EP 7: Wrist injuries - Have I injured my TFCC?

[Music] Hi and welcome to the Climbing Injury Podcast hosted by St. Ankerstofferson 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. [Music] Hello and welcome to another episode of the Climbing Injury Podcast. I'm your host, St. Ankerstofferson, and I'm here with James Walker. Hi James. [Music] Hey Stian, how you going? [Music] I'm going good. It's been a while now, isn't it? Yes, a couple of months now, about three, where are we now? We are in spring, I suppose you would call it, middle of April now, so yeah, been a fair few months since we have done one of these, but we are back to talk about another area of the body. Yes, and today we thought we should try to cover wrist injuries in climbers. I mean, it's been a while for various reasons, but the most important reason is probably that we're both clinicians, so we do more patient work than we do podcasts, so hopefully that will also be beneficial for the listeners that we actually see the kinds of patients and injuries that we discuss here. And the wrist is an area that is not very well covered in the literature when it comes to climbing. Falker Shuffle released a paper last year, or was it in 2022, regarding wrist injuries in climbing from his database in Germany? Let me have a look. I've just got that paper open as we speak, 2023. So yeah, very recent paper by Volcker-Schofel, who is someone we have had on the podcast and is someone who is a very prolific writer of all things climbing injuries. Yes, this paper is entitled wrist injuries in climbers, so very obvious what that's about. Yeah, and we will link to the paper in the show notes as well for people wanting to read. We can try to cover just some basic anatomy of the wrist. The wrist joint is made up by the two forearm bones, so the radius and the ulnar. The radius bone is the forearm bone going to the thumb side of the arm, and the ulnar is the forearm bone going to the pinky side of the arm. So when we say radius and ulnar, then that's sort of like the landmarks if we can just remember radius going to the thumb and ulnar going towards the pinky side, then it's easier to orientate as we speak. So the two forearm bones, they joint with the carpal bones, which is a collection of small knuckles in the wrist. And the reason probably why the joint is made up that way is so that you have a lot of flexibility to position your hand in space to do all the fine motor work that we do with our hands. And there is a bit more space for the joint to move towards the pinky side, which we call ulnar flexion or an ulnar deviation of the hand. And the increase in mobility that way also comes with the cost of less stability on the ulnar side of the wrist. And that makes sense when we look to focus paper and also our own experience that most climbers seems to suffer more wrist pain on the ulnar side. So the pinky side of the wrist, is that your experience as well? Yeah, absolutely. Almost all of the climbers that come into see me will have pain on this ulnar side. And that's kind of what I call it collectively sort of ulnar-sided wrist pain, because what we'll go into shortly is there may be sort of misunderstanding from the patient point of view about why they have pain on that side of the wrist. But yeah, I'm just reading Volker's paper now. And yeah, one of the conclusions is that ulnar-sided injuries were the most common of the injuries that they saw. And actually, another interesting one, just before I forget this, is that within the paper it also says that 70% of the injuries were chronic injuries, rather than acute injuries. And I don't know if you would agree to the a lot of the wrist injuries that present in clinic aren't from an acute kind of single move or a fall onto the wrist. Some of them are, but a lot of them kind of came on gradually over time, which is what we would call sort of like a chronic injury. Yeah, I agree. And I have sort of a hard time with the word chronic, because it also, it often get misread as irreversible, so that I would say that chronic pain or like chronic wrist pain is not an irreversible state. It's just that the pain has been there for a long time, and not necessarily hadn't acute onset, although you can have an acute onset and then have lingering pain for a long time afterwards. But just to make that clear, that chronic is not the same as irreversible. I think that's a good thing, because people often have a fear of their injury going chronic, but then when you define chronic pain, that's pain that I've lasted for more than three months, which is most of the wrists I see have had pain for more than three months. So chronic is a fine word, just don't get it mixed up with irreversible. Yeah, I think just the word chronic has negative connotations attached to it in general. It could maybe be like acute injury or ongoing injury, like that's, you know, the just the actual phrase chronic is a sort of negative phrase, and it doesn't necessarily mean that, you know, again, with things like chronic pain and that sort of whole area of pain that is ongoing and has lots of maybe other things that are linked into it and so forth. We need to make sure we're not mistaking different areas of terminology. When we say chronic risk injury or acute risk injury, it is quite simple in the fact of, because you can have what called an acute into chronic, or like you had it from one incident, like a fall or something like that, it's an acute injury and then it can turn chronic or it can be a slow onset that's been going on for many months that we'd call chronic, but the terminology shouldn't be used as a way of kind of thinking about the severity of the injury or the prognosis of the injury. And this is one of the reasons why means the end, I've spoken about this a lot, but we really value patient education, because it's very, very difficult, especially with climbing injuries and especially