- Email: [email protected]
Circular wrist tape – How to correctly use this technique in climbing and bouldering
ORTHTR 10969 No. of Pages 4
REVIEW
Orthopaedics Traumatology
Sports Orthop. Traumatol. xx, xx–xx (2017) C Elsevier GmbH
www.SOTjournal.com http://dx.doi.org/10.1016/j.orthtr.2017.09.012
and
Summary Rock climbing with its several sub-disciplines is currently gaining in popularity and was recently selected to be part of the next Olympic summer games in Tokyo. The rapid increase in people being enthusiastic about this sport and the rising number of high-level athletes has recently slightly shifted the incidence of climbing specific injuries and we nowadays see more injuries of the wrist. A technique commonly used to treat or prevent injuries of the wrist is the circular wrist tape. As athletes regularly apply this tape inaccurately, we now aimed to clarify how to correctly use this technique by reviewing literature. Keywords Climbing – [4_TD$IF]Bouldering – Hamate fractures – Wrist pain – Taping – Carpus
C. Lutter, V. Scho¨ffl
[2_TD$IF]Circular wrist tape – Korrekte Anwendung im Kletter- und Bouldersport Zusammenfassung Die Trendsportart Klettern mit ihren Unterdisziplinen Bouldern, Lead, und Speedklettern erf€ahrt momentan weltweit einen enormen ,,Boom‘‘. Nicht zuletzt deshalb wurde sie nun erstmals in das olympische Programm der n€achsten olympischen Sommerspiele aufgenommen. Die explosionsartige Zunahme der begeisterten Sportler f€uhrte unl€angst zu einer Verschiebung der sportartspezifischen Verletzungsmuster; da immer mehr Athleten den Sport am oberen Schwierigkeitslimit betreiben, h€aufen sich unl€angst Verletzungen im Bereich des Handgelenkes. Eine hierf€ur h€aufig verwendete Therapieform ist das Circular Wrist Tape. Da diese Tape-Technik in den meisten F€allen aber unzul€anglich verwendet wird, soll in der nun vorliegenden Arbeit Klarheit anhand einer Literaturrecherche zum Cicular wrist tape geschaffen werden. €rter €sselwo Schlu Sportklettern – Bouldern – HamatumfrakturHandgelenksschmerz – Tape – Karpalknochen
REVIEW
Circular wrist tape – How to correctly use this technique in climbing and bouldering Christoph Lutter1,2, Volker Scho¨ffl1,3,4 1 Department of Orthopedics and Traumatology, Klinikum Bamberg, Germany 2 CVPath Institute, Gaithersburg, USA 3 Department of Trauma and Orthopedic Surgery, Friedrich Alexander University, Erlangen-Nuremberg, Germany 4 Department of Emergency Medicine, University of Colorado, School of Medicine, Denver, USA Eingegangen/submitted: 16.02.2017; u¨berarbeitet/revised: 27.05.2017; akzeptiert/accepted: 21.09.2017 Online verfu¨gbar seit/Available online: xxx
[5_TD$IF]Background
C
Wrist [9_TD$IF]taping and strength
limbing related injuries of the wrist and the forearm are nowadays seen more frequently than in the past with the rising number of people being enthusiastic about this sport. As more and more athletes perform the sport on a level which was reached by only a few top athletes in the past, injuries like hamate fractures or other pathologies of the wrist become more common. Besides that, modern training- and competition setups include more gymnastic elements and movements for which a variety of different grip techniques is required [6_TD$IF] [8,15,13]. The circular wrist tape is a technique which is commonly used by athletes in different sports to both strengthen and stabilize the wrist for high compression load (e.g. weightlifting [7_TD$IF][6,16], gymnastics [7,22]) or stabilize the wrist for tensile stress like in climbing where the athlete is pulling on his/her hand [8_TD$IF][8,4]. However, as different sports have special demands on how to apply supporting devices or tapes, we now aimed to clarify a method of sufficient taping of the wrist for climbing and bouldering.
Taping of the fingers and the wrist is often used by athletes (e.g. football players) to ‘‘increase grip strength’’ and to give a subjective feeling of stabilization within the wrist [10_TD$IF][12]. However, in their study published in 1997, Rettig et [1_TD$IF]al. could prove that circular wrist tape, with or without additional taping of the fingers, does not increase wrist strength [10_TD$IF][12]. Contrary to the perceptions of the athletes, Takahashi et [1_TD$IF]al. even showed that tight circular wrist tape can even slightly decrease grip strength when encircled too tight [12_TD$IF][18]. However, no climbing specific data known to us has been published so far on grip strength variations under wrist tape.
