Impact of Taping after Finger Flexor Tendon Pulley Ruptures in Rock Climbers

Climbing while healing: An orthotic intervention for rock climbers with a low- grade A2 pulley injury, a case series

BACKGROUND

Pulley injuries are common among rock climbers, which is a growing population. Hand therapists need a therapeutic intervention which promotes healing and enables participation.

PURPOSE

The purpose of this case series is to detail the functional outcomes of a 12-week protocol using a pulley ring orthosis (PRO) among rock climbers with a grade I, II, or III pulley injury.

STUDY DESIGN

A prospective repeated measures case series followed the healing timeline of four participants who rock climbed while wearing the invervention device, the PRO, with weekly measurements to monitor healing METHODS: Participants with a grade I, II, or III A2 pulley injury were custom fitted for a PRO, which they wore while rock climbing a minimum of 3 times per week for 12 weeks. Weekly check-ins were scheduled for subjective and objective measurements.

RESULTS

All participants demonstrated indicators of full healing, which, in this study, is defined as progressive improvement in strength, function, and pain, without interruption of their typical rock climbing schedules.

CONCLUSIONS

Providers should consider the use of a PRO as a protective orthosis for rock climbing patients with a low-grade A2 pulley injury who want to continue rock climbing while they are healing.

A Biomechanical Analysis of the H-Taping Method Used by Rock Climbers as Prophylactic or Stabilizing Fixation of Partial A2 Pulley Tears

PURPOSE

Rock climbing can lead to upper-extremity injuries, such as A2 pulley ruptures, leading to the bowstringing of the flexor tendons. Climbing finger positions are specific and can put undue stress on the pulley systems. This causes severe hand dysfunction and is a difficult problem to treat, and prevention is important. Using a cadaveric, experimental model, we evaluated the effectiveness of the H-taping method, commonly used by rock climbers, to prevent and treat A2 pulley tears.

METHODS

Using fourteen matched pairs of fresh-frozen cadaveric hands with forearms, four experiments were conducted with 56 paired comparisons evaluating the failure force, fingertip force, and mode of failure (112 total tests). Comparisons were as follows: index fingers- intact versus 50% distal A2 pulley tears without H-taping (control); ring fingers- intact versus H-taping as a prophylactic for A2 pulley tears; little fingers- 50% distal A2 pulley tears with H-tape versus without tape; and middle fingers- H-taping as a prophylactic versus H-taping as a stabilizing treatment of torn pulleys.

RESULTS

The mean index finger failure force was significantly higher in intact vs torn A2 pulleys (control). Failure force for intact H-taped fingers was significantly higher than torn H-taped fingers, but no other finger comparisons for failure force were significant. There were no significant findings in comparison of mean fingertip force values in any of the experiments.

CONCLUSIONS

We found that H-taping is not effective as prophylaxis against A2 pulley ruptures or as a stabilizing treatment method for partially ruptured pulleys.

CLINICAL RELEVANCE

While H-taping has not been recommended as prophylaxis for preventing A2 pulley ruptures, the climbing community has embraced this technique as a preventative measure. The present study provides biomechanical evidence against H-taping for this purpose. Furthermore, it does not appear to aid in increasing fingertip force after injury.

Rehabilitation of Annular Pulley Injuries of the Fingers in Climbers: A Clinical Commentary

ABSTRACT

The annular pulley ligaments of the fingers are one of the most injured anatomical structures in those who participate in climbing. Despite this, there is a paucity of guidance clearly describing the rehabilitation and physical preparation parameters to return to sport following such injuries. The foundation of effective rehabilitation is the judicious application of progressive loading to increase the morphological and material properties of the damaged tissues. We maintain the optimal management of the climbing athlete after a traumatic annular flexor pulley system rupture should be grounded in the principles of strength and conditioning.

A Guide to Indoor Rock Climbing Injuries

ABSTRACT

Rock climbing is an increasingly popular indoor sport with a sizable risk of overuse injuries. Yet, many medical practitioners have little familiarity with evaluating and treating climbing injuries because of the terminology, biomechanical demands, mechanisms of injury, and return to sport counseling needed, unique to the sport. This review seeks to educate practitioners on these aspects. Upper extremity injuries occur more frequently than lower extremity injuries, with finger injuries being most prevalent. Pulley injuries, consisting of rupture of the A2 or A4 annular pulleys are the most common type of injury. Other finger injuries include tenosynovitis of the flexor tendons, as well as lumbrical muscle tears. Elbow injuries occur frequently, with medial epicondylopathy being most common. Brachialis injuries are seldom seen outside of climbing. Lower-extremity injuries are typically more acute in nature, including ankle injuries from falls and knee injuries from strenuous climbing moves.

