Author Archives: Angie

About Angie

Doctorate of Physical Therapy NAIOMT Certified Manual Physical Therapist NSCA Certified Strength and Conditioning Specialist

Beginning Exercises for the Wrist

In the early stages of a wrist injury, (whether it be a sprain, strain, tendonitis, TFCC injury, or after a cast is removed) therapeutic exercise is essential for a quick and complete recovery.  Targeted exercise can help to maintain/gain range of motion, improve swelling, decrease pain, and improve neuromuscular control (aka the nerve-muscle connection).

If the injury is still in the inflammatory stage (early on, still swollen) be sure to keep these exercises in a pain-free range. (Yup – I bolded this.  It’s a big deal).  If you push too hard to fast you run the risk or re-injury and can lose function and extend the return to sport.

If this is a more chronic (old, nagging) pain or you just came out of a cast, feel free to be a little more aggressive.  In this case getting the range of motion back may involve pushing past some mild discomfort (yep – discomfort, not pain).  The goals are a little different as you’re not trying to help with swelling or maintain range, rather you’re starting from a limitation and building back.

The Exercises:

  1.  Wrist circles: With the hand in a relaxed fist, gently roll through the entire range of motion in a clockwise and counter clockwise direction.  The goal is to gain range of motion in all planes without irritation.  Perform 10-20 repetitions in each direction.    photo 3-1 photo 4-1photo 5-1photo 1-2photo 2-2
  2. Wrist AROM: flexion, extension, ulnar deviation, radial deviation, supination (turning the palm and forearm up), and pronation (turning the palm and forearm down): Gently move through each direction of motion (if you’re unsure of the term, check out the blog post on the “Anatomy of the Wrist.” The key with this exercise is to keep the hand open and relaxed while moving as far in each direction as you can.  Do 10-15 reps each direction.
    Ulnar Deviation (left hand)

    Ulnar Deviation (left hand)

    Radial Deviation (left hand)

    Radial Deviation (left hand)

    Wrist extension (right hand)

    Wrist extension (right hand)

    Wrist flexion (right hand)

    Wrist flexion (right hand)

  3. Towel (or putty squeeze): Grip a small towel (rolled up) or some rehab putty (play doh works too); squeeze and relax the hand in a motion that allows you to mash and form the putty.  The goal is not to make a distinct shape (sorry artsy folks) but to engage the flexors of the fingers and hand while encouraging the stabilizers of the wrist to work synergistically (together in a beneficial way) to keep the wrist fixed and stable.  Try to perform this for 1-3 minutes at a time with a rest break in between.photo 2-1
  4. Finger extensions (with and without a rubber band): Simply stated, this involves opening and closing the fingers.  The goal is to keep them extended (straight) and to challenge the finger and wrist extensors.  Try and keep the wrist neutral throughout.  Do 10-15 reps, 1-2 times.  To increase the difficulty add a rubber band; to increase it further, add two.photo 2photo 3photo 4photo 5
  5. Wrist stretches (with over pressure): flexion and extension;
    Flexion: With the fingers extended, pull the wrist and hand down (into flexion) until a stretch is felt on the top of the forearm and or wrist (in the extensor muscles).  Hold this for 30-45 seconds.  Be sure to avoid pain.  To increase the intensity, bend the fingers into a relaxed fist. wrist1Extension: With the fingers relaxed, grab the palm and pull the wrist and hand up (into extension) until a stretch is felt in the bottom of the forearm/wrist (in the flexor muscles).  Hold this for 30-45 seconds.  Be sure to avoid pain.  To increase the intensity, grab the fingers and pull (they will now be in an extended position thus putting more of a stretch on the flexor muscles).photo 1

Progression:

Once these exercises are easy (and pain-free) and your range of motion and flexibility on the affected wrist is equivalent to the other side, it is time to move to some strengthening exercises.  Check out “Intermediate Exercises for the Wrist.” – Coming soon!

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TFCC Injury: the meniscus of the wrist

The Triangular fibrocartilage complex (TFCC) is formed by the triangular fibrocartilage disc (TFC), the radioulnar ligaments (RULs) and the ulnocarpal ligaments (UCLs).

Anatomy of the Triangular Fibrocartilage Disc (TFC):

The TFC is a trianguar, biconcave (concave on both sides and thicker along its periphery) articular disc that sits at the distal ulna, between the ulna and the carpals.  The central portion of the TFC is thin, and is made of fibrocartilage (the type of cartilage that is designed to withstand compressive loads; such as in the meniscus of the knee).  Like in the knee, the inner portion of the TFC is poorly vascularized while the outer edge is well vascularized.  For this reason, often internal tears never heal and the injury become chronic (or are a surgical and not a rehab concern).

