4 May 2010

New look site!

As you can see the site looks rather different. I’ve just spent a good while reorganising and redesigning it. Hopefully it should all be a bit more user friendly now. But I’m eager to hear your feedback. If you like or dislike anything or find any problems I should know about. Please do leave me a comment. I don’t get much time to go through everything with my site very often so sometimes I don’t always spot problems. Thanks for your help!
Apart from the structural and style changes to the site I’ve substantially reorganised my shop, adding more products and shopping in the Euro and US dollar currencies for those whom that will help. These days you are ordering your training books and DVDs from all over the planet. Thanks so much for the support of our shop - it really helps us.
Below I’ve re-posted some really old extended articles I wrote on research and finger injuries that used to live in a different place on my old site. Sorry if you’ve seen them before. I just didn’t want them to disappear altogether.
Now that I’m (hopefully) over the task of site redesign, I can get back to writing posts…

For those into a few sports

Been talking to Tim Emmett over the past couple of days and sharing ideas about training when you are into a lot of different sports. The same points apply if you work a lot and generally have limited time to climb. If routes are ‘your thing’, you’ll want to do mostly routes in your limited time of going climbing. And if you have any time in the year when you’ll be training indoors, it’s likely that endurance will be an immediate high priority. 
This presents a problem for longer term development of strength to move to the next level in climbing. There simply isn’t enough time in the year spent pulling super hard on small holds to get really strong fingers. As always, there are workarounds and they are basic stuff when it comes down to it:
1 - Use brief fingerboard sessions to effectively ‘concentrate’ the strength training into the most time efficient hit. Think of it as the ‘espresso’ of finger strength training. You can get away with it because your time on the routes is keeping your technique sharp. For example, if you are an expedition climber, hang that wee fingerboard rung you packed at basecamp and camp near those lovely granite boulders.
2 - When you do find yourself with enough time to get some bouldering in between routes sessions, you really need to make the most of that time. If you are frequently visiting unfamiliar climbing walls/crags. It’s easy to waste precious time finding the good problems at the right intensity or making some up. Try extra hard to eliminate this by tagging onto locals who can show you what’s what. Don’t be shy, they really wont bite. And if they sandbag you, so what? You wanted a hard session didn’t you. Try not to be put off when you can’t complete many problems. It’s normal if its an unfamiliar situation. Just try hard and you’ve done well.

A review of strength and endurance in climbing

NB: This article used to live in the articles section of my old site. I’ve reposted it here since it was really popular. Note that it’s nearly ten years old now! 
Background
Sport climbing is the branch of rock climbing involving routes protected by pre-placed anchor bolts. The explosion in popularity of sport climbing and organised competitions have prompted a significant rise in participation and standards in recent decades. The focus of this new discipline is the athletic and competitive aspects of movement on rock (Jones, 1991). Coupled with this has been the development of structured and sport specific training techniques among professional and amateur climbers alike (Goddard and Neumann, 1993; Morstad, 2000). Climbing is a physical activity involving repeated movements of the body against gravity by producing forces on the holds on the wall surface via the upper and lower limbs. A considerable movement technique and psychological performance element is also universally recognised in the climbing related literature. The rise in participation, training and organised competitions in climbing and well documented increases in the occurrence of climbing related soft tissue injuries underlines the importance of research which evaluates the physiology of climbing.
The aim of this review is to critically evaluate the current literature concerning the physiological demands and determinants of performance in sport climbing. Particular focus will be given to the forearm, specifically the finger flexors, and the physiological characteristics and adaptations occurring in trained climbers, which confer increased forearm strength and endurance. Future research objectives will also be outlined within this specific area.
Physiological demands of climbing
Rock climbing involves moving over the wall surface supported by four limbs, described by Quaine et al. (1997) as “vertical quadrupedia” (Fig. 1). Early attempts by climbers to identify key aspects of performance on which to focus their training recognised that the centre of acute fatigue during climbing lay invariably in the upper limbs, especially the forearms (Hurn and Ingle, 1988; Goddard and Neumann, 1993). It was observed that in general, the difficulty of the climbing becomes greater when the wall angle becomes steeper and the holds (particularly handholds) become smaller and further apart. The apparent limitation of the forearm in climbing makes physiological sense given its comparatively small muscle mass, not anatomically designed to support forces comparable with body mass (or exceeding it to produce accelerations against gravity). Morstad (2000) (citing unpublished quantitative analyses) argued that even at wall angles 45 degrees beyond vertical, where the lower limb cannot support much of the body mass in the vertical direction, successful movements must be initiated using the lower limb and trunk in order to reduce peak forces required at the hand holds. Although there are few reports in the climbing related literature of significant lower body fatigue, there is anecdotal evidence that lower limb strength is an advantage on certain types of moves, particularly to maintain contact on the footholds on very overhanging rock (Morstad, 2000). 
Unfortunately, no studies have examined lower limb or core strength in trained climbers.
Bouts of sport climbing last for several minutes with sustained periods of intermittent isometric contraction in the finger flexors. Schadle-Schardt (1998) observed mean climbing times of 4.5 minutes during indoor competition climbing. Thus, sport rock climbing must be considered an endurance event. Few studies have attempted to analyse the movement patterns associated with climbing. Billat et al. (1995) observed that upward movement during indoor climbing occurs intermittently. Video analysis revealed that 63% of the total climbing time was spent ascending (vertical displacement of the hips) and 37% was spent maintaining an ‘immobilized’ position (static equilibrium). In climbing, static equilibrium must be maintained at certain times in order to clip the rope into protection bolts, rest individual fatigued limbs and scan and reach for the next holds (Goddard and Neumann, 1993; Sagar, 2001). Schadle-Schardt (1998) measured mean contact times for the fingers on each hold in competition climbing of 10 seconds with 2.4 second rest periods in between holds (presumably spent reaching the next hold and replacing chalk on the hands).
The angle of the wall surface has been shown to be an important influence on the physiological demand placed on the body due to climbing. Noé et al. (2001) examined the biomechanical constraints of static climbing positions at different angles (vertical and 10 degrees overhanging). When vertical and overhanging quadrupedia were compared there was a large shift in the distribution of the supporting forces to the upper limbs, from 43% to 62% of body weight supported by the upper limbs in the vertical and overhanging positions respectively. Given that rock climbs can feature angles of up to 90 degrees beyond vertical, this magnitude of shift appears remarkable and certainly explains the physiological findings (described below) of performance studies which showed much greater energy expenditure and lactate production with only small increases in angle beyond vertical (Watts et al., 1998).  Unfortunately this is the only study to compare supporting force distribution at different angles. Further studies examining a greater range of wall angles would give further insight into the dependence on the upper limbs for support at overhanging angles.
