How to Prevent and Treat Finger Stress Fractures in Young Climbers

Parents are understandably proud of their climbing kids. Perhaps the kids show incredible drive and passion for climbing, or have a natural aptitude for moving fluidly over rock and plastic alike. Maybe they are medaling in local or national comps. But when your kiddo mentions a sore finger that’s been hurting for days, take special note: kids aren’t immune to climbing injuries—and, in some cases, are even predisposed to them.

What is an Epiphyseal Stress Fracture, and Why Haven’t I Gotten One?

An epiphyseal stress fracture is a common overuse injury that occurs in the finger growth plates of youth climbers, often their middle fingers. Youth climbers commonly experience these injuries—which are small cracks in the bone—during or after periodized training plans, which involve climbing the same “style” of routes, or training via the same mechanisms, repeatedly over a period of weeks or months.

If you’re an adult reading this post, you’re probably wondering why you’ve never had an epiphyseal stress fracture in one of your fingers. The reason is simple: Adults are skeletally mature, meaning epiphyseal growth plates have fused, while youth and adolescent climbers remain skeletally immature until puberty ends. Let’s take a look at the anatomy of our fingers and the mechanism of these injuries.

Thumbs have two phalanx bones while our second, third, fourth, and fifth digits all have three. The phalanx bones are connected via synovial hinge joints with greater range of motion typically found into flexion versus into extension. Digits two through four have distal interphalangeal (DIP) joints (which are the first knuckle from the top of the finger) and proximal interphalangeal (PIP) joints (the second knuckle from the top of the finger). Thumbs contain only a PIP joint.

Phalanges are classified as long bones because they contain distal heads, bodies, and proximal bases. Rounded epiphyses can be found at both the distal and proximal ends of phalanges and are separated from the diaphysis by hyaline cartilage growth plates. Growth plates reach their softest and weakest points in childhood and adolescence, and are the most vulnerable to injury during puberty when adolescents realize significant bone growth.

Skeletal maturity is reached when epiphyseal growth plates fuse with the diaphysis, and is typically reached at about 25 years of age. Once the epiphyseal plate disappears, it is no longer possible for epiphyseal stress fractures to occur at the location of the epiphyseal growth plate.

Signs, Symptoms and Risk Factors

Epiphyseal stress fractures are the most common injuries for youth climbers. A study by Rachel N. Meyers et. al. found that these injuries often occur in the middle phalanx of the third digit, which typically receives the most force of any finger due to its physiology and biomechanical effectiveness. However, it is also possible for epiphyseal stress fractures to occur in the second and fourth digits based on finger length differences. For example, men typically have longer ring fingers than pointer fingers, and the reverse is typically true in women. Therefore, youth male climbers may put more force through their ring fingers while youth female climbers may put more force through their pointer fingers, thus making each respective digit more prone to stress fractures.

Typically, repetitive terminal extension of the DIP joint and simultaneous flexion of the PIP joint from chronic crimping in either the half-crimp or full-crimp position is the cause of epiphyseal growth plate fractures. Campus boarding, double-dyno moves, and the use of full-crimp positions are risk factors for developing epiphyseal stress fractures. These risks are even more pronounced during puberty or periods of sustained bone growth.

The onset of epiphyseal stress fractures is typically slow as the stress fracture develops over time. Bartschi et. al. found that none of the 28 youth climbers participating in their study reported a sudden, single traumatic event causing the fracture. Instead, all 28 of these climbers reported a gradual progression of pain during or after climbing over a period of two to six months. Pain is most commonly experienced during dynamic movement on small edges (i.e., campus boarding) or during the half-crimp and full-crimp positions. Tenderness of the back of the PIP joint is common along with swelling around the joint capsule. Additionally, climbers with these injuries commonly experience limited flexion range of motion in the PIP joint.

