Pulley Injuries
Anatomy
Pulleys are annular ligaments that are located throughout the finger with 5 in total, starting at the distal end of the metacarpal (A1) and moving to the proximal palmar side of the phalanges of digits 2-5.
Flexor muscles, FDP (distal) and FDS (proximal) run through the carpal tunnel (located at the wrist) and pulleys before intersecting at the chiasm (campers Chiasm, splitting of the FDS to connect to the medial phalange) this allows the FDP to continue straight to the distal phalanges.
The Thumb is not injured as much (rare). Runs via carpal tunnel on the radial aspect to the osteofibrous channel then is reinforced by two pulleys.
Pulleys' anatomical job is to hold the flexor tendons close to the bone, this distance is known as “Tendon Bone Distance” (TB) and is used to diagnose the severity of pulley injuries via active range and resisted testing under ultrasound machines.
Annular Ligaments (Pulleys) are low in vascularization, provide hyaluronic acid (lubricate, allowing for less resistance in tendon gliding) they also play a role in providing nutrition to the tendons. Although pulleys are lubricated, there is a genetic component to the structure of the inside of the pulley ring, ranging from smooth to rough (like a cat's tongue). Rough inner pulley walls will increase the individual's ability to resist against high loads of force compared to an individual with smoother pulleys. However, the rough surface can potentially lead to increased severity of pulley injuries when they occur.
Wanna Nerd out and learn more about pulley injuries from some of the best in the world?
Check out the Climbing Medicine Academy Podcast and the Climbing Injury Podcast on Spotify!
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Cruciate Ligaments
Three Cruciate Ligaments are present in digits 2-5, aid in keeping the TB low, allowing the flexors to run close to the bone. They receive little load compared to their pulley counterparts and are not commonly injured.
Property of Mark Karadsheh
Method Of Injury
Pulley injuries are commonly seen in maximal effort climbing or close to maximal climbing with improper recovery and rest. Damage to the pulley system is most commonly seen when aggressive angels such as the full crimp are used (full crimp > half crimp > Open hand) accompanied with fatigue the likelihood of an eccentric contraction of the fingers or a dynamic shift in load (foot slip or generating to the next hold) can create an excessive amount of force on the pulleys. Without proper rest and recovery between climbing sessions or too great of an overall volume throughout the year, repeated bouts of excessive force can lead to sprains or ruptures.
Pulleys can withstand significant loads, some studies suggest up to 400 Newtons (roughly 90 lbs) before failure occurs, with loads around 200 -250 Newtons being seen during climbing fatigue and sudden eccentric contractions are major components to pulley injuries.
Primarily an acute injury presenting with a pull or opening feeling of the hand during a climb, in more severe cases an audible pop can be heard. Following the moment of injury swelling, hematoma and pain on palpation is often present. In the case of a full rupture or multiple pulley ruptures, visible bowstringing of the flexors will be present, this can be hard to visually identify, but professionals can palpate it effectively, ultrasound imaging allows us to see TB.
Assessment
Testing Categories:
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Observation
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Palpation
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Range Of Motion
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Tissue Loading
Observation
When suspecting a pulley injury we can first observe the finger to try to identify two symptoms, bowstringing and swelling. We can not see bowstringing in a straight finger, to test for bowstringing we need to put our finger into a flexed position. Bowstringing presents as the flexor tendons pulling away from the bone, compared to the opposite hand to have a gauge of what your “Normal” may look like. If visible bowstringing is present, then you have successfully identified a pulley injury and should seek professional assessment.
Most Pulley injuries will not display visible bowstringing, if you do see bowstringing, it is likely that multiple pulleys have been damaged in the event.
If not bowstringing is present, the next step is to look for swelling, this is not going to tell you the extent of your injury, but will be one piece of the puzzle to help determine the extent of the injury.
Swelling:
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Pulley Strains: No to Mild Swelling
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Pulley Partial Tear: Mild to Moderate Swelling
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Pulley Full Tear: Moderate to Severe Swelling
Palpation
The purpose of palpation is to check for any pain or irregularities, typically this will produce less pain than the range of motion testing, and therefore we perform it second. No palpitations are necessary on the dorsal (back of the hand) we will only be palating the volar side (palmar or palm side). Locate the suspected injured pulley and lightly use your other hand to palpate and move along the side of your finger on both sides. Move to the middle of your finger and lightly palpate.
