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A2 Pulley Surgery
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By Alecks
From Seattle
Aug 29, 2013
Liberty Bell
Ok, I'm aware of the thousands of posts on this topic but... I injured my A2 pulley on my left ring finger bouldering at the gym. My finger exploded. People 20 feet away heard it pop. I heard things like, "Dude, was that your finger?" No bueno. I scheduled an appointment with a hand surgeon whom I saw about 4 days after the injury. In those 4 days I stopped climbing, iced, and did everything I was supposed to do. I had light swelling and light bruising that subsided rather quickly and I regained mobility in my finger to the point where I thought maybe it wasn't so bad and it was just a very dramatic strain. More bark than bite, know what I'm saying? I attributed the remaining immobility to inflammation and figured I could get back to normal soon if I took care of it properly. I was very much considering canceling the Appointment and just self medicating like I usually do (see 1 permanently disfigured pinky finger that turned out to be a torn tendon... I do good work). Since I have health insurance I decided to keep it and go anyway just in case. The Dr. looked at my finger and performed a couple tests and within minutes recommended an MRI to confirm his suspicion of a complete pulley rupture and surgery. I have not had the MRI yet and don't know if it is a complete rupture. I have researched and read many forums, yet I haven't been able to find out from anyone who has had the surgery. So any climbers out there who have had their A2 pulley surgically reconstructed; How'd that go? would you do it again if you had the choice? Was it truly necessary? Anybody get the operation in the Seattle area? Was that the proper use of a semicolon?

Also I know a million people have said this, but don't let it come down to an injury to learn that you have to warm up your fingers (and probably the rest of you) before hopping on your proj. I got away with it for years, until I didn't. Take the time to properly warm up and stretch and you won't have to worry about the prospects of a rainy Seattle winter with no climbing gym. Thank god for skiing.

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By Will S
From Joshua Tree
Aug 29, 2013
I know a couple people who had full-on bowstringing ruptures, no surgery, still climb. Beware the "if all you have is a hammer" thing, where a hand surgeon...well, they want to do surgery. That's their thing.

The other thing I'd mention, is that yes you should warm up, but I have zero confidence that "warming up" does anything to prepare a connective tissue structure like a pulley. It'd be similar to saying "warm up before you sprint so you don't tear your meniscus"...huh?

They can be super loud when it happens. I've had 11 of them. 3 or 4 were scary loud and I was convinced that I was screwed and had done real, permanent damage. But that hasn't been the case. Std rest, ice, and easing back into after about 3-4 weeks is what's worked for me. Of those 11, I've never noticed "bowstringing" you hear about, but it alwasy seemed like that would be hard to notice at A2 anyway. Last one for me was A2 and A4 at the same moment in the pinky. Sounded like a gun going off. 12 months to pain free, but I was climbing as hard as pre-injury within 3 months.

I'd have the MRI and go from there.
Good luck to you.

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By Chris treggE
Administrator
From Madison, WI
Aug 29, 2013
This problem haunted my dreams for 6 years after failing to send in 2008.  Finally got throw a heel over the lip jug -- now I can sleep.  Photo Darin Limvere.
I had a complete A2 rupture in 2005, MRI confirmed. Ortho hand surgeon recommended surgery to reconstruct it. I did a lot of talking with people and also reading in medical journals, and came to the conclusion that for an isolated A2 pulley rupture, surgery was not recommended or necessary. I'd have to look again, but IIRC if you have multiple pulleys ruptured, surgery is generally recommended but still maybe not even necesary. With a single pulley rupture, I definitely wouldn't do it.

I never stopped climbing, but I had to climb on huge jugs for a couple months before easing back into the smaller stuff. Within 4 months I was back where I was before doing it, although my finger hurt during and after climbing for almost a year. It still bowstrings out, and I can't close the finger all the way down when I make a fist, but I never think about it, and there is no functional impairment.

Get the MRI and see exactly what you are dealing with.

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By slim
Administrator
Aug 29, 2013
tomato, tomotto, kill mike amato.
Will S wrote:
I've had 11 of them.


damn!

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By nicelegs
From Denver
Aug 29, 2013
I don't know about surgery but I would suggest that you stay in constant contact with your doc and PT while healing.

I didn't and I ended up with a finger that pretty much always hurts and is severely crooked. I think about cutting it off most days. If it were the pinky and not the ring finger, it'd already be gone.

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By The Blueprint Part Dank
From FEMA Region VIII
Aug 29, 2013
Better quality
Lot of good docs around Seattle. I broke my wrist ice climbing a couple winters ago and saw some folks at The Everett Clinic that were really, really good, two week Indian Creek trip went off without a hitch a couple weeks after the cast was off.

