Finger Flexor Tendon Pulley Injuries

Anatomy

The flexor tendons (flexor digitorum superficialis and flexor digitorum profundus) that run along the front of each finger are encased in a continuous sheath of connective tissue.  Along this sheath, there are five thickened areas that create annular pulleys (A1, A2, A3, A4, and A5) as well as three to four cruciform pulleys.  These pulleys keep the tendon close to the bone when flexing the fingers and provide stability as well as allow forces to be transferred from the muscles in the forearm to their tendons in the fingers.1,2,3,4,5

finger and wrist flexors
finger flexor pulley system
finger flexor pulley system

The crimp grip increases the risk of pulley injury because of the increased forces that are able to be exerted.  The force is especially high on the pulleys, especially the A2 pulley.  A closed crimp grip (using the thumb) exerts even more force, which is why it is used so often especially with smaller holds.1,6,7

open crimp grip
closed crimp grip – thumb is added

Injury

Damage to the flexor tendon pulleys is the most common climbing injury.8,9,10,11,12,13,14  The grading scale regarding the severity of flexor tendon pulley injuries is as follows:  1. Pulley strain 2. Complete A4 or partial A2, A3 tear/rupture 3. Complete A2 or A3 tear/rupture 4. Multiple ruptures or a single rupture with lumbricalis muscle or collateral ligament trauma.  A grade 4 injury requires surgery to prevent long term damage, such as a flexion contracture (the inability to fully straighten the finger).15,16

Often a “pop” is heard followed by significant swelling and pain (at the base of the finger for A2) when trying to extend (straighten) the finger.8,11,13,17,18,19  Pain is also noted when trying to flex (bend) the finger and bowstringing may be able to be detected by resisting finger flexion at the distal phalanx (fingertip) if A2-A4 are ruptured.1,13

torn pulleys with bowstringing tendons in a crimp grip

Prevention

  1. Static Stretching – Holding a stretch for at least 30 seconds after a climbing session and on rest days helps to decrease injuries. (For references and more information, see my article titled “Static Stretching for Rock Climbing”.)
wrist flexor stretch
wrist/finger flexor stretch
  1. Warm up – This is a combination of an aerobic warm up (hiking, jogging, cycling, etc.), dynamic stretching, and the sport specific warm up of easy climbing for 100-120 moves (8-12 boulder problems or 3-4 routes).17,20,21 (For more information, see the article titled “Rock Climbing Warm Up”.)
  2. Taping (H taping) – This way of taping has been shown to decrease the risk of reinjury when a pulley tear or sprain has occurred previously.10
H taping 1
H taping 2
H taping 3
H taping 4
  1. Climbing technique and body awareness – Proper footwork technique and avoiding intense dynamic movements may help to decrease the risk of pulley injuries by reducing excessive grip force and thus placing less stress on these structures.22 Listening to your body and allowing an injury to fully heal before returning to climbing helps to prevent reinjury.

Treatment

Having the grade of tear diagnosed medically helps to determine the treatment as well as to rule out damage to nearby structures.  Grades 1 to 3 pulley ruptures do not typically require surgery.  Surgical repair is recommended for Grade 4 ruptures due to the increased risk of fixed flexion contractures (an inability to fully straighten the finger).1,6,8,11,12,23,24  Some authors have also recommended surgical repair for grades 2 and 3 especially for elite-level climbers.25

Initially, one to two weeks of immobilization with a finger immobilization splint or a “pulley protection splint” is recommended for grades 2 and 3 pulley injuries (no immobilization is required for grade 1).4  After the immobilization period, H taping (see picture in prevention section above) is recommended to protect the pulley while gentle range of motion exercises are begun.

finger flexion – bend the finger until a stretch is felt, hold for a second or two, and repeat 10 times
finger extension – straighten the finger until a stretch is felt, hold for a second or two, and repeat 10 times

The taping is recommended for three months with grades 1 and 2 injuries and six months for grade 3 injuries.  Once full and pain free range of motion of the finger has returned (usually one to two weeks after beginning these exercises), gentle strengthening can be initiated with a hangboard or other strengthening device that allows for controlled movements and the ability to modify the force on the injury site if pain is noted (use the feet to decrease the force on the fingers when using a hangboard).   A crimp grip should be avoided for at least six weeks after the injury.  Movements or exercises causing pain at the site of injury should be avoided as this is the body’s way of indicating that it is being re-injured.  A gradual return to climbing can be initiated when no pain is noted with any of the gripping positions you plan to use.  These can be tested on the hangboard or chosen device.  Full return to activity is realistic in six weeks for grade 1 and 2 injuries.  For grade 3 pulley injuries, a gradual return to climbing may be able to be initiated at six to eight weeks and full functional return by three to four months minimum.6,8,11,12,13,18,26

Some additional treatments are:

  1. Checking for trigger points in the wrist/finger flexors as well as gentle massage to the flexor tendons and pulleys to prevent scar tissue formation
Flexor digitorum superficialis/profundus trigger points 1 – apply direct pressure to any tight or tender spots close to the X and hold for 2-3+ minutes
Flexor digitorum superficialis/profundus trigger points 2 – apply direct pressure to any tight or tender spots close to the X and hold for 2-3+ minutes
  1. Ester Smith, DPT at grassrootsphysicaltherapy.com goes over a solid treatment protocol for this injury on her blog (also featured in trainingbeta.com). This is a great research option for a grad school thesis in areas with high populations of climbers – hint, hint to the students out there.

