Dan Mirsky’s story was similar to dozens of others: he hurt his finger climbing and what he expected to be a short-term injury turned into a chronic one that he couldn’t seem to shake. After injuring his finger while bouldering in Hueco Tanks, he tried taping, resting, and other therapies in an attempt to return to pain-free climbing, but never found any lasting improvement. He was hesitant to seek advice from healthcare providers because he expected to be told he would need to rest and avoid climbing. Every time he got back on a crimpy project or tried to train, his finger injury held him back.
Five months after his initial finger injury, Dan, a climbing coach and professional athlete, was invited to train alongside Sam Elias and Joe Kinder for the 2015 Black Diamond Bootcamp. This would be an arduous three-month climbing training program in which he would immerse himself to become mentally and physically stronger. Immediately following the first three-week training cycle, Dan came into Grassroots Physical Therapy clinic. He was frustrated and desperate for a solution that would get him through the remainder of Bootcamp and beyond.
Dan had been noticing serious deficits while training and climbing. In addition to his left middle finger injury, he complained of getting pumped quickly, neck pain on his left side, and notable weakness in his left arm compared to the right side. Upon examining Dan, it was clear that all of these complaints were related. The “upstream" imbalances and the local damaged finger tissue culminated in a chronic injury and a finger that was unable to tolerate the demands of climbing.
To Dan’s surprise and relief, rest was not the solution for his classic A2 pulley ligament injury. Instead, the answer was a therapeutic protocol of progressive “hanging," in which he would load the impaired finger to remodel the injured tissue and gain back its strength. The hangboard is often thought of as an apparatus that causes finger injuries. Instead, in this article we challenge you to utilize it as a rehabilitation tool. In addition to treating the site of injury, it was imperative to address the dysfunction upstream that persisted throughout his left side. It is common that individuals harbor a pattern of imbalance that makes us susceptible to injuries at our weakest links.
Many climbers we see at Grassroots share Dan’s perspective: skepticism towards medical intervention and frustration over persistent injuries. The following recommendations build on the previous Hang Right articles 1 & 2, and provide rehabilitation guidelines for common finger injuries. Specifically, this protocol aims to address finger flexor tendon strains and annular pulley ligament sprains. The strategies outlined below provide solutions for recovering function in the hand and fingers, remodeling impaired tissue (ligaments and tendons) at the finger, and addressing upstream impairments that may put excessive stress on the fingers.
*The following recommendations have been designed to aid in the repair of general finger flexor tendon strains and annular pulley ligament sprains. We advise you to seek care from a qualified healthcare professional for accurate diagnosis and individualized treatment plans before commencing this protocol. Flexor tendon/pulley ruptures are rare, and require immediate medical attention.
The Local Solution:
The anatomy of the hand is complex. To keep it simple, the most common finger injuries among climbers are strains to either tendons or ligaments. If one of your pulley ligaments is injured, your flexor tendon is likely injured too. Because they are made of similar material, they can be healed through similar strategies. To properly treat these injuries, it is arguably more important to identify the duration of the injury than to determine the exact structure that was injured.
The important question to discern is: Did your injury occur within the past six weeks, or more than six weeks ago? Based on this duration, your body responds to injury differently, and should be treated accordingly. In the first six weeks following an initial injury, it is important to gently recover function, rest and control inflammation (Phase 1). After six weeks, it is essential to actively remodel the tissue (Phase 2).
Phase 1: Grassroots Finger Recovery Program
If your finger injury occurred less than 6 weeks ago, immediately engage in the following program after being cleared by a qualified healthcare professional. Refer to this Grassroots Self Treatment Video for detailed instruction.
- Inflammation control : rest from climbing, ice, compress and tape for support and swelling control. Let symptoms be your guide during this phase. You will likely need to rest from climbing and engage in inflammation control for several weeks.
- Tendon glides: progressively moving each joint in your fingers in a particular sequence to glide the tendons through their full range, as shown in PICS (1) – (4). Repeat 10 repetitions, 3-5 times per day.
- Pen rolling: holding a pen between the pads of your fingers and the top of your palm, and rolling the pen back toward your palm by grasping it with one finger at a time, progressively from your pinky to your index finger, as shown in PICS (5) – (7). Repeat this for 1-3 minutes, 3-5 times per day.
