Climber's Finger Pain: A2 Pulley Injuries Explained
A guide to A2 pulley injuries in climbers, including bowstringing, MRI and ultrasound findings, grading, and return-to-climbing context.
Key Takeaways
- A2 pulley injuries are common search concerns in climbers
- Ultrasound can show dynamic bowstringing
- MRI can show pulley edema and associated soft-tissue injury
The A2 pulley holds the flexor tendons close to the proximal phalanx. Climbers stress it heavily in crimp grip. A painful pop, palm-side finger pain, or visible bowstringing may lead clinicians to consider a finger pulley injury.
Imaging Signs of Pulley Injury
- Increased tendon-to-bone distance during resisted flexion
- A2 pulley thickening, edema, discontinuity, or nonvisualization
- Flexor tendon sheath fluid or reactive tenosynovitis
- Multiple pulley involvement when bowstringing is pronounced
Frequently Asked Questions
Can I keep climbing with a suspected pulley injury?
Return to climbing depends on grade, pain, bowstringing, strength, and clinician or therapist guidance. Imaging can help characterize the injury but does not replace a supervised return-to-load plan.
Should I pay for 3T MRI for an A2 pulley injury?
Only if it answers a question your clinician cannot answer with exam, X-ray, or dynamic ultrasound. Ultrasound can show bowstringing during motion. MRI, including 3T MRI, can show pulley edema, discontinuity, and associated soft-tissue injury.
What does bowstringing mean?
Bowstringing means the flexor tendon lifts away from the bone because the pulley restraint is torn or stretched. It can be measured dynamically with ultrasound or seen on MRI when the separation is large.
Sources
- Schöffl VR, Schöffl I. Injuries to the finger flexor pulley system in rock climbers: current concepts. J Hand Surg Am. 2006;31(4):647-654.
- Bollen SR. Injury to the A2 pulley in rock climbers. J Hand Surg Br. 1990;15(2):268-270.
- Klauser A, Frauscher F, Bodner G, et al. Finger pulley injuries in extreme rock climbers: depiction with dynamic US. Radiology. 2002;222(3):755-761.
- McCarthy CL. Ultrasound of normal and injured ligaments and retinacula of the hand. Semin Musculoskelet Radiol. 2020;24(2):83-100.
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