Finger flexor strength has been extensively measured in trained climbers by a number of studies. The conclusion of these studies appears to be that trained climbers have higher finger strength compared to controls, although methodological differences have provided varying results (Sheel, 2004). An early study by Watts et al. (1993) observed no differences in absolute values of hand-grip strength measured by hand-grip dynamometry in world class climbers and controls. It was suggested that climbers may not need high grip strength per se. Rather, strength to mass ratio was thought to be a more important variable and this was significantly higher in climbers (due to low body mass). Several later studies have measured hand-grip strength, some observing no differences in absolute forces between elite climbers and recreational or non-climbers (Ferguson and Brown, 1997; Watts et al., 2003) and others observing that climbers have higher grip strength (Bollen and Cutts, 1993; Grant et al., 1996, 2001). Grant et al. (1996) recognised that grip strength dynamometry might not provide an accurate assessment of the type of strength required in rock climbing, and developed a climbing specific device for measuring finger strength that simulated more closely the grip styles used on climbing holds (Schweizer, 2001) (Fig. 1, 2). All subsequent studies using this type of grip specific measurement have recorded higher finger strength in trained climbers (Grant et al., 1996, 2001, 2003; Quaine et al., 2003; MacLeod et al., unpublished data; Reid et al., unpublished data). Although climbing moves often involve hanging or moving underneath horizontally aligned finger edges, the types of moves and positions experienced in climbing are extremely varied and it seems likely that some may involve a force requirement greater than that needed to support the body in the vertical direction (such as using ‘undercut’ holds) (Goddard and Neumann, 1993; Sagar, 2001). This view would challenge Watts’ suggestion that climbers do not need to produce large absolute forces. Unfortunately no biomechanical analysis has been carried out on a range of climbing positions/movements to date, in order to determine the supporting force requirements of climbing positions.
Anthropometric characteristics of climbers
Several studies have measured anthropometric data in various populations of climbers. Watts et al. (1993) studied a highly homogenous group of climbers; semi-finalists in a sport climbing world cup event. This study observed that this group were characterised by low stature and very low percentage body fat values (4-14% for men, 10-20% for women).  This finding has been supported by several subsequent studies of trained climbers (Binney and Cochrane, 1999; MacLeod et al., unpublished data; Mermier et al., 2000; Sheel et al., 2003; Watts et al., 1996, 2000, 2003) and percentage body fat has been proposed as a key predictor of sport climbing performance. Grant et al. (1996, 2001, 2003) failed to observe any differences in percent body fat between trained climbers and controls or other athletic groups. However, the absence of significant differences might be attributable to the comparatively low ability of the climbers compared to the studies mentioned above and/or different equations used to estimate body fat percentage..
It is logical that a large body mass or any excess body fat would be disadvantageous in elite level climbing as body mass must be repeatedly moved against gravity. However, it is well known that climbers have long considered excess body fat to be a disadvantage and control it strictly. It is also considered advantageous to avoid hypertrophy training of lower body muscle groups. Hence, the question remains whether body mass and body fat percentage are important determinants of climbing performance or merely a feature of climber’s training patterns (Farrington, 1999). It is conceivable that any performance advantage conferred by maintaining very low body fat may be offset by problems with consumption of sufficient caloric energy to support a rigorous training regime. Longitudinal study of the effect of manipulation of percentage body fat on climbing performance would yield more meaningful data on the subject (Sheel, 2004). Low stature might be an advantage in climbing due to volume-mass ratios. However, any advantage may be offset to some degree by a reach limitation in shorter climbers (Sagar, 2001).
Reach is universally recognised as a common limitation on climbing moves among rock climbers. This has led to ‘ape Index’, a measure of reach relative to height, (arm span/height) being proposed as a performance predictor. Watts et al. (2003) measured ape index in adolescent competitive climbers and found small but significant differences relative to age matched controls. There was no relationship between climbing ability and ape index. Watts suggests this may be due to the lack of variability between climbers. Grant et al. (1996, 2001) found no differences between trained climbers and controls for leg or arm length. The significance of these findings is limited due to the small sample sizes and ability level of the climbing groups. It is not possible to make any conclusions about these variables from the available data.
Given that climbers perform repeated contractions of the forearm muscles and appear to possess greater finger strength than controls, it has been hypothesised that climbers will develop greater forearm muscle mass. Muscle force is highly correlated to muscle mass, whereas no consensus has been reached on whether force per unit muscle mass is influenced by training (Fukunaga et al., 2001). Only three studies have attempted to measure forearm muscle mass in trained climbers and controls. MacLeod et al. (unpublished data) measured forearm circumference is 12 elite climbers and found significantly higher forearm circumference to body mass ratios in climbers. The absence of significant differences in absolute values is explained by the difference in body mass between the subject groups. This finding agrees with those of Watts et al. (2003) who observed similar forearm volumes in competitive climbers and controls, despite the climber’s lower stature and body mass. Reid et al. (unpublished data) measured forearm circumference in height and body mass matched trained climbers and controls. Climbers had higher forearm circumference although the difference was not significant. Again, the low variability in this anthropometric measure calls for further study using larger subject groups and more sensitive methods of measurement.
Mermier et al. (2000) attempted to quantify the relative contributions of anthropometric variables (Height, mass, leg length, percentage body fat), hip flexibility and training variables (grip, shoulder and leg strength, grip and hang endurance, lower body anaerobic power) in a study of 44 trained climbers of varying standard. It was concluded that trainable variables were much more important predictors of climbing ability and that anthropometric and hip flexibility variables were very poor predictors of ability. It was concluded that climbers do no need to possess particular anthropometric characteristics to be successful sport climbers.
 
Flexibility
Body flexibility is another variable which is thought to be relevant in climbing performance as the ability to reach distant holds and maintain positions at extreme joint angles can provide a clear advantage on certain climbing moves (Goddard and Neumann, 1993; Sagar, 2001). Grant et al. (1996, 2001) measured hip flexibility in trained climbers and controls but observed no significant differences. However, issues with the standard of the climbing group discussed above may have affected the validity of the comparison. An intervention study into the effect of flexibility in competitive climbers would yield more useful information.
Fatigue factors in climbing
To successfully complete a sport route, climbers must maintain the ability to make high force, intermittent isometric contractions of the finger flexors. Indeed, competition routes are designed to have progressively more difficult individual movements (the purpose being to separate out climbers of different abilities). Failure to produce the required finger force, coupled with burning, stiff and painful sensations in the forearm (known as ‘pump’) are recognised as being the dominant symptom of fatigue associated with failure to complete a climb, resulting in a fall (Goddard and Neumann, 1993). Finger endurance has been identified as a key attribute of elite level climbers by several studies (Binney and Cochrane, 1999; Ferguson and Brown, 1997; MacLeod et al., unpublished data; Quaine et al., 2003; Reid et al., unpublished data).  Grant et al. (2003) demonstrated that intermediate level climbers do not differ from other athletic groups with respect to finger endurance.
