Introduction: Climbing Overview
Through the ages, rock climbing has been a sport for some and a way of life for others. From the cliff dwellers of the American Southwest to the first ascenders of the Alps and Himalayas, our desire to reach new heights has challenged our endurance, skill, and technology. In modern times, technical climbing has become widely popular, adding new facets and skillsets to traditional mountaineering (14). Historically, provider knowledge of climbing-specific injury patterns and their treatments has been limited, likely due to the fact that these patients represent a highly specific and somewhat rare niche of pathology. Caring for climbers thus can often be a challenge for practitioners, and familiarity with common climbing injuries and how to treat them is essential.
In order to meet the challenges inherent to their sport, climbing athletes must maintain peak cardiovascular fitness and strength. Climbing-specific training both improves physical fitness and reduces the risk for injury; however, naturally, some risk remains (9). By maintaining proper equipment, climbers can in most cases minimize risk. Technological advances have dramatically improved safety with the advent of modern climbing ropes, harnesses, shoes, and protection devices. The remaining risks include human error and environmental hazards. Indoor climbing increases greatly the risk of overuse injury. With indoor gyms, climbers of all ages can climb multiple routes year-round, thereby introducing new challenges to the care of climbers (32).
Mountaineers ascend a mountain using a variety of techniques, from hiking to technical climbing and even ice climbing. By the 1960s, the majority of the world’s major peaks had been ascended, opening the doors for reexploration by many others who looked to follow. Many ascents often require multiple days to achieve the end goal and can require a great deal of equipment and supplies. The environment can pose great challenges ranging from hypothermia to altitude sickness, and even seemingly minor injuries in remote locations can lead to tragedy. Still, most deaths are related to falls (27).
Free climbing, or traditional rock climbing, involves the climber affixing protection (“pro”) in the form of cams, hexes, and nuts to natural rock features and cracks and then attaching quick-draw carabiners into which the rope can be clipped. In this way, climbers ascend one pitch (20 to 50 m) at a time, “cleaning” off the equipment as they ascend. Climbers belay each other to ensure safety with control of the rope in the event of a fall. They then rappel or hike down at completion of the climb.
Sport climbing can be very similar, except that instead of using natural rock features, the quick draws are clipped into bolts — metal devices with a ring that are bolted into the rock face. At the top, the climber uses top chains or rings to affix the rope and rappel down. Sport climbing can be outdoors on natural rock or in a gym with holds bolted into plywood for hands and feet. Sport climbing and traditional climbing typically follow established routes, and maps can clearly identify the most common routes and provide difficulty ratings in order to guide climbers to appropriate challenges for their abilities. Sport climbing has become a regular form of exercise for many and has become a venue for competition for professional climbers across the world.
Some prefer rappelling only, avoiding the up-climb. Ropes are attached to a secure anchor and then belay or rappel devices are used to control the rate of descent down a surface. This requires first hiking to the top of a cliff or hiking out if rappelling down into a canyon.
Bouldering represents a microcosm of sport and traditional climbing. Ropes, harnesses and protection are not used; rather, climbers attack “projects,” staying lower (up to 3 to 4 m) to the ground and using pads and spotters to assist them from below. Bouldering often involves vertical and horizontal components, often progressing to overhanging positions. Ankle injuries from falls and finger overuse injuries dominate the spectrum of injury in bouldering. Bouldering is done indoor and outdoor with similar risk profiles (10).
Solo climbing involves combining the techniques of bouldering with the heights of traditional climbing. No ropes or harnesses are used, and falls are typically catastrophic. Only the most elite climbers even consider solo challenges.
Variations on traditional climbing include canyoneering, ice climbing, and caving. Canyoneers seek adventure in slot canyons, often in the American Southwest, combining hiking with rappelling — often requiring swimming through trapped water in “pots” and “keepers” and utilizing specialized climbing skills to get out and on to the next rappel (see Fig. 1). Packrafting is a specialized variation that involves canyoneering to a river, then inflating a small one-person raft and paddling downstream to an exit point for a hike out.
Ice climbers use crampons and axes, drilling protection into the ice and using quick draws and ropes to progress, similar to sport and traditional climbing. Ice conditions must be ideal and, although fun and relatively straightforward, should be led by the most experienced of ice climbers to ensure safety.
Cavers descend into the depths using rappelling techniques and traverses, often crawling and squeezing through tight stretches. Cavers use ascenders — devices that allow one to climb a rope — to get back out. Proper light sources, equipment redundancy, and experience reduce risks. Caving can involve underwater stretches and even scuba.
The most unique variant of modern climbing is buildering, where climbers ascend man-made structures, typically without protection and often illegally.
