Climber’s Finger: The Pulley Tear

In recent years, climbers have come a long way in terms of knowledge of overuse injuries, and how to avoid them. I started rock climbing in the early 90s, when training for climbing was something only a handful of us did. When I walk into our gym these days, the scene is different. In addition to the rope climbing and bouldering surfaces of varying angles, we now have campus boards, hangboards, system walls, Bachar ladders, gymnastic rings, sling trainers, and more. It’s exciting to see that training for climbing is happening at unprecedented levels.

With the increased popularity of climbing-specific training, it is important to raise awareness about injuries. The past 10 years has seen an explosion in climbing injury research, which is making its way into our sport media. In this article, we will review what every climber needs to know about the most common soft-tissue injury in our sport: climber’s finger.

Modern rock climbing places a tremendous strain on the fingers, arms and shoulders. In the early days of sport climbing, a study of elite competition climbers in the U.S. reported that 95 per cent had upper limb soft tissue injuries and 63 per cent of these were found in the hand. Twenty-six percent of these climbers were found to have finger flexor pulley injuries. These pulley ruptures were then, and are still today, the most common injury affecting moderate and elite level rock climbers.

Closed injury of the finger flexor pulley system is found almost exclusively in rock climbers. It was first described by Dr. S.R. Bollen in 1988, and has come to be known as climber’s finger. Bollen was an orthopaedic surgeon in Leads, England near The Peak District in the mid-80s, which happened to be one of the few places where training for sport climbing was being pioneered. Today, much more is known about climber’s finger.

Anatomy: The finger flexor pulleys are thick ligaments that wrap around the flexor tendons in the fingers. They hold the flexor tendons firmly against the bones, preventing them from bowstringing towards the skin during gripping. Prevailing thought is that the A2 and A4 pulleys are the most important for finger function. Rupture of one or more flexor pulleys can lead to finger stiffness, weakness and chronic pain.

The Biomechanics of Crimping (Why is it dangerous?): The crimp grip is employed by most climbers when grasping small holds. Crimping involves pressing of the tips of the fingers onto the hold with the distal finger joint (closest to the fingertip) hyper-extended and the middle finger joint held in flexion.

Mechanism of Injury (How does it happen?): The classic story is of a climber crimping when the finger is loaded rapidly due to either a foot-slip or pulling dynamically to make a difficult move. There is often a gruesome, audible “pop” at the time of injury, which is called an acute rupture. Another cause results from working a project or trying the same move multiple times. Then, sometime during the climbing, or shortly thereafter, pain and tenderness is felt at the base of the finger.

Diagnosis (How do you know you’ve injured a finger pulley): Despite the ever-increasing popularity of our sport, there is still a lack of knowledge among healthcare practitioners about what climbers do, and what injuries we get. When assessing a climber with a history consistent with a pulley injury, I first look for the following physical signs: pain, swelling, tenderness and sometimes bruising at the base of the finger; pain increase with crimping or direct pressure on the pulley; less pain when gripping with open fingers; and bowstringing of flexor tendons across the middle joint.

After reaching a diagnosis, I confirm it with imaging tests. X-rays should be ordered to rule out a fracture of the bone. When I was a surgical resident, we reviewed all scientific English language studies to determine the best diagnostic test for climber’s finger. We found that dynamic ultrasound and MRI are best for diagnosing this condition, provided that the radiologist performing and reading the test is experienced with these types of injuries.

To summarize, climber’s finger is the most common injury in rock climbers. It is a treatable condition, but is best prevented through safe training and climbing practices. If you have a flexor pulley injury, the surest way to a swift recovery is through early, accurate diagnosis and patience in adhering to a supervised treatment plan.

Treatment

The good news is that with well-timed diagnosis and treatment, most of these injuries will heal without surgery. Recovery time usually varies between six weeks and three months. Returning to climbing too early will lead to a chronic injury that can take many months and sometimes years to heal. Under the supervision of your healthcare practitioner, follow the general guidelines below to hopefully avoid falling into this unfortunate later category:

The Acute Injury Phase (First two weeks post-injury)
-Refrain from all climbing, split the finger and keep swelling down.
The Sub-acute Injury Phase (Two to six weeks post-injury)
-Gentle finger motion and light strengthening exercises, wear tape during the day.
The Late Recovery Phase (Six weeks to six months post-injury)
-Continue H-taping the injured finger up to six months, but no longer. Gradually increase the difficulty of your climbing, but avoid repetitive crimping, if possible. I’ve seen many athletes re-injure themselves during this phase of recovery. Work on other parts of climbing, such as tactics, mental focus, core strength, endurance, sloper strength, compression climbing and flexibility.
The Recovered Phase (After six months)
-By this point your pulley has completely healed, and more importantly, you have done enough active recovery training, that your fingers are strong enough to begin strengthening aspects such as power training, hard crimping and whatever else your body can normally handle.

Prevention

How to prevent finger flexor pulley injury is a huge topic, with the answers rooted in safe, effective strength training practices. Here are some general tips that will go a long way in minimizing your risk of injury.
-Start every climbing or training day with a 10-minute warm up.
-Once warm, build the day’s climbing intensity gradually.
-Vary your climbing and training. You can’t train powerful crimping every day or all year round, nor should you
-Finally, unless you are training crimp strength specifically, or climbing a crimpy route or boulder, crimp only when necessary.

Dr. Yasser El-Sheikh is a plastic & reconstructive surgeon practicing in Toronto, Ont. At the time this article was published, he was the medical/training consultant for Joe Rockhead’s Climbing Team and Corresponding Special Expert to The Medical Commission of the UIAA.