Mild discomfort suggests a possible pulley strain
Moderate discomfort suggests a possible partial tear of the pulley
Full tears are hard will either present with severe Discomfort or no discomfort due to the disruptions of the nerve endings. If you have no pain, continue testing to look for other signs before determining your final results.
Range of Motion
Our Third test will be putting the hand and finger through a full range of motion, due to the minimal amount of force regular ranges of motion put on the pulley, this test should be safe to do, but may cause some discomfort.
Pulley Strain: Possible to present with no or mild discomfort throughout the full range of motion.
Pulley Partial Tear: Likely to present with moderate discomfort throughout the full range of motion with more discomfort while creating a fist.
Pulley Full Tear: A2 and A3 pulleys often present as Partial Tears, but can have severe, moderate or no discomfort due to disrupted nerve endings.
Tissue Loading
If you suspect a full Rupture, DO NOT Perform Tissue loading. If you suspect a partial tear or a strain, you can perform the appropriate loading displayed below.
First, recreate the position that caused the original injury, likely a crimping position (do not full crimp stop at the half crimp position).
Second, using your opposite hand, place a half crimp on the palm of your hand and apply force SLOWLY and LIGHTLY. When discomfort is experienced, there is no need to continue and you should stop the test.
If discomfort is experienced under MILD FORCE, it is likely a partial tear
If discomfort is experienced under MODERATE FORCE, it is likely a mild strain
Repeat step one and two with an open hand position, if you can no discomfort in the open hand position, a pulley strain is likely, however, if discomfort is experienced in this position you may have a partial pulley tear.
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Recovery
Suggested recovery follows the Principles of Unloading, Mobility, and Strengthening, followed by a return to Sport. Time period for each stage will vary based on the degree of the injury. However, the general path to returning to climbing will be similar for each. The timeframe for each stage of recovery will vary depending on the severity of the injury, it is best to seek a professional diagnosis and a return-to-climbing plan.
Supportive Tape
There are two recommended protection recommendations based on the literature, H-Taping, and Pulley Splints. (click the name of the tape job for a video)
H-Tape: More supportive than the figure 8 and just as easy.. Reduces the tendon bone distance and increase strength in the crimping position in injured fingers. Video Linked
Pulley Splints: Medical grade finger splints are ideal for grade 3 and above, holding the tendons closer to the bone taking stress of the pulley system. It is advised to wear the splint 23 hours a day taking stress off the pulley allowing healing. Video Linked
Splints are able to apply more force than the tape, with out cutting off blood flow to the distal finger.
Pulley Injury Grading
Figure 1. Pulley Injury Grades and Recovery Information From Schöffl, V., Schöffl, I., Lutter, C., & Hochholzer, T. (2022). Climbing medicine: A practical guide. Springer International Publishing Springer.
Mobility: Functional Therapy
Manual massage:
Using an acupressure ring can help increase blood flow to the finger increasing the rate of healing, do not perform this excessively or you will aggravate the tissue.
5-8 mins 3 times a day Max
Mobility Flossing:
Wrap your finger with VooDoo Floss or Rock Floss, not to the point where you lose circulation. Test by pressing on the end of your finger and seeing if the blood returns. Once sure the wrap is not to tight, move your finger through full range of motion.
3 sets of 60 seconds once a day.
Tendon Glides: Tendon gliding is meant to run the tendons through the full range of motion promoting healing. Keeping the wrist in a neutral angle promotes the reduction of pressure and increases mobility, strength and blood flow. Video Linked
Property of Handtherapy Group, Tendon Gliding exercise
Loading: Functional Therapy
Extensor Loading: Use a rubber band to load the finger extensors, put one band around the tips of your fingers and spread your hand.
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This helps strengthen the extensors that help to protect the pulley ligaments.
3 sets 60 seconds once per day
No Pain Hangs: Low weight hangs completed on a hang board or using a portable hang board, without a dyno monitor the or pulley system managing load can be challenging on the typical hang board. Using a portable hang board and doing “Farmer Carry hangs” while utilizing properly secured free weights makes managing load much more simplistic. Depending on the grade on pulley injury you have experienced the loading time frame and protocols will differ.