The type of climbing activity greatly affects the risks. Indoor climbing is safer and more controlled; however, overuse injuries abound. Sport climbers incur 3.1 injuries per 1,000 climber hours (19). Proper equipment, inspection and condition, and skilled equipment use can mitigate injury. The greatest risk for serious injury and death comes with mountaineering (1). Environment poses risk ranging from altitude sickness, falling rocks, dehydration, and heat illness to animal and insect envenomation. Remoteness and poor preparation also are factors related to injury and its severity.
Skill level can determine risk, with more elite climbers assuming more risk to overuse and extreme exposure to injury. Less experienced climbers more often experience errors in judgment and lower-level injuries, such as abrasions (33). Interestingly, climbers typically are injured at or below their typical skill level (19). The greatest risk is found in male climbers who have been climbing longer than 10 years and who are lead climbers on more difficult routes (33).
Climbing Injuries by Anatomical Region
Climbers sustain a variety of unique injuries related to specific activities and anatomical region. In the upper extremities, overuse injuries predominate with repetitive strain patterns from training (4,16,17).
Like many athletes, climbers often experience rotator cuff tendonitis, impingement, and tears. Other common shoulder injuries seen in climbers include rupture of the long head of the biceps, SLAP lesions, AC sprains, glenohumeral dislocation, and muscular strains of the latissimus dorsi, rhomboid, and lower trapezius (29).
Specialized holds and maneuvers in sport climbing biomechanically affect the forearm and elbow (28). As an example, improper form often coupled with overuse can lead to injury such as climber’s elbow. Climber’s elbow, which represents a strain of the brachialis, distal biceps strain or tear, and posterior interosseous nerve compression, can cause anterior elbow pain (see climbing-specific injury section for more details). Overuse from grips can predispose climbers to medial epicondylitis. Other common injury patterns related to the forearm and elbow include strain or tear of the pronator teres, ulnar nerve compression, radio-capitellar compression, extensor strain causing lateral epicondylitis, and triceps tendonitis.
The wrist and hand experience overuse related to holds (15). Many types of tendonitis/tenosynovitis patterns may be seen in the wrist (most commonly flexor carpi ulnaris), along with sprains from falls while wedged in a crack, retinacular injury, or triangular fibrocartilage complex injury. Carpal tunnel syndrome is more likely to occur in climbers (seen in 10% to 25% of elite climbers), secondary to flexor tendon hypertrophy and edema (31). Climber’s finger, or flexor pulley injury (see climbing specific injury section for more details), commonly afflicts sport climbers and boulderers. Forces on the small joints of the fingers can cause effusions, synovial irritation and cartilage damage, resulting in “sausage fingers” seen in sport climbers. Tendonitis of the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) can be seen, as well as strain, tear, or laceration in climbers. Mechanical stress inherent in the biomechanics of individual grips (proper and improper) contributes to the development of FDS and FDP tendonitis and tendonosis. Tendonosis can progress to tenoperiostitis (progression of tendonosis involving periosteum). Falls and side strain can cause collateral ligament injury of the fingers. Climbers also can experience flexion contracture, stress fracture (35), epiphyseal fracture in young climbers (24), trigger fingers, Dupuytren’s contracture, ganglion cysts, mallet fingers, or lumbrical tear/shift (28).
Specific hand grips affect injury patterns in climbing. With an open grip, FDP strain is greater than that on FDS but is easier on joints, ligaments, and tendons. The crimp grip (with closed ring) places the majority of strain on FDS, DIP joints, and the volar plate. Pocket grips tend to strain FDP and collateral ligaments, whereas vertical grips focus strain on FDS (See Figure 2). Pinch grips, finger locks, hand stacks, and finger/fist jams can cause overuse strain and torque injuries (13).
Most climbing injuries result from upper extremity overuse, but lower extremities also can be injured. With wide bridging between foot holds, climbers increase their risk for adductor strain or tear. Knee injury also can occur, but with a different mechanism in climbers. Meniscus tears can occur when routes require the climber to use a frog position with knee flexion and external rotation, applying an upward pushing force. ACL tears are typically related to a fall from bouldering height. Recent interest in the literature surrounds the lateral collateral ligamentous (LCL) complex and the heel-hook maneuver, described as a downward force placed on the heel with the hip flexed and externally rotated, knee flexed, and heel locked into a climbing hold, causing LCL complex strain (30) (see Fig. 3).
