Disruption of finger flexor pulleys in rock climbers: prevalence, diagnosis and strategies for rehabilitation - page 2 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.
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