Note the integration of the disc with the ligaments

Note the integration of the disc with the ligaments

The TFC is attached to the wrist joint by the radioulnar and ulnocarpal ligaments (as well as smaller ligaments that attach it directly to the lunate and triquetrum bones).  These ligaments are also stabilizers of the wrist.  For this reason, any tear in the TFC or the TFCC (the disc plus the ligaments) often leads to instability in the wrist – a common problem with gymnasts that often requires bracing that compresses the radius and ulna and limits extension (tiger paws, pegasus wrist supports, etc).

The primary functions of the TFCC:

  • To support the ulnar portion of the wrist by increasing congruence between the ulna and the proximal row of carpals.
  • Load transmission across the ulnocarpal joint (partially load absorbing between the ulna and the carpals)
  • Allows forearm rotation by giving a strong but flexible connection between the distal radius and ulna.Pain under the examiner's thumb with pressure is a positive test

IMG_5511How is the TFCC injured?

As mentioned above, the TFCC complex stabilizes the wrist at the distal radioulnar joint. It also acts as a focal point for the force transmitted across the wrist along the ulnar side during weight bearing activities.  Traumatic injury (such as a fall onto an outstretched hand) is the most common mechanism of injury. The hand is usually in a pronated or palm down position. Tearing or rupture of the TFCC occurs when there is enough force through the ulnar side of the overextended wrist to overcome the tensile strength of this structure.  (Sounds like most tumbling skills right?)  The TFCC is also at risk with gripping or tensile loads (as seen when using a power drill that suddenly binds up or with gripping and pulling – such as many bar/ring skills) and can be torn this way as well.

In gymnastics however, the TFCC can also be injured through overuse injury (both support skills and hanging elements).  As the wrist has evolved over time and is no longer designed for true weight bearing activities, the TFCC is smaller and thinner than analogous cartilage discs (such as the meniscus) in the lower extremities (legs).  With repetitive weight bearing (both compressive and tensile), this area can become inflamed and tendonitis/tendonosis can develop in the anchoring wrist ligaments (often misdiagnosed as a wrist sprain).  The subsequent inflammation can irritate the TFC, causing it to swell and/or weaken overtime.  This causes subtle breakdown in the structure (as well as in the adjacent ligaments) that can lead to a traumatic tear with less force than required for a healthy TFCC.

Symptoms: (aka: why you’re really here…)

The symptoms of an injury to the TFCC are relatively simple, though they are often misdiagnosed as a wrist “sprain.” (Most non-orthopedics will use the term “sprain” as a catch-all for traumatic wrist pain that is not a fracture).

Primary symptoms:

The main symptom is ulnar wrist pain (pain along the pinky side of the hand).  In most cases it is right along the joint line, though some people will complain of “diffuse” wrist pain (a general pain that exists throughout the wrist joint).  Often this pain is increased with weight bearing activities on the wrist (handstands or hanging) and rotation of the wrist (such as turning a doorknob or lifting a heavy pan with one hand).  There is also often tenderness to the touch along the ulnar side of the joint.

Secondary symptoms:

Some other possible symptoms include: swelling in the area, clicking or popping in the joint (aka crepitus) and weakness (usually due to pain inhibition). 

Differential diagnosis: (aka ruling out other more serious conditions)

The biggest concern for a gymnast would be ruling out a fracture.  A fracture at the end of the ulna would present with similar symptoms.  The biggest difference is that with a fracture supination and pronation (twisting) of the forearm would also be greatly limited, if not blocked due to an ulnar dislocation.  If you (or a gymnast that you coach) is unable to twist the forearm without significant pain, my best recommendation is to send them for an x-ray to rule out the fracture.

Diagnosis:

While it’s best to leave the diagnosing to the professionals, there are some quick tests that you can do to differentiate a TFCC injury from general wrist pain.

  1. TFCC provocation test: Hold the gymnast’s hand upright and neutral.  Then perform ulnar deviation (tilt the hand toward the pinky) slowly.  A positive test (meaning you have a TFCC injury) is pain along the ulnar side of the joint.  A negative test (no injury) is reaching the end of the motion without pain.
    Starting position

    Starting position

    The hand is passively ulnarly deviated until end range.  A positive result is pain.

    The hand is passively tilted toward the pinky until end range. A positive result is pain.

  2. Fovea sign: Apply external pressure to the area of the wrist along the fovea of the ulna.  This is the space along the end of the ulna along the lateral side of the joint.  Compare this to the other side.  If there is pain with pressure, the test is considered positive (This is a highly sensitive, newly approved test BUT does not rule out fracture so be warned).

