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Finger Tendon Pulley Injury

Considering the incredible mechanical loading we place on our fingers when climbing, it should be no surprise that they are a most common site of injury. Unfortunately, these pesky finger injuries are often hard to assess precisely and in the early stages tend to be ignored. Many climbers rationalize that they can climb through one injured finger, since they have nine healthy fingers and can still manage to crank at a near-maximum level. Continued climbing on an injured finger, however, may increase the severity of the injury and double or triple (or more) the downtime needed to recover.

Understanding the most common injuries requires some knowledge of hand anatomy (see Figure below). To begin with, there are no muscles in the fingers. Flexion of the fingers and wrist is produced by the muscles of the forearm that originate from the medial (inside) elbow and terminate via long tendons that attach to the middle and end bone of each finger. These two long flexor tendons pass through a tunnel-like, synovia-lined tendon sheath that provides nourishment and lubrication. The flexor tendon and sheath are held close to the bone by five annular or “A” pulleys–as a conceptual model, visualize the whole system of the flexor tendon, sheath, and annular pulley as functioning like a brake cable on a bike.

injury-a2-finger-anatomy-1

Anatomy figures courtesy of Training for Climbing, by Eric J. Horst.

 

Tendon Pulley Injuries

The most common finger injuries experienced by climbers involve partial tears or complete ruptures of one or more of the flexor tendon annular pulleys. In many cases only a partial tear of a single pulley occurs; in more serious incidences, however, one or more pulleys may rupture entirely, resulting in visible bowstringing. The exact nature and extent of the injury is difficult to diagnose without use of magnetic resonance imaging or Dynamic Ultrasonography.

The A2 pulley is the most commonly injured of the five annular pulleys, and you can blame the common crimp grip as the main culprit. In using the crimp grip, near ninety-degree flexion of the middle finger joint produces tremendous force load on the A2 pulley. Injuries to the A2 pulley can range from microscopic to partial tears and, in the worst case, a complete rupture. Small partial tears are generally insidious, because they develop over the course of a few climbs, a few days of climbing, or even gradually during the course of a climbing season. Less frequent are acute ruptures that result during a maximum move on a tiny crimp hold or one-finger pocket. Some climbers report feeling or hearing a “pop”—a likely sign of a significant partial tear, although other injuries could also produce this sound effect.

Depending on the severity of an A2 pulley injury, pain and swelling at the base of the finger can range from slight to so debilitating that you can’t perform everyday tasks like picking up a jug of milk. Slight tears may be asymptomatic when the finger is at rest, but become painful during isometric contraction (as in gripping a hold) or when pressing on the base of the finger near the top of the palm.

injury-a2-finger-anatomy-2

Anatomy figures courtesy of Training for Climbing, by Eric J. Horst.

Treatment of an A2 pulley injury must begin with completed cessation of climbing and discontinuation of any other activity that requires forceful flexion of the injured finger. Doing anything that causes pain will slow healing of the injured tissue and it may even make the injury worse. Therefore, the intelligent climber will cease climbing at the very moment of the injury so that the healing process may begin and the time frame for healing is most brief. By contrast, the immature climber may try to climb through the injury, which certainly means a slower healing time and perhaps even a worsening of the injury.

 

The goal during the first few days following injury is to control inflammation (if present) with ice and non-steroidal anti-inflammatory medicines like ibuprofen or Aleve. Cease use of NSAIDs within three to five days, since long-term use has been shown to impede the healing process and may even weaken tendons. “Buddy taping” to an adjacent finger or splinting of the injured finger can be beneficial during the first few days following injury, especially if you find it hard to limit use of your injured finger. Obviously you must avoid any stressful finger training during the recovery period; however, it is beneficial to gradually introduce some basic activity that may aid in healing. Exercises such as pull-ups, reverse wrist curls, and squeezing a rubber donut or power-puddy are all good as long as they do not cause pain. Use of a heating pad, daily massage and mild stretching will also enhance blood flow and support the healing process.

 

Depending on the severity of the tear, pain typically subsides in two to ten weeks. Becoming pain-free, however is not the go-ahead to resume full-on climbing! This is where many climbers go wrong—they return to climbing too soon and reinjure the partially healed tissue. As a general rule, wait an additional two weeks beyond becoming pain-free, then slowly return to climbing. In the case of a modest A2 pulley injury, this may mean a total of about forty-five days of climbing downtime.

A French study of twelve elite climbers with A2 pulley injuries found that eight subjects were able to successfully return to climbing after forty-five days of rest. More severe pulley tears, however, may require as much as two or three months of rest before progressively returning to climbing. The bottom line on these frustrating pulley injuries is to nip them in the bud by immediately initiating a rest and healing period away from climbing. Each successive day you continue to climb on the injured finger may effectively multiply the length of the healing process (and your eventual time away from climbing).

In the case of a complete or multiple annular pulley rupture, surgical reconstruction is necessary. Hand surgeons have long performed reconstruction of annular pulleys in nonclimbing cases where a deep laceration had damaged the flexor tendon and tendon pulleys. Tendon grafts, harvested from the back of the wrist or forearm, are sewn in loops to replace the damaged pulley.

Treatment Tips for Finger Tendon Pulley Injuries
1. Immediately cease climbing and any other activity that requires forceful flexion of the injured finger. Consult a doctor if there is noticeable “bowstringing” on the flexor tendon.

2. Use ice and consume NSAID medications only if the injury produces palpable or visible swelling. Cease use of ice and NSAIDs as swelling begins to diminish—further daily use will slow healing!

3. As pain decreases—and only when all swelling is gone—begin light daily finger activity such as finger flexions, squeezing a rubber donut, mild stretching, and massage. This light exercise is important to ensure proper healing.

4. Use a heating pad for ten to fifteen minutes, three times a day to increase blood flow and accelerate healing. Smokers should consider breaking the habit, since smoking has been shown to slow healing of tendons and ligaments.

5. Use the therapy describe in #4 and #5 for at least two to four weeks before beginning a gradual return to climbing. Use prophylactic taping every time you climb, and spend the first week or two climbing relatively easy routes with big holds and good footholds.

6. Return to full-force climbing if easy climbing yields no pain. Continue taping and avoid tweaky holds for several months, since complete tendon healing can take 100 days or more. Climb smart!


Copyright 2008 Eric J. Hörst. All rights reserved.