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A2 pulley: ruptured or torn?
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poomasta


Mar 11, 2007, 9:04 PM
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A2 pulley: ruptured or torn?
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With the help of this board and a couple books, I've diagnosed myself w/ an A2 pulley injury. The pain has been there for maybe a month, and I've tried to avoid aggravating the injury in the hope that it will heal itself w/o me giving up climbing. I have accepted that's prob not gonna happen, so I'm taking at least a couple weeks off and then getting back on the rock gradually.

I found this great resource through the RC forums: http://www.climbinginjuries.com/Finger.htm, and I'm planning on using it as my recovery guide, but I'm having trouble figuring out whether I've actually torn the pulley or completely ruptured it. I never heard a "pop" and I don't remember any specific or super-painful incidents that would lead me to believe it was ruptured like described in so many others' stories. What does seem a little odd tho: i have a strange little lump (maybe the size of a BB) under the skin near the injured area on that finger (but not on any other fingers). It seems too localized to be swelling, but i dunno...I was wondering if that could be remnants of a torn pulley, scarring...maybe evidence of healing? ;-)

I suppose going to get an MRI by someone that knows what to look for might be an option, but I wanted to see if others had some ideas on how to diagnose it. Other points: there is no obvious bowstringing, i have full mobility w/o pain when no load is applied, tender to touch, sharp pain when crimping. I would guess it's a tear at most, but the lump is making me question it. Any thoughts / experiences would be most appreciated.

Thanks,
Mike


dhaulagiri


Mar 12, 2007, 12:03 PM
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Re: [poomasta] A2 pulley: ruptured or torn? [In reply to]
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I've had many similar injuries but I have never seen the lump that you are seeing. Judging from the fact that you are able to maintain the general mobility of your finger I would say it isn't ruptured but someone with a medical background would be better suited to address that.


redpoint73


Mar 12, 2007, 12:26 PM
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Re: [dhaulagiri] A2 pulley: ruptured or torn? [In reply to]
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I believe a full rupture is always accompanied by the bowstrining.

I have heard of the lump. I think its the part(s) of the tendon that has torn, and pulled back.

I have had 3 pulley injuries (none of them complete ruptures), only once did I hear a pop. The ones that did not pop took several weeks to heal. The popper took many months. So consider the lack of "pop" a good think, or an indication that your hearing is impaired as well! Tongue


nthusiastj


Mar 12, 2007, 12:34 PM
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Re: [poomasta] A2 pulley: ruptured or torn? [In reply to]
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Hey, I tore my A4 on my ring finger about 2 months ago. I heard 2 loud as hell snaps, like firecrackers when it happened. I didn't climb at all for 2 weeks. Week 3 & 4 i only climbed like once a week and just ran easy laps on 8's and 9's. I kept my finger taped straight to aviod using it. I then took a week off again before climbing. Even then (and now) I'm still SLOWLY ramping up to my old level.

Be glad it's winter and take it easy so that you can have a good summer.

Go see a doc. Make sure you just go to a sports doctor. Even here in Boulder the regular doc didn't know as much as me about the injury. The sports doc had seen many of these injuries though.


(This post was edited by nthusiastj on Mar 12, 2007, 12:57 PM)


acherry


Mar 12, 2007, 12:51 PM
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Re: [poomasta] A2 pulley: ruptured or torn? [In reply to]
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Poo:

My SO, Cracklover, is currently sitting in an examining room in Boston. His symptoms are exactly the same as what you are describing - little bump and all. He's had the MRI done and the Dr. should be reading it as I'm typing this. You should contact him to see what the Dr. tells him. Unfortunately, the Dr.s in the Boston area aren't particularly well versed in climbing injuries, but maybe this guy'll actually take the time to do a little research to recommend treatment.

G'luck.


poomasta


Mar 12, 2007, 1:31 PM
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Re: [acherry] A2 pulley: ruptured or torn? [In reply to]
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Thanks everyone. I'm def interested to hear the outcome of Cracklover's doctor visit. If I don't hear back from you I'll PM him later this evening.

