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About Esther Smith

Esther Smith is a Doctor of Physical Therapy, a Nutritional Therapy Practitioner, and the owner of Grassroots Physical Therapy in Salt Lake City. She is a 5.13- climber who’s reaped the benefits of her own physical therapy practices, having healed a shoulder injury, a finger injury, among others with exercises, stretches, and alternative therapies.

She works almost exclusively with rock climbers, which is rare for a physical therapist. For a complete bio and list of certifications and qualifications, please visit www.grassrootsphysicaltherapy.com. This is my third interviews with Esther, the first one covering shoulder injuries, and the second one on elbow injuries.

This interview is all about fingers. We talk about the most common finger injuries in climbers, why we get them, what they feel like, how to get a proper diagnosis, and mostly… how to make the injuries go away.

During the interview, you’ll hear Esther talking about the videos she created to help you understand what she’s trying to explain. You’ll find all those links below. If you have shoulder, neck, elbow, or other injuries, she also has video tutorials for sale on her website, www.selftreatment.com, which very well may make your pain go away without the help of any practitioner.

Esther Smith Finger Injury Interview Details

  • How she healed her finger injury this year
  • Why it’s important to use the finger instead of resting it
  • Who to see to diagnose it
  • How Dan Mirsky successfully trained through a finger injury rehab
  • Should you tape?
  • What to do about swelling

Video: Finger Injury Management with Esther & Dan Mirsky

Esther Smith Links

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Photo Credit

Louis Arevalo

Transcript

Neely Quinn: Welcome to the Training Beta Podcast, where I talk with climbers and trainers about how we can get a little better at our favorite sport. I’m your host, Neely Quinn, and today we’re on Episode 76. As you can hear, my voice is a little bit weird. I am still sick, it’s been about a month. I kind of got sick, and lost my voice, and didn’t do any podcast episodes, and then I got a little bit better, and then I got re-sick, because I just did a little bit too much. Lesson learned, and a lesson for all of you. If you feel sick, don’t go climbing and hiking and then do a bunch of yard work, because it will make you sick again. But anyway, I’m not going to let this stop me from doing podcasts like I did the last month, I’m just going to work through it, so you’ll have to deal with it.

Today I have Esther Smith on the show again, this is my third talk with her, and today we are talking about fingers. WE’ve talked about shoulders, we’ve talked about elbows, and then today we’re talking about how to deal with the most common finger injuries that climbers get.

Esther is a physical therapist out of Salt Lake City- she specializes in climbers, which I think is really, really rare, and super cool for  us, that we have her as a resource. She sees hundreds of clients every year- well, I don’t know how many, a lot- and so she sees these things all the time. Not only that, but she’s had her own injuries, and she’s built these protocols and used them on herself, and she’ll tell you about her finger injury that just happened recently. So anyway, she’s going to tell you about a couple of protocols for finger injuries, and there are some links that I am going to put on the show notes, and you can find more information about her at grassrootsphysicaltherapy.com, and also she has some protocols for sale, and some free videos, at selftreatment.com. Those things that are for sale are these long videos that she put a lot of time and energy into to make it so you can watch a video and basically have almost all the tools that you need to heal yourself, so that’s pretty awesome. Those will be on trainingbeta.com/media/esther-fingers. I know that’s long, but you can also just go to trainingbeta.com and search for Esther on the whole site.

So before my voice completely goes, here is Esther Smith, I hope you enjoy this.

Neely Quinn: Welcome back to the show Esther, thanks very much for being with me again.

Esther Smith: Thank you Neely.

Neely Quinn: So, how’ve you been doing?

Esther Smith: Well, I was doing really good until two weeks ago. I suffered a foot injury at the climbing gym, and it’s resulted in my needing to have surgery on Monday morning.

Neely Quinn: Oh, no.

Esther Smith: Yeah, it’s kind of a lesson for everybody, and one that I learned the hard way. I was belaying my husband, and he’s a little bit heavier than me, by a bit- 30 or 40 pounds. He took a normal fall up towards the top of a climb, and I was in a position a little ways away from the wall, so that I could see him. I had my belay specs on, and it just- the way that the first draw was clipped and it was low, and the way that it was standing, shot me into the wall like a rocket. I put my bare foot up and it collided with a big globular climbing hold. Basically, it destroyed my arch- the hold went up into the small bones in my foot and blew them apart.

Neely Quinn: Oh my god.

Esther Smith: Yeah- they’re dislocated, ligaments are ruptured, and I have no way of conservatively treating it myself. Even if I wanted it to heal, the bones would heal maligned and I would never have a functioning foot again, like a normal foot, because the arch would fall and collapse and it would just be epic. I’d be looking at a fusion. You have to get the surgery within a couple of weeks because otherwise the results are less and less positive. So yeah, I’m going in Monday morning. They’re going to put some screws in, realign my metatarsal and tarsal joints, and then I’ll be casted for six weeks, and non-weight bearing for about eight weeks or so. So yeah, I won’t be walking again until June.

Neely Quinn: Oh, no.

Esther Smith: It’s epic! And we had just bought tickets to Spain three days before.

Neely Quinn: Oh no!

Esther Smith: And as I saw that orange hold coming at me at 30 miles and hour or whatever it felt like, I was just like “Spaaain!”

[laughter]. And it was a horrific pain- we went right to the ER. I’ve known all a long that something has- people have been trying to tell me “Oh it’s going to be fine, you’ll be able to heal this thing”, but x-rays and MRIs all points to this lisfranc dislocation fracture, so I basically have to have surgery for that. There’s no other way around it.

Neely Quinn: That’s terrible. When were you going to go to Spain?

Esther Smith: The first two weeks of May.

Neely Quinn: So you have to refund them. Can you even refund them?

Esther Smith: Apparently if you have a good doctor’s note they’ll let you change the tickets to a different date without a fee, so we are going to pick a different time, and it’ll be a major treat to look forward to after I can walk again. It’s going to be kind of a journey, but lesson learned. On my end, I should have been paying better attention. I should have had shoes on, and I should have really watched that trajectory, those vectors, and have been standing directly under the draw even though I couldn’t have seen my climber- and been prepared more. He was on a warm up, I wasn’t really thinking he was going to fall. It was all those circumstances where you let down your guard a little bit, and I got tugged right out of that and shot into the wall. My foot took the hit, it could have been worse. Maybe my hands could have been broken, or my face, or whatever. It was crazy how forceful it was. So a heads up to everybody, especially if you’re dealing with weight differential.

A lot of people have been talking about that Om device, which slows down, or doesn’t allow the belayer to be so launched, so I’m going to look into one of those. Although, I think one critique on it is that the climber gets a harder catch. So you kind of trade one for the other, apparently. I haven’t used it, but I’m going to look into it and give it a try.

Neely Quinn: Yeah there’s kind of- I mean, I have to deal with this so much because I’m small. I’ve gone as far as to put backpacks on me with rocks in them [laughs], to slow me down. I’ve thought about getting a weight vest and just wearing it at the gym with my husband.

Esther Smith: Yeah, and the gym is a unique environment because there’s no friction, right? You just get zipped up there. So I think that’s a smart idea, figuring out something like that, just to even out the weight if you don’t use that Om device.

Neely Quinn: What is it? Om? O-M?

Esther Smith: Yeah, I think made by Edelrid.

