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Competitive Sports: Section Articles

Incidence, Diagnosis, and Management of Injury in Sport Climbing and Bouldering: A Critical Review

Jones, Gareth PhD1; Schöffl, Volker PhD1,2,3,4; Johnson, Mark I. PhD1

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Current Sports Medicine Reports: November 2018 - Volume 17 - Issue 11 - p 396-401
doi: 10.1249/JSR.0000000000000534
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Competition climbing will debut as an Olympic sport at the 2020 summer games in Tokyo. The competitive disciplines are sport lead climbing, speed climbing, and bouldering. Sport lead climbing uses a belayed dynamic rope that is attached to the climber. The belayed rope is connected to pre-fixed anchor points during the ascent by the climber and acts as a safeguard in the event of a fall. Speed climbing uses a mechanically assisted belay device from above to protect the climber in the event of a fall. Climbers attempt to complete a 15 meter standardized route in the fastest time. Bouldering involves movement sequences performed on a pre-determined direction of travel, without a rope, at a relative short distance from the ground. Safety mats safeguard the climber in the event of a fall. The popularity and professionalism of climbing is likely to result in an increase in climbing-related injuries as part of the caseload presenting to sports injury physicians and other health care professionals (1).

Previously, we conducted a critical review of the incidence and risk factors for injury in rock climbing (2). Analysis of 11 studies found the mean incidence of injury irrespective of climbing behavior to be 5.81/1000 h (SD ± 11.19), with a point prevalence found to vary between 10% and 81%, irrespective of cause. The most commonly injured structure was the annular pulleys of the fingers, and evidence suggested that epiphyseal fractures in adolescent sport climbers were increasing. The aim of this article is to critically review research on the incidence of injury in sport climbing and bouldering. The pathophysiology and presentation of finger and shoulder injuries is discussed. The diagnostic and therapeutic algorithm for finger injuries originally presented in 2016 (2) is updated.


A search of the following electronic databases was performed on February 9, 2018: Discover, Academic Search Complete (EBSCO), PubMed, Embase, SPORTDiscus, and ScienceDirect. Combinations of the MeSH headers “mountaineering”; “risk factors”; “athletic injuries”; and free text terms “rock climb*” (Boolean phrase); “climb*” (Boolean Phrase); “injury*” (Boolean phrase) “risk factors*” (Boolean phrase) were used in the search. One reviewer (G.J.) reviewed titles and abstracts for relevance according to the following eligibility criteria: A primary study on sport climbing and/or bouldering that reported an estimate of the incidence of injury.


We found eight primary studies with data to estimate the incidence rate of injury per 1000 h of activity (Table). The maximum incidence rate was 13.04/1000 h (3) and the minimum incidence rate was 0.02/1000 h (4). We estimated the mean ± SD of the incidence rate of injury in sport climbing and bouldering from the eight studies to be 2.71 ± 4.49/1000 h (3–10). The mean ± SD incidence rate of injury from five prospective studies was 3.40 ± 5.54/1000 h (3–7). The mean ± SD incidence rate of injury from three retrospective studies was 1.56 ± 2.50/1000 h (8–10). The mean ± SD incidence rate of injury from six studies that sampled injuries from indoor climbing environments was 2.83 ± 5.14/1000 h (3–7,10). The mean ± SD incidence rate of injury from two studies that sampled injuries from indoor and outdoor climbing environments was 2.32 ± 4.00/1000 h (8,9). The mean ± SD incidence rate of injury from two studies that sampled injuries that occurred during competition climbing was 1.92 ± 1.67/1000 h (5,7). One study estimated the incidence rate of injury during competitive sport lead climbing as 0.29/1000 h, competitive speed climbing as 0.00/1000 h, and competitive bouldering as 1.47/1000 h (5). Confidence in the precision of these estimates of the incidence rate of injuries is undermined because of heterogeneity in the methodology of the primary research studies including inconsistency in the use of injury terminology, level of injury reported, data collection procedures, calculation of exposure, and operational measures of performance. There is a need to consolidate reporting standards for epidemiological cohort studies in rock climbing.

Incidence rates and commentary of reviewed studies.

Shoulder Injuries in Climbing

The shoulder typically accounts for 17% of all climbing-related injuries (3,11). Sport climbers and boulderers are particularly susceptible to the development of shoulder injuries due to prolonged and repetitive upper limb movements on vertical or overhanging terrain. A cross-sectional cohort study of 201 climbers found the shoulder injuries to be positively related to the frequency and difficulty of indoor and outdoor sport climbing and bouldering (12). An evaluation of injury trends in sport climbing and bouldering over a 4-yr period found superior labral anterior posterior tears and impingement of subacromial structures to be the most common diagnosis (11). The etiology of impingement is often multifactorial with a complex biomechanical interaction between active and passive anatomical structures within the shoulder (13) with some authors now preferring to describe the condition as Subacromial Pain Syndrome. Definitive diagnoses may include thickening of the coracoacromial ligament, partial or full thickness tear of the supraspinatus, bursal hypertrophy, and tendinopathy. Literature refers to structural narrowing of the subacromial space and dysfunction as “primary” impingement and dynamic instability as “secondary” impingement. Internal impingement refers to the entrapment of soft tissue, such as the supraspinatus, infraspinatus, long head of the biceps tendon, and joint capsule between the glenoid rim and the humeral head (14). Internal impingement may be further classified as posterior superior impingement or anterior superior impingement (14). Determining a differential diagnosis and the severity of pathophysiology of shoulder impingement can be challenging. A systematic review found insufficient evidence to support the use of physical tests to diagnose shoulder impingements and local lesions of bursa, tendon or labrum (15). Although simple physical tests, such as the painful arc, can provide valuable diagnostic information especially in remote settings (16). The British Orthopaedic Association patient care pathway recommends conservative treatment, including injection therapy in the primary care setting, and should a patient require referral to secondary care services, the integrity of the rotator cuff may be assessed using ultrasound and/or magnetic resonance imaging (MRI) (17).

