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.

References

Anderson, M. K., Hall, S. J., Martin, M. (2000) Sports injury management. 2nd ed. Lippincott Williams & Wilkins

Bannister, P., Foster, P. (1986) Upper limb injuries associated with rock climbing. Br. J. Sports Med. 20(2): 55

Bollen, S. R. (1988) Soft tissue injury in extreme rock climbers. Br. J. Sports Med. 22(4): 145-147

Bollen, S. R. (1990) Injury to the A2 pulley in rock climbers. J. Hand Surg. 15B: 268-270

Bollen, S. R., Gunson, C. K. (1990) Hand injuries in competition climbers. Br. J. Sports Med. 24(1): 16-18

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Chasing numbers versus breaking barriers

Peter commented on my last post:

“What about the fact that some (many? most?) climbers are in this game for the sheer fun of it?

It seems to me (from my bumbly-level vantage point) that chasing numbers is 99% drudgery, so many climbers naturally plateau at the point of maximum fun for least effort (however you define those two dimensions).

Tangentially, a few climbers I've known who've played the numbers game inevitably reach a performance plateau no matter how hard they work, and in a couple of cases that's been sufficiently demoralising that they've given the game away entirely.”

I started replying as a comment but thought it might be better as a whole point seeing as he raises such an important question.

Chasing numbers is 100% drudgery because numbers are meaningless. Improving at climbing is entirely different. Depending on how you go about it, it can be a source of endless and deep enjoyment and satisfaction, or it can be hellish.

It’s enjoyable and satisfying if you are oriented towards using all your skills to break the barriers and are good at measuring when you’ve broken them. It’s also enjoyable when you suddenly get an insight into how you have become stuck in your ways or limited in your ideas about how to improve. This is a constant battle (and hence enjoyment). Plateaus are not really frustrating because they are ever more challenging opportunities to play the next round of the improvement game. The early rounds, where all you have to do is show up as a young climber and your muscles get bigger are just the warm-ups. Once you hit your first plateau the game gets much more interesting and ultimately rewarding. More on this in the first chapter of my book.

It can be hellish if you think you are chasing improvement, but deep down you are really chasing numbers. You move from hollow victory to ever more hollow victory until you hit a plateau and realise at the bitter end your top number was no more satisfying than the first. That feeling would make any athlete throw in the towel.

What school can’t teach you about climbing hard

I just did some interviews about my climbing for various publications. The questions, in one way or another, ask “what is your secret”? It’s especially relevant in my case as I can’t answer that I’m naturally strong, or thin or talented or started climbing before I could walk.

I’ve given roundabout answers for years, not understanding the underlying theme myself. In parallel I’ve tried to understand why climbers I’ve coached plateau where they do with apparently all the practical ingredients to keep improving.

Recently I’ve thought and talked a lot about school and it’s effects down the line. Sad as it makes me to say it, I learned my ‘secret’ to doing what I have when I was away from school, which happened a lot.  A lot of school is about explicitly or implicitly working to fit in. To attain the satisfactory standard of your peers and nothing more. The minimum necessary to get an A and then you can coast. But good performance is by definition not fitting in. You won’t find the solution to the technique, motivation, training, financial, practical or unexplained problem that’s holding you back, by waiting for your teachers or peers or someone on a forum to tell you.

I’m not saying they are useless - they are essential for pointing you in the right direction and supplying the initial shove. After that you roll to a stop pretty quickly unless you start producing your own momentum.

Fifteen years of learning to wait to be told what to do and put in the minimum amount of work is really hard to unlearn. Start now!

Examples of climbers doing what others were not:

Jerry Moffatt’s generation were all shy about wanting to really go for it and be truly competitive. Instead, Jerry set his sights publicly on the next horizon even though his ambitiousness stood out to onlookers as brashness.

Patxi Usobiaga understood that there was room to make training for competition climbing more scientific for someone with the will to do or access the necessary learning. His competitors were too busy just showing up at the wall to be bothered with this extra effort.

Adam Ondra probably clocked up more metres of limestone climbed by the time he was five that you have in your whole climbing career. Watching him, you might mistake him for a speed climber. Could you climb as fast as that without messing up?

So if this idea helped me, how? Two examples:

A lot of climbers will try one climb for a few tries, maybe even several days of tries. I got used to this early, because I was rubbish at climbing. So used to it, I thought, why not try not just a few more times, but a lot more times. At Dumbarton rock I tried single moves hundreds of times. Not just the same way every time. I experimented by changing one aspect of the movement each time and recording the results in my mind. After 15 years of this I became probably the weakest 8c+ climber you’ll ever meet. In training I apply the same principle - at the bouldering wall I concentrate during my rests on what happened during the last attempt and what the plan is for the next. This is why I don’t get bored training on my own.

