Episode 2: Pulley Injuries Part 1

Intro Hello and welcome to the climbing Medicine Academy, the podcast The climbing medicine. The Climbing Medicine Academy is hosted by climbing doctor Falka Shuffle from Germany and doctor and physiotherapist. Speaker 2 Schevette Iguena from the Basque Country. Speaker 1 The show is sponsored by Ozkura, the climbing Medicine center of Excellence in the San Sebastian area in the Basque Country. We will discuss the latest and most up to date guidelines for the diagnosis and treatment of climbing injuries, the latest scientific papers and have guests from the climbing community. Be in mind that we cannot provide diagnosis or direct treatment advice. If you have any health condition or complaints, we recommend you to see your local health provider. Welcome to the latest episode of the Climbing Medicine Academy. Speaker 3 It was like Fulprim, I was in a drop knee and anesthetic position and suddenly it just popped. Speaker 2 You only find what you are looking for, and you only look for what you know. Speaker 1 In my clientele, Poly injury is the most frequent injury of all the finger injuries. Speaker 2 You have like a big pop. Speaker 1 And the pulley pain is mostly not in the middle, it's at the level of the pulley, but mostly to one side I think. I cannot do a diagnosis without an ultrasound. Speaker 2 A big pain in the ass to have a combination between PIP capsulitis and partial Pulitzer under 16 years. It's quite weird to have a pulley injury. Welcome to the second episode of the Climbing Medicine Academy. So Fokker, the most well known injury, the most frequent injuring climbers, the most widely research climbing injuring climbing medicine, and one of the greatest fears of a climber and our favorite injury. So I got goosebumps. I'm so excited. How would you introduce this episode? Speaker 1 Well, you know, that's the the climbing injury, the pulley. No, I think it's the climbing injury because it is so climbing specific. It's not that a non climber cannot have a pulley injury. We will dig into that. And I had like football players and and kids, but pulley injuries. But like it's first to describe through bowling climbing like 99.9% of the cases reported aren't climbing. So the pulley injury is just the typical unique climbing injury. So this is it. This is what direct us into climbing medicine. And that's the core topic. I actually did did a lot of research on it and, and you did your PhD on it and we did probably like over 20 papers on it. So yeah, this is super exciting. Speaker 2 Well, so listeners, if you want to find answers to the most common questions that climbers have about how to avoid these injuries, how to manage them, how to progress with loading, whether to tape or not, whether to stop climbing or not, which type of grapes are the most dangerous, and most importantly, how long this injury will last before we can push hard and climb at our limit again. We will reveal all this to you today, right now in this podcast. So ready, steady, go. Speaker 1 So to demonstrate to you actually how pulley injuries are happening and what the climate experiences, we have a little interview with a member of the German national team who just was with me in my clinic last week. Pulley Injury I'm sitting here with one of our team members of the German climbing team. And he just had recently, actually, like five days ago, a finger injury, which turns out to be a Pulitzer. Yeah. What happened? Can you explain it to me? Speaker 3 Yeah, I was climbing in a room. I took like a two finger pocket with my pinky and the middle finger and it was like full crimp. I was in a drop knee and in a static position and suddenly it just popped and I was on the ground. Speaker 1 Yeah, and that happened in a training camp in Japan, actually. Did you hear anything or the people around you? Speaker 3 Yeah, I did hear something. And Elias, he was also with me. He heard it also. Speaker 1 So what did you hear? Speaker 3 A snap. Speaker 1 A snap, Like a blue blush snap. Yeah. And like, where was it? Or at the moment clear to you that you had an injury. Speaker 3 Yeah, it was really clear because I had like a fully injury like four months ago and it was the same and I directly knew what happened. Speaker 1 And what did you do? Speaker 3 Sit down and calm down. And I got a hug from Elias because he also knew what happened. That was really good. Speaker 1 Yeah, and then he had a call and now he's here to check it out. Thanks a lot. Good luck to you. Speaker 2 Volcker, let's start with the anatomy and the bio mechanics. There is a phrase that I have learned from my references in the field of musculoskeletal ultrasound which says that you only find what you are looking for and you only look for what you know. What a beautiful, true and inspiring quote. So first of all, we should know the anatomy. Volcker, can you explain us what is a pulley so? What is a pulley? What is a Pullia? Think about a fishing rod. A fishing rod has a line and it has these rings and these rings actually attach the line onto the rod. So and they are in in certain numbers and certain distances. Because if one if missing the the the fishing line John kind of like hangs through and it's not tight anymore. It doesn't work same like that. We have in our fingers 5 pulleys, like five annual pulleys, which are going around the flex attendance and are attaching them close to the bone. And then we have in addition, to make it more complicated, three more pulleys, the crocheted pulleys, they're super small. They're hard to detect, so we may forget them at the moment. We have them as isolated ruptures as well, but that's super special. So let's, let's stick to like 5 pulleys. And the most important is the A2 and the A4 and then the A3 and then a one and a 5 is not so important anymore. In climbers we have that that is important thing in hand surgery and trigger fingers as that is the problem with the A1. It is important that without the pulleys like you have a longitudinal force, like if you if you form a muscles constrict, then you have a pull in the flexor tendons. And if the pulleys, they, these pulleys are basically transferring this longitudinal strengthen forth into a torque into a rotational moment in the PIP and DIP joint. So that actually makes your fingers flex and in a smooth rolling way. If the pulleys gone, the they may flex at the end, but just like clicking, there's no constantly gripping movement and there is maybe an even diminished flexion at the end. Speaker 2 Nice explanation. So if I'm not wrong Folker, your wife Isa did her PhD about pulley pulley B bio mechanics. I remember how crazy it was to try to understand all those papers. You have done an amazing job to try to understand and share all this knowledge with all the climbing community. So can you tell us what is the main function of a pulley? Speaker 1 So yeah, I don't understand what Iza did when in her PhD thesis she did modelling of the pulleys in the mathematics equations. And basically we try to