Evaluation of physiological standard pressures of the forearm flexor muscles during sport specific ergometry in sport climbers

Diagnostic criteria of forearm Chronic Exertional Compartment Syndrome: A systematic review

BACKGROUND

Chronic Exertional Compartment Syndrome (CECS) of the forearm is characterized by an increase of the pressure in the forearm compartments during repeated activities. Its diagnosis is challenging because of the lack of clearly established diagnostic criteria.

PURPOSE

We aimed to provide a comprehensive description of the diagnostic methods used for CECS of the forearm, to assess if a more effective diagnosis strategy could be identified.

METHODS

We used PubMed, Google Scholar, Cochrane Library and Science Direct databases to search articles. We carried out multiple searches using the mesh terms ("Chronic Exertional Compartment Syndrome" OR "Chronic compartment syndrome" OR "Exertional compartment") AND ("forearm" OR "upper limb"). Inclusion criteria were prospective or retrospective studies on CECS of the forearm including case reports. We used PRISMA guidelines. The included studies were critically appraised using GRADE approach.

RESULTS

A total of 625 articles were screened and 33 studies were included. It represented 590 patients (505 men and 85 women), with a mean age of 26.6 years old. Among them, 282 competed at an elite level. Motorcycling and motocross were the most frequent sports (66%). Six diagnostic methods were employed. Intra-compartmental pressure (ICP) measurement was the most frequently used method in 26 studies. Magnetic resonance imaging was performed in 9 studies, while electromyography was employed in only 2 studies. One study reported the measurement of grip strength using a manual dynamometer, one study compared forearm circumference before and after effort, and one used myotonometry. Various exercise protocols were observed. Stress-testing using a hand-grip was the most common protocol in 14 studies. Exercise duration varied from 2 min to 60 min.

CONCLUSION

Existing data do not provide sufficient evidence to favor an alternative diagnostic method over ICP measurements that should be used cautiously given the absence of formal validation. Non-invasive methods might be easier to use, but should be subjected to further research.

LEVEL OF EVIDENCE

III.

Ultrasound-guided fasciotomy in forearm chronic exertional compartment syndrome: Preliminary results in 12 cases

INTRODUCTION

Forearm chronic exertional compartment syndrome is a rare condition in athletes and musicians who perform repeated prolonged forced gripping movements. It mainly affects young men, and presents with cramp-like pain, beginning on the anteromedial side of the forearm and progressively extending to the entire circumference, and may be associated with muscle weakness and neurologic symptoms. The objective of this study was to report preliminary results of ultrasound-guided fasciotomy in the treatment of forearm chronic exertional compartment syndrome.

MATERIAL AND METHODS

A single-center retrospective observational study was conducted. Forearm chronic exertional compartment syndrome was diagnosed on clinical presentation and pathological intramuscular pressure measurement, defined as >30 mmHg at 1 min after effort. The series comprised 7 men, with bilateral involvement. Mean age was 30 years. All patients were motorcyclists. The mean preoperative intramuscular pressure at 1 min after effort was 60.75 mmHg (range: 30-81 mmHg). The main study endpoint was change in pain on visual analogic scale. Secondary endpoints comprised patient satisfaction, change in competitive sports level, and time to return to sport. Complications were noted.

RESULTS

Six patients (12 forearms) were evaluated. Mean follow-up was 22.5 months (range: 3-48 months). Mean pain rating was 7.3/10 (range: 6-9) preoperatively, and 0/10 postoperatively. All patients were satisfied with the procedure. Mean time to return to sports was 25.5 days (range: 21-30 days). No patients decreased their competitive sports level after the procedure. One patient presented a postoperative hematoma, not requiring surgery.

CONCLUSION

Ultrasound-guided fasciotomy in the treatment of Forearm chronic exertional compartment syndrome is an innovative technique with promising preliminary results.

LEVEL OF EVIDENCE

IV; retrospective cohort.

Forearm compartment pressures and grip strength in elite motorbike racers with chronic exertional compartment syndrome

BACKGROUND

Remarkably little research has been published on chronic exertional compartment syndrome (CECS) of the forearm. This study investigated forearm flexor compartment pressure pre- and post-exercise in elite motorbike racers clinically diagnosed with CECS and assessed their grip strength before and after arm pump exercise.