The intermittent isometric contractions seen in climbing are unusual in sport generally (Spurway, 1999). The nature of isometric exercise has several important consequences for the development of muscular fatigue with repeated contractions. Asmussen (1981) characterised this type of contraction as causing significant increases in intramuscular pressure. This change causes blood to be squeezed out of intramuscular blood vessels and hinders or even completely stops blood flow through the muscle. Blood flow can only resume when the contraction ends. The magnitude of increases in intramuscular pressure, and hence blood flow occlusion, is dependent on the intensity (that is, the percentage of MVC) of the contraction. It is thought that contractions below 10-25% of MVC receive adequate blood flow and can be maintained without muscle fatigue (Asmussen, 1981). Above 45-75% MVC, blood flow is completely occluded in the forearm and fatigue patterns mimic those where artificial occlusion is present (Barnes, 1980; Heyward, 1980; Serfass et al., 1979). Between these values, blood flow is reduced and fatigue occurs, but at a slower rate. There is considerable variability in the extent of occlusion in a given subject and muscle due to the following factors: the prevalent muscle fibre type, the size and structure of the muscle. MacLeod et al. (unpublished data) measured finger endurance using a climbing specific protocol (a ‘crimp’ grip with 10/3sec contraction/relaxation ratio) in trained climbers and controls. The intensity was 40% MVC and times to failure in the climbers were similar to the total climbing times observed in a world cup climbing event (Schadle-Schardt, 1998). The authors suggested that 40% MVC may be representative of the average MVC percentage required from the finger flexors in climbing.
Carlson and McGraw (1971) observed lower isometric endurance in subjects with higher MVC and hypothesised a negative relationship between these variables. Based on these findings, it would be anticipated that the climbers would have shorter endurance times as they exhibit higher MVCs than non-climbers. The literature has demonstrated that this is not the case and it is thought that adaptations present in trained climbers appear to offset any disadvantage due to higher force production (MacLeod et al., unpublished data). Quaine et al. (2003) demonstrated that muscle fatigue, measured by the decline in median frequency of surface electromyogram (EMG) in the active forearm muscles, in a climbing specific finger endurance task was delayed in elite climbers compared to non-climbers. The rate of fatigue in climbers was twice as slow as controls at 80% MVC. The authors concluded that this delay was due to climber’s enhanced ability to recover between contractions, speculating that enhanced vasodilation during rest periods accounted for the climber’s advantage. Reid et al. (unpublished data) also observed EMG fatigue using a similar protocol to MacLeod et al.. Trained climbers and controls had similar times to fatigue and decline in EMG median frequency. However, the climbing group had higher MVC and hence produced significantly higher force for a given test period. Watts et al. (1996) measured maximum hand-grip force before and immediately after a climbing task to exhaustion. Hand-grip MVC decreased 22% after the climbing task and remained depressed for 20 minutes post-exercise. However, later work by Watts et al. (2000, 2003b), which also measured maximum hand-grip and finger strength before and after a fatiguing climbing task showed no drop in ability to exert maximum force. Watts et al. (2003b) showed no change in root mean squared EMG values pre and post climb. However, change in median frequency was not measured. It seems possible that the results of Watts et al. (1996, 2000, 2003b) may be affected by the delay in measuring MVC after the climbing bout ended. It is noted that the measurements were taken within one minute of failure on the climb. However, Quaine et al. (2003) points out that the difference in endurance capacity between climbers and non climbers is due to an ability to recover significantly in the short (5 seconds in this case) rest periods between contractions. Future study employing continuous EMG data during a climbing or climbing specific task is required to fully establish whether loss of finger strength occurs during strenuous climbing.
MacLeod et al. (unpublished data) pointed out that loss of fine muscular control may be an additional causative factor for failure to complete a climbing task. Climbing movements require precise timing of force development, as well as extremely rapid and complex movements of the body. Indeed, it is often necessary to lunge for handholds which require precise placement of the fingers in the most advantageous position on the hold to provide adequate support (Goddard and Neumann, 1993; Sagar, 2001). It seems plausible that falls could be caused even by small decrements in force production on such precise holds, or by loss of coordination due to the effects of muscle fatigue on muscular control. Bourdin et al. (1998, 1999) observed a hierarchical organisation of reaching movements between climbing holds (measured on a climbing ergometer). It was noted that reaching duration was shortened by increased postural constraints, regardless of the destination hold size (and therefore accuracy requirements). This factor appeared to override the speed/accuracy trade-off seen with seated or standing reaching movements. Postural constraints are greater in vertical than overhanging climbing, however, overhanging positions are characterised by greater force requirements from the fingers to support body weight (Noé et al., 2001). It seems plausible that this factor would produce an additional demand for shorter reaching durations. This hypothesis has anecdotal support in the climbing literature (Morstad, 2000). Future studies using a similar protocol to that of Bourdin et al., comparing the organisation of reaching and grasping movements at different wall angles would help resolve this question. Such a study has not been undertaken to date.
Physiological responses and adaptations to climbing
Climbing involves whole body movement against gravity for sustained periods. It appears that the upper body is the primary centre of fatigue in climbing, but the role of the lower body in climbing movements has yet to be quantified (Sheel, 2004). Several studies have measured whole body VO2 during climbing on an indoor wall or climbing treadmill. These studies have shown that VO2 rises during climbing to a moderate proportion of running VO2 max (Billat et al., 1995; Watts et al, 2000). VO2 values are markedly variable between studies, but this can be explained by differences in testing protocol and subject groups. It appears that average VO2 during difficult sport climbing is about 25 ml.kg.-1 min-1 (Sheel, 2004). However, values of 43.8 ml.kg.-1 min-1 were recorded in a maximal treadmill climbing task to exhaustion (Booth et al., 1999). Sheel et al. (2003) showed that climbing VO2 was related to climbing difficulty, with VO2 values reaching 45% and 51% of cycle ergometer VO2max for an ‘easier’ and ‘harder’ climb respectively. However, Watts et al. (1998) observed no increases in climbing treadmill VO2 as treadmill angle increased (four minute climbing bouts at angles between 80 and 102 degrees). It is suggested that arm specific peak VO2 may have been reached, rendering further increases impossible when climbing angle became steeper. In addition, the active muscles may be completely blocked from general circulation during contractions, limiting large increases in VO2 (Asmussen, 1981).
Several studies have measured blood lactate concentration after a climbing bout (Booth et al., 1999; Billat et al., 1995; Grant et al. 2003; Mermier et al., 1997; Watts, et al., 1996, 1998, 2000). The values for blood lactate following strenuous climbing range from 2.4 to 6.1 mmol/l. This large variation is likely to be attributable to different modes of climbing (wall, treadmill or simulated climbing), different subject groups and different intensities of the climbing bouts. Watts et al. (1998) demonstrated that lactate production is related to climbing angle. This finding is supported by Mermier et al. (1997) who observed that lactate production is related to climbing difficulty. Large increases in blood lactate may be surprising given that climbers report that muscular pain and fatigue lies predominantly in the forearm. The small muscle mass of the forearm would not be expected to produce large amounts of lactic acid. However, as mentioned above, the relative contributions of different muscle groups to movement on rock have not been quantified to date. Given that such increases in lactate are observed, and that blood flow may be partly or wholly occluded in the forearm during intermittent exercise at high intensities, it seems likely that lactate may accumulate to high concentrations within the forearm muscles during climbing. No studies have compared lactate production in elite and novice climbers in order to establish whether there is any adaptation in trained climbers which affects metabolite build up during climbing (see section below on blood flow). Grant et al. (2003) observed greater increases in blood lactate during a climbing specific forearm endurance task. It is possible that greater blood lactate could be an indicator of increased lactate clearance from the exercising forearm due to increased blood flow.