look at where the purse perfect position of a pulley is for reconstruction, how the strengths are distributed in between those pulleys. And she, she modeled that into a computer program and I don't understand it. It showed nice pictures. It was super exciting, but it's tricky to understand for a surgical brain. For me. The pulleys are easier, you know, as the fishing rods and the rings are on the fishing rods. They fix the flexor tendons. They make the flexor tendons work, and they actually make make it biomechanically so you can roll in and flex your fingers. Speaker 2 Yeah, yeah, yeah. I always explain to my patients in the clinic that the main function of a pulley is just to keep the flexor tendon close to the phalanx. That easy? But of course, yeah, it's, yeah, it's not easy if you go deeper and deeper. So about bathroom mechanics, there are a lot of papers. Pulleys and cadaver dissections I was quite surprised when I start reading all the literature I that the oldest paper is like almost 30 years ago released. So it's quite surprising. And and you did a nice job. Speaker 1 It's even older. Did you, did you, did you listen? Did you listen to my lecture yesterday? Did you look at the image of Leonardo da Vinci? He already was painting the pulleys in cadaver dissections, just as a remark like that that long we know about the pulleys. He wasn't quite right with the anatomical position, but it also shows that there is a big variation in between the the anatomical positions of the. Yeah. Speaker 2 Yeah, yeah, he was right. He was right. And I'm still so crazy trying to understand all the anatomic variation. Especially I need to know when does the A1 fully end and when it's starting the. Speaker 1 Oh, that is super tricky. Where does the A1 end and the A2 start? That is a brilliant paper by Peter Hahn about that and shows like 15 variations. Yeah. And sometimes even during surgery it's not. It's not even then clearly visible with the plain eye. You need magnifying glasses. And then you know, the pulleys are just sometimes weak structures and it's difficult to see the climber. They're very strong and you have a lot of hypertrophy. And I remember I did want the section where I I found pulleys which were also already calcificated and part of the pulley was already bone. So we have a lot of hypertrophy of the pulleys and climbers. But in non climbers during the surgery they they have very thin and and skinny. Speaker 2 Yeah, yeah, yeah, yeah, I agree. I'm trying to to to understand all the police in catabolic fingers doing dissection and also doing the ultrasound. But yeah, then atomic variation is crazy. And the paper that you you mentioned is so, so beautiful and I really recommend to read this paper. So back in 20 O 9, you did a nice job, a nice paper. One more and you're increasing the load in a cadaveric finger in a crimping grip. So discover which tissues and which pulleys were getting ruptured in which order. So the differences of a concentric and eccentric load, all these topics that are kind of interesting, especially for coaches and climbers. I love all that stuffs, all that stuff. Sorry, but sometimes I have the feeling that it's not easy to understand. And also, when I read a lot of papers, I have the feeling that the older the paper is, the better the content, you know? The importance of dynamic load and the importance of a concentric and eccentric load So Fokker, how do you remember those days like 20 years ago? What did you learn from all these papers? Speaker 1 Well, in those papers basically, and that is mostly the work of Isa. My wife and I just helped her on the surgical part. We worked with the anatomical department of the university and we had this loading machine, which is basically a, a motor driven mechanical loading machine for finger flexion and extension. And Andy Schweitzer, brilliant climbing researcher from Switzerland and, and hand searching in Zurich, he, he gave us the machine and with that machine we could actually load pulleys in eccentric and concentric movements during dynamic movements. Because up to that point there were strength tests made and performed for the pulleys, but there were just static strength test. So basically, you know, you used to cave a finger and there was the pulley and you put in a piece of cord underneath it and then you just load it with weights until it like tore. But that is not the thing which is actually happened during movement. And during climbing we are having very important things in behalf of like do we do a concentric movement or eccentric movement and then we have the tendon gliding underneath the pulley and we have the surface of the pulley itself. We know that the pulley surface is not even it's like a bit little bit hooked and in bats, for example, that that bats can hang effortless at night time in their sleep and on the ceiling. And that's because they have a tendon locking mechanism where basically the flexor tendons and the pulley interlace and they hook into each other. So they need to actively flex and relax the pulleys so they can move their digits and actually release the holding position and start flying. And we also thought about does that maybe is the same thing in humans? Like do we have different kind, different kind of roughness of the pulleys where there would be more or less friction? And if you would have more friction underneath the pulley, would that make you more prone for injury or would that make you with a more given finger strength? You know, there are people who started climbing and they can, you know, compass after like 5 days. And there are other peoples who climbed in five years and they can compass and they don't have finger strength. So finger strength in comparison to like upper body strengths, biceps or anything. It's pretty much a given thing by birth or by genetics. And we thought maybe it was just a matter of friction underneath the pulleys. We did one study of that, which is was a PhD thesis. But it's not, it's never published as a paper because we couldn't prove it there. But so though back in those days we actually started working on fresh frozen cadavers with the machine of Andy and started loading them. They had two papers out there with two different questions. 