Instability of the [13_TD$IF]wrist in climbing Patients suffering from instability feeling in the wrist or unspecific wrist pain are often diagnosed with injuries of the ligaments and capsules or even with bone marrow edema of the carpal bones or carpal fractures [14_TD$IF][8,4]. The pain and discomfort mainly arises in radial/ulnar abducted positions of
C. Lutter, V. Sch€offl
Circular wrist tape
1
REVIEW Sports Orthop. Traumatol. xx, xx–xx (2017)
the hand or while performing an undercling (position of the hand in maximum supination) [14_TD$IF][8,4]. During climbing or bouldering, the majority of thenar and hypothenar muscular strength is transferred to carpal bones and the distal part of the radius by the transverse carpal ligament (TCL) causing frequently occurring reactions of the lunate and the distal radius [15_TD$IF][5]. Biomechanical analysis postulate, that carpal bones (especially the lunate) are in a more unstable position if maximum strength is applied in a slightly ulnar abducted and dorsal flexed-[16_TD$IF]position of the hand [5]. This goes along with the findings of one of our recent studies, showing that the lunate is frequently affected by bone marrow edema in rock climbers causing wrist pain [17_TD$IF][9]. Despite that, we previously
published a study in which we reported that high stress of flexor tendons can even cause fractures of hamate bone, especially of the hamate hook [18_TD$IF][8]. It is comprehensible that radioulnar joint instability or anatomic predispositions such as incongruent wrists (pos./neg. ulnar variance) can encourage the development of problems in this region – especially in powerful pronation (so called ‘‘gaston’’ position of the hand) or supination (so called ‘‘undercling’’ position of the hand) or while pushing with the hand instead of pulling [19_TD$IF] [13].
Anatomy and biomechanics Lately there has been confusion about proper terminology of two structures covering the nerval
structures, muscles and tendons within the wrist: ‘‘flexor retinaculum of the wrist’’ and ‘‘transverse carpal ligament’’. Besides these two terms, authors used other titles such as ‘‘flexor retinaculum carpi’’ or ‘‘carpal palmar ligament’’. In their anatomical study from 2010, Stecco et [1_TD$IF]al. therefore tried to identify differences and ‘‘define appropriate terminology’’ [20_TD$IF][17]. As the authors could highlight clear differences among the two structures regarding thickness/tightness, soft tissue composition and nerve innervation, they suggested to abandon the term ‘‘flexor retinaculum of the wrist’’, as it does not appoint one unique structure. The authors recommended to use the term ‘‘transverse carpal ligament’’ (TCL) for the fibrous and thick lamina between hamate/pisiform and
Figure 1 Circular wrist tape technique. (A) Commonly encircled but incorrect position (encircling the distal radio-ulnar joint (DRUJ)) for circular wrist tape in climbing and bouldering (see arrowhead). (B) Correct starting position (skin fold of the wrist) distal of the DRUJ (see arrowhead). (C) Application of the tape by encircling [1_TD$IF]2–3 layers around the wrist. (D) Initial tight circular wrist tape after application (tape will loosen during first minutes of climbing); blood circulation remains unrestricted.
2
C. Lutter, V. Sch€offl
Circular wrist tape
REVIEW Sports Orthop. Traumatol. xx, xx–xx (2017)
scaphoid/trapezium and the term ‘‘reinforcement of the antebrachial fascia’’ (RF) for the thickened distal part of the palmar sided forearm fascia. Both structures adhere partially and though represent two different anatomical structures [20_TD$IF][17]. Different factors of carpal stability are discussed controversially: congruency between the carpal bones, tendons, negative intra-articular pressure, and ligaments of the wrist [21_TD$IF][20,2,3,10,1,21,19,11]. Though, it has been shown, that the TCL is an important structure preventing increased inter-carpal mobility and excursion of flexor tendons (such as after carpal tunnel release) [2_TD$IF] [20,3,1]. Furthermore, the RF is considered to be substantially involved in proprioception [20_TD$IF][17]. Differentiation between TCL and RF is also possible in MR imaging [23_TD$IF][17].
Taping technique Commonly used tapes for climbing are rigid (non-elastic) tapes like Leukoplast[24_TD$IF] [3_TD$IF] hospital (BSN medical, Hamburg – Germany). Unlike finger tapes, where thin strips of tapes are used [25_TD$IF][14], wider tapes are recommended for circular wrist tape [12_TD$IF][18]. As climbers need stability within the wrist but also a high level of flexibility, we therefore recommend tape stripes of 2.5 cm. This width allows rise of pressure within the carpal with preserved flexibility of the wrist [26_TD$IF](Fig. 1). Due to the fact that this taping technique achieves an increase of the carpal and thus add stability within the wrist and not the distal part of the forearm, we highly recommend a tape placement distal of the styloid process of the ulna (skin fold of the wrist) [27_TD$IF](Figs. 1–3). By that, the carpal architecture including the TCL will be supported [28_TD$IF](Figs. 2 and 3). In contrast to the publications of Takahashi et [29_TD$IF]al. and Rettig et al. who investigated athletes directly after taping the wrist, we recommend j
Figure 2 Anatomical preparation of the distal forearm and the wrist. Circular wrist tape positioned correctly. (A) Arrowhead indicates localization of the ‘‘reinforcement of the antebrachial fascia’’ (RF) being the superficial aspect of the ‘‘transverse carpal ligament’’ (TCL) (also see Fig. 3(B) arrowhead). (B) Circular wrist tape supporting the carpal architecture.