Neely Quinn: Okay I’m going to put that in the show notes, because I think that it’s a good tool- maybe- for some people.

Esther Smith: Yeah, worth checking out, people seem psyched on it.

Neely Quinn: Well thanks for sharing. I’m sure that you’ll heal up eventually, and I’m really sorry to hear that. It’s kind of crappy because this year you already had a finger injury, which took a few- four months to heal, and that’s what we are talking about today. Why don’t you introduce the topic today and tell us that story.

Esther Smith: Sure. So we wanted to move downstream. We started this podcast series talking about the shoulder, and then we did elbow issues, and now we are down at hand and wrist. The main focus today should be on the flexor tendon pulley injuries that climbers get, because that’s the most common thing I see. They’re also usually not well managed. Climbers don’t necessarily know what to do with it when it happens. If you go to see an average medical provider that isn’t really experienced with climbing, they might not have the best rehab strategies.

A lot of the time, you just see climbers with chronic finger issues that go on and on, for years and years, and there’s no resolution. What I’ve been able to design over the last handful of years, treating all these hundreds of finger injuries, is a really really cool protocol to rehab those flexor tendon issues in a way that strengthens them and makes them resilient again, so people can climb pain free without tape, or any need for any crutches, or band-aid treatment.

In my case, I was at the Red River Gorge. It was the other only vacation I’ve had in a long time, besides the one I’m not going on [laughs]. The vacation gods are against me. And I had a weird thing happen there, where I had this allergic reaction that began developing on the trip. It got so bad that I had to go to the ER, and they pumped me full of steroids. So I had this megadose of Dexamethasone, and the next day I went out climbing, and got on a few pitches. On the third pitch, it wasn’t even a hard pitch, and I wrapped my fingers into a hold, and pulled up on it, and I just heard the loudest pop. It sounded like rock breaking. My husband heard it from his belay stance, and I was still hanging on. It wasn’t even a strenuous move, and I just looked down at my hand and finger, and I was like “Oh my god, I just blew my tendon”. So I was like “Lower me”, but I was still standing there, hanging on the wall. It was bizarre. What it turns out happened, is that the Dexamethasone- I didn’t even think about it- systemically weakened my tissue, most likely. That would be the only cause for such a freak, low stress, type of injury. I get down on the ground, and it’s super sore, numb, weak, shaky, you know? And I was like “Okay, I gotta deal with this now”. I’ve never had one that bad myself. In fact, I’ve never had a discreet flexor tendon pulley issue. Immediately, I was like “Okay, what do I always tell me people?”. So I went and engaged in my acute treatment program.

I wasn’t even really worried about it. When it happened I was super bummed, because it was in the middle of my Red River Gorge trip, and I had this crazy allergic reaction going on at the same time, so we actually flew home early. I got back, and I dealt with my finger, and it was really kind of interesting to me to actually go through my own process and feel it inside my own body, because it was only ever something I had instructed people to do, and I hadn’t felt. It was good to feel, and it really refined how I treat those now, and so I want to share that with you guys- the acute care management and what to do when it first happens.

On the other side of that, we have a story that we can share about Dan Mirsky, and his chronic finger flexor tendon issue. I want to show how those kind of end up weaving together- treatment for those, whether they are chronic or acute, they end up merging, and you follow a very similar protocol. It’s just on a different timeline.

I thought that at some point, we can kind of cover some of the common problems of hand/wrist issues among climbers, and then we can go more specifically into these protocols for managing these flexor tendon pulley issues.

Neely Quinn: Cool. Yes. This is so structured and I love it. I love talking to you [laughs]. Okay so I don’t know exactly where you want to start, but my burning question that I want to start with is that everybody gets these finger injuries, and inevitably somebody will come up to me, or another friend, and they’ll be like “What do you think is wrong with me? Feel my finger. Push around on there. What is it? Is it a pulley? Is it a tendon?”. So how do people figure out what exactly it is that is wrong with them, and can they do that on their own?

Esther Smith: Aha. Yeah. That’s probably the most pertinent question that you can ask, Neely, because the diagnosis is where it’s at. For what you have going on, you really need to identify the correct diagnosis, the correct anatomy that’s injured, so you can treat it effectively. There’s so many different things that can happen. If we are just talking about the finger, I’ve see this crazy myriad of presentations, and I’m always blown away that climbers have all this weirdness that happens at their finger.

Esther Smith: The bottom line is, it’s a little tricky to self-diagnose. It’s best if you can see a skilled provider- a PT, an orthopedic physician, somebody who maybe even can do ultrasound imaging, to see the extent of the pulley tendon damage.

Neely Quinn: Oh, ultrasound would be best?

Esther Smith: Well, it’s one way, and it’s cheaper than an MRI, to see that tissue damage. And it can be very local. You can look up, just in your local area, somebody who does ultrasound diagnostics for flexor tendon or finger issues. You’ll probably find somebody in your area. That’s a good way to go, but I never rely on that. I usually just do my physical exam, and I stress test the finger, and try to determine what’s going on via these different physical exam tests, which would be hard to relate to you over the phone. But I think that- again- the McKenzie physical therapists that I’ve mentioned before, they would probably be decent- even if they aren’t familiar with climbing- at examining the fingers. There are hand therapists, both that are occupational therapist or physical therapists, that are all over the place. They should do a good job of diagnosing the issue. So it’s hard to do on your own.

I’ve never seen somebody walk in my clinic with a flexor pulley issue that has bowstringing or has had to go to surgery, but they do happen, right? We know people who have had to have surgery for them, and they’re on the more extreme end of rare cases. I think for the most part people strain their long tendon, the flexor tendon, and there’s two that run up to the fingers. You can do some discriminating to find out if it’s the deep one or the superficial one. Usually the long tendon is strained, and the crossover pulley is pulled, torn, but usually not fully ruptured.

Neely Quinn: Okay, so for those of us who aren’t super familiar with anatomy. The tendon goes up your finger, correct?

Esther Smith: Longitude- along the course of the length of the finger all the way up, and it starts in your elbow. It starts in your forearm. The pulley goes over the top of the tendon and it tethers it to the bone.

Neely Quinn: It sort of goes across your finger, not longways, right?

Esther Smith: Correct, kind of horizontal. We are incredibly simplifying the anatomy of the finger here, because there’s so much incredible architecture to make our fingers work the way they do. If you pick up an anatomy book or look up the anatomy of the finger online, you’ll be like- whoa, there is so much going on here. There’s so much going on, it’s insane. So all the mechanisms to get our finger to flex and extend, it is intricate, and it’s a hard area, in that sense, to diagnose, especially self-diagnose.

The deal is that those pulleys that we are most familiar with being torn or ruptured, damaged, they tether they long tendon to the bone, so that when you bend your finger,  you don’t get pull-away of the tendon from the bone. They’re like these little straps all along your finger, to strap the tendon down. We need our tendon, the long tendon, to glide really smoothly through those little straps. If you’ve ever heard people with “trigger finger”, that’s because they’ve formed these little adhesions and they get stuck, because the long tendon can’t slide through those little straps. It’s kind of a long tendon and the strap that gets injured mostly, when we hear the pop, have that weakness and pain and tenderness on the pad. If you’re pushing around on your own finger, and you’re like “Yeah, I’ve got tenderness at this knuckle and this knuckle”, you’re probably feeling some amount of tendon damage on that area, and pulley damage, you just don’t know how severe.