1 was comparing hanging to crimping position and then loading and then seeing in which position which pulleys would tear firstly or give way. So we we saw that in a crimping position mostly the A4 pulley was the the first one to tear. You cannot distinguish between fingers because we had single fingers in that and the second in in a in a hanging position. We had a variation of events which lead leaded to an end of the experiment. Meaning the end of the experiment could be A2 pulley failure, A2 pulley tear, A4 pulley tear, flexor tendon tear, Bony avulsion of the pulley, breakage of the finger flying through the whole room or something. So in in this conclusion, in the grim position, we had mostly A4 pulley injuries and then we compared eccentric versus concentric. And here we found that in the eccentric movement we had mostly A2 pulley injuries versus in the concentric movement. All of those things were happening. And if you look at a climber and that's, that's the interesting part. And we're still working on, on some, some matters there. The gripping during a move is not a concentric movement. It's not, you're not gripping a rope that is an active cause concentrate movement. But in the climbing position, you get to a hold, you sort your finger onto the hold. That's the start. That's the that's a concentric movement. But then you do your move. And during that move, you're not pulling on the finger, but the finger is basically keeping the hand in the position while you pull your body up above that hand position. So basically in the moment you start pulling yourself upward, you're eccentrically loading your pulleys. So I think the eccentric stress during climbing movement is what is actually mostly happening and causing the pulley ruptures. Speaker 2 I agree. Speaker 1 You also measured the forces and strengths directly underneath the pulleys with 4th plates, which was quite tricky but also interesting. Speaker 2 Wow, that was brilliant. Such a good reasoning. So after all the conclusions that you got from your own papers, do you agree that well, do you agree with your own statement that the A4 pulley rupture is usually happened in concentric load and the A2 in eccentric load? Are the A4 pulley ruptures usually in concentric load and the A2 in eccentric load? I'm asking this because sometimes I have the feeling that in many eccentric loads you can also get ruptured A4 pulley. As you said, most of the grips are eccentric, so I think that you will I. Speaker 1 I wouldn't say the statement as as you put it right there, because that's too the, the problem is the we looked at isolated fingers. And if you look at a hand, then you have totally different strengths distribution because the fingers are of different lengths. And then you're not totally actually late loading them because you're always having a torque and inward rotation, meaning you're putting more stress on the fourth finger than onto the first finger for the second finger, for example. And by that and also the the length difference between the 4th and the 5th finger, the fourth finger gets the most load and then the eccentric face hits there first. So that's why I think we have a lot of A4 pulleys, but I think the movement of the hand is so complex that to give a single statement is to it it it's not possible. But do you think? Speaker 2 I agree. I agree. I definitely agree, but it that that was a nice reasoning. So interesting, I think that now. Speaker 1 Did you did you have had a pool injury yet? Speaker 2 That's a good question. I was expecting this question for you, so yeah. Speaker 1 And how did it happen? What did you do? Speaker 2 In eccentric load, both of them, I was doing a one finger primping in in a sport climbing Rd. like five years ago. And yeah, there was a pop sound and that was the most common puller rupture mechanism of injury. And then like 2-3 years ago, but well, three years ago exactly because it was in, in February, yeah, I was recovering from a police train and I was trying to do everything in, in extension grip just because I was a bit scared with crimping. And it was also a bit still painful for me to crimp. So I was trying to avoid. But you know that sometimes you have some bullet problems or, or some wolves that you have to print. And I was, I was not ready for that. So it was a really small pop sound again. So I wasn't lucky. So yeah, I, I did five years ago a complete A4 pulley rupture and three years ago A4 and A3 pulley rupture. So yeah, I have a bit of experience and this is quite funny, but I always recommend to the PDS that are coming to our courses. It's only a joke but I always recommend them to have a pulley rupture because you learn a lot and. Speaker 1 Pulley rupture, pardon, I think you always learn a lot if you, if you as a doctor or a medical professional are a patient as well. You need to be in surgery as a patient to understand how a patient feels there. It's a totally different perspective. Same with pulley injuries. You understand it better if you've had it, but as I said yesterday also like I had my fair bit big, big share of climbing injuries, I had many of them. I don't need to have all of them. Speaker 2 Yeah, Yeah, I agree. I agree. Yeah. But I think that you are like quite sad, you know, when you get injured. So this is like a positive rate of the situation. So if you're APT or a coach or a physician and you get injured, there is a positive side. So yeah, I think that that's interesting. OK, so Fokker, let's move to the epidemiology of pulley injuries. Epidemiology of pulley injuries So it is widely known that injuries mainly occur in the fingers, followed by the shoulders and then the elbows. And the police account for approximately 30% of all climbing injuries. So tell us more about the police epidemiology, as many of the papers about this topic are yours. So yeah. Speaker 1 Yeah, if you say it's more, it's more, it's approximately 30% of climbing injuries. It, you know, it depends on what numbers you're looking at. If you look at the deny starter for exam and these are the data from the American emergency departments which are open available and there were like four or three studies on them. I we did one as well. So they record climbing injuries and obviously, of course the most frequent climbing injury they they record in an ER as an ankle sprain and tip rib, ankle fractures and then like big joint injuries because people with the pulley injury, they don't go to the ER anomaly. Also, they may only get to see a doctor after a few days because it doesn't get better. And then you have the numbers I have from our clinic and we have numbers there since 25 years, and we compare them. It's very nice data nowadays because every patient fills a questionnaire and gets into the database. So we can directly compare against what we've seen 20 years ago. So we'll see trends and changes in injured distribution. So like we looked at the change of injured distribution after climbing became an Olympic sport, for example, some injuries became more prone, others less. But obviously also those numbers have a bias because nobody who breaks his ankle in Munich is going to drive to Bumberg to get his first opinion through me. But if you have a pulley injury and you're in a remote area and you don't have a hand search in there, you're more likely to come to see me in Bumberg for a second or third opinion. So I see a filtered, a filtered variety of climbing injuries. But in my clientele pulley injury is the most frequent injury of all the finger injuries and overall still the the the most frequent followed by tenosynovitis, capsulitis and and then some shoulder issues. So it is very common and I see it every clinic. I'd have like 2-3 pulley injuries, fresh ones. Speaker 2 OK. And do you think that this trend, I mean this epidemiology is the same in experienced or older climbers? Speaker 1 We also found in older climbers, we did one study in older climbers. Of course we have more osteo tritis conditions there, but we in finger injuries, you also found pole injuries. Yes, it's different in kids. Obviously kids is a completed. I have one case with a kid with a pulley injury and that was a 2 1/2 year old kid playing in the sand with his brother. But in climbing kids up to the age of 16, we don't see pulley injuries. 