about range of movement exercises that actually improve the range of movement of the joint because trying to normalise range of movement in any joint makes sense. Most climbers who have this joint problem will not be able to tuck their fingertips into the palm of their hand. So imagine you're trying to get your fingertips on your palm side, down to touch almost the a-two, probably like the bottom part of your finger. Most climbers have this joint problem will not be able to do that and optimising the range of movement, so doing exercises that actually push into that stiffness in the control the way I think is pretty useful. And the new thing that seems to work quite nicely is just on almost daily kind of light loading on the joint. So I sometimes give some either not, we're not really interested in doing that in like a super progressive way, like we would have a poly injury to try and adapt and strengthen the tissue. We're just doing it from a point of view of loading a joint helps to increase the number of fluid production, helps to sort of get the brain, it's kind of desensitised to load, we're doing some light daily loading, either feet on finger boarding or using a portable board, can be quite nice when people often feel it feels better after that, you know, they will load in and immediately, so I can feel it's a lot easier. But the absolute number one thing in the treatment of these is the modification of load. I think that's a good example of how to do that. and the modification of grip type in my opinion. And that's quite simple really, having, yeah, I like to say instead of the very start of what's talking about these joint issues crimps, it's a crimp problem. So open hand, free finger drive, slopers, things like that, are going to be way less stressful on these joints than small crimps. Volume and intensity, so volumes just being mount of climbing you do, what a number of climbs in the session and intensity is absolutely difficult to go over the grade. And then I think also the type of climbing, so if you are jumping around on holes and dynamically loading and jumping around on a board, that's kind of going to be more stressful than doing some climbing in a bit more of a controlled way. And then last of all, the finger intensive training, so yeah, if you're just trying to keep up with tons of your finger warning, then notifying how you do that is going to be useful. But like I said before, it is not often a case of just a couple of weeks of doing this and it'll be fine. It can often take a really extensive period of time to really reduce this problem to the point of resolution, not just reduce it symptomatically, so then you can start to push again and it kind of re-retets. Yeah, did I miss anything out? Steve, is that covered most of the sort of tips for the approach for this type of injury? - Yeah, we, I think we managed these quite similar. I've also sent a couple for steroids injections. If they, if like the conservative way hasn't worked for a prolonged period of time, which is quite easy. I don't have like, I don't have any massive issues doing that. I joined, they can handle small doses of cortisol really well compared to tendons. So I don't, it's not like you do four or five injections yearly on these fingers. So if that's a necessity to get people forward, then that's a good option. And I think it's worth mentioning as well. But like you say, then load management and management of grip types and holds are key. So and that sort of like, you can embrace a lot of variety in climbing, you can spend some time improving on different kind of grip types that you're not as good as. So like embrace that variety and use it as an advantage. I think it's, I think it's very, very wise and keep people climbing so you don't get into that cycle like we mentioned with the team side of it is of just staying off it for four weeks and then going back into it and then get this bumpy road of backing off and going back in. So I think like I said to you have some light load. So so that you get some continuous into your training with the good hold types for your finger depending on the PIP or the DIP joints. And I also say to people that this is, maybe this is like our ceiling at some point. Like if you push really hard on your training then your finger joints will let you know at some point. So same as if you run a lot then something will will tell you that you have to pull in the brakes a bit. So it's not like every time you get joint pain that there is a severe inflammation but you can have some joint pain which is sort of just a signal that you should change something. So like change your training plan or get some more rest or vary more in terms of wall angles and grip types. And there's not necessarily something that if you've had it once and I got rid of it it will never happen again. It will usually will serve as some sort of a ceiling. And I think that's how I have experienced it for myself over the last couple of years that if I have like really good hard fingery sessions on a spray wall then my joints will definitely let me know that they don't want that session the day after. So it's a different set between that sort of joint pain and the actual scene of it is