It has been suggested above that climber’s superior finger endurance may result from an increased ability to recover from isometric contractions. Ferguson and Brown (1997) measured forearm blood flow by venous occlusion plethysmography after intermittent isometric contractions of 40% MVC. Trained climbers had significantly higher vascular conductance following the exercise bout. The authors concluded that climbers demonstrate enhanced vasodilator capacity, which is attributed to adaptations of the local vascular bed, including increased capillary density, capillary cross-sectional area or alterations in local dilator function related to endothelial change (Delp, 1995; Smolander, 1994; Sinoway et al., 1986; Snell et al., 1987).  MacLeod et al. (unpublished data) monitored changes in forearm blood oxygenation continuously during a climbing specific endurance test using near infra-red spectroscopy (Fig. 3).  Oxyhaemoglobin levels in trained climbers were significantly lower during contraction phases (attributable to higher force production) than controls, but recovered to a significantly greater extent during 3 second rest phases. It was concluded that ability to restore forearm oxygenation (by increased blood flow) was an important predictor of success in an endurance test of this type.
The pressor response to isometric exercise has also been identified as a variable of interest. Isometric exercise causes increases in both systolic and diastolic blood pressure (BP) greater that would be expected for equivalent dynamic exercise, reaching a peak at the point of fatigue (Asmussen, 1981). The large increases are caused both by rises in intramuscular pressure, exceeding systolic pressure and blocking blood flow into the active muscles, and sympathetic vasoconstriction in other tissues in order to re-direct blood flow to working muscles. Increased sympathetic activity is triggered by the muscle metaboreflex and a central command component. Significant rises in systolic and diastolic BP have been observed during a climbing specific task (Ferguson and Brown, 1997; MacLeod et al., unpublished data). Increasing central arterial BP has been shown to enhance force production during isometric contraction (Wright et al., 2000). MacLeod et al. hypothesised that an increased pressor response would confer a performance advantage in the endurance tests by opposing occlusion caused by the muscular contraction, thus permitting increased intramuscular blood flow. No differences were found between BP responses for trained climbers and controls during a climbing specific task. Ferguson and Brown (1997) observed an attenuated BP response in trained climbers, an adaptation known to occur following endurance training. The authors hypothesised that the reduction in muscle sympathetic nerve activity could be caused either by reduced chemosensitivity in of the metaborecetptors or reduced build up of metabolites in trained individuals. The latter possibility would seem to be contradicted by the evidence of MacLeod et al. who found significantly lower muscle oxygenation during climbing specific contractions, and by those of Mermier et al. (1997) who found that lactate production is related to climbing difficulty. However, further study is required in this area to fully elucidate the responses and adaptations of pressor response in trained climbers.
It is concluded from the available data that sport climbing relies on both aerobic and anaerobic energy pathways. It seems likely that increased climbing difficulty and/or angle causes more reliance on the anaerobic system. Further research is required, examining both central and peripheral adaptations and responses to climbing, in order to fully understand the physiological determinants of climbing performance.
Summary
Current understanding of the mechanical and physiological demands of sport rock climbing has revealed that performance is dependent on a wide array of physiological, anthropometric, movement technique and psychological factors. The centre of physiological fatigue and performance limitation lies predominantly in the forearm musculature. It appears that successful sport climbers have developed greater finger strength and endurance than other populations. As climbing difficulty increases there may be increased reliance on the anaerobic system, particularly in the forearm, coupled with increased lactate production and blood pressure. Enhanced climbing specific endurance may be the result of an increased forearm vasodilatory capacity allowing better recovery from intense contractions of the finger flexors.
Future research objectives have been noted in the text. Much of the research to date has focused on comparison between trained climbers and controls and is descriptive in nature. It seems likely that the results of several studies seeking to establish their physical characteristics have been weakened by problems with availability of subjects of appropriate training status (Sheel, 2004). The diverse nature of the sport of climbing, with its many disciplines compounds this problem. Future studies of this nature should seek to recruit subjects who participate in similar patterns of climbing activity, for example sport climbing competition teams.
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Watts, P. B., Daggett, M., Gallagher, P. and Wilkins, B. (2000). Metabolic response during sport rock climbing and effects of active versus passive recovery. International Journal of Sports Medicine, 21, 185-190.
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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!

A2 pulley injuries review re-posted

Disruption of finger flexor pulleys in rock climbers: prevalence, diagnosis and strategies for rehabilitation.
NB: This article was formerly in the articles section of my old website. It was really popular so I’ve reposted it here.
Background
The sport of rock climbing has developed into a mainstream, competitive sport with considerable popularity. This growth is likely to be partly attributable to the virtual elimination of the significant danger aspect in rock climbing, within the disciplines of sport climbing (routes protected by pre-placed anchor bolts) and indoor climbing. In addition, the explosion in numbers of indoor climbing centres and organised competitions in most cities in Europe and the U.S. have prompted a significant rise in participation. The focus of these new disciplines is the gymnastic, athletic and competitive aspects of movement on rock (Jones 1991).
The history of structured and specific training patterns in rock climbing spans only the past few decades (Morstad 2000). Today, considerable sport specific literature together with increased availability of climbing facilities has fuelled a dramatic rise in standards throughout the sport, such that its basic biomechanical demands have changed and continue to change. Today’s hardest rock climbs feature angles up to and beyond 45 degrees beyond vertical (Goddard & Neumann 1993). On such overhanging terrain, the legs cannot support much of the body mass in the vertical direction; they can only push the body along the plane of the surface (Fig 1). As the angle increases, the forces exerted shift increasingly to the smaller muscles of the upper limbs. This area is also the focus of rock climber’s training regimes with exercises such as ‘deadhanging’ (isometric hangs from fingertip edges) and ‘campus boarding’ (a form of training based on plyometrics which involves jumping between fingertip sized rungs on a wall) (Goddard & Neumann 1993; Morstad 2000). The forearm, specifically the finger flexors have been identified by several studies as the most significant centre of muscular fatigue during rock climbing (Watts 1998). 
Figure 1. Elite level climbing places high demands on the fingers.
In climbing movements, the fingers produce tension on a hold to support a proportion of the body mass while the elbow and shoulder joints flex to pull the body upward. The isometric contraction of the finger flexors is interrupted when reaching towards the next hold. Finger flexor strength has been shown to be a determinant of performance in rock climbing (Bollen & Cutts 1993; Grant et al 1996). 
Holds used by climbers, even at a recreational level are remarkably small (often less than 10mm deep) and can often accommodate only 1-4 digits (Bollen 1990). Several different grip styles can be used to maximise the force produced on holds (Goddard & Neumann 1993). Bollen identified one style in particular, known as “crimping” which is of particular relevance to injury patterns among climbers. It is thought that over 90% of climbers use this grip style regularly (Bollen 1988). Crimping involves placing the fingertips on the hold with the distal interphalangeal joint (DIP) held extended while the proximal interphalangeal joint (PIP) and the metacarpophalangeal joint are held flexed. 