Neely Quinn: Yeah.

Esther Smith: You can kind of identify that based on “Do you have a lot of range of motion loss, is there a lot of pain and swelling, is there a lot of tenderness?”, you know? If that’s all extreme or you have any visible bowstringing, popping away from that tendon, then you would want to go see a medical professional. What I’m saying is that most climber injuries are on the low to medium scale of severity, and can be managed conservatively. People do it all the time, they don’t do anything- they just tape it, right? And they continue on. What I want to try and introduce, and I made a YouTube video, is four or five essential things that you can start doing to almost do your own assessment and inventory of your issue. That’s now live, this YouTube video, on the Grassroots Physical Therapy Facebook, you’ll have it for this interview, and you can go to the Grassroots Self-Treatment YouTube page for that as well.

There’s a series of little skilled exercises you can go through to take inventory and assessments. Start to move the finger acutely and see what’s up. It’s what I did immediately at the Red, as soon as I got back to Margarita’s house, to asses my own injury.

Neely Quinn: Okay.

Esther Smith: I don’t know if that answered your question.

Neely Quinn: No, it does, but let me ask two simple questions. When you heard that pop, what was the popping sound?

Esther Smith: The pop was a failure of tissue. So it wasn’t necessarily that that strap blew fully, right? The pulley didn’t necessarily blow, but tissue failed and released, and so it’s failure of tissue that you hear popping, potentially, or an escape of air. It’s probably a little combination of those two things.

Neely Quinn: And your diagnosis of that injury was what?

Esther Smith: I would call it a flexor tendon pulley strain, or pulley sprain, since it’s more of a ligament structure.

Neely Quinn: So- oh so flexor tendon pulley strain. So it’s just the pulley, it wasn’t the tendon that got hurt.

Esther Smith: It was both.

Neely Quinn: It was both, okay.

Esther Smith: A flexor tendon strain plus pulley sprain, or strain, however you want to say that.

Neely Quinn: Okay, so, and then the other question was when I injured my finger, I had pain mostly on the sides and not on the pads of my finger. Would that be more of a pulley thing?

Esther Smith: Uh, it might be less of a pulley thing in that case. A lot of times, the pulley you feel more discreetly on the palm aspect of the pad. On the sides, you can still get pulley stress on the sides for sure, but on the sides you have these collateral ligaments, these ligaments that reinforce the knuckles side to side. You also have a bunch of other stuff going on on the sides of your fingers. The side knuckle issue is handled sometimes differently than that palmar aspect of the finger.

Neely Quinn: Okay, which we are not going to talk about today?

Esther Smith: Probably not, that gets a little tricky. There are so many nuances that can happen at the finger, especially at the side of the finger. Is your joint stiff and your knuckle stiff?

Neely Quinn: It was. As a caveat for this, I did do it bowling so it’s [laughs]- it’s not super pertinent to this conversation, but I was just curious.

Esther Smith: I see that all the time. At the finger, you can have joint problems. Like a stiff knuckle problem, which might be what a little bit of happened to you. Your knuckle got stuck in the hole of the bowling ball or whatever, or stressed that way. You might have created a joint derangement in your knuckle, and created some range of motion loss and stiffness there, and some stress to the outside ligaments, perhaps.

The hand- I did a full internship in PT school on hands, and it’s and amazing, very nuanced part of our body. It’s super interesting, and obviously one of those areas where climbers get injured the most. I’d say hands, then shoulder second, and elbows. It’s the terrible triad kind of thing. We can talk about that, but I wanted to say that there can be joint problems at the fingers that have nothing to do with the flexor tendon pulley. That can include the derangement problem, which is the displaced tissue inside of the joint that makes it stiff and painful. You can have arthritis, you can have ligament problems, then you can look and you can have tendon problems, and you can tendinitis, or tendinosis. Out of the hand and wrist you can have tendon sheath problems, and those are called tenosynovitis. Carpal tunnel. You know, there are so many different diagnoses happening.

The big picture, I think, with understanding that, is that if you can get a diagnosis from somebody in your local area, and you can get a handle on what anatomy is injured and start to think big picture with things, because anytime you have a finger, hand, wrist issue, you need to look upstream. You need to go back and see- is there any dysfunction at my elbow, or at my shoulder, or at my neck- that might be contributing to this or causing it? Sometimes neck issues cause pain to be referred out into the hand and fingers, and it has nothing to do with a local hand problem- it can be a neck thing.

There’s kind of a lot to think about, but in the case of the flexor tendon pulley issue, usually you know it, right? Because of the pop, the failure of your finger, and you know that you really shouldn’t be grabbing rock again, because it’s weak and painful and sore. We need to be talking about what to do next on that. I don’t know if you want to address any other common issues outside of the flexor tendon pulley issue, if there’s interest in the carpal tunnel issue, or talking more about the upstream contributions, or those kinds of things?

Neely Quinn: Can you describe what carpal tunnel is? I have a feeling that a lot of people have it and they don’t know it.

Esther Smith: Carpal tunnel can affect climbers because it is associated with repetitive stress and strain. The deal is that carpal tunnel is named because it is a part of your anatomy of your wrist. The carpal tunnel is the area on the palm aspect of the wrist, where there is this little bony tunnel made by your carpal bones. Through that tunnel goes your flexor tendons, that go out to your fingers, and a nerve, called your median nerve. There is this tight band of tissue over the top that forms a roof, and that’s the tunnel. The thing is, inside that tunnel there isn’t a lot of space, because there’s bones on the floor and the walls, and then there is a tight band of tissue that makes the roof. If you get inflammation there, there’s nowhere for that to go. The inflammation is caused by repetitive stress and strain at the carpal tunnel and that causes irritation of the nerve mostly- the median nerve.

People with true carpal tunnel will experience numbness usually, and tingling, in the thumb pointer and middle finger distribution of their hand, and they will experience weakness in certain muscles, and maybe even atrophy of certain muscles in the hand. It’s actually a more- I don’t see it that often. People are like “I have carpal tunnel because I have wrist pain”, but no, carpal tunnel is a very specific presentation. You can look that up online and see what that looks like, and it’s caused by that local irritation at that carpal tunnel space of anatomy.

With that said, people with carpal tunnel, at the wrist, usually have something going on upstream that is also causing nerve irritation, or tension to be developed in those flexor tendons. It’s not just a wrist issue, you gotta be like “Well, why are my flexor tendons so tight and irritated, why is that inflammation developing in that small space?”. Usually, you need to treat the whole arm and even the neck to get rid of carpal tunnel. So, yeah. That’s a common one.

People get DeQuervain’s, tenosynovitis, and intersection syndrome, we see that in the clinic, from climbing. But a lot of time it happens, like they were out doing something. You were bowling, right? They could be hammering too much or something, that causes it. I don’t know. But work related stuff. And those are issues that are brought on again, by local, overuse, repetitive stress and strain, around intersection points of tendons, or the sheath parts of tendons. So the same deal. You need to be implying everything you know about inflammatory control, massage. A lot of the same stuff that we use for tendinitis at the elbow you would use for those tendon problems at the wrist, forearm or hand.

Neely Quinn: It seems like a lot of people probably have a lot of overuse from working on a computer a lot.

