4 May 2010

Pulley injuries article

NB: This is an old article and is now superseded by the book I've written on climbing injuries. There is a whole chapter on finger injuries and what you can do about them! Make or Break is in my shop here.

Finger pulley tears are now more common than any other in rock climbing, yet few climbers know much about how to treat or even avoid pulley tears. After trawling the scientific and climbing literature on the issue (not to mention treating my own injuries!), I realised there was plenty of knowledge out there…
Definitions and Diagnoses
The first problem is deciding what your injury is! Most of us can’t afford to pay for specialist sports injury consultations or therapy and it’s safe to say that your GP alone is unlikely to provide an accurate diagnosis or strategies for repair of this extremely sport specific injury. 
There are two tendons which flex your fingers and are tensioned while you pull on holds. The tendons are held in place by the flexor pulley system; a series of ligamentous bands stretching over the tendons, along the length of the fingers. The pulleys withstand astonishing forces, especially during crimping. If these forces are high enough or if there is a sudden additional loading, they can and do tear. The severity of the tears can range from partial tears of isolated pulleys to complete rupture of several pulleys!
Often there is an audible popping noise if a pulley ruptures, (remember you might not hear this if you are concentrating on the job in hand!). Later there may be visible bowstringing, where the tendons can be seen to bulge in the finger when you flex it against resistance. This might not be obvious if the finger is too swollen and painful to examine. If you suspect a rupture, you MUST try to see a specialist to have a scan (ultrasound, MRI or CT) and receive expert advice. Complete rupture may require splinting and/or surgery to repair and ignoring the problem can lead to further tears, permanent loss of ability to bend the finger and arthritis.
Partial tears of isolated pulleys are much more common and heal remarkably well compared to certain other ligament injuries. You might feel a sudden twinge of pain in the affected finger (and possibly a small pop). However, it is possible not to notice the injury at all during the climb or session. There might be localised pain and tenderness over the area the next morning or the next time you climb. The most commonly injured pulley is A2, which is near the base of your finger. A1 or A5 tears almost never occur. If you have a pulley injury, and the acute inflammation is not too bad, it should still be possible to pull on holds with a fully open-handed grip without pain. If the pain becomes much worse during or after crimping, this indicates a pulley injury.
Another common finger injury is flexor unit strain. These are tendon strains which often occur in the ring finger when using two or three finger, open handed holds. Unpleasant twinges of pain are felt along the length of the tendon through the finger and palm. For this injury, follow the treatments below and avoid gripping positions which irritate it.
Preventing pulley tears
If you have a history of repeated finger injuries, or even if you just want to protect against ever getting one, you must look at your climbing and lifestyle. Tears are most often caused when you are pulling hard on a crimp and your feet slip off, placing a sudden additional load on the pulleys. To avoid injuries in general, you must try to be in control of your movement as much as possible. This is a difficult and multifaceted skill to learn! An important thing to understand is that it is possible to stretch your abilities to the absolute limit, pull with 110% and climb explosively, yet still be ‘in control’. The goal is to be more aware of what your body is doing and how it moves. In this way you can predict what it will do before it happens. If you can improve this skill you will not only prevent injury but climb better too! Try to feel how your feet are positioned on each foothold, feel the traction. If you can do this then you will be ready if they slip.
Climbers who don’t get injured often tend to have a good balance of gripping styles. Before my first pulley injury, I was one of the many climbers who crimped everything, even pockets. Once I was forced (by injury) to train using open handed, I realised that this grip is much stronger and less tiring on certain holds. You don’t have to learn the hard way!
Some climbers use finger tape on healthy fingers or old injuries to try and prevent pulley tears. The consensus of a few scientific studies is that tape is not strong enough to absorb injury causing forces. Tape appears to be useful only in the early stages of repair when the pulley is weak and you are not climbing hard. It’s also important to consider your general health, diet and lifestyle. Good sleep is essential for tissue repair during training and if you are tired, your sloppy technique will predispose you to tweaking your fingers. Don’t underestimate the importance off gentle and progressive warm up during a session.
Treating pulley tears
In this article I have focused on the self administered treatment/prevention of minor pulley injuries (where hand function is not severely limited). If you suspect a pulley rupture you should see your doctor/specialist straight away. For less serious tears, long lay-offs and surgery are thankfully not necessary and with prudent care, the injury should heal very well. It is crucial to understand that the extent and speed of your healing is down to what YOU do during the recovery. The outcome is dependent largely on the effort and diligence you contribute to the process.