with risks to find informed information sort of online and so forth. And yeah, I mean, we can just talk about that straight away. We just briefly mentioned this before we started recording, but yeah, what the people come into the clinic and say to you, Steve, if a patient's got all-nissided risk pain, what's the kind of the first thing that they say? Well, usually they've Googled on the side of risk pain, nor just risk pain, and the first thing that pops up in a Google search would be a TFCC injury. And a TFCC, like if my Norwegian can translate into English, so that TFCC is the triangular fibro cartiligious complex, is that approved by an Englishman? That's very good. That was a test, that's why I have to explain that. Thank you. Thank you. So for now, we'll just stick with TFCC, I guess, but this fibro cartilage in this complex binds together the bones of the forearm and also stabilizes the wrist on the owner's side. And we can sort of like compare it maybe to the meniscus and the knee. So it is a stabilizing structure on the owner's side of the wrist and it's at least most talked about injury when it comes to risk and usually what most people fear that they've damaged if they have this almost either wrist pain. And a cute TFCC injury or tear could obviously be serious and could need surgery but the injuries are quite rare and not all TFCC injuries even need surgery. So I think it's valuable to discuss the difference between all of the side of a wrist pain which could be a lot of things and a TFCC injury. Yeah, absolutely. I reckon 90% of the climbers that come and see me with wrist pain will just sit down and I say, "How can I help?" and I think I've torn my TFCC. It's very difficult because I've literally just done it now. I've been speaking, I've just googled like wrist pain and climbing or wrist pain and climbers. And almost every single article on the front page of Google is just saying about a TFCC injury. So why wouldn't the person who looks at this kind of think that that is the problem basically. So yeah, it can be very tricky for the patient not to assume that. And again, we just spoke before about the word chronic pain and what connotations that can have to the person's thought process about the problem. But the problem with the word tear is also what they assume is the problem there. So we do get this with knee injuries, people think maybe I've torn my meniscus. In terms of meniscus injuries that go on to require surgery in the knee, really the only one that is almost certainly requires surgery is something called the bucket handle tear in the meniscus, which is a very significant tear and is very unlikely to improve with rehabilitation and so forth. It's very, very common to get small little tears in the meniscus in the knee, same with the shoulder, small little tears in the rotator cuff. It doesn't mean that you need surgery. But if you think when you've got this pain on the all the side of your wrist that you have torn the TFCC, it's very difficult to think, well, how is that going to improve or how is that going to be repaired without something like surgery or do I need to completely take eight weeks off to put in a cast to allow it to heal. These are the problems with that Google saying that everyone has this TFCC tear. If we just go on to one of the main points of a Volker's paper that we discussed, the wrist injuries and climbers, the actual number one diagnosis of the patients that they saw is some called sign ofitis of the all-no-corple recess. In very simple terms, rather than them saying that most people have tears of these structures in the TFCC, what they're saying is that that side of the wrist almost has a sign ofitis, which if anyone remembers back to the podcast we did on fingers where we talked about sign ofitis of the finger joint, it's that irritation of the joint capsule in that area. From our point of view, like me and Stien, we haven't sent a single climate that we've seen with wrist pain for surgery. I think that was right, Stien, wasn't it? That's what you said as well. Yeah, I haven't sent anyone to surgery. I've sent some to an orthopedic consult where we discuss a TFCC injury to see if it's worth doing an operation or not, but we haven't ended up doing surgery on any of them. Yeah, so even in those occasions where there is a natural TFCC tear, which what we're basically trying to get across here is that not every climate with wrist pain on the other side has a TFCC tear, most probably don't. And even if you do, the chances of you requiring something significant like surgery are probably reasonably small. So I think one of the other points we've gone to discuss Stien is, I mean, how often are we actually seeing them? We've waited this long to actually talk about wrists on the podcast. And is that because we don't see them very much or is that because the other things are sort of more common? And yeah, if you've seen more in recent years compared to sort of five years ago, what's your thoughts on that? Well, in general, I see more climbing related injuries as there are more and more people climbing. And obviously, the wrist is quite exposed to a lot of load basically and different kinds of movements in climbing. So I tend to see more wrist pain and wrist injuries now than I did like five, six, ten years ago. And like besides more people climbing, there's also a lot of people doing more and more indoor climbing, which is set a lot on slopers, bigger holes, bigger volumes. So I tend to see slopers to be, it's wrong to say a risk factor, but at least it stresses the wrist a lot, way more than the fingers. So maybe there's a combination like more people climbing, more people doing the set, like the commercial set bowlers in the gym, big moves on bigger holds. So like from a slower point of view, then you climb a lot more on slopers when you have a long indoor season. You do steeper climbs on jugs where