 

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing injury related topics.  Subscribe here to get the latest posts and like my facebook page for updates and more information.  My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

 

1 Kubiak EN, Klugman JA, Bosco JA.  Hand Injuries in Rock Climbers.  Bulletin of the NYU Hospital for Joint Diseases • Volume 64, Numbers 3 & 4, 2006.
2 Bovard R.  Pulley Injuries in Rock Climbers (letter to the editor).   Wilderness & Environmental Medicine.  Allen Press Publishing Serv;Spring2004, Vol. 15 Issue 1, p70.
3 Schoffl V, Heid A, Kupper T.  Tendon injuries of the hand.  World J Orthop 2012 June 18; 3(6): 62-69.
4 Schneeberger M, Schweizer A.  Pulley Ruptures in Rock Climbers: Outcome of  Conservative Treatment With the Pulley-Protection Splint-A Series of 47 Cases.  Wilderness Environ Med. 2016 Jun;27(2):211-8.
5 Zafonte B, Rendulic D, Szabo RM.  Flexor pulley system: anatomy, injury, and  management.  J Hand Surg Am. 2014 Dec;39(12):2525-32; quiz 2533.
6 Warme WJ, Brooks D.  The effect of circumferential taping on flexor tendon pulley failure in rock climbers.  Am J Sports Med. 2000 Sep-Oct;28(5):674-8.
7 Schweizer A, Hudek R.  Kinetics of crimp and slope grip in rock climbing.   J Appl Biomech. 2011 May;27(2):116-21.
8 Crowley T.  The Flexor Tendon Pulley System and Rock Climbing.  J Hand Microsurg (January–June 2012) 4(1):25–29 DOI 10.1007/s12593-012-0061-3.
9 Schöffl V, Popp D, Küpper T, Schöffl I.  Injury trends in rock climbers: evaluation of a case series of 911 injuries between 2009 and 2012.  Wilderness Environ Med. 2015 Mar;26(1):62-7.
10 Schoffl I, Einwag F, Strecker W, et al.  Impact of Taping After Finger Flexor Tendon Pulley Ruptures in Rock Climbers.  Journal of Applied Biomechanics, 2007; 23:52-62.
11 Schöffl V, Hochholzer T, Winkelmann HP, Strecker W.  Pulley injuries in rock  climbers.  Wilderness Environ Med. 2003 Summer;14(2):94-100.
12 Schöffl VR, Einwag F, Strecker W, Schöffl I.  Strength measurement and clinical  outcome after pulley ruptures in climbers.  Med Sci Sports Exerc. 2006 Apr;38(4):637-43.
13 Schöffl VR, Schöffl I.  Finger pain in rock climbers: reaching the right differential  diagnosis and therapy.  J Sports Med Phys Fitness. 2007 Mar;47(1):70-8.
14 Pozzi A, Pivato G, Pegoli L.  Hand Injury in Rock Climbing: Literature Review.  J Hand Surg Asian Pac Vol. 2016 Feb;21(1):13-7.
15 Schöffl V, Hochholzer T, Winkelmann HP, Strecker W.  Pulley injuries in rock  climbers.  Wilderness Environ Med. 2003 Summer;14(2):94-100.
16 Smith LO.   Alpine climbing: injuries and illness.  Phys Med Rehabil Clin N Am. 2006 Aug;17(3):633-44.
17 Schweizer A.  Sport climbing from a medical point of view.   Swiss Med Wkly. 2012;142:w13688.
18 Rohrbough JT, Mudge MK, Schilling RC, Jansen C.  Overuse injuries in the elite rock climber.  Med Sci Sports Exerc. 2000 Aug;32(8):1369-72.
19 Merritt AL, Huang JI.  Hand injuries in rock climbing.  J Hand Surg Am. 2011 Nov;36(11):1859-61.
20 Hockhoelzer T, Schoeffl.  One Move Too Many…  Druckerei Sonnenschein,  Ebenhausen, 2003.  p. 109.
21 Schweizer A.  Biomechanical properties of the crimp grip position in rock climbers.  J Biomech. 2001 Feb;34(2):217-23.
22 Koukoubis TD, Cooper LW, Glisson RR, Seaber AV, Feagin JA Jr.   An electromyographic study of arm muscles during climbing.  Knee Surg Sports  Traumatol Arthrosc. 1995;3(2):121-4.
23 El-Sheikh Y, Wong I, Farrokhyar F, Thoma A.  Diagnosis of finger flexor pulley injury in rock climbers: A systematic review.  Can J Plast Surg 2006;14(4):227-231.
24 Klauser A, Frauscher F, Bodner G.   Finger Pulley Injuries in Extreme Rock Climbers: Depiction with Dynamic US.  Radiology. 2002 Mar;222(3):755-61.
25 Bouyer M, Forli A, Semere A, Chedal Bornu BJ, Corcella D, Moutet F.  Recovery of rock climbing performance after surgical reconstruction of finger pulleys.  J Hand Surg Eur Vol. 2016 May;41(4):406-12.
26 Holtzhausen LM, Noakes TD.  Elbow, forearm, wrist, and hand injuries among sport rock climbers.  Clin J Sport Med. 1996 Jul;6(3):196-203.