I needed to be able to understand training to be able to adapt the advice written in training books with less error. So I studied it for 6 years at university. This was the shortest way to getting the answers I needed - the shortcut! The long way round is to stumble around with trial and error and poor bits of advice forever. My good fortune was that I came to realise it was the shortcut.

One dimensional coaching, or self-coaching

More climbers these days are starting to take advice from coaches, or from mentors among their peers, either directly or in written form. Great! But while the organisation of climbing coaching is still somewhere between primitive and non-existent (depending where you are in the climbing or geographical world), there are some big problems.

You’ll have heard of the expression; “For the man holding a hammer, everything looks like a nail”. Be aware that the advice you receive from climbing coaches is much more related to the background of the coach than your needs!

It’s also of true of other fields such as law, medicine etc. See a physiotherapist and they’ll provide a therapeutic answer to your problem. See a pharmacist, they’ll prescribe some pills etc..

Climbing coaches based and schooled indoors are likely to offer you solutions involving things you can do in the climbing wall. Thats fine, but it might not be all you can do, by a long way.

Try harder?

Climbers I’ve coached are sometimes quite dramatically split on their ability to try hard. A lot of them can move well on the rock, have fingers of steel, but just can’t grit their teeth and fight their way through a crux.

A lot are at the opposite end of the scale, they take a deep breath every single time they step on the rock and get themselves ready to give everything all the way to the top/bitter end.

This has some good effects, acute and long term. The long term effects are that the delivery of a high level of muscular effort provides a stimulus to get strong. The acute effects are you sometimes hit a slap for a hold you otherwise wouldn't. But it’s not all good. 

Climbing isn’t sprinting. A continuous output of maximum workrate through the whole bout is the thing to do on the 100m track. In climbing, this causes as many problems as benefits. Application of force (effort) can only be done if your foot or hand is on the exact right spot of the right hold. And to get it there accurately you need to be quite calm.

So climbing hard is tough challenge of switching instantly between a mental state of calm decision making and feedback from the hands, feet and body position, and the explosive delivery of force during execution of the hard move.

Try hard, but only at the right moment.

Climbing for active rest

Some of you commented from my last post asking if you could use light climbing as active rest between hard climbing days, and how to judge the intensity. Yes you can do this, but there are some obvious pitfalls. The first is obviously if the ‘light’ climbing isn’t light enough. It’s more of a problem if you are sport climbing than any other discipline. The routes have to feel really quite easy, so at the end of the session you should probably feel fresher than at the start.

Climbers on short (1-2 week) sport climbing trips often tell themselves they’ll just have a light day as active rest so they can avoid having to discipline a boring full rest day while staying at a dream destination. Tough as it is in the short term, the full rest day often works out better down the line. Most climbers standard goes steadily downhill during trips as they  to more volume than they can handle and end up with hands and muscles so totally trashed they can hardly look at a route by the last day. So while on trip, when you are doing more climbing than you are generally accustomed to, full rest is often the best idea. But if you are climbing at home and especially if you know the active rest  climbs/circuits you want to do, you will be less tempted to overdo it, and you might actually help your recovery.

If you are bouldering for some reason it’s a little easier psychologically to discipline yourself to an easy session, just focusing on movement, and jumping off anytime you hit a hard move or get pumped. It’s also easier to fit a very short session in, just ‘swinging past’ the crag to nip up a handful of problems in 30 minutes and then leave before breakfast/lunch or on the way to something else. Adventurous trad is by far the easiest and best active rest day for climbers. It’s great fun, and it’s not hard to find routes that will still feel engaging without being physically challenging. If you are up to it, free-soloing on easy ground is a nice active rest day that's definitely not for everyone.

Don’t get hung up on which grade would be the correct intensity - it’s a guaranteed way to get the intensity wrong. Just focus on how you feel. If you feel like you are recovering and feeling fresher as the session goes on, you’ve got it right.

Serious resting

I have been reading many books recently in research for a book I am writing. Reading texts on different aspects of professional sport, and training science always makes me feel small. I understand a little more each time how amateur climbing training is compared to real athletes. One of the biggest areas climbers let themselves down is when it comes to resting.

The term ‘resting’, just like ‘training’ causes all sorts of problems in discussion about it’s optimisation, because it brings up a very limited idea of what it involves. So lets think about it by it’s proper and more descriptive term - restoration. When we think of resting between bouts of climbing/training, it conjures up ideas of forgetting about your sport for a bit and just doing something else. Often the something else contributes to rather than relieves the training stress. 