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By Aerili
From Salt Lake City, UT
Aug 30, 2013
The West Desert...it's not just for climbing, suckers! <br /> <br />Photo by Samantha
Will S wrote:
The other thing I'd mention, is that yes you should warm up, but I have zero confidence that "warming up" does anything to prepare a connective tissue structure like a pulley. It'd be similar to saying "warm up before you sprint so you don't tear your meniscus"...huh?


Actually, I think I would disagree with this, Will. I feel that warm-up is probably protective for a wide range of joint and muscle structures. Muscles themselves are a major component of a joint's integrity/stability. They are controlling the joint's movement (and lack of movement to a degree, although the capsule and ligaments also restrict movement). Muscles contain the proprioceptors which allow the body to control the joint's position and changes in position (and associated velocities and accelerations). All these things are involved in injury mechanisms typically. Therefore warm-up, which essentially "tunes up" the neurological input to the musculoskeletal system, should affect a cascade of structures.

Pulleys do have blood flow, and while they more of a "passive restraint" in the finger system (than, say, tendons), warming up would increase blood flow to them and thus influence their viscoelastic behavior and alter their performance, much like a muscle-tendon unit...I would imagine.

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By Alecks
From Seattle
Sep 10, 2013
Liberty Bell
Thanks for all your input, I really read it and digested it. If anyone is interested, after exhaustive research and talking with multiple surgeons and hand therapists, I'm going with surgery. MRI confirmed full a2 rupture and probable a4 rupture. I am having the operation done by Dr. William Wagner from the Seattle Hand Surgery Group. He is a climber and really broke down (no pun intended) on what is going on in my hand. And it is true that most people don't need surgery for this injury, even a full rupture. but the extent that my hand doesn't close seems to warrant the operation. If anyone is interested, I can let people know the results after I get back to climbing. Seems like i'm the guinea pig to some extent.

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By Fan Z.
From Washington, DC
Oct 24, 2013
Iceland buildering
Alecks A. wrote:
If anyone is interested, I can let people know the results after I get back to climbing. Seems like i'm the guinea pig to some extent.


Sorry to hear about your injury, Alecks. How did the surgery go? And the recovery so far? I'm interested because I've been climbing for the past two years with a right ring finger that has either a A2 pulley strain/rupture, a volar plate avulsion, or a boutonniere injury. (An orthopedist said boutonniere 8 months ago, but I'm not so sure now.)

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By Alecks
From Seattle
Oct 25, 2013
Liberty Bell
Fan Z:

I'm six weeks out of surgery and things are going well. I can't put weight on my finger yet but I can use my hand fine and everything should heal up nicely. I definitely do not regret going though with the operation. At least at this point. I haven't started climbing on it yet.

I'm not sure what it is you are asking. However, unless you deal with your finger injuries soon after they occur it becomes increasingly difficult to get them to heal right. for example, in my pinky finger I have a boutonniere deformity (from punching a wall... by accident) that I didn't do anything about. And, its just like that now. It hurt for a while. Now it doesn't. It doesn't affect my climbing/life so I don't care. But if I wanted to do something about it now, I think it would be very very difficult. I felt that my ring finger injury WAS going to affect my climbing/life so I chose to do something about it right away since I was fortunate to have the option.

I'm kind of just rambling so pm me if you have a specific question.

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By Fan Z.
From Washington, DC
Oct 25, 2013
Iceland buildering
Alecks, good to hear your recovery is going well so far. I guess I didn't have any other specifics questions. Was just curious because occasionally I consider doing something about my finger, i.e., take extended time off or seek opinion of a second orthopedist or PT. But it's hard to find an ortho who understands climbing injuries, and even harder to commit myself to taking time off. My finger injury doesn't interfere with daily life, and only gives me pause in climbing when crimping really hard. There's swelling and pain around the PIP joint after climbing hard for consecutive days without rest, but otherwise, I don't feel like it's significantly affected my progression. I'm rambling, too, so will stop here. Hope you have a full recovery.

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By Jowell Bacon
May 1, 2014
Alecks, hey, now that we're almost 6 months out from surgery, I imagine you've begun to climb again? Any updates on the finger? Regrets? Hopes for the future? I have a full A2 tear and partial A4 in my left ring, have been told by 2 very good hand surgeons in the bay area that I'm a candidate for surgery, but have yet to set a date. I'm 3 months out from the injury, don't have pain, but my finger feels very weak, and I have about a 15 degree bend in the finger. Haven't tried to climb again yet and have been told by one surgeon that 6-8 weeks of PT may help loosen the PIP joint.