to apply the circular wrist tape rather firm [30_TD$IF](2–3 layers) due to the fact that even the non-elastic tape loosens a little bit within the first minutes of climbing [31_TD$IF][4,12,18]. This will ensure a best as possible ‘‘strengthening’’ and
‘‘stability’’, even though this might be placebo-like effects [10_TD$IF][12]. However, our group showed that this taping technique does not always grant relief from wrist pain; some athletes even describe an increase
Figure 3 Anatomical preparation of the distal forearm and the wrist. Circular wrist tape positioned incorrectly. (A) Arrowhead indicates localization of the ‘‘reinforcement of the antebrachial fascia’’ (RF) as superficial aspect of the ‘‘transverse carpal ligament’’ (TCL). The deeper, stronger lamina of the ligament can be seen slightly distal of the arrowhead. (B) Circular wrist tape positioned proximal of the RF/TCL.
C. Lutter, V. Sch€offl
Circular wrist tape
3
REVIEW Sports Orthop. Traumatol. xx, xx–xx (2017)
of wrist pain while using this tape caused by the pressure rise [18_TD$IF][8]. Furthermore, some studies showed that preventive (finger-) taping in general is not to be recommended and can even increase injury rate [32_TD$IF] [14,23,24]. Whether or not these findings can be transferred to taping of the wrist remains unclear so far. However, it is crucial to be aware of the potential benefits and disadvantages to guarantee optimal care when supervising climbing athletes.
Conclusion Circular wrist tape can add beneficial effects like a feeling of increased stability or ‘‘strengthening’’ of the wrist and the hand when performed correctly. Based on anatomical circumstances and expertise from our clinical studies, we recommend a very distal and initially tight (multiple-layer) application of the tape. In cases of discomfort under circular wrist tape, the patient should be disadvised from this supporting technique.
References [1] [3_TD$IF]G.R. Fisk, The influence of the transverse carpal ligament (flexor retinaculum) on carpal stability, Ann[34_TD$IF]. Chir. Main 3 (4) (1984) 297–299. [35_TD$IF][2] M. Garcia-Elias, Kinetic analysis of carpal stability during grip, Hand Clin. 13 (1) (1997) 151–158. [36_TD$IF][3] G.M. Gartsman, J.C. Kovach, C.C. Crouch, P.C. Noble, J.B. Bennett, Carpal arch alteration after carpal tunnel release, [37_TD$IF]J. Hand Surg. 11 (3) (1986) 372–374. [38_TD$IF][4] T. Hochholzer, V. Schoeff, One Move Too Many, Lochner, Ebenhausen, 2016. [39_TD$IF][5] T. Hochholzer, T. Bayer, G. Straub, V. Scho¨ffl, Overuse bone marrow edema of the hands in sport climbers, Sport Orthop[40_TD$IF]. Traumatol. 29 (2013) 219–224.