Thanks again.
Mike


kylerose


Mar 12, 2007, 3:32 PM
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Re: [poomasta] A2 pulley: ruptured or torn? [In reply to]
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Hi,
I'm glad you like my site (climbinginjuries). It's rare that surgery is necessary for these types of injuries. So it won't matter if it's a full rupture or not. Assuming no surgery, the treatment would be the same. At this point rest is key. When you can start exercising the finger without too much pain, go for it. Wolff's law says scar tissue lays in the direction of stress. So it's good to let the finger know what kinds of stresses it will be dealing with (climbing) while it's in the healing phase.

The bumps are synovial cysts. Unless they're causing trigger finger they aren't a concern nor is there effective non-surgical options. You might be able to massage them out, but that's doubtful. They probably won't ever be a big problem though.

-k


poomasta


Mar 12, 2007, 5:40 PM
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Re: [kylerose] A2 pulley: ruptured or torn? [In reply to]
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My curiosity as to whether it was a full rupture vs a tear was really just driven by how long I should expect to be away from climbing.

As a side question, I've heard of Wolff's law, but thought that only applied to bone growth (or degeneration). I did a bit of research and it looks like Davis' law applies to soft tissue...maybe that would have something to do with how scarring is affected by stresses during the healing process.

Anyway, thanks again kyle for the great resource...I've already passed your website on to a friend.

As far as increasing blood flow to speed healing...anyone have thoughts on this idea of submerging the injured hand alternately in a hot / cold bath to boost circulation? i don't get the point of the cold water...wouldn't the hot be sufficient?

thanks
mike


macblaze


Mar 12, 2007, 9:41 PM
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Re: [poomasta] A2 pulley: ruptured or torn? [In reply to]
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poomasta wrote:
My curiosity as to whether it was a full rupture vs a tear was really just driven by how long I should expect to be away from climbing.
Injured the A2 pulley on December 5 or so. A partial rupture cause I heard the pop but the bowstringing wasn't overly bad.

No climbing until about January 20. Taped climbing with a real sensitivity to pain for another month or so. I climbed in a friendly Gym competition on March 2 or so and I can honestly say that the routes I couldn't do were because of general weakness or lack of ability and not pain.

It still hurts and I still tape it almost immobile but I flashed a 5.10+ which was close to my limit before the injury...

poomasta wrote:
As far as increasing blood flow to speed healing...anyone have thoughts on this idea of submerging the injured hand alternately in a hot / cold bath to boost circulation? i don't get the point of the cold water...wouldn't the hot be sufficient?

It's what my physio recommended to me and it worked pretty good. I think the idea is to get the constriction and expansion thing going with blood vessels. As an added bonus, my hand used to feel pretty good afterwards...

Take it easy and it'll come...


kylerose


Mar 12, 2007, 10:06 PM
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Re: [macblaze] A2 pulley: ruptured or torn? [In reply to]
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yes, wolff's law was first written for bones, but the theory applies the same to tissue. no matter.

Yes, the idea behind contrast baths is warm blood rushes in to replace the cold and you get good circulation. The problem with finger injuries is that fingers just don't get good supply. There isn't alot of research to support quicker healing, but can't hurt.

How long until you can climb? Last year I injured my finger in january (no pop) and didn't seriously climb until early may. Now I'm climbing better than ever. Hopefully, you'll return faster. My best advice for finger injuries is to be patient and work on the rotator cuff.


Partner cracklover


Mar 13, 2007, 6:32 AM
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Re: [kylerose] A2 pulley: ruptured or torn? [In reply to]
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For those who were curious about my Dr's appt.

This was appointment number 4. This was the first time they actually looked at an MRI of my finger. It's now 3.5 months since the injury.