Any thoughts you have would be much appreciated. I miss climbing so much and just want to get back in the game. Trying to figure out if surgery is the best way to do that.

Thanks man, hope all is well.

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By Fat Dad
From Los Angeles, CA
May 1, 2014
I'd be curious about the results too. I injured my A2 (possibly the collateral ligament as well) and while the pain wasn't significant, the joint felt weak for a good six months. Climbing on it just wasn't an option. I am only now considering going back to the gym for some mellow jug pulling. If the pain/weakness returns, then I may consider seeking treatment, so I'd like to hear how your's went.

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By TBrumme
From denver, co
May 1, 2014
My injury sounds pretty similar to Jowells. Here's the story:

Heard 2 loud pops while gym climbing, no pain. At first didn't realize it was my finger that made the noise, I thought the climbing hold had cracked. Stopped climbing that night. Still no pain and only minor swelling. Saw 2 hand surgeons that week; one wanted surgery asap; the other said wait and see since I could always do surgery later. I chose the latter option.

For the first few weeks after the injury I had full range of motion. Then, at some point I was unable to straighten my finger. Still no pain, but no matter how hard I tried I couldn't straighten it. Didn't have health insurance at that point so I just let it be and kept climbing. Aside from a loss of strength in that finger and the inability to put my hand in tight-hand cracks, it hasn't affected me too much.

I now have health insurance and am tired of bloodying my knuckle in hand/finger cracks so I'm seeing another hand surgeon. His advice is to try to straighten it using PT (tension splint 8hrs/day) and then talk about surgery once its straight. Just started PT last week. Getting an MRI next week to see what is really going on. Probably do surgery in late fall so that I'll have skiing to keep my mind off of not being able to climb.

ring finger can't extend beyond that angle
ring finger can't extend beyond that angle


tension splint
tension splint

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By Fan Z.
From Washington, DC
May 2, 2014
Iceland buildering
TBrumme wrote:
... His advice is to try to straighten it using PT (tension splint 8hrs/day) and then talk about surgery once its straight. Just started PT last week. Getting an MRI next week to see what is really going on. ...


Good luck with your recovery, TBrumme. My right ring finger looks identical to yours in that it's bent about the same amount as yours, and can't be straightened. Let us know how your tension splint and PT work out for you.

I tried the same thing (tension split and PT) without success for 5 weeks before giving up. Have been climbing with the finger in this condition for almost 3 years now. In addition to the problem with tight finger cracks you mentioned, my finger swells up after hard crimping, which is how it usually limits my route selection.

X-ray showing bone chip on right ring finger
X-ray showing bone chip on right ring finger

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By Pontoon
From Minneapolis, Minnesota
May 2, 2014
No capitalization after semicolon. Glad I could at least answer one of your questions. The rest has been informative for me though. Great topic.

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By TBrumme
From denver, co
May 2, 2014
Fan Z. wrote:
Have been climbing with the finger in this condition for almost 3 years now. In addition to the problem with tight finger cracks you mentioned, my finger swells up after hard crimping, which is how it usually limits my route selection.


Any plans for surgery? Honestly if it weren't for cracks, I wouldn't bother dealing with it.

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By Alecks
From Seattle
May 2, 2014
Liberty Bell
So I had pulley reconstruction surgery last september. My surgeon (Dr. William Wagner of Seattle Hand Surgery Group, Big Shout Out!) used about 14 cm of dead guy (or gal) tendon and wrapped it around my bone and tendon about 4 times. I could not be more pleased with the results. I was back climbing within 3 months and I am climbing harder now than I was before the surgery. Yes, the finger is weaker, and I think about it while crimping and I have a 4 inch scar going from the top of my palm all the way up to the last joint, but I am so glad I did it. id be happy to chat about it. send me a pm if interested. I

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By Fan Z.
From Washington, DC
May 2, 2014
Iceland buildering
Alecks wrote:
So I had pulley reconstruction surgery last september. ..., but I am so glad I did it. id be happy to chat about it. send me a pm if interested. I


That's great to hear, Alecks! If your surgeon were in the DC area, I'd definitely want more details. So does your experience suggest that dead tendon is as good as live tendon when used for reconstructive surgery? Or I am missing something?

TBrumme wrote:
Any plans for surgery? Honestly if it weren't for cracks, I wouldn't bother dealing with it.