7 seconds on 3 seconds for 5 - 7 reps with a 2-3 minute rest between sets for 3 total rounds.
Low Pain Hangs: Following the same format of “No Pain Hangs” by using either a hangboard system or portable hang board increases the load to create mild discomfort of the finger. Pain should be low 2/10 during the exercise. Pain should not persist for more than 3 minutes post-exercise. If pain is present the following day, usually in the morning, reduce load.
7 seconds on 3 seconds for 3-5 reps with a 2-3 minute rest between sets for 4 total rounds.
Property of Jared Vagy, Climb Injury Free. Loading Timelines, and grips for various pulley injuries
Return to Climbing
Keep in mind not all easy climbing is the same, avoid insecure feet, dynamic movements and excessively small holds. Loading should be done on secure, easy terrain (i.e large footholds, small secure moves).
Easy Climbing:
Avoid Half crimping and Full climbing. Climb with and open hang on large comfortable holds on faces equal to or less than vertical. Keeping the Climbing 2-3 grades below your onsight grade.
Moderate Climbing:
Beginning to use soft half crimps on a mild angle, less than to vertical walls if using large stable feet and holds. Keep climbing 1-2 grades below your onsight grade.
References
Schöffl, V., Schöffl, I., Lutter, C., & Hochholzer, T. (2022). Climbing medicine: A practical guide. Springer International Publishing Springer.
Vagy, J. (2018). Climb injury-free: A proven injury prevention and rehabilitation system. The Climbing Doctor.
Miro PH, vanSonnenberg E, Sabb DM, Schöffl V. Finger Flexor Pulley Injuries in Rock Climbers. Wilderness Environ Med. 2021 Jun;32(2):247-258. doi: 10.1016/j.wem.2021.01.011. Epub 2021 May 6. PMID: 33966972.
Schöffl, V., Hochholzer, T., Winkelmann, H. P., & Strecker, W. (2003). Pulley injuries in rock climbers. Wilderness & Environmental Medicine, 14(2), 94–100. https://doi.org/10.1580/1080-6032(2003)014[0094:piirc]2.0.co;2
Schneeberger, M., & Schweizer, A. (2016). Pulley ruptures in rock climbers: Outcome of conservative treatment with the pulley-protection splint—a series of 47 cases. Wilderness & Environmental Medicine, 27(2), 211–218. https://doi.org/10.1016/j.wem.2015.12.017
Hooper, J. (2024, December 1). A2 pulley rehab manual. Hooper’s Beta. https://www.hoopersbeta.com/library/a2-pulley-manual-for-climbers
The Climbing Doctor. (2023, May 16). How to rehab a climbing finger pulley injury. https://theclimbingdoctor.com/how-to-rehab-a-climbing-pulley-injury/?srsltid=AfmBOoptTkfKwEkCZ5z5q53ejbo9xLws5_xUSxOYKMvnZfFPGw53uvFf
Tenosynovitis
Tenosynovitis is an inflammatory condition that affects the sheath covering the flexor tendon and is the most common overuse injury in the rock climbing community. The cause of this injury can be both chronic overuse, which gradually develops over time, or a more acute onset stemming from a single hard training day. Typically, it presents with point tenderness of the tendon sheath at the rim of the pulley, commonly at A2 and A4, and sometimes includes palpable swelling. Due to the location of this injury, it is often mistaken for a pulley injury and can lead to prolonged symptoms due to improper recovery. Therapy is primarily conducted through conservative measures, although some cases may require localized steroid injections. However, the prognosis for this injury is good, and it rarely requires invasive treatment.
Figure 1. Property of Orthoinfo - AAOS Anatomy of the finger
Anatomy
Although this injury commonly occurs near the A2 and A4 pulleys, the injury itself is not damage to the pulley. In order to understand this injury, we have to look at the flexor muscles of the hand and forearm: the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS). The FDP and FDS are covered by a tendon sheath (Figure 1) filled with synovial fluid that acts as a lubricant, allowing the tendons to slide smoothly back and forth. Inflammation of the tendon sheath causes the flexor tendons to create friction at the location of inflammation, leading to the pain felt during movement.
