Pulley Injury - Complete Rehabilitation Program for Climbers
PT Jeff’s comprehensive rehabilitation program for finger pulley injuries. See below for Videos as well as anatomy, healing times, tendon glides, Wave Tooling, H-taping, progressive strengthening, and return to climbing progression.
Pathophysiology
Finger pulleys are thick, fibrous bands of connective tissue that hold your finger flexor tendons tight along the finger bones. The pulley’s prevent “bowstringing” of the tendon while the tendon is under load.
Injury to the pulley’s are common among rock climbers. Proper management of pulley injuries is crucial for a full return to sport and to decrease the chance of re-injury.
Key Points
Climbers most often injure the A2 Pulley in the ring finger. Other pulleys are susceptible to excessive forces as well with the middle finger being the next most commonly injured digit.
The A2 Pulley is located at the base of your finger near the junction with your palm. The A1 pulley is more in the palm itself, over the MCP (Metacarpal Phalangeal Joint).
Treatment for a mild to moderate injury requires a balance of protection, scar mitigation, and progressive loading strategies for the injured tissues.
More severe injuries require medical evaluation, possible immobilization, and sometimes surgical intervention.
If pain is very severe, swelling is significant, or you can see or feel “bowstringing” of the tendon, then you should seek medical attention. ER visits are usually not indicated but seek medical evaluation within the first 3-10 days if you suspect a more severe injury.
Key Signs of A pulley injury
· Immediate onset of pain over the pulley that is often times associated with an audible popping sound (there is not always a pop, so you can still have a pulley injury even without the sound).
· Pain is usually quite severe especially with direct pressure over the pulley or with trying to crimp or pull with the affected digit (do not keep gripping holds and pulling to try and convince yourself that you are not actually injured!!).
· Swelling is often present over the affected pulley. Bruising can sometimes be present.
· Pain is typically localized directly over the pulley and tends to be worse along the sides of your finger. If you flex the injured finger then gently pull out on your fingertip you should feel pain along the pulley.
· If the pain radiates into your hand or wrist then it is probably not a pulley injury and may be an injury to one of the flexor tendons.
· Stiffness, swelling and tenderness along the knuckles themselves (the PIP or DIP joints) is usually not a symptom of a pulley injury and can be due to a capsular strain, arthritis, collateral ligament strain, extensor hood injury or other problems.
Part 1: Identification, Anatomy, Wave Tool treatment, tendon glides, and beginning isometric strengthening for pulley injuries
Stages of Healing
Tissue healing can be divided into 3 overlapping phases: Acute/Inflammatory, Reparative, and Remodeling phases.
Acute Phase: Homeostasis & Inflammation (Days 1-5)
· Blood vessels constrict, platelets stick together, coagulation occurs and fibrin threads are formed to stop bleeding, seal the injury site, and create a scaffolding for the re-building process.
· Macrophages and white blood cells clean the area and secrete growth factors and cytokines to stimulate fibroblast proliferation.
· Inflammation is a necessary part of normal healing and is only a problem if the response is too aggressive or lasts too long. Ice is helpful to reduce pain and may help reduce inflammation, but has not been proven to improve the overall healing response. NSAID’s can also be helpful but only if the pain or swelling are excessive in the first few days.
Repair & Proliferation Phase (Days 3-21)
· New blood vessels form and the body starts to re-build the damaged tissue with Type III Collagen (scar tissue). This collagen is weak, disorganized, and easily re-injured. Pain free movement is crucial in this phase to help the new collagen align itself parallel with the normal forces placed on the tissue. Gentle massage and Wave Tool work can also be helpful in this stage.
Remodeling & Re-Organization Phase ( Days 14-2 years)
· Type III Collagen is replaced with stronger and better organized Type I collagen. It’s critical for this re-organization to occur so that the damaged pulley tissue is strong and healthy enough to handle the stresses of climbing. A very controlled and progressive loading program is crucial for this re-organization to occur. Wave Tool use with the edges can help stimulate a healthier “healing response”.
Treatment Flow-Chart
Part 2: How to H-tape a pulley so you can train and climb while putting less stress on it.
Part 3: How to use bands with the Tension Board and Tension Block to rehab your Pulleys and Tendons back to strength
Pre-Climbing Resistance Training
Begin this progression 5-10 days post injury
Only progress to the next training level when you can perform the prior level with minimal or no pain
Go slowly with all motions and progress with resistance levels carefully. If you are mildly sore for 30 minutes to 1 hour after a session that is fine. If soreness persists for several hours or into the next day then you must decrease intensity.