    Pain under the examiner's thumb with pressure is a positive test

    Pain under the examiner’s thumb with pressure is a positive test

Treatment:

Treatment depends largely on the severity of the tear and how limiting it is to training and activities.  Like any ligamentous injury, a TFCC tear can be separated into grades I-IV (with grade I being mild, no permanent tearing; and grade IV being a complete rupture of the involved ligaments).  In the less severe cases, the ligaments will slowly heal (as they were not completely torn) and normal function can be regained.  In the more severe cases (grade III – IV), surgery is an option to re-stabilize the TFCC and the wrist joint.  This is due to the fact the fully torn ligaments (and cartilage) do not actually regenerate to heal themselves.  Rather then will “scar down” as the body lays down additional collagen (connective tissue) in an effort to “patch” the injury.  Only a doctor (orthopedic) will be able to formally grade the injury, so if there is a severe disruption in function, it is this author’s recommendation that  medical intervention be sought out. (There is a great deal of information about surgical repair online, however this is not the focus of this article)

Acute (early inflammatory phase): within 2-4 weeks after the initial injury

In all cases, during the initial inflammatory period rest (so no gymnastics), ice and immobilization are the recommended protocols. The best position for the injured wrist is in a neutral position (see below) and supported by a brace.  The brace should be worn during daily activity to protect the wrist, and removed to allow for gentle movement and ice.  The type of brace is non-specific, but during this acute phase, should support the wrist and the hand (by wrapping around the thumb).

One of many options for bracing the wrist

One of many options for bracing the wrist during the acute/inflammatory phase

While the wrist is braced during activities of daily living, it is important to do gentle mobility exercises and hand motions to ensure that no motion is lost and to assist in the elimination of swelling.  These exercises include: wrist circles, gentle wrist range of motion, towel squeezes (can also be putty squeezes), and opening and closing the hand into and out of a fist.  (For a detailed view of these exercises, see “Beginning Exercises for the Wrist”)

During this time it is also important to ice the wrist periodically.  This can be done with a gel pack, bag of frozen peas, or a Ziploc bag of ice cubes.  Be sure to put a thin towel layer between the skin and ice, and only leave the ice on for 15 minutes at a time.  This should be done 4-5 times a day, to deal with swelling and help to alleviate pain.

After the inflammatory phase:

While there is no way to know for certain (without the hands on assessment of a professional) whether or not the injury has progressed beyond the acute or inflammatory stage, a general guide that can be used is the return of full, pain-free motion.  At that time, it is prudent to progress to some light weight bearing and more resistive exercises (see “Intermediate Exercises for the Wrist”).  It is also important to consider functional bracing to protect the injury and to minimize pain until full strength is regained.

Functional Bracing:

Not every TFCC injury or wrist instability can be completely rehabilitated with exercise alone (especially during the first month or two).  Often functional bracing (bracing during activity to support the instability) can allow a gymnast to continue to train while still protecting the newly healed TFCC (which will remain fragile until about the 6 month mark).

There are many braces on the market.  Here are some details about three that have been used in the sport with success.  (They are listed in random order – not a numerical rating system).

  1. Tiger Paws (aka Golden Paws): These are a more rigid wrist support (though now they do offer different inserts to vary the stiffness) that cover the wrist part of the hand.  Their purpose is to limit wrist extension/ulnar deviation.  In the case of a TFCC injury, they are very effective at protecting it once healed as they restrict the position that place the most stress on it.  The negative: they cover a portion of the hand and some gymnasts find that uncomfortable on balance beam.2874Tiger-Paws-Beige2. Pegasus wrist supports:  This brace compresses the radius and the ulna which providing a small block against end range extension and ulnar deviation.  The big difference between this brace and golden paws is that the Pegasus wrist supports do not cross onto the hand.  Some gymnasts may find this more comfortable – especially on balance beam (plus they can be used at the lower levels on parallel bars).  The negative: they do not support as completely as the Tiger Paws for TFCC because they do not block end-range extension fully.Pegasus_Wrist_Su_4e9e5105499513. Wrist Widget:  This is a newer style of brace and is more minimal in its design.  It was specifically designed for TFCC injuries and has been marketed for athletes, weekend warriors, and regular folks alike.  Like the Pegasus wrist brace, it compresses the ulna and the radius for support.  It does not restrict motion in any way, but rather supports the distal radioulnar joint so that the connecting ligaments of the TFCC are not as “stressed.”  In the gymnastic world this offers a minimalist way to brace the wrist that is still effective at protecting the TFCC and decreasing pain.41vuUHzYPVL._SY450_

Summary:

  • The TFCC (Triangular Fibrocartilage Complex) is composed of a disc (similar to the meniscus in the knee) and several adjacent ligaments on the ulnar side of the wrist.  It supports the ulna and maintains joint space in the wrist during weight bearing (both hanging and support activities).
  • Injury is caused by trauma (usually into compression or strong traction) and in gymnasts, overuse.
  • Treatment involves rest, ice, stretching/strengthening, and functional bracing.  It is key to allow the injury to rest during the inflammatory (acute) stage to minimize the risk of chronic pain.

