## 8 Discussion  
This systematic review provides valuable information for diagnosing pulley injuries. Instrumental evaluation studies have extensively focused on ultrasound, establishing it as the gold standard for diagnosis [23; 26]. Studies have primarily concentrated on diagnosing A2 and A4 pulley injuries, as they are the most affected and anatomically compatible with ultrasound diagnostic techniques (US). Studies, such as [PERSON], [PERSON]; et al., 2017 [23], attempted to diagnose A3 pulley injuries with limited success. Ulrasounds were compared \begin{table}
\begin{tabular}{c c c c c c c c c c c c} \hline \hline
**Studies** & **1 \({}^{*}\)** & **2** & **3** & **4** & **5** & **6** & **7** & **8** & **9** & **10** & **11** & **Total** \\ \hline [PERSON] & Yes & Yes & No & Yes & Yes & Yes & No & Yes & Yes & Yes & 8/10 \\ \hline [PERSON] & Yes & Yes & Yes & Yes & No & No & Yes & No & Yes & Yes & 7/10 \\
2023 [24] & Yes & Yes & Yes & Yes & No & No & Yes & Yes & No & Yes & No & 6/10 \\ \[PERSON] & Yes & Yes & Yes & Yes & No & No & Yes & Yes & No & Yes & No & 6/10 \\
2003 [19] & Yes & No & Yes & Yes & Yes & No & No & Yes & No & Yes & 5/10 \\ \hline [PERSON] & Yes & No & Yes & Yes & Yes & No & Yes & No & Yes & Yes & 5/10 \\
2002 [21] & Yes & No & Yes & Yes & Yes & No & No & Yes & No & Yes & Yes & 5/10 \\ \[PERSON] & Yes & No & Yes & Yes & Yes & No & No & Yes & No & Yes & Yes & 5/10 \\
1998 [29] & Yes & No & Yes & Yes & Yes & No & No & Yes & No & Yes & 5/10 \\ \[PERSON] & Yes & No & Yes & Yes & Yes & No & No & Yes & No & Yes & 5/10 \\
1999 [27] & Yes & No & Yes & Yes & No & No & No & Yes & No & Yes & 4/10 \\ \[PERSON] & Yes & No & Yes & Yes & No & No & No & Yes & No & Yes & No & 4/10 \\
1999 [22] & Yes & No & Yes & Yes & No & No & No & No & Yes & No & 4/10 \\ \[PERSON] 2023 [24] & No & Yes & No & Yes & Yes & No & No & No & No & Yes & No & 4/10 \\ \[PERSON] 1990 [28] & No & Yes & No & Yes & Yes & No & No & No & No & Yes & No & 4/10 \\ \hline [PERSON] 1998 [11] & Yes & Yes & No & Yes & No & No & No & No & No & Yes & Yes & 4/10 \\ \hline [PERSON] 2014 [17] & No & No & No & No & Yes & No & Yes & No & No & Yes & No & 3/10 \\ \hline [PERSON] 1990 [18] & No & Yes & No & No & No & No & No & No & No & No & No & 1/10 \\ \hline [PERSON] 2019 [25] & Yes & Yes & No & No & No & No & No & No & No & No & No & 1/10 \\ \hline [PERSON] 2020 [31] & No & No & No & No & No & No & No & No & No & No & No & 0/10 \\ \hline \end{tabular}
\end{table} 
Table 2: Assessment of methodological quality of studies using the PEDro scale. with MRI in several studies, resulting in a sensitivity of 98% and a specificity of 100% [21]. Four reviewed studies utilized cadaver hands as samples, allowing for the simulation of injuries and applying a specific gradual tendon tensioning force but with limitations. Cadaveric tissue has different properties and ages compared to in vivo studies using ultrasound on younger patients and climbers. As confirmed in various studies [22], an athlete's climbing tendon will have greater thickness than a potential cadaver, leading to different biomechanical properties. In vitro studies always introduce biases compared to in vivo studies but offer the benefit of simulating an injury before data extraction. The image quality in ultrasounds depends on the transducer frequency and coupling agent used. The reviewed studies employed frequencies ranging from 7.5 MHz to 40 MHz, with many reports recommending a minimum of 14 MHz [23]. Various coupling agent types were used: a gel or silicone pad could hinder active finger flexion [21; 22], which could be avoided using a water tube [19]. Direct contact between the transducer and finger could reduce TBD with operator pressure. In all studies, except for [PERSON], [PERSON]; et al 2023 [24], conventional ultrasound gel was not used despite being more suitable than other agents. The ultrasound diagnostic method involved calculating TBD. This distance between the tendon and bone was measured by placing the probe above the affected pulley.