Surgery may be considered when conservative treatment fails and for individuals with significant or consistent pain and/or loss of function. Arthroscopic repair of acute and chronic tears of the rotator cuff and Superior Labral Anterior Posterior repair with primary long biceps tenodesis (18) have produced favorable functional outcome with participants returning to high-level climbing performance.

Epiphyseal Growth Plate Fractures of the Fingers in Adolescents

The average age of competition climbers has decreased significantly in the last 10 years (1). Adolescent competitive climbers engage in structured training programs designed to improve performance but paradoxically places large amounts of stress on an immature skeleton. There are few studies on adolescent climbing populations, although initial data suggest an increase in epiphyseal fractures of the promixal interpahalangeal joint (2,11,19,20). A secondary analysis of adolescent climbing data found that 50% (13/26) of all reported injuries were fractures of the growth plate (19). A case series of 22 injuries found a higher proportion of growth plate fractures in adolescent male climbers (n = 14) than adolescent female climbers (n = 4) with the middle finger to be affected in 95% of cases (20). Early identification of such injuries is desirable to avoid serious complications such as premature closure of the growth plate leading to asymmetrical deformity of the finger.

The risk of growth plate fractures is suggested to be associated with unrestricted use of dynamic finger training apparatus and failure to monitor training and competition load (2). Nonmodifiable risk factors may include growth velocity and hormone regulation (20). Clinical examination may reveal localized swelling, pain, and/or tenderness on the dorsal aspect of the proximal interphalangeal joint usually of the middle or ring finger. Magnetic resonance imaging and computed tomography (CT) should be used to confirm diagnosis as plain radiographs may not “rule out” a fracture (21). The most common fracture presentation reported in adolescent climbers to date is a Salter-Harris type III (21,22). Conservative measures for nondisplaced fractures usually allow most climbers to return to pre-injury activity levels. However, complications may arise due to injury severity (Salter-Harris type IV or V) and in cases of nonunion. Surgical intervention using percutaneous spot drilling epiphsiodesis has shown encouraging results (23).

Annular Pulley Injuries

The annular pulleys of the fingers are the most commonly injured structures in climbing (11). Climbers usually present with pain and tenderness on the palmer aspect of the finger and an audible “pop” may be reported to have occurred at the time of injury. When the finger is flexed discreet bowstringing of the tendon may be indicative of multiple pulley rupture (A2, A3, and A4). Ultrasound imaging confirms diagnosis of A2 and A4 pulley rupture when dehiscence between tendon and bone is greater than 2 mm (24). Anatomical variation in the origin of the A3 pulley means a threshold dehiscence greater than 0.9 mm between volar plate and tendon is predictive of A3 pulley rupture (24). Climbers with chronic degenerative change to the annular pulleys have been found to have a dehiscence greater than 2 mm in absence of rupture (25). Magnetic resonance imaging may be considered in cases of high-grade injuries and when ultrasound is inconclusive (21). Surgical reconstruction using the loop and a half technique with an auto graft of the palmaris longus muscle is currently the preferred method for repair of the A2 and A4 pulleys in climbers (26). A new transosseous variation of this repair has recently undergone a feasibility study with the authors concluding favorable outcomes as it reduces the likelihood of extensor tendon irritation with the extensor hood (27). Of note, conservative management of triple pulley rupture (A2, A3, and A4) using thermoplastic rings also has produced positive results (28). Treatment using thermoplastic rings should commence immediately, providing tendon bone distance can be satisfactorily reduced, and confirmed by ultrasound.

Diagnostic Algorithm for Finger Injuries

In 2016, we developed a diagnostic and therapeutic algorithm for finger injuries in climbers for the identification of annular pulley injuries and epiphyseal fractures in adolescents (2). We have updated the algorithm (see Fig.) to reflect the latest research and practice-based evidence including new surgical options for epiphyseal injuries, differential diagnosis consideration for chronic tendonitis, and preference of MRI rather than plain X-ray for growth plate fractures.

Diagnostic and therapeutic algorithm for suspected annular pulley and epiphyseal injuries.


The findings from our critical review provide an estimate of the incidence of injury in sport climbing and bouldering. We estimated the mean ± SD of the incidence rate of injury in sport climbing and bouldering from the eight studies to be 2.71 ± 4.49/1000 h. Differences in injury terminology, data collection procedures, calculation of exposure, and operational measures of performance used by authorship teams are likely to account for the variance found. Differential diagnosis and the clinical management of finger and shoulder injuries in climbers is challenging. In particular, early identification of growth plate injuries in adolescent climbers is paramount.


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