By Björn Alber, MSc Sports physiology, MD specialized in sports and rehabilitation medicine
Dr 8a – presentation and 4 tips for climbing injuries
I was approached by the founder of 8a.nu, Jens Larssen, on the sunny beach of Tonsai two Christmases back. Today I am a shareholder of 8a.nu and a regular contributor to the forum. Since the start, Dr 8a forum has had a lot of interest. This is not surprising, climbing injuries and rehabilitation are a part in any passionate climber’s life.
My own sports background is in Kayaking where I have a number of National and Nordic Championship titles as well as placing in the finals in the World Championships as a member of the Swedish Olympic team. Of greater interest for climbers is my background in sports physiology research and medical practice as specialist in sports medicine. I have coached several national teams in different sports as well as being the team physician. For more than 25 years I served as a teacher for the Swedish medical association of sports and since the mid 80s I’ve run a private medical practice specialized in sports.
My own interest in climbing started with traditional climbing in the 80s. As injuries started to pile up my interest was more or less dormant in the 90s but the wonderful Thai limestone got me back in the game in 2000. There has been interest in older and heavier climbers in the forum and sadly I belong to both groups, weighting more than 90 kg with an age above 55 years. But my passion for climbing is undeterred by this and I will go on trying to improve myself and share my medical expertise to keep fellow climbers climbing.
For all of us the main focus is to climb as well as possible and stay away from injuries. The following paragraphs will outline the 4 most common climbing related injuries (in my opinion), their cause, how to prevent them and rehabilitation.
The best prevention of all - warm up before maximal exertions and rest when you’ve trained too much!
The fact is that a good warm up will not only substantially decrease your risk of getting injured but also increase your performance output by over 10%. The speed of nerve transmissions is faster, oxygenation in the active tissues higher, muscular strength and endurance elevated etc. Always put yourself though a really good warm up focusing a bit extra on the fingers. Start by squeezing a foam ball to pump up your forearm (see picture), stretch the flexor tendons shortly and follow by climbing a couple of really easy routes - this will get your blood circulation going
The 4 most common injuries
Cruciate ligament tears. As the fingers contain no muscles the power to bend the finger comes from the forearm muscles and is transmitted through tendons that go all the way to the tip off the fingers. The tendons themselves run inside tendon sheaths and are kept in place near the finger bones by the so called annular and cruciate ligaments. With acute overload or prolonged overuse these ligaments will become inflamed, swollen or might even break entirely. In a worst-case scenario the tendons themselves might even break.
Fairly common in climbing is also collateral ligament rupture. It is situated on side of the finger joints and occurs when too much force is put sideways on the fingers.
Cut down on climbing in general and specifically on crimpers. Tape quite tightly just under the first finger joint (tape the injured finger to the adjacent one to take the load off from the injured one) before climbing. Warm up the fingers by squeezing a foam or rubber ball/climbing putty. Build up strength and durability by rational strength training – e.g. ”hit strips”, barbell rolls and/or carefully executed campusing with adequate rest.
In case of a tendon or pulley rupture first be sure to have it properly diagnosed. In some instances surgery might be necessary. In those cases the faster you get there the better the outcome!
On the rehab side of an injury it is paramount to keep blood circulation high. You could try Dave MacLeod’s icing method. Idea is to submerge the injured part of the hand in ice cold water. Important is to have correct water temperature. Something that is cold enough to make your body first think that it is losing the finger and then realize that with maximal blood circulation the hand can be saved (you will find a video of this in the threads of the Dr 8a forum.).
I found the method and MacLeod’s reasoning very interesting to follow. It is a controversial way of increasing blood flow and benefits the healing process. Having been involved in human thermal physiology research for a couple of years I am convinced that MacLeod’s reasoning is sound. There is however potential drawbacks if the method is applied to other structures than fingers. As MacLeod correctly points out the potential threat of cooling the fingers can be ignored by the body if the rest of it is in thermal balance and thus a higher circulation can be achieved locally in the fingers. This would not happen if tried with shoulders, knees or a foot. To combine this strategy with "twin" taping the finger and anti-inflammatory drugs would most likely speed up healing. When working hard on small grips and crimpers, it also makes prophylactic (to avoid injury) sense to tape the cruciate ligaments in the base of the fingers. Excellent instructions and references to scientific studies can be found in Eric J Hörst’s book Training For Climbing.