maybe the fingers aren't limiting factor anymore. So you just get a lot of traction and rotation in the wrist. But these are all just speculations and based, probably on the stories people tell when they come to see me. And I think the most important part of a patient's history if there is that if it has been an acute injury or not like an acute incident. So I give someone grabs an on the cut or a stoper or a volume or a mantle and they feel something let go in their wrist or even like if they fall, but that's quite obvious then I think that acute incidents is worth to to investigate further because stabilizing structures like the TFCC, you can obviously have degeneration of it. But if you have an acute injury to stabilizing structure, then at least you need to make sure that the wrist is an unstable. So like if you if you have torn something between the ulna and the radius, so like the distal radial ulna joint or if there's a big tear and the TFCC complex, then I think that's worth investigating. And if you suspect there's structural instability, then you should do an MRI scan to see. But more often than not, it's more like a progressively increase in joint pain, following climbing on maybe stoper's sort of volumes or one. Yeah, absolutely. So there's an important distinction there that there's a difference between what we call a structural instability and sort of feeling of instability. So when people have sore wrists, they will say it feels weak, it doesn't feel sort of stable, it doesn't feel like I can pull through it as much and so far. Sometimes they might even say it sometimes feels a bit clicky, but there's a difference between not and a true kind of structural instability where I like to be insane if there was the mechanism of the injury, the history of what actually happened if there was a real sort of acute kind of incident. And then after that, there really doesn't feel something right with the wrist and there's not really signs of any improvement from all of the normal simple things. That not so time to potentially get it looked at and investigated in more detail. But most of the ones that we tend to see aren't like that and they're either a slow onset or came on over a few sessions or you know, on a climbing trip where things were particularly slopier or that sort of stuff. So yeah, there's an important distinction and it comes back to that sort of history and symptom presentation that from the physiotherapist point of view is really important as well as the actual assessment. And yeah, I think, I suppose if we were to summarise again the sort of whole types or the sort of moves or so forth that the I have a cause, wrist pain or when people have wrist pain they don't like. I think the main ones for me would be slopers but also undercuts. People with wrist pain don't like to be in that uneven. undercut position. Full extension of people don't like, so say press moves or mantles. I guess there's not really huge amount of mantles inside but maybe people are climbing outside. Yeah, any of us, any other things that risks don't like? Stay in. Well, I think like the repetitive nature of working a problem is something that the wrist could probably not like. So if your project has an undercut, so do like where you have to twist it into the undercut. So you could sort of like just imagine crossing into an undercut where you where you flex your hand towards the pinky side and you rotate the forearm to come into it. And then you like try to pull really hard to get out of that position. Then you have a combination of like all not deviation, which is called and you rotate the wrist and you also extend the wrist backwards. And not necessarily that you're exposed to an acute injury, but if that's the crux move of a root or a boulder problem and you keep on doing that move then that's sort of the same mechanism as crimping a lot on small holds. So you just you compress the joint surface on the other side towards each other. So you just irritate the joint a lot, which also is shown in falcon's paper where you see side of itus, which is a reaction to stress within the joint and also bone marrow edema, which is probably caused by compression of the joint surfaces. So you get this this something of fluid in within the bones basically bone bone bruises more or less. So I think like every position where you twist an angle towards the pinky side could probably cause pain, especially if that's a move on your project and you do that move over and over again. And I remember that from working a problem, boulder problem that I eventually did, which had like the crux was the first move. We had to go from matching matching a slope to start and then you move like up and backwards. So like you go up with the right hand to a side pull and every time you did that your wrist got flexed towards the pinky side and you had to maintain a lot of tension in in the lower lower arm to to maintain body position as you hit the upper hold. And like I remember I could try to do that move. So when you were going to the side pull, so like yeah, I can try to describe it like you start matching on a slope or like a slopey ledge like 45 degrees. Let's get some, let's get into this a bit more. Where were you? How old were you? How hard was the boulder? Come on, we want to know details here. It's a boulder not not too far from from Oslo and it's given 8b and I did a stand start up it way, way back and this is now, I don't know, maybe six, seven years ago that I did the sit-start, which is in my first descent, but that move felt impossible for me to begin with and then over the seasons it's got more and more together and for me the main crux was to start off this matching matching the start hold, bad feet and then go up and backwards into a side pull. So like left arm stays low and then you reach the side pull with your right arm and my body couldn't move when I hit the side pull. So like