90% or 95% is growth bite fractures and that is the finger injury in a, in a, in a growing skeletal hand and not the pulleys, but it's the same in like in the, in the large joints. You know, in, in adolescents, we don't see so many ligamental injuries in the knees or in the ankles. We see them, but rarely. It's more more prone for epiphasal gross blood fractures there as well. Speaker 2 For the have you ever seen any 141516 years old climber with a pulley injury? I mean a a complete pulley rupture. Speaker 1 Not that I remember. Yes, same for me. Maybe there was 1 and I would need to look in the database and stuff. I don't think so. Speaker 2 And how many do you know? How many police have you seen so far? Ish. Speaker 1 I stopped. I stopped counting when they were like over 400 something and that was like more than 10 years ago because I wasn't paying, I wasn't doing the records consistently. I, I did records for like 4 years, 25 years ago, then not for 10 years. Then we restarted. Then you know, I I don't have numbers for everything I saw, but for sure couple thousands. Speaker 2 Well, so I think that is a big message for the listeners that if you're a climber under 16 years, it's quite weird to to have a pulley injury, maybe a police train, but not a big issue. So I think that this is a good message. OK, let's move to the diagnosis. So nowadays we have a lot of information on how to diagnose the use of ultrasound has smart before and after. But if that weren't enough, we also have articles of Thomas buyers, for example, where they have used seven Tesla Mr. Is and even dynamic Mr. Is. This is great and we are very grateful for having technological advancements. But Folker, how do you start back in the atheists diagnosing the police? How to Diagnose Tenosynovitis Let us know. Speaker 1 Before we go to to the diagnosis, but on it, it's part of the diagnosis, but that that's going to the history. Like what does the climate complain about? It's a sudden pain in the finger. It's a pain which goes, which becomes more prone if you load the finger. That's a very important differential to tenosynovitis because tenosynovitis gets better during climbing, hurts after climbing. And just by the history of because both hurt at the same spot, both hurt at the end of the pulley, but just by the history of 95% of the, of the, the patient's complaints. I I know the diagnosis nowadays and there's a popping sign. Must there be a popping sign? No, that's not always a popping sign. Is a popping sign always a pulley injury? No, I've had people complaining about a lot of pops and it's just like fingers shifting a little bit like cracking joint or anything. But the popping sound is an indication like a whiplash sound on the crack. You belayer hears that and then looking at the finger. First of all is a tech is a clinical exam that is basic and the clinical exam is mostly exclude also other injuries like I'm absolutely make sure in every patient and that's standard surgical training that the flexed dictator and performance and superficial tendons are fine. You need to test them isolated because they have some cross functions. Extended tendons are fine range of motion, swelling point tenderness. Sometimes you see edema and the pulley pain is mostly not in the middle. It's at the level of the pulley, but mostly to one side because, and that's interesting because we saw, we saw that in the cadaver dissections like the crack probably like 50 pulleys or more. And they never tear right in the middle. They all it's always more like an avulsion on, on one side. So that's why the pain is either on the radial or on the ulnar side and not right in the center. So it's, it's not, not tearing right in the middle apart. And then I do the ultrasound and nowadays with the ultrasound we can directly visualize the pulley and stuff in Back in the 80s, I had a 7.5 megahertz probe. This is like flying and flying a compact plane with March 1 in the in the fog or something, so you don't see it a lot. But then we could only look at the distance of the flexor tendon to the bone. But at least by these indirect signs, we could get a diagnosis. At least we could get a diagnosis. This is a very serious pulley injury or or nothing at all. Do we need the point is do we need the diagnosis to treat that? That is a lot discussed question. I personally think absolutely. I think I cannot do a diagnosis without an ultrasound. I've seen more than thousands pulley injuries. But without the ultrasound, if it's not like a 234 pulley that that is easy, I wouldn't dare to give a diagnosis. And then yes, I would not just treat the finger according to the symptoms. I would really want to know what, what is the problem? Because there can't, there can be some serious conditions which will actually not heal conservatively. And if you miss them, not getting a diagnosis, which is in some countries difficult, I understand that. But then you treat in the wrong direction. But do you think would you, would you dare clinically to say that pull that guy has an A23 or an A1 or an A2 half tear? Speaker 2 That's a good question. I think that we will love in our clinic, we'll love to play a game which is try to to figuring out which pull is affected. But I mean like trying to be a specific because I think that with a good examination and assessment and without using the ultrasound, if you have experience on on this field, you know the diagnosis in 8090% not always. So I think that if you have experience without using the ultrasound, you can figure it out quite well, which which is a diagnosis. But of course, I think that as you said, the ultrasound is really, really recommendable. And honestly, I think that for me the ultrasound is necessary. So yeah, I agree with you. And then I also want to stress out the, the thing that you have mentioned about the, the, the attachment of the pulley, because I remember that couple of years ago when I met you, the first question that I did to you, I'm sure that you are not going to remember, but I asked you back then, I asked you like Fokker, is the pulley always getting ruptured from the attachment or is it in the bowler aspect? And you, you told me all this information, which is brilliant about, about your paper and about your experience on cadaveric fingers. So I think that this is really important because in in 10-15 minutes we are going to speak about the ultrasound and and about direct and, and direct signs. But I think that is really, really important, especially in partial tiers to