METHODS

Elite motorbike riders with a clinical diagnosis of CECS of the right forearm when racing were recruited during the opening rounds of a British Superbike season. Their grip strength and forearm flexor compartment pressures were measured before and after a set exercise programme.

RESULTS

Of the 11 riders recruited to the study, 10 completed the full testing regime. The mean pre-exercise forearm compartment pressures [11.7 mmHg (range 7-17 mmHg)] significantly increased post-exercise [30.5 mmHg (range 15-45 mmHg)], with a mean increase of 18.80 mmHg (P < 0.0001). The mean pre-exercise grip strength [50.61 mmHg (range 37-66.7 mmHg)] decreased post-exercise to [35.62 mmHg (range 17.1-52.5 mmHg)], a mean decrease of 14.99 mmHg (P < 0.0001).

CONCLUSION

There is a statistically significant increase in the forearm flexor compartment pressures in elite motorbike racers with CECS, but with marked variability of these values. Grip strength decreases statistically significantly following onset of symptoms of CECS of the forearm.

MRI findings in chronic exertional compartment syndrome of the forearm: Using signal intensity ratio as a diagnostic tool

BACKGROUND

Chronic exertional compartment syndrome (CECS) of the forearm is a rare but important cause of morbidity amongst athletes involved in strenuous upper limb activities. The diagnosis remains challenging due to the absence of objective, reproducible diagnostic studies.

OBJECTIVES

To assess and quantify signal intensity (SI) changes of involved muscles in patients with CECS of the forearm compared to healthy control subjects competing in similar sporting disciplines. Also, to objectively measure MRI SIs within muscle compartments when using a pre- and post-exercise regime and calculating a signal intensity ratio (SIR) between post- and pre-exercise studies.

METHOD

The study retrospectively examined MRI scans of patients treated for CECS of the forearm and compared these to the MRI scans of asymptomatic high-level rowers. A specific, reproducible pre- and post-exercise MRI scanning protocol was utilised in both patient and control subjects between 2011 and 2020. Signal intensities were evaluated pre- and post-exercise in involved muscle groups and ratios were calculated.

RESULTS

A total of 86 SIs were measured (43 pre- and 43 post-exercise) in nine study participants (five patients and four controls). After post:pre-exercise comparisons, a statistically significant difference was found between control and patient groups (p = 0.0010). The extensor carpi radialis, flexor digitorum profundus and flexor digitorum superficialis muscles were most commonly involved.

CONCLUSION

This study confirms that significant SI changes are apparent in patients with CECS of the forearm when making use of a standardised pre- and post-exercise MRI protocol. Furthermore, SIR may be used to accurately diagnose CECS of the forearm.

Epidemiology of upper limb chronic exertional compartment syndrome (CECS) in the French Motorcycle Federation racers: Results of a national questionnaire-based study

Upper limb chronic exertional compartment syndrome (CECS) has been described in amateur and professional motorcycle racers, but there is no published data about its prevalence. The purpose of this study was to define the awareness, prevention and prevalence of this syndrome in licensed motorcycle racers in competition in France. Secondary purposes were to determine the functional impact of CECS and post-treatment outcomes. The 20,641 licensed racers in competition of the French Motorcycle Federation were sent a self-assessment questionnaire about upper limb pain and CECS physical examination findings, functional impact and treatment outcomes. The satisfaction level was assessed after each type of treatment. Acceptability rate was 6.35% with 1311 racers responding. CECS was unknown by 29% of racers. Prevention methods were unknown by 10% of racers. Less than 50% of racers modified their bikes. The prevalence of upper limb CECS in competitive racers was 9%: 8.7% forearm, 0.2% thenar, 0.1% hypothenar and 0.4% first dorsal interosseus compartments. The prevalence was 16% in international level racers, 11% in national level racers and 7.3% in regional level racers. A quarter of racers were satisfied or very satisfied with the outcomes of conservative therapy and rehabilitation. Only 67 racers underwent surgical treatment for their upper limb CECS: 31 by open fasciotomy, 23 by minimally invasive fasciotomy and 13 by endoscopy-assisted compartment release. In these 67 racers, the mean visual analog score for pain improved significantly (p < 0.001 95% CI [3.1-4.5]) with 81% satisfied or very satisfied with surgery outcomes. This epidemiologic self-assessment questionnaire for upper limb CECS is a new concept. This study screened for CECS and offer information regarding evaluation, treatment, and management.

