Pulley Injuries Explained – Part 2

This is part 2 of 2 in an article series on pulley injuries. Click this link to read part 1 of 2.

In Part 1 of this article, we discussed the anatomy of finger pulleys, the biomechanics behind our flexor tendon/pulley system, and the implications these factors have on our climbing. In Part 2, I’d like to shed some light on pulley injury specifics, including the injury grading system and what tissues/structures are affected, and then I will walk you through what conservative management of a pulley injury looks like. The good news for climbers today is that climbing-specific surgeons, like Dr. Volker Schöffl, now view surgery as a last resort for single pulley injuries, and only recommend it for multiple pulley ruptures.1 I will finish with some injury prevention strategies to keep you all climbing strong and healthy. Read on to learn more why you may not need surgery.!

Pulley Sprain vs. Pulley Rupture:

Let’s start by defining some terminology. Remember that our pulleys are ligaments. A sprain/strain describes a stretch or partial tear of a ligament (“strain” is usually reserved for injuries to a muscle or tendon, but some of the literature mentions a strain of the pulley). A pulley rupture is a complete tear of the ligament, where no part of the tissue remains in contact with the other side. Now that you have an understanding of the terminology, let’s discuss specifics.

Injury Specifics:

A pulley injury is graded on a scale from I-IV, with I being the least severe and IV being the most severe. Here is the breakdown:

  • Grade I – pulley sprain
  • Grade II – complete rupture of A4 or partial rupture of A2 or A3
  • Grade III – complete rupture of A2 or A3
  • Grade IV – multiple ruptures as in A2/A3, A2/A3/A4, OR single rupture A2/A3 WITH trauma to the lumbrical muscles or other ligaments.

Schöffl & Schöffl, 2006

Injury Symptoms:

Many people who sustain a pulley injury will report hearing a loud “pop” at the time of injury. You may, however, not hear a sound at all. Other injury indicators might be localized pain at the site of the pulley with severe tenderness to the touch, and multiple pulley ruptures (and occasionally a single rupture) may present with “bowstringing” of the tendons. Here is a list of potential signs and symptoms:

  • Most commonly occurs over the A2 pulley (ring finger most common)
  • Tenderness to touch along pulley
  • Swelling, redness and inflammation at the base of the finger
  • Stiffness and/or pain with bending the fingers
  • Painful to actively crimp and grip

Injury Implications:

The unfortunate and sobering part of injuring a pulley is that it is typically recommended that you take a break from climbing and allow time for your tissues to heal. Yes, that means limiting your climbing, but it can be a really good opportunity to focus your attention on other things. Being injured is never what we want, but often times it presents a beautiful moment to reflect and plan for the future. Whether it inspires you following the injury to start a training program or to train more intelligently moving forward, or maybe to completely spend time and energy on other parts of your life, injuries can be good teaching moments in our lives. If you’re currently dealing with an injury and looking for some strategies to handle the down time, feel free to reach out to me (mattdestefanopt@gmail.com). I’m happy to help.

Pulley injuries take a long time to fully heal, especially complete pulley ruptures, but at least there is evidence now supporting conservative management, such as physical therapy, so you don’t have to deal with surgery. Let’s briefly discuss typical rehabilitation timelines, and then I will share some figures created by Will Anglin depicting the general information in graphic form. You can also refer above to the table from the Schöffl & Schöffl article from 2006.2

Typical Injury Timelines:2–4

The most important part of rehabbing these injuries is to respect the injury, take the timelines seriously, and listen to your body. Everyone will have a different experience, but don’t do too much too soon, or you may set yourself back and have to start all over. Be sure to read the Rehab Protocol in the Treatment Section below for more detailed guidance.

Below I have explained the general timelines, and included graphic representations of the timelines courtesy of Will Anglin.

