###### Abstract  
Objectives: This systematic review addressed the following questions: what are the most recommended diagnostic criteria for pulley injuries in finger flexors among climbers? What is the best functional or classification clinical test for these injuries based on the available evidence? Materials and Methods: Following the PRISMA Statement checklist, a systematic literature review was conducted between August and September 2023, using a search on the PubMed database with a string of keywords and MeSH terms. The PEDro scale was used to analyze bias in the individual studies examined. Conclusions: Based on the exclusion criteria and research question, 14 articles with heterogeneous study designs were selected. Studies involving diagnosis through clinical examination or instrumental tests were analyzed. The data obtained provide an overview of different diagnostic and classification criteria for the injury under consideration. Ultrasound remain the gold standard in diagnosing finger pulley injuries. The distance between the tendon and bone is the most used diagnostic criterion, with a distance greater than 2 mm corresponding to an A2 or A4 pulley injury. The clinical sign of bowstringing coincides with a multiple pulley injury involving A2, A3, and A4. Clinical signs, ultrasounds, and grip strength should be evaluated for a comprehensive diagnosis. A grip deficit of 41.4% corresponds to a pulley injury. climbers; sport 2024202430030  
directly attaching to the bones, while A1, A3, and A5 attach to the polar plate rather than the bone [10]. The cruciate pulleys are located between the annular pulleys, ensuring the tendons remain aligned [11; 12]. The lumbrical muscles, although small, are significant in evaluating injuries to the finger pulley system due to their proximity to the flexor tendons. The growing popularity of climbing has increased the technical and physical demands on the fingers, leading to greater stress on bones, joints, and soft tissues. When climbing, a significant amount of body weight is often supported by the distal phalanx on small holds or pockets, sometimes just a few millimeters deep [12]. Climbers use various hand positions depending on the type of hold, with the most common being the crimp grip (which includes both half and full crimp) and the sloped grip [13]. The sloped grip is typically used for sloping holds and involves flexing the proximal interphalangeal joint (PIP) by about 50\({}^{\circ}\) and the distal interphalangeal joint (DIP) by around 20-30\({}^{\circ}\), which is considered safer for the A2 pulley [14; 15]. Table 90 of climbers, involves flexing the DIP joint between 90\({}^{\circ}\) and 100\({}^{\circ}\), with the PIP joint in maximal hyperextension to grip small edges [16]. The full crimp position differs from the half crimp in that the thumb is actively used, resting over the first distal phalanx, sometimes partially over the second, which increases stress and the risk of injury to the finger [13]. The crimp grip also causes the wrist to extend slightly, adding to the force exerted by the flexor tendons, with additional ulnar deviation and supination of the carpal joint leading [1; 2]. The first description of this type of injury was in a case report 1990 [10; 17; 18]. Over the years, documentation regarding finger pulley injuries in climbers has increased [9; 12; 14; 16; 19]. The fourth finger (ring finger) is the most affected, followed by the third finger (middle finger). The most frequently reported finger injury is the isolated A2 pulley lesion. The distal part of the A2 pulley starts to open, and the injury can progress to a complete or partial lesion, even before involving other pulleys. Biomechanical studies suggest that pulley injuries are more likely to occur when eccentrically loaded. In fact, patients with this injury report feeling a \"pop\" in the finger as soon as they lose foothold, and the entire body weight is loaded eccentrically on the finger, causing an injury.