Below are common signs and symptoms of growth plate fractures:

• Tenderness on the back of the PIP joint
• Swelling
• Finger stiffness

Because crimping and dynamic movement places significantly more force through the fingers than activities of daily living, the impact outside of climbing is typically minimal. Symptoms can be aggravated during high-exertion activities such as lifting heavy objects or manual labor. The most impactful limitation outside of climbing may be participation restrictions for multi-sport athletes. Youth and adolescent climbers may be limited in motions such as throwing and catching which require flexion of the PIP joint and high impact to the fingers.

Assessment

Finger epiphyseal fractures are typically assessed with both a clinical examination and imaging. Clinicians should use the following considerations to rule in the likelihood of this diagnosis:

Age

Clinicians can rule OUT the likelihood of an epiphyseal fracture in adult patients. A study by Olva Kvist et. al. found that growth plates typically close in females by age 17 and in males by 19 . Patients significantly older than 19 years of age are unlikely to have an epiphyseal stress fracture. Clinicals should be cautious when using age as a diagnostic factor, however, because the timing of growth plate closure is variable.

Flexion Range of Motion in PIP Joint

Epiphyseal fractures typically lead to decreased flexion range of motion in the PIP joint adjacent to the fracture. Typical range of motion in digits two through five is between 100 and 110 degrees. Clinicians should perform both active and passive range of motion tests in the affected finger and compare their findings to the contralateral digit. If a growth plate injury on both sides is suspected, clinicals should compare flexion range of motion to digits two through five on each side. Clinicians should not use PIP flexion range of motion as the primary diagnostic test because limited ROM can present as a sequela to swelling due to a number of other common finger injuries (capsulitis, joint sprains, collateral ligament damage, and tenosynovitis).

Dorsal PIP Joint Tenderness

Finger epiphyseal stress fractures typically occur on the back of the proximal epiphyseal plate of the intermediate phalanx. Tenderness to the back (dorsal) aspect of the affected PIP joint can be a strong indicator of an epiphyseal stress fracture, especially if the patient has pain in the third digit.

Ruling Out Pulley Injuries

While pulley injuries are a common finger injury in adult climbers, they are less common than epiphyseal stress fractures in youth climbers. Because the A3 pulley is located on the palmar aspect of the PIP joint, this diagnosis should be ruled out.

To rule out a pulley injury, clinicians should assess for tenderness on the palmar and lateral surfaces of the finger, and also perform a manual muscle test (MMT) of the flexor digitorum superficialis. If the patient does not feel pain on the palmar and lateral aspects of the finger and the MMT fails to elicit pain to the palmar aspect of the PIP joint, the clinician can rule out the likelihood of an A3 pulley injury.

Ruling Out Tenosynovitis

Tenosynovitis is a common climbing injury that may also be brought on by overuse. Typically, Tenosynovitis results from an increase to training volume, intensity, or both. To rule out the likelihood of this diagnosis, clinicians should look for swelling that is diffuse to the finger with noticeable tenderness or swelling primarily to the palmar aspect of the finger. Conversely, swelling with epiphyseal stress fractures is typically more localized to the area surrounding the fracture and PIP joint.

Ruling Out Capsulitis

Capsulitis may present with symptoms quite similar to an epiphyseal stress fracture, including:

• Limited range of motion
• Pain with active finger flexion
• Swelling of the PIP joint
• Tenderness on the dorsal aspect of the PIP joint (although tenderness with capsulitis typically surrounds the joint)
• Occurs after overuse

Despite the similarities, there are some fundamental differences between these injuries. Pain with capsulitis typically occurs the morning after a climbing session due to the buildup of fluid that occurs after sustained use. Additionally, capsulitis may elicit a persistent dull, aching pain to the joint, while epiphyseal stress fractures typically elicits sharp pain during climbing. Another difference is that climbers typically experience capsulitis to the DIP joint, while epiphyseal stress fractures are more commonly found in the PIP joint.