Climbers also see various ankle and foot pathologies. Ankle sprains can occur as a consequence of climbing shoes tending to be small and preferring supination of the foot, leading to both dorsiflexion and the more common plantarflexion-inversion sprains. Climbers also may present with numbness or tingling secondary to shoe tightness (11). Falls from up to 3 m can predispose to ankle and foot trauma, but this risk can be reduced with adequate mats. Falls into a climbing surface or falls into ropes on an overhang may produce unique pathologies, which can produce osteochondritis dissecans (OCD) of the talus. The literature identifies posttraumatic OCD in climbers as a known complication of ankle sprain or dislocation (20). Other commonly seen pathologies include hallux valgus (common in those who climb >5 years), blisters, and toe nail contusion or loss.
As in many sports, core strength is critical to climbers, and climbing can impose specific injury patterns. The cervical spine is vulnerable to strains and degenerative changes, often exacerbated by belay position, the belayer vigilantly looking upward at the climber. Strains and disc injury involving the lumbar and thoracic spine can occur because of repeated stress from falls in harness causing hyperextension injury. Pectoralis imbalance can cause an increase in both thoracic kyphosis and lumbar lordosis. Climbers experience abdominal strains by reaching or during falls, particularly with an improperly fitted harness.
Lastly, injuries to the head and skin also are relatively common. Head injuries typically involve slamming into the rock with a fall or from falling rocks striking the climber, or more commonly, the belayer. Helmets protect both climbers and belayers when used. Falling rocks or pebbles and falling ropes also can lead to injuries of the eye. A flipped rope end can cause a hyphema to the anterior chamber of the eye, which can be prevented with eye protection. Abrasions, or “climber’s rash,” typically affect the lower extremities of less experienced climbers. Lacerations and sunburns occur with some regularity in outdoor climbers.
In general, climbing-specific injuries are less common than many other sport-related injuries. When injuries do occur in climbers, however, a lack in both scholarly literature and physician education regarding the clinical findings, diagnosis, and management of these injuries limits practitioners’ ability to properly care for climbers in many circumstances. Understanding the conditions specific to climbing will help providers diagnose, treat, and communicate with their patients who climb (34). Mastering this interesting subset of injuries will broaden the provider’s understanding of anatomy, biomechanics, and injury in general as well (3).
“Climber’s finger” is an injury unique to climbers and generally represents some degree of strain or tear within the flexor pulley system in the digits of the hand. These injuries can either be acute or due to chronic overuse. Injury commonly involves A2, A3, or A4 flexor pulleys, with injury to the A2 flexor pulley being the most common. Climber’s finger has been shown to represent close to 30% of finger injuries seen in climbers (4). Different hand grips and specific techniques contribute to the development of pulley injuries. Roughly 50% of elite climbers have some degree of pulley injury (7). The mechanics of different grips place varying degrees of strain on the pulley system: at 90°, pulleys sustain more tension than the tendons themselves. The grading of the injury is based on the specific pulleys injured and the total number of pulleys affected (see the Table).
Climber’s finger presents with a history of a “pop,” swelling, and pain. Alternatively, climbers with a chronic-type injury present with a longstanding history of discomfort and feeling of relative weakness. Physical examination may demonstrate swelling and reproducible pain. Bowstringing of the flexor tendon of the affected digit also may be seen. The most commonly involved digit is the fourth digit of the nondominant hand. Musculoskeletal ultrasound (MSKUS) has been shown to be highly effective in diagnosing pulley ruptures with 98% sensitivity and 100% specificity (12); however, MSKUS is user dependent. Magnetic resonance imaging (MRI) will show edema and increased tendon-to-bone distance secondary to anterior subluxation of flexor tendons (36).
Treatment of climber’s finger depends on the grade, with nonsurgical treatment preferred up to grade 3 injuries. With a grade 1 injury (pulley strain), immobilization is not recommended. Patients should undergo physical therapy (PT) for 2 to 4 wk, then return to light climbing at 4 wk. Full climbing can be resumed at 6 wk, with taping for stability for 3 months. Grade 2 injury (complete rupture of the A4 pulley or partial rupture of A2/A3) is best treated with 10 d of immobilization, followed by 2 to 4 wk of focused PT, with resumption of light climbing at 4 wk and full climbing at 6 to 8 wk. Again, taping for 3 months is recommended. With a grade 3 injury (complete A2 or A3 rupture), 10 to 14 d of immobilization is recommended. PT is scheduled for 4 wk, and the use of a tool such as a thermoplast also is suggested. These patients can return to light climbing at 6 to 8 wk and full climbing at 3 months, with taping for a total of 6 months. In all cases, nonsteroidal anti-inflammatory drugs (NSAID) are the only pharmacologic recommendation for control of pain and inflammation (22). Evidence is lacking, but platelet-rich plasma may be beneficial in treating lower grade pulley injuries.