Anatomy of the Wrist

The Wrist:

The wrist is a complex joint that connects the radius and ulna (the 2 bones in the forearm) to the carpals in the hand.  In most textbooks you’ll find that wrist’s purpose is stated as follows: “The wrist (and hand) allow for the manipulation of objects in space and provide us with the dexterity required for fine motor skills.” While that is the case for most people’s requirements of their wrists, gymnasts often use this joint as a weight bearing structure, and as such, injury is common.

Osteology of the Wrist:

The wrist is the junction of the distal end of the radius and the carpal bones.  It is often compared to the ankle joint(s) in structure, however through evolution, the wrist has become more delicate and lost many of the characteristics that would allow it to be a truly effective “weight-bearing’ joint.  The bones are smaller, there is less cartilage, and the ligaments are thinner – a  trifecta of risk for injury and instability.

Osteology of the WristThe eight carpal bones can be divided into two rows of four bones.  The proximal (or closer) row is composed of: (running from thumb to pinky) the scaphoid bone, the lunate bone, the triquetrial bone, and the pisiform bone.  The distal (or farther) row is composed of: the trapezium bone, the trapezoid bone, the capitate bone, and the hamate bone.  Why are the names important? They’re not (unless you’re heading into the medical field) – but it helps to know so that I can tell you that the scaphoid is the most commonly fractured as its location makes it more susceptible to weight and force.

Palmar view of the carpal bones

Palmar view of the carpal bones

Though there is no direct connection between the carpals and the ulna, there is a cartilaginous disc (shown in the picture below) that acts to allow increased congruence between the ulna and the carpal, as well as maintain the space on the ulnar side of the joint.  This disc is known as the Triangular Fibrocartilage Complex (or TFCC) and is commonly injured in weight bearing activities.

Palmar view of the TFCC

One reason that the wrist is so complicated is because every small bone forms a joint with the bone next to it (aka “Intercarpal Joints”).  This means that technically, there are “dozens” of small joints in the wrist that assist in allowing such versatility of movement.  Articular cartilage covers the ends of each of the bones where they meet in a joint, thus improving glide and protecting joint integrity.  For our purposes, we need only look at “three” functional joints in the wrist:

  1. The distal radioulnar joint: This is the point just prior to the wrist where the radius and ulna connect.  This is not a synovial joint, but rather exists because of the interosseus membrane (a thick ligamentous structure that connects them).  This is best described as a “pivot” joint and allows (in conjunction with the proximal radioulnar joint at the elbow) the forearm to pronate (turn down) and supinate (turn up).  The stability of this joint is essential for any weight bearing on the hand and wrist as it creates the “mortice” for the proximal carpals.
  2. The radiocarpal joint: This is the intersection of the distal end of the radius and the proximal row of carpals (as described above).  It is a true synovial joint, meaning that there is a joint capsule containing lubricating fluid within. The proximal row of carpals is convex on the concave radius.  This joint allows the hand and wrist to move down (palmar flexion) and up (extension or dorsiflexion).  In gymnastics, more extension is required than most other sports as weight bearing forces the wrist into that position.  For this reason, often the radiocarpal joint is hypermobile (extra flexible), bordering on unstable, and is very susceptible to injury.  This joint also allows a side to side glide which causes the hand and wrist to “tilt” left and right into radial deviation and ulnar deviation.
  3. The midcarpal joint: This is the intersection of the proximal row and the distal row of carpals.  Though it is not a “true” joint and it is often overlooked in many introductory anatomy texts, it is essential for achieving end-range motion (something gymnasts require). There is not as much motion available in this “joint” as the radiocarpal, but these bones glide to allow to the same motions as the radiocarpal joint.  Think of the joint as a “helper joint” in that alone it cannot perform the motions, but rather boosts the radiocarpal joint’s range.

The Ligaments of the Wrist:

In the wrist, the ligaments are the passive supports that ensure that the structure of the joint is maintained.  There are many ligaments in the wrist joint, and rather than name them all, we can group them into two categories:

  1. Dorsal Intercarpal Ligaments: A series of ligaments that extend transversely across the dorsal (back) surface of the wrist connecting the carpals to one another and the carpals to the radius/ulna.

