Climbing Injuries

Rock Climbing has become a passion of mine since I joined Mission Cliffs in San Francisco 4 years ago.  Although I do not do any outdoor climbing, bouldering has become a primary source of exercise for me. When consistently hitting the wall I see immediate strength and body composition changes.  As a Physical Therapist I have a unique perspective on the training effect and injuries occurring due to trauma and more importantly, overuse.  Although many varieties of climbing exist (bouldering, soloing, sport climbing with belay, competition climbing, and alpine) we will be referring primarily to sport climbing (short belay) and bouldering because these styles are used indoors at gyms.

The Sport and related Injuries

Rock Climbing is becoming increasingly popular among not adrenaline type fitness seekers.  It was known more as an extreme sport, but as more gyms are incorporating climbing walls the sport has grown to 9 million participants each year.  With the surge in interest among non skilled climbers comes increased risk of injury.  The most common injuries in rock climbing are caused by falls and include fractures, sprains, and strains that occur in the lower extremities.  Ankle sprains make up the majority of acute injuries in climbers.  Overuse injuries were reported at 44%, 19% at more than one site in a study published in the British Journal of Sports Medicine.

I am more interested in overuse component because as a physical therapist I have seen an increasing number (or shoulder and knee injuries) in this population.  Hand and wrist iuries are by far the most common overuse injuries, but is not my expertise so I will be focusing on shoulder and knee injuries I have seen in climbers.  This sport requires power strength, endurance strength, flexibility, technique, patience, and TECHNIQUE.  Those who lack technique or are untrained (poor core and shoulder stability or flexibility deficits) are at risk for overuse injury.  At the same time, many seasoned climbers are solely die-hard climbers.  Just as any other sport, climbing requires cross training and balance maintenance through flexibility and strength training.  Climbers develop shortened latissimus dorsi, increased kyphosis and “climbers neck (forward head posture)” which can lead to Upper Crossed Syndrome.  Other injuries include elbow, wrist and hand tendonopathies, and Spinal Pain (which is beyond the scope in this blog).  In addition to overuse, some of the skilled techniques used in climbing can also be problematic.

Problematic Skills

1)  Edging – Refers to placing the leg in external rotation (frog leg position) with the majority of the load through the big toe.  At same time incorporating a lift in the heel will provide additional foot stability for ascending and creating power more securely.  If there is not enough hip mobility/ stability or calf/foot stability the knee can become the fulcrum point leading to sprains, strains or imbalances.

Edging Technique

2)  Stemming -  Refers to using counterforce to support yourself between two spots.  This requires flexibility at the hip and shoulder and joint stability to facilitate extremity stability on the wall when there is minimal  holds available in a corner or between two rocks.  Lack of either can lead to shoulder, hip, or knee injuries.

Stemming Technique

3) Manteling and downpressure -  Refers to the downward pressure through your arms to create counter force or to match your feet to your hands to get higher.  Both of these techniques require a downward pressure and depression of the scapula (serratus activation).  Lack of shoulder or core stability  or enough flexibility may lead to shoulder injuries.

Mantel Technique

4) Straight armed resting, lieback, or “using bone, not muscle” – Refers to locking out your elbows and using counter force with the feet while leaning away from the wall.  Although this technique saves energy and allows you to rest, much of the rest may be going through the shoulder capsular stabilizing structures

Injury Trends seen in Physical Therapy

1) Shoulder Impingement – This is probably the most common overuse injury I see in climbers and is also the most treatable and preventable.  Once the rotator cuff or bicipital tendon become injured or painful, the best thing to do is “active rest.”  As stated before, many avid climbers do not train their imbalances with cross training and will usually get away with it.  With shoulder impingement, rest from climbing is imperative.  In addition, get in the wight room to strengthen the rotator cuff and scapular stabilizers for improved balance around the shoulder.  If posture is the problem, then get on the foam roller and do your corrective exercises to align the tissues around the glenohumeral and scapulothoracic joints (shoulder and shoulder blade).