In the case of a grade 4 injury (multiple pulley ruptures or A2/A3 rupture with lumbrical or ligament injury), surgery is indicated. The goal of surgery is to prevent flexion contractures and decreased range of motion secondary to flexor tendon bowstringing. Most recent studies have shown that pulley reconstruction versus repair has demonstrated superior postsurgical outcomes (26). The Widstrom technique (loop and a half) is most commonly used, but the Weilby repair is an alternative. Postoperatively, patients are immobilized for 14 d, followed by 4 wk of PT. Again, a thermoplast or ring is used. Patients return to light climbing in 4 months and progress to full climbing in 6 months, with taping for at least 1 year (5).
Prognosis is generally good for these injuries, and most climbers do well with conservative management. Approximately 10% of injuries lead to chronic or persistent pain. In general, surgical treatment should be considered when pain persists or with inability to return to prior climbing level (22).
“Climber’s elbow,” a brachialis strain or tear at the musculotendinous junction, is another unique injury to climbers. Traversing climbs, engaging strong flexion and pronation of the elbow, with insufficient firing of biceps brachii in a flexed and pronated position, lead to compensatory firing of brachialis and acute or chronic overuse (16).
Climbers complain of pain with flexion and pronation, often presenting after a prolonged or difficult climb or after increased climbing intensity without sufficient rest between climbs. Physical examination often yields pain in the anterior elbow along the margin of the brachialis distally and is worsened with elbow flexion and pronation (8). Partial tears or ruptures present with swelling and ecchymosis.
Diagnosis is often made with physical examination and history, and MSKUS or MRI can be helpful in determining the degree of injury or in diagnosing elusive cases.
As with climber’s finger, treatment of climber’s elbow is generally conservative. Rest for 2 to 4 wk in the case of a strain with resumption of modified climbing only after the patient is pain free works well in milder cases. Climbing should be two to three levels below normal, with reduction in both frequency and intensity. PT can be effective when performed by a therapist skilled with the injury, with a focus on strengthening opposing muscle groups. Medication is limited to oral NSAIDs for inflammation and pain (16).
In the case of complete rupture, surgery is indicated and preferably performed within 1 to 2 wk of the injury. Surgical management is considered also if conservative management fails. Postoperatively, patients are splinted at 90° for 7 d, followed by a hinged brace set at 45° initially with advancement to full range of motion by 8 wk. Patients may begin strength-building exercises 1 wk postoperatively with isometric, low-intensity exercises to triceps and shoulder musculature. By the second week postoperatively, patients may begin strengthening biceps and brachialis utilizing isometric, low-intensity forearm flexion in a neutral plane. This will progress to active range of motion exercises in a single plane by the third to fourth week for flexion, pronation, and supination. Progressive resistance training is initiated at 8 wk postoperatively, and light sport-specific training may resume at roughly 3 months. Full recovery is expected to take place after several months. The specific length of activity restriction is individualized, and it depends on both the severity of the initial injury and progression through the rehabilitation process.
Whether treated conservatively or surgically, injured climbers typically resume full climbing levels without pain with adequate rest, PT, and strength training.
Extensor hood syndrome
Thought to be derived from extensive use of the crimp position, another injury seen almost exclusively in climbers is the extensor hood syndrome (EHS). EHS consists of the constellation of arthritic changes affecting the tendinous sheaths of the fingers with resultant irritation and inflammation. Chronic injuries to the flexor tendons of the hand often accompany EHS, and these are seen typically after years of climbing and a string of overuse hand injuries (6). Chronic finger injuries in climbers predispose toward progressive arthritic changes with the formation of significant bone spurring. These bone spurs produce irritation to the extensor tendons of the hand and present as a tenosynovitis (2).
Patients with EHS tend to have an extensive climbing history, with an average of 19 years of climbing experience (25). These patients have a history of chronic flexor and extensor tendon injuries with evidence of small joint arthritic changes. Patients generally complain of dorsal-sided pain of PIP and/or DIP joints (in the extensor hood region). A clinical picture similar to that of osteoarthritis may be present, including symptoms such as morning joint stiffness. Physical examination often elicits a 3° to 5° extension deficit of PIP and/or DIP joints and may demonstrate tenderness to palpation dorsally along bone spurs (25).
Both MSKUS and plain radiography play a role in diagnosis. Ultrasound, under skilled use, can demonstrate edema or effusion around the affected extensor hood. There also may be notable change in the path of the extensor tendons secondary to arthritic changes (spurs) along the extensor tendon pathway. With x-ray, dorsal bone spurs in proximity to PIP and/or DIP joint margins may be visualized, but the severity of radiographic findings rarely correlates to subjective symptom severity.
