How to Prevent and Treat Finger Flexor Pulley Injuries

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phil wiese  micro-crimp french connection V6 happy boulders rock climbing bouldering california

Phil Wiese micro-crimping on French Connection (V6), Happy Boulders, Ca.

You sit below the crimpy Go Granny Go (V5) on the Grandma Peabody boulder in Bishop, California. With one last effort, you lunge for the top rail. Then, suddenly, your feet skate and a loud “pop” echoes off the wall. Pain sears through the base of your middle finger—you’ve blown a digit and your climbing trip is over.

As the owner of Eastern Sierra Physical Therapy and Wellness, the author of Beyond Tape: The Guide to Climbing Injury Treatment and Prevention, and a local Bishop climber, I see finger pulley injuries regularly—they’re the most common climber finger injury. To climb longer and stronger, it’s important to understand our hand anatomy and how pulley injuries happen, as well as how to prevent and treat them, and to restrengthen an injured digit.

Anatomy

Three bones and three hinged joints make up the finger. Ligaments connect and stabilize the bones, while tendons connect muscle to bone, transferring to the bone any forces created by the muscles. Flexor tendons in the fingers attach to muscles in the forearms that pull on the tendons, bend the fingers, and allow us to crimp. Connective tissue encases the tendons, forming a sheath with five thickened areas that create the annular pulleys (A1, A2, A3, A4, and A5), which keep the tendon close to the bone when bending the fingers.

Causes

A loud “pop” and then significant swelling and pain often indicate damage to the flexor-tendon pulleys. For A2 pulley injuries, the most common pulley injury for climbers, the pain usually arises at the base of the finger and is noticeable when trying to straighten or bend the finger. For A2–A4 ruptures, there may be bowstringing—bulging at the base of the finger—which can be detected by resisting finger bending at the fingertip. (In this latter case, consult an orthopedic surgeon, as it can indicate a serious, grade 4 tear; see “Treatment.”)

Crimping increases the risk of injury because of the increased forces exerted on the pulleys, especially the A2. A fully closed crimp grip, with the thumb over the index finger, exerts even more force. Typically, this injury stems from either warming up poorly or a desperate, dynamic move to a tiny crimp, often with poor footwork and body positioning.

Prevention

The best way to deal with finger injuries is to not get them in the first place. Prevention requires warming up well, climbing with proper technique, and static stretching.

Warm up

Warming up well begins with an aerobic warm-up—hiking, jogging, cycling, or elevating the heart rate for 20–30 minutes. For outdoor climbers, that means the approach. For gym sessions, try jumping rope for a few minutes. Then engage in dynamic stretching—stretching a muscle through continuous motion, briefly bringing it to its end range. Finally, begin a sport-specific warm-up of easy climbing for either 100–120 moves, 8–12 boulder problems, or 3–4 routes. In the 2001 study “Sport Climbing From a Medical Point of View” in Swiss Medical Weekly, Andrea Schweizer showed that warming up increased the pliability of the finger flexor tendons, which allows them to absorb more force.

Climbing technique and body awareness

Proper footwork and avoiding intense dynamic movements may decrease the risk of pulley injuries by reducing overgripping or shockloading of the fingers. As a rule, avoid dynamic movements, especially to crimps, and focus on slow, precise footwork and core engagement. Note any pain or twinges to prevent further injury.

Static Stretching

This involves holding a stretch for at least 30 seconds, two to three times. Static stretching is best reserved for rest days and post-climbing, as some studies have shown that static stretching prior to an activity can decrease performance.

  • Prayer stretch: Place the palms together in front of the chest with the fingers pointing up. Rotate the palms forward toward the floor until you feel a good stretch.
  • Wrist and finger flexor stretch: Straighten one elbow, and reach that arm forward with your palm up. With your other hand, bend your fingers down toward the ground until you feel a stretch.

Treatment

If you get injured, first seek a diagnosis from a climbing-knowledgeable physician or orthopedic surgeon, who can assess the damage with an ultrasound or MRI. This will help determine the level of care needed as well as rule out damage to nearby structures. Let’s look at the grading scale of finger injuries as well as rehab solutions:

Grade 1: Pulley sprain

Definition

A partial tear of a single pulley

Solution

No need for immobilization. Begin gentle range-of-motion exercises—bend the finger until it feels tight, hold for 2–3 seconds, relax, and repeat 10 times for several sessions each day. Now perform the same exercise, only straighten the finger. Avoid pushing through pain.

Grade 2: Complete A4 or partial A2, A3 tear/rupture

Definition

Either the A4 pulley is completely torn, or A2 and A3 are both partially torn

Solution

One to two weeks of immobilization with a finger-immobilization splint or a pulley-protection splint, available online. Gentle range-of-motion exercises. H-taping (see below) for three months while climbing.

Grade 3: Complete A2 or A3 tear/rupture

Definition

A2 or A3 pulleys are fully torn

Solution

One to two weeks of immobilization with a finger-immobilization splint or a pulley-protection splint, available online. Gentle range-of-motion exercises. H-taping (see below) for six months.

Grade 4: Annular Pulley Ruptures

Definition

Single or multiple ruptures with possible lumbricalis muscle (the muscle between the metacarpal bones) or collateral ligament trauma

Solution

Surgical repair is recommended due to the increased risk of fixed flexion contractures, an inability to fully straighten the finger. (Some studies have also recommended surgical repair for grades 2 and 3, especially for elite-level climbers.) Consult with your surgeon about rehab options, as they can vary depending on the damage to your tendons.

H-Taping

Step 1.

Step 1.

For preventing reinjury, H-taping your fingers is more effective than traditional circumferential taping. To H-tape, tear a four-inch piece of athletic tape from the full width of the roll. Then, tear from each end to leave a ½” bridge connecting the two ends. Place the middle section along the palmer side of the joint in the middle of the finger. Wrap the section of the finger closer to the hand first; bend the taped joint to 30 degrees and wrap the other section of the finger.

Step 2.

Step 2.

Step 3.

Step 3.

Re-Strengthening

Once your finger has a full, pain-free range of motion (often one to two weeks after starting the rehab exercises), you can begin gentle re-strengthening. Use a hangboard, finger-strengthening device, or any training apparatus that allows for controlled movements and the ability to modify force on the injury site if you feel pain. While hangboarding, use your feet and avoid crimping—or any movements that cause pain—for at least six weeks post-injury.

Once you’re noting zero pain with normal grip positions on the hangboard, you can return to climbing. A full return to activity is realistic in six weeks for grade 1 and 2 injuries, and six to eight weeks for grade 3 injuries, with a full functional return by three to four months minimum. Meanwhile, grade 4 injuries require around 4 months off, with a full functional return after 6–12 months.

To further help healing, check for myofascial restrictions (aka trigger points) in the wrist and finger flexor muscles in the forearm and apply direct pressure to any area that feels tight or tender; hold for 2–3 minutes, feeling for a release of the restriction. Massaging the flexor tendons and pulleys prevents scar-tissue formation and increases range of motion.  

Mike Gable lives in Bishop, California, with his wife and two energetic little kids. A climber of 10 years, he owns Eastern Sierra Physical Therapy and Wellness, and donates 100 percent of the net profits from his book Beyond Tape to service-oriented local and global nonprofits.

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