[41_TD$IF][6] J.W. Keogh, P.W. Winwood, The [42_TD$IF]epidemiology of injuries across the weight-training sports, Sports Med. (2016). http://dx.doi.org/10.1007/ s40279-016-0575-0. [43_TD$IF][7] L.S. Kox, P.P. Kuijer, G.M. Kerkhoffs, M. Maas, M.H. Frings-Dresen, Prevalence, incidence and risk factors for overuse injuries of the wrist in young athletes: a systematic review, Br[4_TD$IF]. J. Sports Med. 49 (18) (2015) 1189–1196. http://dx.doi. org/10.1136/bjsports-2014-094492. [45_TD$IF][8] C. Lutter, A. Schweizer, T. Hochholzer, T. Bayer, V. Schoffl, Pulling [46_TD$IF]harder than the hamate tolerates: evaluation of hamate injuries in rock climbing and bouldering, Wilderness [47_TD$IF]Environ. Med. (2016). http://dx.doi.org/10.1016/j. wem.2016.09.003. [17_TD$IF][9] C.H. Lutter, T. Bayer, T. Scho¨ffl, V. Rock, Climbing Related Bone Marrow Edema of the Hand: A Follow-up Study, CJSM, [48_TD$IF]2017 (accepted 2017). [10] J.K. Mayfield, Wrist ligamentous anatomy and pathogenesis of carpal instability, Orthop[49_TD$IF]. Clin. North Am. 15 (2) (1984) 209–216. [50_TD$IF][11] J.K. Mayfield, R.P. Johnson, R.F. Kilcoyne, The ligaments of the human wrist and their functional significance, Anat[51_TD$IF]. Rec. 186 (3) (1976) 417–428. http://dx.doi. org/10.1002/ar.1091860307. [10_TD$IF][12] A.C. Rettig, K.S. Stube, K.D. Shelbourne, Effects of finger and wrist taping on grip strength, [52_TD$IF]Am. J. Sports Med. 25 (1) (1997) 96–98. [53_TD$IF][13] V. Scho¨ffl, C. Lutter, Acute and chronic instabilities of the hand and wrist, [54_TD$IF] Sports Orthop. Traumatol. (2017). http://dx.doi.org/10.1016/j.orthtr. 2016.11.002. [5_TD$IF][14] I. Schoffl, F. Einwag, W. Strecker, F. Hennig, V. Schoffl, Impact of taping after finger flexor tendon pulley ruptures in rock climbers, J[56_TD$IF]. Appl. Biomech. 23 (1) (2007) 52–62. [57_TD$IF][15] V. Schoffl, D. Popp, T. Kupper, I. Schoffl, Injury trends in rock climbers: evaluation of a case series of 911 injuries between 2009 and 2012, Wilderness [47_TD$IF]Environ. Med. 26 (1) (2015) 62–67. http://dx.doi.org/ 10. 1016/j.wem.2014.08.013. [58_TD$IF][16] J. Siewe, J. Rudat, M. Rollinghoff, U.J. Schlegel, P. Eysel, J.W. Michael, Injuries and overuse syndromes in
Available online at www.sciencedirect.com
ScienceDirect 4
C. Lutter, V. Sch€offl
Circular wrist tape
[60_TD$IF][17]
[12_TD$IF][18]
[63_TD$IF][19] [64_TD$IF][20]
[65_TD$IF][21]
[67_TD$IF][22]
[69_TD$IF][23]
[24]
powerlifting, Int[59_TD$IF]. J. Sports Med. 32 (9) (2011) 703–711. http://dx.doi. org/10.1055/s-0031-1277207. C. Stecco, V. Macchi, L. Lancerotto, C. Tiengo, A. Porzionato, R. De Caro, Comparison of transverse carpal ligament and flexor retinaculum terminology for the wrist, [37_TD$IF]J. Hand Surg. 35 (5) (2010) 746–753. . http://dx.doi.org/ 10.1016/j.jhsa.2010.01.031. K. Takahashi, S[61_TD$IF].-i. Demura, Effects of [62_TD$IF] different taping pressures of wrist taping using rigid tape on grip strength exertion, Am. J. Med. Sci. Med. 2 (6) (2014) 122–125. http://dx.doi.org/ 10.12691/ajmsm-2-6-2. J. Taleisnik, The ligaments of the wrist, [37_TD$IF]J. Hand Surg. 1 (2) (1976) 110–118. M. Vanhees, F. Verstreken, R. van Riet, What does the transverse carpal ligament contribute to carpal stability? J Wrist Surg. 4 (1) (2015) 31–34. http:// dx.doi.org/10.1055/s-0034-1398486, PMC4327719. R.G. Volz, M. Lieb, J. Benjamin, Biomechanics of the wrist, Clin[6_TD$IF]. Orthop. Relat. Res. (149) (1980) 112–117. M.R. Wolf, D. Avery, J.M. Wolf, Upper [68_TD$IF] extremity injuries in gymnasts, Hand Clin. 33 (1) (2017) 187–197. http:// dx.doi.org/10.1016/j. hcl.2016.08.010. K.Y. Woollings, C.D. McKay, C.A. Emery, Risk factors for injury in sport climbing and bouldering: a systematic review of the literature, Br[4_TD$IF]. J. Sports Med. 49 (17) (2015) 1094–1099. http://dx.doi.org/ 10.1136/bjsports-2014-094372. K.Y. Woollings, C.D. McKay, J. Kang, W. H. Meeuwisse, C.A. Emery, Incidence, mechanism and risk factors for injury in youth rock climbers, Br[4_TD$IF][70. J. Sports Med. 49 (1) (2015) 44–50 . http://dx.doi. org/10.1136/bjsports-2014-094067.
