Injuries to the Finger Flexor Pulley

System in Rock Climbers:

Current Concepts
Volker Rainer Schöffl, MD, Isabelle Schöffl, MS

From the Department of Trauma and Orthopaedic Surgery, Klinikum Bamberg, Bamberg, Germany; De-
partment of Trauma and Orthopaedic Surgery, Friedrich Alexander University, Erlangen-Nuremberg, Ger-
many; and the Institute of Medical Physics, Friedrich Alexander University, Erlangen-Nuremberg, Germany.

Closed traumatic ruptures of finger flexor tendon pulleys began to be recognized specifically
over the past several decades. This injury, although rare in the general population, is seen
more commonly in rock climbers. This article analyzes this type of injury and the current
diagnostic and therapeutic criteria. Ultrasound and magnetic resonance imaging are used to
differentiate between a pulley strain, partial rupture, complete rupture, or multiple ruptures.
Grade I to III injuries (strains, partial rupture, single ruptures) are treated conservatively with
initial immobilization and early functional therapy under pulley protection. Grade IV injuries
(multiple ruptures) require surgical repair. (J Hand Surg 2006;31A:647– 654. Copyright ©
2006 by the American Society for Surgery of the Hand.)
Key words: Pulley injuries, rock climbing, annular pulleys, flexor tendon, climbing.

losed traumatic ruptures of finger flexor ten- forcing structure of the tendon sheaths, forming a

C don pulleys presented as a new complex in-

jury in rock climbers during the mid-
1980s.1–5 Further reports followed giving various
diagnostic and therapeutic recommendations.6 –13 Al-
though the open injury of the pulley system demands
a primary reconstruction,4,14 there have been no clear
guidelines for the procedure with a closed pulley
rupture. Initially a surgical repair was the primary
recommendation although currently a nonsurgical
approach, at least for the single rupture, has become
the mainstay of treatment.5,13–23 This noninvasive
approach is based on biomechanical analyses of the
flexor tendon pulley system,16,24 –29 in addition to the
very good functional results of several climbers who
got better by means of self therapy.4 Several studies
have shown a good to excellent outcome after con-
servative therapy19 –21 and the strength deficit in the
finger flexion caused by pulley rupture, which occurs
initially, resolves quickly.30 Magnetic resonance im-
aging (MRI) has been the main diagnostic aid,7,31–34
although ultrasound examination has proven an ex-
cellent diagnostic aid with lower costs.20,33,35– 40
Anatomy
The finger flexor tendon pulley system performs in
combination with the cruciate pulleys as a rein-
fibro-osseous channel through which the flexor
tendons are maintained close to the phalanges.
There are 5 annular pulleys (A1–A5) and 3 weaker
cruciate pulleys (C1–C3). Great variety in the pul-
ley anatomy can be observed.11,41– 43 The A2, A3,
and A4 pulleys are fairly constant in their occur-
rence.
Biomechanics
The main function of the pulley system is to maintain
the flexor tendons close to the bone, thus converting
linear translation and force developed in the flexor
muscle–tendon unit into rotation and torque at the
finger joints. A loss of 1 or several of the pulleys will
cause bowstringing, which leads to a loss of strength
and a decreased range of motion.9 These deficits are
a function of the specific pulley or pulleys being
ruptured. The A1 and A5 pulleys are expendable.44
With respect to the other pulleys, the importance of
each pulley is controversial. Many investiga-
tors2,4,5,9,45,46 maintain that the A2 and A4 pulleys
are the most important for preventing bowstringing,
thus ensuring optimal force transmission. The A3
pulley, however, has an important part in controlling
the degree of tendon bowstringing as well and is
most effective for maintaining the tendon close to the