Contrary to popular belief, months of complete lay-off from climbing is not required and is likely to stunt the healing process! All injuries follow a well defined and staged healing process. The first stage is inflammation and this usually lasts a few days to a week. Inflammation is a good thing as it triggers the later stages of tissue repair. However, chronic inflammation (from climbing too hard, too soon) can cause further tissue damage. It’s important to stop climbing completely until the inflammatory phase is past. It’s hard to know exactly how long the lay-off should be, but in general it should be 1-3 weeks. Too short and you risk chronic inflammation and too long and the tissues become naturally weaker and scarred. Once you can move the finger through its normal range of movement without pain, its time to start using it again gently. Using the injured part encourages healing in the same way that training makes your body stronger. 
Build up carefully over weeks and back off if the pain and tenderness increases. Climbing with a completely open handed grip produces little strain on the pulleys and thus you may be able to climb harder by using strictly only this grip until you can crimp again. Such discipline and change to your climbing style is extremely hard to maintain and it might only take one lapse of concentration to crimp again and risk further injury! It follows that this approach may be best confined to careful use of a fingerboard and certainly not where any dangerous climbing is involved.
Ice therapy
Increasing the blood flow to the area helps to speed healing greatly. Gentle climbing or exercise is an obvious way of achieving this. A little used, but massively effective method of increasing blood flow is ice therapy. If significant cold is applied to the skin, the blood vessels in the nearby area (in this case the hand) constrict to reduce blood flow and prevent cooling of the blood. However, when moderate cold is applied there is an initial reduction in blood flow followed by significant dilation of the blood vessels and subsequent increase in blood flow of up to 500%. This is called the ‘Lewis reaction’. The cycle of blood vessel constriction and dilation takes around 30 minutes and thus the cold application should last this long. Place your injured hand in a pot or small bucket of cold water with a few (roughly 5) ice cubes added. Leave your hand in the water for the length of the treatment. If your hand hasn’t gone pink and feels flushed with blood after ten minutes, the water is too icy. Try to use the ice at least once or twice a day. Don’t use this treatment on a freshly injured finger where there is significant inflammation!
Deep friction massage (DFM)
DFM helps to break up the loose network of scar tissue which forms in an injury, promoting its realignment and strength. Rub the pulley with your thumb, applying firm pressure (moderate pressures dont produce the desired effects). The thumb motions should run lengthwise along the affected part of the finger. Only use DFM when your injury is already well past the initial inflammatory stage and stop if you feel the massage is irritating the pulley or causing excessive pain. Use DFM for a few minutes at a time and begin with very brief applications. 
Stretching the injured finger is another vital treatment you must apply to ensure adequate healing. Stretching promotes blood flow and tissue growth.  You should stretch the finger until it feels tight and hold this position for 10 seconds. After holding it may be possible to stretch a little more, held for up to 30 seconds. Never stretch the finger aggressively; it shouldn’t be painful. You can stretch the injured finger as often as you like but particularly important before and after a climbing session.
Some climbers use anti-inflammatory drugs such as Aspirin or Ibuprofen (from a class of drugs called NSAIDS). NSAIDS have been used to reduce ongoing inflammation and allow continued training. NSAIDS can be useful where there is chronic inflammation, in conjunction with lay-off. However, in general the inflammatory process should be seen as vital and upsetting its progress will prevent normal progression to the tissue building stages of healing, and ultimately result in permanent dysfunction. If a pulley injury is persistently painful and tender, you need rest or reduction in your climbing level and perhaps a change in climbing style until the injury has a chance to progress.
Taping allows you to climb while taking up to 10% of the strain off the affected pulley. Recent scientific studies have confirmed its effectiveness in supporting the injured pulley in the early stages of healing. It was suggested that the greatest support came from taping nearer the middle finger joint where A2 was injured. Tape has poor tensile qualities compared with healthy pulleys. Therefore, there is no advantage in continuing to use tape once the injury is nearly recovered. 
The single most important aspect of any rehabilitation is that you are in control of the recovery and you recognise that hard work and patience brings good results. Work hard at the treatments outlined above and be positive! Seeing results of rehab treatments can be just as rewarding as seeing results from hardcore training. Recovery from pulley tears will still take time, so be patient and don’t overdo it. It can be very disheartening when the pulley is still painful after three months despite all the effort. However, if you just stick with it you will be cranking it out again a few weeks later. Finally, it’s also my experience that my best ever periods in climbing have always been just after recovery from finger injuries!