Long-Term Outcome of Mini-Open Surgical Decompression for Chronic Exertional Compartment Syndrome of the Forearm in Professional Motorcycling Riders

OBJECTIVE

To evaluate results of mini-open fasciotomy (MOF) in high-level motorcycling or motocross riders with chronic exertional compartment syndrome (CECS) at long-term follow-up (minimum 5 years).

DESIGN

Case series.

LEVEL OF EVIDENCE

IV.

SETTING

University Hospital/Private Practice.

PATIENTS

Fifty-four professional motorcycling riders treated with MOF for a CECS of the forearm from January 2006 to June 2011. Inclusion criteria comprised: high-level motorcycling or motocross riders, clinical symptoms of CECS for at least 6 months, diagnosis confirmed using preoperative compartment hydrostatic pressure measurement and/or magnetic resonance imaging of the forearm, minimum follow-up of 5 years.

INTERVENTIONS

A MOF to obtain decompression of all compartments was performed in all patients.

MAIN OUTCOME MEASURES

Visual analog scale; a subjective scale to measure strength; QuickDash functional scores. Time to resume full riding capacities as short-term evaluation.

RESULTS

A total of 54 patients who underwent 77 MOF procedures overall (23 bilateral) were included. The mean age was 23.6 ± 5.2 years. Mean Visual Analog Scale decreased from a preoperative value of 68.2 to a 3-month postoperative value of 26 (P < 0.001). Mean QuickDash scale was 84 at preoperative registration, falling to 20, 3 months after surgery (P < 0.001) and down to 12 at 1-year follow-up (P = 0.017). The average time to return to full riding capacities was 3.5 ± 1 week.

CONCLUSIONS

Mini-open fasciotomy resulted safe and effective for the treatment of chronic exertional compartment syndrome in high-level motorcycling or motocross riders. The good outcome at follow-up resulted stable at 5 years and the incidence of complications remained low. Our data demonstrate that the resolution of symptoms is reliable and durable. Pain recovery was immediate after surgery, instead functional scores showed a more gradual recovery throughout the 12 months after surgery.

CLINICAL RELEVANCE

Mini-open fasciotomy is a reliable treatment for CECS of the forearm in professional motorcycling riders. This treatment should also be considered in young riders due to the absence of tardive relapse reported in this study.

Compartment Syndrome of the Foot: An Evidence-Based Review

Compartment syndrome of the foot (CSF) is a surgical emergency, with high risk of morbidity and poor outcome, including persistent neurologic deficits or amputation. Uncertainty remains regarding surgical approaches, pressure monitoring values, and the extent of surgical treatment. This review provides a summary of the current knowledge and reports evidence-based diagnostic and therapeutic management options for CSF. Articles describing CSF were identified from MEDLINE, PubMed, and Cochrane databases up until February 2018. Experimental and original articles, systematic and nonsystematic reviews, case reports, and book chapters, independent of their level of evidence, were included. Crush injuries are the leading cause of CSF, but CSF can present after fractures of the tarsal or metatarsal bones and dislocations of the Lisfranc or Chopart joints. CSF is often associated with persistent neurologic deficits, claw toes, amputations, and skin healing problems. Diagnosis is made after accurate clinical evaluation combined with intracompartmental pressure monitoring. A threshold value of <20 mmHg difference between the diastolic blood pressure and the intracompartmental pressure is considered diagnostic. Management consists of surgery, whereby 2 dorsal incisions are combined with a medioplantar incision to the calcaneal compartment. The calcaneal compartment can serve as an "indicator compartment," as the highest-pressure values can regularly be measured within this compartment. Appropriately powered studies of CSF are necessary to further evaluate and compare diagnostic and therapeutic options.

Chronic exertional compartment syndrome of the forearm

Chronic exertional compartment syndrome (CECS) is an overuse injury characterized by increased intracompartmental pressure during exercise. CECS has been described in the foot, thigh, and trunk, but 95% of cases occur in the lower leg. Interestingly, CECS may also affect the upper extremities and has been best described in the forearms. Unfortunately, due to the rarity of this condition, there is no consensus regarding its diagnosis and treatment. This review seeks to discuss the prevalence, etiology, diagnosis, and treatment of CECS of the forearms, which has been described in the literature.