Corresponding author: Dr. med. Christoph Lutter, Klinikum Bamberg, Department of Orthopedics and Traumatology, Klinikum Bamberg, Germany. E-Mail: [email protected]
REVIEW
Orthopaedics Traumatology
Sports Orthop. Traumatol. xx, xx–xx (2017) C Elsevier GmbH
www.SOTjournal.com http://dx.doi.org/10.1016/j.orthtr.2017.09.012
and
Summary Rock climbing with its several sub-disciplines is currently gaining in popularity and was recently selected to be part of the next Olympic summer games in Tokyo. The rapid increase in people being enthusiastic about this sport and the rising number of high-level athletes has recently slightly shifted the incidence of climbing specific injuries and we nowadays see more injuries of the wrist. A technique commonly used to treat or prevent injuries of the wrist is the circular wrist tape. As athletes regularly apply this tape inaccurately, we now aimed to clarify how to correctly use this technique by reviewing literature. Keywords Climbing – [4_TD$IF]Bouldering – Hamate fractures – Wrist pain – Taping – Carpus
C. Lutter, V. Scho¨ffl
[2_TD$IF]Circular wrist tape – Korrekte Anwendung im Kletter- und Bouldersport Zusammenfassung Die Trendsportart Klettern mit ihren Unterdisziplinen Bouldern, Lead, und Speedklettern erf€ahrt momentan weltweit einen enormen ,,Boom‘‘. Nicht zuletzt deshalb wurde sie nun erstmals in das olympische Programm der n€achsten olympischen Sommerspiele aufgenommen. Die explosionsartige Zunahme der begeisterten Sportler f€uhrte unl€angst zu einer Verschiebung der sportartspezifischen Verletzungsmuster; da immer mehr Athleten den Sport am oberen Schwierigkeitslimit betreiben, h€aufen sich unl€angst Verletzungen im Bereich des Handgelenkes. Eine hierf€ur h€aufig verwendete Therapieform ist das Circular Wrist Tape. Da diese Tape-Technik in den meisten F€allen aber unzul€anglich verwendet wird, soll in der nun vorliegenden Arbeit Klarheit anhand einer Literaturrecherche zum Cicular wrist tape geschaffen werden. €rter €sselwo Schlu Sportklettern – Bouldern – HamatumfrakturHandgelenksschmerz – Tape – Karpalknochen
REVIEW
Circular wrist tape – How to correctly use this technique in climbing and bouldering Christoph Lutter1,2, Volker Scho¨ffl1,3,4 1 Department of Orthopedics and Traumatology, Klinikum Bamberg, Germany 2 CVPath Institute, Gaithersburg, USA 3 Department of Trauma and Orthopedic Surgery, Friedrich Alexander University, Erlangen-Nuremberg, Germany 4 Department of Emergency Medicine, University of Colorado, School of Medicine, Denver, USA Eingegangen/submitted: 16.02.2017; u¨berarbeitet/revised: 27.05.2017; akzeptiert/accepted: 21.09.2017 Online verfu¨gbar seit/Available online: xxx
[5_TD$IF]Background
C
Wrist [9_TD$IF]taping and strength
limbing related injuries of the wrist and the forearm are nowadays seen more frequently than in the past with the rising number of people being enthusiastic about this sport. As more and more athletes perform the sport on a level which was reached by only a few top athletes in the past, injuries like hamate fractures or other pathologies of the wrist become more common. Besides that, modern training- and competition setups include more gymnastic elements and movements for which a variety of different grip techniques is required [6_TD$IF] [8,15,13]. The circular wrist tape is a technique which is commonly used by athletes in different sports to both strengthen and stabilize the wrist for high compression load (e.g. weightlifting [7_TD$IF][6,16], gymnastics [7,22]) or stabilize the wrist for tensile stress like in climbing where the athlete is pulling on his/her hand [8_TD$IF][8,4]. However, as different sports have special demands on how to apply supporting devices or tapes, we now aimed to clarify a method of sufficient taping of the wrist for climbing and bouldering.
Taping of the fingers and the wrist is often used by athletes (e.g. football players) to ‘‘increase grip strength’’ and to give a subjective feeling of stabilization within the wrist [10_TD$IF][12]. However, in their study published in 1997, Rettig et [1_TD$IF]al. could prove that circular wrist tape, with or without additional taping of the fingers, does not increase wrist strength [10_TD$IF][12]. Contrary to the perceptions of the athletes, Takahashi et [1_TD$IF]al. even showed that tight circular wrist tape can even slightly decrease grip strength when encircled too tight [12_TD$IF][18]. However, no climbing specific data known to us has been published so far on grip strength variations under wrist tape.