Youth climbers experiencing pain on the back of the finger should seek imaging, and should suspect a growth plate fracture instead of capsulitis. If the imaging is negative, the injury may still be an injury other than capsulitis. Therefore, youth climbers should be careful with this diagnosis and obtain an opinion from a licensed physical therapist.

Imaging

Clinicians may use imaging to rule in the likelihood of an epiphyseal stress fracture. The Salter-Harris Type III is the most common type of fracture with these injuries, and is usually found at the dorsal aspect of the intermediate phalanx. This fracture passes vertically from the epiphysis through the entire growth plate, but does not impact the metaphysis.

Bartschi et. al. discussed that x-rays are the most common imaging tool used to diagnose these injuries, but found that x-rays do not effectively detect mild fractures unless providers assess both lateral and oblique views. Bartschi et. al. instead recommended using either an MRI or CT scan to effectively diagnose an epiphyseal stress fracture. Given that MRIs and CT scans are both expensive, and that CT scans use radiation, oblique plane x-rays may be suitable for diagnosing these injuries.

Prevention of Epiphyseal Stress Fractures

There are a number of climbing techniques that can be avoided or modified to prevent epiphyseal stress fractures. Additionally, youth climbers can safely follow some strengthening and stabilizing exercises that specifically aim to offload the amount of force through their fingers . Parents and coaches of youth climbers can implement the techniques discussed below to build better habits in their climbers and reduce the likelihood of developing epiphyseal fractures.

*The focus of this blog post is on the prevention of epiphyseal stress fractures. Therefore, a detailed rehabilitation protocol will not be discussed. Should you or your child currently have an epiphyseal stress fracture, please consider reaching out to a licensed physical therapist as soon as possible.

Additionally, you can find a great reference protocol by reading “Returning to Climb after Epiphyseal Finger Stress Fracture” by Rachel N. Meyers, et al. 9

Avoid or Modify

Double-Dyno Campus Boarding: Avoid

Meyers et al. found that campus boarding during childhood and adolescence is the single biggest risk factor for climbers developing early onset osteoarthritis. Additionally, double-dyno campus boarding is the biggest risk factor for developing epiphyseal stress fractures. Youth climbers should avoid double-dyno campus boarding until they reach skeletal maturity (Meyers et al. recommends that climbers less than 18 years old refrain from all double-dyno movement). Should youth climbers choose to campus board, they should periodize their training and only perform exercises that put relatively little stress through the fingers.

For example, youth climbers can campus board once weekly for three weeks, and should then refrain from campus boarding for at least one month before beginning their next three week protocol. I provide examples of relatively low-strain campus board exercises below.

1×1 Ladders: Matching

Climb rungs in numerical order while matching on each rung.

1×1 Ladders: Alternating

Climb rungs in numerical order but do not match. Instead, bump each hand to the next succeeding rung.

Offset Ladders

Start with one hand on rung 1 and the other hand on rung 2. Bump your hand from rung 2 to 3, and then the other hand from rung 1 to 2. Continue until the final rung.

Max Bumps

Start with hands matched on rung 1 and bump one hand up each rung in numerical order until failure. Repeat with the other hand.

Max Skips

Start with hands matched on rung 1 and make the biggest move possible with one hand. Then, drop back down to rung 1 and repeat with the other hand.

Weighted Hangboarding: Avoid

If you follow climbers on Instagram, you have likely seen videos of climbers hangboarding with an absurd amount of weight, or doing weighted pull-ups with an even more absurd amount of weight. You have probably also seen climbers send V15 and never make a single post about hang ing with weight!

The truth is that weighted hangboarding does make your fingers significantly stronger. However, this training technique places an extreme amount of stress through the fingers and is a major risk factor for youth climbers who have not yet reached skeletal maturity. Climbers less than 18 years old should avoid hangboarding with significant weight. Youth climbers can, however, train weighted pull-ups if they maintain a full overhand supinated or pronated grip on the pull-up bar.