diagnose the attachment of the pulley short axis. I think that this is really interesting because many of the tiers are as you said in in this anatomic attachment. So, yeah, I think that I just want to stress out this point because I think that is brilliant. So, yeah, OK. And. Speaker 1 There can even be a Bony avulsion. There was a a paper recently, I don't know if you've seen that, I'll send it to you, where they had a reattachment of the Bony avulsion of a complete pulley. And I've seen one case like that. Speaker 2 Yeah, that's super interesting. Yeah. So in like 20 years ago, I think that it was exactly 20 years ago or maybe 21, you did your first paper about pulley injury classification that you divided into 4 different grades. Pulley Injury Classification Can you explain us the classification please? Speaker 1 Yeah, there was like 2003. Yeah. Well, I came back from a night shift and went for a run and was really tired. And then I thought like, well, you know, this pulley thing, this is really like weird. Like you have one pull, you have 3 pulleys. There must be a classification. Trauma surgeons love classifications. So during that run, I came up with the idea, well, you need to figure out something. So because then it's easier and then you can, can, can, can guide the rehab time, the, the time of climbing and stuff like that. So, and then I used the numbers of my patients and we evaluated that. And that first classification was basically a pulley strain is Grade 1 tear of the A4, is grade 2 tear of the a A2 by three is the is grade 3 and grade 4 is multiple pulley injury. Because from our experience the A4 just healed so much faster than a full tear of the A2. So it made sense to separate those. And this classification we worked with for like 15-18 years and we ratified it just lately with Chris letter together in the BGSM where we would actually subdivide grade 4 into A&B because grade 4A would be a 2-3 and a 3-4. Those are quite well treatable concertively because the old classification would give all grade 4 so surgical recommendation. And then we have grade 234 which should go under which still should undergo surgery in the main therapy. There are exemptions, but the main recommendation is is surgical and a 2334 grade 4A can be conservative under certain aspects. Meaning what time after the injury you start with the with the immobilization with the pulley stabilization rings and then how much the bolstering is and stuff like that. But that was the first classification and the idea was mainly target the therapy. So give something to the climbers at hand where it's OK, a four goes like six weeks off climbing and you can do this and that after 13 days, after 13 weeks or so versus A2 will be different and longer. So we worked with that quite for a long time and I think it it it worked quite well. Speaker 2 I think that it's super useful. And if 20 years later we are still using the same classification, you know, I think that everything is said. The unique question that I have about this classification is about a partial tiers. Because I think that now with all the technological advancements and with the high quality proofs, now we are able to see the the partial tiers quite well. And now we are doing quite much research on this topic. So I think that we it would be cool to include these partial tiers in your classification that I know that in the latest paper on this field, you already did it. But I think that this is kind of interesting because now we are learning a lot, a lot thanks to the ultrasound about about the partial tiers. So yeah, I'm quite excited about this. Speaker 1 Yeah. I mean, I mean, absolutely. And this is like, you know, we went, we published a paper, told them three. So basically they worked, was done 1999, 2002, 1001. And and I had the first ultrasound unique in my in my hands and sort of taught myself, like I just call in friends and climbers in the evening and we'll do ultrasound on their fingers just to learn and to see how it would look like. And we had no idea. There were no benchmarks. There were no nothing. I had also nobody to discuss this but and and and and nowadays the machines, it's like compare a spaceship or the 1st moon craft and or like ATV, let's say ATVI remember the landing on the moon. I'm so old, I remember watching moon landings on TV with my parents and there was like black and white and blurry. And now you have HHD high resolution and that's the same for the diagnostic units. And of course, we will need like the, the classifications will be outdated because there will be new topics coming up and we need to ratify it and, and and and redo it according to the new standards. Yeah, yeah, yeah. Speaker 2 I agree. I agree. I think that there is a. Speaker 1 And you and you should only also touch it according. You know, you can say that for nowadays you could say, but that classification, you know, it doesn't show like half fleet torn police and stuff like that. Yes, of course not because like in 1999, I mean, nobody could see a a partial tear. So yeah, yeah, it makes sense. We need to go on. Speaker 2 And I still absolutely it makes sense. And even if you are not able to see the partial tears because of the technology, we are still using the same classification as I said. So I think that it's still really useful and it's so good. Speaker 1 Yeah. But see like how, how we change our surgical, our surgical procedures like ACL tears at that time we we'd open up the knees and like have like 15 centimetre long scars and people in a cast for six weeks afterwards. So it's completely changed nowadays. And of course we will have more change than those classifications also. Speaker 2 Yeah, yeah. I think that the partial tears come included. But anyway, I think that this is super useful. I have a question about a classification because sometimes I think that it's a big pain in the ass to have a combination between PIP capsulitis and partial Pulitzer. Combination of PIP capsulitis and partial pulley injury And I think that it's quite common. And there you have two different pens, you know, one is related to the joint with the capsulitis and the other one is directly related with the pulley. So I think that this is also a big nightmare. Even if it's not a multiple polar rupture, it can take really, really long because there is a lot of swelling. So what experience do you have on on this kind of injuries which is a combination between the two main injuries of the fingers? Speaker 1 Yeah, I'm, I'm just thinking because like I don't remember a patient of mine who had a capsulitis and a partial pull it here at the same time. Most of the time I see an injury and the capsulitis come secondary, like I see capsulitis after extensive tendon slip or extensive tendon tears or strains and then causing damage to the joint capsule and then the capsulitis flares up. But, and I don't know how these injuries come at the same time because the pulley is like anatomical wise the pulley is distinct. It's it's further away