Sports Medicine 20 (3): 199·205. 1995 0112·1642/95/00:>9-o199/S03.50/0

INJURY CLINIC

© Adis International Umited. All rights reserved.

Rock Climbing Injuries Jennifer C. Haas and Michael C. Meyers Department of Health and Human Development, Montana State University, Bozeman, Montana, USA

Contents Summary . . . . .. .. .. .. . . . . . . . . . . . . . . . . . . . . . . . 1. Equipment . . . .. . 2. Terminology . ... . 3. Incidence of Injuries . 3.1 Hand and Wrist . 3.2 Elbow and Shoulder 4. Aetiology of Injuries 4.1 Hands 4.2 Wrist . . 4.3 Elbow .. 4.4 Shoulder 5. Prevention of Rock Climbing Injuries . 6. Conclusions . . . . . . . . . . . . . . .

Summary

. . .... .. 199 201

201 201 . 202 202 202 203 203 204 204 204 204

Rock climbing has become increasingly popular in the past decade. However, the increased participation exposes a greater number of climbers to potential injury. The risks involved with climbing increase in proportion to the skill-level of the climber: the higher the skill-level, the more hours are required for training and on more difficult routes. The hands are used as tools for the ascent, with much of the climber's weight placed upon the fingers and also distributed through the wrist, elbow and shoulders. The combination of repetitive climbing and the excessive weight-bearing demands of the sport result in cumulative trauma to the upper limbs. Prevention should begin with educating climbers on the potential risk for injury. Although adequate rest between climbs and decreased training when pain is first encountered would aid in alleviating numerous problems, additional research directed towards improving training, treatment and rehabilitation programmes is warranted.

Rock climbing has become a popular recreational pastime. It has been estimated that over 100 000 participants are scaling rock walls in the US .[1] Rock climbing evolved from the traditional adventure-climbing which dates back to the

1700s.[2] European countries initially dominated the sport and climbing expeditions challenged people against the elements at high elevation. Snowand ice-packed mountains were the medium for these early alpine ascents. In order to scale the

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Fig. 1. Common hand-holds used in rock climbing.

lower mountains and cliffs, mountaineers developed basic climbing skills and techniques. Rudimentary safety equipment was introduced in the early 1900s. Ropes, pitons and carabineers gave climbers aid and protection for the more difficult climbs. Not until the 1960s did rock climbing evolve into the sport recognised today. Advanced technology has developed lightweight shoes, safer equipment and artificial aids. Climbers are now able to focus more on style and technique, which has facilitated a new level of competition referred to as 'sport climbing'. Sport climbing is characterised by explosive, athletic movements often against the clock or another competitorPl Early accounts of climbing injuries ranged from broken bones and severe lacerations, to fatalities. These injuries were primarily due to falling, faulty equipment, or forces of nature, such as snowy con© Adis International Limited. All rights reserved.

ditions and temperature.£ll Today, rock-climbing injuries are no longer limited to acute trauma. Surveys involving of 460 climbers revealed that overuse syndromes are more common than acute injuriesPl The increased number of overuse injuries is due to a greater number of people in training and the higher skill requirements and challenges across all levels. Climbing has become a competitive sport with elite climbers competing in the Grand Prix professional circuit for large financial incentives. Elite climbers display dedication to training and skill-advancement similar to other professional athletes. Actual climbing and training place a large stress on the upper extremities, resulting in injuries to the upper body. Although the potential for injury in rock climbing has increased due to greater participation and degree of competitive skill required, focus in this area of sport injury has Sports Med. 20 (3) 1995

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Rock Climbing Injuries

been limited to case studies, surveys and anecdotal information. Therefore, the purpose of this article is to review the aetiology and prevalence of rock climbing injuries.