Doctor was supremely unhelpful. Didn't even recognize the big obvious black bump that appeared in the same spot on every one of the MRI slides until I pointed it out to him. At that point he grudgingly admitted it *could* be a ganglion. I doubt it's a ganglion, since I've had probably a dozen, and they don't make my entire A2 pulley tender and swollen. But whatever. He's pretty much done all he's going to do. So at this point I'm on my own.

At least it's clear that if there was a partial rupture of the A2 pulley (3.5 months ago, when it happened) it's mostly healed. So I'm just going to start climbing on the finger again, with lots of tape, on easy climbs, and just hope for the best.

GO


Partner drrock


Mar 13, 2007, 6:54 AM
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Re: [kylerose] A2 pulley: ruptured or torn? [In reply to]
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kylerose wrote:
How long until you can climb? Last year I injured my finger in january (no pop) and didn't seriously climb until early may. Now I'm climbing better than ever. Hopefully, you'll return faster. My best advice for finger injuries is to be patient and work on the rotator cuff.

I think this is about right and it probably doesn't matter if you completely or partially tore the pulley. Either way it takes several months to heal and no surgery is typically recommended for an isolated A2 injury. I wrote this about my healing time from a complete rupture:

"after about 5-6 months, my finger and strength are good as new without surgery or any specific therapy. I climbed very light for about 3 months, then slowly started increasing and now am completely back to where I was if not better. I do tape pretty tight around that area every time I climb. If I don't, it is sore for a while. But if I tape tight, then no problems.

So this could be an example of the natural history of a complete A2 pulley rupture. "

Check this old thread from my original injury. You may have already read it, and I apologize if it's old news.

http://www.rockclimbing.com/...guest=7979889#516501

It looks like you are out for a couple months. I never actually completely stopped climbing except for a few weeks. I just climbed pretty light and spared that finger. I was worried that whole time I was delaying the healing process by continuing to climb, but in the end it sounds like it really did not delay anything. I still had some tenderness over the area for a day or so after climbing for about a year. Then it was gone completely. Still have some bowstringing and can't make a complete fist on that side, but there are no physical limitations from it.

An A2 rupture is a climber's right of passage. Be proud and take it like a man. Wink


Partner drrock


Mar 13, 2007, 7:08 AM
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Re: [dhaulagiri] A2 pulley: ruptured or torn? [In reply to]
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dhaulagiri wrote:
I've had many similar injuries but I have never seen the lump that you are seeing. Judging from the fact that you are able to maintain the general mobility of your finger I would say it isn't ruptured but someone with a medical background would be better suited to address that.

You can have a complete A2 rupture and maintain mobility. The impaired mobility from a pulley rupture is usually because of pain, not a mechanical problem. The pulleys simply keep the tendons close to the bone so when you flex your fingers they don't pull away. A tendon rupture on the other hand would impair mobility.

I'll bet you've had some tendon problems if you've redpointed Whiskey a Go Go. That thing is mean looking. Nice work.


dhaulagiri


Mar 13, 2007, 7:36 AM
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Re: [drrock] A2 pulley: ruptured or torn? [In reply to]
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drrock wrote:
dhaulagiri wrote:
I've had many similar injuries but I have never seen the lump that you are seeing. Judging from the fact that you are able to maintain the general mobility of your finger I would say it isn't ruptured but someone with a medical background would be better suited to address that.

You can have a complete A2 rupture and maintain mobility. The impaired mobility from a pulley rupture is usually because of pain, not a mechanical problem. The pulleys simply keep the tendons close to the bone so when you flex your fingers they don't pull away. A tendon rupture on the other hand would impair mobility.

I'll bet you've had some tendon problems if you've redpointed Whiskey a Go Go. That thing is mean looking. Nice work.

Thanks, that thing is one of the best routes anywhere, unbelievable good and pure. I think I was between tendon problems at the time, tweaked one later that month.


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Mar 13, 2007, 7:38 AM
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Re: [drrock] A2 pulley: ruptured or torn? [In reply to]
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FYI, the standard therapy for a fully ruptured A2 pulley is more aggressive than what drrock is suggesting.