Esther Smith: Yes, super true. Yup. Again, ergonomics and posture, dealing with your alignment when you’re working. How can you support your hand and wrist at your keyboard station, and how can you do out of work or at desk therapy for yourself to make it so that everything isn’t so pissed off. Doing, like I said, ice-heat, and TLC on your wrist and hand, I like rice bucket work, self-massage with the arm aid. Selftreatment.com, these videos that we are selling, we made one just recently for hand and wrist. It’s an hour long, all about taking care of that body part, because so many climbers are also computer people, or laborers, manual people.

It’s really important that we don’t just tax our body with our sport and our job, that we actually step aside and do some really good TLC to avoid those injuries, or deal with them if we have them. You can check that out soon, and in a couple of weeks we will have that hand and wrist kit available. It’s gong to be awesome- it’s got all my favorite things to do to take care of that area.

Neely Quinn: Okay, and I’ll put a link to that in the show notes too. One last note on that, is my husband- he works on a computer all the time- and he was having wrist and finger and forearm pain. He actually got a new kind of keyboard, where you’re not stretching your fingers out to reach for keys all the time, and it’s super ergonomic, so your hand is sort of curved down a little bit. It’s the nerdiest thing ever, and all his coworker coders have it. It’s a completely different keyboard, I can’t even use it, but apparently that helps people too.

Esther Smith: I’ve seen those, that’s a great recommendation.

Neely Quinn: Okay, so let’s get into- I mean, I want to hear about how you helped Dan and how you helped yourself. What was the actual process?

Esther Smith: Okay, cool. Yeah. So that’s the best part, because I’ve kind of developed these protocols over the years, and I’m not sure that anybody else is doing it quite like I am, for fingers and for this idea that- like Dan, he came to see me at the start of the BD Bootcamp two years ago. He had been really debilitated and limited by this chronic finger. It was similar to mine, right? This flexor tendon and pulley strain deal. It wasn’t a rupture, he didn’t need surgery, he had been dealing with it for a year or two previous.

Neely Quinn: Did he have a pop when he first did it?

Esther Smith: Yup. And it was just like, he tried bouldering and he worked some hard moves, and he tried again, and he was already kind of tired, and it was that failure when he was tired and stressed it heavily, that it popped on him. That happens a lot. People will be on the systems board, and they’ll be trying really hard, they’ll sense a little overstress, but then the try one more time and it goes. I think people need to be really careful about that fatigue failure, and watching that.

Neely Quinn: I’m sorry- I have so many questions.

Esther Smith: That’s okay, we have time.

Neely Quinn: So my husband just did this to himself, too. He was on the Moonboard, and he was tired, and he was like “Oh I’ll just try this one more time”. He strained his finger, however, there was no popping sound, and I think that’s common too. Does this sort of protocol go for people like that too, without the pop?

Esther Smith: Yeah. Does he have pad tenderness on the palmar aspect?

Neely Quinn: Yes.

Esther Smith: Yeah, it’s just no pop. It doesn’t have to pop to be a pulley flexor issue. He basically- you know, I don’t know if you could say it’s less severe, if it doesn’t pop- probably not. I don’t know how to qualify that, but he probably has exactly what we, Dan and I, both had. He would want to be managing that the way I’m going to tell you. Most likely- I’ll say this with a grain of salt, right? I haven’t diagnosed anybody who’s listening, and people have to figure it out for themselves. I want to give the community this protocol, because I think it’s so effective. I haven’t had, I don’t think, a person not do well on this protocol. It works.

Neely Quinn: Okay, that’s great.

Esther Smith: But you need to have an accurate diagnosis, right? And you need to know what you are treating, so the treatment can be effective. You need to keep in mind that this isn’t a one size fits all deal, and there’s so much like we talked about that can happen.

So Dan comes to see me, and he is a couple of weeks away from having to start this very intense, rigorous BD Bootcamp with Sam Elias and Joe Kinder. He’s like “I don’t know if I’m going to be able to train because I have this limiting finger problem. How am I going to campus, and how am I going to Moonboard” and all that, right? And he also has, in addition to the finger, a long history- this is his left finger- and he had a long history of left arm issues, which I see all the time. So like a little bit of over pumping on the forearm on his left side, a little bit of elbow funkiness on his left side, some shoulder instability, and then some chronic neck pain.

I just want to highlight that most people with finger issues also have something else going on in the system. I did too, in fact. I had a little bit of an inner elbow soreness or tweak, that wanted to be a tendinitis, but I wouldn’t let it because I was treating it. But that was there when I went on my trip. You know, maybe that set me up a little bit, even though I think the steroids are to blame for the crazy failure that I had. You want to be aware that if you have this left neck issue, shoulder instability, or elbow stuff, that you might be more prone to getting a finger injury. Take care of those things so you can spare your fingers.

But anyways, he’s like “I don’t know if I can train. Everything I’ve been told when I go see somebody is to rest it, to tape it, to limit my climbing”.  After I diagnosed him, and it was what I thought it was, this flexor tendon pulley issue. I said “We’re not going to have you rest. In fact, we are going to load this thing up. I’m going to have you hanging in two finger pockets tomorrow”. He looked at me with the widest eyes, and was like “What the hell, I did not expect that from you”. I was like “Yeah man, you’ve had this going on, you’ve already rested it, you’ve already taped it and that hasn’t worked. You go to load it, and it’s not resilient, right? You feel the pain when you go to use it. We have to make this tissue resilient again”.

It’s the same thing that we do with a chronic tendinitis. We remodel the tissue, we use the physiology within your own body to go in there and repair the damage, because the damage has just stuck around. The deal is that you need to reinstate the body’s healing process. That’s where the loading comes in. My favorite way to do that- most people injure their ring finger or their middle finger in climbing. I don’t know if you’ve noticed that, but those are the heavy hitters.

The way to start this out is to see what it feels like on both hands, to go into a deep two finger pocket that allows you to be pretty comfortable and not have a lot of direct pressure on the pad that’s hurt, you know? You don’t want to be in a two finger pocket and just have the pain be a result of the pressure. You want to feel how much stress is on your injured tissue when you’re in a pocket, because of the load of your bodyweight, not exactly the direct pressure- does that make sense?

Neely Quinn: Yeah, I mean, how deep are we talking?

Esther Smith: It can vary per person. When I was doing it, I didn’t use a hangboard. I used these little two finger pockets that were on the systems wall. Dan was able to use a two finger pocket on a Beastmaker board.

Neely Quinn: Okay, so that’s only like two pads.

Esther Smith: Exactly, so somewhere around two pads. So you put your two fingers in there, and you see what it’s like to hang at bodyweight. If you’re like “No go, I can’t hang because it hurts”, and it feels too weak to hang at bodyweight, then you unload yourself a little bit. Use a pulley system, or a band underneath you to see how much bodyweight you need to take off to be able to hang on the two fingers, with only a reproduction of mild familiar discomfort.

Neely Quinn: Mild- what?

Esther Smith: Mild familiar discomfort. Meaning, it reproduces your pain a little bit.

Neely Quinn: Okay, so it is a little bit painful.

Esther Smith: Yes, and the reason why, is just like when we do a remodeling for a tendinitis or a tendinopathy, and you use the Flexbars, or whatever, or the hammer drill. You’re like, oh, there’s my pain, and you do five reps of it. The reason why you need to have that pain is that you need to know that you are stressing that tissue, and creating a little micro-inflammatory response. It’s the micro-inflammatory response that brings the healing troops in. It’s the only way that your body is going to break down the old tissue and rebuild new tissue, is if you get blood there, and you get the immune system there. You have to recreate some microinflammation to do that.