everything is attention from your toes to your fingers but every time I did this first move I had to like flex my left wrist towards the pinkie side and it was basically that first move that kept me off the boulder for a long long time and so after like 45 minutes into every session then my left all no side of the wrist starting to get more and more painful and then it could might be two days and it was all good and I could go back to the boulder but it just shows that like just imagine you doing deep squats like really as to the grass deep squats and you do that straight for 45 minutes with a bit of weight on your shoulders then probably your knees would start to hurt at some point just because you compress the joint in a very specific angle over and over again and so I think that's probably like the main the main risk and then also maybe the most important part of risk mitigation is to be aware of the wrist position on different holds so that if if you feel that it gets painful the more you try and move then the wisest things to do is to break it up a bit and give a bit more rest and maybe not have that many goals on that specific move. So in that example you just gave my corrective thinking that actually wasn't a sloper or a undercut that you were going to it was actually a side pull to the main thing with that is the amount of ulnar deviation that you were sort of going into is that correct. So yeah that's that's interesting because we didn't actually mention that before but that's more of a positional thing and I suppose like with a lot of injuries it's to do with the total amount of load going through it and if it's a dynamic load so climates climates will have done moves where you are on holds and you do a big slap up to a sloper you can usually hear the person doing that move because it's such a sort of loud kind of impact and that's the other thing isn't it that sometimes with with slopers like you kind of are slapping up to them you know what I mean the people will know that term slapped up to a sloper rather than moved up to a crimp you know what I mean like it's it can be a sort of quite an aggressive force that you're also going to these positions with so yeah that's interesting that you kind of that move that you were talking about the main problem now was the main problem basically was the position of your wrist in the hold if that side pull if it was the same distance exactly the same move but that side pull that just been turned around so it's a flat edge and a crimp you would not have got risk pain from that move would you agree with that yeah I would say so that it was the position of the side pull that and then the amount of attempts going into every session on those kinds of moves basically so when you look at it that way then it's basically the same thing that happens if you have a crimp on your project and you keep on doing that for 45 minutes then at some point your fingers will probably start to ache and the same thing happens with the wrists and I think that's an important distinction that that is not a TFCC injury or a damage it's just an irritation within a joint which is also seen as sign of it is yeah that makes sense and I also think that with with slopers then like imagine when you grab a crimp then like a straight straight on crimp not not a side pull but just like hanging on a crimp then your wrist is quite neutral so it hasn't moved in any direction towards the pinky side or the thumb side and it's a bit extended so like if you flex it a bit backwards whereas when you grab a sloper then at least there's not a lot of extension in the wrist anymore you sort of just flex the wrist to the other side so you press the whole palm and you fingertips down to the sloper and you flex your wrist and then if you have usually you have some sort of angle on the holds as well so like you tend to flex the wrist a bit more to the on the side and you palm or flex it as well so that places a lot of stress on the wrist joints as well. Well even the position the flexed wrist position is what called an open-pact position of the joint we talk about this open-pact and closed-pact position so wrist extension is a stable position for a joint imagine you were going to push something heavy I don't know like trying to get push some card that's broken down or so with example yeah yeah push something heavy push a big trolley or something like that you would you would do it if your wrist extended it's a stable position if you tried to push that with your wrist flexed it's kind of you wouldn't even do that it's a weird thing so yeah the basically the design of a sloper as such puts your wrist in a mechanically disadvantageous position and like I see I'm saying when we crimp especially when you full crimp if people listen in just almost like full crimp on the edge of something or full crimp on the edge of their palm of their other hand your wrist is in wrist extension it's a stable position for the hand and the wrist so the issue with slopers is that your wrist is in an unstable position I think the problem with undercuts is again it's an unusual position. position for the wrist and the way that we try and twist and talk our wrist to get, to get sort of the maximum amount of power within the system. But also the problem with undercuts is you're again in a mechanically disadvantageous position, you've not got a lot of the big powerful pulling muscles in the direction of force that they are if you're in a crimp and pulling down above your head. And also climbers generally tend to be pretty tight in what we call supination, which is the sort of turning your hand up towards the sky, rather than your hand down. We see that a lot when we do an ultrasound scans of fingers, climbers have a hard time just even putting their hand on the bed flat for a period of time because they're quite tight. So getting into those positions is kind of awkward for the