TRest as a New Diagnostic Variable for Chronic Exertional Compartment Syndrome of the Forearm: A Prospective Cohort Analysis of 124 Athletes

OBJECTIVES

To measure the accuracy of currently used intracompartmental pressure (ICP) diagnostic variables for forearm chronic exertional compartment syndrome (CECS) and a new ICP diagnostic variable, TRest, the recovery time between the maximum ICP and return to resting pressure.

DESIGN

Retrospective cohort. Level evidence IV.

SETTING

University-affiliated tertiary hospital.

PARTICIPANTS

Patients with suspected forearm CECS, 1990 to 2014.

INTERVENTIONS

All patients underwent physical examination and exertional stress test, preceded and followed by measuring ICP in all suspicious CECS. Surgery was proposed when indicated. Minimum follow-up was 18 months. Final diagnosis was established at the final follow-up.

MAIN OUTCOME MEASURES

Intracompartmental pressure measurements: PRest (baseline/pre-exercise pressure), P1 min (pressure 1 minute after exercise), P5 min (pressure 5 minutes after exercise), and TRest. Patients rated their pain and completed Quick-DASH in all follow-ups. Patients ultimately were classified into 4 groups (true positives, true negatives, false positives, and false negatives) for each ICP measurement relative to the final diagnosis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

RESULTS

A total of 124 male athletes were diagnosed with CECS, 27 bilateral. Accuracy with standard ICP diagnostic variables was lower (sensitivity 73.5%, specificity 84.2%, positive predictive value 97%, and negative predictive value 31.4%) than with TRest (SN 100%, SP 94.7%, PPV 99.3%, and NPV 100%); 23% of patients would have been missed following the standard ICP diagnostic criteria.

CONCLUSIONS

Diagnostic thresholds for current standard ICP measurements should be lowered. TRest, a new measure, might be more accurate.

Endoscopic Single Approach Forearm Fasciotomy for Chronic Exertional Compartment Syndrome: Long Term Follow-up

BACKGROUND

Chronic exertional compartment syndrome of the forearm is an uncommon condition, occurring in some populations such as athletes. The standard surgical treatment for professional athletes who cannot avoid trigger activity is an open forearm fasciotomy, which may require a long recovery time. The aim of this study is to present a new endoscopic single approach forearm fasciotomy technique and outcomes of at least 3 years follow up.

METHODS

We performed the endoscopic single approach forearm fasciotomy in 4 forearms in 3 men with the mean age of 25 years. All of the patients were evaluated at a mean follow up of 46 months using the Visual Analog Scale (VAS) for pain and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

DASH improved from 21.71 to 5.39, VAS score improved too All the patients referred pain absence after the stress test performed at 20 kilos and 40 kilos. In our series no post-operative complications were observed.

CONCLUSIONS

The new mini-invasive technique has proved to be safe, reliable in a long-term follow-up. The main advantage is the shortening of the recovering time, that leads to a faster return to the professional activity.

Motorcycle racer with unilateral forearm flexor and extensor chronic exertional compartment syndrome

We discuss a case of a 26-year-old man, a motorcycle racer, who presented with progressive pain, weakness and swelling of his right forearm and loss of power in his index finger, experienced during motor racing. Chronic exertional compartment syndrome (CECS) of both flexor and extensor compartments of his forearm was diagnosed by dynamic intracompartmental muscle pressure measurements. After fasciotomies, all symptoms were resolved and the patient was able to improve on his preinjury racing skills, without any limitations. A literature review and a surgical 'how-to' for correct release of the extensor and deep flexor compartments of the forearm are provided.

Surgical Decompression of Exertional Compartment Syndrome of the Forearm in Professional Motorcycling Racers: Comparative Long-term Results of Wide-Open Versus Mini-Open Fasciotomy

OBJECTIVE

To compare the long-term results of 2 surgical techniques for forearm chronic exertional compartment syndrome (CECS) in professional motorcycling racers and to study a new diagnostic variable for CECS, TRest.