with a more severe inflammation that you need to handle. You agree? - Yeah, absolutely. And the variety of climbing and training I think is a really useful one because yeah, during my questioning of the person who comes in with this injury I always asked them about sort of what sort of climbing they do and what sort of climbing they like and they're doing sport climbing, older and track climbing and whatever. But with these people who come in these joint problems I always get a section I'm like, okay so you really like crumpy problems? No, I do not know that. It's very much a crumpy problem or a lifestyle kind of small hole type of climber who gets these problems. So and we like to train what we're good at really and we like to do what we're good at. So often we get into a habit of going into the things that we're good at and maybe even sort of doubling down on that. So and there's this interesting thing with climbers where the sort of half crimp is to sort of go to weight to do any sort of training whether that be finger boarding or camp saying or board climbing is kind of hard to dry holds on. So the higher intensity kind of climb intense to begin towards grip positions that maybe load joint. So even if it's just like why don't you change your finger boarding for a while to just train drag free finger drag and why don't you have periods of time where you are climbing on slow person bigger holds and maybe on the con ball and stuff like that rather than just always gearing towards those kind of overhanging small kind of a hold. So yeah, I think that's the other side that I was talking about before whereas you come to the physiotherapist because you're sort of it's become unmanageable and what both physios and patients need to be careful obviously don't just treat the symptoms and we're going back to that pain thing, aren't we? You know, how are we doing? Yeah, much better. It feels much less painful and symptomatic. Thanks very much. But if that person comes back to you in three months or six months at the same problem, well, you've not really resolved anything. So education on the actual how they are approaching their training because let's not misunderstand this. Pauli injuries sometimes have just happened. Join issues don't just happen. It is absolutely something you have done as the climber who has caused these joint issues. And I know that doesn't mistake that as me saying it's kind of your fault that that's happened because obviously people aren't necessarily in any way doing this purposely or recklessly but absolutely it's to do with the amount of repetitive stress on the joints due to the load or volume or training type or hold type that you like to do. So understanding that is really key for more long term and restricting these problems. Yeah, I agree. And I also think it's important to mention that we often recommend people to try to build capacity to tolerate higher loads. So like you see these adaptations in the joints of more experienced climbers that they have thicker bones and broader bases of the joints. So you have some sort of adaptation to load. And if you want to climb on harder grades, at least outdoors, then at some point you would probably have to crimp and then it's obviously something here with the load management so that you're able to to auto regulate that in a good way. But intuitively, then a lot of climbers they start to climb on smaller edges as they get better. But that's not the most controlled way of training on smaller holds. You could throughout a winter of indoor training. You could still just do no hangs on a fingerboard and then just practice on crimps. And that has a specificity to it in that grip position that will cause some sort of adaptation to, like in the joints so that you could probably tolerate a crimping position better when you go out and spring. So there are ways of regulating and controlling the load in a good way using a portable fingerboard or a hangboard at home without really provoking the joints too much. They tend to be provoked when you go on smaller cramps on steeper walls and you do dynamic moves on them. That's usually where it happens. And also what that can do, what you're describing there is you can almost educate the brain on how to hold properly. So again, having the fingers close together, having the support of all of the fingers, getting the little finger engaged, these kinds of things. But also what it can do is help to develop the, what we call intrinsic strength, the intrinsic muscles in the hands like the lumbar muscle in the interrosi muscles, which will help then to sort of support and stabilize the joints and stop them getting isolated and rotated so much. And that can also help to offload the actual sort of joint itself. Yep. Alright, so now we've discussed something that is in very close relation to crimping position. So then we can move on to something that is not very much related to a crimping position, which is flexotendent strains and lumbarical shift syndromes. So I was just taking for granted that you were done with the joint pain now. So we could, so we could move on. So we're both pulley injuries, often tino-cinivitis and joint pain are correlated with half crimped full crimp