Alan said...

Just an observation/query regarding taping of an injured pulley. I diagnosed myself with a torn A3 a few months ago. A climbing layoff did not help at all and I have since been climbing with an open handed grip. I am using finger tape while climbing to help prevent my knuckle from bending fully and this helps prevent me from crimping and promotes the use of open handed grips. I don't know if this actually helps but if anything, it reminds me every time I try to crimp that I shouldn't, not yet at least.

Fultonius said...

Hi Dave,

I'm going to be out of climbing for about 9-12 months due to knee surgery and rehab.

I'm trying to do some regular chin-ups/fingerboard work to maintain strength (not too bothered about endurance, as I always seem to be able to get that back quite quick).

I was interested and encouraged by the point you made in 9 out of 10 climbers about 1 session a week being enough to maintain strength.

Is there much information about the reversibility of tendon/pulley strength? It would be nice to come back to climbing with the risk of pulley/tendon injuries minimised.

Also, is there any other excercises I can do to maintain strength? I'm going to do some specific core strength stuff to.


Feel free to follow my progress: http://pcl-rehab.blogspot.com/

Anonymous said...

Hi Dave. I just today strained my ring finger pulley A2 while bouldering. I've been planning on going ice climbing in two weeks- would ice climbing or pull ups delay the healing process? I know that you are not a doctor but I would still appreciate your opinion. Thanks!
Ps. Your blog is great!

Unknown said...

Hi Dave,
great post on pulley injuries. Unfortunately I had to read it because I torn my A2 last year (even gave a copy to the rehabilitation expert in my hospital. Reading up on rehabilitation and getting back on the wall I saw one of your articles about eccentric training and found the following article http://iospress.metapress.com/content/c3410185m88k1324/
using the following device: http://www.turntillburn.ch/cms/ttb/index.php?id=81
could you share your thoughts on this

chris said...

Hey Dave,

Great book, Great blog, thanks for all time and info put into the climbing community.

I was wondering if you could touch on something for people rehabbing a pulley strain. Mine has had a strain for 6 weeks and is still not happy to crimp on. I have been climbing exclusively open handed and can still climb full sessions especially training endurance. Once the finger is warm over a endurance session (after 1-2 hours) the finger feels fine and can half crimp with no pain (still only climb open). However the next day the finger feels stiff in the morning and is slightly swollen. This can be rested off in a couple of days or warmed up again for a 2nd day of endurance and still performs fine. So what i would like to know is, in your experience, would you think its ok to continue like this and allow the injury to come right over time or would it make more sense to back off for a month(s). It does not hurt while climbing/training or after i just dont want to prolong the recovery time to getting back to cruxy climbing.



Jess said...

I came across this, because I was reading about pulley injuries. I have an injured middle finger pulley and it is my first tendon or pulley injury that I had to stop climbing for and I was not sure what to do. These suggestions are very helpful, because I want it to heal properly. Some people I climb with have told me about the ice baths and the resting. I was wondering if you had any suggestions and if there are any ways to tell when you should start climbing gently again? Also, should I tape it everyday? Some people have told me not to tape it at all. What do you think?