1. Equipment A climber primarily relies on hand and leg strength complimented by sturdy equipment to scale a rock wall successfully. Climbers require 3 standard items for protection: climbing shoes, nylon rope and a harness. The type of shoe is dependent on the level of climbing ability and personal preference. All shoes, however, have high-friction soles and are close fitting. A harness is worn to connect the climber to the rope, with special hardware such as carabineers, quick-draws and anchors, used to assist in the ascent. A carabineer is an aluminum link used to connect various pieces of the climbing chain. Quick-draws are sewn runners connecting 2 carabineers, and are used to hook the rope into an anchor. Artificial anchors, also known as chocks, are designed to fit into constrictions or bottlenecks in the crevices of rock. A climber may attach a carabineer to the anchor to ensure a safe ascent. Chalk is often used to aid a climber's grip, since climbing gloves are typically avoided due to interference with tactile sensation and secure handholdsJ4]

2. Terminology There are various types of ascent techniques, hand holds and hand jams used in climbing (see fig . I). Face climbing is the standard technique used to achieve upward progress through a climber's own efforts.[l] The hands and feet are placed on edges, dihedrals, flakes and cracks in the rock, in an attempt to move vertically. In this type of ascent, the climber is free of attending ropes, nuts, bolts and pitons, which are employed only as backup in case of a fall. Bouldering, or climbing on large rocks where the use of a rope is unnecessary, is primarily used to practice climbing skills and to develop strength without a major threat of falling. © Adis International Limited. All rights reserved.

Crack climbing involves jamming the hands, fingers and feet in wedges of a rock waIU 1,4] There are 5 common hand holds used when climbing. The 'open grip' is used for large hand holds. The hand functions like a claw as it holds onto the curvature of a rock. In this technique, the forearm muscles are the primary movers that keep the fingers from extendingJl] The most frequently used grip, however, is the 'cling grip', in which the fingers are bent at the distal interphalangeal joint with the thumb wrapped over the index finger. The 'vertical grip ' involves bending the distal interphalangeal and proximal interphalangeal joints and pulling down on the hold. This grip is especially used for tiny crevices and often only the fingernails are in contact with the rock surface. The 'pocket grip' involves placing 1 or 2 fingers directly into a hole. The long finger is often used because of its superior strength and the flexor tendon holds much of the climber's weight. The 'pinch grip' is used with small protuberances, using a squeezing or pinching action with the thumb and index finger. Two types of hand jams are commonly used in place of hand holds. The classic jam involves placing the hand in an appropriately-sized crack with the muscles of the hand expanded to anchor the body. The second type of jam involves wedging the fingers in a bottleneck or constriction within a crack.[2] In many instances limbs are twisted or stacked within a crack to improve stability.

3. Incidence of Injuries Studies have primarily focused on injuries attributed to accidents, weather conditions and high altitude exposureJ4,5,6] Recently, advances in rock climbing have led to an increase in the number of overuse injuries rather than acute traumap,8,9] Epidemiological studies concerning overuse injuries in rock climbing have mainly concentrated on the upper body[IO,1l ,12] (see table I). An extensive study[13] reported 237 injuries in 332 climbers. Of these, 65% were described as overuse injuries and of these cases 90.3% involved the upper extremities. In another study[8] 89% of Sports Med. 20 (3) 1995

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Table I. Incidence of rock climbing injuries Number of injuries reported

Reference

Number of injuries by site hand

hand/wrist

wrist

Bannister et al. 1171 Bollen[81

n= 4

2

1

n = 86

33

9

Bollen{ lOI

n =62

Bollen et al. (9)

n =67

43

Lewis et al.l 11 ) Maitland(12)

n= 1 n=96

34

Shea et al.(4)

n=46

Hand and wrist injuries account for approximately 44% of all rock climbing injuries.[4,8-11] Respondents to a questionnaire[12] indicated that out of 102 overuse injuries, the hand was most frequently injured_ The most common site of injury to the hand is the proximal interphalangeal joint areaJ3,12,14,15] Shea and colleagues[4] noted that 54% of climbers reported pain in the distal interphalangeal and proximal interphalangeal joints of the index and long fingers. This is followed by injury to the A2 pulley of the flexor sheath of the fingers, the flexor digitorum profundus and superficialis tendons of the forearm, the proximal phalanx and the ulnar collateral ligament of the first metacarpophalangeal joint.[4,7.9.13,)6] Acute carpel tunnel syndrome (CTS), wrist extensor tendinitis and wrist sprains have also been reportedJ4.10.17] Using magnetic resonance imaging, hand and wrist injuries of 20 elite climbers were found to include annular ligament tears, lesions of the flexor tendons, tenosynovitis, ganglion cysts and joint effusion.[16] All rights reserved.

