You felt the pop on a V6. You knew before your fingers came o% the wall. It’s been two months. The pulley still aches when you crimp. You’ve been taping. You’ve been resting. You’ve been telling yourself you’ll start back light next week. You haven’t. You don’t trust the finger and the projects are stacking up.
If you climb in Boulder, you have a doctor problem. The general orthopedist treats your finger like a generic hand. The hand specialist treats your finger like surgery prep. Most clinics in this town do not see fifty climbers a month and don’t recognize what an A2 actually needs.
I’m Dr. Aneesh Garg. I treat the three most common climber injuries — pulleys, climber’s elbow, and shoulders — with the protocols that actually return climbers to projecting grade. Here’s how we approach each one.
Pulley injuries — the A2 question
The pulleys are the ligaments that hold your flexor tendons against your finger bones. The A2 pulley at the base of the finger takes the most load. The classic mechanism is a closed crimp with a sudden load — a foot pops, the finger gets shock-loaded — and the pulley fails. Pulley injuries are graded one to four. Grade I is a sprain. Grade II is a partial tear. Grade III is a complete rupture of one pulley. Grade IV is multiple pulley rupture with bowstringing visible on imaging. Grades I, II, and III are conservative cases. Grade IV is the only one that’s regularly considered for surgery, and even then there’s debate.
The standard advice you get online and from generic orthos is: tape, rest, climb light at six weeks, full strength climbing at three months. That’s a reasonable conservative protocol. It also gets you back at significantly diminished trust in the finger for another six to twelve months. Most climbers don’t fully forget about the injury for over a year.
The regenerative approach I use:
Ultrasound-guided PRP injection at the pulley. We image the pulley, identify the tear or the inflammatory thickening, and inject multi-spin leukocyte-rich PRP at the site. The pulley needs leukocyte-rich PRP — that’s the right prep for ligamentous tissue. We don’t use a singlespin generic preparation.
Dynamic Shockwave follow-up. Focused ESWT at low energy levels around the pulley site over the following three to four weeks. The shockwave accelerates the cellular response and the collagen reorganization. For climbers we tune the shockwave protocol carefully — too aggressive at the wrong time is counterproductive on small ligaments.
Climbing-specific PT. We work with physical therapists in Boulder who treat climbers specifically. The progressive loading protocols for finger return-to-climb are different from generic hand therapy. Hangboard protocols, taping strategies, projecting return — the climber-specific work matters.
The end result is climbers returning to full grade climbing typically six to ten weeks faster than conservative care alone, and with a finger that feels trustworthy again.
“Climbing injuries are not generic hand injuries. The protocol matters.”
Climber’s elbow — the medial and lateral story
Climber’s elbow is one of the most under-diagnosed injuries in the sport. Most climbers eventually develop one of two patterns: medial epicondylopathy (inside of the elbow, golfer’s elbow) from heavy crimping and full-crimp positions, or lateral epicondylopathy (outside of the elbow, tennis elbow) from open-hand and slopey climbing, big lockoffs, or any forearm rotation under load.
The mistake most climbers make is treating it like a tendon problem to rest off. By six weeks of relative rest, the tendon hasn’t healed — because chronic tendinopathy is not primarily inflammatory, it’s degenerative. The tendon needs to be re-loaded and given a biological signal to remodel. That’s not how anti-inflammatories and ice work.
The combined PRP plus focused shockwave protocol is the right tool for chronic climber’s elbow. Multi-spin leukocyte-rich PRP at the tendon under ultrasound guidance, followed by three to five focused shockwave sessions across six weeks, plus a heavy slow resistance loading protocol with the right PT.
Most climbers I see for elbows have been struggling for six months or more and have already tried rest, the bands, eccentric loading on their own, and one or two cortisone shots from the general ortho. The cortisone often makes things worse long-term because it weakens the already-degenerative tendon. We have to undo that and restart healing.
Climbing shoulders — the impingement and labral question
Climbers’ shoulders take a beating. The combination of overhead reaching, dyno loading, lock-off positions, and lap-sized antagonist deficits creates patterns that show up as anterior shoulder pain, posterior cuff tightness, internal impingement, or sometimes a labral injury.
The evaluation matters enormously here because the treatment varies. A subacromial bursitis pattern responds to focused shockwave plus PRP at the bursa. A rotator cuff partial tear responds to PRP at the tear site and shockwave at the muscle-tendon junction. A labral fraying or partial tear requires careful evaluation — some respond beautifully to PRP, some need surgical consultation. A SLAP tear in a climber doing a lot of overhead and reaching needs honest evaluation about whether biology can heal it or whether the surgical option is the better one.
For most climbing shoulder injuries that don’t involve a full-thickness rotator cuff tear or a major labral disruption, the regenerative protocol works well. I evaluate every shoulder carefully on the first visit, often re-image with ultrasound in the office, and we build the plan from there.
90%+ CLIMBER PATIENTS REPORT 75%+ IMPROVEMENT
6-10 WEEKS FASTER BACK TO CLIMBING ON COMBINED PROTOCOL
Why most clinics in Boulder don’t get climbing!
Boulder has the highest climber density in the country. It also has a lot of generic sports medicine and orthopedic clinics. The disconnect: most of those clinics don’t see the volume of climbers needed to recognize the subtleties.
The questions that matter to a climber are different. What grade do you climb? What’s your project? Is your injury limiting you on crimps specifically or also on open hand? Is it the dyno that catches it or the lockoff? When did you last hangboard? What’s your antagonist work look like? These are the questions a doctor needs to ask to actually help. We ask them because we live this sport too.
The cost question — and the alternative
The cost of regenerative care for a climbing injury is comparable to the cost of a year of partial climbing — the gym memberships you barely used because the finger hurt, the trip to Bishop you cancelled, the projects you didn’t try, the antagonist PT you paid for that didn’t move the needle. Insurance doesn’t cover PRP or shockwave. Cherry financing handles the rest with 0% APR for qualified patients.
What we offer in return is most climbers back on grade in a meaningful timeline. Not “off the wall for another year.” Not “I’m still tweaky on crimps.” Back on the wall with a finger or elbow or shoulder you trust.
What climbers ask before booking!
Should I get an MRI before I come in?
For most pulleys, no — ultrasound in the office is more informative for soft tissue grading. For shoulders with possible labral involvement, sometimes yes. We make the call after the physical exam.
How long off the wall after PRP?
Typically one to two weeks of rest from climbing, then progressive return per a climbing-specific PT protocol. The exact timeline depends on the structure injured and the grade.
Can I keep training non-injured grips and antagonists?
Almost always yes. We don’t shut climbers down completely. We work around the injury and keep you climbing-fit.
Will this hold up to projecting at my grade?
If we get the injury fully resolved and you commit to the loading protocol, yes. The patients who follow the protocol are projecting their previous grade and often progressing past it within months.
Do you treat tweaks early or do I have to wait for it to be chronic?
Earlier is almost always better. The first six weeks of an injury are the easiest to influence. Don’t wait until it’s been six months — come in the week after the tweak.