  • Grade I – Pulley Sprain

    • 6 weeks is the recommended time to return to FULL climbing activities, but you’ll work your way up to that. No immobilization is necessary, and passive range of motion (ROM) exercises should be performed. You’ll want to protect the injury using tape (H-taping; taping technique described briefly below and in depth in a future article) and perform functional exercises at about the 2-4 week mark. After 4 weeks, you can start easy climbing to regain strength, coordination and body awareness, but don’t push it. At 6 weeks you can begin full climbing to regain full ability. You can wear tape for up to 3 months once you return back to climbing.
  • Grade II – Complete A4 rupture or Partial A2 or A3

    • 6-8 weeks is the recommended time to return to FULL climbing activities, but again you’ll work your way up to that. Immobilization is necessary this time to protect the injured tissue, and 10 days is indicated. Passive ROM exercises after immobilization phase. You’ll again want to protect the injury using tape and perform functional exercises starting at the 2-4 week mark. After 4 weeks, you can start easy climbing to regain strength, coordination and body awareness. At 6-8 weeks you can begin full climbing to regain full ability. You should wear tape for up to 3 months once climbing again.
  • Grade III – Complete A2 or A3 rupture (Most common pulley injury – A2)

    • 3 months are recommended for a return to FULL climbing activities due to the biomechanical implications of an A2/A3 pulley rupture. Immobilization for 10-14 days is necessary to protect the pulley and after the immobilization/splinting process, you will use a thermoplastic pulley ring provided by a doctor instead of tape (more on the ring later). Passive ROM exercises following immobilization. Functional exercises will begin at the full 4 week mark, and EASY climbing will commence after a 6-8 week period from injury onset. At 3 months you can begin full climbing activities, and you’ll wear the pulley ring (or tape) for roughly 6 months after climbing begins again.
  • Grade IV (surgery indicated) – multiple ruptures as in A2/A3, A2/A3/A4, OR single rupture A2/A3 WITH trauma to the lumbrical muscles or other ligaments

    • A full 6 months are required to return to FULL climbing due to the surgical implications necessary to treat a Grade IV pulley injury. Immobilization lasts for 14 days post operation. 4 weeks are required before initiation of functional exercises, but passive ROM exercises are suggested leading up to this point. A pulley ring will be utilized throughout this process. EASY climbing will have to wait a full 4 months and FULL climbing activities won’t start until roughly 6 months post surgery. The taping/pulley ring timeline may last for over a year post surgery.

**In following these graphic representations created by Will Anglin, I want to point out three things to assist you on your path:

  1. In the graphics he mentions supportive taping throughout the whole process, but I want to remind you the importance of using an actual Pulley Ring. Taping will help, but it will not be as rigid and supportive as a thermoplastic ring. If you have a Grade II-IV pulley injury, please seek out a clinician who can fit you with a pulley ring.
  2. During the “functional exercise” phase, it is highly recommended that you work alongside a physical therapist or other healthcare professional to ensure that you’re loading the tissues properly and not over doing it. Remember that everyone will have a unique timeline of their own, influenced by genetics, diet, stress, activity level etc., so guidance from a PT is very valuable. Make sure you check out the rehab protocol described below!
  3. In the representation of Grade IV recovery, you will notice a large gap from week 6 to 4 months. During this period, physical therapy and functional exercises should continue. Movement is key to your success, but only by following the guidelines expressed in this article or provided by your PT or surgeon.

Grade I

Grade II

Grade III

Grade IV

Here is another author’s take on return to sport timelines: Gnecchi and Moutet12

*Taken from their book titled, Hand and Finger Injuries in Rock Climbers.
**In the timelines, you’ll see a percentage of “RL” listed. This is the percentage of your redpoint level (RL).

Grade I-III Suggested Timeline

Grade IV Suggested Timeline

***Another brief caveat about these suggested timelines. They are guidelines to give you an idea of what to do and what to expect. But two things to keep in mind:

  1. Everyone is going to heal at a different pace, and

  2. You really should seek specialized medical attention if you think you may have injured a pulley, especially if you suspect a full rupture.

Treatment:

Now that you have an idea regarding the typical timelines of these injuries, let’s dig deeper into the actual treatment strategies and interventions for pulley injuries.

Contrary to popular belief, only a Grade IV Pulley injury (multiple pulley ruptures) requires surgical repair. According to Dr. Schöffl and other clinicians, Grades I-III are now successfully managed with conservative care.2,3 What does this mean for you? It means you may not need surgery. Any chance to avoid surgery is beneficial. Some of the inherent risks following surgery include neurovascular impairment, infection, scar formation, graft failure (surgical revision necessary), synovitis (inflamed joints), stiffness, and tendon impingement.3,5 By avoiding these risks, and surgery in general, your chances of returning to climbing sooner are enhanced. Read on to see what conservative treatment looks like.