    Dorsal Ligaments

    Dorsal Ligaments

  2. Palmar Intercarpal Ligaments: A series of ligaments that extend transversely across the palmar (front or volar) surface of the wrist connecting the carpals to one another and the carpals to the radius/ulna.  These ligaments are thicker than the dorsal ligaments (which works our well for gymnasts as these ligaments support the front of the wrist and palm in weight bearing).  Two named ligaments exist: the palmar (volar) radiocarpal ligament and the palmar (volar) intercarpal ligament.
    Palmar Ligaments (termed Volar Ligaments)

    Palmar Ligaments (termed Volar Ligaments)

    There are additional ligaments that assist in attaching specific carpals to one another, but for our purposes are not necessary to discuss.  (If you have specific questions about the ligaments, please email me or post a question in the comments section).

Muscles of the Wrist:

Similar to the muscles that control the movement of ankle, the wrist and hand muscles are located primarily in the forearm.  Often they work in groups (aka synergistically) to allow for the dexterity and movement of these joints.

The tendons of these muscles are longer from the end of the muscle belly to the insertion, and thus require two thick bands at the wrist to anchor them in place:

  1. The anterior band, known as the Flexor Retinaculum (aka transverse carpal ligament), travels across the palmar side of the wrist and forms the “Carpal Tunnel.” This tunnel is supported on the sides and back by the carpal bones, and has all of the flexor tendons (in synovial sheaths), the median nerve, and several arteries and veins traveling through it.carpaltunnel
  2. The posterior band, known as the Extensor Retinaculum anchors the extensor tendons and assists in supporting the posterior structure of the wrist.

Alright, on to the muscles…In order to simplify a rather massive amount of information, I’ve divided these muscles into the action they perform.

Anterior and Posterior views of the muscles that control the wrist and hand

Anterior and Posterior views of the muscles that control the wrist and hand

  1. Flexion: bending the wrist towards the palm. Muscles include: Flexor Carpi Ulnaris (prime mover), Flexor Carpi Radialis (prime mover), Palmaris longus (tightens the skin and fascia in the palm), Flexor Digitorum Superficialis (finger flexor, assists only).

    Wrist flexion (right hand)

    Wrist flexion (right hand)

  2. Extension: bending the wrist backwards; the primary position for weight bearing. Muscles include: Extensor Carpi Radialis Longus (prime mover), Extensor Carpis Radialis Brevis (prime mover), Extensor Carpi Ulnaris, Extensor Digitorum (assists only).

    Wrist extension (right hand)

    Wrist extension (right hand)

  3. Radial Deviation: tilting the hand and wrist toward the thumb and radius.  Muscles include: Flexor Carpi Radialis & Extensor Carpi Radialis (they work together to cancel the flexion and extension and instead just pull toward the radius). This motion is more important in weight bearing activities on the balance beam, rings, pommels, and p-bars when using the wrists to maintain an inverted position.

    Radial Deviation (left hand)

    Radial Deviation (left hand)

  4. Ulnar Deviation: tilting the hand and wrist toward the pinky and ulna. Muscles include: Flexor Carpi Ulnaris & Extensor Carpi Ulnaris (they work together to cancel the flexion and extension and instead just pull toward the ulna). This motion is more important in weight bearing activities on the balance beam, rings, pommels, and p-bars when using the wrists to maintain an inverted position.
    Ulnar Deviation (left hand)

    Ulnar Deviation (left hand)

    The anatomical complexity and versatility of the wrist is what allows gymnasts many of the abilities required for skill acquisition.  However, these same traits also lend the wrist to injury and overuse – but I’ll save that discussion for a later date.

Rips

As any gymnast, beginner through elite level can tell you, if you work on uneven bars, high bar, parallel bars, rings, or pommel horse – you’re going to rip.  It’s an unfortunate fact of gymnastics.  The good news?  Unlike most of the injuries that I’ll write about on this blog, a rip is actually beneficial….

Let me explain –

A rip is the wound caused by a callous tearing off the hand.  It is an area of non-mature skin that is suddenly exposed when the thickened layers above it tear off.  It is typically painful, and depending on the depth/thickness of the callous, it can bleed.

Typical high bar/uneven bar rip (along the surface that bears weight)

The process of ripping is actually beneficial in the long run because it causes your hands to toughen.  When you first begin to work bars, or when your training requirements increase, the increased workload causes your hands to break down in an effort to remodel.  As you spin, swing, pivot, and move around the bar, the friction between your hands and the bar causes the top layers of skin to “bubble” up and pull away from the layers underneath.  This causes a “blister.”  When the force exceeds the strength along the edges of the blister, the top layers of skin “rip off” and tada – you have a rip.  As you continue to train and after the new rips thicken and heal, you begin to build callouses (areas of thicker skin that are more dense, dry, and resistant to the forces placed upon them).  These callouses are a requirement of any seasoned gymnast – they are as important as good strength or flexibility.  That said, like other tools, they must be maintained.