from the joint capsule. You know, from my understanding, a capsulitis can just come off the hematoma in a joint or some effusion and then you have like pressure in in the joint and the mechanical receptors start firing and stuff like that. But the pulley partial tear does not involve as no contact with the joint capsule. So is it just random or do you think they are linked together? Speaker 2 I think that in the cases that I'm having with this combination, usually they are like climbers with quite much experience, many years climbing, usually those fingers with a bit of osteoarthritis in the PIP, then they have a capsulitis. They cannot bend the the finger, they cannot flex the finger really well. There is a lot of joint effusion in the ultrasound image, so this is a capsuletes for me and then they just continue climbing and then they have a small pulling. Speaker 1 And then they get secondary. Speaker 2 You know, so it's a combination, but. Speaker 1 So the capsule is basically it's the minor injury leading to a major injury. That's quite interesting because we know, we know this in soccer that 90% of the ACL tears in soccer players, they are just the the following up a minor trauma and minor injury beforehand which was not treated adequately. So probably that is a good explanation. Yeah, yeah. Speaker 2 Yeah, that's quite common also. Well, we know, but in the upper lane when you have elbow standinopathy, then you are using more your shoulder or if you have a wrist injury. I mean, there are a lot of. OK, so let's move now to the to the ultrasound. Is ultrasound the gold standard for pulley diagnosis? So Fokker, do you agree that the ultrasound is the gold standard pulley diagnosis tool or you still think that the MRI can be useful to rule out other injuries? What's your opinion in this film? Speaker 1 Oh, it can be useful. I, I absolutely. The gold standard is the gold sun is the ultrasound. It's easy available. It's everywhere available. It's dynamic and we need to force flexion to really measure any distances. You can do that in very special Mris, but most in experimental setups. Sometimes I do an MRI, but then it's all always more scientific reasons than pure diagnostic ones. Maybe if I expect edema in the bone which I can't see in the ultrasound. I I never do an MRI anymore for excluding anything for the. Speaker 2 For the pulley. Speaker 1 After the ultrasound I did when I started doing surgery because I wasn't trusting myself, I I used MRI just to back up my ultrasound knowledge but not anymore. Speaker 2 Yeah, yeah, I agree. I agree. We always use the the ultrasound. But then if there is a injury of the joint, I think that MRI can be really helpful also, OK. And well, I think that it's quite interesting to speak also about the ultrasound exploration system, because in a systematic review that we did a couple of years ago, the main conclusion was that there is a big heterogeneity. What it means that each sonographer or each author was using a completely different way to explore the finger by the ultrasound. So some of them they were using the water tank or they were using the gel pad, other only the gel. Then the finger position, the active force flexion resistance, I mean, it's quite tough. And then is the finger, the flexural tendon is not flat, it's a circular tissue. So I think that the reliability between the sonographist is quite low to make sure the TBD. So I think that we have to find a consensus between the sonographers just to make sure that all of us are doing the exactly same measurement. So yeah, do you think that this can be interesting Folker to find like a consensus between between us, between all the sonography stuff, climbing indoors? Speaker 1 Absolutely. Because first of all, like the amount of forced flexion is important. And for the studies we did, we always had a forced measurement in the amount of first flexion. Because it matters if it's one Newt meters or 100 Newt meters, because that will change the TB. Then it is super important at which point you measure the TB and that point needs to be evaluated should be the same. Because otherwise TB measurements could not, cannot be compared. We found quite a good sensitivity for the ultrasound for the A3 and that's cadaver study we did with a Willow plate. Before doing that, we spent a long time figuring out at what points we would actually measure and so that they would be standardized also like mid portion of the base fellings where it's the mid portion. How do you actually get it? How do you measure it? How do you measure it? How do you measure the length? And we did compare that to Cadeva, the sections of of of the measurements and you did similar studies. And I completely agree we should have a general classification for or like normal normalisation for the measurement points to actually be able to compare different studies or results from different sonographs. But as you, you, you know and, and you do a lot of that, we have indirect signs that is the tendon bone distance and we have direct signs now audience because we have bigger eyes than we used to have. And I think the direct signs are getting more and more important. And I will just ask you about the direct signs in a second. And what I think for me is also super important is the dynamic imaging the dynamic as dynamic aspect, like an intact tendon is gliding through and underneath the flex the pulley and a torn pulley actually changes the course of the tendon. The tendon is not gliding. It's like jumping up and down and flaring and flapping, but it's not gliding anymore. But what what for you? What are the direct signs you would be looking for in in pulley injuries? Speaker 2 Yeah, I think that is how. Speaker 1 Important, are they? And what are you looking for? Yeah. Speaker 2 That's a good question, really interesting. Honestly, I did my my my PhD about about a 10 number distance in pulley injuries. I learned a lot, but I have to admit that nowadays I'm using much more the direct signs than the indirect signs. So I think that if there is a sonographist or a therapist or a physician with not much experience on this field, I think that activity is super useful. You can measure the activity and then you can know or you can guess if it's a complete rupture or if it's a partial rupture. So we have done a bunch of papers on this, on this topic. But nowadays in the clinic, I'm using much more the direct signs. And for me the main, main findings are the lack of pulley. You are not able, you are not seeing the pulley because the pulley is missing. So one of them is that you are not able to see the pulley. I think that the second finding that for me is also really interesting is the the Tenon one distance. But without measuring the Tenon one distance, you know you can see the shape of the Tenon as you said. So if it's like flat and not concave, you know that something is happening, then you have a lot of effusion, a lot of synovitis as a consequence of the rupture. And then I also think that it's really interesting