Instability of the [13_TD$IF]wrist in climbing Patients suffering from instability feeling in the wrist or unspecific wrist pain are often diagnosed with injuries of the ligaments and capsules or even with bone marrow edema of the carpal bones or carpal fractures [14_TD$IF][8,4]. The pain and discomfort mainly arises in radial/ulnar abducted positions of
C. Lutter, V. Sch€offl
Circular wrist tape
1
REVIEW Sports Orthop. Traumatol. xx, xx–xx (2017)
the hand or while performing an undercling (position of the hand in maximum supination) [14_TD$IF][8,4]. During climbing or bouldering, the majority of thenar and hypothenar muscular strength is transferred to carpal bones and the distal part of the radius by the transverse carpal ligament (TCL) causing frequently occurring reactions of the lunate and the distal radius [15_TD$IF][5]. Biomechanical analysis postulate, that carpal bones (especially the lunate) are in a more unstable position if maximum strength is applied in a slightly ulnar abducted and dorsal flexed-[16_TD$IF]position of the hand [5]. This goes along with the findings of one of our recent studies, showing that the lunate is frequently affected by bone marrow edema in rock climbers causing wrist pain [17_TD$IF][9]. Despite that, we previously
published a study in which we reported that high stress of flexor tendons can even cause fractures of hamate bone, especially of the hamate hook [18_TD$IF][8]. It is comprehensible that radioulnar joint instability or anatomic predispositions such as incongruent wrists (pos./neg. ulnar variance) can encourage the development of problems in this region – especially in powerful pronation (so called ‘‘gaston’’ position of the hand) or supination (so called ‘‘undercling’’ position of the hand) or while pushing with the hand instead of pulling [19_TD$IF] [13].
Anatomy and biomechanics Lately there has been confusion about proper terminology of two structures covering the nerval
structures, muscles and tendons within the wrist: ‘‘flexor retinaculum of the wrist’’ and ‘‘transverse carpal ligament’’. Besides these two terms, authors used other titles such as ‘‘flexor retinaculum carpi’’ or ‘‘carpal palmar ligament’’. In their anatomical study from 2010, Stecco et [1_TD$IF]al. therefore tried to identify differences and ‘‘define appropriate terminology’’ [20_TD$IF][17]. As the authors could highlight clear differences among the two structures regarding thickness/tightness, soft tissue composition and nerve innervation, they suggested to abandon the term ‘‘flexor retinaculum of the wrist’’, as it does not appoint one unique structure. The authors recommended to use the term ‘‘transverse carpal ligament’’ (TCL) for the fibrous and thick lamina between hamate/pisiform and
Figure 1 Circular wrist tape technique. (A) Commonly encircled but incorrect position (encircling the distal radio-ulnar joint (DRUJ)) for circular wrist tape in climbing and bouldering (see arrowhead). (B) Correct starting position (skin fold of the wrist) distal of the DRUJ (see arrowhead). (C) Application of the tape by encircling [1_TD$IF]2–3 layers around the wrist. (D) Initial tight circular wrist tape after application (tape will loosen during first minutes of climbing); blood circulation remains unrestricted.
2
C. Lutter, V. Sch€offl
Circular wrist tape
REVIEW Sports Orthop. Traumatol. xx, xx–xx (2017)
scaphoid/trapezium and the term ‘‘reinforcement of the antebrachial fascia’’ (RF) for the thickened distal part of the palmar sided forearm fascia. Both structures adhere partially and though represent two different anatomical structures [20_TD$IF][17]. Different factors of carpal stability are discussed controversially: congruency between the carpal bones, tendons, negative intra-articular pressure, and ligaments of the wrist [21_TD$IF][20,2,3,10,1,21,19,11]. Though, it has been shown, that the TCL is an important structure preventing increased inter-carpal mobility and excursion of flexor tendons (such as after carpal tunnel release) [2_TD$IF] [20,3,1]. Furthermore, the RF is considered to be substantially involved in proprioception [20_TD$IF][17]. Differentiation between TCL and RF is also possible in MR imaging [23_TD$IF][17].
Taping technique Commonly used tapes for climbing are rigid (non-elastic) tapes like Leukoplast[24_TD$IF] [3_TD$IF] hospital (BSN medical, Hamburg – Germany). Unlike finger tapes, where thin strips of tapes are used [25_TD$IF][14], wider tapes are recommended for circular wrist tape [12_TD$IF][18]. As climbers need stability within the wrist but also a high level of flexibility, we therefore recommend tape stripes of 2.5 cm. This width allows rise of pressure within the carpal with preserved flexibility of the wrist [26_TD$IF](Fig. 1). Due to the fact that this taping technique achieves an increase of the carpal and thus add stability within the wrist and not the distal part of the forearm, we highly recommend a tape placement distal of the styloid process of the ulna (skin fold of the wrist) [27_TD$IF](Figs. 1–3). By that, the carpal architecture including the TCL will be supported [28_TD$IF](Figs. 2 and 3). In contrast to the publications of Takahashi et [29_TD$IF]al. and Rettig et al. who investigated athletes directly after taping the wrist, we recommend j
Figure 2 Anatomical preparation of the distal forearm and the wrist. Circular wrist tape positioned correctly. (A) Arrowhead indicates localization of the ‘‘reinforcement of the antebrachial fascia’’ (RF) being the superficial aspect of the ‘‘transverse carpal ligament’’ (TCL) (also see Fig. 3(B) arrowhead). (B) Circular wrist tape supporting the carpal architecture.