Method of Injury
The cause of this injury can be both chronic overuse, which gradually develops over time, or a more acute onset stemming from a single hard training day. It is important to note that this injury can occur while performing loads that are under the climber's physiological limits (i.e., the injury can occur from easy climbing and doesn't have to stem from high forces).
Chronic onset is often due to an increased load of training and/or intensity, leading to the accumulation of microtrauma to the tendon that doesn't have time to heal. This is very common among ambitious or driven climbers. The onset of this injury commonly occurs in the crimped position, as the angles through which the flexor tendon and its sheath have to travel under the pulley are quite sharp, creating increased flexion on the tendon and friction on the rim of the pulley, particularly at the A2 and A4 pulleys. This repetitive stress can lead to chronic inflammation within the tendon sheath.
This injury can also be triggered by an acute stimulus, such as one or two hard climbing days or sessions.
Assessment
Self-diagnosing this type of injury can be quite challenging and is not recommended. It is recommended that you consult a medical professional, preferably one who can conduct an MRI to check for any halo effect present in the finger. Diagnosing this injury can be difficult because its symptoms often resemble those of pulley injuries. To better understand your injury, consider performing the following tests and exploring the provided links. Both Hooper Beta and The Climbing Doctor offer informative videos that can help you understand these injuries and begin your rehabilitation process. Video Linked
Tenosynovitis typically presents with the following symptoms:
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Pain around the edge of the pulley (the rim of the pulley)
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Minor swelling that can be felt on the palmar side of the finger
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Pain that may extend down into the forearm (less common)
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This condition most commonly affects the A2 and A4 pulleys
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An MRI will often reveal a halo effect, indicating increased fluid accumulation.
Testing
These tests are commonly not going to cause pain with a pulley injury, but may present with pain if you are dealing with a tenosynovitis injury. However, one way to separate these injuries is to look back at your climbing history, was there a foot slip or a pop in your finger that led to this pain? If not, and it snuck up on you, the pulley injury is less likely, but not completely out of the question, as they can also be due to overuse and fatigue.
Extension stretch of the fingers
Property of Hooper’s Beta
Open Hand Drag Position
You can use this chart, developed by Hooper’s Beta, to help separate these injuries.
Property of Hooper’s Beta
Property of Hooper’s Beta
Recovery
Although flexor tenosynovitis is one of the most common injuries climbing the surgical, rehabilitation, and supportive techniques are still not well documented in the literature. There is a lack of studies regarding the effectiveness of taping protocols for this injury, and so there will be no recommendation regarding taping protocols. If you refer to Hooper’s Beta, there is one taping technique he speaks to if you are interested in taping while climbing.
Deloading
As with all injuries, we want to allow the swelling to subside before beginning to rehabilitate the aggravated tissues. This process can take anywhere from 24 to 72 hours or longer if continuous aggravation is applied to the area.
Recommendations:
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No load for 24-72 hours- Compression using a self-adhesive wrap
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Ice for pain and inflammation
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Continue compression overnight and throughout the day if possible
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Use of a putty or soft stress ball to squeeze throughout the day, NO pain should be experienced here
Note: Compression should be light and should not limit range of motion or restrict blood flow.
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Loading
Unlike many injuries, there is mixed information regarding whether or not you should refrain from climbing during the early stages of recovery. However, it is important to reduce the number of movements that are known to irritate the injury. Before we get back on the wall, we should start to load the tissue to ensure that any easy climbing does not stimulate pain rated over a 2/10 or last for more than a few seconds after the exercise. Since we know that the angles during crimping are the primary culprits for this injury, we want to avoid the following:
Avoid:
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Crimping Full
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Crimping
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Small edges and holds
While loading, it is important to do so progressively and safely. If the injury is severe, wait until swelling and pain have subsided before loading the tissue. Loading the tissue can promote increased blood flow and enhance the effectiveness of recovery, but increasing the load too quickly will do the opposite and prolong your recovery.
When returning to loading, it is important to increase the weight slowly and start with an open hand grip using a handboard or portable hangboard with added weight. Keep the pain level under 2/10 and ensure it doesn't linger for more than a few seconds.