To tape or not to tape: annular ligament (pulley) injuries in rock climbers-a systematic review

Background

Popularity of rock climbing is steadily increasing. With its inclusion in the Olympic Games this will likely continue. Injuries from rock climbing are also increasing. The most common injury is to the flexor pulley system, consisting of the finger flexors and five annular ligaments (pulleys). Treatment of this injury includes taping of affected fingers, but evaluation of this treatment was previously lacking. The aim of this review was therefore to assess whether taping is associated with better outcomes than non-taping. A secondary aim was to present treatment recommendations or areas for future research.

Methods

Systematic searches of PubMed, Scopus, SPORTDiscus, Cochrane Library, PEDro and CINAHL. Free text searches of Google Scholar. Citation searching. No restrictions to language, date of publication or study design. Included studies were assessed using Cochrane scale for clinical relevance, by two independent authors. Results were presented in narrative synthesis. Certainty of evidence (GRADE) was assessed by three authors. Review was done according to PICO-protocol and reported according to PRISMA-guidelines.

Results

After removing duplicates, 595 records were identified. Eight studies and one case report (in nine articles, one poster) were included, consisting of 206 rock climbers, four non-climbers, 23 pairs of cadaver hands. Clinical relevance ranged from 0 to 5 (median 2). Evidence of low to moderate certainty suggests that taping might reduce bowstringing of the finger flexor tendons by 15–22%. Evidence regarding pain, time for return to sports, shearing forces against pulleys, pulley ruptures and maximum voluntary contraction (MVC) were all regarded as “very low”, “very low to low” or “low”, and were not considered reliable. Evidence of moderate certainty suggests that taping has no effect on MVC or muscle activation in uninjured rock climbers. No adverse effects of taping were reported.

Conclusion

Low to moderate evidence suggests that taping might reduce bowstringing of the finger flexor tendons. Moderate evidence suggests that taping has no effect on MVC or muscle activation in uninjured climbers. For other outcomes more studies evaluating the effects of taping are needed.

Trial registration: PROSPERO CRD42021241271, date of registration: 18-04-2021.

Finger Flexor Pulley Injuries in Rock Climbers

Finger flexor pulley system injuries are the most common overuse injury in rock climbers. These injuries occur rarely outside of rock climbing, owing to the sport's unique biomechanical demands on the finger. As rock climbing continues to grow and earn recognition as a mainstream sport, an understanding of how to diagnose and treat these injuries also has become important. Our purpose is to describe current concepts in anatomy, biomechanics, clinical evaluation, imaging, prevention, and treatment strategies relating to finger flexor pulley system injuries. Our literature search was performed on PubMed with MeSH terms and keywords as subject headings to meet the objectives of this review. The "crimp grip" used in rock climbing is the mechanism for these injuries. The A2, A3, and A4 pulleys are at the highest risk of injury, especially when loaded eccentrically. Physical examination may reveal clinical "bowstringing," defined as the volar displacement of the flexor tendons from the phalanges; however, imaging is required for characterization of the underlying injury. Ultrasound is highly sensitive and specific for diagnosis and is recommended as the initial imaging technique of choice. Magnetic resonance imaging is recommended as an additional imaging study if ultrasound is inconclusive. Properly warming up increases the amount of physiologic bowstringing and is thought to prevent injury from occurring. Pulley injuries may be classified as grade I through IV. Conservative treatment, including immobilization, the H-tape method, and the use of a protective pulley splint, is recommended for grade I to III injuries. Surgical repair is reserved for grade IV injuries that are not amenable to conservative treatment.

Olympic competition climbing: the beginning of a new era-a narrative review

Climbing as a competition sport has become increasingly popular in recent years, particularly the sub-discipline of bouldering. The sport will debut in the Tokyo Summer Olympic Games. National and international competitions have three disciplines: lead (climbing with rope protection), bouldering (climbing at lower heights with mattress floor protection) and speed (maximum speed climbing on a standardised route in 1-on-1 mode). There is also a 'combined mode' of all three disciplines (combined) which forms the Olympic competition format; all competition formats are held on artificial walls. Existing literature describes a predominantly low injury frequency and severity in elite climbing. In comparison to climbing on real rock, artificial climbing walls have recently been associated with higher injury rates. Finger injuries such as tenosynovitis, pulley lesions and growth plate injuries are the most common injuries. As finger injuries are sport-specific, medical supervision of climbing athletes requires specific medical knowledge for diagnosis and treatment. There is so far little evidence on effective injury prevention measures in top athletes, and antidoping measures, in general, requiring further work in this field. An improved data situation regarding high-performance climbing athletes is crucial to ensure that the sport continues to be largely safe and injury-free and to prevent doping cases as extensively as possible.