The Journal of Hand Surgery 647

648 The Journal of Hand Surgery / Vol. 31A No. 4 April 2006
phalanges as a consequence of its positioning at the
proximal interphalangeal (PIP) joint.9,44,47,48
Injury Patterns
Most injuries to climbers are concentrated on the
hand and fingers, with flexor pulley injuries being the
most frequent.6,7,19 –21,49 –51 The middle and ring fin-
gers are the most prone to injury.23,30,52,53 This find-
ing is to be expected because the middle finger is
used commonly to pull in isolation but seems sur-
prising involving the ring finger. It is understandable
if the function of finger crimping during climbing is
analyzed further. In climbing there are 2 different
general finger positions for holding on to an edge, the
hanging and the crimp positions (Figs. 1, 2). In the
crimp position the distal interphalangeal joints are
extended, the PIP joints are flexed, and the metacar-
pophalangeal joints are extended. The carpus is ex-
tended slightly to increase strength development for
finger flexion. In the crimp position the carpal joint
Figure 1. The hanging finger position.
Figure 2. The crimping position.
deviates slightly ulnarly and has mild supination,
placing increased stress on the ring finger. Even if the
ring finger appears to be less powerful than the
middle and the index fingers, this rotational moment
increases stress and injury potential to its pulleys.54
Furthermore the middle finger is protected on both
sides by fingers of approximately the same length,
whereas the small finger is much shorter than the ring
finger and thus gives less support. Injuries to the
index finger are rare because it is stabilized through
the thumb and the middle finger.
In the hanging finger position all the distal inter-
phalangeal, PIP, and metacarpophalangeal joints are
flexed. Burtscher and Jenny55 mathematically ana-
lyzed forces on various finger positions and found a
force of 599 N on the pulley system in the PIP joint
if it is in a flexed position of 135°. The biomechani-
cal analyses by Bollen2 showed a force of 450 N on
the A2 pulley. Roloff et al29 found the force acting on
the A4 pulley to be 269 N in maximum force pro-
duction during the crimp position. Considering these
high forces on the pulley system, the maximum load
to tear the pulleys needs to be considered. Lin et al26
found a maximum tear load of the A2 pulley of 400
N whereas Widstrom et al56,57 found a maximum tear
load of 137 N. These studies show that the forces on
the pulleys in the crimping position are very close to
their biological tearing force. If in addition to these
high forces the climber’s hand slips off a hold or a foot
comes loose, the biological strength of the pulley sys-
tem can exceed its strength limit and fail (Fig. 3).
 Schöffl and Schöffl / Injuries to the Finger Flexor Pulley System 649

joint capsular injuries, fractures, or atraumatic epiph-

yseal fractures in adolescent climbers must be per-
formed. Clinically it rarely is possible to give an
exact diagnosis and to distinguish between pulley
strain, partial or complete rupture, and other differ-
ential diagnoses so further diagnostic evaluation is
necessary. For further evaluation an algorithm13,21
was introduced and can be used as a clinical guide
(Fig. 4).