2) Shoulder Labral damage – Unfortunately this injury is becoming more common and if too severe cannot be treated without surgery.  There are several ways the labrum (the connective tissue surrounding the socket of the shoulder that provides stability) is injured depending on the location of the lesion.  SLAP (Superior Labrum Anterior to Posterior), Bankart, or Hill Sachs Lesion involve different pathologies in the capsule of the shoulder.  SLAP tears may occur from overuse of the bicep tendon (common with pulling movements) or from putting the shoulder in awkward reaching back positions used in stemming.  Bankart and Hill Sachs lesions are usually seen in hypermobility or dislocations which may occur during manteling/down pressure or during falls.

3)  “Lateral and posterior knee pain” – I have seen a myriad of injuries at the knee presenting as IT band Syndrome, hamstring tendonitis or ligamentous instability.  Many of the patients believe the injuries are related to other activities (no trauma during climbing).  However I believe the hip rotation movements seen with toe in and out holds eventually leads to microtrauma in any of the structures mentioned above.  Many people do not know that there are actually three joints at the knee (Patellafemoral, Tibiofemoral and the overlooked proximal Tibiofibula joint).  When technique gets sloppy or there are flexibility deficits at the hip, the proximal tib-fib joint may be repetitively strained and lead to instability.    This combined with excessive calf work required for the heel up technique (mentioned above) leads to dysfunction, cysts, or joint changes.  The same mechanism of injury can also lead to meniscus tears.

The Patellafemoral, Tibiofemoral and Proximial Tibiofemoral Joints

Treatment = Prevention

1. Warm up and Stretch: This may involve several minutes on the bike or dynamic sub maximal movements to heat the muscles.  Many climbers will start with easy routes.  Because these emphasize using the already dominant muscles it is not optimal for waking up the muscles that control balance in the joints.  For warm up and stretching I recommend doing yoga (sun salutations) or lunge matrices with arm movements to loosen up the whole body.  Here is a video of the Gary Gray common lunge matrix.

2. Work on your Imbalances: If your hamstrings or hips are tight, stretch them.  If your lats or pecs are tight, stretch them.  Again this can all be accomplished by doing regular yoga.  Every climber should be doing preventative shoulder stability and core/hip stability exercises.  This doesn’t mean doing more climbing to strengthen your body.  It means finding the exercises that isolate the weaknesses (usually the rotator cuff, middle/lower traps and deep hip rotators).  If you are not sure what your imbalances are, find a trainer or physical therapist.

3. Rest between climbs: I recommend climbing no more than every other day in order to prevent injury resulting from fatigue.  It is best to do your imbalance correction exercises on the days you do not climb which will ultimately enhance your performance and prevent injury.

4. Off Season: Just as you should rest your body between work outs, you should take 1-3 months off every year for recovery.  Every other sport requires an off season in order to allow the body to recover…so does climbing.  This is all part of periodization and strength training professionals have this down to a science.  It works not only for injury prevention, but will also enhance your performance in the long run.

5.  Power Training:  If you do not currently have an injury such as the one described above, power training may be necessary.  For beginner or advanced climbers who are looking to advance their performance this may be the missing link in training.

6. Improve your technique – practice, practice and practice.  Take beginner and intermediate courses. Work out with experienced climbers.  This is by far the most important component of prevention.

Other Options

Unfortunately if prevention does not keep these common injuries from occurring, Rest and Rehab is a necessity.  From Experience, overuse injuries can be frustrating with sports requiring the amount of power used in Rock Climbing.  Many shoulder and knee injuries may ultimately require surgery if not treated conservatively early into the pathology.

Thanks to one of my loyal patients encouraging me to climb, I was hooked.  It is my hopes that the sport continues to grow safely.  The benefits to recreational and fitness climbing are numerous if you train correctly.  Check out the links below for more information on Rock Climbing injuries and fitness.

http://www.rock-climbing-for-life.com/climbing-injury.html

http://abcnews.go.com/Health/story?id=8165004&page=1

http://www.bodyresults.com/s2climbing-flexibility.asp

http://www.climbinginjuries.com/page/shoulders

http://orthoinfo.aaos.org/topic.cfm?topic=A00015

http://www.hyperstrike.com/Rock-Climbing-Workout-Article-105.aspx

Bridging the Gap Between Health Care, Wellness, and Fitness

Health Care is changing.  Cost of services are going up as the tests and treatments are becoming more elaborate, technical, and expensive.  Insurance companies are requiring additional justification for services rendered and reimbursement denials are more common.  Most people have large deductibles and co-pays for single visits (up to 75$ or more).  However, one thing that has become common knowledge is that if people are not physically active, they will have a significant increased risk of heart attack, stroke, diabetes, or bone/joint related diseases.  The general population understands this but, people are still getting lost in the system (not getting better, getting frustrated, and returning in 6 months for the same problem).  The answer to this problem is bridging the gap between health care, wellness, and fitness. 

