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Pulley injuries

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Journal of Hand Therapy 31 (2018) 416e420
Contents lists available at ScienceDirect
Journal of Hand Therapy
journal homepage: www.jhandtherapy.org
JHT READ
FOR
CREDIT ARTICLE #563.
Practice Forum
Pulley injuries in rock climbers: Hand therapy clinical application
Lori Algar OTD, OTR/L, CHT a, *, Matthew Moschetto OTS b
a
b
Department of Hand Therapy, Orthopaedic Specialty Group, P.C., Fairfield, CT, USA
Department of Occupational Therapy, Sacred Heart University, Fairfield, CT, USA
New techniques using either taping and/or a custom fabricated pulley ring are recommended by these
authors to treat pulley injuries in rock climbers. Either technique provides support to the injured pulley and
allows rock climbers to continue their meaningful activity while the pulley heals. e KRISTIN VALDES, OTD, OT,
CHT, Practice Forum Editor
cohort study8 examined outcomes following pulley reconstruction
with the use of a thermoplastic ring over the pulley for 90 days
Introduction
In the past, the frequency of treating rock climbers in the hand
therapy clinic may in part have been determined by geographical
location. However, the sport of rock climbing is increasing in
popularity1 and will be included in the 2020 Olympic Games.2 This
may cause an influx in the number of pulley injuries treated by
hand therapists as these are the most common injuries sustained
by rock climbers, occurring as 15.4% of all climbing injuries.3
Pulley injuries in rock climbers and traditional hand therapy
pulley injury treatment
Rock climbers often assume what is termed a crimp position
(Fig. 1), a position of extreme flexion at the proximal interphalangeal (PIP) joint and hyperextension at the distal interphalangeal
joint, to achieve greater strength in grip. This position applies
approximately 287 Newtons (N) of force on the A2 pulley and 226 N
at the A4 pulley.4 The A4 ruptures more often in climbers because
the actual strength of the A2 pulley has been found to be greater
than that of the A4.5 Flexion of the digit causes most stress to the
distal end of the A2 pulley and the proximal aspect of the A4 pulley,
as the A3 pulley does little in the way of supporting the tendon.6,7
Hand therapists are tasked with providing protection for the A2
and A4 pulleys for either conservative or postsurgical management.
Our classic circumferential pulley ring may not be the best option
for pulley protection especially in high-demand climbers. A recent
* Corresponding author. Department of Hand Therapy, Orthopaedic Specialty
Group, P.C., Fairfield, CT 06825, USA. Tel.: 203.337.2677; fax: 203.337.2675.
E-mail address: [email protected] (L. Algar).
Fig. 1. Crimp position.
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http://dx.doi.org/10.1016/j.jht.2017.05.019
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417
phalanx (just proximal to the PIP joint) for A2 pulley injuries as the
tape did little to absorb flexor tendon force on the pulley or
decrease bowstringing.9 In addition, studies on treatment outcomes for rock climbers who used conventional circumferential
taping and thermoplastic rings to treat pulley injuries find
increased tendon-phalanx distance (or bowstringing) via ultrasound.10, 11
Alternative methods for pulley protection
H-tape
Schoffl et al12 proposed the H-tape method for pulley protection. This method of taping considers the point at which the tendon
has the greatest distance from the bone during flexion (the PIP
joint), which is also where deflection of flexor tendon force is most
important. In a research study using ultrasound on rock climbers
with pulley injuries, the H-tape method was found to significantly
decrease tendon-phalanx distance, whereas other tape applications
did not change this measurement.12
Schoffl et al12 recommend a 10 cm by 1.5 cm piece of Leukotape.
The tape should be cut in half through the length from both ends
but leaving a 1-cm bridge uncut in the middle (Fig. 2). The tape
should first be applied to the distal end of the proximal phalanx at
the bridge of the tape and then the proximal straps should be
wrapped around the proximal phalanx. The PIP joint should be
flexed and then the remaining 2 distal straps secured around the
proximal middle phalanx (Fig. 3).12
Fig. 2. Leukotape cut for H-tape application.
Pulley-protection orthosis
postoperatively. Only 18 of 30 participants had a return to near
normal status related to flexor bowstringing.8 A biomechanical
study found that it is minimally effective to apply tape circumferentially at the proximal phalanx and at the distal proximal
In 2016, Schneeberger and Schweizer13 developed and tested a
novel design of what they termed a pulley-protection orthosis.
Their design is like the conventional pulley ring, but it has cutouts
on the sides of the orthosis to allow firm fixation with inelastic tape
Fig. 3. Application of the H-tape.