Comprehensive Review of Rock Climbing Injuries

Increasing numbers of people are participating in the sport of rock climbing, and its growth is expected to continue with the sport's Olympic debut in 2020. Extreme loading of the upper extremities, contorted positioning of the lower extremities, rockfall, and falling from height create an elevated and diverse injury potential that is affected by experience level and quantity of participation. Injuries vary from acute traumatic injuries to chronic overuse injuries. Unique sport-specific injuries to the flexor tendon pulley system exist, but the remaining musculoskeletal system is not exempt from injury. Orthopaedic evaluation and surgery is frequently required. Understanding the sport of rock climbing and its injury patterns, treatments, and prevention is necessary to diagnose, manage, and counsel the rock-climbing athlete.

Joint Mobility Protection during the Developmental Age among Free Climbing Practitioners: A Pilot Study

Sport-climbing popularity increased intensely over the past years. Particularly, children's and adolescents' interest therein is constantly growing. Despite a large effort in preventing injuries and muscle overloads, a fine-tuned training for each sensitive phase of child development is still needed. The objective of the study was to evaluate an innovative training program aimed at the preservation of joint mobility during the developmental age. This article relies on the results of a steady training program allowing to retain joints integrity among the practice of sport climbing in children. Joint mobility changes have been monitored before and after a one-year training program in fifteen subjects aged between 8 and 18 years. Subjects were divided into three groups depending on age (Turgor Secundus, Proceritas Secunda and Turgor Tertius). The motor tests administered were the sit-and-reach test, coxo-femoral mobility test and scapula-humeral mobility test. Our results showed that one-year training improved joint mobility at each analyzed phase, suggesting that this training program could improve mobility and flexibility. Given the importance of joint mobility preservation for discipline-related injuries prevention and eventually recovering, it is essential to provide a specific training program as a route to approach sport climbing, and even more importantly, at an early age. This work represents a preliminary study in order to demonstrate both efficacy on the joint mobility and the requirement of our playful work to support the global sport-climbing workout.

Multiple flexor tendon pulley ruptures in a division 1 collegiate football player

Injuries to the hand and digits are common in football players. To our knowledge, there have been no reports on multiple flexor pulley ruptures in football players treated non-operatively through splinting and taping techniques. A 22-year old collegiate defensive lineman sustained an injury resulting in complete disruption of the annular 2, 3, 4, and cruciate 1 and 2 pulleys. The patient was successfully treated with serial custom splints for 12 weeks. Our splinting and taping techniques and timing of these have not been previously described. This case illustrates a successful treatment option in football players with multiple flexor pulley ruptures.

Closed rupture of the flexor tendon pulleys of the thumb

Closed rupture of the thumb flexor tendon pulleys is rare and, to our knowledge, the MRI findings associated with this injury have not been described in the radiology literature. The injury can result in nonspecific clinical and physical exam findings and advanced imaging may be crucial to diagnosis. A familiarity with the normal anatomy of the flexor mechanism of the thumb and the imaging appearance of pathology is therefore necessary. We report a case of a 31-year-old female nurse with ruptures of several of the thumb flexor pulleys and the corresponding findings on MRI.

Rate of force development and maximal force: reliability and difference between non-climbers, skilled and international climbers

The goal of this study was to assess (i) test-retest reliability between sessions and within sessions, and (ii) the difference among three skill levels (international n = 12, skilled n = 10 and non-climbers n = 9) for finger flexor maximal force (Fmax) and rate of force development (RFD) at different time scales. Each climber performed a maximal finger flexion on a dynamometer in two different conditions: half crimp and slope crimp. The inter-session revealed no difference with low to high correlation from 0.56 to 0.94. Intra-session reliability reveals intraclass correlation ranging from 0.40 to 0.98 for all groups. The coefficients of variation ranged from 7.77% to 28.34% for RFD and 2.90% to 9.99% for Fmax. Maximal force, expressed as an absolute or normalised value, reveals a significant difference between all samples (22.11% difference between international and 38.58% between skilled and non-climbers). Finally, the difference in RFD_200ms and RFD_95% among the three groups suggests that the practice of intensive climbing causes many changes in neural and structural factors. Last, RFD_200ms and RFD_95% are highly reliable and can be used to discriminate samples, suggesting that these variables could be used in monitoring training.