climber anyway and it puts a lot of mechanical stress through it. So that almost certainly plays a part into why we see the onset of these injuries come on in those positions or when someone does have this pain, they tend to avoid those things. But like with most injuries that we've spoken about in this podcast so far, the good and bad thing about most climbing injuries is you can often work around them. The good part of that is most of the time with this any sort of wrist injury, people can find certain types of holds that kind of don't cause much pain. It's kind of the opposite to fingers. If you have a wrist injury and a finger injury at the same time, then you're going to be struggling because basically in a nutshell, wrist injuries don't like slopers, finger injuries don't like small crimps. That's very generalised but that kind of sums it up a little bit. But people with wrist problems they often can avoid this whole type, that whole type, this type of move, this style of climbing and they can continue to climb which is great. The problem with that as we've discussed is as in general as climbers, we tend to push our luck, we tend to do as much as we possibly can. And if we don't quite get that balance right, there's certain moves that actually still kind of irritate your wrist and can kind of keep it irritated and so forth for a sort of longer period of time and maybe people want. Yeah, I think that the grip position and body position also includes wrapping volumes, which is more and more common in gyms these days. You do the occasional wrap outdoors as well but not nearly as common as on indoor gyms. So you can wrap with the pinky on top or you can wrap with the thumb on top and either way you just try to hang on a ledge sort of thing and press down on it which causes a lot of rotation within the wrist joint and you're also trying to move your body around in the most advantageous position. And that's just that. Just explain that a little bit more. I reckon there'll be some people listening who don't understand what you mean by wrapping a volume. Yeah, so I can volume if you have a three dimensional volume. So like three squares. Is that right? Or like three triangles? Yeah, like three triangles and you put that on the wall. Yeah, and then you try to wrap that on top for instance. So if you come from strictly underneath this triangle, you can try to wrap your hand around the top part of it. For instance, with your pinky on top. Would that be called a, would that be called a guppy? You think this block? I don't know. I think that's called a guppy. Gas down is like a backwards sort of side pull isn't it? I think this. I'm pretty sure that's called a guppy. Well, at least we call it a guppy for now. Yeah. So you can wrap it as a guppy with the pinky on top or if you want to move sort of like more sideways off the volume. So maybe push to one of the sides then you would try to wrap the volume the other way around. So you try to wrap it with your thumb on top instead. So that causes a lot of all-nerflexion as well. So that's a quite strange grip position for the hand to be in. A hand position where it's quite hard to engage the muscles in a good way. So that leaves you with a more exposed position for the wrist. And I think also if we can move on from the volumes, that was very hard for an Norwegian guy to explain. I think the supination part is worth expanding on because like you said, the supination is when the palm of the hand faces upwards. So like imagine a bicep curl or an underling. And the wrist can rotate even though your forearm doesn't rotate anymore. So like if your supination stops at like 45 degrees, then your wrist can continue. So if your supination is restricted, you can sort of like dig into an undercut and then the rotation in the wrist can sort of like passively continue. So it's sort of like the same as with the shoulder. Like if you're, if the flexibility in your, in your thoracic spine is poor. So you can't really extend your back or your thoracic spine. You have to get more mobility out of the shoulder joint. And the same goes with the forearm and the wrist. So like if you have one very stiff slinky feather and then you have a very soft slinky feather and they're both connected, then you would be able to pull more on the flexible part of it, which obviously then you pull more on the stabilizing structures of the wrist. So like you said, we see a lot of climbers with restricted supination. And if, if it helps to increase the supination, like the range of motion, so that the wrist is in a better position when you come into an undercut, for instance, then that would be a good advice for rehabilitation. Yeah, absolutely. And when it comes to rehabilitation, then like we started with, then even though you have a TFCC injury or degeneration and you've decided not to undergo surgery for it, then it's still a conservative management of it. So you try to avoid the most aggravating positions, maybe switch from slow first to smaller holds for a period of time. Like you could probably do a lot even though you can't do everything. So focus on the a lot part and like don't poke the bear too hard when it comes to aggravating the wrist pain and it would, and the pain will slowly just go away even though it can take several months. So there's a lot, like you said, there's a blessing in the curse with how much you can work around inclinement. So the good thing is that you can work around a lot of the moves as, and at the same time, you can address things like restricted supination and maybe even the lack of strength because you can't build strength to stabilize the wrist better. So you can build strength in flexing the wrist. So like the typical wrist wrench exercises so that the wrist muscle can stabilize the joint better when you come into all these strange positions that we encounter inclinement. Yeah, well, that's right. As you were