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NB: This is an old article and is now superseded by the book I've written on climbing injuries.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.

Rest

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

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.

Drugs

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

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!