other

20

31

12

27

11

23

9

17

3.1 Hand and Wrist

Lim~ed .

shoulder

1 6

the total number of injuries (115) involved the upper limb, which was attributed to the nature of the sport, with the upper body used as the primary tool during ascent. Notwithstanding, lower body injuries do occur and usually involve lacerations, contusions and abrasions.[5]

© Adis International

elbow

34

3.2 Elbow and Shoulder

Shoulder and elbow injuries have been reported in 61 % of elite climbers.[lO] Frequently, climbers may experience injuries in a number of combinations, i.e. shoulder-elbow and elbow-hand.[l2] The medial epicondyle, lateral epicondyle and the anterior elbow are common sites of appendicular injury, with anterior elbow pain commonly diagnosed as either brachialis tendinitis or triceps tendinitisJIO]

4. Aetiology of Injuries Most rock climbing injuries are chronic in nature, caused by repetitive performances requiring skill, technique and power.[3,IO,12] Common factors contributing to overuse injuries are excessive exercise, increasing the training workload too rapidly, improper training techniques and inadequate restJl2] Whereas the typical way to develop strength and skill is primarily by climbing, most training regimens will involve some form of upper body exercise that duplicates the actual sport,[2] exacerbating the exposure to chronic stress. Hangboards are commonly used to develop finger and forearm strength. This apparatus features various handholds resembling those on a climb. Training practices may also include repetitive pull-ups, (where a climber uses only one or two fingers), 'dead hangs' employing the use of large and small handholds with the climber hanging in straight arm position for an extended period of time and 'lock offs'. These are performed similarly to a dead hang, but the climber pulls the body up so that the chest Sports Med. 20 (3) 1995

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Rock Climbing Injuries

is even with the hands and then attempts to hold this position for as long as possible.[19] These types of exercise place excessive strain on the climber's fingers. Recent literature suggests that, although this type of training may be beneficial, such exercises should be used in moderation to avoid exacerbating an existing injury.[2.4.12] Many climbers do not receive adequate rest between c1imbs.[11.I2] Instead they are constantly employing various training techniques or exercises to improve their skill. [20] Furthermore, climbers often continue to climb when injured.[4] Fatigued muscles have a decreased ability to contract or to withstand repetitive movements, often resulting in stress-related injuries. [21] The degree of climbing skill is another factor associated with injury.!13] As degree of skill and level of competition increases climbing routes become steeperP] The exposure to steeper vertical angles causes body weight to be supported primarily by the upper extremities, so predisposition to upper limb injury increases. 112 ] In addition, as climbing strength improves, smaller and more difficult handholds are attempted, exposing the flexor digitorum profundus and superficialis tendons to increased risk for injury.[22] However, this area of research remains equivocal: other studies find no correlation between climbing difficulty and the number or types of injuries.[8] 4.1 Hands

Injuries can effect a competitor's ability to climb and compromise a safe ascent.l 4] Most hand injuries involve the tendon and joints of the fingers which are often chronically swollen as a result of repetitive climbing.[12,15] The fingers are not designed to endure the demands of excessive weightbearing as seen in this sport.[14,20] Since both hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint are required by most hand holds, excessive distal interphalangeal pain may result from an imbalance of flexor and extensor forcesP3] The cling grip has been commonly associated with extensive distal interphalangeal pain and injury, due to the amount © Adis International Limited. All rights reserved.