Full-Crimp Grips: Try to Avoid

There are three types of crimp grips in climbing: Full-Crimp, Half-Crimp and Open-Hand Crimp. Each grip type listed above places a decreasing amount of force through the fingers. Youth climbers should try not to overuse full-crimp grips because full-crimping forces the DIP joints into terminal extension and increases the compression on the PIP joint, which is a major risk factor for epiphyseal stress fractures.

Prolonged Training Board Climbing: Be Cautious

The use of training boards has exploded since Ben Moon’s creation of the Moon Board in 2005 . Training with these boards has become a staple of many climbers’ training protocols due to the plethora of boulder problems programmed into each board, the variability in wall angle, and the ability to increase training volume in short sessions.

However, these boards place large amounts of stress through the finger joints, especially at steeper wall angles. Youth climbers should limit their climbing on training boards to twice per week, and should climb at angles where they can consistently avoid full-crimping while sending problems.

Synergistic Strengthening and Stabilizing

The following exercises are suggestions for strength and stability exercises that youth climbers can safely integrate into their training protocols. These exercises will increase the climber’s overall level of fitness, and help to offload a small amount of the force placed through the fingers while climbing by strengthening synergistic muscles and increasing joint stability.

Shoulder Exercises

Banded External Rotation: 3 Sets x 8-12 Reps

Hold each side of an exercise band and, with your elbows tucked at your side, move your arms outward until you meet maximal resistance. This exercise targets shoulder strength and rotator cuff stability.

Banded Horizontal Abduction: 3 Sets x 8-12 Reps

Hold each side of an exercise band with your arms out in front and parallel to the group. Pull each side of the band until your arms are at your sides and the band is flush across your chest. This exercise targets shoulder and upper back strength.

Type-Writers: 3 Sets x 8-12 Reps

Grab a pull-up bar with your palms facing forward and with your hands slightly wider than shoulder width. Pull yourself up until your shoulders are at equal height with the bar. Move yourself side-to-side and stop when you are either unable to hold the bar with the hand on the opposite side or you are no longer able to keep your shoulders at the same height of the bar. Each rep involves moving to both sides and back to the central starting position. This exercise targets shoulder strength.

Is, Ys and Ts: 3 Sets x 8 Reps of Each Position

This classic exercise is effective for strengthening and stabilizing the shoulder, and can easily be progressed or regressed based on the climber’s ability levels. Begin with an inclined bench raised to 45 degrees. Rest your chest on the bench and, with dumbbell weights, complete eight reps of each exercise:

• I’s: Lift both arms out directly in front of you and then slowly return to the starting position
• Y’s: Lift both arms out in front of you but at a 45-degree angle away from your head. Slowly return to the starting position.
• T’s: Lift both arms out directly to your side at a 90-degree angle from your head. Slowly return to the starting position.

To regress this exercise, eliminate the use of weights. To progress the exercise, lay on an exercise ball instead of an incline bench and/or increase the weights of the dumbbells.

Wrist Stability Exercises

Wrist stability is vital to climbing and maintaining safe crimp grip positions. If you have been climbing for a long time, you have likely heard of someone injuring their TFCC (Triangular Fibrocartilage Complex). The TFCC is on the outside of the wrist and is particularly vulnerable to injury.

The following exercises will help you to stabilize and strengthen your wrist, further reducing the stress placed through the fingers. The goal of each of these exercises is to feel fatigued by the end of each set.

TheraBand Rolls: 3 Sets x 15 Reps

While holding a TheraBand out in front of you with both hands, roll each wrist forward and then back to the starting positions. Complete 3 sets of 15 reps with each hand. This exercise targets strength in the rolling hand and stability in the other hand.

TheraBand Bends: 3 Sets x 15 Reps

While holding a TheraBand out in front of you with both hands, roll your wrist forward while bending the bar down and inwards. Complete 3 sets of 15 reps with each hand. This exercise targets strength in the rolling hand and stability in the other hand.

