8 Tendon Rehabilitation Principles for Rock Climbers

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Written by: Jason Smith, MSc(PT), CSEP-CPT, CIDN, FCAMPT, Registered Physiotherapist

Rock climbing can be a strenuous sport, and is especially strenuous to the muscles of our upper body. This is largely due to the tremendous tension we must generate in our body to keep us on the wall. No muscle-tendon system is stressed more than the finger flexor group of our hands and forearms. Of course, the smaller the holds are, and the steeper the route is, the harder our muscles have to work. Injuries involving the finger flexor tendons and muscles are very common in our sport, and can take a long time to heal, especially if appropriate injury management is not initiated early. If you think you’ve experienced one of these unfortunate injuries, there are some important principles for you to consider that will ensure you get the most out of your tendon rehabilitation:

*Note: This article is designed for informational purposes, and is not designed to replace an individualized rehab protocol. It is intended for those familiar with rock climbing. To obtain clarification regarding any unfamiliar terms, feel free to directly email the author at jsmith@grsm.ca

Anatomy

The finger flexor group is composed of many tissues. The main tissues which are subject to injury are:

Muscles and their associated tendons:
- Flexor digitorum superficialis (FDS)
  - Originating from the inner aspect of the elbow, branches into 4 separate tendons that attach on the 2^nd to the last finger bone towards each of our finger tips
- Flexor digitorum profundus (FDP)
  - Lies deeper to the superficialis, with the same origin running all the way to the end of our finger tips
  - Studies have shown stress through the tendon pulley system and FDP is greater than the FDS during crimp gripping, and hence it is more commonly injured
- Injury: Both of these muscles and tendons are subject to strains (partial thickness tearing) as well as full thickness tears.

Tendon pulleys
- Our tendon pulley system is a series of short bands that keep our long finger flexor tendons close to our bone.
- This anatomical design increases strength of these tendons, and prevents “bowstringing” of the tendon away from the finger during gripping.
- Injury: Tendon pulleys are prone to sprains (partial tears) and full thickness tears, most commonly at the A2 to A4 pulleys pictured below

Flexor tendon synovial sheath
- Our synovial sheath is essentially a cover that surrounds our flexor tendons, designed to reduce friction to the tendons
- Injury: If excessive and repetitive compression occurs to this sheath, it can become inflamed, leading to a condition called tenosynovitis

Forearm Flexor Musculature: A. Superficial musculature including flexor digitorum superficialis (Sublimus), B. Deep musculature including flexor digitorum profondus, C. Flexor tendon sheath visible in blue ⁵

Finger flexor tendon pulleys pictured in A. From the side and B. From the palm side of the hand⁶

REHABILITATION PRINCIPLES

PRINCIPLE 1: Recognize these common signs and symptoms of flexor tendon system injury:

- Feeling a sudden popping sensation along the palm side of one or two fingers while climbing
- Presence of pain or discomfort that has not subsided on the palm side of the finger(s). Pain may also be present along the palmar aspect of the forearm up to the inner aspect of the elbow
- Reproduction of pain while gripping certain holds (e.g., worse on crimps vs. open hand grips) or making a fist
- Presence of localized swelling in the finger or one or more knuckles

PRINCIPLE 2: Seek a proper diagnosis

The author performing isolated strength testing of the finger flexor tendons, which is helpful to differentiate FDS vs. FDP injury, differentiate tendon pulley injuries, and track improvement in strength over time.

A specific diagnosis that is able to determine which tissue is at fault is paramount to achieve well-guided rehabilitation
Injuries can vary dramatically, from the less serious tendon-sheath swelling or synovitis, to more serious muscular strains and finger tendon pulley sprains.
A good assessment should include the following at a minimum:
- A thorough subjective history which typically identifies the mechanism of injury, past medical history, and climbing goals among other things
- Strength measurement using a device such as a crane scale in different grip positions (e.g., crimp vs. open grip), differentiating which is more painful, and identifying the primary site of pain or discomfort. This can be continued throughout rehabilitation to measure gains in strength as you progress back to climbing (See video above)
- A cursory scan of the upper and/or lower body to identify contributory strength or flexibility deficits at other joints and muscle groups that may cause weak links in the chain

PRINCIPLE 3: Rest!

