The Common Climbing Injury You’ve Never Heard Of (Pulley Thickening Causes & Fix)

Hooper’s Beta Ep. 148

Introduction

Most climbers have probably never heard of this injury, yet thanks to the power of ultrasound, we can now identify it as one of the most common afflictions that I see, causing discomfort, pain, and even weakness in climbers’ fingers. It’s a phenomenon generally referred to as “pulley thickening” in the medical field, though I prefer to call it “injury-induced pulley thickening” (or IIPT, for short) to help differentiate it from another form of pulley thickening that happens as a normal adaptation to climbing. Though the two types of pulley thickening are quite similar in some ways, there are some key differences that make IIPT a real problem for climbers. In fact, it’s giving a LOT of climbers a hell of a time even though most of us have never heard of it.

So, if you’ve had some annoying finger pain and maybe even a weird little lump in your finger, be sure to stick around to learn what causes IIPT, how you can identify it, what you can do to fix it, and of course, how long it’ll take until you’re back to 100%.

What Does IIPT Feel Like?

Let’s start by nailing down what exactly IIPT actually feels like.

By the way, we have a brand new FREE interactive questionnaire on our website that we specifically designed to help you assess and understand your finger injury. Emile and I spent an entire year developing the algorithms for this tool so you can get a better understanding of what’s causing your pain, how severe it is, and how to recover from it. Please note this is for educational purposes only and is not a substitute for professional medical advice or diagnosis, but it’s an awesome way to jumpstart your injury knowledge. Did I mention it’s free? Link in the description or go to hoopersbeta.com/finger-tool.

IIPT typically begins with mild discomfort near the A2 or A4 pulley. Symptoms are most often provoked by crimping and direct pressure over the pulley (like a jug or a barbell that presses on the pulley when you grab it). Initial symptoms may not be noticeable during a climbing session, but they can show up later that day. Over time, the pain becomes more prominent and persistent with activity and may even begin to bother you the morning after a session as well.

As the condition progresses, the pain around the pulley becomes even harder to ignore to the point where strength and performance start to suffer. Sometimes, you may still be able to crimp fairly well when done in a slow and controlled manner, but the pain tends to be worse when moving dynamically and loading the pulley rapidly. 

Finally, you may start to notice a palpable mass, lump, or thickness under the skin in the painful area. When it’s in the A2 region, it tends to be a lump that’s fairly obvious when you compare it to the same region in other, uninjured fingers. When it’s in the A4 region it can be a bit more subtle, and sometimes rather than an obvious lump it will simply feel like a diffuse thickening or elevation. Either way, if it’s IIPT it will be firm and rigid, unlike a cyst which will feel ball-like, compressible, and mobile. Pressing directly on this lump can create significant discomfort in many cases, though not all.

Keep in mind, if you start comparing fingers to feel for any potential lumps or thickening, you should compare multiple fingers to get a proper reference point. It’s not uncommon for climbers to have some thickening in the same finger on both hands, which can throw off your comparison and make you think you don’t actually have any thickening at all.

Now, with all these signs and symptoms (and our assessment tool), it should be fairly straightforward for you to determine if IIPT is what’s causing your finger pain. However, if for some reason you just can’t seem to make a determination, scheduling an ultrasound scan with a qualified professional is your best bet for a proper diagnosis as it’s quite easy to see IIPT with this type of imaging.

What Causes IIPT?

It can often help your recovery if you understand what caused your injury in the first place, not to mention the peace of mind it can provide. With IIPT specifically this level of understanding is also useful for avoiding future injuries, so let’s discuss that now.

In short, the cause of IIPT is our body’s response to chronic or acute stress on the annular ligaments in our fingers, primarily the A2 and A4 pulleys.