Due to the rise in health care costs, there is an incentive and desire for longevity around the treatments that patients are seeking.  Some people are doing personal training, massage therapy, tai chi, or other forms of cash based programs.  Some are going out on their own in the gym, hiking trail, or pool.    Many are successful with an independent fitness and prevention program, but some people really do need guidance, technical assessment, manual treatment, and correspondence with their health care provider.   When a client is referred for rehabilitation (due to a functional limitation), they follow with a series of visits to progressively improve their ailment.  Once that patient has become independent with the management of their ailment or they have returned to being able to care for themselves, the medical necessity ends.

After 1-2 months of Physical Therapy, most people still have large deficits due to long standing pre-existing weakness, general de-conditioning, or lack of time / motivation to continue their program.  Insurance does not pay for lack of follow through.  Lack of improvement beyond 2-3 visits will typically necessitate denial of services the insurance company.  Most patients form a  bond with their Physical Therapist and want to continue therapy.  WHY NOT?  By offering a cash based program at the same facility at the price that is generally less than the cost of one co-pay (10-20$/class), patients can continue doing wellness classes.  In addition it is more personal and motivational working with the same Physical Therapist and facility that got you through the initial injury recovery process (such as a total knee replacement).

We can take it a step further by bridging the gap between cashed based wellness classes and performance enhancement.  That same client who has recovered from his total knee replacement and has attended a general conditioning class for seniors (cash pay) for 2 months thinks he is ready to resume golf.  Medicare does not not identify golf as an essential functional activity and will deny any services that attempt to use it as justification for continuing treatment.  Why not get an assessment, video analysis of the golf swing, and online home exercise program by the same Physical Therapist that treated you 2 weeks after your knee replacement?  This program is much more expensive than the wellness classes but that one visit will get you on track to enhancing your golf game, injury free.  This same model can be used for the triathlete recovering from Achilles tendonitis or the office employee with neck pain who wants to lose 20 lb.

Bridging the Gap between all levels of physical health care will be the only option in the next couple of years.  Currently, patients are being lost in the system due to lack of follow through, compliance of rehabilitation, and insurance coverage limitations.  Patients will be required to care for themselves regardless of their ability to remember exercises, motivation levels, or recovery time.  The Physical Therapist can act as a resource and coach through the entire process.  This movement towards a “Wellness Model” is being introduced an utilized in many clinics.  Ideally “Wellness Facilities” will become commonplace in Physical Therapy and Fitness practice for better outcomes with all levels of wellness.  I hope that eventually insurance companies will see the lasting benefits of a structured prevention program and include “Wellness Club” memberships in their health care plans.

Bad Posture – Don’t Let Your Work Habits Lead to an Athletic Injury

Background

Bad posture is the greatest risk factor for musculoskeletal pain in our culture.  The average American spends 7+ hours at a computer, interactive phone, or television screen. A century ago, the average American spent most of his / her time doing manual work in the field or factory. With this change in work style over the past 100 years has come a pathetically severe increase in spinal pain and dysfunction. We have converted into a society that has to find / make time to stay fit and strong for prolonged postural endurance. With this change in lifestyle, more people do not exercise because they do not know how to incorporate them into the day.  WHY IS THIS SO BAD? Because, it leads to muscle imbalances (weakness/paired with shortening) in the upper and lower body thus creating a perpetual cycle of worsening symptoms.

As a level 3 TPI Medical Professional (Titleist Performance Institute),  this is important topic because many of my golfers are at the desk all day, then hit the course in the same posture.  This performance on top of dysfunction predisposes them to a laundry list of ailments:  neck, shoulder, back, hip, or upper extremity pain, Carpal Tunnel, Tennis elbow, Golfers elbow, and Headaches just to mention a few.  This dysfunction can also affect endurance athletes just as severely  (cyclists, runners, rowers, swimmers).  The challenge with all these sports is that they require maintaining a slightly flexed posture for long duration.  Our guts, abdominal, Upper and Lower Traps, and Serratus Anterior (boxer muscle) are not conditioned to do this if you already have slouched posture.  In If you are a weekend warrior do not train for your sport, you are predisposed to the diagnoses above.  You might think, oh, this won’t happen to me.  Just wait, it will happen if you don’t train correctly.