DESIGN

Retrospective case series.

LEVEL OF EVIDENCE

4.

SETTING

University Hospital.

PARTICIPANTS

Thirty-four patients identified from a surgical database who had been operated on for upper-limb CECS.

INTERVENTIONS

The purpose of the study was to report and compare the long-term results of 2 surgical techniques using fasciotomies [wide-open fasciotomy (WOF) versus mini-open fasciotomy (MOF)] for forearm CECS in professional motorcycling racers.

PATIENT CHARACTERISTICS

Pain [visual analog scale (100-point scale)] and functional scores (Quick-DASH) at 3 months after surgery and at regular intervals during clinical visits. Surgical complications: Level of satisfaction with the outcome. Time to return to full activity after surgery.

RESULTS

Thirty-four racers, 22 with bilateral involvement (n = 56), were diagnosed with CECS and were treated either with WOF (n = 24) or MOF (n = 32) depending on the surgeon's indication. Mini-open fasciotomy was usually selected in cases who need a faster recovery because of competition schedule. Visual analog scale and Quick-DASH improved 63 and 73 points, respectively (P < 0.001) with no significant difference between both surgical methods (P = 0.512). Both WOF and MOF were equally effective. Ninety-four percent of the patients were satisfied after 45.35 ± 12 months of follow-up, with no significant difference between surgical groups (P = 0.642). The time to return to full activity was 2.7 ± 1 week, also with no significant difference (P = 0.544). The time between when the stress testing was halted for pain and the return to baseline pressure (TRest) was superior to 15 minutes (defined as the mean minus 2 SDs) in 100% patients.

CONCLUSIONS

Surgical open or mini-invasive fasciotomy is equally successful in motorcycling racers with forearm CECS. Although the sensitivity of TRest is quite high in our series, further studies are still needed to validate its diagnostic value.

CLINICAL RELEVANCE

Surgical open or mini-invasive fasciotomy is equally successful in motorcycling racers with forearm CECS.

Endoscopic decompression for chronic compartment syndrome of the forearm in motocross racers

PURPOSE

Sporting activities that involve repetitive stress to muscle compartments can elicit chronic exertional compartment syndrome. Its occurrence in the lower leg muscle compartments is most common, but other locations are less well known and the pathophysiology is not completely understood. In motocross racers, chronic exertional compartment syndrome can occur in the muscles of the lower arm. Currently, the only accepted treatment of correctly diagnosed chronic exertional compartment syndrome is surgical release of the fascia, which successfully relieves pain and allows patients to return to full activity. Open decompression is considered as the gold standard of treatment. This clinical paper describes our new endoscopic technique and investigates the functional outcome after surgery.

METHODS

We report on a series of 154 chronic exertional compartment syndromes afflicted motocross racers treated with an endoscopic release of the lower arm muscles. An MRI scan before and after strenuous exercise of the hand flexors (repetitive grip until exhaustion for 15 min) was performed to confirm the clinical diagnosis of chronic exertional compartment syndrome. Symptom severity before and after surgery was assessed using a visual analogue scale.

RESULTS

Preoperative symptom severity scores were 1.1 ± 0.3 before exercise and 7.4 ± 1.5 after exercise. Post-operatively, these were 1.0 ± 0.2 and 1.7 ± 0.9. The pre- versus post-operative symptom scores after exercise were significantly different (p < 0.0001). No perioperative complications occurred, and at 6 weeks, all of the racers resumed their sportive activities.

CONCLUSION

It can be concluded that endoscopic release of the superficial compartment of the forearms of motocross racers diagnosed with chronic exertional compartment syndrome is a valuable treatment option, with mild post-operative pain and fast recovery.