positions. Then the flexotendent strain and lumbarical shifts in rooms are more associated with the open hand drag positions like open three finger, two finger monos, where you, where your PIP joint is extended and your DIP joint is flexed. So you have two sets of flexor muscles. So you have the the profundus and the superficialis and the profundus goes all the way out to the DIP joint and flexes the DIP joints, whereas the superficialis muscle attaches to the interfalling and flexes the PIP joint. That was a lot of word in one sentence. Sorry for that. So when you hang on to a pocket, like say a two finger pocket where you just hang on from the tip of your fingers or just the outer, outer pads, so to say, most of that load is transferred into the flexor digitorum fundus. And what usually happens is that you get an acute increase in load, so like maybe a foot pop or you pull hard and then you get a strain in the muscle tendon junction going into the forearm, which usually presents itself. It could be painful around the wrist. It could be painful around like inside of the hand, but most commonly I find that there's pain running up to the forearm as that's where the muscle mass of the flexor digitorum fundus is. And then clinically it would be painful to pull in that exact position and the pain is almost gone if you flex in a half-crimp position. Is that resonating good with you James? Yeah, that's right, that's why I will see either a two-finger pocket or somebody in a three-finger drag where maybe that little finger has kind of come off or popped off and they suddenly loaded that ring finger or like you say in a two-finger pocket. What happens when you're in a two-finger pocket or even a three-finger drag is that you will tuck the fingers into the palm that aren't in the hold. So if everyone is listening to their hand and they're in like a two-finger pocket position often their index finger and their little finger will be tucked into the palm. And the reason that you do that intuitively is because it improves the mechanical advantage in their fourth production within the system but what it does do is therefore there's a high level of load and strain and likes the end of saying yeah most of the time people come into me and say I got like an almost electric shock shooting things like down through my wrist and into my forearm that it kind of just dropped off the wall there and there. So yes in terms of the difference between injuries within the actual finger I get and I don't tend to see with these flex-attended strains they usually if we are looking at them from the point of an assessment and an ultrasound scan she's actually pretty normal on your ultrasound scan isn't it very I don't think I've ever seen like an actual tear within the actual tendon itself or even within the muscle this is very much what we call like a strain rather than that I don't know if you have seen any sort of actual tears. No I don't see I don't think I've ever seen any big intramuscular damage on an ultrasound scan on these injuries which is quite it's not funny maybe more surprising that people can like barely lift two kilos of the ground in that position where they injured themselves and then you can't really see any structural damage so I think that says something about the how specific that reposition is that it doesn't really take a lot of load to to provoke the pain and when it comes to grading of muscle injuries then like this this would be a grade one sort of muscle strain probably where the muscle fibers attaches to the tendon as the tendon runs through the muscle and down into into the palm and out to the fingertip and often I use ultrasound more to show people and explain to them that I do understand that this is really really painful but at least there's no massive injury done so we have we can like safely say that we have to start to load this progressively which seems to be a common theme of this episode and yeah I've actually sent athlete and I remember I sent an athlete to a competition a bowling comp a week after they injured they're like they had a flex of tendon strain and the reason why we did that was because the athlete could hang from one hand on four fingers in a half crimp without any pain and the athlete was really good on climbing with four fingers on on a high level and we agreed that they would have to climb on four fingers not to provoke or to re-injure themselves and with that skill level it was okay the athlete could cope with that and it worked out fine so it says something about like how big the difference can be in the grip positions as well so and I often use that as an advantage that as long as we keep loading the muscle tendon unit it's not like you don't load the flex of the eitorin profundus in a half-crim position is just that you add some more meat to the bone so we can start loading in in safe so to say grip positions quite early and then expose progressively and controlled to to more open-handed positions so that's that the same way that you approached them yeah absolutely yeah like you were saying it can be super sore in an open-handed position but they can have no pain in a half-crimp and again it goes back to the experience of the climber like the