Level 1) Isometric Holds: 5 x 5 x 5 program (see videos)
Using a flat edge such as the side of the table or counter edge, or use a Tension Block or Flashboard (see video). Open grip position only. NO CRIMPING. Use all four fingers, gently pull on the edge just to the point of feeling pain over the pulley. Now back the pressure off until no pain or only very mild pain is felt, this is where you will do the hold. Pull for 5 seconds, 5 reps. Now pull with three fingers (index, middle, ring). 5 second hold, 5 reps. Now very carefully and gently pull with the injured finger and the finger next to it (middle and ring). 5 second hold, 5 reps. Perform up to 5 times on the days you perform the exercises.
Use a two days On/One day Off cycle for performing exercises.
Level 2) Isometric Holds Using Resistance Band: 5 x 5 x 5 program (see videos)
Using light resistance bands and a portable grip device such as the Tension Flash Board or Tension Block. Make sure you can accurately reproduce resistance at each session. Keep track of bands used, holds used, and distance from anchor. A “keeper” sling around your wrist is recommended so that you can let go of the board if any pain is felt. (see video). Begin with the largest grip surface and all four fingers. Open grip positions only. With arm straight walk backwards until mild pain is produced over pulley, now step forward and ease resistance until no pain or very mild is felt. Hold 5 sec, 5 reps. Now repeat with 3 fingers (index, middle, ring) for 5 second holds, 5 reps. Now very carefully and gently repeat with two fingers (middle and ring) 5 second holds, 5 reps. Perform up to 5 times on your exercise days.
Still Two days on One day off. (you will progress faster if you have adequate recovery time)
Level 3) Resistance Bands with Climbing Specific Movements (see videos)
Using the Tension Flashboard or Tension Block attached to the bands. Open grip positions only. Now start with careful pulling for the following three motions.
A. Archer Position (pretend your pulling a bowstring back) Four fingers for 10 reps, 3 sets.
B. Undercling Position. Four fingers for 10 reps, 3 sets.
C. Palm Down Pull. Keep your palm down, facing the floor, and pull straight back. Four fingers 10 reps, 3 sets.
Perform twice on the days you are allowed to do the exercises.
One day On/One day Off exercise cycle
Progress to three fingers then two fingers with the same motions and reps. Very carefully! May take several days to be able to advance. You can also advance to smaller grip surfaces if no pain is noted .
Remember: Every injury and every individual is different. Progress at your own pace and listen to your body.
Return to climbing progression
Begin the climbing progression 14-21 days post injury. You should be doing all resistance band exercises without pain prior to initiating the climbing plan.
The climbing will be in ADDITION to the resistance bands. Follow the frequency plan listed under each climbing level.
Perform a minimum of 4 days of climbing at each level prior to proceeding to the next difficulty level. Advance only if pain levels are not increasing and workouts are done with a minimum of pain or strain.
Resume Rotator Cuff & Periscapular Strengthening. Bands work great for this as well.
Basic Climbing:
· Top Rope only. No bouldering. No leading.
· 3 FULL letter grades below Onsight level (i.e. a 12a onsight climber could start on maximum difficulty of 5.9).
· Work on balance, foot work, pushing with legs, fall practice, breathing, flexibility…. Let go if any pain or twinge is felt.
· Climbing and Resistance bands will be on the SAME day. 2 days on/1 day off.
Harder Climbing:
· Top Rope only. No bouldering. No leading.
· 1 Full letter grade below Onsight level (i.e. a 12a onsight climber could start working on maximum difficulty of 11a).
· Climbing and Resistance bands will be on the SAME day. 2 days on/1 day off.
Lead Climbing / Bouldering:
· Approach all climbs like you would a project. Feel out moves and holds. Top rope first as necessary.
· Work on minimizing strain and climbing efficiently. Work on core tension, elbows in, scapulae engaged….
· Choose a different climb if you have pain on any of the individual holds. Lead only after you’re confident the movement and holds are ok for your particular injury.
· You can start to introduce full crimping with your resistance band workouts and slowly introduce full crimping to climbing routes.
· More Rest is now needed. Follow the schedule below to optimize recovery. Bands are still done on the SAME day as climbing.
Each week should have a minimum of 3 climbing rest days with 2 rest days in a row. If you’re feeling sore or aren’t progressing, then you should take 3 rest days in a row to allow for tissue recovery and repair processes. Below is a sample 14 day training schedule. Adjustments to the schedule are fine but it’s best to follow the rest requirements.
Redpoint/Onsight Training: Begin working towards harder onsight climbing, your project grades, and normal training routine.
· Once your working back towards your project grade you may take less rest days and progress towards your pre-injury workout schedule. Keep in mind, however, that rest days are critical for preventing re-injury and chronic tissue break down, and to repair tissue micro-damage.
· Soft Tissue injury healing is not always linear. You will have ebbs and flows in your rehabilitation progress. Look at the bigger patterns and look forward to the ultimate goal of getting back to climbing again!