Diagnostics
According to the algorithm and the reports of Gabl et
al16 anteroposterior and lateral radiographs always
should be performed to exclude fractures or volar
plate avulsion injuries and chronic overuse fractures
in adolescent climbers. If there also is suspicion of an
atraumatic epiphyseal fracture in the face of a nega-
tive radiograph then further evaluation through MRI
is essential because early stages of epiphyseal inju-
ries sometimes only are visible on MRI sequenc-
es.58 – 60
The MRI has proven to be highly accurate in detect-
ing pulley injuries in many studies15,19,31,33,34,61,62 and
is accepted widely The MRI cannot directly detect the
damaged pulley but the T1 sequences show the dehis-
cence of the tendon from the bone and the T2 sequences
help to distinguish tendonitis, peritendon inflammation,
Figure 3. Complete rupture of A2 and A3 pulley. intra-tendon substance lesions, and partial ruptures.
Nevertheless the high cost associated with MRI inhibits
its use in a universal fashion with digital injuries. Re-
Clinical Findings
Most climbers report an acute onset of pain while
performing a hard move or slipping off a foothold.
Sometimes a loud popping noise is noted. There is
palpation tenderness on the palmar aspect of the
injured pulley, accompanied by swelling and some-
times hematoma. If the patient develops tension in
the flexor tendon against resistance then a subluxa-
tion of the flexor tendons may be detectable. Visible
bowstringing only occurs with multiple pulley rup-
tures. When the A2 pulley ruptures an increased
distance of the flexor tendon to the bone can be
palpated if the injured finger is opposed to the thumb
in a crimping position. In complex lesions with mul-
tiple pulley ruptures or in combination with an injury
to the lumbrical muscles an extension deficit of the
proximal interphalangeal joint can occur, leading to
contraction. This extension deficit also is caused by
intra-articular hematoma in the PIP joint with swell-
ing in the palmar aspects of this joint. Differential
diagnosis between tendonitis, which also can have a
sudden onset after intensive training in climbing, Figure 4. Diagnostic–therapeutic algorithm.
650 The Journal of Hand Surgery / Vol. 31A No. 4 April 2006
Table 1. Pulley Score
Grade Injury
Grade I Pulley strain
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 A2/A3, A2/A3/A4, or
single rupture (A2 or A3) combined with
lumbricalis muscles or collateral
ligament trauma
cently ultrasound examination has lead to the same
diagnostic accuracy, if not better, than the MRI by
allowing a dynamic examination.17,33,35– 40 Ultrasound
examination can be considered the gold standard and
only in cases of doubt should an additional MRI be
performed.21
Grading
For further scientific evaluation and therapeutic
guidelines a grading score was developed (Table
1).21 Grade I injuries are pulley strains with no in-
creased dehiscence of the bone to the tendon on MRI
or ultrasound (⬍2 mm). The complete rupture of an
A4 pulley has a very good prognosis, sometimes
leading to full recovery within 4 to 6 weeks. This
injury has the same general severity as a partial
rupture of the more essential A2 or A3 pulleys. These
injuries are rated grade II. The complete rupture of
the A2 or A3 pulleys, leading to a prolonged recov-
ery, is rated grade III. Grade IV injuries include
complex lesions with multiple pulley injuries or sin-
gle pulley injuries combined with lumbrical muscle
damage or collateral ligament rupture. This latter
grade injury leads to a functional deficit if not re-
paired surgically Grade I to III injuries should have
conservative therapy and grade IV injuries should
have surgical repair.
Therapy
In 1990 Bollen2 and Tropet et al5 reported on a climber
with closed traumatic pulley rupture. Both investiga-
tors, Bollen with conservative treatment and Tropet
with a surgical procedure, achieved good functional
results. Over the past decade further studies about sur-
gical and conservative treatment were reported6 –13,51
but without general guidelines on treatment. Initially the
indication for a surgical repair was more common al-
though currently a nonsurgical approach, at least for the
single rupture, has become the standard treat-
ment10,17,19 –23,51,63– 65 and has shown good to excel-
lent outcomes (Schöffl I, et al, in press).19 –21,30 This
approach is based on biomechanical analyses of the
flexor tendon pulley system16,24,25,28,29,54,66 –70 and the
very good functional results of many climbers who had
self-therapy after pulley rupture.4,6,7 The initial strength
deficit disappears after 3 to 6 months.30 Bollen1,4 re-
ported a survey conducted at the British National
Climbing Championships in 1989 during which 18
climbers showed increased bowstring phenomena of
the fingers. None of these athletes had any kind of
previous therapy at the time of the competition and all
had good function and few complaints. Gabl et al16
used MRI, visible bowstring, and ultrasound examina-
tion17 to determine the indication for conservative or
surgical therapy. They performed surgery if the bow-
string of the flexor tendon on the MRI extended prox-
imal to the base of the proximal phalanx of the involved
finger.
Even though a conservative approach to the single
pulley injury has become the treatment standard,
little distinction has been made concerning the im-
portance of the different pulleys. Because an A2-
pulley tear has a prolonged recovery in comparison
with an A4 tear, we suggest the earlier-mentioned
grading system21 and the therapeutic guidelines of
Table 2.21
Conservative Therapy
Based on the biomechanical analyses of Bollen,1 non-
surgical treatment is becoming standard for the single
rupture. Bollen1 described a tearing force of 500 N for
a 1.5-cm–wide tape above the A2 pulley, which allows
good protection of the pulley. Although newer studies
by Warme and Brooks70 could not find a different
pulley tearing force with or without tape and
Schweizer68 could not show the biomechanical benefits
of taping, this type of conservative treatment results in
very good functional outcomes.10,17,19 –23,51,63– 65 We
recommend an initial immobilization period of 10 to 14
days after the trauma using a palmar splint combined
with edema control therapy. Early functional therapy
should follow (finger gymnastics, elastic-band hand ex-
ercises, putty or compression balls) with pulley protec-
tion through tape or thermoplastic/soft-cast ring splint.
Easy sport-specific activities are allowed for grade III
injuries after 6 to 8 weeks under pulley protection
(tape). Full-sport activities can be performed after 3
months but taping should be continued for at least 6
months. With the development of the H-tape introduced
a biomechanically based new taping method allowing
grade II injuries shorter treatment periods (Table 2)
(Schöffl I, et al, in preparation). The initial strength
 Schöffl and Schöffl / Injuries to the Finger Flexor Pulley System 651

Table 2. Therapeutic Guidelines

Grade I Grade II Grade III Grade IV
Injury Pulley strain Complete rupture of A4 Complete rupture Multiple ruptures as
or partial rupture of A2 or A3 A2/A3, A2/A3/A4,
A2 or A3 or single rupture
(A2 or A3)
combined with
lumbricalis muscles
or ligamental
trauma
Therapy Conservative Conservative Conservative Surgical repair
Immobilization period None 10 10–14 14
after surgery, d
Functional therapy, wk 2–4 2–4 4 4
Pulley protection Tape Tape Thermoplastic or Thermoplastic or soft-
soft-cast ring cast ring
Begin easy sport- After 4 weeks After 4 weeks After 6–8 weeks 4 mo
specific activities
Begin full sport-specific 6 wk 6–8 wk 3 mo 6 mo
activities
Duration of taping 3 3 6 ⬎12
through climbing,
mo

