I paddled several thousand kilometres with clients last season, and one common observation was how many paddlers have poor anatomical wrist alignment. Poor wrist alignment can easily result in tendonitis, which occurs when a tendon (a chord of tissue that connects muscles to bones) becomes inflamed as a result of irritation or stress. Tendonitis often manifests itself initially with tenderness in the wrist and forearm, with swelling of the surrounding soft tissues. Symptoms tend to worsen during and after physical activity, and they may worsen over time.
If left untreated it can result in significant swelling and pain, with associated loss of the normal range of motion that can ruin a paddle day, or more seriously, compromise an entire expedition.
Do you check your own wrist alignment? Are you attuned to checking other peoples wrist alignments? How do these wrists look?
The most common alignment issue is to hyper-extend or hyper-flex the wrist on the top arm:
Correct alignment should look like this, with the forces being transmitted directly through the strong skeletal system, minimising the forces on soft tissue, tendons and ligaments.
An open and relaxed hand with a light grip go a long way to avoiding tension, even assisting with balance and blade control. Paddlers should also consider learning some wrist stretching exercises, certainly prior to hard paddling in challenging conditions.
Early identification and correction are always the best treatment. All paddlers should observe for correct wrist alignment in each other, and take seriously any complaints about sore wrists. Once a problem is identified, we probably need to stop paddling, get ashore and conduct a detailed assessment of the issue. The following treatment plan is for an acute injury, professional medical attention should be sought for ongoing treatment or serious injuries.
1. Assessment: Get to skin to compare both sides and make an assessment of the damage. Key things to check with any musculoskeletal injury:
- Circulation: Evaluate the colour, temperature and capillary refill beyond the point of injury to ensure that we have no vascular or nervous impairment. Is the skin all the same colour on both hands? All the same temperature? Squeeze a nail bed for five seconds and watch it blanch. Good capillary refill should take place within two seconds (if hands not too cold).
- Sensation: Ask the patient if there is any pain and where the pain is. Is there any numbness, tingling or pins or needles? Check that the patient can feel you touching the area around and beyond the injury.
- Movement: Ask the patient to move the injured area in a normal range of motion, indicating where there is pain or resistance.
If the patient has a good blood supply and beyond the point of injury and there is no neurovascular impairment, then it is not an emergency, but we do need to prevent the condition getting worse.
2. Pain Management: We may need to assist with managing the pain. Cooling can be helpful in the acute (immediate) injury, as it reduces pain and inflammation. Use ice (not next to skin) or cool water for 10 minutes on, 10 minutes off. But, too much cooling also reduces blood flow through vasoconstriction and inflammation is a necessary part of the healing process. So, use cooling sparingly to reduce immediate pain and swelling only.
If painkillers are required, then it is best to use paracetamol for the first 48 hours. Paracetamol does have anti-inflammatory properties (like ibruprofen although not as effective). But, ibuprofen acts as a platelet aggregator inhibitor, and this can prevent clotting and promote bleeding, it also inhibits the inflammatory processes that are necessary for healing; ibuprofen is best used after the initial 48 hrs for effective anti-inflammatory effect and pain relief.
3. Treatment: Long term treatment may include physiotherapy, surgery, acupuncture etc. In the acute phase on the beach however, we only really have a couple of options.
We need to move the injury, not simply rest it. If we rest an injury completely, we reduce blood flow, and blood flow brings healing nutrients and oxygen as well as removing damaged cells and metabolic waste. Muscle contractions also activate the lymphatic system further supporting waste removal and healing. So we aim to rehabilitate by gently restoring an active range of motion with gradual introduction of functional activity.
If severe, or we need to continue to use the injured wrist, we should aim to support the injury, preferably in a neutral anatomical alignment, preventing any further irritation through hyper-extension or hyper-flexion. The next blog post will go in to these taping methods in detail.
You will by now have noted that there is no mention here of the traditional RICE (rest, ice, compression and elevation) methodology for acute muscular injuries. This is for sound reasons, paddlers are often not able to totally rest the injury - and, as demonstrated above, we want to move the injury - not totally rest it. Ice provides immediate beneficial pain relief, but may delay healing. Neither compression nor elevation have any actual medical evidence to support them. RICE and its variants are too simplistic and not supported by evidence.
So our advice is to carefully examine and assess the extent of the injury. Manage the pain, and then support the injury appropriately - ensuring that there is gentle movement and exercise. I have used these techniques to support paddlers to complete expeditions, it works.
Sea Kayak Argyll & Bute regularly run Outdoors Emergency and Advanced 1st Aid courses. We also run a specific Sea Kayaker 1st Aid training day as an addition, which includes taping methods and other sea kayak specific injuries.
Next post in this series: Paddling Injuries Wrists #2 - taping wrists for support.