Cause #1: Chronic (Repetitive Microtrauma)

First, chronic: During climbing, high loads are transmitted through the flexor tendons to the pulleys, especially in grip positions like the crimp grip. Repeated strain, especially near one's maximum capacity, can lead to microtears in the pulleys. This initiates a cascade of inflammatory and repair processes. While this isn’t inherently a bad thing, over time it can become a problem if this repair process isn’t able to keep up with the amount of damage to the tissue. In other words, if the wear on your pulleys from climbing and training outpaces your normal recovery capacity, you’ll eventually encounter some issues. Namely, the new tissue that your body lays down to try to heal can be disorganized rather than neat and tidy, reducing the strength and elasticity of the pulley. It’s sort of like trying to weave an entire rug in an hour; you’ll definitely make something rug-like, but it’ll be pretty crappy compared to the one you work carefully on for a month. In anatomical terms, we call this crappy rug-making process “fibrosis,” which ultimately leads to a physical increase in thickness of the pulley. It is, in a sense, a chronic accumulation of your “work” exceeding your recovery. But that’s not the only cause.

Cause #2: Acute Trauma 

Next up, acute trauma: The stress our pulleys encounter is not always limited to microtears. Sometimes, a larger or even complete tear of the pulley can occur, like from a sudden excessive load on your finger from foot slip. As a result, we get some pain around that pulley. So where does IIPT come into play here? With complete pulley tears, it likely doesn’t. But with partial tears, the onset of IIPT is essentially determined by how good our recovery strategy is.

If we follow an adequate recovery protocol after the partial tear, our pulley can heal up fairly quickly without any lingering issues. But (and this is a big ole BUT), if instead we do not help it heal properly within the first month or so, the tissue-repair process is often unable to complete the way it should, leading to persistent inflammation around the struggling pulley and eventually the same fibrotic thickening we described earlier. In essence, inadequate recovery efforts once again lead to an ugly rug, and no one wants that.

Why the pain, though!?

Whether our IIPT stems from a chronic or acute issue, the pain is caused by similar factors. Inflammation causes nearby nociceptors to become more sensitive, nerves can get compressed and aggravated, and of course if you’re dealing with a partially torn pulley, your body is trying to get you to reduce the force on the pulley. Nearby structures like the synovial sheath around our flexor tendon can get irritated as well, causing further issues. And all of these things tend to get exacerbated when we put the entire area under pressure during climbing, whether that’s from internal pressure (a strenuous crimp, for example) or external pressure (like when a hold physically presses on the injury site).

What if I feel thickening but no pain?

At this point some of you may be feeling around your fingers and noticing you do have some pulley thickening, but no pain. Does this still mean you have IIPT? Most likely, yes; the process was probably just slower with less pronounced inflammation and aggravation of the area. (Or, in some cases, people have just ignored the discomfort so long they stop noticing it.) Climbers naturally develop thicker pulleys as a response to the high forces of climbing, but if it’s thick enough that you can actually feel it with just your fingers, it’s likely IIPT.

Okay, let’s get to the good stuff now: recovery!

Recovery

As with any injury, your exact approach to recovery should mainly be determined by the grade of your injury. If you’re not sure what this is, remember you can use our free assessment tool to help.

1. Reduce Aggravating Factors

Naturally, the first step is to eliminate the thing that got you here in the first place: exceeding your pulley’s ability to recover between climbing/training sessions. That does NOT mean you should stop all physical activity or go into “full rest” mode. But it DOES mean you need to reduce the aspects of your routine that are aggravating your pulley and hindering your recovery.

If your finger hurts more than about 2/10 during or after climbing (or after a particular exercise), you’ll need to temporarily reduce the volume, intensity, frequency, or all three. You can do this with any combination of the following:

  • Switching to lower-angle grip positions (think drag, chisel, and open-hand)

  • Focusing on a different style of climbing

  • Switching to lower-grade climbs

  • Ending sessions early

  • Cutting down the number of sessions you do per week

  • Focusing on non-finger-intensive training (think resistance training or mobility work – avoiding activities that may cause direct pressure over the area)

For more severe cases of IIPT, I typically recommend you stop climbing for a week to try and reduce the inflammation to a more manageable level. This doesn’t mean you won’t be doing any finger training though; I prefer my clients immediately start loading the tissue with specific exercises, which we’ll talk about in a little bit.