D. Overuse injury
All climbers subject themselves to forces that load the joints to microtrauma. In the long run this will most likely increase the risk of arthritis (and thus arthrosis). Swollen and hurting finger joints are a sure sign of ongoing inflammation and are most likely due to overuse.
In the acute (here and now) phase you should refrain from climbing all together for at least a couple of weeks. If it hurts a lot then cool the fingers with cold water or an icepack (with a piece of cloth in between to avoid damage to the skin). Hot immersion in water, anti-inflammatory gel and anti-inflammatory medication (2-4 weeks) will help to stop the inflammatory process. Massage and regularly stretch the fingers. Start using gel balls or therapeutic clay regularly to work the fingers with (say 3 x 5 minutes per day). This will, by increasing the synovial fluid circulation, help prevent aggravation of the problem. When getting better restart the climbing activity on a low level (vertical wall with big holds or slopers). Use hot water immersion regularly and continue to use the gel balls (always before climbing to warm up!).
Citing Dr. Volker Schöff from his book One Move Too Many... (You can find the book in 8a webshop) "There are a lot of climbers that have been on the cutting edge of climbing for many years but have developed no signs off arthritis. The ones that do develop arthritis seem to be the ones that don't take care of their injuries but climb through them". Supplementing your diet with Glucosamine (600mg daily) has been scientifically proven to help the joints to withstand stress better. Taking Condroitin might also be beneficial (common as a combined supplement with Glucosamine in U.S but not in Europe). In medical practice I have found that adding high quality unsaturated fat oil capsules (fish oil, or even better, seal oil) to this will enhance the effect (not scientifically proven at this moment).
So everybody who wants to climb hard, take swollen joints seriously! Give them a break, be thorough in your warm up and stretching, and you will be more likely to be a happy high end climber in the years to come and less likely to get unusable hands when older.
Epicondylitis. This is an inflammation that origins in the extensor muscle (outside of elbow – e.g. tennis elbow). In order to obtain maximum grip strength the bending action of the muscles on the inside of the forearm is counteracted by the extending action of the muscles on the outside of the forearm. The flexing muscles being far more powerful, the extending muscles will be overloaded and cramped. This will produce poor blood circulation in the tendon area which in turn will enhance development of a usually very persistent inflammatory response. Specific strength training and stretching will prevent as well as heal this problem.
It is possible to have inflammation on the flexor side also (though not nearly as often since climbing strengthens these muscles). This might occur due to overuse (remember, a thoroughly worked muscle needs up to 4 days to re-cooperate and make gains in strength and endurance).
Are the extensors really necessary for a good grip function?
Anatomy lesson part one. Flex your wrist and curl your fingers maximally. Now, try to force the fingers open with your other hand. Easy wasn't it? Now try it again but with your wrist straight. Impossible, right? Thus the extensors are crucial in delivering grip strength. Most people neglect them but take a look at the outside part of the forearm close to the elbow. When pinching, a little muscle bulges (pronator teres) there. This is a characteristic of a good climber. This, in combination with the strong extensor, is what you want for strong grip.
The real trick is to get this muscle "in par" with your flexor muscle. So start working on balancing the two!
Do a lot of stretching for the medial as well as the lateral muscles (at least 4 times a day and always before and after climbing). Stretch your flexors by placing your palms, fingers pointing away, on a table in front of you and then lean forward. Keep the stretch for 15 seconds. Flexing your extensors is a more bit complicated. Place one arm (palm upward with wrist and elbow flexed) in the palm of your other hand and (while keeping your wrist flexed) extend the elbow. Keep the stretch for 15 seconds. (See figure!)
Increase your forearm circulation by frequently squeezing foam ball. Even better is if you have Metolius GripMaster or similar with rubber bands installed. This allows you to work your extensors as well. Use Voltaren gel on your forearm on training days. Get back to climbing by starting with easy climbing and over a succession of weeks build up to full power.
3. Shoulder instability and rotator cuff syndrome
Four small muscles keep the upper arm bone rotating on the very small socket of the shoulder’s Scapula bone. Since climbing mostly affects the pulling muscles around the shoulder, the pushing muscles as well as the specific rotation muscles of the shoulder will be too weak (in comparison) to keep the arm in the socket. This might cause a number of problems. This can be prevented by specifically strength training the pushing muscles and the foursome of stabilizing muscles of the ”rotator cuff”. As I see it, shoulder injuries are the most common sports related injury (though not among climbers).