BOSU Planks and Pushups: 3 Sets x 30 seconds; 3 Sets x 10 Reps

Complete standard chest-down planks on the BOSU ball with your fingers facing forward. To progress this exercise, do BOSU push-ups instead. Keep in mind that the goal of this exercise is not primarily to increase push-up strength, but to increase wrist stability in weight-bearing positions. This exercise targets wrist strength and stability.

PVC Pipe Forearm Rotation: 3 Sets x 8-12 Reps

Hold a PVC pipe near its end and, with your elbow to the side and arm out in front, slowly rotate your wrist as far as you can to each side. Make sure to progress this exercise to feel fatigue by the last rep by either using a longer PVC pipe or holding the pipe closer to the end.

Core Strength Exercises

Core strength contributes significantly to climbing success, particularly on steep angles and in roofs. Maintaining tension and foot contact with the wall to avoid cutting feet can significantly reduce the stress put through the fingers when climbing. While cutting feet is typically associated with finger injuries other than epiphyseal stress fractures, consistent tension through the body may reduce the demands on the fingers when climbing steep angles, and could preserve the long-term integrity of the epiphyses.

The core exercises listed below are simply suggestions. Effective climbing core exercises work the abdominals, but also target back extensors, hip flexors, and glutes.

Hanging Leg Raises: 3 Sets x 8-12 Reps

Hang on a pull-up bar with your palms facing forward grip shoulder-length apart. While avoiding swinging your torso, lift each leg up in front of you individually until they are parallel to the floor, and then slowly return to the starting position. Repeat with the opposite leg. This exercise targets the lower abdominals and hip flexors.

Progress the exercise by lifting both legs at the same time. Progress the exercise further by doing the “Windshield Wiper” exercise (see video below).

High Planks and Variations: 3 Sets x 30 Seconds

Maintain a high plank position and complete one of the following exercises. Note that the exercises are listed in ascending order of difficulty, and this list can be used for exercise progression. This exercise targets abdominal muscles and back extensors, and also may work the shoulders and upper body.

• Maintain a high plank position, and lift each arm off of the ground and back into the starting position. Video here.
• Maintain a high plank position, and lift alternating arms and legs off the ground and back into the starting position. Video here.

Kettlebell Plank Pushes (Dalugas): 3 Sets x 10 Reps on Each Arm

Place a 30-pound kettlebell on a slider in front you. While maintaining a low plank position, push the kettlebell forward and pull it back towards your body (1 rep). Complete 3 sets of 10 reps with each arm. Each set should take approximately 45 seconds. This exercise targets core muscles, back extensors, and shoulders.

https://youtu.be/3SF1ROE-CBs?si=WqNLnpMCddN4rAoZ

See a Doctor of Physical Therapy

We have all heard the phrase “do not believe everything you read on the internet!” While this article and others may directly relate to you or your child’s injury, there is no substitute for receiving an expert opinion from a licensed physical therapist. They will consult evidence-based practice and their own experience to get you or your child back on the wall as quickly as possible. Ideally, seeing a physical therapist familiar with climbing can help you understand how the injury occurred and how to prevent similar injuries in the future.

Early diagnoses are key with epiphyseal stress fractures to prevent long-term damage. Meyers et al. found that youth climbers who train consistently on campus boards and experience epiphyseal fractures can experience early onset osteoarthritis up to 10 years after their injury. Additionally, improperly diagnosed and/or treated epiphyseal fractures can lead to incongruency of the articular cartilage and permanent damage to the finger.

It is helpful to understand the basics of how physical therapy operates in your home state. Some states have a direct access policy, meaning you and/or your child can seek care from a licensed physical therapist without a referral from a primary care physician. Also, some states have begun to allow Physical Therapists to order imaging that can reduce the time it takes to establish a proper diagnosis and begin treatment, and can reduce the likelihood of long-term damage.

About the author

Daniel (Dan) White is a second year Doctor of Physical Therapy student and Research Assistant at The University of Colorado. He has been climbing since 2015, engaging primarily in sport climbing and bouldering. Dan worked as a competition youth climbing coach for the AZR Ascenders in Scottsdale, AZ, from 2017 until 2020.