• Gentle circulatory massage to the area 1-3 minutes daily, as shown in PIC (8).
Gentle active range of motion exercises:
- Rice bucket: gently perform a variety of wrist and finger motions with the resistance of the rice in a bucket, as shown in PICS (9) – (11). Be sure to keep a straight line between your forearm and hand (what we refer to as “a neutral wrist"). Perform 30 seconds of each suggested motion, 1-2 x daily.
- Light putty gripping: Pull apart putty with different grips, as shown in PICS (12) – (14).
- Towel gathering: get your tendons moving by gathering a towel in your hand, maintaining a neutral wrist. Perform 1-5 minutes daily, as shown in PICS (15) – (16).
- After the first week, avoid ibuprofen as it has been shown to inhibit tendon remodeling.
- Consume nutrients that facilitate tissue healing including anthocyanins (found in red, blue and purple fruits and vegetables), turmeric, omega 3 fatty acids, and mineral-rich foods such as bone broth. In addition be sure to stay hydrated during this period.
- Spend time working on upstream solutions, which we will discuss below.
It is recommended that you do not climb or engage in “Phase 2: Remodeling" (outlined below) until you regain full motion in each knuckle/joint and you test your tolerance to load at your injured finger (described in Phase 2: Load Testing). Time off climbing will vary depending on the severity of your injury. The direct area of injury will likely remain sore when pressure is applied until you engage in Phase 2, but will no longer be tender with everyday motions. If you fail to regain full knuckle/joint range of motion after six weeks from the initial injury, it could suggest an underlying joint issue that needs to be assessed by a qualified provider.
If your finger injury occurred more than 6 weeks ago, and you have full motion at each knuckle, perform the exercises described in Phase 1 and begin to remodel the injured tissue with the Phase 2 exercises. It is essential that the appropriate load be applied to stimulate the body to repair the damaged tissue and lay down new collagen for a stronger tendon. It is possible to return to gentle, gradual indoor and outdoor climbing during Phase 1 and 2, but it is important that climbing does not hurt and that is does not make your symptoms worse. You can use supportive taping such as “buddy taping" when climbing, but not during your exercises.
Phase 2: Grassroots Finger Remodeling Program
Begin with a gentle 10-30 minute warm-up using a selection of Phase 1 exercises.
After warming up, the load test is a 10-second hang at body weight or reduced bodyweight (described below) with proper "hang right" form. To test your tolerance to loading find a hangboard with a comfortable and deep two-finger pocket that accepts your fingers at least into the second pad. Hang from the injured finger and one adjacent to it (usually the middle and ring fingers). Let your other fingers fold down out of the way but be sure to keep all of your first/proximal knuckles straight or extended as shown in the "Two-Finger Pocket Hang" photo.. We recommend loading your injured finger through hanging because it provides the most relevant strengthening of your tendons and ligaments for returning to climbing. The two-finger pocket hang allows the stress to be targeted at the injured finger. As you get stronger with your hangs you should find that you are able to tolerate increased intensity when climbing.
Two–Finger Pocket Hang
This exercise is designed to produce low-grade symptoms (whether strain or slight pain) during the hang. Remember that hurt does not equal harm, and the symptoms you feel indicate the low-grade breakdown and remodeling of the injured tissue. These symptoms must resolve within 10 minutes after the hang, with no loss of motion or associated stiffness produced by the exercise.
If you are unable to perform this exercise at body weight, if your symptoms last longer than 10 minutes, or if hanging is intolerable, remove body weight through a pulley system, by using jibs with your feet or with assistance from a resistance band.
Two–Finger Pocket Hang + Pulley System
Note that the symptoms you feel should not be caused by direct pressure of your finger against the hold but from the stress of loading your finger. Avoid symptoms of direct pressure by adjusting the hold. If two-finger pocket hangs fail to elicit your symptoms, you may need to begin with another grip that sufficiently loads your injury to elicit the same symptom response. In this case, test a variety of grips and holds to identify which seems the most effective for you.
Perform 3 reps of the 10-second hang with 2-3 minute rests in between. Following load testing, any strain felt during the hangs should resolve within 10 minutes and there should be no stiffness or loss of range of motion. When you have met these criteria you may begin the remodeling section of Phase 2.