An early study investigating common rock climbing injuries reported that the hand and wrist was the commonest site of climbing related injury (Bollen 1988). Incidence of pain, sometimes accompanied by swelling on the volar aspect of rock climber’s fingers, often centred near the PIP joint was a common complaint (Bannister & Foster 1986; Bollen 1998). Bollen hypothesized that the site of such injury might be the flexor pulley system. The purpose of the flexor pulleys is to maintain the position of the flexor tendons, flexor digitorum superficialis (FDS) and flexor digitorum profundis (FDP) close to the phalanges. In a 1988 case study Bollen observed pain and swelling over the volar aspect of the proximal phalanx of the middle finger in a 20 year old rock climber. Avulsion of the FDS of FDP tendons was ruled out, as flexion against resistance was possible. There was visible and palpable ‘bowstringing’ (bulging of the flexor tendons away from the phalanges) at the PIP joint, pointing to rupture of one or more of the flexor pulleys. There is no mention of any confirmation by imaging of this diagnosis. The climber described the injury as occurring suddenly while holding onto a ‘pocket’ hold with only the middle and ring fingers. The climber’s feet slipped and caused sudden increased strain on the fingers, with immediate pain, swelling and subsequent bruising experienced locally on the affected finger. Bollen suggested that this type of injury was already well known among climbers and the study prompted a larger investigation of its prevalence. Pulley injuries among climbers had already been described in the French and German literature (rock climbing is particularly popular in both countries) as early as 1985 (Schweizer 2000).
Prevalence
Bollen & Gunson (1990) examined 67 world-class climbers at the first ever rock climbing indoor world cup event in 1989 for signs of current of previous hand injury. Flexor pulley injuries constituted by far the most common complaint, affecting 26% of the climbers, mainly affecting the ring finger. The injury was diagnosed by observation and palpation of flexor tendon bowstringing on resisted flexion compared to the same finger on the other hand. The injuries had occurred suddenly while falling or slipping while pulling maximally on a small hold, causing localised pain and varying degrees of swelling and bruising on the affected finger. Again, no imaging was used no attempts were made to classify the severity of the pulley injury. It was noted that the climbers considered firm taping with non-stretch zinc oxide tape around the affected part of the finger allowed continued training in the presence of injury and made the injury “feel better”. 
A more recent study (Wyatt et al 1996) reported one case of pulley injury in nineteen climbers presenting to a local A & E with a range of climbing related injuries. A comprehensive review of patterns of all types of rock climbing injury by Rooks (1997) suggested that 30% of all injuries are centred around the PIP joint and that such injuries are present in 50% of sport climbers. The study suggests possible PIP injuries comprise of flexor pulley tears, FDS insertion rupture or PIP collateral ligament strains. Rooks suggests that any of these injuries may progress to fixed flexion deformity or contracture of the PIP joint and athroses. Bollen & Gunson (1990) also found evidence of fixed flexion deformity in 24% of climbers as well as chronic PIP collateral ligament injury and two cases of FDS tenoperiositis. 
Rohrbough et al (2000) studied the prevalence of ‘overuse’ injuries in a group of elite climbers attending a national level climbing competition (n = 42). Collateral ligament injury at the PIP joint was most prevalent (40%) and only 1 competitor had no signs of upper extremity injury. Evidence of A2 pulley injury was present in 50% of the climbers. 26% of these showed evidence of bowstringing while a further 24% had pain over the A2 pulley but no clinical bowstringing. The authors suggest that A2 pulley injury where bowstringing is absent is the result of an isolated pulley rupture. Other finger injuries described included flexor tendon strains (referred to as Flexor unit strains) and tendon nodules. The authors note that most subjects who had consulted health professionals following their injuries reported a lack of appreciation by professionals for the demands of climbing on the body, and little help with diagnosis or treatment prescription. Gabl et al (1999) suggested that prevalence of flexor pulley injuries among recreational climbers (outside the professional competition circuit) might be far greater than the literature would suggest. Most case studies have been based on patients who present to medical practitioners with an injury. Gabl suggests that 60-70% of injured climbers do not seek medical attention. Both Gabl et al (1998) and Bollen & Gunson  (1990) sampled elite competitors at an international event. Clearly, this sample excludes those competitors who are in layoff due to injury.
The general finding from the studies described above is that PIP joint injuries among rock climbers are most prevalent on the middle and ring fingers. It is likely that this is because these fingers are most often used on ‘pocket’ holds, which can only accommodate two fingers. Other pathologies in this area, which have been described, include tenosynovitis (Bannister & Foster 1986) and abnormalities of the phalanges (Bollen & Wright 1994). The radiographic changes included formation of thickenings of the proximal phalangeal cortices at the attachment of the distal edge of the A2 flexor pulley.
Given the range of injuries experienced by rock climbers centring around the fingers and the PIP joint in particular, there is a clear need for application of detailed knowledge of the functional anatomy of the fingers in diagnosis of finger injuries. Furthermore, there needs to be an establishment of sound and thorough diagnostic techniques for climbing related injuries to ensure appropriate treatment is subsequently applied.
Functional anatomy of the flexor pulley system
The flexor tendon sheath of the fingers is a continuous connective tissue structure running from the metacarpophalangeal joint to the DIP joint. The transverse fibres of the palmar aponeurosis may also be considered part of the pulley system (Phillips et al 1996). The flexor pulley system is a series of thickened fibrous tunnels running across the flexor tendons that maintain and stabilise the position of the flexor tendons close to the phalanges during flexion (Martinoli et al 2000). There are five annular pulleys, A1-A5, positioned where the sheath is required to be stiff. Three cruciate pulleys, C1-C3, are aligned over the tendons where the sheath must flex. The continuous flexor sheath contains a synovial membrane that allows tendon gliding and assists (along with the vinculae tendinum) with tendon nutrition.
The A1 pulley is situated anteriorly to the metacarpophalangeal joint capsule. The A2 pulley lies over the proximal phalanx. This pulley is the longest pulley and has a well-developed distal free edge containing synovial fluid. A2 is considered the most important pulley as flexor pulley system function is most affected by excision of this pulley. There are well-defined ridges on the proximal phalanx where the A2 pulley attaches, particularly at the distal edge. These attachments can become thickened in climbers as age advances (Bollen & Wright 1994). A1 and A2 must absorb bowstringing forces from both the FDS and FDP flexor tendons. The A3 is a narrow pulley overlying the PIP joint capsule. The A4 pulley, again slightly longer than the joint pulleys, lies over the centre of the middle phalanx. The smaller and only recently described A5 pulley lies over the DIP joint (Phillips et al 1996). During flexion, the cruciate fibres become more transversely aligned and the edges of the annular pulleys draw together to become a continuous fibrous tunnel. The length of each pulley varies with the length of the digit and thickness varies with the relative length of the pulley.
The mechanical advantage or moment arm of the flexor tendons depends on the perpendicular distance between the joint and tendon. The flexor pulley system effectively reduces the moment arm of the tendons over the finger joints by keeping them very closely apposed to the phalanges. By doing this, the tendon excursion required to provide a given range of joint flexion is greatly reduced. The pulley system permits 180 degrees of angular motion across the PIP and DIP joints for 2.5 cm of tendon excursion (Rispler et al 1996). This function is important and makes physiological sense as muscles are capable of producing extremely large forces but incapable of shortening many times their own length (Hunter et al 1984). Thus, an intact pulley system is considered essential for normal hand function and pulley ruptures are regularly treated by surgical reconstruction (Lin et al 1990). Sectioning of the A2 and A4 pulleys results in a need for 30% greater tendon excursion to obtain an equivalent PIP joint flexion (Le Viet et al 1996).
