Curse of the Vikings: Dupuytren’s

I have Dupuytren’s disease. Both my parents are in the early eighties and are just now displaying signs of it. I am worried that I could have the more serious Dupuytren’s diathesis as I fit its target profile: male, have early onset—I’m 47, have bilateral hand involvement and Garrod’s pads (callouses on the back of the finger knuckles). I recently took up climbing again which may have sparked the condition. I windsurf, mountain bike, hit the gym, and am an accomplished violinist. I worry that these activities may worsen the condition. I saw a surgical consultant. She was kind and tried to reassure me that there was nothing that should be done at this stage.

Radiotherapy has come up as a potential therapy, but I am not especially keen to do this as it seems unproven. Do you advocate using corticosteroid injections, and is there a significant risk of tendon rupture if I decided to climb again? 

—Richard, England

Dupuytren’s disease is a fibrosing disorder affecting the palmar fascia and causes a finger to contract, possibly eventually getting stuck in that position. We can thank the Vikings, promiscuous ruffians who spliced their genome into the European community. Blue eyes, as well as the unfortunate Dupuytren’s disease, are common Nordic traits.

You may carry the Dupuytren’s gene and never have a problem. In fact, the reasons why it suddenly becomes active are little known. There are a few correlates, the strongest being a family history of the disease. Manual work, alcoholism, liver disease, diabetes, thyroid issues, smoking, and epilepsy are also known risk factors.

Over time the Dupuytren’s contracture causes the affected finger to permanently draw into the palm. The disease process can halt at any time and for any period, and then start up again, so the ostensible end result can be a slightly flexed finger, or the finger can become so flexed it is a functional hindrance.

Most climbers are not overly affected by Dupuytren’s, since the disease takes a long time to progress to the point that the finger position is bothersome. I have seen many climbers continue to climb at an elite level even as the contracture worsens. Remember that the contracture really only prevents you from straightening the finger fully.

[Also Read 30 Years of Climbing Accident Data: An Investigative Report]

When the extension deficit becomes an issue, I suggest either cologenase injections or percutaneous needle fasciotomy (see sidebar). Bear in mind that the chance of recurrence of Dupuytren’s is high no matter the treatment, so choose a course that is minimally invasive. I wouldn’t say that surgery is unnecessary these days, that would be silly, but it is considerably down the list of frontline options.

On the topic of a Dupuytren’s diathesis (a more aggressive form of the disease that can lower your life expectancy), it is arguable that any increase in mortality is outstripped by the fact that you climb in England, where you will spot a unicorn before you see a bolt. The reason why Dupuytren’s diathesis can shorten your life is unclear, and may or may not apply to you anyway.

Appreciating that there is ongoing discussion around Garrods pads versus Dupuytren’s nodules, the former are also known as violinist pads, and their presence is equally up for debate—I am sure you didn’t become “an accomplished violinist” by looking at it! Your parents appear to have a mild case given their age and presentation; again, that doesn’t fit with you having a diathesis; typically parents will have the diathesis as well. You do have an early onset (before the age of 60) and bilateral involvement, but this alone does not definitively qualify you.

Being active may or may not hasten the onset of finger contracture. The downstream effects of being inactive, however, can have a vast array of downsides, from mental health to heart disease.

Certainly, worrying about what is beyond your control will lead to a reduced life expectancy.

Treatments for Dupuytren’s

Percutaneous Needle Fasciotomy (aka Needle Aponeurotomy)

Take a horse-sized hypodermic needle, delicately shove the blade-like end into the fibrotic cords that are dragging the finger into flexion, and give a strategic wiggle. Take a small step to the side and repeat. Once the cord is weakened by multiple cuts, push the finger straight such that the remaining tissue breaks. Don’t worry, you will have a local anesthetic. The treatment does not take long, and the outcome, straightening your finger, is immediate. You can saunter off for a climb the following day, albeit your palm will feel like you ran it through your grandma’s sewing machine.

Enzyme injections

An enzyme, collagenase clostridium histolyticum (trade name Xiaflex in the USA), is injected into the Dupuytren’s cord. Revisit the good doctor a day later, once the enzyme has worked its magic, and she will point over your shoulder and say “Check that out!” and will slam your finger straight, breaking all the weakened fibrotic restraints. She may or may not say “Ta-Da!”—finger is straight. Brilliant. You can resume normal recreational activities after a week or so.

Efficacy for both of the aforementioned approaches varies depending on disease severity and which joint is affected.

Radiotherapy

I think weeing on it—unproven but historically popular for a variety of ailments—carries a lot less risk for roughly the same amount of hope. Radiotherapy has close to zero in terms of supporting data, not to mention a whole shebang of shitty side effects.

Corticosteroids

This is largely a thing of the past without any of the retro cool factor. Save your money, buy a twin-fin long board and go surfing. Oh, you live in England. Sorry. Trying to influence early disease progression with steroids such as triamcinolone is an experiment only. You would be at risk of local tendon rupture for several weeks after administration.