Prevention:

An ounce of prevention truly is worth a pound of cure.  When you rip, you have to take time off that apparatus to let the wound heal. So it comes at no surprise, that preventing rips should be the goal.

Maintain your hands:

  • Shave/smooth your callouses: Using a pumice stone, smooth and thin out the callouses that do form on your hands.  In the case of gymnastics, a thicker callous is not always a stronger callous.  By keeping the excess dead layers from building up, and by keeping them smooth, there is less of a chance of them getting caught and torn.
  • Keep your hands moisturized: When you’re not in the gym, wash off the chalk and use a basic hand lotion to keep the callouses from cracking and to keep the skin they attach to stronger.
  • Use ice/heat to deal with general soreness
  • Don’t over train – if you notice that your hands are close to ripping, decrease your training if possible.  Allow the skin to remodel without forcing the rip.

Use grips: If you’re on the equipment enough to rip, it’s probably time to get some grips.  There are many types, and each is beneficial for a certain event and level.

  • Palm grips: If you’re new to the sport, start with palm grips.  These can be used on any piece of equipment, and are relatively inexpensive.  They cover the palm with a layer of thick material and can add friction if maintained.  Sizes are based on the length of your palm and vary by manufacturer, so look at the sizing guide to be sure.
Beginner palm grips; cover the palm (sit at the base of the middle 2 fingers). Retail for $12.50 – $16.50 online
  • Dowel grips: These are designed for high bar, uneven bars, and rings (but be aware – the model and style is different between the three apparatus).  The grip sits on the distal phalanx of the fingers (just past the last knuckle) and cover more of the fingers than a palm grip. The dowel in the grip loops over the top of the bar and helps to increase the mechanical advantage provided by the grip (makes hanging/swinging a little easier).  For this reason, these are a better tool for the more advanced gymnast – anyone beyond a basic routine that is doing tap swings and flipping dismounts.  Sizing with dowel grips is very important – there is a risk of the grip locking if the palm portion is too large (another reason to never use the grip models across the different apparatus).  For that reason, be sure to read the size charts on the website.  When the grips arrive, they will be stiff and seem small – as you work on them, they will stretch.
    Uneven bar dowel grips (note that there are 2 finger holes); retail for about $50.00 – $65.00 online.
    High bar dowel grips (note the shorter length and 3 finger holes). Retail for $50.00 – $65.00 online.
    Rings dowel grips (note the narrow width). Retail for $50.00 – $65.00 online.

Treatment:

Once you have a rip, you’ll need to treat it correctly if you want your recovery time to be less. It’s important to stop what you’re doing immediately (please don’t keep swinging on a fresh rip just because you think you’re beast).  As it is a wound, there is a risk of infection, and as common courtesy to your other teammates, you’ll want to avoid getting blood and interstitial fluid all over the equipment.

  1. Trim the rip: Using nail clippers (or if you’re daring, a pair of nail scissors) trim away the remaining edges of the torn callous.  You want the skin along the edges of the rip to be pink/healthy and firmly anchored to the underlying tissues.  This will prevent any further progression of the rip when you return to swinging.  Some gymnasts will just tear off the excess skin.  If you’re skilled this is fine, but be aware that you can tear off healthy adjacent tissue and make the rip bigger and more painful.
  2. Clean the rip: Using warm water and regular soap, scrub for 30-60 seconds.  No doubt it will burn, but you have to clear out any bacteria and the chalk to ensure that you don’t get an infection and to allow the skin to heal.  Avoid hydrogen peroxide or rubbing alcohol as they can kill healthy cells and actually slow the healing process.  If the rip is bleeding, try Bactine – this is more gentle and also has an analgesic (pain-reliever) in it.  The spray version works well so there is no need to “swab” or “dab” at the rip – this is only going to make it more painful!
  3. Cover the rip: If you’re heading back to the apparatus that day, I’d recommend “New Skin.” It’s basically sterilized clear nail polish that instantly seals the rip and provides a protective layer (yes, it burns like mad).  Get your own bottle because it’s brush on and is unsafe to share with your fellow gymnasts.  I use 2-3 coats (it takes about 60 seconds for each coat to dry) to ensure good coverage.  I would also recommend that if your grips don’t cover this spot, make a tape grip (see below) to give an extra layer.  New-skin is nice, but nothing can compete with the friction from a giant swing.
    new-skin liquid bandage (burns like mad but works great for same-day return to swinging)

    If you’d rather, Spenco 2nd skin moist burn pads are a great soothing option – they just don’t stay in place well if you keep swinging.  Cut them to size (they usually come in a 3″x4″ sheet) and place the gel side down on the rip. I’d recommend using them after practice that day and cover with a band-aid/tape to keep in place overnight.  This will take the “sting” out and speed the recovery/maturing process of the immature skin layers.