2. Range of Motion Work

Next up: simple range of motion work. This means fully flexing and extending your fingers in three different positions to encourage blood flow and tissue movement.

  • Position 1 is at the bottom of the hand (close to the wrist).

  • Position 2 is in the middle. 

  • Position 3 is at the top (where you may have palm calluses).

To start, touch your fingers to position 1. Try to move your fingers as shown, rather than trying to immediately curl your fingers all the way down. Then, fully extend your fingers and repeat for position 2 and 3.

I typically recommend about 4-6 reps per position, performed multiple times per day throughout your recovery.

3. Manual Therapy 

Next: manual therapy or massage. While research on the efficacy and mechanism of manual therapy is limited, I still recommend it because it costs you virtually nothing and could improve your outcomes. It’s basically a zero-risk, potential-gain situation. There are plenty of poorly evidenced therapies out there that I do not currently think are worth the time, but for me manual therapy is different in that its proposed benefits are exactly what we want to help us recover from IIPT: tissue remodelling and reorganization.

I typically recommend daily manual therapy for 3-5 minute intervals at an intensity dictated by your current level of irritation/inflammation. The main thing you want to avoid is going too hard or too long and irritating things further, so make sure you keep the pain at or below the usual 2/10 threshold.

4. Off-The-Wall Tissue Loading

Next is a bit more exciting: off-the-wall tissue loading. This is critical for recovery because our bodies need a stimulus to kickstart adaptation. In this case, that means getting our pulley back to full function. The stimulus can come from just about any adequate load to our fingers, even climbing. However, climbing is not a particularly controlled environment. It’s too easy to go too hard or not hard enough, making it less than ideal when we specifically need MORE control to optimize our recovery. So, rather than relying on climbing as our main recovery stimulus, we should switch to a method that allows for precise control over intensity. Once we do that, we can start at low intensities and gradually ramp things up as our recovery progresses. At a certain point, the recovery exercise will actually transition into a strength training exercise, allowing you to regain, maintain, or even improve your prior level of finger strength.

There are four primary tissue loading methods I like to use for IIPT recovery.

Static Submax Holds

The first tissue loading method in your recovery should be static submax holds. These can be started immediately because they are meant to be low intensity. You’ll simply pull on a 20-25 mm edge with one or both hands for 30 seconds, rest for 30 seconds, and repeat.

To help you gauge how hard you should be going with this exercise, use the following guidelines:

  • Keep the discomfort/pain at or below the usual 2/10 threshold (we don’t want to be causing significant irritation).

  • Keep intensity low enough that you do not feel fatigued at the start of each rep.

I typically recommend 12 reps in total with these, half in an open hand position and the rest in a half crimp. In the early stages of recovery, perform this twice a day. In later stages you can reduce to once a day since you should be doing additional tissue loading activities at that point, You can discontinue completely once you start doing recruitment pulls or block pulls.

Mobile Board Rows

Next, we’ll want to vary our tissue loading tactics with a more dynamic variation. We’ll accomplish this by performing band-resisted rows on a comfortable edge. We can modulate the intensity with the thickness of the band, the amount we stretch it, and the speed at which we pull. To gauge how hard you should be trying, use similar guidelines: discomfort/pain at or below 2/10 and no fatigue at the start of each set.

I typically recommend 4-6 sets of 10-15 reps, with half the sets in an open hand position and the rest in a half crimp. Perform roughly three times per week.

Recruitment Pulls

Next we’ll be progressing our tissue loading with recruitment pulls, which add a beneficial neural-recruitment factor into the mix. We achieve this by picking a 20-25 mm edge and pulling as hard as we can over the course of 5-8 seconds, starting at low intensity and gradually increasing to your maximum tolerable intensity within the first three seconds. Rest for a second or two, then repeat.

This style of finger training should feel quite a bit different from the other tissue loading exercises as all the force is coming from you trying to curl your fingers rather than simply resisting your bodyweight or a band. As with the previous exercises, limit your intensity so any discomfort/pain does not exceed 2/10.