deficit will be compensated for after 3 to 6 months but
the dehiscence between bone and tendon will remain
the same in ultrasound follow-up examinations. In a
recent study Schöffl et al30 showed no persistent finger
strength deficit with excellent functional outcome by
the Buck-Gramcko score.71
Surgical Repair
Grade IV injuries require surgical repair to prevent
functional deficits.11,17,19 –21,72 Clinically the flexion
of the distal interphalangeal joint is reduced and
sometimes an extension deficit of the proximal inter-
phalangeal joint occurs.1–7,16,17,19 –21,30,45,51 The ba-
sis for surgical repair are the biomechanical studies
of Lin et al26 and the comparison of surgical repairs
performed by Widstrom et al.56,57 A simple suturing
of the remaining incomplete rims of the pulley tears
have proven insufficient so a reconstructive-type re-
pair is essential. Various methods have been de-
scribed: Kleinert and Bennett73 repair after Weilby’s
idea, belt-loop technique of Karev et al,74 single-loop
technique according to Bunnel,75 Lister28 repair with
flexor retinaculum, palmaris longus tendon trans-
plantation through the volar plate according to Doyle
and Blythe,76 loop-and-a-half technique of Widstrom
et al,56 triple-loop technique by Okutsu et al,77 and
the extensor retinaculum graft by Gabl17 and Mou-
tet.11
Considering the biomechanical analyses of Wid-
strom et al56,57 and the reports of Hahn and Lanz,42
we favor the loop-and-a-half technique of Widstrom
et al56 with a free transplant of the palmaris longus
tendon. Even considering that Weilby’s repair as
described by Kleinert and Bennett73 has been re-
ported as having the best functional results, sport
climbers need a higher tearing force of the recon-
struction. This ability is maximized by the loop-and-
a-half technique. Nevertheless the final decision is
made during the surgery according to the anatomic
situation. For reconstruction of the A3 pulley the
loop-and-a-half technique is not an ideal solution
because the loop can cause irritation on the extensor
tendon at the proximal interphalangeal joint. In this
situation an extensor retinaculum graft should be
used. Gabl et al,16,17 Moutet et al,11,12 and Voul-
liaume72 reported good results using this graft, but
mostly on single pulley ruptures. In prolonged recov-
ery after grade III injuries, especially with tendonitis
or partial A2 ruptures in combination with A3 rup-
tures, a tenosynovectomy with pulley repair through
an extensor retinaculum graft is recommended. After
surgery we recommend initial immobilization for 2
weeks followed by early functional motion with pul-
ley protection through thermoplastic or a soft-cast
ring for 4 weeks. Taping should be continued for at
least 6 months during sports activities. Overall the
final treatment results are good with near or normal
motion and strength, allowing a return to sporting
activities. In 7 patients with grade IV pulley ruptures
652 The Journal of Hand Surgery / Vol. 31A No. 4 April 2006
who had surgical reconstruction we found 4 excel-
lent, 2 good, and 1 fair result according to the Buck-
Gramcko score.20,71 The functional result was excel-
lent in 1, good in 5, and fair in 1 patient whereas the
sport-specific abilities were excellent in 1, good in 3,
and fair in 2 patients.20
The closed traumatic pulley rupture in rock climb-
ers appeared as a new injury pattern in the 1980s.
With clinical suspicion and exclusion of a fracture or
joint capsular/collateral ligament lesion, ultrasound
allows differentiation between a pulley strain and a
partial, complete, or multiple rupture. If the ultra-
sound fails to give an exact diagnosis then an MRI
should be performed. The injuries are graded accord-
ing to a system to define therapeutic standards. Grade
I to III injuries (strains, partial ruptures, single rup-
tures) are treated conservatively with initial immobi-
lization and early functional therapy under pulley
protection. Grade IV injuries (multiple ruptures) re-
quire a surgical repair. For reconstruction we prefer
the loop-and-a-half technique of Widstrom et al56
with several excellent alternatives being the Weilby
repair73 or a retinaculum extensorum graft.11,16,17
After surgery an initial immobilization period fol-
lowed by functional therapy is performed. Although
closed pulley ruptures initially were typical for
climbers, whose fingers experience high-impact
forces, the injury also might be common in non-
climbers. As we have become more aware of this
injury we have diagnosed 8 cases of closed pulley
ruptures on nonclimbers within the past 7 years. The
traumatic mechanism was nearly the same including
the lifting of heavy items with crimped fingers.78
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
article.
Corresponding author: Dr. Volker Rainer Schöffl, Department of Trauma
and Orthopedic Surgery, Klinikum Bamberg, Bugerstr. 80, D-96049
Bamberg, Germany; e-mail: volker.schoeffl@t-online.de.
Copyright © 2006 by the American Society for Surgery of the Hand
0363-5023/06/31A04-0021$32.00/0
doi:10.1016/j.jhsa.2006.02.011
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