competition climbers they've got to have that ability to not expose a drop there a little finger or have a foot slip and things like that so depending on the person it can be sometimes a period of time where I'm not recommending so much climbing but sometimes I say that they can in a half-crimp if you're lapsed you can find so this is an example where taping can be extremely useful because what we basically want to prevent is any of the fingers, usually the ring finger that coming isolated. If you look at your hand, the index and the ring finger are a similar size and the middle finger is obviously a little bit longer, but not too this similar. But most people have a significantly smaller pinky. So what we want to do is make sure that that pinky isn't coming off and exposing the ring finger and also putting you into a direct position. So you can really effectively use a taping ethical or de taping where basically you can tape the ring finger and the little finger together. And then that really prevents the chances of that sort of open hand position being exposed. And even to be honest, if a person's on like a four finger open hand, like a sloper, then even then they don't often get too much problems of ears, really, when that kind of finger is isolated. And it's very much to do with how much you're talking in the other finger. So for example, if you have this problem and you really took the little finger down towards your palm and then pull, I feel a lot more painful than if you're loading in a free finger open, but your little finger is straight if I can sense. So yeah, we can-- these are much better injuries to treat, shall we say, the poly injuries, because they're much easier aren't they? There's-- they tend to get better quicker. There's not something that's torn and we're waiting to heal. They don't tend to get irritated, pain sensitive. They don't tend to be stubborn and reacquire and things like that. It's more of an understanding about certain things to avoid. And then Latsdien says, kind of starting to then, after a period of time, progressively build up the tolerance of the tissue into those open hand positions again. And it's written like a lot of finger injuries. We tend to use some of portable boards to lift weight off the ground to do that. And then also you obviously recreate that on the wall as well when it kind of feels ready. Yeah, so that's about it. So about those. Yeah, I agree with-- especially with the progressive loading with portable finger boards, I found really helpful, because it's so easy. If you have a force cell as well, then it's quite easy. But if not, the cheapest way is just to start lifting weights off the ground. And then you can start off as low as you want, and you can build up through longer hangtimes. And the progression ladder is sort of the same as with the pulling tree. That you start off on an acceptable amount of pain when you load it. And you feel safe, and then you build it up towards heavy load, shorter hold time or hang time. And then more like jumping catchin' and more back into normal climbing. And I find that last face, as with the pulling trees, really, really crucial that you can build up the capacity to tolerate how to properly land a three-finger drag, for instance. So yeah, it's not a massive difference between how to address this injury as opposed to a pulling tree. It's just different repositions. And you don't have to worry that much about any swelling in the finger, because usually you just pull on the muscle tendon going through the hand into the arm. So-- Yeah, absolutely. So what we can do that is I think we might have wondered why we've grouped the lumbarical injury and the effects tendon strain. And the reason for that is because they tend to happen in the same kind of mechanism of injury, and actually the rehabilitation is very similar. So I'll just explain what we mean by lumbarical injury. So basically, within the actual palm of the hand, you have some small muscles that are pulled lumbarical muscles. And these are super interesting in the fact that they don't have a bony attachment. They originate from a tendon, and they attach to a tendon. It's very unusual. So they would originate on the actual flexor tendon on the palm side. And let's take the lumbarical between the ring finger and middle finger. Basically, what happens is you have an attachment onto one of the flexor tendons, but also the other flexor tendon. And then what happens then is the muscle kind of goes towards the fingertips. And then it actually comes and attaches to the extensor tendon. And what we call the extensor, what on the back of the fingers is a really bizarre muscle, actually, which it helps to flex the metacarpal phallengial joint at the same time of extending the PIP proximal fund gial joint. So actually, these muscle groups help with your pinching grip type. But that's never how they're injured. And they're injured from these kind of pockets or isolated, free finger dragging. And the reason we call it a shift syndrome is because the muscle is attached to one tendon, and it's attached to the adjacent tendon. And maybe you go into like a two-finger pocket where it happens is one of the tendons gets pulled one way from being