The Case For Conservative Treatment:

In a Grade IV pulley injury, there is extensive disruption to the finger flexor/pulley system, usually in the form of bowstringing that alters the mechanics of the finger to such an extent that surgery is required to reinstate the normal biomechanics. In Grades I-III, the system is only biomechanically altered to a minor degree, and that is why we can proceed without surgical intervention. But, even in Grade I-III injuries, the tendon does initially move away from the normal tracking close to the bone. The Schneeberger and Schweizer study3 showed that with conservative, non-surgical treatment, all injured fingers in the study regained the proper tendon tracking close to the bone, and reduced the tendon to bone distance by statistically significant amounts. This returned the fingers to ideal biomechanics and was achieved after an average 67 days post injury.

The single most important aspect to conservative management of an acute pulley injury (and post surgery) is to protect the pulley so that it can heal properly. Dr. Schöffl and Dr. Schweizer have both reported extensively in the literature on the importance and utility of using a pulley ring (thermoplastic ring) to protect the pulley during a course of rehabilitation.3,6 Unlike circumferential taping of the finger/pulley, a pulley ring is rigid and will not stretch as tape would. In addition, the pulley ring is placed over the distal portion of the proximal phalanx unlike H-taping described later. Below is an image of the pulley ring used in the Schneeberger study. You’ll notice concavities on the sides of the ring. This is to protect the nerves, arteries, and veins in your finger from being compressed (tape does not discriminate where it applies force, and neurovasculature may be impaired by taping). This protective method (ring/tape) is utilized both during and after the rehabilitation process to allow the pulley to heal with minimal stress to the tissue.

Below is an example of the process that a hand therapist will go through to fabricate the splint

Click here to read an article and see a video about the process

Dr. Schöffl made a post on his Instagram about custom colored pulley rings. So yea, it’s a thing. Check it out here.

Information about splinting and how to rehab pulley injuries are also included in the book Climb Injury-Free and the Rock Rehab Pulley Protocols

That’s essentially it. Rehab time is the main difference between the traditional method of surgically repairing ALL pulley injuries and now conservatively managing Grades I-III with the intentional use of a pulley ring. (Also, without surgery you have more freedom to use your finger earlier, but guidelines are still in place.) The literature shows that outcomes are excellent with conservative management, and most climbers return to their prior level of climbing.3 Remembering the timelines introduced above, this means that unless you have a major Grade IV injury and surgery, your rehab time should be shorter than a surgery rehab. If they treated ALL pulley injuries with surgery that would mean that any injury to the pulley would keep you from climbing for at least 6 months (and without actively using your finger for at least 45 days). Thanks to the diligent research endeavors by the names above, we now have the evidence and clinical expertise to get you back to climbing sooner.

A Brief Note on Taping Technique:

I will be writing a more in-depth article on finger taping in the next few weeks, but I want you to have accurate information now to properly protect your finger. Tape has been mentioned as a way to offload the force applied to the pulley, but remember that the pulley ring is the best method. Check out this video by Dr. Volker Schöffl showing you how to tape with H-taping. Dr. Isabella Schöffl shows that this method is most optimal for protecting the A2 pulley as it best limits the tendon-bone distance.7 Some important considerations pointed out in the video:

  1. Use broad tape initially so you can pull the strips in half, creating the “H” or “X”.
  2. Don’t pull the tape directly from the roll onto the finger. Tear the tape off first.
  3. Apply central pressure directly over the A3 pulley (PIP joint).
  4. Slightly flex the PIP to about 60˚ when placing the tape. This allows for better tendon-bone approximation.
  5. Tighten distal strips first, then proximal strips.
  6. When pulling the tape around the proximal and middle phalanx, you can pull it tighter than other taping techniques. (Just make sure you don’t lose circulation.)
  7. Cover your work with skinny tape at the end to avoid the tape unraveling.

Interventions And Prevention Strategies:

Throughout this article, the research authors and I have mentioned “functional therapy” or “functional exercise,” but what does that mean? This is termed to describe rehabilitation exercises that restore function to the injured area, structured in a way to effectively return you to optimal performance. When we rehabilitate an injury, we need to respect the proper healing times and we need the exercise progression to apply a therapeutic stress to the healing tissues. I have some helpful tips and exercises for you here, but I do highly recommend seeking the guidance of a physical therapist or another healthcare professional to help guide you through your process.