In addition to its importance in maintenance of appropriate lever arms, an intact pulley system, through its effects on tendon excursion, is essential for flexor tendon function and health. The flexor tendons of the hand do not ‘glide’ as such through the synovial and fibro-osseous sheath. The tendons are attached to the paratenon that surrounds it (Hunter et al 1984). This relatively elastic tissue is relaxed during the mid-point of tendon motion. When the fingers are more flexed or extended, thus the peritendinous structures are stretched. This stretching uses energy and has been recognised as an important factor in tendon transfer. Furthermore, abnormal patterns of tendon excursion (the result of pulley malfunction) cause the phenomenon of ‘creep’, where the surrounding structures become permanently stretched. This effect causes an inflammatory reaction that eventually results in additional fibrous tissue deposits. It has also been shown that fibrous tissue deposits form under the bowstringing flexor tendons in the presence of pulley tears. Both these phenomena lead to flexion contracture, a condition that has been described in rock climbers suffering from pulley injury.
Strength and efficiency of the flexor pulley system
The pulley system of the middle finger is the strongest of the digits, followed by the index, ring and little fingers (Bowers et al 1994; Marco et al 1998). The strengths of the individual pulleys have been extensively studied with varying results (depending on testing protocol), as have the effects of pulley excision. 
Pulley excision or rupture causes varying degrees of loss of flexion, depending on the extent and position of the pulley rupture. Tropet et al (1990) noted that in a rock climber diagnosed with A2 pulley rupture, active flexion of the PIP joint was impossible. Yet when the affected finger was gripped anteroposteriorly by the examiner, flexion became possible once more. Lin et al (1990) studied the mechanical properties of the pulleys in cadaveric specimens. They found that the maximum breaking strength (Newtons/mm pulley length) were similar for the annular pulleys. However, due to the different lengths of the pulleys, the maximum breaking loads differed significantly. A2 was strongest (407 N) followed by A1 and A4 (209 N). A3, A5 and the cruciate pulleys had much lower breaking loads (<100 N). Load deformation curves were also produced, showing that A2 and A4 tend to be stiffer and less deformable than the other pulleys. An important conclusion from this study was that surgical reconstruction of pulleys should pay attention to pulley position, thickness and length. When pulleys were reconstructed using a ‘belt loop’ technique, near normal breaking strengths could be achieved. Bollen (1990) suggested that the force produced on the pulleys by a 70 Kg man supporting his body mass through one finger using a ‘crimp’ grip would be sufficient to exceed the breaking strengths reported by Lin et al. A similar study (Marco et al 1998) suggested that such an estimate may be an underestimation and the forces produced by supporting body weight may be three times as great as the breaking strengths recorded for pulleys in their cadaveric specimens. However, it is recognised by Marco et al that he age and fragility of the specimens may have adversely affected pulley strength. 
Marco et al replicated a ‘crimp’ grip and measured breaking strengths of the pulleys with the hand and flexor system essentially intact. The flexor tendons were attached to a loading device and force was applied until failure of all the pulleys and ultimately avulsion of the flexor tendons. With this grip, a distinctive pattern of failure was observed in most cases. A4 ruptured first, followed by A3, A2 and finally the FDS and FDP tendons. A1 did not rupture in any of the 21 fingers tested. Breaking loads were significantly lower that of Lin et al. Lin et al used specifically designed hooks to load the pulleys evenly. In vivo, the forces on the pulleys during ‘crimping’ may be unevenly distributed, creating a ‘cheesewire’ tearing effect. Marco et al suggest that the absence of skin on the volar aspect of the specimens may have reduced the breaking loads observed. These authors also observed that once pulleys A2-A4 had ruptured, the direct transfer of bowstringing force of the FDP tendon of the overlying FDS tendon caused avulsion of FDS. This finding has clinical significance, demonstrating the need for prudent management of pulley injuries in order to prevent the more serious complication of tendon avulsion.
Bowers et al suggested that occurrence pulley rupture in vivo is dependent on the degree of flexion of the finger. They suggest that the correct conditions for pulley injury are created when a sudden additional force is applied while the pulleys are already loaded and the finger is flexed to a high degree. In their case study of nine patients with pulley rupture, the A2 pulley ruptured first. Again A1 ruptures were not observed. Several other case studies have suggested that A2 pulley rupture is the most common injury among climbers (Cartier et al 1985; Tropet et al 1990; Moutet et al 1993; Gabl et al 1998). Many of these studies used evidence of clinical bowstringing across the PIP joint as the main diagnostic indicator of A2 injury. However, Marco et al observed that pulley ruptures rarely occurred as isolated events and that clinical bowstringing was only evident after A2-A4 had ruptured, a finding supported by 16 case studies by Martinoli et al (2000). Le Viet et al (1996) observed both isolated A2 and A4 ruptures as well as combined injury to the pulleys in seven patients.
Rispler et al (1996) identified a need to detail the efficiency of each flexor pulley in order to determine the functional importance of each. The rationale for this is that during reconstructive flexor tendon surgery, the surgeon must balance a need to preserve pulley function for reasons outlined above and allow sufficient access to the flexor tendons to allow repair and prevent postoperative adhesions forming. Rispler and co workers examined the effects of random pulley excision on a range of functional measures, using cadaver specimens. A5 sectioning produced no difference in tendon excursion efficiency or work (force produced by the flexed finger multiplied by excursion) efficiency, and was deemed expendable. Similarly, A1 sectioning had no impact on excursion and actually improved work efficiency of the flexor system. A2, A3 and A4 each made significant individual contributions to tendon function. However, A2 sectioning alone produced little reduction in work efficiency despite significantly affecting excursion. The authors concluded that A4 rather than A2 was the most important pulley, contradicting earlier findings. The authors recommend that reconstructive surgery should aim to preserve at least A2-A4 in order to protect normal functioning.
Diagnosis of pulley injury
The importance of accurate diagnosis for preventing further injury and preserving normal hand function has been clearly outlined above. Greater understanding among physicians of the nature and demands of rock climbing would benefit appreciation of the mechanism for pulley injuries. However, such injuries have also been documented in non climbers (Le Viet et al 1996). There are several methods of assessment of suspected pulley injuries available. In addition, there are some prevalence issues that are of note here.
Early studies used the appearance of clinical bowstringing as the main indicator of pulley tears. The appearance of bowstringing is clearly a simple and conclusive method of diagnosis at the initial examination of the patient. Depending on the extent of the injury (i.e. how many pulleys have ruptured), bowstringing may be apparent on the volar aspect of the proximal phalanx, PIP joint, distal phalanx or all three. Bowstringing maybe visible and palpable in the resting finger, but due to the weak pulley effect of the skin, palpation during resisted flexion should also be performed. Active flexion should be possible by the patient in the absence of tendinopathies, but range may be severely limited if several pulleys are damaged. In addition, late presentation by the patient may result in the development of fixed flexion contracture by mechanisms discussed above. Several studies have indicated that isolated pulley rupture may not produce sufficient bowstringing to be detectable either at examination or by a range of imaging techniques (see below). Thus, more information should be sought at examination. 