The science behind it

Overuse of some muscles in your body creates inhibition of the the muscle on the other side of the joint.  Technically the agonist gets tight and the antagonist gets weak.

1.  Upper Crossed Syndrome (UCS) – by Dr. Vladamir Janda

• Shortened Upper Trapezius, Levator Scapula PAIRED with a Weak Lower and Middle Trapezius
• Shortened Subocciptials and Sternocleidomastoid PAIRED with a Weak Longus Coli (deep neck flexors)
• Shortened Pectoralis Major and Minor PAIRED with a Weak Serratus Anterior

2.  Lower Crossed Syndrome (LCS)

• Shortened Iliopsoas PAIRED with a Weak Gluteus Maximus
• Shortened Erector Spinae PAIRED with a Weak Rectus Abominis
• Shorted TFL and Quadratus Lumborum PAIRED with a Weak Gluteus Medius

In layman’s terms:  if you have flexed hips (from sitting), a forward head on neck/neck on shoulders, and rounded shoulders it leads to these muscle imbalances.  When do you technically have UCS or LCS?  When the impairments above lead to pain or dysfunction in your daily life or with sport.   Think you are at risk or have it?  It is not too late.  Start doing your corrective exercises now.

Treatment

1.  Assess your desk posture and set up – This might require purchasing a new chair, desk, or keyboard and getting rid of the lap top.  Key rules in desk posture:

-Feet flat on the ground
-Chair at a slight decline to keep your pelvis in neutral
-Elbows at 90 deg with your keyboard just above lap level (this might require installing a keyboard tray under your desk)
-Wrists at neutral and mouse at same level as your keyboard (this might require installing a mouse tray on your keyboard tray)
-Screen at eye level during good posture.  This one is killed by using a lap top or working from the phone because you are constantly looking down.
-Make sure you don’t need glasses or don’t have screen blindness from staring at the screen too long.  This will lead to slouching.

2.  Do corrective exercises to reverse your posture throughout the day.  Stretch the tight muscles and strengthen the weak ones.  See below.

3.  Force yourself to take a break while working at the computer every 20-40 min.  If needed, time yourself with an application on your computer.

4.  If you are already having symptoms of spinal pain, headaches, or shoulder pain contact a medical professional (MD, Physical Therapist, or Chiropractor).  If the impairments have not become painful yet, seek body work from a massage therapist or learn exercises from a personal trainer.

5.  Do not train the dysfunction you have!  If you know you have this, change your workout routine now!  The benefits will outweigh the “rest period” from your typical lifting or exercise routine.  The most common misconception is that biceps and chest should be worked more than the upper back.  In reality this TRAINS your postural dysfunction.  Anther misconception is that working the Lats is working the back.  Well yes you are working the back but at the shoulder the Latissimus Dorsi is an internal rotator.  If there is an imbalance, your shoulders will begin to round forward creating a slouched posture.

My Favorite Exercises for Prevention:

1.  Foam roller exercises – angles in the snow, scissors, transverse mobilization, pec stretch and threading the needle

2.  Scapular strengthening combined with rotator cuff exercises – Y’s, W’s and T’s on Physioball

3.  Gluteal strengthening - bridges, clams, and balance exercises that work on coordinating the gluteals with core muscles

4.  Stretching the Hamstrings (if they truly are short), hip flexors / Quads, Pectoralis Major and Minor, Latissiums Dorsi/Quadratus Lumborum and suboccipitals.  In my experience, stretching the Upper Traps and Levator Scapula may provide short-term relief but the symptoms usually won’t change until you correct the other imbalances.  This is why you sometimes feel like you get no relief from a massage on your sore neck/shoulder muscles.

5.  Core stability exercises for endurance – NO, not sit ups.  Doing planks and half kneeling exercises where you have to use your stability against the gravity or position you are in work better for waking up the weak muscles.

Links:

Golf’s C posture by the Golf Fitness Guys

Greg Rose’s Lower Crossed Syndrome – from Titleist Performance Institute on Golf Channel

Ergonomic options for the laptop computer