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418
L. Algar, M. Moschetto / Journal of Hand Therapy 31 (2018) 416e420
Fig. 4. Pulley-protection orthosis.
without compression of the digital nerves and blood supply
(Fig. 4).13 The orthosis can be applied to provide force to the flexor
tendon to keep close distance to the bone allowing the pulley to
heal at an effective length.13 In a cohort study of 47 rock climbers
with pulley injuries conservatively treated with this orthosis
design, tendon-phalanx distance was reduced.13
To fabricate this orthosis, thin, long pieces of orthosis material
covered with paper tape can be secured to the involved digit to
allow the appropriate side cutouts (Fig. 5). The finished orthosis can
be applied just proximal to the PIP joint and secured with inelastic
tape (Fig. 6).
Clinical implications: translating rock climbing interventions
into other pulley injury cases
Hand therapists are likely familiar with providing protection to
injured finger pulleys after traumatic flexor tendon injury; however, we were not able to locate research on the use of pulley rings
outside of the rock climbing research. The H-tape method and the
pulley-protection orthosis may be appropriate substitutes for
typical circumferential pulley rings. Hand therapists may consider
use of these alternative designs to offer rock climbers and others
with traumatic pulley injury best evidence-based practice.
Fig. 5. Fabrication of the pulley-protection orthosis.
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419
Fig. 6. Completed pulley-protection orthosis.
Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.jht.2017.05.019
References
1. Chang CY, Torriani M, Huang AJ. Rock climbing injuries: Acute and chronic
repetitive trauma. Curr Probl Diagn Radiol. 2016;45:205e214.
2. Bisharat A. Olympics add climbing, surfing, and skateboarding for 2020. Natl
Geogr Mag. 2016. Available at: http://www.nationalgeographic.com/adventure/
activities/climbing/climbing-surfing-skateboarding-at-2020-olympics/. Accessed
March 19, 2017.
3. Schoffl V, Popp D, Kupper T, Schoffl I. Injury trends in rock climbers: evaluation
of a case series of 911 injuries between 2009 and 2012. Wilderness Environ Med.
2015;26:62e67.
4. Schoffl I, Oppelt K, Jungert J, Schweizer A, Neuhuber W, Schoffl V. The influence
of the crimp and slope grip position on the finger pulley system. J Biomech.
2009;42:2183e2187.
5. Lin GT, Cooney WP, Amadio PC, An KN. Mechanical properties of human pulleys. J Hand Surg Eur. 1990;15:429e434.
6. Marco RA, Sharkey NA, Smith TS, Zissimos AG. Pathomechanics of closed
rupture of the flexor tendon pulleys in rock climbers. J Bone Joint Surg Am.
1998;80:1012e1019.
7. Hume EL, Hutchinson DT, Jaeger SA, Hunter JM. Biomechanics of pulley
reconstruction. J Hand Surg. 1991;16:722e730.
8. Bouyer M, Forli A, Semere A, Chedal Bornu BJ, Corcella D, Moutet F. Recovery of
rock climbing performance after surgical reconstruction of finger pulleys.
J Hand Surg Eur. 2016;41:406e412.
9. Schweizer A. Biomechanical effectiveness of taping the A2 pulley in rock
climbers. J Hand Surg Eur. 2000;25B:102e107.
10. Gabl M, Rangger C, Lutz M, Fink C, Rudisch A, Pechlaner S. Disruption of the
finger flexor pulley system in elite rock climbers. Am J Sports Med. 1998;26:
651e655.
11. Schoffl V, Hochholzer T, Winkelmann HP, Roloff I, Strecker W. Pulley injuries in
sport climbers [in German]. Handchir Mikrochir Plast Chir. 2004;36:224e230.
12. Schoffl I, Einwag F, Strecker W, Hennig F, Schoffl V. Impact of taping after
finger flexor tendon pulley ruptures in rock climbers. J Appl Biomech.
2007;23:52e62.
13. Schneeberger M, Schweizer A. Pulley ruptures in rock climbers: outcome of
conservative treatment with the pulley-protection splint- a series of 47 cases.
Wilderness Environ Med. 2016;27:211e218.
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420
L. Algar, M. Moschetto / Journal of Hand Therapy 31 (2018) 416e420
JHT Read for Credit
Quiz: #563
Record your answers on the Return Answer Form found on the
tear-out coupon at the back of this issue or to complete online
and use a credit card, go to JHTReadforCredit.com. There is
only one best answer for each question.
#1. In rock climbers pulley injuries are the most common injury
and account for approximately________ of their injuries
a. 30%
b. 25%
c. 20%
d. 15%
#2. The crimp position of the digits includes
a. hyperextension of the DIP and PIP
b. extreme flexion of the PIP and DIP
c. hyperextension of the DIP along with extreme flexion of the
PIP
d. hyperextension of the PIP along with extreme flexion of the
DIP
#3. The most vulnerable pulley to rupture in the crimp position is
the________ pulley
a. A4
b. A3
c. A2
d. A1
#4. The status of pulleys has been studied using
a. X-rays
b. ultrasound
c. MRIs
d. EMGs
#5. The authors offer an H type pulley protection system as an
alternative to the traditional O ring design
a. false
b. true
When submitting to the HTCC for re-certification, please batch your
JHT RFC certificates in groups of 3 or more to get full credit.
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