    Spenco moist burn pads (soothes, but not durable enough to swing with)
  4. Keep the rip smooth and “crack free”: In this case, as the rip heals, you want to be sure that the edges where the new and old skin meet are not rough or uneven (a pumice stone works great).  Use chapstick on the center of the rip (as long as there isn’t any blood and it’s been about a day since it first happened) to keep the skin hydrated.  If it dries out a “cracks” you’ll likely see another rip in the next day (even deeper and more painful than the first).  It can also be beneficial to soak the rip in an epsom salt & warm water mixture for 10 minutes at night.  This will sooth the “ache” and help to toughen then skin so that there is less pain the next day.

Tape Grips:

Tape grips are a quick solution to cover the rip in the gym without wrapping the whole hand in tape (we all know that will roll up and interfere with practice).  A tape grip can be used under your grips, or just to cover the palm while tumbling, on balance beam, etc.

The palm portion of the tape grip is reusable, and often lasts through 2-3 solid practices before breaking down.  The grip is anchored to the wrist with tape, and can be secured with or without pre-wrap (depending on amount of arm hair/comfort required).

Tear of a length of tape (about 18 inches)
Fold the tape over so the sticky sides meet and crease it (now it is half-width and the outside is no longer sticky).
Bend the length in 1/2 and make a loop at the top (be sure to avoid twisting the tape). This loop is there the finger will go.
Using tape, stick the two halves together (start 1-1.5 inches below the loop and go to the end). Do not tear the tape yet.
Flip the grip over, and run the tape up the opposite side to the same point just below the loop. Tear here and be sure everything is “securely stuck”.
Place the loop over the finger just about the rip. Be sure that the “wide side” of the loop is against the hand for comfort.
Begin to anchor the grip at the wrist with tape. Be sure to hold the “tail of the grip” in place (not shown) so that it doesn’t twist.
After wrapping one full-length around the wrist, fold up the excess “tail” and wrap again. This will ensure that there are no loose ends in the way of skill performance.

Beginning Therapeutic Exercise for Inversion Ankle Sprains

With a grade 1 ankle sprain, you can begin gentle therapeutic exercise even while there is some swelling and pain (in standing/walking) that remain.  These exercises are designed to be very gentle – and it should be noted that they should be pain-free at all times.   All of them are non-weight bearing and designed to reduce swelling, regain motion, and begin re-training proprioception.

Beginning exercises for a grade 1 sprain (while there is still swelling/pain):

Ankle circles: With the leg supported (or elevated if there is still some swelling), make circles with foot at the ankle.  The goal is to make the largest circles possible, but it is essential that you stay within a pain-free range.  As the ankle continues to heal, you can make the circles larger and larger.  Do 15-20 times both clockwise and counter-clockwise.  This can be repeated 2-3 times a day.

Ankle Circles

Ankle plantar flexion/dorsiflexion: this is simply pointing and flexing the foot in a pain-free range.  With the leg supported (or elevated if there is still some swelling), focus on moving the foot without it twisting in or out.  The goal is smooth and controlled motion.  Do 15-20 times, 2-3 times a day.  Again, keep the motion in a pain-free range and progress when able.

Ankle alphabets: With the leg supported (or elevated if there is still some swelling), write the alphabet with the foot by moving at the ankle.  Be sure to keep the leg still and move slowly and in a pain-free range.  Start with 1-2 times through, from A to Z, and do this 2-3 times a day.

Ankle alphabets: draw the alphabet (upper or lowercase doesn’t matter)

Beginning exercises for a grade 1 ankle sprain (after the pain had subsided):

Once you no longer have pain in the ankle with walking and the swelling is beginning to subside, you can progress to some more advanced exercises.  The goal of this phase of rehab is to continue to restore motion, strengthen the affected muscles, and begin re-training proprioception (in closed chain  – aka in weight bearing).

First, begin by doing all of the exercise listed above for 1 set as the “warm-up.”  Then also include the exercises listed below:

Ankle PREs (progressive resistive exercises): Done with the therapy band, these movements strengthen the muscles of the lower leg that help to externally stabilize the ankle.  The key to these exercises is to only move the foot/ankle and keep the lower leg still.  Be sure to have the leg supported.  Do 10-15 reps for 1-2 sets, only once per day.  Choose a band that is mildly to moderately difficult, but not painful or hard.  You can tie the band to anchor it, have a partner help you, or can use the other foot to anchor it.  (see the therapeutic resistance bands link under “rehab modalities for more info on band difficulty/progression)

Ankle PREs (includes all 4 directions – not sure about the eye guard, but it can’t hurt)

Single Leg Stand (SLS):This exercise is designed to retrain balance and proprioception.  Be sure to start with the hands on or near a cabinet for protection in case you lose your balance.   Try and balance on the foot for 30-45 seconds without using your hands/stepping down.  Do this 2-3 times, once a day.  Keep the heel flat (do not rise onto the toe).