Neely Quinn: Okay, when you worked with me on my shoulder, you were basically saying that it shouldn’t be painful.

Esther Smith: Yeah, that’s because we were not treating your thing as a tendinitis, a tendinopathy, or that kind of presentation. We were treating your shoulder thing as more of a derangement, like displaced tissue. You have all of this impaired anatomy in there, and we  need to get your stronger, stretch things, more stable, and we needed to get your neutral rest position of your joint restored. That’s super different than dealing with a flexor tendon thing. A flexor tendon thing needs to be loaded, and you need to re-engage that healing process. In your case, you needed to not have any inflammation, right?

Neely Quinn: Right.

Esther Smith: But in this case of a chronic tendon problem, the reason it’s still there after all those months to years, is because the body never healed it.

Neely Quinn: Okay.

Esther Smith: It’s like distorted, weak, kind of degraded tissue. I actually have to have the body go in there and put tissue down.

Neely Quinn: Two questions. One is what if you get on the hangboard on these two finger pockets and you have to take off 90% of your weight?

Esther Smith: Then start there.

Neely Quinn: Oh, really?

Esther Smith: Yeah.

Neely Quinn: Okay so no weight is too much.

Esther Smith: No weight is too much.

Neely Quinn: No negative weight is- like it’s fine.

Esther Smith: Yeah, that’s a good question, because you could not use your bodyweight and you could load it up with resistance. But I think, that for whatever reason, the fingers heal better if they’re loaded in a hanging position than if they are gripping some crimp thing and pulling in, you know? You see those devices where you have a rubber band and a little piece of wood or something, and you can pull it in. For whatever reason, I don’t think the body gets the best signaling, or it doesn’t rehab as well, as if you hang it like you are climbing.

Neely Quinn: Okay, and interestingly, when I had my finger injury from bowling, I was like “I’m going to rest it, I’m resting, I’m resting”, and finally I was like, screw it, I’m just going to climb hard and see what happens, and that’s when it started to get better.

Esther Smith: Yeah, so you probably did a little bit of work yourself.

Neely Quinn: My second question was when he was done with hanging, should he have had pain afterwards, and if so for how long? What’s too much?

Esther Smith: Good question. So he’s there, and he’s identifying that “Okay, I can hang at bodyweight, I feel some discomfort” and when he comes off of the hold after ten seconds, he should have no lasting discomfort within a minute or two after being in the hanging position. It should dissipate pretty much immediately. That’s the perfect amount of load, is the one that you feel when you are on it- so you produce your familiar discomfort- and when you get off, you are no worse. You have no lasting discomfort, you go back to baseline.

Neely Quinn: And how many sets and reps was he doing?

Esther Smith: Alright, so here’s the deal. You start at the weight that allows you to do that, and you do 3-5 hangs for 10 seconds. You rest, for 2-3 minutes in between each of those hangs, and that’s it. You do that about two or three times a week. I would say two is good, three would be maximum, sessions spread out.

You need to warm up before you hit the hangboard to do this, so you either can go climb on jugs if that’s what you’re tolerant to, you can do the rice bucket, you can go through that YouTube video that I gave you. It has rice bucket, finger glides, pen rolling, all the stuff to warm up your tendons before you go and test it on the hangboard, so that’s important. So warming up, doing that, finding the amount of bodyweight plus or minus, that allows you to feel your familiar discomfort, ten second hold, get off, rest, and do like I said 3-5 sets of that.

What happens is, you have to progress that. You want to continue to make the tendon more and more strong over time. Over the course of 6-8 weeks, you’re going to return to the hangboard, right? Let’s say you do, in the first week, you’re at body weight, and you do that two sessions. The next week you go back, and you find the same two finger pocket, and you hang in it, and you’re like “Oh, that no longer produces that familiar stress or strain”. Now, you add 5 pounds to yourself, alright? To your harness, you add 5 pounds, and you test that, and you’re like “Okay, now I feel it again”. So then, for that week or however long it takes, you use that 5 pounds over body weight, and the same recipe. Same 10 seconds, 3-5 sets, 2-3 minute rest, okay?

Neely Quinn: Okay.

Esther Smith: And then the next week happens, and you’re like “Oh, five pounds no longer does it”, and you add five pounds progressively in the two finger pocket hold over the course of 6-8 weeks until you reach about 20-30 pounds over body weight.

Neely Quinn: Oh wow.

Esther Smith: And then you’re probably getting into a place where you can climb without feeling it, you know? You basically have taken this tendon and you’ve made it stronger and stronger and stronger, week by week by week. Every week, the body is like “Oh, there’s more needed here, so we are going to lay down more tissue, we are going to clean this area up even more. This human is telling me that I need to repair this because there is a demand on it that we need to be resilient to”. So that’s the deal. You progressively add weight beyond body weight to plus 20-30 pounds over body weight. Dan did this, and it worked remarkably well, because as he was in the training program, he could then be like “Oh, now I can campus, because my body weight is no long as much of an issue to my finger”. He went and he could put out all his power and do all these strenuous moves because the tendon kind of grew with him, and got stronger with him. Versus had he done nothing, and he just tried to do that stuff, the tendon would have always been too weak and too damaged to be there with him.

Once you do the two finger for several weeks, maybe you’re in that 3-4 week range, and you’re like “Man, I’m rocking these two finger pocket hangs out, I’m at 20 pounds over body weight, I wonder what it would feel like to crimp on this thing”, and that’s exactly what I did too. I said “Two fingers are feeling great, I’m going to go to an 18 mil half crimp”, and I did the same process. Start at body weight or less than body weight. If you feel familiar discomfort, that’s perfect as long as you feel no worse after. You do 10 second hangs, and you do the 3-5, you rest in between, and you progressively add 5 pounds to yourself for several weeks until that hold no longer does it. So I did that on two finger pockets, half crimp, and an open crimp. The crimps were all 18 mil edges on the Beastmaker.

In the course of, you know, that time that I was remodeling it, I was progressing my climbing up into my regular gym- before I couldn’t touch a 5.12 hold because they just get too small, and it was really cool to see that as soon as my tendon got strong enough, I was like “Oh, I don’t feel it anymore when I climb, because I’ve been doing my hangs”. So your climbing just kind of gradually improves and matches your hanging tolerance.

Neely Quinn: Yeah. So wait- when did you know you should add the crimp in again?

Esther Smith: When I was satisfied with how strong my two finger pocket had gotten.

Neely Quinn: What do you mean satisfied?

Esther Smith: I was like plus 20 over body weight, and kind of tapering. Like I was saying to myself “I’m good here, now I’m ready to try another grip”.

Neely Quinn: Okay. So is that what you would suggest for there people, or could they put it in earlier?

Esther Smith: I would not suggest putting it in right away. I would just evaluate just the two finger pocket right away. For somebody who maybe doesn’t have- I guess they could do two finger pocket with index and middle, but I’ve treated people who have flexor tendon issues, and a two finger pocket doesn’t produce their strain. It’s weird. But a crimp does, so in that case, if you’r not assessing the two finger to produce your familiar stress or pain, then that might not be applicable for you, and then you would go right to a half crimp or open crimp, or whatever type of grip. Maybe it’s a pinch grip with a pinch block- whatever type of grip reproduces it, that’s the one that you are going to load up first. Then explore the other ones.