The Climbing Doctor’s Advice:

Doctor of Physical Therapy, Jared Vagy, has done an excellent job of laying out the framework of any injury through his Rock Rehab Pyramid. This framework gives you a process to follow as you deal with any injury, in a methodical manner to allow the tissue to heal properly and fully. The different stages, from beginning (bottom) to end (top), include:

  1. Pain, Inflammation, and Tissue Overload,
  2. Mobility,
  3. Strength, and
  4. Movement.

So what do each of these mean? Starting from the bottom of the pyramid, you’ll initially want to unload the affected tissue, then regain mobility in and around the injured tissue, and finally strengthen the tissue with a follow up level to utilize movement strategies to change your old movement patterns and create newer, healthier ones to avoid injury in the future. When performing functional exercises during the Rock Rehab Protocol, there will be multiple levels of each layer in the pyramid. In other words, there will be 3 unloading exercises/techniques, 3 mobility techniques, etc. Dr. Vagy goes into full detail in his new book titled Climb Injury-Free, but below is a little snapshot of things to do for pulley injuries.

Snapshot of Dr. Vagy’s protocol:

  1. Unloading the tissue – H-Tape (Be sure to watch the video above from Dr. Schöffl himself, explaining the technique.)

2. Mobility – Tendon Glides: Perform 3 sets of 10 reps, 2-3 times per day.

Variation: Think about doing these tendon glides in a more climbing-specific posture.

3. Strengthening – Rubber Band Finger Extensions (to strengthen the antagonist muscles and reduce the pressure on the healing pulley): Perform 3 sets of 15 reps with 5 second isometric holds; once per day.

4. Movement – Once you have unloaded the tissue, regained mobility, and strengthened the tissue, now it’s time to change old habits, and create healthy practices that will decrease the likelihood of future injury. Here is advice from Dr. Vagy:

  • Instead of pulling hard from small edges, remember to push with your feet too.
  • Instead of making dynamic moves from small edges, try to move more statically. Remember from Part 1, that when we move dynamically off of a crimp, the force on the pulley increases 62%! So try to move through small edges statically when you can. Obviously there is no way you can avoid dynamic moves from crimps forever, especially if you climb higher grades, but only do it when necessary.
  • Instead of using a full crimp all the time, limit its use, and utilize a half crimp or open hand posture more frequently.

To learn more about Dr. Vagy’s protocols and his Rock Rehab Pyramid, check out this link to his book titled Climb Injury-Free.

Additionally, below is a video by The Climbing Doctor that outlines in detail how to recover from a pulley injury. The video presents an in-depth discussion of how to splint, mobilize, and strengthen the finger so that you can return to climbing at full strength.

Esther Smith’s Advice:

Doctor of Physical Therapy, Esther Smith, of Grassroots Physical Therapy in Salt Lake City has created an amazingly comprehensive protocol for treating pulley injuries. As the physical therapist for the Black Diamond pro climbing team, Dr. Smith has put together an article for you to view on the Black Diamond website, so be sure to go check it out here! Anyone with a finger injury may look at a hangboard and cringe, but Dr. Smith explains how the hangboard can be used as a tool to help heal fingers in the later stages of injury. I strongly encourage you to go read the article. Below is my synopsis of the protocol.

***As a general rule, unless your finger is bowstringing (Grade IV injury) then you can utilize this protocol. Be honest with the timeline. If your injury is less than 6 weeks old, make sure you abide by Phase 1. Go seek a PT or other medical professional if you injure your finger.

Timing:

Dr. Smith has specifically made the distinction between the two phases of the pulley injury with Phase 1 being the early acute phase, and Phase 2 being the later remodeling phase. Injury onset up to 6 weeks puts you in the acute phase, and anything over 6 weeks is considered the remodeling phase. The reason for the distinction is related to the nature of tissue healing. In the early days/weeks after a sprain injury, the ligament is regenerating in a more gross fashion with less specificity or organization. During this time period, the healing tissue is lacking strength and it is imperative that you do not overload it. Moving forward into the later stage of tissue remodeling, the tissue is gaining strength and must be loaded appropriately t