- A period of rest is generally recommended. Whether this is full rest or modified activity will depend upon multiple factors including:
  - Which tissue is injured
  - The degree of damage
  - The level of inflammation/ current stage of recovery
  - Climbing-specific goals
- While multiple tendon pulley sprains can lay you up for months, a mild synovitis may require just one week of rest or a period of modified activity
- Putting in rest in the short-term can reduce overall injury recovery time dramatically, while climbing through pain carries the risk of further injury that will delay recovery

PRINCIPLE 4: Return to climbing with restrictions

- After an initial period of rest, there is tremendous value in remaining active by staying on the rock. Your rehab specialist may have specific recommendations for you to consider. Here are examples of restrictions that are commonly used with rock climbers:
  - Limit pulling hard on the most provocative grips
    - This advice should be fairly self-explanatory. If the half crimp position is typically where you experience pain, try to choose climbs that limit pulling aggressively with this grip. With tendon pulley injuries, crimp grip loads the pulleys significantly more than an open hand or sloping grip. The use of an open hand grip during tendon rehabilitation may be recommended to avoid tendon atrophy while modulating load on the healing pulleys. ⁴
  - Climb statically
    - Avoid quickly loading tendons by pulling quickly to get to the next hold, or by shock-loading the tendon on initial gripping (“throwing” for a hold).
    - Increasing the dynamic strength of our tendons should be performed in a controlled training setting once cleared by your therapist, and after an initial base of strength and endurance has been established through static climbing
  - Focus on endurance rather than power
    - Endurance climbing typically involves spending a longer time on the wall pulling less hard, and in the case of tendon rehab, it is a safer way to climb when getting back on the wall. This will allow you to get a good workout to scratch that climbing itch while minimizing your risk of injury.
  - Continue to keep climbing pain-free
    - If you’re second guessing whether you’re in too much pain, you’re in too much pain! Get off the wall and cool-down. Don’t sacrifice all the hard work you’ve put into your recovery for the glory of one gym session.

PRINCIPLE 5: Taping

Demonstration of taping techniques. H-taping is applied to the middle finger while circumferential taping is applied to the ring finger³

Your therapist can help you determine the value of taping by testing your strength production on a measuring device such as a crane scale that measures pulling strength. Testing no tape vs. taped generally leads to some very helpful conclusions.
There is support from studies for use of H-taping with tendon pulley injuries, showing decreased tendon bone distance up to 16%, which partially restores the mechanical advantage of the pulley system. This is further associated with a 13% crimp strength increase while taped compared to no tape. ³
Common methods of taping include circumferential taping and H-taping, both of which are pictured above.

PRINCIPLE 6: Isometric loading

The author performing isometric tendon loading of the 4^th digit, primarily loading A. Flexor digitorum superficialis and B. The Flexor digitorum profundus tendons

Eventually, assuming you’ve sustained some damage to a tendon or pulley, your injury will progress from scar tissue formation to a remodelling phase. This is when your therapist will advise that you begin to load the injured tissue.
Loading will typically start with isometric exercise, which involves sustaining tension in the tissue without the muscle shortening or lengthening. This mimics how we load the tissue during climbing, and helps us to avoid re-injury.
When using isometric loading for tendon tissue rehab, we must follow certain principles
- Keep the load pain free
  - Part of loading the tissue is helping to rewire our nervous system¹ Often when we have experienced recurrent pain when loading a tissue, our brain will wire this pain-response into our loading pattern, such that we continue to experience pain even after the tissue has healed! This can lead to development of chronic pain if the load is not controlled in a pain-free healthy manner.
  - By loading the tendon in a pain-free manner progressively, we should see a gradual increase in tendon strength and a gradual decrease in pain
- Isolate the affected tissue
  - Tendons and muscles work synergistically in our body, meaning multiple different tissues can contribute to perform the same movement. Therefore if we allow these tissues to contribute during our rehab, we can risk ineffectively loading the injured/ target tissue.
  - What this means for us typically with flexor tendon rehab, is performing the isometric on a single effected finger initially, and in the most-provocative or weakest position as determined by strength testing (i.e., ½ crimp vs. open hand grip)
  - Typical parameters for initial tendon loading are 1-2 sets of 10 repetitions holding for 5 seconds of pain free loading, once to twice daily.
  - The load should be progressively applied, and progressively let go over the course of 5 seconds, with the goal of achieving close to maximum pain-free loading. No pain is best, but any discomfort more than a 1 or 2 / 10 is too much!