Neely Quinn: Okay.

Esther Smith: I had pain reproduced in all three. So I needed all three to be remodeled, and they all kind of worked on my tendon a little bit differently.

Neely Quinn: Okay.

Esther Smith: Yeah. So that’s the deal. It’s amazing. It’s super awesome. Now with that said, alongside the hanging, it’s really important that you are doing all the other good stuff for your finger that, again, is outlined in that YouTube video pretty well. Tendon glides, pen rolling, rice bucket work. You can use the Theraputty stuff for grip strength, kind of working your hands that way. I do a ton of self massage up in my hand with the finger massager tool, the Arm Aid up through my forearm. I stretch my chest, and my flexor line. When we talked about fascial lines the last time, in the elbow, how our muscles are connected al the way through our upper extremity, all the way to the tips of our fingers… if you have a flexor tendon problem, you better be stretching your forearm, your biceps, your pec, and your lat.

Neely Quinn: Hmm.

Esther Smith: So between when I am resting, between my hangs, I’m on the ground or on the bench doing my stretches and dong my rehab, during the 2-3 minute rest.

Neely Quinn: Okay, you think that’s good to do it between trying hard like that?

Esther Smith: Yeah, I’m not asking you to sit there and statically stretch your finger. That wouldn’t be great, like pull your finger back and then go hang on it. I’m saying you actively mobilize the thing. You won’t see in that protocol any pulling of the finger directly and doing a static stretch, so it’s totally fine to go lay down on the foam roller and do floor angels. You’re moving,  you’re gliding, you’re making everything psyched and happy, you’re bringing blood flow, you’re doing all the right things to get the body to repair itself, and to not be strung up. You’ll see- maybe your husband had this when he hurt his finger- did he have any pain or pull in his palm or forearm?

Neely Quinn: Yeah, for sure.

Esther Smith: Yeah, so if you don’t deal with that, your finger is going to be tight and sore and restricted indefinitely. You have to deal with the upstream tension that got developed, because you have to realize that the flexor tendon is connected to the muscle that starts in your forearm, and that muscle is connected to your bicep, and that muscle is connected to your shoulder girdle. You gotta work upstream when you are doing this rehab as well.

Neely Quinn: Okay, two questions. When you injured yourself, how long after you injured yourself did you start?

Esther Smith: Great question. I had a little bit of a weird scenario. I had a kind of allergic reaction, so I was on Prednisone for a month, which is a steroid. I couldn’t tell what was going on in my finger super well, because all my inflammation was snuffed by the Prednisone. So mine was a little delayed. What I would try and encourage people to do is if you’ve acutely injured it, you can start with the YouTube stuff. The rice bucket, the tendon glides, blah blah blah. You can start all that, but I would not touch a climbing hold for a couple of weeks. Give it a chance to just settle down, get the inflammation out of there. I would encourage you that if you have stiffness in the joint, if it doesn’t bend or straighten all the way, to try and get as much of that back before you start doing the loading, so that you have a finger, where although it’s injured and it can’t deal with climbing, it still moves appropriately.

Then you’re doing all this good kind of acute rehab stuff, and then maybe a couple of weeks after the injury, if you feel ready, you can tip toe your little fingers into the two finger pocket and check it out. I was freaked to do it. I was like “What?! Am I really going to do this?”. And I put my fingers in there, kind of snuck my toes off the ground, and then first time I tried it I was like “Nope, not ready, not happening”. So I walked away, came back a day or two later, tried it again, and I was like “Okay, I can do it now”. I just did body weight for a while, and it was a week or two before I felt like I could add 5 pounds, and then the poundage went right up from there. Within there, four weeks I was done with it.

Neely Quinn: So that first time you stepped up to it and said “Nope, not doing it”, it was like sharp, shooting pain that you had? It wasn’t that slight familiar pain?

Esther Smith: Yeah, it just felt weak, it felt like it might want to fail. My body was like “Don’t put weight on this thing”, you know? I think people can be aware and receptive to that in their own skin. But yeah, give yourself a couple of weeks, don’t touch anything, just do the acute rehab stuff, ice it, control the inflammation, regain your range of motion, then tip toe your way around into this thing. Use a pulley assist or something, just to kind of start to feel it.

In that time too, I was starting to climb again, as I was first starting to rehab the finger. I was climbing on like 5.10s, and I buddy taped. I don’t really encourage people necessarily to think that the direct taping around the pulley is going to do anything for them. To me it seemed better to just say “I’m going to help this finger out by taping it to it’s neighbor, so any time I am climbing it has a little bit of assistance, but I’m not masking or trying to think that the tape is going to make it stronger”.

Neely Quinn: Okay, so only buddy taping.

Esther Smith: That’s my call on that, but people swear by local tape around there, as long as you don’t think that it’s really actually serving as a replacement pulley for you. It’s not. You need to be really receptive of how climbing is stressing it, because people introduce climbing way too soon, and then it just goes on and on, you know? They overload it. They start climbing, and maybe they’re fine, their adrenaline starts going, but then after climbing, or maybe the next day, it’s lastingly sore.

Neely Quinn: Yeah.

Esther Smith: That’s too much. And you know that from your shoulder, right? You don’t want to be made worse after.

Neely Quinn: Right. Okay, so guidelines about climbing. When to start climbing, how much to climb, what do you think? You were saying a couple of weeks? Or no- because yours was a little bit different because of the Prednisone, but for normal people?

Esther Smith: Yeah, normal people, sure. I would say to rest completely for a couple of weeks, do your rehab, and control the inflammation, and restore range of motion. Then, go and play on some jugs. The problem is that most of the time, it’s the direct pressure that’s the worst. So jugs kind of suck [laughs]. But you can’t crimp, so you’re a little bit, you know, in a tricky spot there. I think that after a few weeks, I would just encourage you to play around on really really moderate climbs. Go up a pitch, come down, and check your finger by doing your glides. Keep inventory and assessment of your status between pitches. I’d come down, I’d glide it, and be like “Nah, that feels fine, I can do another pitch”, and do another pitch, then kind of check it. I would only do 3-4 pitches, call it good for a week or two.

Then I started to do my hangs, and then as I did my hangs, I could move form 5.10s to 5.11s without making it worse, without feeling like I was going to blow it again, and then progressively as my hangs got up to their top load, then I was back feeling like I was climbing more at my normal capacity without any pain during climbing. I would not advise to climb and feel pain climbing. I would only advise to really identify that familiar pain when you are doing your hangs, because that’s a controlled environment, you know exactly what you are doing, you can come off, you can put your feet on the ground, and there’s no dynamic nature to it. When you’re out climbing and you go to latch a hold, and that was the wrong thing to do, then it’s too late. So, I would really encourage you to just ease back into climbing super slow.

Overall, like I said, even with that Prednisone weirdness that I had, I was back to climbing pretty much full capacity- well, a little sub full capacity- within two months. Then kind just gingerly taking it up, and within about four months I was pretty much 100%.

Neely Quinn: And if you hadn’t done that rehab- that could have just gone on a long, long time, like it did for Dan.