Abduction (lift of the arm outwards) combined with outward rotation is the weakest force in the shoulder and most easily damaged. The muscles that stabilize the upper arm (Humerus) in its socket on the shoulder bone (Scapula) are very important for the correct movement and stability of the shoulder. This holds especially in quick movements like dynos, and lock offs. It is very important to have a correct muscle balance between outward and inward rotating shoulder muscles. Typically I see guys who have been focusing on developing their chest muscles and forgot their back. This causes Pectoralis (chest muscles) to overpower their Traps, Romboids and rear Deltoids (back muscles). The tendon of the Supraspinatus muscle will be swollen where the tendon has a very narrow passage on the front part of the shoulder. Some get this so called impingement more easily because their Scapula (the bone structure prominent on the rear of the rib cage) is shaped like a spoon. This narrows the above mentioned space for the tendon of the Supraspinatus muscle as it makes it way down and forward to connect to the upper part of the Humerus (upper arm bone). People with this unfortunate anatomical makeup tend to have constantly recurring problems until they undertake surgery.
As mentioned above the worst cases will need surgery, especially if the imbalance has resulted in a tear of the long biceps tendons insertion in the shoulder (SLAP and/or Bankart lesion). The rest of us will get away by: 1) Stretching the tendon religiously. Put the hand of the injured arm on the opposite hip. Grab the elbow of this arm with your good arm and pull down and in. Resist this motion by pulling back and up with your back muscles. If done correctly, this will give a feeling of discomfort on the front of your injured shoulder. Keep the stretch for a minimum of 15 seconds and repeat a minimum of 4 times a day. This will considerably help the healing process. It also helps to restore blood circulation by pressing out fluid from the tendon. If you have a very severe case, a mixture of Cortisone and a local anesthetic injected around the most swollen part of the tendon will speed up recovery (normally you can continue climbing but no pressing of weights for 3 weeks). This should be done by a sport medical specialist only. Even if the injury is not very bad, I would still recommend taking anti-inflammatory drugs regularly for 2-3 weeks. This would help to reduce the inflammatory process. As you get better you should, as mentioned earlier, work on stabilizing back muscle strength in general and specifically train your Supraspinatus. Supraspinatus training is best done by the following method. Stand up and lean slightly forward. Keeping the arm straight out from chest to the side, bend the arm 90 degrees at the elbow. Grab a small weight and let the hand rotate forwards and down, and then rotate it back up. This should be done slowly. Do 3-5 sets of 12-25 repetitions. As you get better, increase the weight and reduce the amount of repetitions and sets (max. 12 reps and 3 sets). When you can do this effort painlessly with more than 5 kg (11 pounds), you are most likely fully rehabilitated. A good idea is to keep the arm in the correct position with the aid of a bracket (Shoulderhorn, made in USA). This device will help in focusing the strain correctly.
The best idea of all is to start doing stretching and strength training exercises before having any problems. This way you will most likely never have any should problems!
The twisting motion of a knee-drop, the pulling and twisting motion of a high heel hook or the high tension bending force in a wide stance strain the ligaments. The so called meniscus (small cartilage disk) of the knee might tear or show sign of overload. A meniscus tear will leave your knee accident prone and unstable for good.
Put some effort into stabilizing strength training. The only leg exercise that a climber really needs to do in order to shield from knee problems is to use a ”quadriceps table”. This means sitting with support under your knee and your lower leg hanging free. Slowly extend your leg until straight and keep it there for one second. Then, even more slowly, lower it. Hang a couple of kg of weights around your ankles to make the exercise more effective. If injured, the best idea (after a proper diagnosis) would be to get an arthroscopic (peephole) operation/trimming for ligaments and meniscus done. A meniscus tear operated in this way allows climbing in a week. A neoprene knee wrap with a hole for the kneecap effectively keeps the injured knee warm and stabilizes it so you can start climbing again faster.
Good climbing and keep away from injury!
MSc Sports physiology, MD specialized in sports and rehabilitation medicine
For more detailed discussion check “Climbing related injuries” and “Hand manual” from the Dr 8a forum