PRINCIPLE 7: Load integration

- A typical load integration strategy I use with my clients is a recovery hangboard protocol, which helps to integrate the injured tissue function into working again synergistically with the other digits, taking advantage of powerful fascial connections throughout our fingers, palm, and forearm. We are now approaching loading more similarly to what we encounter when we rock climb.
- Use the following guidelines during load integration
  - Perform one arm at a time, twice weekly with your feet on the ground unless advised otherwise
  - Keep loading close to maximum pain-free load similar to your isolated loading protocol
  - Perform loading without tape unless advised otherwise by your therapist
  - Gradually load and unload the tendons.
  - The goal here is progressive exposure of your tendon to varying loads, so don’t pull so hard you injure yourself! To borrow a phrase from Eric Horst, the number one goal of training is don’t get injured! ²
  - Rest at least one full day after hangboarding before climbing
  - An example of a recovery hangboard protocol is as follows:
    - 5s hold, 10s rest. Repeat 4 times. Rest 1 minute. Repeat again (2 sets per hold type) on the following holds:
      - 4 finger open hand grip
      - 4 finger ½ crimp
      - 2 finger inside pocket (middle and index)
      - 2 finger outside pocket (middle and ring)

PRINCIPLE 8: There are endless principles!

- The effectiveness of your rehab should be tailored specifically to your needs. Other effective methods of rehabilitation may include but are not limited to:
  - Hands-on treatment (manual therapy) to address flexibility deficits and help remodel scar-tissue
  - Acupuncture based treatment such as dry-needling to modulate excessive nervous system input to muscles that perpetuate inflexibility
  - Stretching, mobilization or myofascial release of your forearm flexors or other inflexible muscles and joints
  - Addressing climbing technique faults that may overload tissues unnecessarily causing premature overuse and failure
  - Strength training to address weaknesses up the chain
  - Determination of advanced consultation including referrals for imaging, or to specialists such as sport medicine physicians and orthopaedic surgeons

**Watch for future articles regarding other common climbing injuries and self-rehabilitation guidelines

Jason Smith, MSc(PT), CSEP-CPT, CIDN, FCAMPT
Registered Physiotherapist

Jay has been rock climbing for 5 years, and has been treating rock climbers more regularly for the past 4 years. Jay graduated from McMaster University in 2011 with a Masters of Physiotherapy. His previous education includes a Bachelor of Arts in Kinesiology in 2009 from Western University. Jason has obtained his FCAMPT (Fellow of the Canadian Academy of Manipulative Physiotherapy) designation. This designation is internationally recognized, and follows a comprehensive post-graduate training program that solidifies manual therapy skills, teaches advanced clinical reasoning, and allows him to perform spinal manipulation. Jay is also certified in Integrative Dry Needling, which he uses to release muscular restrictions throughout in the body. Jay is also a Certified Personal Trainer with the Canadian Society for Exercise Physiology (CSEP-CPT).He enjoys working with high level athletes, especially towards the later stages of their rehab as they approach return to sport. In addition to this, Jay is a certified Sport First Responder, and former team physiotherapist for the Guelph Gryphon’s Men’s Varsity Rugby team.

References

Hoeger Bement et al. Dose response of isometric contractions on pain perception in healthy adults. Medicine and science in sports and exercise. 2008, 40(11):1880-1889.
Horst, E. Training for Climbing. 3^rd Falcon Guides; 2016.
Schoffl et al. Impact of taping after finger flexor tendon ruptures in rock climbers. Journal of applied biomechanics, 2007;23:52-62.
Schweizer et al. Biomechanical properties of the crimp grip position in rock climbers. J Biomech, 2001; 34(2):217-223
Standring S. Gray’s Anatomy. Churchill: Livingstone; 2008.
Zafonte et al. Flexor pulley system: anatomy, injury, and management. J Hand Surg Am, 2014;39.
Video music credit: bensound.com