Esther Smith: Absolutely, it would have just stayed around. And that’s what I see, is it just sticks around with people. I don’t think that people are indemnifying this remodeling concept for the tendon and the finger that you need to reinstate that inflammatory process, you need to work with your own physiology to get it to heal, and you need to do all the upstream/downstream work as well. The other thing Nelly, that was really important for me, when I was rehabbing and climbing, was to really work on my footwork, to unload my hand. I was like “Man, I don’t know that I was fully conscious of the fact of the more that I do with my core and footwork and my legs, I can take so much of the stress and strain off of my finger”. I worked on drills and things like that to really work on my lower body, and to take the stress off. It made me a better climber as a result.

Neely Quinn: You know, I just noticed that yesterday. I was climbing and I was like “I climb way differently now than I did before”. Through these shoulder injuries and the finger injury, I’m finding myself pushing more, and using different parts of my hands more.  I think that everybody could probably benefit from that, so we don’t always stress our fingers. And like you said, I’m using my feet and legs more to propel myself, so I’m not just locking off on my fingers all the time.

Esther Smith: Yeah, I think that’s so important. I was fortunate enough to have Thomasina Pidgeon, she was in town, and she did a little climbing assessment with me while I was injured. She identified, she was like “Yeah, you can do all these drills and movement skills to have better footwork, push more use long arms, don’t be so arm-y when you climb”, and it really helped me. It progressed my injury and my rehab, and yeah, again, it’s going to transfer to being a better climber. And in the meantime, work on your shoulder stability. Work on all the good core work, so that you’re not creating failure out at the part of you body that interacts with your environment, because the shoulder is weak or unstable. You can do all that work too, to help your finger heal.

Neely Quinn: Right, while you’re injured, you may as well lift some weights basically, or use some bands.

Esther Smith: Yeah, and do Pilates, and do things that really create really good shoulder stabilization.

Neely Quinn: Okay, so major warnings for people, just to reiterate. What I don’t want from the episode is for people who have pretty severe finger injuries to go out and try hard and make their injuries worse. How do you limit making your injuries worse?

Esther Smith: You gotta be just really respectful of what you are feeling when you’re engaging in whatever you are doing. So I would, you know- and that’s the thing. Let’s not mask it with a bunch of Ibuprofen. Let’s actually feel what’s happening. And the other thing is that Ibuprofen in that chronic situation is not helping, because it’s snuffing inflammation when you want inflammation- you want a little bit. Let’s not mask it with tape, and Ibuprofen, and all these things. And be really careful, and controlled when you go to test it. That’s where I was saying, like, barely sneak your feet off the ground, see what it feels like to load your fingers that way, come out, and give yourself five minutes to see if it’s okay. And if it was okay, then try it one more time. Just be really careful and cautious.

I think people are gonna be more apt to hurt themselves climbing too quickly than they would to be doing these loading procedure. People are super timid to do these loading procedures, but then they’ll go out and try a v5 in the bouldering area. I’m like “What the heck man?”.

Neely Quinn: I know, and when you say it out loud right here, it’s so obvious that it’s not what we should be doing, and that the hangboard is way better. We just think of the hangboard as being so intense, but it doesn’t have to be.

Esther Smith: No, take body weight off, use the band, use a pulley. The hangboard doesn’t have to be thought of as this intense thing, or this injury producing machine. That’s why, going back to the other podcasts, is you need to hanging right, first of all. Don’t hang sloppy when you are doing your rehab, which I see people doing. That’s not going to produce good results out at the finger. You need to be really stable in your trunk, and your core, and  your shoulder girdle. Your elbows need to be in position. You hang like that, and then you’ll have a really good read on what’s going on. If you hang all slopped out, it’s probably going to hurt and it’s probably going to injure you in more places than one. I think that’s crucial for climbers. We have to be hanging right when we are on the hangboard, and really really delicate and detailed.

Stop for a second, take some inventory, take some assessment, listen to your body, don’t mask it. Do your little rehab stuff in between, and really be careful with progression to climbing. It’s climbing when we aren’t really thinking, we have adrenaline, and we are going back to our old behavior. That’s where we are at a little bit of risk of not paying attention and making things worse.

Neely Quinn: So overview of this last hour is, basically if you get injured, take a couple weeks, do the stuff that’s on the YouTube videos which I will link to for the- what did you call it? The pre…

Esther Smith: Kind of like acute finger care.

Neely Quinn: Right, acute finger care. And then you can start doing the hangs, maybe start doing a little bit of climbing, maybe start those at the same time, or it sounds like you started climbing little bit before you started doing your hangs?

Esther Smith: Um, no actually. I assessed my hangs at body weight before I climbed.

Neely Quinn: Alright, and that’s what you suggest. And then do the whole progression that we just talked about.

Esther Smith: And feel free to take a month off. If that’s what you want to be safe, there’s no rush unless you’re just uber- like you gotta climb. That’s kind of up to the individual, and also up to the severity of the injury. Somebody who really had a full on finger flexor thing, yeah, maybe they need to be 4-6 weights before they start their hangs. But I think the by and large, you can start to kind of stress that tissue a little bit. It’s sort of like if you developed an early tendinitis at your elbow. After a few weeks of rest, you’re ready to start kind of dealing with that tissue a little bit, and you don’t want to just have it go on and on, where it’s not being cared for in that way. It’s good to start kind of checking it out, and seeing what’s up, and just don’t make yourself worse after, don’t blow it up.

I think we can say something Neely, about nutrition and about how you can do things physiologically to assist yourself with tissue healing, like taking Turmeric and Black Cherry and Holly Basil, and staying hydrated, and taking a lot of Omega 3s and 6s, bone broth, and all the good things that will help with tissue regeneration that climbers maybe aren’t so great about doing. Assist yourself that way too in the recovery process with your nutrition, and everything else you are doing with the upstream idea as well.

Neely Quinn: We could do a whole episode on nutrition for inflammation, but all of those things sound good. I get a lot of questions- magic bullets for supplements, for finger injuries. It seems like there really isn’t anything, it’s just time and doing these kinds of protocols.

Esther Smith: Yeah, yeah. Exactly. I think understanding the nature of the problem, so people should be getting inaccurate diagnosis, they should hopefully be in touch with a good care provider that is assisting them in their process of recovery. And understanding that we can’t always be afraid. If something is chronic and we are involved in a tendon problem, or a pulley problem in this case, at the finger, don’t be afraid to stress that tissue in a very controlled and therapeutic manner. That’s the thing that often gets people better and is missing. The other thing that’s missing is that people get really stiff and tight in their joints and soft tissue and then need to make sure that they have full, pain free range of motion while they are improving their strength.

Neely Quinn: Okay. You mean that they shouldn’t be doing this unless they have full range of motion?

Esther Smith: Yeah, like I said, kind of that idea, like maybe with your husband or even with yourself in that situation with your finger. If you finger isn’t fully straightening or bending, it’s probably not a good idea to load it too much. You really want to restore that with the rehab stuff that I’ve given in the video and other things, before you put a lot of demand on it.

Neely Quinn: Oh okay, got it. The other two questions, maybe these should be the last because we are kind of going over. So a lot of people have swelling, like their finger will actually puff up. What do you have to say about that?

Esther Smith: Get that gone before you do your loading. Do everything you know- you can do spiral taping on the finger to kind of push the swelling out, you can do the stuff in the YouTube video, you can ice it, contrast, you can have acupuncture. Anything you know to get the swelling out would be good. Some people have chronic swollen knuckles, and that’s not like a flexor tendon thing, that’s a swollen knuckle thing. That’s usually because it’s a derangement of the knuckle or something going on in that knuckle and they need some good therapy right there. That’s a little bit different than what we are talking about with the swelling as result of the soft tissue stress.