to apply the circular wrist tape rather firm [30_TD$IF](2–3 layers) due to the fact that even the non-elastic tape loosens a little bit within the first minutes of climbing [31_TD$IF][4,12,18]. This will ensure a best as possible ‘‘strengthening’’ and
‘‘stability’’, even though this might be placebo-like effects [10_TD$IF][12]. However, our group showed that this taping technique does not always grant relief from wrist pain; some athletes even describe an increase
Figure 3 Anatomical preparation of the distal forearm and the wrist. Circular wrist tape positioned incorrectly. (A) Arrowhead indicates localization of the ‘‘reinforcement of the antebrachial fascia’’ (RF) as superficial aspect of the ‘‘transverse carpal ligament’’ (TCL). The deeper, stronger lamina of the ligament can be seen slightly distal of the arrowhead. (B) Circular wrist tape positioned proximal of the RF/TCL.
C. Lutter, V. Sch€offl
Circular wrist tape
3
REVIEW Sports Orthop. Traumatol. xx, xx–xx (2017)
of wrist pain while using this tape caused by the pressure rise [18_TD$IF][8]. Furthermore, some studies showed that preventive (finger-) taping in general is not to be recommended and can even increase injury rate [32_TD$IF] [14,23,24]. Whether or not these findings can be transferred to taping of the wrist remains unclear so far. However, it is crucial to be aware of the potential benefits and disadvantages to guarantee optimal care when supervising climbing athletes.
Conclusion Circular wrist tape can add beneficial effects like a feeling of increased stability or ‘‘strengthening’’ of the wrist and the hand when performed correctly. Based on anatomical circumstances and expertise from our clinical studies, we recommend a very distal and initially tight (multiple-layer) application of the tape. In cases of discomfort under circular wrist tape, the patient should be disadvised from this supporting technique.
References [1] [3_TD$IF]G.R. Fisk, The influence of the transverse carpal ligament (flexor retinaculum) on carpal stability, Ann[34_TD$IF]. Chir. Main 3 (4) (1984) 297–299. [35_TD$IF][2] M. Garcia-Elias, Kinetic analysis of carpal stability during grip, Hand Clin. 13 (1) (1997) 151–158. [36_TD$IF][3] G.M. Gartsman, J.C. Kovach, C.C. Crouch, P.C. Noble, J.B. Bennett, Carpal arch alteration after carpal tunnel release, [37_TD$IF]J. Hand Surg. 11 (3) (1986) 372–374. [38_TD$IF][4] T. Hochholzer, V. Schoeff, One Move Too Many, Lochner, Ebenhausen, 2016. [39_TD$IF][5] T. Hochholzer, T. Bayer, G. Straub, V. Scho¨ffl, Overuse bone marrow edema of the hands in sport climbers, Sport Orthop[40_TD$IF]. Traumatol. 29 (2013) 219–224.