Restoration is a better word because it describes the true goal, which is restoration of the capacity to train. For most people, rest days involve going to work. Everyone has to. But for a lot of people, going to work involves psychological and/or physical stress of other types. Even though the stressors are of a completely different nature, they add to the total amount of stress the body must recover from. And the result is incomplete recovery from the training. Of course, you can’t always do that much about it. Fine - but most climbers don’t recognise that their ‘normal’ training becomes overtraining during times when life gets busy and stress gets overloaded.

And restoration is not just about rest. Training is by definition an exceptional use of the body. And in response the restoration must be of exceptional quality if you expect your body to put up with such abuse for years on end. The quality of the rest time can be increased in all sorts of ways. Good sleep and diet are just the basics. 

Light general exercise is a really useful way to accelerate the recovery from summative general stress. Massage, heat, stretching, are three of countless other therapies that add to the speed you can recover from overworking your body. 

Serious climbers with the time to do all this stuff don’t do it either out of laziness or just being constantly too focused on the training to concern themselves with the other half of the picture. Serious weekend warriors with busy lives don’t do it either, often because they think all that stuff is only for the elite who do enough hard training to warrant it. It’s a mistake though - busy recreational climbers at a low-medium level in climbing suffer from overuse injuries just as much as the elite. Why? Because the recovery state of these climbers is poor and there is not enough build up of training load over time.

Another problem is that young climbers have never felt the frustration of long term injuries, and there is no message from the body that the tissue damage has already started. Young climbers - I guarantee those of you still trying to climb hard in 10-15 years time will curse yourself for not thinking about this now.

Scarpa Instincts review

My sponsors Scarpa have several major new rockshoe models coming through this year. First up of these is the instinct slipper. Trying them on at the trade show in Germany, I thought Wow! They are super comfortable. In fact, excellent comfort is one of the biggest things I have to say about the slippers. The fit seems well designed with no nasty pressure points and my toes feel exceptionally comfortable yet still held firmly enough for good performance. Like the Stix before them please don’t be put off by the toe downturn which feels normal as soon as the boot starts to break in after an hour or so bouldering.

Performance - The shoes have an all new rubber which seems to perform well and the grab is excellent on steep ground. In fact, I’d say they were the best shoes I’ve climbed in for training on steep ground or indoor walls and have now become my staple climbing shoe for all training, indoor climbing or coaching. 

The only downside for me is the softness. My Scarpa colleague Andy Earl loves them for this very reason, and I guess it’s a matter of taste, but for long trad pitches or sport routes which aren’t so steep I do like 4mm rubber rather than the Instinct’s 2mm. 

So like most people now I wear my Instincts for all training/indoor for it’s grab on steep rock, sensitivity and unbeatable comfort. But for trad or big sport pitches I’ll still be in my beloved Stix until I get my hands on the first 4mm Vapour slippers when the stock arrives.

For indoor use I’d rate the Instincts 9/10. Lovers of stiff shoes might think 8/10 and lovers of soft shoes might think they are the best on the market. For trad/easier angled use it’s a 6/10 from me but then my feet seem to need that 4mm rubber or they get tired!

youtube of them in action on my board below:

Understanding how muscles adapt

Whenever I post on this blog about the nitty gritty of strength or endurance training regimens, many comments come back looking for a more detailed explanation. From my last post, in the comments we got into talking about training anaerobic endurance and effects of training generally on different muscle fibres.

This is where things get tricky because muscles and complex structures, and the adaptations they make to training are also fairly complex. Picking over the surface of some details and using this to make inferences about how to train is shaky ground. My general advice or those who want to understand training at a muscle physiology level rather than the simple prescriptive or principle based level that you’ll get from coaches and coaching books, is to read thoroughly through the anatomy and physiology of muscle. I’m not trying to be difficult here, but understanding training will always seem confusing with only partial knowledge of the physiological picture. Perhaps adding a good exercise physiology text to your pile of training books would be a good help and reference. Any of Ron Maughan’s books are excellent resources. His book Basic and applied sciences for sports medicine has a superbly clear chapter on muscle and it’s adaptations which by an old lecturer of mine Neil Spurway. Spurway’s writing on muscle, like his lectures, are a great pleasure to read!

But back to the nitty gritty. Reeve was commenting just then about anaerobic training, asking:

“What is the certain type of force which a muscle must be exposed to over months and years to develop (presumably) fast twitch fibres? And if I do anaerobic work, thus growing my intermediate fibres, what effect will I notice in my climbing? Will I feel stronger? Increase my muscle's capacity to handle lactic acid? Or just have bigger heavier guns?