to see if there is a scar tissue or not, but it's quite tricky because I'm so surprised. How fast is the scar tissue building in the finger? I still cannot understand really well the estology that is behind this healing process. But yeah, I think that the lack of pulley, all the fusion, the scar tissue and then the shape of the tendon, I think that yeah, those are the main findings in direct sayings. And I think that I want to focus my next papers on this field because I think that they can be really useful. What is more, I try to, I try to do some papers on this topic like a few years ago, but one of the main comments of the reviewers was that before starting with the with the direct signs that I need to, to finish with activity, you know, So I think that now we are finishing all this story with activity and in the next future in, in, in a close future, we were, we are going to start with direct signs. So do you agree with me, Volcker? Speaker 1 Yeah, yeah, absolutely. What what what other means of diagnostics will you use for Poly injuries? Other Diagnostics for Poly Injuries Like I know you have papers for some some other means like can you tell us about it? Speaker 2 Yeah, For me, and I was speaking about this topic with Tyler Tell Nelson, I think that the finger strength measurement is really, really, really interesting because honestly, I would say that at the beginning for diagnosing the ultrasound is really useful and then you can make a control of the TBD. But I think that in the rehabilitation process, the finger strength measurement is even more useful than the the ultrasound. So I think that I'm using the ultrasound, I'm using the finger strength measuring devices. And then for me, the most useful is also the palpation, you know, because sometimes with the basic tools we can, we can know the diagnosis. So I would say that that yeah, the test, the palpation, the finger strength deficit measurement and the ultrasound are the main tools that I'm using nowadays for, for, for pulley diagnosis. Speaker 1 And then the nice thing is that you can show it to the patient. You know, you can show him where the pulley is missing and show him the other finger. And, and it's, it's, it's not complicated. He can understand it, he can see it. And then he may even better follow your advice if you understand I. Speaker 2 Understand. OK, so I have a short game for you, Fokker. Pulley rupture game It's going to be quite funny. So it's focused on the pop Sounds OK. Speaker 1 Yeah. Speaker 2 So I'm I will simulate the pulley rupture sounds, the pop sounds and you have to guess which injury is it. So let's try. Are you ready? Yeah. Challenge accepted then. OK, I'm going to start. You have like a big pop like this one. What would you say? Like it's like super loud and you know, all your friends are are listening the same pop sound. What would you say? Pulley and which injury of the pulley like a big pop sound? Speaker 1 The pulley tear. Speaker 2 Yeah, but which one? A4 or A2? Speaker 1 A2. No A2. Speaker 2 I agree and if you have a a pop sound like this one but it's not that loud but you know that there is something wrong, which one would you say? Speaker 1 That could be the A4. I agree that could be the a four. But you know, like like my A2 sound was completely different. Mine was like tearing a piece of leather apart, like and you know why? Speaker 2 I have a. Speaker 1 Hypothesis. It wasn't. Speaker 2 Why? Why tell me? Yeah. Speaker 1 Because I had a tennis synovitis and I got a cortisone injection from my consultant the same day and I didn't do any break. So I went training in the in the evening and warmed up and then the pulley just like gave up. Speaker 2 Yeah. Speaker 1 And then? Speaker 2 Yeah, it sucks. It sucks. Yeah, I'm lucky. And then if you have, as you said that you have like a leader and you are like breaking the leader, I think that this could be a tenosynovitis as you said. Speaker 1 That's a chronic fatigue tier after tenosynovitis. Speaker 2 And in my opinion, some partial tiers are also quite similar, you know, So if you are like, yeah, that could be a partial tier and then a pop could be a completer, but you can have a big partial tier that is also like a pop. So in my opinion the main conclusions are like a big pop A2 a pop but it's like more inner not that loud A4 a small pop. It could be also not common, but a big partial tier and then a could be a partial rupture. But those are speculations They. Speaker 1 You need to sell that to Apple and the Apple board should you you should sell it to Apple and the Apple board should make an application where they actually record whenever you're climbing and then you can go to your doctor and and play the pop song and then you don't need the so we're. Speaker 2 Going to start beatboxing then, right? Speaker 1 We can start digging into pop songs. Speaker 2 So those are just the speculation. This is not science, but I think that it's really interesting. I know, I know. And the lubricalis vulgar. I think that you can have also a pop sound with a big Lumbricalis injury, yeah. Speaker 1 And you know, you know why, because I think the flex attendance, they leave the course, they change their their course suddenly because you know, one of the stabilisates gives way on one side and then there's tensioner, the tenant goes off to the side. Speaker 2 Yeah, I agree. OK, focus. So I have some short questions for you and those questions are not mine. OK. So by social media we we got we received some questions. So I'm going to start asking to you. So you have done much research on a three pulley injuries, how important it is and how do we diagnose? How important is a 3 pulley injury and how do we diagnose it? I think it's super important because it actually shows me if it's is a single or a double pulley. Injury Diagnostics is you. We measure the vola plate tendon distance because the A3 comes from the vola plate and not from the Bony insertion. And it shows us the difference between a grade 3 and a grade 4A injury. So we've done lots of research to, to get to the point where we can for sure now diagnose it with the ultrasound and I, I use that everyday. Speaker 2 I think that for me this is the most challenging exploration, you know, for me the a three you have to do a big flexion of the PIP. So it's like a real crimping position. So I think that you need a lot of gel that's quite tricky. Second question, do you think that we have cruciform pulley injuries? Speaker 1 Yes, I have a paper on them but it's super tricky to diagnose but yes. Speaker 2 Those are those all these, all these questions are not mine, but I think that they are really, really interesting. Speaker 1 Oh. Speaker 2 Sorry, So what is the flip phenomenon? Speaker 1 Flip. That's what we call like flap irritation phenomenon, meaning that if if the the pulley tears on one side as it only always does and basically there's there's stress on the flexa tendon and the flap of the pulley can get interscalated underneath the tendon. Basically