Performance rock climbing
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The treatment recommendations are controversial as some hand surgeons still treat single pulley-disruptions with reconstruction . Non-operative treatment is generally functional. The healing-time is between 2 to 3 months and full load-bearing can be expected after 4—6 months. We recommend the use of a special pulley protection ring fig. After two months, the ring is replaced by a pulley protection tape fig.
If the injury is left untreated or protected only with a tape the amount of bowstringing remains the same. If, however, two or even more pulleys are disrupted for instance A2 an A3 or A2, A3 and A4-pulley , the amount of bowstringing increases substantially leading to a loss to the active flexion range of motion of the finger and a reconstruction of the ligament has to be considered. This can be performed with a graft from the extensor retinaculum or a free tendon graft. The results of such interventions are generally good and do not differ much between techniques [13, 25, 26].
However, whether all these patients need a reconstruction at all is still being debated. We have seen a series of patients with multiple pulley ruptures who returned to their previous climbing level without restriction except for a small loss of flexion range of motion. It has to be taken into consideration that pulley reconstruction leads to a rehabilitation time of several months. Many climbers try to protect their flexor tendon pulleys by applying a circular tape around the proximal phalanx. Their intention is to prevent an injury of an otherwise healthy flexor tendon sheath pulley system.
Whereas in the situation of a disrupted pulley a certain amount of bowstringing can be relieved by a tape, any effect of a protective pulley-tape around an intact pulley is very unlikely [27, 28]. Probably more important to prevent a pulley injury is the correct warming-up procedure and the avoidance of a pronounced crimp grip position. This consists of finger flexion exercises with therapeutic silicon rubber mastic and slowly increasing load to the finger flexors with climbing for 20—30 minutes.
This effect could only be shown when performing climbing movements and was not observed with other warming-up techniques. Therefore we recommend climbing about 3—4 routes with 40 moves or 8—12 boulder-problems  with increasing intensity. Chronic tenosynovitis of the flexor tendons is the second most common finger problem in rock-climbers.
Clinically the A2 or A4 pulleys are painful upon palpation; sonographically synovitisor scar formation and an alteration of the pulley similar to that of a trigger finger can be observed. Besides reduction of training intensity and strict prevention of the crimp-grip-position, local or systemic NSAID medications or steroid-infiltrations into the flexor tendon sheath are possible. The development of this problem can sometimes be very frustrating with recurrent painful periods lasting more than a year.
Nevertheless, the prognosis is favourable and operative treatment such as tenolysis or a synovectomy are rarely necessary. In difficult sport climbing routes, particularly in lime-stone crags, very small holes called one or two-finger pockets are sometimes only deep enough to provide a hold for the distal phalanges.
These often very shallow pockets are blocked with only one or two fingertips. In order to increase the loading of one finger, all other not loaded fingers are completely flexed into the palm while the load-bearing finger is nearly extended fig. A side effect of this manoeuvre is that the flexor digitorum profundus tendons in the hand are shifted in different directions to one another. The common origin of the lumbrical muscle belly III and IV from two adjacent flexor digitorum profundus tendons are moved apart and may suffer a strain or muscle tear.
This usually happens when pulling on a one-finger-pocket resulting in a sudden sharp pain in the palm. Clinically, pain in the palm can be provoked when grasping a one or two finger pocket but not when loading all fingers with a similar degree of flexion . To prevent the formation of scar tissue in the lumbrical muscle belly and to prevent further injury, it is very important to start doing stretching exercises immediately following injury. This is done in the same way the injury was provoked but with much less load. A similar injury pattern is observed in the carpal tunnel at the wrist or in the extrinsic finger flexors in the forearm.
Similar stretching exercises are recommended. Granite crack climbing requires its own specific techniques. Jamming and mortising the hand, arm, leg and even the whole body into a crack — depending on the size — is mandatory. Small cracks 1—4 centimetres in width are climbed by jamming contorted fingers into the crack fig.
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If climbers slip off the rock with their feet, sudden high torsional forces are applied to the fingers, which may lead to fractures, ligament tears or even dislocation of the finger joints. These mostly non-climbing-specific injuries can usually be treated by conservative means taping, small splints if only ligaments are concerned be aware of hardly visible impression fractures. However, the ligaments and capsular structures of the finger joints are complex and provide stability not only in the radio-ulnar direction.
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Therefore, instability has to be assessed by a physician in order to decide which kind of tape or splint is needed. If the treatment is inadequate, a later instability, deformation or contraction may develop. Only the ulnar collateral ligament of the metacarpophalangeal joint of the thumb skiers-thumb is an injury, which often has to be treated surgically.
The problem in this situation is that the torn ligament may dislocate proximally over the adductor tendon and stay away from the original insertion . Since no healing potential exists, this type of injury has to be excluded by a sonography or a MRI. As bouldering has become more and more popular, falls onto the wrist, even if protected with a crash-pad portable mattress have led to wrist injuries. But also falls during rope climbing with a swing against the wall absorbed by the hands are similar to high-energy trauma cases.
Distal fractures of the radius are usually quite painful or have an obvious deformity when dislocated so that the climber shows up shortly after injury on an accident and emergency department. In contrast, injuries to ligaments scapholunate or lunotriquetral ligament disruption , TFCC triangular fibro cartilage, ulno-carpal disc and particularly fractures of the scaphoid are very often only slightly painful.