Conservative management of EHS remains the mainstay; however, this injury is relatively unstudied, with therapeutic evidence lacking. Treatment includes reduction of stress/load on the involved joints and tendons. NSAIDs are recommended for pain and inflammation, and some patients find relief with anti-inflammatory hand baths. Climbers with EHS should modify climbing to two levels below normal (25). Consideration also should be given to injection of cortisone into the affected tendon sheath.
Prognosis with conservative management has been excellent, but further study is needed. The study by Schöffl et al. (25) of EHS shows that all 12 patients recovered completely from both symptomatic and performance standpoints within 3 to 4 wk of initiation of conservative therapy.
A fairly rare injury more unique to climbers is posttraumatic OCD. Any athlete can experience posttraumatic OCD, but climbers may have a unique predisposition due to mechanisms of potential injuries. Climbers may sustain foot and ankle injuries by falling from a distance or from slamming into the climbing surface.
Posttraumatic OCD presents as a potential complication of sprain or fracture and can be easily missed, as radiographs often do not show the injury. If a climber complains of persistent ankle pain beyond 6 wk, additional imaging should be considered. Serial x-rays may reveal the injury, but if negative in the setting of high clinical suspicion, MRI is indicated to rule out OCD (20).
Pearls for Treating Climbers
A few general “pearls” will guide physicians caring for climbers. First, climbers must be adequately prepared through tendon strengthening, including opposing muscle groups, and with work on flexibility to avoid strain. Low weight and high-repetition training can be helpful. Body weight exercises and using training boards to strengthen and harden digits in preparation for climbing can help. Taping, used by many climbers, can prevent pulley injuries. A novel method of “H-tape” produces added protection by dividing the tape into two strips with a bridge in the middle, with the bridge placed at the volar PIP, then the strips placed circumferentially on either side of the dorsal PIP (23).
Paramount to injury prevention, climbers must give themselves ample recovery time, especially after the gym with multiple climbs at high difficulty levels. Rest for 24 h must be given for recovery after training and rest for 48 h after climbing or a hard training session. Climbers also must understand that with aging, the recovery time will be longer. Further, in the setting of overuse and injury, rest times need to be lengthened significantly and medical attention sought when not improving or with more significant injury.
Proper rehabilitation can take from weeks to months, depending on the injury, and careful attention must be given to help climbers understand how to modify their climbing in order to progress without sustaining further injury or preventing full recovery. Rehabilitation involves stretches, range-of-motion exercises, modalities, and low-weight/high-repetition strengthening, with a crescendo transition from modified climbing to full activity. Antagonist strengthening will ensure a balanced, long-term recovery. Modifications in technique, such as grip changes, may be necessary with certain injuries. Formal therapy with therapists experienced in climbing injuries will prove invaluable.
Physicians need to understand surgical indications and when to recognize failed conservative therapy. Compliance to postoperative protocols and rehabilitation proves critical to the ultimate surgical success.
Helping climbers to understand risks and to be prepared will aid in injury prevention. Climbers should have proper instruction and climb with trusted climbers, meticulously learning and rehearsing use of anchors, knots, and equipment. They need to understand their abilities and limitations. By keeping logs, including falls on ropes, and dating equipment and adhering to detailed inspection and equipment care (including storage and protection), climbers ensure safety. They should always have a plan and leave an itinerary with others and be prepared with maps/GPS, a first-aid kit, and adequate food, water, and protection from the environment. Helmets and eye protection should be used, particularly for outdoor climbing.
Practitioners must learn about climbers and climbing injuries if they are to effectively care for them. Climbers often sense that they know more than their doctors about climbing injuries and are discouraged when told to stop climbing or “what did you expect?” This can delay proper diagnosis and contribute to poor compliance to treatment plans. Understanding how to diagnose climbing injuries and how to treat them, including surgical indications, will contribute to a powerful encounter for patients.
Physicians who treat athletes do well to understand a multitude of sport-specific injuries. Climbing is just one example, and providers who understand the sport not only can effectively treat pathology, but also could even use climbing itself as therapy. As an example, rock climbing can serve as an excellent rehabilitation modality to regain strength, balance, and function in the case of ankle sprain in any athlete. General fitness, strengthening, and weight loss can be benefits also of regular climbing. Understanding and trying out various sports will help athletes to know that providers “speak their language” and forges trust. Ultimately, this improves compliance and optimizes treatment outcomes.
The authors declare no conflicts of interest and do not have any financial disclosures.
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