SLS

Gastroc & Soleus Stretches: (calf stretching): In an ankle sprain, especially if there was some immobilization, the calf muscles will likely tighten.  It is essential to stretch them out to allow the right amount of dorsiflexion on a landing (so that the anterior ankle structure are not over-stressed and re-injured).  There are two main muscles that attach into the achilles, the gastroc (short for gastrocnemius) and the soleus.

The gastroc stretch is the traditional calf stretch.  Start with the affected leg behind you, toes forward, heel flat.  Then lean forward until a stretch is felt in the upper portion of the calf.  Hold for 30 seconds.  Do 4 repetitions, 1-2 times a day.

Gastroc Stretch (the back leg is straight; the front leg carries the weight.  The stretch should be felt high up in the calf muscle.)

The soleus stretch is similar to the traditional calf stretch, but the back leg is bent. This focuses the stretch on the soleus muscle (which lies deep to the gastroc).  This will likely be felt lower down in the leg (more along the achilles tendon).  Hold for 30 seconds. Do 4 repetitions, 1-2 times a day.

Soleus stretch (notice that the back leg is bent; the weight should be over the front leg)

Once these exercises become easy and your form is consistent (no loss of balance, no pain, and no “shaking” with movement), you can consider progressing to the next block of exercises.  In most cases, it will take about 1-3 weeks to progress through these exercises.  Be sure to take your time and don’t rush – if the ankle is not appropriately retrained, there is a VERY high risk of re-injury.

Remember, a grade 2 sprain is more severe, and should be checked out by a medical professional prior to the initiation of any self-rehabilitation.  That said, once the ankle has healed > 4 weeks, (ligamentous injury takes 4-6 weeks), you can try the grade 1 exercises and progress through as if it were a grade 1 injury.  It is even more important to rehab the grade 2 ankle sprain carefully and fully as there was more ligamentous and nerve injury than in a grade 1 sprain.

(And because I know you need reminding, be sure to ice after these exercises if they make the ankle sore or if any swelling remains.  72 hours is not the “limit” and rather ice should be used any time the healing joint is painful or swollen.)

 

Use of the foam roll for self myofascial release

Often times pain is caused by tight fascia and muscle.  The myofascial junction (the point where the muscle and the fascia meet) is often an area of tenderness and increased tone (resting tightness).  While stretching is important in injury prevention, it alone cannot address this area. In conditions like patellar tendonitis, IT band tendonitis, or with simple delayed onset muscle soreness (DOMS) myofascial release can be essential in eliminating pain.

There are many ways to perform self myofascial release.  In the context of this article, I’ll focus on the use of a foam roll.  This is a relatively mild-moderate tool and may not alleviate small points of tightness in the muscle/fascia.  If you feel that it it not “reaching that spot” you might want to progress to a tennis or lacrosse ball (to be discussed in a later post).  There are different levels of “firmness” available and this is often described as density.  I’d recommend a moderate density and you don’t need to invest in any of the rolls with odd patterns/edges – these are more gimmick than they are based in research.  Keep it simple and you’ll see progress.

Basic foam roll, 6″ in diameter and 36″ long.  Available online from many companies.  Look for a price under $20 before tax/shipping. Most running stores also sell them in shorted lengths if transport is an issue (12-24″ long).

You can roll over any muscle/connective tissue in the body.  The keys to remember for safety are to avoid rolling across joints or areas of skin damage (bruises, open cuts, rashes) as this can cause harm.  Traditionally, you should roll across the length of the muscle, and focus over sore spots.  The duration of the treatment can vary, but about 1-3 minutes is usually sufficient to cause significant relaxation and lengthening in the muscle/fascia.  Try to roll after a good warm-up so that you have enough circulation to the muscles.  It can also be done after a workout to decrease the amount of soreness.  (In other words, just don’t roll when you’re “cold” and have been sitting)

Listed below are the links to YouTube videos that I’ve posted on several muscles in the body.  If you need more of a description, drop me an email and I’d be happy to elaborate!

More muscles to come!  For the Gymkana members reading this, I’ve donated 4 foam rolls to the team (located in the study lounge).  Please take care of them and use them often after practice!