of hyperextension that it requires.[20] Hyperextension of the proximal interphalangeal joint occurs when the finger is jammed into a small crack, involving one plane of motion which increases vulnerability to trauma due to the inability of the climber to change hand/finger position.[23] Tendon injuries of the hand occur most frequently at the flexor profundus (the flexor that moves the distal interphalangeal joint using the muscles in the forearm) and the flexor superficialis (the tendon which bends the proximal interphalangeal joint regions).[JO] Pain felt by this popular hand hold may be attributed to the sharp angle position of the tendons and increased stress placed on the metacarpophalangeal and proximal interphalangeaIJ2,8,20] Hand holds that require traction movements, such as the cling and pocket grips, add additional stress on flexor tendons, often resulting in strain or tendinitis.[20,24] Acute and chronic injury to the A2 pulley of the flexor sheath causes bow-stringing of the flexor tendons commonly observed in the long and ring fingers.[4] The role of the flexor sheaths is to prevent the tendons from bow-stringing as the finger is flexed PO] This pathology is unique to climbing and has recently been given the name of 'climber's finger' .1 14] Finger jamming and the pocket grip have been indicated as the leading causes of chronic collateral ligament injury.l2,20] When using the pocket grip, injury is minimised when the pull is in line with the axis of the finger and not levered from side to side.l 20]

4.2 Wrist Repeated wrist flexion in combination with extreme loads has led to symptoms commonly associated with CTS.[II] CTS affects individuals who frequently perform tasks that demand repetitive digital manipulations.!25] Pain is felt in the median nerve due to compression within the carpel tunnel.[23] Researchers have observed that carpel tunnel canal pressures involved in continuous climbing may exacerbate existing CTS symptoms.[II] Other wrist injuries can be attributed to falls or Sports Med. 20 (3) 1995

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losing a grip, resulting in injury to the wrist extensors located at the radiocarpal joint.[8] 4.3 Elbow 'Climber's elbow' involves strain and subsequent inflammation to the brachialis and is often diagnosed as brachialis tendinitis.[8] Due to the pronated and semi-flexed position of the arms during climbing, the majority of the strain is transferred through the biceps brachia. Lateral epicondylitis, similar to tennis elbow, has also been reported in some cases.[l2] This condition is produced by isometric contraction of the wrist extensors when the elbow is placed in an extended position, as observed with repetitive pull-ups.l8,23] 4.4 Shoulder Rotator cuff inj ury and impingement syndromes of the shoulder are associated with the various overhead positions of the upper limbs during the majority of climbing.[8.23] Climbing involves fine adjustments of the glenohumeral joint and demands intricate control of the small hinges while gliding on a moving scapular surface.[25] Damage to the long head tendon of the shoulder is commonly associated with the use of training apparatus, primarily hangboards.[l7] As climbers support their weight using the strength of the fingertips, with their arms extended, increased stress is transferred to the tendons of their shoulders,l2]

5. Prevention of Rock Climbing Injuries Many climbers tape their fingers for protection and support.[4] Taping the potential trouble-spots around the wrist, fingers, forearm and elbow has been recommended, especially around the fingers and between the joints to reinforce the flexor tendon pulleys,l2,2o.22] Taping the back of the hands and wrist, as well as taping the fingers in a figure of eight pattern supports the fingers and protects the skin from abrasions. This method leaves the joints relatively free, minimising restrictions during a climber's performanceP2] © Adis International Limited. All rights reserved.

The prevalence of rock climbing injuries will no doubt continue to rise with the increase in participation. Regular training and conditioning is essential for aspiring climbers. With the availability of indoor climbing gyms, they are able to train year round and have minimal time for recovery. Due to the prevalence of participants training year-round, the high degree of difficulty in this sport and the numerous physical risks associated with climbing, efforts should focus on optimising more effective rehabilitation programmes. Acute injuries that would have traditionally healed during an off-season, may nowadays deteriorate to more chronic conditions with continued training or inattention to medical advice. Moderation is essential to progressively improve physical condition during rehabilitation without traumatic self-inflicted setbacks. In addition, restructuring rehabilitation programmes to enhance recovery without further exacerbation of musculoskeletal micro-trauma and fatigue should accelerate a safe return to climbing. Ideally proper medical attention should be sought early on in the progress of an injury. Such attention should incorporate advice from sports medicine specialists familiar with climbing who utilise an aggressive rehabilitation approach.

