Rehab and Splint Applications
What is a Pulley Injury from Rock Climbing?
Pulleys in our fingers act much like the eyelets on a fishing rod. They work to keep the tendons that flex our fingers close to the bone, to create a mechanical advantage and limit “bowstringing” of the tendon on the hand. Pulleys are made out of very strong ligamentous connective tissue. There are 5 flexor pulleys in each finger (A1-5), the A2 and A4 pulleys being the most relevant to climbers. The muscles that flex your fingers and whose tendons run through these pulleys are the flexor digitorum profundus and flexor digitorum superficialis, both of which originate in the forearm.
Finger Flexor Tendons Pulley Injuries
Pulley injuries occur when the ligamentous pulley structure cannot accommodate the forces being placed on it and it eventually shows structural failure. This is often associated with a loud pop, especially with a grade iii sprain. This happens through an excess of tolerable load placed on the fingertip. The angle of the finger joint near to the hand (PIP) also influences the amount of force translated to the pulley system, particularly the A2 pulley. The greater the angle (see: closed crimp position) the greater the amount of force. Anecdotally, pulley failure is usually seen when the crimped finger opens (eccentric failure) rather than when actively closing down.
Should you be learning “How to H Tape”?
A quick scan at the crag will usually reveal more taped digits than climbers but how much is that tape really helping? Of the two most common pulley taping methods: circumferential and H-taping, only H-taping showed any kind of clinically significant reduction in tendon to bone distance meaning that it can simulate some of the mechanical advantage provided by a pulley. While this may protect superficial soft tissue what this neglects to address is the stretch of tape and how just a couple climbs will render any benefit from the tape moot as it becomes more slack. Taping also carries the risk of altering biomechanics potentially leading to compensations or injury elsewhere.
Taping would also not be recommended as a prophylactic measure. From Dr. Schöffl, author of “One Move Too Many” and researcher of pulley failure re: preventative taping: “…we could not discern any positive effects either on the tendon-bone distance or on the finger strength for the healthy finger.”
How to use a Pulley Splint
Rigid pulley splints, rather than tape, are able to provide the requisite amount of force and stiffness for pulley remodeling and correct force translation. The splint acts to keep the tendon close to the bone allowing for the pulley to heal, to be unloaded and resist bowstringing forces. The duration of wear is dependent on the severity of injury and would be assessed during an in-clinic visit but can be up to 8 weeks and be worn up to 23 hours a day. In later stages of pulley remodeling the rigid splint can even be used during activity and climbing.
It is a good basic rule to avoid climbing on a painful finger. If the finger continues to be painful it should continue to be splinted unless you have confirmed via Diagnostic Ultrasound to confirm that the pulley has healed tight and that pain your are dealing with is from some other cause. That being said if you sprain your pulley and the pain goes away quickly that doesn’t mean you get to toss your splint. It’s generally wise to splint for a bare minimum of 4-6 weeks for mild to moderate sprains even if they don’t hurt. We’ve heard of two many climbers bouncing back quickly, returning to climbing only to find later that they have been extending their sprain into the next pulleys up or down the finger. This is a major concern because if you extend through both the A2, A3 and A4 pulleys then you may need surgery to repair this injury. And who would like to skip the chance of surgery by making a the choice to protect the your finger a few weeks longer.
There are two primary pulley splints out there: the Pulley Protection System (PPS) developed by Swiss physician Dr. Schweizer and the SPOrt from Dr. Warme, an orthopedic surgeon and professor here at the University of Washington. Both are excellent options but we’ve been lucky here at Union PT to be able to work directly with Dr. Warme. Additionally the SPOrt can be made to fit the A4 pulley whereas the PPS is strictly for A2 pulley injuries.
How to Rehab a Pulley Injury
Acute Phase
Healing from a pulley injury is best explored in stages. In the beginning stages following injury we want to unload the pulley from finger forces, prevent the formation of scar tissue, control symptoms, and maintain and regain mobility. Here are a few examples of mobility and gentle exercises that we may prescribe:
- Tendon Glides
- Rice Bucket Grasp/Extend
- Putty Exercise
- Finger Extension With Band
Progressive Loading Phase
Once we have achieved a normalized range of motion, tenderness and pain has abated and everyday activities are tolerated, it becomes important to begin the loading phase. Our tissues adapt to the loads and stresses that we place upon them. To develop strong, stiff, robust connective tissue that can handle the strong and variable stresses and loads that climbing places on hands and fingers it is important to introduce a graduated and safe loading program. As we begin to load our fingers we want to make sure that 1.) any strain or soreness is transient and resolves quickly, 2.) no loss of motion, 3.) no loss of function.
Hangboarding: Particularly important in the healing phase is using a pulley system to take off some bodyweight for appropriate finger loading. There are many different hangboard protocols out there but in this phase I use 10s repeaters with a 2 min rest between sets.
Velocity Pulls & Density Hangs: Very late in the rehabilitation we continue the progressive loading but begin to add a little bit of a safe and controlled speed element that can mimic the forces and recruitment speed necessary for a return to climbing.
Climbing: Climbing may actually take place in the progressive loading phase provided it is done submaximally, with the splint and without any of the lingering soreness, loss of motion or function responses addressed earlier.
When Rock Climbers should Seek Care for a Finger Injury
Injured fingers and hand injuries come in many different shapes and sizes. Along with that, pain over a pulley does not necessarily mean an injury to the pulley itself. Furthermore, it is also important to take into account “upstream factors” like scapular weakness, thoracic outlet syndrome, or even just poor climbing mechanics that can place undue stress and forces on our finger structures. To ensure a thorough diagnosis, create a recovery plan that is right for you and if deemed necessary, have a pulley splint specifically made and fitted, please schedule an appointment at our Seattle-based physical therapy office, where we specialize in treating climbing injuries.
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About the author:
Jon Sparks, PT, DPT, CSCS is a physical therapist at Union PT in Seattle. He is experienced in treating acute and chronic industrial injuries, postoperative rehabilitation and orthopedic injuries. He enjoys staying up-to-date with evidence-based treatments. Outside the clinic Jon is thoroughly obsessed with rock climbing. When not climbing, he enjoys traveling, exploring new restaurants and snowboarding.
Edits by Mitch Owens PT.