Yes, you can leave it alone, and the muscle will eventually take up most of the tension lost from the lack of mechanical advantage from the missing A2 pulley, but if you go this route, you'll probably never gain full strength or mobility, and this will also put more strain on the other pulleys in that finger.

There is a standard surgery that's usually done, where they create a new pulley out of a piece of one of your other tendons. This, apparently (I've only read about it) is pretty successful.

Again, this is only for a fully ruptured A2 pulley (that's the pulley right at the base of your finger, just before it enters your hand).

GO


zeke_sf


Mar 13, 2007, 7:56 AM
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Re: [cracklover] A2 pulley: ruptured or torn? [In reply to]
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Damn, Gabe, your story is exactly why I'm trying to heal my own tendon. I've gone to the doctors in the past for a different tendon problem (achilles tendonitis), and I already know the medical establishment's attitude towards soft-tissue injuries. I could easily spend $100s in co-pays just getting to somebody who might be able to help me. Meanwhile, I have a buddy who broke an arm and is back climbing hard in little more than a month. There is no justice....


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Mar 13, 2007, 8:13 AM
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Re: [zeke_sf] A2 pulley: ruptured or torn? [In reply to]
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zeke_sf wrote:
and I already know the medical establishment's attitude towards soft-tissue injuries. I could easily spend $100s in co-pays just getting to somebody who might be able to help me.

Where's Hans Kraus when we need him?

GO


Partner drrock


Mar 13, 2007, 9:01 AM
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Re: [cracklover] A2 pulley: ruptured or torn? [In reply to]
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cracklover wrote:
FYI, the standard therapy for a fully ruptured A2 pulley is more aggressive than what drrock is suggesting.

Yes, you can leave it alone, and the muscle will eventually take up most of the tension lost from the lack of mechanical advantage from the missing A2 pulley, but if you go this route, you'll probably never gain full strength or mobility, and this will also put more strain on the other pulleys in that finger.

There is a standard surgery that's usually done, where they create a new pulley out of a piece of one of your other tendons. This, apparently (I've only read about it) is pretty successful.

Again, this is only for a fully ruptured A2 pulley (that's the pulley right at the base of your finger, just before it enters your hand).

GO

You may be right. I suppose what you suggest about increased tension on the other pulleys in that finger makes sense. I don't know about the lack of regained strength, but mobility is a *tiny* bit impaired. I never notice it either climbing or in daily life. I have heard that the mechanical advantage is greater in the fingers actually without the pulleys, so theoretically strength should be improved. I wouldn't suggest deliberately rupturing your pulleys though for this purpose. Not sure if this is actually true, as I slept through most of physics class.

There was a somewhat recent article in Wilderness and Sports Medicine in 2003 by Volker Schoffl and colleagues who suggest based on their prospective research of 600 climbers, 74 of whom had pulley ruptures during the study period (single or multiple). They graded them, and the bottom line is that they found that grade 1-3 responded well to conservative, non-surgical measures where grade 4 basically required surgery for function. Their grading scheme was:

Grade 1: Strain
Grade 2: Complete A4 or partial A2 or A3
Grade 3: Complete A2 or A3
Grade 4: Multiple ruptures *or* a single rupture combined with lumbricalis muscle or collateral ligament damage

You can argue with their treatment schema and how they came up with the design of the study, but the bottom line is that they did not do surgery on Grade 1-3 and those people had very little pain or functional impairment after 3 months. They did have those folks off of climbing for 6-8 weeks, I think, with early finger therapy for mobility.

I did not have this data when I was making my decision. The surgeon wanted to operate on the finger and do the repair you mention with the palmaris longus tendon, but mentioned that I would be out of climbing completely for 4-6 months, no exceptions. I was not willing to concede to that and figured I would probably be better by 4-6 months anyway, and I was right, for better or worse. Everything I had read up to that point lead me to believe that while surgery was an option, it was certainly not necessary. This all happened right around the time this article came out, and it's not like this is a huge hand surgery journal that this guy would have been reading in any case.