in the hold and tucking your finger in. The other tendon is being pulled your way. And you get this like shearing, shifting force. And that's where you can get an interesting actual muscle. So a person will actually feel this within the palm of their hand. It'll feel like it's between the two tendons. And the way for you to recognize that is in you sort of draw a line directly down the middle finger, that I record down the ring finger, that down the little finger. It's sort of in between those lines. But what I tend to find is that sometimes it can maybe be a little bit of both. It can be a little bit of a flex attending strain. I'm the number of strain, almost at the same time. The good news about the number of strain is that their muscles, so muscles, have a little blood supply, a year or much quicker than connective tissue like police. And again, with the correct knowledge and information around grip types and how to sort of work around this. And so forth, I don't tend to find these injuries are particularly particularly bad in the sense of they're not super, super, you know, well, first of all, climber likes them because they can still mostly current climbing in some capacity. But they don't kind of go on and on and on. And the rehabilitation is pretty much the same as what we were talking about for the flex attendant. I don't know whether there's an element of this being because actually people pulling on two finger pockets and one-o-pockets, especially indoors, is really not very common at all. So whatever it's to do with the fact that they don't want to necessarily get back to doing that in the opposite way of most people want to get back to half-grimping or full-grimping, I'm not sure whether it's much harder. We mentioned, for example, the climber and that, the Frankenjurer in Germany where it's kind of pockets everywhere. I wonder whether the rehabilitation of those people for these injuries is a lot harder due to the fact that that's exactly what you want to get back to. And also, they want to get back to doing that in a very high level of capacity. Yeah, I'm not sure about that, but Draco. Well, I would say that if I lived in the Frankenjurer or lived in bux in France, for instance, or in Margolif, and I got a lumbarical shift syndrome or an injury to the lumbarical muscle, while I was working on projects in those areas that would be way more detrimental to me than if I would have it living in Oslo where I mainly crimp. So it would be harder to rehabilitate it in a more joyful way, because you would be more exposed to those grip positions outdoors no matter what you do. So I would speculate the same as you, that it would be probably a bit harder to treat them. But like you say, muscles, they tend to heal up quite nicely and quite quick. And if you do a good, good rehab process, then you should be back to where you were and keep on building on that. And I think that it also, especially for those that doesn't live in areas with a lot of pockets or open-handed grip positions, that it's, I think, it's quite clever to include those hangs in your warm-up drills, for instance, that not necessarily that you train them specifically to build strength or to become better unless you have a goal on building your strength in an open hand position. but if you only train your heavy duty that hangs on a half-crimp, then you don't really train in an open hand position ever. So to do that in a controlled way on a hangboard, as a warm-up drill, I think at least is a some way of maybe reducing the risk injury when you grab onto a pocket at some point. So that could maybe be some advice to take in. But like you say, then most climbers are quite happy to keep on climbing and it's quite easy to avoid those grip positions when you climb in doors or outdoors in areas where there's not a lot of pockets. Yeah, absolutely. All right, great. I think that's pretty much everything that I'm going to say about those last two things. So message and for us, please answer here. No, I think we covered the lesser-known finger injuries for the Lumbarical Shifts Syndrome. If you Google Lumbarical Shifts Syndrome, there's a good illustration of what you explain James, which is maybe easier for people to look at a picture compared only to hearing you explain it so that if you, if people are curious on why it's called a Lumbarical Shifts Syndrome, it's quite easy to understand when you look at the illustration. Besides that, I'll just say thanks for another good hour and a half of nerding on climbing injuries and already looking forward to the next one. Absolutely. I think, yes, I think maybe on the next one we will maybe move away from the finger. Yeah, this will be now what, six and a half hours that people listening about fingers. Maybe they might want to hear about another part of the body. So maybe we'll move on to another part of the body. Yeah. And if people want to reach out to us on social media and actually, excuse me, ask our request, then in sort of specific things that we have missed or if they've even got any questions, then, yeah, feel free to ask for us as well. Alright, cool. Then we'll just say goodnight James until next time. Just stay on the last beat till you get it. Cheers.