Effects of finger taping on forearm muscle activation in rock climbers

Flexor tendon pulley injury is associated with a change in relative activation of the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) muscles. The purpose of this study was to determine the effect of taping of the fingers on relative muscle activation of the FDS and FDP muscles in uninjured rock climbers. Muscle activation in 10 healthy volunteers were recorded using intramuscular electromyography (EMG) during a static hang with subjects utilizing the crimp grip without tape, with a circumferential tape and with an H-tape in random order. EMG data were normalized to a static hang with a non-crimp grip (RVC). Average EMG activity of the FDS as a percentage of RVC was 102.4 ± 59.1 without tape, 116.9 ± 35.3 with H-tape and 99.3 ± 35.3 with circumferential tape. Average EMG activity of the FDP as a percentage of RVC was 96.6 ± 40.0 without tape, 98.9 ± 30.3 with H-tape and 90.6 ± 28.7 with circumferential tape. Taping did not have a significant effect on average relative muscle activation of the FDS or FDP muscles (p = 0.069). This study showed that finger taping may not significantly affect the activity of the FDS and FDP during static holds while rock climbing.

Flexor Tendon Pulley Injuries in Rock Climbers

Closed pulley ruptures are rare in the general population but occur more frequently in rock climbers due to biomechanical demands on the hand. Injuries present with pain and swelling over the affected pulley, and patients may feel or hear a pop at the time of injury. Sequential pulley ruptures are required for clinical bowstringing of the flexor tendons. Ultrasound confirms diagnosis of pulley rupture and evaluates degree of displacement of the flexor tendons. Isolated pulley ruptures frequently are treated conservatively with early functional rehabilitation. Sequential pulley ruptures require surgical reconstruction. Most climbers are able to return to their previous activity level.

Biomechanical investigation of 'figure of 8' flexor tendon repair techniques

This biomechanical study compared the original Al-Qattan repair with other modifications postulated to reduce bulk and friction, thereby potentially improving outcome. A total of 32 cadaveric digits with intact flexor apparatus were used. In each digit, the flexor digitorum profundus and flexor digitorum superficialis tendons were cut cleanly in Zone 2. We tested Al-Qattan's technique along with three modifications using stronger suture material and varying the number of strands across the repair site. Of the four repair techniques, the modified Al-Qattan's technique using two 'figure of 8' 4-0 Fiberwire core sutures (Group 4) had the best balance of ultimate tensile strength (50.9 N), 2 mm gapping force (38 N) and friction. The modified technique provided a stronger repair for early active mobilization and has less friction than the originally described repair.

Jam Injuries of the Finger: Diagnosis and Management of Injuries to the Interphalangeal Joints Across Multiple Sports and Levels of Experience

Context:

Jam injuries of the finger are frequently encountered in general orthopaedic and sports medicine practice. The finger joints in particular are very susceptible to traumatic injury, but in the absence of severe deformity, digital trauma is often downplayed in the hopes of a more rapid return to game play.

Evidence Acquisition:

Articles published from 1966 to 2015 were reviewed to capture historical and current views on the presentation, diagnosis, and treatment of jam injuries in athletes.

Study Design:

Clinical review.

Level of Evidence:

Level 5.

Results:

Although jam injuries are frequently grouped together, they represent a host of injuries that can be challenging to differentiate. A thorough knowledge of finger joint anatomy and injury mechanism is critical to perform an appropriate examination, establish an accurate diagnosis, and identify a treatment plan for each patient.

Conclusion:

Every member of the athletic care team must be aware of the spectrum of digital injuries, including the basic signs present on examination, which may indicate the need for more formal workup. Additionally, preventing injury through athlete education is paramount to athletic care.

Stress examination of flexor tendon pulley rupture in the crimp grip position: a 1.5-Tesla MRI cadaver study

OBJECTIVE

The objectives of this study were the evaluation of flexor tendon pulley rupture of the fingers in the crimp grip position using magnetic resonance imaging (MRI) and the comparison of the results with MRI in the neutral position in a cadaver study.

MATERIALS AND METHODS

MRI in the crimp grip position and in the neutral position was performed in 21 cadaver fingers with artificially created flexor tendon pulley tears (combined pulley rupture, n = 14; single pulley rupture, n = 7). Measurement of the distance between the tendon and bone was performed. Images were evaluated by two readers, first independently and in cases of discrepancy in consensus. Sensitivity and specificity for detecting combined pulley ruptures were calculated.

