Knot on Call

Pain at the base of the thumb usually starts small — a jar lid, a car key, a firm handshake. For a lot of patients it's the most common form of hand arthritis, and it's also one of the most treatable if it's caught before it limits daily function.

A fall onto the thumb usually gets waved off as a sprain. Enough of the time it's actually a torn ligament — and the two look identical for the first 48 hours. Here's the exam that tells them apart, and why the window to fix it matters.

Eleven days in the Inside Passage tested the safety framework built across ten issues of this column. Here is the honest debrief — what performed as designed, what needed real-time adjustment, and what the field taught us that paper planning could not.

Persistent swelling around a finger joint can mean very little or quite a lot depending on the details. Some of those details are time-sensitive in ways that are not obvious from the outside — including one that constitutes a same-day surgical emergency.

Night splinting is the first thing most physicians prescribe for carpal tunnel. Nerve gliding exercises — which address a different component of the problem entirely — are the second thing, and they are far too often never mentioned at all.

This piece was written before departure and published while we were on the water. Eleven weeks of safety planning met the Alaska coast on May 28th. Here is what that looked like from the dock — and what I left behind while we were gone.

Carpal tunnel release is performed over 500,000 times per year in the United States. It is also one of the most poorly explained procedures in advance — which creates unnecessary anxiety and unrealistic expectations about recovery. Here is the honest version.

Morning hand stiffness is one of the most normalized symptoms in clinical medicine. It is also one of the most diagnostically important — and the single most useful question is one most physicians never ask: how long does it last?

Ten issues. Ten weeks of building a framework from first principles. Tomorrow it meets the actual conditions it was designed for. The gear is packed, the kit is built, the communication plan is set. Safety Officer Ben is ready. The Alaska after-action content begins when we return in early June.

Twenty-seven years of operating on people who trained through pain has given me a very specific opinion about sport's most durable myth. Productive discomfort and joint-localized pain are categorically different signals. Treating them the same way is how you end up on my operating table.

Dupuytren's contracture is progressive, genetic, and one of the most fascinating conditions in hand surgery. The Viking disease connection, the table-top test, and why treatment is most straightforward before the finger is completely bent down — not after.

Not all hand numbness is carpal tunnel. Thoracic outlet syndrome is one of the most frequently missed diagnoses in upper extremity medicine — overlapping with carpal tunnel, cervical disc disease, and rotator cuff pathology. The pectoralis minor connection and the self-test you can do right now.

Cold water immersion after resistance training consistently reduces soreness and consistently blunts the inflammatory response that drives muscle adaptation. You are trading gains for comfort — and that is a legitimate choice, as long as you know you are making it. What the 2026 evidence actually supports.

The house is quiet, the family is away, and the final pre-departure window belongs entirely to Safety Officer Ben. The communication plan, decision fatigue on multi-day expeditions, and the rule I'm setting for our group before we board.

One of the most common concerns from patients who need a brace but are reluctant to wear one. True disuse atrophy requires prolonged near-complete immobilization — not a wrist brace worn during symptomatic activities. The correct use case, and when the brace becomes the problem.

Photography on an expedition is not a passive activity. The 100-400mm telephoto produces the same sustained eccentric wrist and forearm loading I spend part of my clinical practice treating. Weight distribution, wrist position, lens support, and how to document an Alaska expedition without the wrists paying for it.

Early in my career, cortisone was the answer to almost any musculoskeletal question. The evidence that accumulated over two decades complicated that reflex considerably. What changed in my practice — and the distinction between cortisone as treatment versus cortisone as bridge.

One of the best-selling supplements in the United States. The evidence for its effectiveness is considerably less impressive than its marketing. What the GAIT trial actually showed, why so many people feel it helps anyway, and what I tell my own patients.

Mallet finger is one of the most commonly undertreated hand injuries — not because it is complex, but because the window for non-surgical treatment closes quietly while people wait to see if it resolves on its own. It does not resolve on its own.

Seven weeks of building the Safety Officer Ben framework from first principles. With departure four weeks away, that framework becomes a packing list — cold water protection, thermal regulation, footwear, wound management. Built from mechanism, not a retail checklist.

Trigger finger is a specific mechanical problem with a specific solution — and the sooner it is addressed, the simpler that solution tends to be. A corticosteroid injection resolves it completely in the majority of early cases. Do not normalize a finger that catches.

De Quervain's is not bad luck — it is a predictable response to a predictable loading pattern. The mechanics behind Mommy Thumb, Gamer's Thumb, and Fly Fisher's Wrist are identical. Understanding them changes how you think about prevention and when to act.

Hook injuries, deck falls, and the wrist loading of extended fly casting — a hand surgeon who fishes offshore and plans to fly fish in Alaska has a professional relationship with the injuries this sport produces. Most are not dramatic. Most are also entirely preventable.

The three-layer system is a physiological response to how the body manages heat and moisture in cold, wet environments — not a marketing framework. Why age changes the calculation significantly, and what that means for a multi-generational expedition.

Why new parents, gamers, and fly fishermen all develop the same condition — the anatomy behind Mommy Thumb, Gamer's Thumb, and Fly Fisher's Wrist. Why cortisone works here when it doesn't for tennis elbow, and the treatment hierarchy that actually resolves it.

CMC arthritis vs. De Quervain's tenosynovitis — two conditions that hurt in the same neighborhood but require completely different treatment. The Finkelstein test and CMC grind test that tell you which one you're dealing with.

The injuries I see most predictably are not the dramatic ones — they are the falls. And falls start at the ground. Every fall prevention conversation is also a hand and wrist injury prevention conversation. Your hands go out first — which means what is on your feet determines what ends up on my operating table.

Phalen's test — the classic prayer-hands maneuver — has a false negative rate of roughly 25%. Durkan's compression test cuts that number significantly. Here's the technique, what a positive test means, and why this is the test I rely on in the clinic.

"If you can move it, it's not broken" is wrong. Movement tells you whether the tendons are working — not whether the bone is intact. Here's what actually tells the difference, and the mallet finger window you cannot afford to miss.

Tennis elbow has forty different treatments because none of them truly works — except one. Eccentric loading of the wrist extensors has genuine evidence behind it. Here's the protocol, why it works, and why your instincts about rest are wrong.