I typically recommend about 4 sets of 3 reps, performed roughly three times per week.

Block Pulls

Next we’ll add block pulls, which are an easily measurable, progressible means of finger strengthening. Block pulls are “yielding isometric” (as opposed to the “overcoming isometric” recruitment pulls), which will help round out our finger recovery.

Block pulls require a mobile board and attachable weights or a cable machine, the most common set up being a loading pin and plates. Simply use a half crimp position to lift the weight off the ground (do this by straightening your legs rather than pulling with your back or arm). Hold for 1-2 seconds at the top before controlling the weight back down to the ground.

To determine how much weight to use for your working sets, use the following guidelines:

  • Pain: At or below 2/10 (nothing new there).

  • Grip position: If you can’t maintain the half crimp for the entire duration of each rep (i.e. your fingers start opening up partway through), you need to reduce the weight.

  • Rep completion: If you can’t stick within those two parameters for all the recommended reps and sets, you need to reduce the weight.

Since this is meant to be an end-stage recovery / strengthening exercise, you should be using as much weight as you can while still sticking within these guidelines. And don’t forget to progress the difficulty by adding weight over time as your strength improves and pain reduces.

I typically recommend about 2-3 warm up sets of 6-10 reps and then 3-4 working sets of 3-5 reps. These can be performed up to three times per week, but you may need to reduce that frequency depending on how much and how hard you’re climbing at this point. We don’t want to end up with the same situation that gave you IIPT in the first place, so you need to ensure you don’t start exceeding your recovery capacity again. 

5. Taping

Finally, one additional consideration is taping, though for IIPT this is completely optional and depends on personal preference. For some, the support of tape seems to reduce stress on the thickened pulley thus reducing pain with activity. The benefit of that is it can allow you to climb and train at higher intensities without exceeding the pain threshold we’ve mentioned multiple times at this point. For others, though, the increased pressure from the tape will simply cause more discomfort, in which case it’s not worthwhile. I encourage you to try it out and see what feels better to you.

Prognosis

I’ve seen a lot of IIPT cases—and I’ve even dealt with it myself! If not treated properly, it can be an incredibly frustrating condition with how long it persists and degrades your performance. For that reason, the earlier you identify the issue and start your recovery, the faster you’ll be able to return to full performance and minimize long-term impact. For mild to moderate IIPT, the typical timeline is about 8 to 12 weeks. For more severe cases, you’re looking at more like 13 to 18 weeks. Of course, the quality of your recovery efforts will be a large determining factor here. If you put it off or don’t take it seriously, it could be 6 or 9… months!

The Most Convenient Way to Recover

If you want to take the guesswork out of your recovery, save yourself a whole lot of time, and get a program that’s specifically designed for your grade of injury, you can get that today on our website at hoopersbeta.com/recoveryblueprint. These are the exact injury-specific programs I’ve used in my practice to help hundreds of climbers beat their injuries and return to climbing pain-free, and now they’re available on our website for a ludicrously low price. These step-by-step, day-by-day programs are designed to guide you from the initial stages of healing all the way to regaining full strength and returning to peak performance. Whether you’re managing IIPT or another climbing-related finger injury, our Recovery Blueprints offer a proven approach to recovery from injuries that are so often misunderstood by practitioners unfamiliar with climbing.

Until next time…

Train. Climb. Assess your finger with our new tool. Send it with your new recovery program. And… repeat! As needed 🙂


Citation

  • Schreiber T, Allenspach P, Seifert B, Schweizer A. Connective tissue adaptations in the fingers of performance sport climbers [published correction appears in Eur J Sport Sci. 2015;15(8):iii. doi: 10.1080/17461391.2015.1126214.]. Eur J Sport Sci. 2015;15(8):696-702. doi:10.1080/17461391.2015.1048747


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Written and Presented by Jason Hooper, PT, DPT, OCS, SCS, CAFS

IG: @hoopersbetaofficial

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www.emilemodesitt.com

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