saying, almost all of them don't require surgery. Like, yeah, me and Cian would have said before that none of them that we've seen so far, and that's a lot of arrests really, have had surgery and even some of them that have been for orthopedic opinions or so far have not required those. So yeah, the prognosis for wrist is very good. Yeah, like we were trying to get across before, they're not all TFC injuries. The vast majority are going to be like some sort of irritation or sign ofitis of that all on the side of the wrist. There is a lot of structures around there that can be communicated and we're not going to go into so much detail about that sort of diagnostic diagnostic side of it, but the prognosis is very good. They can take time. They can take a little bit of time to settle. Probably not too dissimilar to the PIP, the middle joint finger issues that can be a bit of a nuisance to kind of settle down. But actually just while it's still in my mind when you're speaking there, one of the things that I wanted to speak about and get your opinion on is we get asked a lot of the physios about things like braces and taping and supports and this sort of stuff. And a lot of the time this sort of jury is out on whether they're useful, but from a completely adding and a total point of view for whatever reason I seem to find at time and time again, the either wrist taping or these things called wrist widgets that are sort of like a band thing with two straps on it that people can pull quite tight around their wrist. The climbers that I see seem to really like them. They seem to think that they're really useful almost always. So we'll go on to talk a little bit more detail about maybe rehab, but yeah, it's sort of an observation I've had and most of the time now when someone says, "What's reckon about these wrist widgets?" I say, "Well, people seem to really think that they're quite useful and the majority of the feedback is that that is the case." So my question to you was, "Do you find that?" And also, if you do, why do you think that people think that they are just so useful? So yeah, two parts of that question. Yeah, I find them useful as well. Both the wrist widgets and the wrist taping, so it's sort of like just a circular tape around the wrist. I think it's important we could start with what you said earlier, like we have to make a distinction between a structural instability and the feeling of instability. So like if you've done an MRI and see that you're joined, the TFCC is torn or the distal radio all the joint is unstable, then I wouldn't just recommend taping it with sport taping, go back to climbing because then you have a structural issue that you need to address. But I think that this feeling of instability gets a lot better if you tape it. So like it feels tighter. So I think for me at least that's the main explanation of why people find them useful. And the bullet that I presented earlier, then that was how I did it. I did that. I tried that move for 45 minutes and then my wrist started to hurt a bit and then I taped it and I kept going for another 45 minutes and then the wrist was a bit painful for a couple of days and then it was okay. And I don't think that that tape was able to like really stabilize my wrist a lot, but maybe just enough so that I could continue. But at least it felt more stable. So I also think that if we've ruled out the serious stuff, then I don't see why we can't use tape or wrist which is at least in the start of rehabilitation process. And then as you build strength and the pain goes down, then we can slowly just get rid of the training wheels basically. Yeah, and that's important as well, isn't it? Because yeah, you see climbers with elbow straps, taped fingers, wrist widgets and you sometimes think, I swear I've seen that climber with that tape or that wrist brace for like the last 18 months now or something like that. And that maybe is just for their brain. As in like they psychologically, they can't sort of cope without it. And it's really important to, yeah, really important to sort of understanding. And now I actually stole this phrase from you, Nasty. And I use it all the time. And you said something like when you rehabilitate something, you have to eventually get painless, fortless movement. I don't know if you make it. Painless, painless, painless, thoughtless, fearless. That's not Michael. That's Louis Gifford's court. So, okay. You can claim it because I thought it was you that said it. That would, that would, that would be stealing from a dead guy. But Louis Gifford was a great, thoughtful British physiotherapist. Sort of like before his time when he came to to understanding of the understanding of pain and rehabilitation, in my opinion. And that phrase have always stuck with me. Like the end goal is to restore fearless, thoughtless, um, movement. So, thoughtless feelings. And if you have a wrist strapping on, you definitely haven't got fearless or fortless movement because all of your thoughts leading up to the session. So, you know, they are, they seem to be super useful for wrists for whatever reason that may be. But it's really important to sort of graduate away from them. Yeah. And I think like if you say that, say that you play soccer or rugby or something, and you've sprained your ankles. And you know that there's, there's no ligaments torn in your ankle. But it still feels a bit better, not, not to like really strap your ankle up into an orthotic or like really stiff taping, but it helps to just play some tape around the, the foot and the ankle, which gives you like more sensory feedback from that area to the brain. So, it's sort of like, you can change input and change output. So, it could be less pain from taping just because of that stimulation of the skin. And it can feel more stable just because you get a bit more information on the joint position because the tape pulls on the skin as you