[41_TD$IF][6] J.W. Keogh, P.W. Winwood, The [42_TD$IF]epidemiology of injuries across the weight-training sports, Sports Med. (2016). http://dx.doi.org/10.1007/ s40279-016-0575-0. [43_TD$IF][7] L.S. Kox, P.P. Kuijer, G.M. Kerkhoffs, M. Maas, M.H. Frings-Dresen, Prevalence, incidence and risk factors for overuse injuries of the wrist in young athletes: a systematic review, Br[4_TD$IF]. J. Sports Med. 49 (18) (2015) 1189–1196. http://dx.doi. org/10.1136/bjsports-2014-094492. [45_TD$IF][8] C. Lutter, A. Schweizer, T. Hochholzer, T. Bayer, V. Schoffl, Pulling [46_TD$IF]harder than the hamate tolerates: evaluation of hamate injuries in rock climbing and bouldering, Wilderness [47_TD$IF]Environ. Med. (2016). http://dx.doi.org/10.1016/j. wem.2016.09.003. [17_TD$IF][9] C.H. Lutter, T. Bayer, T. Scho¨ffl, V. Rock, Climbing Related Bone Marrow Edema of the Hand: A Follow-up Study, CJSM, [48_TD$IF]2017 (accepted 2017). [10] J.K. Mayfield, Wrist ligamentous anatomy and pathogenesis of carpal instability, Orthop[49_TD$IF]. Clin. North Am. 15 (2) (1984) 209–216. [50_TD$IF][11] J.K. Mayfield, R.P. Johnson, R.F. Kilcoyne, The ligaments of the human wrist and their functional significance, Anat[51_TD$IF]. Rec. 186 (3) (1976) 417–428. http://dx.doi. org/10.1002/ar.1091860307. [10_TD$IF][12] A.C. Rettig, K.S. Stube, K.D. Shelbourne, Effects of finger and wrist taping on grip strength, [52_TD$IF]Am. J. Sports Med. 25 (1) (1997) 96–98. [53_TD$IF][13] V. Scho¨ffl, C. Lutter, Acute and chronic instabilities of the hand and wrist, [54_TD$IF] Sports Orthop. Traumatol. (2017). http://dx.doi.org/10.1016/j.orthtr. 2016.11.002. [5_TD$IF][14] I. Schoffl, F. Einwag, W. Strecker, F. Hennig, V. Schoffl, Impact of taping after finger flexor tendon pulley ruptures in rock climbers, J[56_TD$IF]. Appl. Biomech. 23 (1) (2007) 52–62. [57_TD$IF][15] V. Schoffl, D. Popp, T. Kupper, I. Schoffl, Injury trends in rock climbers: evaluation of a case series of 911 injuries between 2009 and 2012, Wilderness [47_TD$IF]Environ. Med. 26 (1) (2015) 62–67. http://dx.doi.org/ 10. 1016/j.wem.2014.08.013. [58_TD$IF][16] J. Siewe, J. Rudat, M. Rollinghoff, U.J. Schlegel, P. Eysel, J.W. Michael, Injuries and overuse syndromes in
Available online at www.sciencedirect.com
ScienceDirect 4
C. Lutter, V. Sch€offl
Circular wrist tape
[60_TD$IF][17]
[12_TD$IF][18]
[63_TD$IF][19] [64_TD$IF][20]
[65_TD$IF][21]
[67_TD$IF][22]
[69_TD$IF][23]
[24]
powerlifting, Int[59_TD$IF]. J. Sports Med. 32 (9) (2011) 703–711. http://dx.doi. org/10.1055/s-0031-1277207. C. Stecco, V. Macchi, L. Lancerotto, C. Tiengo, A. Porzionato, R. De Caro, Comparison of transverse carpal ligament and flexor retinaculum terminology for the wrist, [37_TD$IF]J. Hand Surg. 35 (5) (2010) 746–753. . http://dx.doi.org/ 10.1016/j.jhsa.2010.01.031. K. Takahashi, S[61_TD$IF].-i. Demura, Effects of [62_TD$IF] different taping pressures of wrist taping using rigid tape on grip strength exertion, Am. J. Med. Sci. Med. 2 (6) (2014) 122–125. http://dx.doi.org/ 10.12691/ajmsm-2-6-2. J. Taleisnik, The ligaments of the wrist, [37_TD$IF]J. Hand Surg. 1 (2) (1976) 110–118. M. Vanhees, F. Verstreken, R. van Riet, What does the transverse carpal ligament contribute to carpal stability? J Wrist Surg. 4 (1) (2015) 31–34. http:// dx.doi.org/10.1055/s-0034-1398486, PMC4327719. R.G. Volz, M. Lieb, J. Benjamin, Biomechanics of the wrist, Clin[6_TD$IF]. Orthop. Relat. Res. (149) (1980) 112–117. M.R. Wolf, D. Avery, J.M. Wolf, Upper [68_TD$IF] extremity injuries in gymnasts, Hand Clin. 33 (1) (2017) 187–197. http:// dx.doi.org/10.1016/j. hcl.2016.08.010. K.Y. Woollings, C.D. McKay, C.A. Emery, Risk factors for injury in sport climbing and bouldering: a systematic review of the literature, Br[4_TD$IF]. J. Sports Med. 49 (17) (2015) 1094–1099. http://dx.doi.org/ 10.1136/bjsports-2014-094372. K.Y. Woollings, C.D. McKay, J. Kang, W. H. Meeuwisse, C.A. Emery, Incidence, mechanism and risk factors for injury in youth rock climbers, Br[4_TD$IF][70. J. Sports Med. 49 (1) (2015) 44–50 . http://dx.doi. org/10.1136/bjsports-2014-094067.
Corresponding author: Dr. med. Christoph Lutter, Klinikum Bamberg, Department of Orthopedics and Traumatology, Klinikum Bamberg, Germany. E-Mail: [email protected]