Secondly, you state that recruitment will get poorer with endurance training. Is is possible to maintain it whilst endurance training (maybe by a few deadhangs at the start of each session, say)? I imagine (although this is purely specultation) that the body is capable of maintaining high levels of potential recruitment without having to use them all the time (I can deadhang then go to the fridge and hold an egg). Is there any truth to my speculation?”

High (near maximum) forces are needed to develop fast fibres. By high forces I mean hard boulder problems or hanging on a fingerboard with as much weight as you can hang on for less than 10 seconds or so. If you do anaerobic work, you’ll get better at that anaerobic work, and not much else. We come back to the specificity principle! Anaerobic work won’t make you stronger - the forces are too low. In fact recruitment is lowered to make the muscle more efficient at sustaining work over the length of sustained sport routes. Yes this work creates better tolerance of the chemical imbalances of hard anaerobic work in the muscle. Muscles won’t get dramatically larger.

As for maintenance of recruitment during anaerobic training - yes, some high force work mixed in is the thing to do to maintain it. One session a week bouldering while you are training a lot of endurance for a sport climbing trip would be a good example. A little fingerboard before your endurance sessions would have the same effect, but not as good.

Why not? Because ‘recruitment’ is not a simple attribute of a muscle that rises and falls. Lots of people think of it this way - simply the number of fibres the muscle can recruit for contraction. The reality is much more complicated. Recruitment composes of the number of fibres recruited, the frequency and firing pattern and timing of the firing, and the ability of the central nervous system to supply a strong enough stimulus. But we can understand it much more simply as the body ‘learning and remembering’ how to pull hard on holds. 

Endurance training in climbing is a constant reminder for the body teaching it to use the minimum of force. Hard bouldering is the exact opposite on the hardest moves. Using a fingerboard is great to stimulate the forearm muscles and remind the fast fibres to grow and be responsive. But it’s important to show the system some hard bouldering on a real climbing wall in order that the whole nervous system remembers how to pull hard.

Measuring gains

My last post and comments from them reminded me of a significant problem in training for climbing, or anything where you train component skills/strengths away from the competitive arena of the sport - measurement of gains. 

KT was just commenting noting good gains from training anaerobic endurance on a fingerboard - great! In my head my immediate question was - where was the gain measured? On the fingerboard? Or in the ‘real’ climbing? It made me realise that the significance of this question might not be immediately apparent.

If you train on a fingerboard for climbing, then gains measured on the fingerboard (personal bests on the exercises) give useful information that the training is working or not. However, if gains are happening on the fingerboard but not the ‘real’ climbing, then there is information about whether it’s been the right kind of training.

Naturally, It’s necessary to obsessively monitor both, and any other measure you can get your hands on. Measuring changes in performance variables in as many different situations as possible allows you to make many deductions and useful monitors about the effectiveness of the training choices and how well you are adapting to it.

Some important points linked to this:

The ultimate measure of training effectiveness is the final climbing performance, and this measures both the adaptation of the component skill being trained, and also how much it’s contributing overall. For example if you put a lot of time into improving raw finger strength on a fingerboard over a year or two, but climbing ability actually goes backwards (quite common) then maybe the time taken to achieve the strength gain has caused losses in far more influential areas. Maybe there is some information in there about your real weaknesses.

That said it’s easy to underestimate the value of basic strength or endurance gains from a basic strength exercise because it takes time to work it’s way into your climbing technique. In my book I discussed this effect - The body needs to ‘learn’ that it has the new strength and this only happens when you leave the hangboard and go back to performing for an extended period. An extended period means anything from a month to a year or more.

While you measure gains in one area, remember the ones you are neglecting are going backwards, not staying still. Take this into account when measuring effects in overall climbing performance. Similarly, if your training is improving several separate areas at once, as is normal, don’t be too quick to attribute gains to one possible cause, when it could be the other(s).

The common tendency is for sports people to only measure one or two components of their game - the ones they like training the most, and put all gains or losses in ability down to these.

- Climbers who use campus boards a lot tend to know their personal bests on a given board very well, even if they are climbing well but haven’t been campusing they go back on the board and when unable to touch a previous PB, feel they must have got weaker and their good climbing form must be down to other factors like technique etc. Not necessarily.  The specificity of basic strength exercises is not to be underestimated, and strength measured on one piece of apparatus is only truly a measure of strength on that apparatus, not strength generally.