Unknown said...

Hi Dave,

Thanks for this great article (and blog, and book...). I'm wondering if you have any advice about an avulsion fracture? I had thought I'd torn my A4 pulley - had all the classic symptoms (2 loud pops, unable to crimp, etc.). But after x-rays and ultrasounds, it looks as though there is no tendon tear, but an obvious avulsion fracture instead. I can't find a lot of information about it online wrt to climbers. I'll see a specialist next week, but she's not a climber, so might not understand that my intent, in the long-run, is to put a lot of pressure on that finger again. I'm worried the bone may be permanently weakened. Thanks for any advice! Looking forward to your next book...

Sienna Christie said...

I've been doing ice therapy for so long now whenever my fingers feel a little bit stretched, though I can say that other information from your post will be very helpful to me as well. Thanks!

Sienna Christie

Unknown said...

Hi Dave,
This article is great and should stay up for reference. I've written about my recovery after tearing my A3 pulley... www.terryjameswalker.com/climbinginjuryrecovery.html
worth a read for anyone on the comeback.

Lila Machado said...

Hello!, very interesting post about Pulley injuries. 6 weeks ago I heard a "POP" on my pinky finger and stopped for a couple of days but the started climbing. On a boulder problem I crimpped too much and starting hurting again. Since then is very swollen around the interphalangeac joint, it has -5ยบ of extention (which means I can't fully extend it, and hurts when I try to extend it).. I'm very worried, what could it be?

Dave MacLeod said...

You'll need to ask you hand surgeon Lila. Not much point proceeding with treatment without professional diagnosis.

Unknown said...

Just mildly tweaked my finger, and I stumbled upon this article. Interesting read, I'll have to get your book next!

One thing, though: NSAIDs are generally not recommended anymore for any sort of tissue injury because they delay the healing process through the same mechanism that kills the pain. A safer analgesic is acetaminophen (Tylenol), at least as long as you stay below the max recommended daily dose; acetaminophen isn't an NSAID, so it doesn't mess with inflammation at all.

Again, great read, thanks for sharing!

Dave MacLeod said...
This comment has been removed by the author.
Dave MacLeod said...

Brian, This is a 5 year old article and now superseded by a more up to date and extensive discussion in Make or Break. You may be broadly right about NSAIDs although that debate is far from over and it remains a possibility that very limited and short term use of NSAIDs in specific situations may be useful situations, especially where an error in rehab results in excessive inflammation. I do not use it myself, but it's important to be clear that the research is as yet far from conclusive that it should not be used in any circumstance.

Unknown said...

Fair enough---I didn't mean to imply there are never appropriate situations for NSAID use, only that for most people, most of the time a better choice is acetaminophen---especially if they are treating their injury outside the supervision of a medical professional. I realized [before commenting] this is an old article and that your new book likely contained a more up-to-date and extensive discussion, I just figured I would mention it here since your web article is still well-frequented and likely a common source of advice for injured climbers.

No need to publish this comment if you don't want; I couldn't find a way to privately contact you via Blogger and figured this would be the most effective way!

Dave MacLeod said...

Sure thing - and thanks for commenting. It's so critical that people understand the complex and case-specific using the treatments on offer. That was one of the reasons Make or Break became such a big book!

Unknown said...

Hey Dave,

I've had pain and a possible tear of my A1 pulleys of my ring finger on both hands. One healed up with a ganglion formation on the injury, and the other I just recently injured. Not crimping, not losing footing and holding on by my fingertips.... Just climbing in the gym. A twinge and then pain at the touch in the area below my second knuckle. Any idea why I might be doing this, and any ideas about how to best treat? I'm way more interested in prevention, and will follow the advice on this blog, but I'd like to not blow out all my tendons...


Dave MacLeod said...

Have you read Make or Break Alison? The information in that is very extensive for both prevention and treatment.