But just doing everything you can do to control that inflammation. That’s the first two weeks that I’m talking about, of resting and not loading it. That first 7-14 days is when you just want that finger to be chill, and get happy and healthy again. What happens is if the first two weeks go by, the swelling is gone, and you just want to go back to climbing, well it’s probably going to still hurt. What you’re up against then, is that the tendon is still damaged and isn’t resilient to stress or load. That’s what you’re going to be remodeling and changing with the loading program.

Neely Quinn: Okay. Last question is you talked a little bit about when you know, or that it’s pretty rare to need surgery. But when do you know that it’s really, really bad?

Esther Smith: Ah, yeah. Tough. I mean, maybe you kind of know [laugh]. I don’t know. Like I knew when my frickin foot- like I had to go to the ER. I knew my foot was bad. My finger happened and I was like “Oh, this is something I can manage”. I’ve never seen the extreme full version of full on, bowstringing, blown out, finger pulley thing.

Neely Quinn: That’s what I mean- what do you mean by bowstringing? Because that’s what you said earlier and I don’t think that everyone knows what that means.

Esther Smith: I think literally it would look like if you bent your finger that you would see a bulge in your pad that would suggest that the tendon doesn’t have its little strap anymore, so it’s pulling away from the bone and creating a bowstring or bulge.

Neely Quinn: Okay.

Esther Smith: It would probably be very swollen, you probably would have difficulty with even the initial rehab exercises that I showed in the video. If you can do those, if you can tolerate kind of moving around in some grain, you can’t tolerate your tendon glides of the pen rolling, and it hurts, and it hurts all the time- it hurts at rest. All of those things might be kind of red flags. And you know, big deal. Go get it assessed and you can move on.

We shouldn’t be so afraid of seeking medical attention when we need it, and seeing a provider for an accurate diagnosis. It will serve you, because then you can move forward with confidence. I think just big, hot, bad injuries, you kind of know. Give it time, give it those initial two weeks. This would be another thing Neely- if it’s not better after 14 days and you’re still like “Man, I don’t know if I can load this thing”, hone maybe that would also be a good indication that you should go get it looked it.

Neely Quinn: Okay, and I think this will be my last question. You mentioned the McKenzie practitioners, and for the people that didn’t listen to the elbow or the shoulder, can you just describe what that is?

Esther Smith: It’s basically for physical therapists, it’s a post-graduate credentialing process that you become certified in the McKenzie method of mechanical diagnosis and therapy. That’s what I’m certified in. And what that does, it just gives us this really awesome assessment and treatment kind of platform and tool kit to work from, so that we can diagnose things based on how somebody presents. So it really details treatment, like if you have a stiff knuckle and knuckle problem, a joint problem, we would call that a derangement. I would treat that very different from a contractile dysfunction, which is what you are dealing with with the tendon thing. It’s just that it allows me to say that if you don’t have a climber PT in your area but you want to go to a PT that will think about the body in that physiologic way and give you really cool self-treatment strategies, McKenzie PTs do that.

I feel pretty confident in recommending people to the McKenzie Institute website to find a provider, and that each provider even if they aren’t super experienced in climbing, should be able to get you going on a good treatment protocol.

Neely Quinn: Okay.

Esther Smith: It’s just that this treatment protocol is kind of like “Esther Protocol”, so you better be psyched that I just gave you my secrets.

Neely Quinn: I think a lot of people are going to be psyched. I’m psyched. I mean, I’ve never heard of anybody having some protocol that’s worked for hundreds of people, so hopefully this will help a lot of people.

Esther Smith: I think so, just know that it’s not a one size fits all deal. People have to be careful, walk down that road, and listen to their bodies, and hopefully get back at it as a result. I’ve had really good success with it

Neely Quinn: Did we miss anything?

Esther Smith: I don’t know man, I think we might have covered it. But we have more podcasts where we can discuss any…

Neely Quinn: Lingering questions.

Esther Smith: Lingering questions. And I just have to say that I’m really psyched with the selftreatment.com, the three new videos that are coming out for climbers. One is the healthy shoulder, one is a kit just for climbers that is the best mobility and strength stuff just for climbers, that’s going to be just over an hour long, movement- basically practice for climbers, and then we also have a healthy hand/wrist one. Anybody with these issues will get a lot of good stuff out of those.

Neely Quinn: And what are the dates those will be available?

Esther Smith: I’m in the editing process right now, so probably towards the end of April. Now that I’m laid up, it might be faster. I got more time! But towards the end of April, May, those will be available on selftreatment.com.

Neely Quinn: Okay, I think that’s it. Anything else that’s going on in your practice? And also, if you want to see Esther, through these podcasts, you’ve told me that there are people coming to you from different countries and different states, and people are flying in. That is an option, and she is in Salt Lake. Do you want to talk about how people can find you?

Esther Smith: Yeah, just find me on grassrootsphysicaltherapy.com, and selftreatment.com, or Grassroots Physical Therapy on Facebook. My practice here with the other two therapists that work with me, Katy Scott Martin, and Katie Blumenthal, we are treating climbers every day. It’s so cool to put our heads together and see that these protocols are really working. We have people flying in from all over, and even just helping our local community is really, really fun and satisfying. For me, just recently going through my own little finger issue and coming out on the other side of that, and just being really encouraged that the body has an amazing ability to heal itself. You just have to give it the right tools, treatment strategies, and the right environment. I saw it happen in my own finger, so it can probably happen from everyone else, and hopefully I will have the same results with this foot.

Neely Quinn: Yeah, good luck with your surgery on Monday, I hope it goes well.

Esther Smith: Thank you, I hope so too.

Neely Quinn: Alright, well thank you very much, and we will talk to you soon.

Esther Smith: Okay, thanks.

Neely Quinn: I hope you enjoyed that interview with Esther Smith. If you have finger issues, I hope that these protocols and this advice helps you, because I know that it’s like to have a finger injury, and it sucks. I think I said this in one of the last interviews with her, but when I was in Salt Lake a couple of months ago, I was staying with my friend Leif and his wife Lindsey. Leif went and saw Esther for his shoulder, and his shoulder was really bad. She helped him through it, and he is 100% now. He said that the joke is “If Esther Smith tells me to eat lima beans while standing on my head, I will do it” [laughs]. So, that’s one person who vouches for her, and there are a lot of other people who can vouch for her. Anyway, I hope that her advice will help you. Again, you can check her out at grassrootsphysicaltheraphy.com, and grassrootstherapy.com, and like I said, there will be links to all of this stuff in the show notes on trainingbeta.com.

As always, if you need any help with your own training, and you want a program that you can just follow step by step and not need to make your own program up, you can go to trainingbeta.com and we have a ton of programs there for climbers of all abilities and all types. I hope those will help you.

With that, thank you very much for listening all the way to the end, and I hope you talk to you next week!

TrainingBeta is a site dedicated to training for rock climbing. We provide resources and information about training for routes, bouldering, finger strength, mental training, nutrition for climbers, and everything in between. We offer climbing training programs, a blog, interviews on the TrainingBeta Podcast, personal training for climbing, and nutrition for climbers.


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