Physical Therapy will be Dan’s second career as he coordinated medical residency and fellowship programs across Arizona and Oregon for eight years prior to beginning his DPT program. He is interested in pursuing a career in orthopedic and oncology physical therapy, and looks forward to spending his career working in the Front Range.

Dan lives in Denver with his wife, Cece, and spends his free time climbing, hiking, skiing (badly), and traveling. You can contact him via email (daniel.p.white115@gmail.com) or Instagram (@dan_white18).

About the contributors

Dr. Jared Vagy “The Climbing Doctor,” is a doctor of physical therapy and an experienced climber, has devoted his career and studies to climbing-related injury prevention, orthopedics, and movement science. He authored the Amazon best-selling book Climb Injury-Free, and is a frequent contributor to Climbing Magazine. He is also a professor at the University of Southern California, an internationally recognized lecturer, and a board-certified orthopedic clinical specialist.

To learn more about Dr. Vagy you can visit theclimbingdoctor.com or visit him on Instagram @theclimbingdoctor or YouTube youtube.com/c/TheClimbingDoctor

Kevin Cowell is a physical therapist, clinical instructor, and rock climber based out of Broomfield, CO. Kevin owns and operates The Climb Clinic (located at G1 Climbing + Fitness) where he specializes in rehab and strength training for climbers and mountain athletes. He found his passion for climbing in Colorado while attending Regis University for his Doctorate of Physical Therapy and has since become a Certified Strength & Conditioning Coach (CSCS), Board-Certified Orthopaedic Clinical Specialist (OCS), and a Fellow of the American Academy of Orthopaedic Manual Physical Therapy (FAAOMPT).

You can contact Kevin via email at kevin@theclimbclinic.com or by visiting www.theclimbclinic.com. Also, be sure to follow Kevin at @theclimbclinic on Instagram for free rehab and strength training resources.

Julien Descheneaux is a master of physical therapy who dedicates himself exclusively to rock climbing injuries, having treated over 1,200 climbers. He’s been covering Quebec competitions as a certified Sport First Responder since 2014. He is also the author of the online class “Climbing injuries at the upper quadrant” for the Quebec PT Board (OPPQ) and gives regular clinics and conferences on the subject. He founded PhysioHR in 2016, the first PT clinic inside a rock climbing gym in Canada and is currently the resident PT at Bloc Shop Chabanel.

You can contact Julien via email at julienlephysio@gmail.com or by visiting https://www.physioescalade.com/.

Todd Bushman is a doctor of physical therapy, clinical instructor, Certified Strength and Conditioning Specialist (CSCS), and climber of mountain, rock, ice, and plastic. Todd is a dedicated climbing specialist based out of Bozeman, MT where he practices full time. He is actively pursuing advanced training to become a Certified Orthopedic Manual Therapist (COMT) through the North American Institute of Orthopedic Manual Therapy. Todd is also available for remote consultation regarding climbing injuries, movement analysis, and strength training.

You can contact Todd via email at todd.climbingcoach@gmail.com or visit him @try.hard.pt on Instagram.

Carly Post is a physical therapist in Los Angeles, California. She is passionate about climbing and enjoys helping people move better and optimize their ability to participate in their lives to their fullest potential. She can be reached at carlypos@usc.edu and on Instagram at @carlypost 

References

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10. Phalanges of the hand. Rad A. Published November 13, 2023. Accessed December 5, 2023. https://www.kenhub.com/en/library/anatomy/the-phalanges
11. Rock Climbing Finger Tenosynovitis. Simon A. Published March, 2022. Accessed December 5, 2023. https://theclimbingdoctor.com/rock-climbing-finger-tenosynovitis/#:~:text=Tenosynovitis%2C%20or%20inflammation%20of%20the,flexor%20digitorum%20profundus%20(FDP).
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