it's what we call a Stena lesion of the thumb in the skiers thumb. Basically the the trunk of the former pulley gets in between the bone and the flexa tendons. So we cannot relocate the flexa tendons to its channel by a ring and basically that flap is hindering the flexitan from free gliding causing friction and and and effusion. And sometimes we didn't need then secondary remove the flap. So I had a couple of patients where I needed to do a secondary surgery because of a flap. So that's why we see a flap as a primary indication for surgery. Speaker 2 Yeah. Speaker 1 This is in a single polio injury. Speaker 2 Yeah, Yeah. This is really interesting. Well, I think that the next question you have already answered, but just in case I'm going to ask you to Is it possible to find calcifications in the police? Speaker 1 Yeah, yeah, they, they, they calcificate and they can even get into in the Bony attachment of being like bone channels, almost circular. Speaker 2 The next question is about estology. Do you think that a pulley get regenerated? I mean it's repaired or we only have scar tissue after a pulley rupture? That's tricky if. Speaker 1 I think it's scar tissue as an every ligament injury also in the FTA or anything, it's scar tissue. But like if you use the clamp right away and we have a good, good pressure on it, the scar tissue is small and a lot of the pulley is still there. Speaker 2 Yeah, I agree. I completely agree. OK. And the last question, is it more painful a partial tear than a complete tear? Speaker 1 Yes. Speaker 2 Absolutely. Speaker 1 Same in in, you know, in all other ligaments, like if one, if a ligament tears, all the fibers shoot and then they're dead. So it's sudden pain and then the pain diminishes. But if you have 1/2 torn pulley, then the flexor tendon is constantly irritating that remaining part of the intact pulley and that's causing stress and inflammation. So yes, definitely yes. Don't you think so? Speaker 2 Yeah, yeah, I agree. I absolutely agree. What is more, even a pulley strain, a Grade 1 pulley injury can be much more painful than a complete pulley rupture. Speaker 1 Oh yeah, than an than an A4, which is painful for three or five days and then it can get much, much better. Speaker 2 What I was thinking is about the about the scar tissue that you said. Sometimes what you know, what is quite tricky for me just to make a, just to distinguish between scar tissue and a thickening of the pulley, like a pulley adaptation, you know, because sometimes the ultrasound image is. Speaker 1 That's super tricky because you can have adaptation after partial tears. Speaker 2 Yeah, yeah, yeah, I agree. OK, so Folker, we are finishing the the first, well the second episode of the Climbing Medicine Academy, but we have some short questions. Short Questions So I'm going to start asking to you and it it has to be really quick. OK, so really short answer. So Fokker H2 complete rupture or a through and a three and a four multiple rupture. Which one do you prefer? Speaker 1 For me, yeah, a 3-4, yeah. Speaker 2 I agree. H taping or X taping for the pulleys. Speaker 1 For pulleys H taping, yeah. Speaker 2 We will speak about this in the next episode. OK. Ultrasound or dynamic MRI? Ultrasound. Yeah. How many papers do you have about police, do you know? Speaker 1 No. Speaker 2 OK, that's 15. I think that's more than that. OK, the most common injury in police, you have to choose one option, Partial rupture complete. Which pulley? What's the most common for you? Speaker 1 A4 complete rupture. I agree. Speaker 2 Which book do you recommend for physician pities or coaches about police that's. Speaker 1 The thing we wrote, it's called climbing medicine. I think it's it's OK. Speaker 2 Yeah, yeah, yeah, you have to promote that one for sure. I have it and it's brilliant. So I really, I strongly recommend this one. And the last question for you, which advice will you give to a climber with with a pain in the finger? Speaker 1 Like a fresh plane since like a sudden onset. Speaker 2 For the day, just taping and continue climbing. Keep climbing or visit a physician or APT. Speaker 1 Well, first rest ice compression, stop climbing, give it give it a few days and see. And then if it's not getting any better by like these basic measurements, go and get it checked out directly. I I'm I'm a big fan of a straightforward good diagnosis and then you can target your rehabilitation much easier and better than just like neglecting it and waiting and neglecting like my my my experience. I had a fresh A2 after tennosynovitis. I rested 3 days, started climbing again. I did a competition 10 days later, sucked in the competition. It was all crimping and I was in pain climbing wise for like 10 months and I could only climb after 10 months with ibuprofen so that was not the smart option and I would not do it again. Speaker 2 OK, so your answer is just too busy. Speaker 1 So it's it's on me, I think. Speaker 2 What? Yeah, sorry. You're. Speaker 1 Can I shoot a few? We need to finish but a few short question. Pulley Ruptures Did you ever tear a pulley on purpose on? Speaker 2 No, no, no, I was joking. No, of course. Speaker 1 When will you have your next pulley rupture? Never. Speaker 2 Hopefully. Speaker 1 Best prevention for pulley ruptures? Speaker 2 I think that good finger strength training and a good control on finger load. Speaker 1 Do you think there are people who are more prone to get a pulley rupture than others? Speaker 2 Yes, I think that it's related with bio mechanics. I think that the key of a pulley rupture is the hyperextension of the DIP joint. In my opinion. I was observing this and I think that this is quite interesting to research. I think that is. Speaker 1 Because it stretches the tendon. Yeah, Yeah. And last question, what would you prefer to have, capsulitis or A2 polyter? Speaker 2 A capsulitis, A capsulitis for sure. But I think that we will speak about this topic in the episode of capsulitis. But I think that a capsulitis is a disaster box. We have to speak about this plenty of times because sometimes it's linked with osteoarthritis, other times it's just linked with a torn and other other times it's just swelling. So I think that inside this disaster box, capsulitis can be quite nice injury and or can be a big pain in the ass. So yeah, definitely capsulitis before I to complete yeah. Speaker 1 Cool, so let's wrap this up. Speaker 2 OK. Thank you, Folker for sharing all this information with us. I think that we are really lucky having you. You have done a lot of research on this topic, so it's a pleasure. So listeners, in the next episode, we will continue with prognosis, treatment algorithms, surgery, rehabilitation, return to play, what means for us return to climbing, which is the main concern of the climber, about how long does the injury take? Complication, interviews with special guests, cases and some home take messages and also some tricky questions as always. So thank you. See you in the next episode. Bye, bye, bye bye.