Injuries and overuse syndromes of the fingers are the most common problems in rock climbers. While injuries to the finger flexor pulley system and tenosynovitis are well known to be frequent problems, other syndromes like the lumbrical shift syndrome or flexor tendon ganglions are rather unknown. The differential diagnosis of finger pain in rock climbers involves many differential diagnoses and can be quite difficult. The diagnostic and therapeutic procedures for the evaluation of finger pain in rock climbers are demonstrated. More than 20 different diagnoses need to be considered. After taking a thorough history, clinical examination and radiography the ultrasound is the most helpful diagnostic aid. Being a cheap and harmless examination it provides plenty of information for further differential diagnosis. A linear array transducer with 10-12 MHz in a prone position performing longitudinal and transversal planes is mostly used. Only occasionally an additional MRI is necessary. The physiologic adaptations due to the high impact of rock climbing onto the fingers need to be strictly separated from pathologic change. The rising number of epiphyseal fractures in young climbers must be observed critically and information needs to be given out to parents, trainers and the athletes themselves. The question of the influence of high intensive climbing and training in young age and a possible higher risk for osteoarthrosis of the finger joints needs to be further explored.