move your ankle. And I wouldn't say that you absolutely shouldn't do that, but at some point you need to get rid of that and, and might be on, be on your own. So, so yeah, I think if, if we ruled out the serious stuff and then start with a widget or a tape and then build up strength, build up confidence, and then we can get rid of the tape or the widget further down the road. And if you encounter similar movements that you know will, can cause pain or problems, then maybe you should use them for that move. If that move is really important for you, just, just, there's a, there's a safety buffer, but it shouldn't be necessary though. Yeah, and I guess that would be the idea of like weaning, weaning off using the, whatever you're using, whether it be finger tape or wrist strap, you know, if you are warming up, maybe you don't need to use it. If you are doing some crimps and doing some bigger moves on crimps, don't need to use it. If you're starting to get back into slopers and confidence wise, it really helps you to sort of use that, then that's fine, but then starting to potentially use it with the wrist widget, then make the move easier, maybe bigger feet or something like that, and then use it without and sort of build up that kind of concept of, progressively increasingly intensity. And then you can like add, add string training to that. So what I like to do with strengthening wrist is you can, you can do dead hangs and lock offs on slopers instead of jugs so that you just get used to the sloper position. Like, most training facilities, indoors now are very well equipped, so they usually have slopers on the campus board, not only the small campus runs, so you can like go from just hanging dead hanging on slopers to lock off on slopers to footless work on slopers and like progress it that way. I'm quite fond of pinch blocks, so where you can extend your wrist and really squeeze hard to build both grip strength and wrist strength as well into extension. And then also this wrist wrench exercise where you have a bar where you can flex flex your wrist inwards as if you were to to pull down on the sloper. And the main advantage with, excuse me, main advantage with strength training is that you can control everything so you can control the razor movement, you can control the velocity, you can change the, you can adjust the load and control the load. And then progressively increase the load as you get stronger. Yeah, absolutely. And that position you were talking about say with like a wrist wrench, it basically puts you almost into a flexed wrist position and you can kind of like lift weights, but even a pinch block, what I've done with people who've, they have the pinch block and out of course he gets you into wrist extension, but that helps to strengthen around the areas of the wrist and is quite climb and specific. But even so sometimes you're using almost scooping up the pinch block, do you know what I mean? So you're in that sort of flexed position and using the whole pinch block as a sort of undercut, not undercut, that's the wrong word, like a sloper kind of flexed wrist like you were using it as a wrist wrench can sometimes be quite useful because the position so you get into slopers aren't always that perfect sort of flexed position like on a wrist wrench. And even just doing this with dumbbells, if a person picks up a dumbbell and drops their form up so it's next to their index finger and then lifts the dumbbell up in a sort of almost like sloper style position, that can be a very simple way to build that specific kind of wrist strand from a, from a climbing point of view. And if we're talking about wrist specific, sorry, climbing specific wrist strength, I often actually do some loading in like a undercut position, so I will get like a portable finger board. And people could do this in different ways. Sometimes we just use bands attached to certain anchor points and then sort of pull in in an undercut position with the portable fingerboard sort of flipped upside down. People can either do sort of reps of actually pulling in and holding it like they were doing like a bicep curl sort of, you know, strength or they can hold it and hold the position for a length of time. But they can change the elbow and show the position so it can be like a high undercut or a low undercut. But the other time things I've done with this is put got out hooked up to like a pulley system. So people if they want to, they can actually put a specific amount of weight on it and it can hold it so it can be a bit more measurable. So in terms of almost climbing specific rehab for wrists and loading, there's some good exercise. Any other climbing specific ones that are useful? - No, I think I've never tried the undercut way that you tried. So I'm gonna try that definitely. But yeah, I like to mix it up between lifting and hanging and I think rehabilitation is only training in the presence of an injury. So and we know that to build strength is an important part of risk mitigation. So I think that like you do the same things in rehabilitation as you do in strength training. It just different loads and different consideration when it comes to pain and how much how irritated the joint will be from different types of exercises, which is why we need to individualize. So we need to have a big arsenal of exercises that we can go through with people. But if you can like add pinch block and wrist wrench, for instance, to your dead-ang sessions, it doesn't necessarily take that much longer so that you can actually focus a bit on strength training as a preventive measure as well. - Yeah, and I also think, we've not discussed these, but we probably should just to, it might seem obvious, but don't miss out the sort of real common sense box standard like wrist loading exercises. So going through your wrist extension, your wrist flexion, and I also think some sort of reverse bicep curls and