RESULTS

Tendon bone distances were significantly higher in the crimp grip position than in the neutral position. Sensitivity and specificity for detecting combined pulley rupture were 92.86 % and 100 % respectively in the crimp grip position and 78.57 % and 85.71 % respectively in the neutral position. Kappa values for interobserver reliability were 0.87 in the crimp grip position and 0.59 in the neutral position.

CONCLUSION

MRI examination in the crimp grip position results in higher tendon bone distances by subjecting the pulleys to a higher strain, which facilitates image evaluation with higher interobserver reliability, higher sensitivity, and higher specificity for combined pulley rupture compared with examination in the neutral position.

Flexor pulley system: anatomy, injury, and management

Flexor pulley injuries are most commonly seen in avid rock climbers; however, reports of pulley ruptures in nonclimbers are increasing. In addition to traumatic disruption, corticosteroid-induced pulley rupture has been reported as a complication of treating stenosing tenosynovitis. Over the last decade, there have been 2 new developments in the way hand surgeons think about the flexor pulley system. First, the thumb pulley system has been shown to have 4 component constituents, in contrast to the classic teaching of 3 pulleys. Second, in cases of zone II flexor tendon injury, the intentional partial A2 and/or A4 pulley excision or venting is emerging as a component for successful treatment. This is challenging the once-held dogma that preserving the integrity of the entire A2 and A4 pulleys is indispensable for normal digit function.

Tendon injuries of the hand

Tendon injuries are the second most common injuries of the hand and therefore an important topic in trauma and orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons, but less frequent injuries, e.g., damage to the functional system tendon sheath and pulley or dull avulsions, also need to be considered. After clinical examination, ultrasound and magnetic resonance imaging have proved to be important diagnostic tools. Tendon injuries mostly require surgical repair, dull avulsions of the distal phalanges extensor tendon can receive conservative therapy. Injuries of the flexor tendon sheath or single pulley injuries are treated conservatively and multiple pulley injuries receive surgical repair. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger an “intrinsic” tendon healing to guarantee a good outcome. Many substances were evaluated to see if they improved tendon healing; however, little evidence was found. Nevertheless, hyaluronic acid may improve intrinsic tendon healing.

Surgical repair of multiple pulley injuries--evaluation of a new combined pulley repair

PURPOSE

We report on a combined repair of multiple annular pulley tears using 1 continuous palmaris longus tendon graft to restore strength and function.

METHODS

We treated 6 rock climbers with grade 4 pulley injuries (multiple pulley injuries) using the combined repair technique and re-evaluated them after a mean of 28 months.

RESULTS

All patients had excellent Buck-Gramcko scores; the functional outcome was good in 4, satisfactory in 1, and fair in 1. The sport-specific outcome was excellent in 5 and satisfactory in 1. Proximal interphalangeal joint flexion deficit slightly increased in 1 patient and remained the same in the other 5. Climbing level after the injury was the same as before in 4 and decreased slightly in 2 climbers.

CONCLUSIONS

The technique is effective with good results and has since become our standard treatment. Nevertheless, it is limited in patients with flexion contracture of the proximal interphalangeal joint.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

The flexor tendon pulley system and rock climbing

Rock climbing has increased in popularity over the past two decades. Closed traumatic rupture of the finger flexor tendon pulleys is rare among the general population but is seen much more commonly in rock climbers. This article reviews the anatomy and biomechanics of the finger flexor tendon pulleys, how they may be injured in rock climbing and how these injuries are best diagnosed and managed.

Flap irritation phenomenon (FLIP): etiology of chronic tenosynovitis after finger pulley rupture

After a pulley rupture, most climbers regain the full function of their previously uninjured fingers. However, in some cases of pulley rupture, a persistent inflammation of the tendon sheath is observed. In this study, 16 cadaver fingers were loaded until pulley rupture and then studied for the rupturing mechanism. In addition, two patients with this pathology were investigated using ultrasound and MRI, and received surgery. In 13 fingers, a rupture of one or several pulleys occurred and almost always at the medial or lateral insertion. In one finger, a capsizing of the pulley underneath the intact tendon sheath was observed, leading to an avulsion between tendon and tendon sheath. A similar pathology was observed in the ultrasound imaging, in MRI, and during surgery in two patients with prolonged recovery after minor pulley rupture. In cases of prolonged tenosynovitis after minor pulley rupture, a capsizing of the pulley stump is probably the cause for constant friction leading to inflammation. In those cases, a surgical removal of the remaining pulley stump and sometimes a pulley repair may be necessary.