Loading Protocols
Low-Intensity Hangs: 30 seconds on, 30 seconds off for 5-10 reps.
(feet on the ground just weighting the fingers with a very light force,
Once there is no pain during low-intensity hangs:
Low/Moderate Farmer Carries: 15 seconds on, 60-90 seconds off for 3-5 reps (using 20-30 lbs).
This is where we can begin to climb if the tissue tolerates the load well and there is no pain after your sets.
References
Schöffl, V., Schöffl, I., Lutter, C., & Hochholzer, T. (2022). Climbing medicine: A practical guide. Springer International Publishing Springer.
Mohn, S., Spörri, J., Mauler, F., Kabelitz, M., & Schweizer, A. (2022). Nonoperative Treatment of Finger Flexor Tenosynovitis in Sport Climbers-A Retrospective Descriptive Study Based on a Clinical 10-Year Database. Biology, 11(6), 815. https://doi.org/10.3390/biology11060815
Hooper, J. (2023, August 17). This common finger pain is not a pulley injury (how to fix it). Hooper’s Beta. https://www.hoopersbeta.com/library/flexor-tenosynovitis
Capsulitis
Capsulitis is often described as a chronic form of synovitis in the finger joint, simply put, its long-term inflammation of the joint and its surrounding capsule. This condition can be caused by mechanical overload, meaning too much stress on the joint from activities like frequent or intense climbing, especially with repetitive finger loading (like crimping or jamming).The inflammation process involves increased production of enzymes that irritate the synovial tissue, as well as pressure buildup from excess joint fluid. This pressure can cause microtrauma and small tears in the joint cartilage. Over time, this leads to joint pain, swelling, stiffness, and reduced range of motion. If left untreated, capsulitis may progress into chronic osteoarthritis due to ongoing cartilage breakdown
Anatomy
This condition commonly affects the interphalangeal (IP) joints, where articular cartilage covers the ends of the phalanges. These joints are enclosed by a fibrous capsule lined with a synovial membrane, which produces synovial fluid essential for joint lubrication and smooth, pain-free movement. Excessive fluid accumulation in the joint cavity increases intra-articular pressure, which irritates the joint structures and initiates a cycle of overstrain, further fluid buildup, and chronic inflammation of the synovial membrane.
Capsulitis in climbers often happens because of repetitive stress on the finger joints, especially when using certain grips like crimping, finger jams, and pockets. These grips put a lot of force on the same side of the joint over and over again, which can irritate the joint capsule (the tissue around the joint). When climbers keep doing this over time, it can cause inflammation and pain in the joint, leading to capsulitis.
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Method Of Injury
Capsulitis in climbers happens when the joints in the fingers get stressed and inflamed from doing the same gripping movements over and over. Grips like crimping, finger jams, and pockets put a lot of pressure on the finger joints, which can cause small injuries in the tissue around the joint. The injury can get worse if climbers don’t give their fingers enough time to recover. When the fingers are constantly used without rest, the inflammation in the joint capsule can become chronic, causing long-term pain and limiting performance.
Capsulitis can also occur acutely, often from a sudden or intense movement that places a lot of stress on the finger joint. This could happen during a fall, an unexpected slip, or when a climber suddenly grips a hold too forcefully. In these situations, the joint capsule can get overloaded in a single, high-force event, causing immediate inflammation and pain.
Property of BoulderFlash
Assessment
Capsulitis is most apparently marked as swelling in and around the joint, reduced range of motion (ROM), with feelings of discomfort or slight pain in the finger or joint. These symptoms are most noticeable after a climbing session, the morning after a climbing session will show exacerbated signs due to the limited movement in our sleep leading to fluid accumulation in the joint.
Symptoms:
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Finger Stiffness (significant in the morning after climbing)
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Decreased ROM
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Pain around the injured joint
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Irritation after training
Testing
Active ROM
With your hand held straight, try curling your fingers so they touch the upper section of your palm. If there is a noticeable difference in range of motion between your affected and unaffected fingers, it may indicate irritation in the joint.
Property of The Climbing Docotor - Nanna Brandt
Joint Over Pressure
Using your non-injured hand, apply gentle pressure to the DIP joint (the joint closest to the fingertip) of the injured finger at the end of its range of motion. Compare this to your non-injured fingers. Reduced range of motion and pain during this test may be signs of capsulitis.