Begin with a gentle 10-30 minute warm-up using a selection of Phase 1 exercises and/or gentle climbing if it is pain-free. Do not perform the loading program if you are fatigued. It is important to be fresh and rested so that the loading program will stimulate your body to repair and remodel instead of causing further tissue damage.
Use the load determined in “Load Testing" to commence the remodeling section of the program. Perform a 10-second hang 3-5 times, with each hang separated by a 2-3 minute rest, 1-3 x/week at that same weight until this no longer produces your familiar symptoms (strain or slight pain).
Once the initial load no longer produces your familiar symptoms, you can add 2.5-5 lbs. at a time above body weight (or add back to your bodyweight if you had to remove weight), progressing to 15-30 lbs. over body weight, over the course of the next 6-8 weeks. Stay within the same symptom parameters each time you change the load: familiar symptoms produced during the hang, soreness lasting no more than 10 minutes following and no stiffness or motion loss. The load can be advanced within a session if you decide that the load is not producing your familiar symptoms, or can be increased gradually over a period of 6-8 weeks. Typically you need to increase the load weekly to continue to remodel the tissue and reproduce your familiar symptoms.
Two–Finger Pocket Hang + Added Weight
Once you can hang with 15 lbs. over bodyweight, you can continue to add other grips to this program.
If you are having continued problems with pinching or crimping you should be doing a similar progression with those grips. Start assessing whether you can stay within the same symptom parameters with a different grip at body weight, then progress as tolerated. You can mix in one or two other hang/pinch grips into the same session: warming up, then performing a 10-second hang, separated by a 2-3 min rest, 3-5 sets of each grip, 1-3 times per week.
You can stop this program once you have no residual symptoms while climbing or training and/or you have achieved a two-finger pocket hang with 20–30 lbs. over bodyweight with no symptoms. Congratulations, you have successfully repaired the damaged tissue!
See this Healthy Hand and Wrist video for a comprehensive program.
- Try rice bucket workouts to facilitate finger, wrist, and forearm strengthening and joint mobility. See this How to Rice Bucket video.
- Engage in finger, wrist and forearm tissue lengthening through certain key stretches and self-massage. Watch these videos to optimize your “upstream" support system: Healthy Shoulder, Healthy Neck and Climber's Kit.
- Consider why your finger was loaded inappropriately in the initial injury. Was it a result of your injured finger being the weak link in the system? Was your finger being excessively burdened by poor control of your torso or shoulders, or sub-optimal footwork? Meet with a physical therapist or movement coach in your area to help identify these negative patterns and imbalances.
- Consider the myofascial patterns that can contribute to injury (see Hang Right articles 1 and 2 for more info) – One of the most common examples of myofascial imbalances are when the muscles on the front-side of our body are short and tight, and the muscles on the back-side of our body are over-stretched (lengthened) and weak. Healthy hanging requires a balance between the muscles in the front and the back. This can be accomplished through a properly designed strength-training program.
Dan was thrilled. He was able to effectively continue his physical therapy program while progressing in the BD Bootcamp training, allowing his A2 pulley ligament and flexor tendon to fully repair. Over the course of a couple weeks and a gradual advancement of his remodeling exercises, the familiar chronic tenderness in his finger dissipated. In addition to fully recovering, Dan gained a deeper understanding of himself, discovering that balancing the body as a whole allowed for proper function of the individual parts. When we address the imbalances that perpetuate injuries at our weak-links, we are empowered to train smarter and climb harder. Through his focused training and rehabilitation, Dan was not only able to resolve his injury, but he also improved his overall physical fitness and resilience. He gained renewed confidence in his own body and its ability to heal. He could push himself like never before without getting injured.
Acute and chronic finger injuries most often occur because our fingers are the weak link in the system, and not because one specific finger is weak. We can support our finger health by building a strong upstream support system. By adopting a holistic view of injuries and focusing on what our bodies need in order to recover and to remodel, we can often actively rehabilitate and continue to climb and train while healing.
Words: Esther Smith; Images: Andy Earl
Esther Smith, DPT, Cert. MDT, NTP is a Physical Therapist, a climber and the owner of Grassroots Physical Therapy in Salt Lake City, UT and selftreatment.com. She is the physical therapist for the Black Diamond Pro Climbing Team and many other climbing ambassadors.