Frequently these injuries are seen only several months after the initial trauma. A ligamentous injury is quite difficult to treat at such a late stage and the prognosis is much worse. Scaphoid-fractures almost always turn into a non-union if left untreated and mostly end up in degenerative changes of the wrist SNAC [scaphoid non-union advanced collapse] . We recommend thoroughly investigating a wrist, which has been painful for more than three weeks to exclude such an injury.
A climbing-specific injury that we have observed is the indirect fracture of the hamate hook during a repeated attempt of an under-cling-grip on a difficult boulder. This climber held his wrist in an ulnar-abduction where the FDP-tendons of the small and ring-finger are deflected by the hamate hook. The high forces at the hamulus finally led to a basal-fracture of the hamate indirect fracture type. The fracture could be treated successfully with a special splint in ulnarand radial deviation of the wrist .
Climbing of particularly difficult routes with small holds leads to very high impact-forces on the finger bones and joints with impressive changes of the thickness of the cortices fig. Whether rock-climbing leads also to a degenerative arthritis of the finger joint has already been debated and investigated by different authors [33—35].
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They described radiographical changes of finger joints of long-term climbers such as osteophytes, subchondral sclerosis and joint space narrowing. Nevertheless, none of those authors could show clear evidence of an increased rate of degenerative arthritis compared to an age-matched group of non-climbers [33—35].
In these studies the radiographs were mostly performed in an anterior-posterior view and the changes of the joints were assessed according to the Kellgren and Lawrence  or the Altmann score .
We conducted a study  where we investigated the anterior-posterior and the lateral views of the fingers in a group of 31 Swiss performance sport climbers. The mean of years of climbing was 20 years and the mean of the highest reached sport climbing level was 8b redpoint French grade, corresponding to UIAA grade We observed that in the lateral views fig. However there were almost no other apparent changes such as subchondral cysts, osteolysis or joint space narrowing. Most of the climbers concerned had performed bouldering at a high level and were older than 35 years. These climbers reported rare episodes of slight pain and stiffness on the dorsal side of the joints when hitting hard objects or after climbing intensively with the crimp-grip-position.
This can be explained by an irritation of the dorsal side of the joint capsule by the osteopytes . The pain usually disappears after 3—5 weeks, sometimes corticosteroid-injections are necessary and very rarely such an osteophyte has to be removed. Even when calcified parts or osteophytes are broken off and freely move in the joint, they are taken up by the joint capsule and become asymptomatic after several weeks. We still do not know the long-term effects of sport climbing to the finger joints.
The oldest climbers performing the sport at such a high level are generally not older than early fifties. However, it seems that the changes observed have arisen through adaptation and do not show the same pattern of the common inherited degenerative arthritis poly-arthrosis. By doing so, the joints are loaded in a midway-position whereas the joint contact area remains as large as possible. The full crimp-grip where the thumb overlays the index finger should therefore be avoided wherever possible. Particularly in young adolescent climbers or in children, the full crimp-grip-position has to be avoided.
The growth plates of the finger bones are not closed until the age of 17—19 years, are the weakest structures of the finger, and are most susceptible to injuries [42, 43]. In the full crimp-grip-position a shift of the middle phalanx results in a very high load proximal to the dorsal part of the base of the middle-phalanx. This may lead to growth-plate overload, consolidation and partial necrosis and finally to growth plate fracture Salter-Harris II fracture, fig.
Premature partial or complete closure of the growth-plate with uneven or interrupted further growth of the finger bone ending up in a considerable axial-deviation or foreshortened finger may follow. Even complete destruction of the joints and early degenerative changes are possible. As soon as pain without obvious trauma in the PIP-joints is apparent in an adolescent, the crimp-grip-position should not be tolerated at all until the pain disappears or the growth-plates have closed at the age of 17—19 years.
Regular radiographic controls are mandatory. Carpal tunnel syndrome, the most common nerve compression syndrome  is also the most common reason for surgical nerve decompression in climbers and is managed in the same manner as in non-climbers without disadvantage possible tendon bowstringing at the wrist.
But also the radial nerve at the elbow and proximal forearm may be an origin of pain supinatortunnel syndrome. Since this is purely a motor nerve, only weakness of the wrist and finger extensors and a dull pain are perceived. Stretching exercises and deep friction massage of the supinator muscle are usually helpful and surgery is rarely necessary. Rarely affected is the median nerve at its passage through the pronator teres and the ulnar nerve at the elbow cubitaltunnel syndrome and at the hypothenar. Digital nerves may also be compressed  but rather acutely neuropraxia when squeezed into cracks or holes activating a sharp electrifying pain directly over the nerve with a hyposensitivity and numbness distal to the injury.
Symptoms usually disappear after a few weeks. In contrast to the commonly observed trigger finger of the A1 pulley, climbers mostly suffer from finger flexor tendosynovitis as mentioned above, usually at the A2 pulley, which is not associated with triggering. Ganglion cysts are found in climbers around the A1 and the A2 pulley, are usually only a few millimetres in size but rock-hard and may provoke pain under direct pressure during climbing. Again, digital nerves may come under pressure of such a cyst, which occasionally requires excision.
Performance rock climbing
Besides the nerve compression syndromes around the elbow, the most commonly disturbing pain in climbers is the epicondylitis or epitrochleitis. These insertion tendinopathies can be very annoying but are usually self-limiting and rarely require surgery. Infiltrations of any medication  had no effect in a recent study and steroids in particular should be avoided. An effective treatment option is active strengthening  of the elbow flexors. With his friends he went back to the woods and created new routs and focused on the style of climbing.