Quantification of Incomplete A2 Pulley Ruptures and the Question of Coexistent A3 Pulley Ruptures in Sport Climbers

ObjectivesTo quantify the extent of A2 pulley ruptures and the presence of a potential coexistent A3 pulley rupture in sport climbers.MethodsProspectively and consecutively acquired patients presenting to Balgrist University hospital with an A2 pulley rupture due to sport climbing in the period of March 2024 to May 2025 were diagnosed with ultrasound. The extent of the rupture was measured and quantified directly and indirectly in the ultrasound records, as well as the tendon-to-bone distance [TBD] and assessed for a possible coexistent A3 pulley rupture.ResultsFrom March 2024 to May 2025 34 consecutively and prospectively evaluated patients (25 males, median age 34.0 years) with an A2 pulley rupture were analysed. Most patients (94.1%) presented with an isolated rupture of the A2 pulley, only two patients (5.9%) had a simultaneous rupture of the A2-A4 pulley. None of the A2 pulley ruptures were complete with a median percentage of a rupture of 63.6%. All A2 pulleys ruptured from the distal to proximal end with a remaining median proximal part of 36.3% accordingly.ConclusionsOur findings suggest that in sport climbing the A2 pulley predominantly ruptures partially beginning from its distal end, which supports its excellent prognosis. Complete A2 pulley ruptures and coexistent A3 pulley ruptures could not be observed and therefore may be very rare and may be negligible as their own therapeutic entity. Consequently, we simplified the grading system of pulley injuries for our clinic. However, further research including larger case numbers is needed to confirm our findings.