7. Conclusions The unique demands of rock climbing result in injuries specific to climbing, such as finger trauma and climber's elbow. Although prior studies have primarily focused on epidemiology and aetiology of rock climbing injuries, recognition and further study of overuse injury patterns observed in rock climbers are required which will help reduce injury and enhance rehabilitation. However, given the repetitive nature of the sport, preventing the overuse injuries from climbing may be difficult. However, adherence to correct technique, an avoidance of excessive training and a greater understanding of the sport from both a medical and scientific standpoint is warranted to enhance performance and decrease predisposition to potential injury in this popular activity. Sports Med. 20 (3) 1995

Rock Climbing Injuries

References I. Addiss DG, Baker SP. Mountaineering and rock-climbing injuries in US national parks. Ann Emerg Med 1989; 18: 975-9 2. Long J. Rock climb. Evergreen, Colorado: Chockstone Press, 1993 3. Jones D. Injuries survey report. Rock Ice 1990; 36: 52-4 4. Shea KG, Shea BA, Meals RA. Manual demands and consequences of rock climbing. J Hand Surg 1992; 17 A (2): 200-5 5. Bowie WS, Hunt TK, Allen Jr HA. Rock climbing injuries in Yosemite National Park. West Med 1988; 149: 172-7 6. SmootJ. Is rock climbing really dangerous? Rock Ice 1993; 58: 52-8 7. Cole A. Fingertip injuries in rock climbers. Br J Sports Med 1990; 24: 14 8. Bollen SR. Soft tissue injury in extreme rock climbers. Br J Sports Med 1988; 22: 145-8 9. Bollen SR, Gunson CK. Hand injuries in competition climbers. Br J Sports Med 1990; 24: 16-8 10. Bollen SR. Upper limb injuries in elite rock climbers. J Coli Surg Edinburgh 1990; 35 Supp!.: S18-20 II. Lewis RA, Shea OF, Shea KG. Acute carpel tunnel syndrome. Physician Sportsmed 1993; 21 (7): 103-8 12. Maitland M. Injuries associated with rock climbing. J Orthop Sports Phys Ther 1992; 16 (2): 68-73 13. Largiader U, Oelz O. An analysis of overstrain injuries in rock climbing. Schweiz Z Sportmed 1993; 413 (3): 107-114 14. Bollen SR. Injury to the A2 pulley in rock climbers. J Hand Surg [BrlI990; IS: 268-70

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IS. Hochholzer T, Heuck A, Krause R, et al. Injuries and overuse disorders in sports climber: 2 case reports. Ther Umsch 1993; 50 (4): 263-7 16. Heuck A, Hochholzer T, Keinath C. MRI of the hand and wrist of sport climbers. Imaging of injuries and consequences of stress overload. Radiologe 1992; 32 (5): 248-54 17. Bannister P, Foster P. Upper limb injuries associated with rock climbing. Br J Sports Med 1986; 20: 55 18. Hess GP, Cappiello WL, Poole RM, Hunter Sc. Prevention and treatment of overuse tendon injuries. Sports Med 1989; 8 (6): 371-84 19. Prichard N. The performance guide for climbers. Evergreen, (CO): Chockstone Press, 1994 20. Robinson M. Get a grip on injury prevention and treatment. Climbing 1988; 108-13 21. Renstrom P, Johnson RJ. Overuse injuries in sports. Sports Med 1985; 2: 316-33 22. OsiusA. Wrapitup. Women's sports and fitness 1992July/Aug; (14): 106 23. Gould JA III, editor. Orthopaedic and sports physical therapy. St Louis, Missouri, The C. V. Mosby Company, 1990 24. Della-Santa DR, Kunz A. Stress syndrome ofthe fingers related to rock climbing. Schweiz Z Sportmed 1990; 38(1): 5-9 25. Reid DC. Sports injury assessment and rehabilitation. New York: Churchill Livingstone, 1992

Correspondence and reprints: Jennifer C. Haas, Department of Health and Human Development, Montana State University, Bozeman, MT 59796-0336, USA.

Erratum Vol. 19, No.6, page 402, line 2: In the summary the phrase 'high external and apparently low internal validity respectively' should read 'high internal and apparently low external validity respectively'.

[Abernethy P, Wilson G, Logan P. Strength and power assessment: issues controversies and challenges. Sports Med 1995; 19: 401-17J

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Sports Med. 20 (3) 1995