The dreaded pulley injury is the bane of a rock climber’s existence.
Rock climbers are required to grip small holds, pull on cracks, and support a great deal of their weight on their fingers. With sport climbing growing in popularity in recent years, an associated subset of injuries unique to the finger & hand have been growing as well3. A significant proportion of climbing injuries (over 20%) are flexor pulley strains, a structure sensitive to damage1. Well, those numbers sound important- so what is a pulley?
On the palm side of each finger is a series of complex structures called pulleys. These pulleys are composed of a thick, fibrous, force resistant material2. Their primary job is to keep the tendons of the finger plastered down to the bone.
Without pulleys, the tendon would not be able to pull effectively on the fingers, reducing how strong one’s grip is2. Each finger (pointer through pinky) has 8 pulleys, labelled A1-A5 & C1-C3 after their orientation (photo 1). Each hand grip used by a climber exerts different amounts of force on these pulleys. Unfortunate for us, the most effective way to hold a small ledge is also the position of highest stress on the pulleys- the crimp grip (photo 2)1.
How do pulley injuries occur?
All pulley injuries follow the same pattern of injury. The fingertip pad is violently extended, while the middle joint remains in a bent position. This can happen if a climber is performing a crimp grip & then falls3. To visualize how much abuse these poor things go through- forces applied to the fingertip can be magnified by 3-4X at the pulley1. This means, you as a 70kg climber who falls while maintaining a crimp grip can place up to 240kg worth of force on that small structure! Needless to say, the finger still holding on (usually the ring finger) is susceptible to injury4. Risk factors for pulley injuries include novice climbers attempting hard routes, lack of warmups & too short of a time between workouts1.
For the majority of pulley injuries, conservative management by a rehab professional is adequate.
You were climbing, you heard a pop, and now your finger hurts. Now what?
First and foremost, we have to take a look at the severity. For the majority of pulley injuries, conservative management by a rehab professional is adequate. Healing timelines for low grade injuries range from 6 weeks-3 months for a full return to sport1. During this time, your rehab professional may recommend immobilizing the finger for a few days to weeks. After this period, they will take you through a gentle range of motion exercises, tendon gliding exercises, taping strategies, and progressively strengthen the finger2.However, if the tendon “bowstrings” (see photo 3), the pulley has been fully ruptured1. This will unfortunately require surgical intervention and carry an average 6 month return to sport timeline3.
How do we prevent pulley injuries? Take it slow and steady when you train. Pulleys, like all other parts of our body will respond to training and become stronger. Additionally, a special tape job called an H-tape must be donned while climbing for months post-injury1.
Have fun & play safe.
Quinn, Physio
References:
1. El-Sheikh, Y., Wong, I., Farrokhyar, F., & Thoma, A. (2006). Diagnosis of finger flexor pulley injury in rock climbers: A systematic review. The Canadian journal of plastic surgery = Journal canadien de chirurgie plastique, 14(4), 227–231. https://doi.org/10.1177/229255030601400405
2. Shapiro, L. M., & Kamal, R. N. (2020). Evaluation and Treatment of Flexor Tendon and Pulley Injuries in Athletes. Clinics in Sports Medicine, 39(2), 279–297.
3. Ginszt, M., Ginszt, A., Berger, M., Gawda, P., & Tarkowski, Z. (2016). Finger flexor pulley injury of sport climbers – Literature review. Polish Annals of Medicine, 23(2), 191–194. https://doi-org.login.ezproxy.library.ualberta.ca/10.1016/j.poamed.2016.01.009
4. Zafonte, B., Rendulic, D., & Szabo, R. M. (2014). Flexor Pulley System: Anatomy, Injury, and Management. Journal of Hand Surgery, 39(12), 2525–2532. https://doi-org.login.ezproxy.library.ualberta.ca/10.1016/j.jhsa.2014.06.005