Property of The Climbing Docotor - Nanna Brandt
Compression + Distraction
With the injured finger straight, use your other hand to gently compress the joint. If this causes pain, try gently pulling on the finger to create space in the joint (distraction). If the pain decreases with distraction, this is a strong indicator of capsulitis.
Property of The Climbing Docotor - Nanna Brandt
If there wasn't an obvious acute event that caused the injury, climbers should review their training logs to check for any sudden increases in training volume or intensity. A rise in either can significantly stress the joints and increase the likelihood of developing capsulitis. Similarly, if a climber has had a long break from climbing and then suddenly returns to their training, this can also put extra strain on the joints, making capsulitis more likely.
For a more accurate diagnosis, it's recommended to get an ultrasound on the injured finger. If there is extra synovial fluid compared to the other fingers, it’s a strong indication that capsulitis is present. This can help confirm the diagnosis and guide the next steps for treatment.
Recovery
Since capsulitis is an overuse injury, the first step in recovery should be a full deload of the affected tissue. This gives the joint a chance to calm down and resolve the inflammatory response. It’s important not to load the tissue during this phase, as doing so could prolong the recovery time. However, light activity that doesn’t aggravate the area can help increase blood flow and may support healing.
Although there’s some conflicting information about icing these types of injuries, ice can help relieve pain and improve range of motion, even if it doesn’t directly speed up recovery. In more chronic cases, some research suggests that applying heat may be more beneficial.
Unloading
Mobility
Once pain and inflammation have decreased, the focus shifts to promoting healthy tissue recovery through light rehabilitation. Techniques such as light massage, self-joint mobilization, passive mobilization, and active mobilization can help improve blood flow and support the healing process
Light Massage: Lightly, massage the area with the non affected hand to increase blood flow
Self Joint Mobilization: Place your thumb under the affected finger, use your non affected hand to apply light traction to the joints on a 1-2 second pull relax timing.
Property of Evolution Physical Therapy & Fitness
Passive mobilization: Lightly push the end of your finger inwards, and hold for 5-8 seconds repeat 3-5 times.
Active mobilization: Tendon gliding, move your fingers through full ROM while keeping your wrist and the back of your hand straight.
Property of Hand Therapy Group
Strengthening
No Pain Hangs: Low weight hangs completed on a hang board or using a portable hang board, without a dyno monitor the or pulley system managing load can be challenging on the typical hang board. Using a portable hang board and doing “Farmer Carry hangs” while utilizing properly secured free weights makes managing load much more simplistic. To start we want to be using an open hand grip as we Slowly progress the load and eventually bring back the half crimp position.
Recommended hang durations:
30 seconds on 2-3 minutes off 2-3 sets.
Progressing to
7 seconds on 3 seconds for 5 - 7 reps with a 2-3 minute rest between sets for 3 total rounds.
Final Thoughts
As you return to climbing, it’s important not to overdo it. Jumping back in too quickly with high intensity and volume can cause the injury to flare up again. At the end of the day, this was an overuse injury, and recovery requires a gradual return to activity over several weeks. Keep a training log to track intensity, frequency, and volume, and pay close attention to how your fingers feel during sessions, afterward, and the following morning. This doesn’t mean you can’t climb it just means you need to balance your sessions and reduce the excessive load placed on your fingers.
References
Vagy, J. (2023). Clinical management of finger joint capsulitis/synovitis in a rock climber. Frontiers in Sports and Active Living, 5. https://doi.org/10.3389/fspor.2023.1185653
Schöffl, V. R., Lutter, C., Lang, H.-C., Perl, M., Moser, O., & Simon, M. (2025). Efficacy of a new treatment algorithm for capsulitis of the fingers in rock climbers. Frontiers in Sports and Active Living, 7. https://doi.org/10.3389/fspor.2025.1497110
SIG, C. (2023, May 16). Capsulitis and synovitis climbing - swelling of the fingers. The Climbing Doctor.
https://theclimbingdoctor.com/swelling-of-the-finger joints/#:~:text=Synovitis%2Fcapsulitis%20are%20marked%20by,of%20fluid%20in%20the%20fingers