No plans for surgery, but that option is always in the back of my head, especially after a lot of hard crimping. I'm just breaking into finger-sized cracks, so that's not a big concern for me (yet?). The main way in which my finger has hindered my my climbing progression is that I am reluctant to project crimp-oriented routes at my limit, whereas I'm willing to project routes past my limit if they don't have any crimps. Maybe I'll look into surgery next winter...

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By nicelegs
From Denver
May 2, 2014
TBrumme.

I have basically the same finger as yours. My MRI was almost a year after the injury and the surgeon I consulted essentially said he wouldn't touch it.

It has gone through some really really sore times, lately though, it's just crooked.

I found that if I tape that finger, cracks aren't too bad. I do hate having to monkey around with finger jams that no longer work and I am simply not as able to climb flared hands anymore.

I've done tons of splinting and stretching FYI and nothing has ever had a lasting effect. I wouldn't put much hope into PT fixing that finger for you.

Mine was 5 years ago in January. It's fine but it's a long way from right. It will never be the same. Sucks getting old.

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By TBrumme
From denver, co
May 2, 2014
nicelegs wrote:
I found that if I tape that finger, cracks aren't too bad.


I tried taping it and I still ended up tearing up the knuckle and bleeding through the tape.

bleeding through the tape
bleeding through the tape


What was the surgeons reasoning for not doing surgery? If that's the case I'd honestly rather amputate it. It's not doing me any good like it is as it's got no strength and simply limits my climbing. If I cut it off at least it wouldn't get in the way of my climbing.

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By travisgunn
From las vegas, nevada
May 2, 2014
ooo la la
TBrumme wrote:
I tried taping it and I still ended up tearing up the knuckle and bleeding through the tape. What was the surgeons reasoning for not doing surgery? If that's the case I'd honestly rather amputate it. It's not doing me any good like it is as it's got no strength and simply limits my climbing. If I cut it off at least it wouldn't get in the way of my climbing.


I think about amputation every time I climb. It makes perfect sense. Did the PT and used the finger un-bender forever, and it didn't do shiz. Never looked into surgery but I have numerous friends that guarantee that can straighten it out for me.

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By nicelegs
From Denver
May 2, 2014
At the time I was climbing strong and getting stronger. He didn't want to cause further damage. Basically it was the option of a strong and painful bent finger and a straight and possibly weak and painful finger.
he
I think something internal that breaks down tissue (cortisone comes to mind) to get it to the point of flexibility then rebuild slowly with a focus on straightness. Trouble is, that finger would be much more prone to reinjury forever after that. At least now, with all the scar tissue, I can't really hurt it. And if I must mono, that's the one I use in hopes I might tear it off.

I have a friend who is a climber and accupuncturist who thought he could gradually break down the scar tissue with needles. I never tried it and he's moved out of the area, so I'm probably not going to try it with a full price accupuncturist.

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By robrobrobrob
May 2, 2014
I love this thread. Almost 4 years ago I heard a pop, iced and didn't climb. Then went to a hand surgeon who suggested PT. Went through a lot of that, and got my finger far straighter.

Flash forward to this winter, and my ring finger starts curling in again. Went to a different hand specialist , and she suggested surgery. Actually 2 surgeries. Had the first one 2 weeks ago today, opened up the top to clear the joint and ensure extensor tendon was in the right place. Recovering from that now. I'm in for some weeks of serial casting and extension splints.

Once we regain some extension she will fix the 2 pulleys that are damaged. Unless. Oh how I fear that word right now. If we can't stretch the flexion tendon I will have to have fractional lengthening of that tendon, which will lead to some loss of strength.

Dr says the good news is that I have no arthritis in the PIP joint, small comfort when I am waiting for this flexion tendon to unbend my finger. Ugh. Not likely to have much time on the rock this summer!

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By Alecks
From Seattle
Oct 7, 2014
Liberty Bell
So it has been a little over a year since surgery on my pulley rupture and I am happy to report complete success on the operation. I'm climbing all the time and climbing as hard as ever. I still tape, but I suspect that its more mental. I avoid overly crimpy routes, but when I have to crimp It feels strong and I have confidence in it. This should probably be the general approach to climbing. I'm also playing more guitar than ever, which was another concern of mine at the time. So Surgery worked. Shout out to my surgeon Dr. Bill Wagner at Seattle hand surgery group.

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By TBrumme
From denver, co
Oct 8, 2014
Alecks wrote:
I am happy to report complete success on the operation. I'm climbing all the time and climbing as hard as ever.


Congrats on the successful surgery Alecks! What was your range-of-motion prior to surgery? My finger still has a permanent bend to it; thinking of skipping PT (trying to straighten with a splint) and going straight to surgery.

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