Single portal endoscopic treatment for chronic exertional compartment syndrome of the forearm

Chronic exertional compartment syndrome of the forearm is an unusual disease not commonly found in the daily practice of a hand surgeon. This condition is quite rare in the general population but occurs more frequently among musicians and athletes, with the highest incidence found in professional motorcycle drivers. It is mainly because of a critical augmentation of the extracellular pressure of the forearm compartments. The diagnosis is mainly clinical, based on stress dynamic tests and intracompartmental pressure measurements. Traditionally, the treatment of this disease has revolved around trigger activity suspension. In the case of professional athletes, this solution cannot be considered and thus the standard surgical treatment consists of an open forearm fasciotomy. This procedure usually requires a lengthy operation period and has a long recovery time before patients can resume their regular activity. Different surgical endoscopic solutions with mini-open techniques have been proposed to shorten this time and reduce the incision size. The aim of this study was to present a new technique for endoscopic-assisted fasciotomy of the forearm in chronic exertional compartment syndrome using a single mini-incision. Four surgical procedures were performed in 3 patients. They were all treated at our center for this condition, and in one case the disease was found on both sides.

The relationship between climbing ability and physiological responses to rock climbing

Aim. The aim of this study was to examine the relationship between submaximal and maximal physiological responses to rock climbing for climbers of differing abilities. Methods. Twenty-six male climbers performed a submaximal climbing test on a known circuit at 90° (vertical) and 105° (15° overhanging) inclination and speed 25 movements·min⁻¹. A maximal test was undertaken on a similar circuit at the same speed with inclination increasing by 10° for each successive 3 min stage. Results. Mean oxygen consumption and heart rate (HR) increased with wall inclination and climbers reached a mean (±SD) peak V˙O2 of 40.3 ± 3.5 mL·kg⁻¹·min⁻¹ during the maximal test. Self-reported climbing ability was negatively correlated with V˙O2 and HR during the submaximal test at 90° (V˙O2, r = −0.82; HR, and r = −0.66) and at 105° (V˙O2, r = −0.84; HR, and r = −0.78) suggesting an increased exercise economy for climbers with a higher ability level. Conclusion. Findings from this study indicate that there is a relationship between wall inclination and the physiological demand of a climb. However, the increased technical ability and fitness of higher level climbers appears to an extent to offset the increased demand through improved exercise economy which in turn leads to an increased time to exhaustion and an improvement in performance.

Chronic exertional compartment syndrome of the forearm in adolescents

PURPOSE

Chronic exertional compartment syndrome (CECS) is a well-known process, although rare in the forearm. The diagnosis is based on history, clinical examination, and compartment pressure readings. My objective is to present the largest series of CECS of the forearm in adolescents and describe my experience in its management and evolution.

METHODS

I reviewed 5 patients, 4 male (competing in motorcycling or motocross) and 1 female (CECS in both the legs and forearms), aged between 15 and 18 years. Volar and dorsal compartments were affected in 3 patients and isolated volar in 2 cases. The clinical diagnosis was objectively confirmed by measuring ICP with a low-pressure digital transducer (Stryker).

RESULTS

Open fasciotomy was carried out in 4 patients. They resumed their athletic activities 6 weeks after surgery without complications, increasing their athletic performance level in line with their preoperative status. All these patients remained asymptomatic, recovering their previous competitive levels. The results were objectively classified as excellent in all 4 cases. After a mean follow-up of 6 years, the condition has not relapsed in any of the patients. Two of the patients agreed to a new ICP measurement 1 year after the surgery, showing normal values.

CONCLUSIONS

CECS in the forearm in adolescents is a rare condition that occurs after puberty. A high index of suspicion is necessary to diagnose it. It is based on symptoms and ICP measurements. Most patients are competing motorcyclists. Surgical treatment, involving isolated decompression of the superficial volar compartment, is safe and effective (restoring normal ICP).

Self-reported ability assessment in rock climbing

Level of ability within rock climbing is generally expressed in terms of a "best ascent", rated using various grading systems within the sport. The most common method of obtaining this information is via self-report. The aim of this study was to examine the validity of self-reported climbing grades. Twenty-nine competitive rock climbers (17 males, 12 females) were first asked to report their current (defined as within the last 12 months) best on-sight lead ascent grade (Aus/NZ). The participants then climbed a specifically designed indoor route, under on-sight conditions (one attempt, no route practice or preview), to obtain an assessed grade. The route increased in difficulty, and was such that the distance achieved by the climber corresponded to a particular grade. The mean (±standard deviation) self-reported and assessed grade was 22.6 ± 3.4 and 22.0 ± 3.0 (Aus/NZ) respectively. Despite slight over- and underestimations in males and females respectively, there was no statistically significant difference between self-reported and assessed on-sight climbing grades. The results of this study suggest that self-reported climbing grades provide a valid and accurate reflection of climbing ability.