Anyway, good discussion about a common problem. If it were me, with a complete single A2 rupture without any other associated damage, I would absolutely not allow any surgeon to operate and I would recommend the same for anyone else.

Edited for clarity and spelling, duh.


(This post was edited by drrock on Mar 13, 2007, 9:12 AM)


poomasta


Mar 13, 2007, 10:09 AM
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Re: [cracklover] A2 pulley: ruptured or torn? [In reply to]
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Thanks to all for sharing their knowledge. I've committed to taking two weeks off, doing the rehab activities, and easing myself back into climbing following that. When i do get back in the gym, I'm gonna focus on climbing open handed on friggin everything and staying under the pain threshold for several weeks.

So...here's something crazy:
the weird little lump I have in my finger (some of you have postulated that it's a ganglion or synovial cyst) has decreased in size significantly following about 4 hours of operating a weed eater in the back yard! This was not an intended result, just some long overdue yard work, but it happened nonetheless. I wore padded gloves cuz I was worried about exacerbating my finger's condition, but I'm guessing the vibrations from the weed eater were still sufficient to help break down the lump. Maybe I'm crazy, maybe it will come back...or maybe the weed eater has some therapeutic value ;-) YMMV...


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Mar 13, 2007, 10:39 AM
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Re: [poomasta] A2 pulley: ruptured or torn? [In reply to]
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poomasta wrote:

So...here's something crazy:
the weird little lump I have in my finger (some of you have postulated that it's a ganglion or synovial cyst) has decreased in size significantly following about 4 hours of operating a weed eater in the back yard! This was not an intended result, just some long overdue yard work, but it happened nonetheless. I wore padded gloves cuz I was worried about exacerbating my finger's condition, but I'm guessing the vibrations from the weed eater were still sufficient to help break down the lump. Maybe I'm crazy, maybe it will come back...or maybe the weed eater has some therapeutic value ;-) YMMV...

Definitely a ganglion cyst, then. And what you're saying makes perfect sense. I used to get ganglion cysts from operating a push-mower through heavy grass. Basically, it's a little balloon of fluid caused by a break in the pulley sheath allowing the synovial fluid inside to herniate out a little. You can get them (in my experience) through hard vibrating things against the fingers so it stands to reason that you can pop them that way too.

Just be aware, when they get popped, they often come back.

I'd suggest that you keep massaging the area to keep any synovial fluid in where it belongs, and maybe the tear will heal up on its own. Although now I'm exiting the realm of medical knowledge and getting into guesswork.

GO


kylerose


Mar 13, 2007, 4:21 PM
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Re: [cracklover] A2 pulley: ruptured or torn? [In reply to]
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ganglion cysts don't appear on hands. Those appear on the dorsal surface of the wrist. The bumps are cynovial cysts.


lhwang


Mar 13, 2007, 6:35 PM
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Re: [kylerose] A2 pulley: ruptured or torn? [In reply to]
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kylerose wrote:
ganglion cysts don't appear on hands. Those appear on the dorsal surface of the wrist. The bumps are cynovial cysts.

Ganglion cysts can actually involve pretty much any joint in the hand or fingers. Some people call them synovial cysts. Essentially the same thing although you can't tell the difference just on location... you need histology (ganglion cysts have fibroid linings, synovial cysts have synovial linings).


(This post was edited by lhwang on Mar 13, 2007, 6:41 PM)


kylerose


Mar 13, 2007, 9:09 PM
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Re: [lhwang] A2 pulley: ruptured or torn? [In reply to]
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In reply to:
Ganglion cysts can actually involve pretty much any joint in the hand or fingers. Some people call them synovial cysts. Essentially the same thing although you can't tell the difference just on location... you need histology (ganglion cysts have fibroid linings, synovial cysts have synovial linings).

Looks like I was wrong. You can get a ganglion cyst on a finger. Thanks for the correction. After looking around I found this resource.
http://www.eatonhand.com/hw/hw013.htm

Thanks again.


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