maybe some hammer curls, they're also good to sort of load the wrist and work on the other sort of areas of the kinetic chain. And again, like a lot of the processes if actually through range movement, often sometimes with wrists there can be actually moving the weight through range can be uncomfortable. So you can start with static isometric loading like a lot of rehabilitation, go from that sort of static isometric if it's painful into sort of through range stuff into maybe more dynamic stuff. But the real simple things of those kind of wrist extension wrist flexion exercises, I think are still pretty useful. And then one of the things that I also tend to do is actually that ulnar deviation, the thing that we were saying is quite a common cause of the injury, sometimes actually working into that in exactly the same ways. If you've got a finger injury, you shouldn't be scared to sort of go into full crimp and load it into full crimp when it's appropriate for the actual wrist actually loading it in an ulnar deviation and either sort of putting the wrist into that position and loading it in a different way. Sometimes for example, I might do like a slight offset shoulder press. So something that's loading the wrist where you sort of deviate your wrist to one side and actually do a shoulder press it's almost like a bad form shoulder press. But it's a way that someone can almost confidently get that wrist into that position, under load and you can sort of do a little bit of two for one exercise way, doing a bit of a shoulder press as well or just doing some actually isolated ulnar deviation with like an offset dumbbell is can be quite useful as well, both from a confidence point of viewable. So loading that on the side of the wrist. So yeah, not sort of dismissing your more kind of traditional kind of wrist loading exercises as well is definitely an important point. - Yeah, I agree. And like, you can, like the static exercises are found very useful if you have like a severe ulnar irritation or a TFCC injury where moving into ulnar deviation can be painful then the static ones are really good, both an extension and flexion. And also to train the pro-nation supination of the forearm grabbing hold to a barbell or something and just rotate your forearm from side to side and maintaining a stable wrist through out. So you don't let go as this, for instance, if the supination movement stops then you shouldn't let the wrist continue to go try to maintain a stable grip position so that you can also expose a bit to the rotational forces in the wrist as well. These are probably really hard to just imagine as we discussed them. Luckily, I've done some good photography of these exercises that we discussed here, which will be presented in the book that hopefully will get out this fall. So then people can have a look at the exercises in that as well. - Yeah, let's talk about that, let's see. Tell us a little bit about that. - Yeah, well, I mean, the book idea was all, that started many years ago and I didn't really want to write a book on climbing injuries because I found it too hard to present something very complex in a simple enough manner. But then it eventually grew on me and then took me to different colleagues around the world, including yourself and made me start this podcast with you as well to discuss more and then the more, yeah, I guess I kind of like gruesome confidence that this was actually a feasible project to see through. So the last year I've been working on a book that will be called The Climbing in Dre Bible, preliminary at least, where I want to try to present and discuss the most common climbing related injuries from a medical point of view, but also presented in a way that should make it possible to use as a self-help guide as well. So maybe it can land somewhere between climbing, the climbing medicine book from Falker Schaffel and his colleagues and make a break book by David McLeod. So yeah, now I've just finished an Norwegian manuscript. You've read the English translated version of Don De Photography and it's now in the design process and then hopefully it will be released in October. - Yeah, great. I mean, I think people will recognize those books you just mentioned, but also obviously it's not the first time you've written a book, the actual climbing Bible. It has been out for quite a while now hasn't it? And I think a lot of people will recognize that. It's in a lot of climbing walls and things like that. Certainly in the UK is, I kind of see it all the time. And yeah, I've read it like you say and it's great. It kind of covers everything that you would want to be covered. And I think what it'll be is a really nice book for climbers who have injuries to sort of use and reference and grab it and kind of go through and give them some instant information that would be really useful. And I think it'll also be useful for clinicians, I have experienced clinicians or people who just don't know much about climbing injuries and just want a reference point. So yeah, it'll be really good to see it in its sort of full form, all shiny and glossy. - Glossy and shiny. - Yes, but yeah, I'm looking forward to it. I think it'll be super useful for people. - Yeah. So yeah, we can talk more about the book in future episodes. But I think we're gonna leave it for tonight for wrists and then try to not have another four month off time between episodes. So we can aim for at least one more before this summer holidays, isn't we? - Absolutely. - Absolutely. If people listening have anything they want us to discuss in more detail, then feel free to drop us a message on Instagram or wherever you can find us and we'll see what we can dig up. If not, we'll just sit there and chat to each other about all the geeky stuff that makes up our work. - Yeah. Absolutely. - All right. All right. - Good speed. You got like, was just like, see you later. - Bye. (upbeat music)