If the injury is fresh, there may be evidence of local swelling, tenderness and pain over the affected area. The patient should be questioned about this and the occurrence of the injury. Pulley ruptures commonly occur during ‘crimping’ manoeuvres during climbing, especially if there was a sudden additional loading due to a hand or foot slipping off a hold. Injuries are more common while climbing in cold weather of while warming up. Patients have also commonly experienced an audible ‘pop’ or ‘bang’ at the time of rupture, sometimes accompanied by pain and immediate swelling. However, these indicators do not necessarily occur in limited or partial pulley tears (Rohrbough et al 2000). 
Imaging has been used to detect clinical bowstringing and reinforce the findings of initial examination. Imaging is often expensive and may only be necessary when the findings of an examination are unclear. This may often be the case if pain and swelling interfere with the examination procedure. The merits of using various imaging modalities have been reviewed in the literature. MRI, CT and ultrasonography have all been used successfully to detect bowstringing. X-ray scanning is not helpful to pulley injury diagnoses unless injury to bony tissue is suspected (Bowers et al 1994). For example, x-ray may be required if avulsion of one of the flexor tendons at its insertion is suspected. Le Viet et al (1996) reported excellent results in visualising flexor tendon bowstringing using computed tomography (CT) scanning on a sagittal plane. Bowstringing was more obvious when the finger was scanned while flexed against resistance. The authors recommended this type of imaging as comparative examination of the opposite finger and use of flexion against resistance is possible. 
Gabl et al (1998) used MRI scanning on sagittal and coronal planes both to confirm diagnoses and measure a range of clinically relevant variables. The researchers were able to diagnose both complete isolated tears and partial pulley tears (of A2) using MRI. Such detailed information on the extent of the pulley damage was possible as the extent and position of the flexor tendon bowstringing was clearly visible. Patients with incomplete pulley tears were successfully treated with a non-operative treatment protocol. The main finding of the study was that bowstringing, observed at MRI that extends proximally as far as the base of the proximal phalanx should be treated with surgical reconstruction.
Given the expense and limited availability of MRI and CT scanning, more recent research has examined the effectiveness of ultrasound as a viable diagnostic tool for pulley injury. Klasuer et al (1999) recognised the potential of ultrasonography in this area as it can detect soft tissue anatomy and inflammatory changes. It was hypothesised that this type of imaging may be of particular use for finger injuries as the required penetration depth is low, allowing increased resolution with use of higher scanning frequencies. This study provided valuable information on the anatomy and pathophysiology of the pulley system. By comparing a group of 34 elite climbers who had recently experienced suspected pulley injury to age and sex matched controls several variables could be measured to establish patterns in health and disease. It was demonstrated that clinical bowstringing was completely absent even during resisted flexion in controls. This demonstrates the relative inelasticity of the pulley structures. 26 symptomatic fingers among the climbers demonstrated increased (0.14 cm) flexor tendon to phalanx distance. A further 3 demonstrated bowstringing of 0.31 cm with complete rupture of the A2 pulley confirmed by subsequent MRI scanning. This result points to a greater proportion of partial tears among climbers than previously recognised in the literature. The climbers also demonstrated increased flexor tendon thickness (0.56 cm) compared to controls (0.42 cm). In addition thickening of the A2 pulley was observed in the climbers (0.11cm) compared to controls (0.08 cm). Several other pathologies were observed on the climbers including tenosynovitis, cysts, and thickening of the PIP joint capsule. In addition tendon gliding function could be visualised in real time. Thus, Ultrasound is a highly attractive modality for the imaging of this type of injury. However, other studies have raised concern about the requirement for considerable skill in interpretation by the radiographer and the potential inter-observer variability. 
Another study (Martinoli et al 2000) compared the effectiveness of ultrasonography and MRI scanning in 16 injured elite rock climbers. Again, healthy fingers showed the flexor tendons aligned very close to the phalanges at ultrasound scanning. The pulleys were again visible as a hyperechoic line on the volar aspect of the tendons. Again, partial tearing of the A2 pulley was diagnosed by thickening of A2 in the absence of significant bowstringing. The diagnoses from MRI and ultrasound scanning correlated well. Ultrasound was recommended by the authors as a viable and inexpensive method of scanning finger injuries to achieve accurate diagnosis. 
Non-operative treatment protocols
There are two main protocols available to treat pulley tears, pulley reconstruction at surgery or conservative treatment with rest, splinting and NSAIDS. The factors influencing the decision of the practitioner as to which protocol to choose includes how old the injury is, success of previous conservative treatment, competitive level of the athlete being treated, the age of the patient and most importantly, the extent of the pulley damage. 
As discussed above, the prevalence of isolated partial tears among climbers may have been underestimated by the literature. Patients with partial tears, often of A2 are not thought to be at risk of fixed flexion contracture or flexor tendon avulsion (providing appropriate treatment and advice are given) and may even have been able to continue training with the injury (Bollen 1988). Thus, non-operative treatment is recommended in these cases (Gabl et al 1998). Some of the studies discussed above have used splinting of the injured finger followed by gradual progressive increases in use before resumption of previous levels of training. All studies have reported successful results and it is thought that the flexor pulley system repairs well compared to other connective tissue structures. However, Rohrbough et al (2000) indicates that there remains some disagreement between researchers as to the treatment of pulley tears. Tropet et al (1990) suggested that conservative repair may lead to a chronic weakness of flexion. However, there are numerous reports of successful return to top level climbing following pulley tears (Bollen 1990) and chronic bowstringing should theoretically translate to increased strength in the finger flexors by increasing mechanical advantage (at the expense of range of motion). The main components of non-operative treatment regimes are discussed below. 
If the injury is fresh, then a standard RICE procedure should be followed. However, many cases present several weeks or even months after the initial injury as normal daily life activities are not adversely affected by partial tears. There is little information available in the literature regarding splinting techniques. Techniques used for post-operative treatment are discussed below. Some literature has suggested layoff from climbing for up to 3 months. However it is well known that underuse results in sometimes severe degeneration of connective tissue structures as well as muscles (Kirkendall et al 1997). Hunter et al (1984) suggests that passive range of motion and gentle activity should be commenced after three weeks. Sandmeier & Renstrom (1997) conclude from a review of treatment principles in tendon disorders that exercise should be encouraged and will promote healing. It is added that resumption at a lower level of the athletes sport may cause frustration and over ambitious rates of progression, leading to re-injury. Thus, an alternative therapy such a squeezing a ball may be useful. However, while such therapy is useful in promoting healing in the injury, it does not prevent atrophy of other healthy tissues. These concerns are of particular relevance in rock climbing as very few athletes, even at world class levels have a coach to monitor and discipline the rehabilitation program. 