Chronic exertional compartment syndrome of the forearm: a case series of 12 patients treated with fasciotomy

Chronic exertional compartment syndrome of the forearm is rare in the published literature. We report the outcome of a series of 12 patients treated with fasciotomy over a 14 year period. All patients underwent dynamic intra-compartmental pressure testing using a slit catheter technique before surgery. Raised intra-compartmental pressures on exercise, typical symptoms and the absence of other diagnoses were criteria for offering surgical intervention. The superficial flexor, deep flexor and extensor compartments were released. Median follow-up was 9.5 years (range 7 months to 12 years). Median patient-reported percentage improvement after surgery was 88% (range 0%-100%). Median time to return to full activity was 9 weeks. Eleven out of 12 patients were satisfied, very satisfied or extremely satisfied with the outcome of surgery. Fasciotomy can be an effective treatment for chronic exertional compartment syndrome of the forearm.

Evaluation of injury and fatality risk in rock and ice climbing

Rock and ice climbing are widely considered to be 'high-risk' sporting activities that are associated with a high incidence of severe injury and even death, compared with more mainstream sports. However, objective scientific data to support this perception are questionable. Accordingly, >400 sport-specific injury studies were analysed and compared by quantifying the injury incidence and objectively grading the injury severity (using the National Advisory Committee for Aeronautics score) per 1000 hours of sporting participation. Fatalities were also analysed. The analysis revealed that fatalities occurred in all sports, but it was not always clear whether the sport itself or pre-existing health conditions contributed or caused the deaths. Bouldering (ropeless climbing to low heights), sport climbing (mostly bolt protected lead climbing with little objective danger) and indoor climbing (climbing indoors on artificial rock structures), showed a small injury rate, minor injury severity and few fatalities. As more objective/external dangers exist for alpine and ice climbing, the injury rate, injury severity and fatality were all higher. Overall, climbing sports had a lower injury incidence and severity score than many popular sports, including basketball, sailing or soccer; indoor climbing ranked the lowest in terms of injuries of all sports assessed. Nevertheless, a fatality risk remains, especially in alpine and ice climbing. In the absence of a standard definition for a 'high-risk' sport, categorizing climbing as a high-risk sport was found to be either subjective or dependent on the definition used. In conclusion, this analysis showed that retrospective data on sport-specific injuries and fatalities are not reported in a standardized manner. To improve preventative injury measures for climbing sports, it is recommended that a standardized, robust and comprehensive sport-specific scoring model should be developed to report and fully evaluate the injury risk, severity of injuries and fatality risk in climbing sports.

Physiological responses to rock climbing in young climbers

Key questions regarding the training and physiological qualities required to produce an elite rock climber remain inadequately defined. Little research has been done on young climbers. The aim of this paper was to review literature on climbing alongside relevant literature characterising physiological adaptations in young athletes. Evidence-based recommendations were sought to inform the training of young climbers. Of 200 studies on climbing, 50 were selected as being appropriate to this review, and were interpreted alongside physiological studies highlighting specific common development growth variables in young climbers. Based on injury data, climbers younger than 16 years should not participate in international bouldering competitions and intensive finger strength training is not recommended. The majority of climbing foot injuries result from wearing too small or unnaturally shaped climbing shoes. Isometric and explosive strength improvements are strongly associated with the latter stages of sexual maturation and specific ontogenetic development, while improvement in motor abilities declines. Somatotyping that might identify common physical attributes in elite climbers of any age is incomplete. Accomplished adolescent climbers can now climb identical grades and compete against elite adult climbers aged up to and >40 years. High-intensity sports training requiring leanness in a youngster can result in altered and delayed pubertal and skeletal development, metabolic and neuroendocrine aberrations and trigger eating disorders. This should be sensitively and regularly monitored. Training should reflect efficacious exercises for a given sex and biological age.

Indoor climbing elicits plasma oxidative stress

PURPOSE

Indoor climbing is a worldwide sport with particular physiological and physical demands. The purpose of this study was to analyze the effect of sustained indoor climbing until exhaustion on plasma oxidative stress markers, and to relate it to whole-body dynamic exercise performed at the same percentage of maximal oxygen uptake (VO2max).