Given the fact that several different grips can be used in rock climbing, it should theoretically be possible to resume climbing as soon as the inflammatory phase is over. If the climber uses only an open handed grip (Goddard & Neumann 1993) where the DIP joint is flexed and the PIP joint remains at zero degrees of flexion. Using this grip, only the A5 pulley is required to resist a flexor tendon bowstringing effect, and injury to this has not been described in the literature. In the presence of pulley tears, bowstringing does not occur unless the PIP joint is flexed. Moreover, patients with pulley tears report that pain from the injury disappears when this grip is used for climbing (Schweizer 2000). However, such a protocol may be difficult and dangerous for the climber to undertake as the crimp grip is widely used and is likely to be habitual. It is plausible that finger exercises performed on a finger board with strict adherence to an open handed grip (routinely used in normal training patterns) may be a safer method of preventing atrophy of other tissues during rehabilitation and promoting psychological health of the injured athlete. There are no reports in the literature of the viability of this technique.
NSAIDS may be of use to control excessive inflammation where an injury becomes chronic. Indomethecin has been shown to increase tendon strength and collagen content (Kirkendall et al 1997). The rationale for using NSAIDS during rehabilitation of connective tissue areas is primarily to reduce inflammation, which is assumed will lead to a speeding up the healing process. A secondary objective is to reduce pain from the injury, either in the acute phase or later, to allow a resumption of the activity. Reviews of the use of NSAIDS in healing have reported unconvincing results (Sandmeier & Renstrom 1997). It is clear that the inflammatory phase is a vital stage in healing and mediates initiation of the later stages of repair. Gailey & Raya (2001) suggest that therapeutic interventions should not necessarily be aimed at eliminating inflammation, but rather “maximizing the conditions for connective tissue regeneration”.
Chronic inflammation and edema at the site of an injury may result in certain phagocyte cells with short lifespans to die and leak their enzyme contents into the injury site, thus damaging healthy tissue. In addition the high pressures caused by excessive edema reduce blood flow to the area. The enzymatic reactions involved in collagen synthesis are dependent on oxygen availability at the injury site (Anderson et al 2000). Under normal circumstances, the inflammatory stage of repair lasts only a week or so. After this period is completed, rehabilitation should focus on increasing blood flow to the injury and improving range of movement.
Stretching is recognised as an important promoter of formation of strong compacted scar tissue (Gailey & Raya 2001). Two types of finger flexor stretch have been detailed in climbing literature. These involve pulling the finger in the varus direction, effectively hyper extending the metacarpophlangeal joint and PIP joint (Gresham 1996). Deep friction massage (DFM) has been successfully used to treat ligament tears and promotes local hyperaemia, analgesia and reduction of adhesion formation. DFM is applied perpendicular to the direction of the fibres in the tissue being treated. The aim of this therapeutic modality is to separate fibres, mechanically assisting alignment in the appropriate direction. Flexor pulley fibres run in a transverse direction and it follows that massage should be longitudinal along the affected finger. Studies have shown that the effects of DFM are dependent on mechanical force. Heavy pressure must be applied to promote fibroblast proliferation.
A relatively poorly understood method of increasing local blood flow is ice massage. Ice is routinely used to reduce circulation, swelling and pain during the acute inflammatory phase. In this type of therapy (cryotherapy) significant cooling is applied to reduce the skin temperature to 12-15 Celsius. This results in vasoconstriction and resultant reduced blood flow. However, it has been observed that more gentle cold application to a small area around the injury has a somewhat different effect. The skin temperature should not fall below 15 Celsius. After a brief period of vasoconstriction, there is a large reactive hyperaemia. Lewis first described this reaction in the hands in 1930. The Lewis reaction is thought to be a tissue protective mechanism, but its function is not well understood (Lemons & Downey 2001). The reactive vasodilatation occurs after 30-40 minutes of cold application and when the hand is sufficiently warm once more, vasoconstriction occurs once more and the pattern continues in an oscillating fashion. Thus, the treatment should ideally last 30-40 minutes and should involve only moderate cooling. 
Circumferential taping of the injured pulley is widely and routinely used for both prevention and rehabilitation of pulley tears among rock climbers. Non stretch, zinc oxide tape of 1.3 cm width is used. Schweizer (2000) tested the effectiveness of pulley taping. The findings were that taping was minimally effective in relieving load from the A2 pulley. The effect was maximised (10% of bowstringing force) when the tape is positioned near the distal end of the proximal phalanx. The tape absorbed progressively less bowstringing force as the force produced at the fingertip increased. This result has two implications. Firstly, taping is likely to be most effective during the earlier stages of rehabilitation when the forces produced by the fingers are lower. Secondly, taping is unlikely to prevent pulley injuries, as these are likely to occur when forces on the pulley are maximal. This finding is supported by Warme & Brooks (2000) who showed that taping had no effect in preventing pulley ruptures in cadaveric specimens.
Surgical pulley reconstruction
There is disagreement in the literature about the requirement for surgical repair of pulleys. While it is clear that an intact pulley system is crucial to long term hand function, successful repair can occur with conservative treatment. Surgery if often carried out where there is complete rupture of more than one pulley. Various techniques have been used to repair pulleys. Where the ends of the pulley are intact, a simple end to end suture or Kapandji’s technique (Tropet et al 1990) has proven effective. Otherwise grafting from the FDS tendon or palmaris longus is generally performed (Hunter et al 1984). Repair of at least A2-A4 is necessary to retain normal function and prevent fixed flexion contracture. Ideally all pulleys should be repaired and A2 should be greater than 0.5 cm wide in order to adequately withstand bowstringing forces (Lin et al 1990). Studies have shown that correctly repaired pulleys can reach similar breaking loads to healthy pulleys. Patients are kept in a dorsal extension block plaster split for three weeks with the interphalangeal joints in extension. Passive motion exercises are commenced immediately after. 
Prevention
As discussed above, circumferential taping is of limited preventative value. Decreased reliance on the crimp grip, cautious use of holds which fit less than three digits, and a more controlled climbing style have all been recommended to avoid injury. (Goddard 1993). Attention should be paid to the feet as well as the hands as pulley tears often occur as a result of additional loading following the slip of a foot. Gradual progression in training load and thorough warm up and stretching procedures are also important (Gresham 1996). Warm up has been shown to improve the elastic properties of the flexor pulleys (Schweizer 2000). Diet is another factor influencing tissue health and thus predisposition to injury. O’Brien (1997) suggests that adequate supply of proteins, carbohydrate, vitamins and various minerals, particularly iron, manganese, copper and zinc are important for connective tissue turnover. 
Summary
The crimp grip used by 90% of rock climbers produces extremely high bowstringing forces from the finger flexor tendons on the digital annular pulley system. Partial tears of isolated pulleys or more significant rupture of several pulleys at once are the most prevalent injury among climbers. Injury is most often found in the A2-A4 pulleys and these pulleys are essential for normal hand function. Bowstringing may be palpable at examination, allowing diagnosis of pulley injury. Various types of imaging will assist accurate diagnosis, especially if examination is not possible. If several pulleys are ruptured, surgical reconstruction is recommended. In less serious tears, non operative rehabilitation has been shown to be successful in restoring normal function and previous levels of sport performance. Rehabilitation should include several techniques for increasing blood flow to this relatively avascular tissue. Taping of the flexor pulleys is of benefit during the early stages of repair but is unlikely to prevent pulley injury.
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