METHODS

Fourteen male indoor climbers continuously climbed a competition-style route until exhaustion. Oxygen consumption and heart rate were continuously monitored during the climbing exercise. One week later, subjects performed a treadmill running protocol with the same duration and percentage of VO2max as that of climbing exercise. Blood samples were collected at rest, immediately after, and 1 h after both exercise protocols to analyze plasma levels of reduced (GSH) and oxidized (GSSG) glutathione, malondialdehyde (MDA), protein sulfhydryl (-SH) and carbonyl (CG) groups, total antioxidant status (TAS) and uric acid (UA), and total blood leukocytes, neutrophil, and lymphocyte counts.

RESULTS

Compared with running, climbing significantly increased the %GSSG, MDA, CG, TAS, and UA and decreased the GSH and -SH content. Blood counts of total leukocytes and neutrophils increased immediately after and 1 h after both running and climbing (P<0.05), although counts were higher in climbing than in running (P<0.05). Lymphocytes significantly increased from baseline to 0 h, although they decreased below baseline 1 h after climbing (P<0.05).

CONCLUSION

Data demonstrate that indoor climbing induces plasma oxidative stress. Moreover, results suggest that an ischemia-reperfusion prooxidant-based mechanism related to climbers' sustained and intermittent isometric forearm muscle contractions might have significantly contributed to observed plasma oxidative stress.

Radiographic adaptations to the stress of high-level rock climbing in junior athletes: a 5-year longitudinal study of the German Junior National Team and a group of recreational climbers

BACKGROUND

Radiographic adaptations and changes in adult climbers are a well-known fact, but few data are available for young climbers.

HYPOTHESIS

Radiographic adaptations have been shown for highly active young climbers. The question arises whether these adaptations may lead to an early onset of osteoarthrosis in the fingers.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Ten members of the German Junior National Team (GJNT; 21.0 +/- 1.6 years) and 10 recreational climbers (RC; 19.9 +/- 1.9 years) were examined using a standard questionnaire and radiographs of the hand. For comparison, radiographs of 12 young nonclimbers (control group [CG]) were evaluated.

RESULTS

The climbing level of GJNT increased significantly during the 5-year evaluation period (P < .01) and was significantly higher than that of the RC (1999: P < .01, 2004: P < .01). There was no increase in finger contractures or finger joint capsular width during the 5 years. Stress reactions were found in 8 of 10 of GJNT (1999 and 2004) and increased in RC from 2 of 10 (1999) to 3 of 10 (2004). No osteoarthrotic changes were found in 2004. There was no significant difference for the Barnett-Nordin Index between GJNT, RC, and CG. Years of climbing (P < .01), participation in climbing competitions (P < .01), hours of training per week (P < .01), number of training units per week (P < .05), and climbing level (2004) (P < .01) were significant factors for development of radiographic stress reaction in all athletes (GJNT and RC).

CONCLUSION

Intensive training and climbing leads to adaptive reactions such as cortical hypertrophy and broadened joint bases in the fingers. Nevertheless, osteoarthrotic changes are rare in young climbers. A longer follow-up is necessary to evaluate whether these adaptive stress reactions may lead to an early onset of osteoarthritis.

Biomechanical model for the determination of the forces acting on the finger pulley system

A mathematical model proposed by Hume et al., 1991. Journal of Hand Surgery-American Volume 16, 722-730 for the determination of the forces acting on the A2 and A4 pulley was used. The parameters necessary for this determination include the angle of flexion, the positioning of the pulley with respect to the centre of rotation in the proximal interphalangeal joint (PIP), the relative mismatch between bone and tendon width at the location of the respective pulleys as well as the tendon height at this position. This model was further developed to include the stiffness of the respective pulley, as well as the fact, that there are two flexor tendons of which only one passes through both pulleys. Each parameter was then evaluated using a sensitivity analysis proposed by Fasham et al., 1990. Journal of Marine Research 48, 591-639 in order to determine their relative importance for the outcome of the model. The most important parameter proofed to be the positioning of the pulley with respect to the centre of rotation in the PIP joint. This observation enabled us to give the best possible placement for a pulley graft after pulley rupture.