Injuries Associated with Rock Climbing

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1 Injuries Associated with Rock Climbing Murray Maitland, BSR, MSc, PT' R ock climbing is a sport that emphasizes both physical and emotional challenges (Figure 1). Over the past 30 years, rock climbing has become a popular recreational and competitive sport on both natural rock and artificial walls. During this time, technology has improved safety, and participants have been able to travel to climbing areas more readily. As of 1979, an estimated 100,000 people climbed actively in the United States (15). A 1983 British Mountaineering Council survey gathered data on 146 artificial climbing walls and estimated 200,000 climber days in Britain per year. In August, 1990, 1,526 rock climbers were registered at the University of Calgary Outdoor Pursuits Centre. Both the popularity and challenging nature of this sport combine to increase the prevalence of traumatic and overuse injuries. The majority of studies concerned with injuries in rock climbing have focused on climber falls, exposure to the elements, altitude, and impact injuries from rock or ice fall (I, 2, 6, 8, ). These papers describe epidemiology and demographics of serious, often life-threatening, climbing injuries. However, the majority of traumatic injuries in the acute stage are considered to be minor in nature, and most are not brought to the attention of emergency medical personnel (6). In fact, there are far greater numbers of overuse injuries than traumatic injuries. Repetitive, high torque movements in rock climbing have been shown to be associated with a unique This study was undertaken to understand the clinical presentation of injured rock climbers as well as possible mechanisms of injury. A survey was conducted of rock climbers registered at the University of Calgary Outdoor Pursuits Centre climbing wall in order to document the distribution of traumatic and overuse injuries associated with climbing. One hundred forty-eight people responded; the mean age was 28 years, with a range of years. Of those that responded, 49 stated they had sustained a total of 124 injuries in the past year as a result of their climbing activities. Traumatic injuries (eg., falls) accounted for 18% of injuries and predominantly affected the lower limbs. The majority of injuries (82%) were categorized by the respondents as overuse injuries. Upper extremity injuries were the vast majority and accounted for 63% of all injuries. Hand overuse injuries predominated (28% of all injuries), although elbow injuries were a close second (19%/0). Combined upper extremity overuse injuries were common. This apparent pattern of overuse injuries could be related to the architecture of climbing walls, climbing styles, training techniques, or relative weakness of specific anatomical structures. Consideration of the anatomical distribution of injuries associated with rock climbing may be useful in injury prevention and in rehabilitation of the injured climber. Key Words: climbing, overuse injuries, survey ' Clinical and research physical therapist, The University of Calgary, Sport Medicine Centre, Calgary, Alberta, Canada This project was supported financially by the University of Calgary Sport Medicine Centre Physiotherapy Research Fund. distribution of overuse injuries in this population (2-5, 9). Most of these studies have focused on hand injuries (4-6). Recent literature suggests that particular advances in rock climbing have led to an increase in the number of overuse injuries (5.9). With the introduction of artificial climbing walls, it is now possible to climb through all seasons and to climb in regions that previously did not have appropriate landscape. Consequently, climbing walls have had several effects on the sport of climbing. For example, the walls are usually built in regions of high population density, providing a greater opportunity for many individuals to attempt the sport. For the serious climber, proximity leads to more climbing and higher levels of ach- ievement. Furthermore, climbing walls are designed to maintain a high standard of safety, which permits climbers to consistently test their abilities at the highest levels of their physical capacity. Artificial climbing areas have also led to the development of sportclimbing competitions. In this sport, competitors attempt to climb routes as quickly as possible. Although they are well protected from falls by a rope from above, adding a competitive aspect may lead to increased intensity of training and higher levels of difficulty. The purpose of the present study was to provide further documentation of the patterns of injuries in rock climbers. This information is intended to provide clues to understanding the clinical presentation of Volume 16 Number 2 August 1992 JOSPT

--.. - ------.!. experience for both natural rock and artificial walls. Quantity of weekly rock climbing activity was assessed in three categories: current, peak-season, and off-season hours.

The Yosemite Scale, grade 1 to grade 6, has commonly been used to described the technical difficulty of rock climbing in North America.

A representative climbing move at The m..# University of cdlgary climbing wall (from Craig concerned with DolicklHorizon Photoworks, with permission).

2 !. experience for both natural rock and artificial walls. Quantity of weekly rock climbing activity was assessed in three categories: current, peak-season, and off-season hours. Degree of difficulty was assessed using the Yosemite decimal method (5.0 to 5.13) in two categories: most often attempted and highest level attempted. The Yosemite Scale, grade 1 to grade 6, has commonly been used to described the technical difficulty of rock climbing in North America. A full description of the I rating scale is available in most North American climbing guidebooks. The difficulty of a climb is Most studies FIGURE 1. A representative climbing move at The m..# University of cdlgary climbing wall (from Craig concerned with DolicklHorizon Photoworks, with permission). the symptomatic, injured rock climber, as well as the mechanism of injury and methods of rehabilitation. METHODS Survey questions appear in Appendix 1.' Questionnaires were distributed to rock climbers registered at the University of Calgary Outdoor Pursuits Centre climbing wall by two methods. First, from March, 1990 to July, 1990 climbers attending the University of Calgary indoor climbing wall were requested to complete the survey. Second, in September, 1990, 200 surveys were mailed to climbers selected randomly from a list of 1,526 registered climbing wall users. Two methods were used to eliminate repeat respondents. First, all questionnaires were identified by the climber's name. Second, if the randomization chose a previous respondent (three cases), another random number was selected. Questions were directed at the climber's age, previous year's climbing experience, and his or her injury injuries in rock climbing have focused on climber falls, exposure to the elements, altitude, and impacf injuries from rock or ice fall. arrived at by consensus of experienced climbers and is based on comparisons to previously graded climbs. Grade 5 is the level that is of interest to rock climbers, and so it has been subdivided into an interval scale. At the lower end, 5.0 ("five zero") is relatively easy. Climbs of 5.9 ("five nine") and 5. I0 ("five ten") are considered difficult. The scale continues to be pushed into the upper limits ("five thirteen" etc.) as more difficult climbs are accomplished. Historically, grade 6 has been reserved for a different style of climbing, and so grade 5 will always be extended in this manner. Australia, Europe, Britain, and other regions have devel- oped their own rating scales, which are comparable to this system. Injuries were categorized by the respondents as a result of trauma, overuse, or exposure and then localized by anatomical diagrams. The severity of injuries was rated according to the degree of pain, the duration of symptoms, and the level of disability. RESULTS The University of Calgary Outdoor Pursuits Centre climbing wall opened in May, From May, 1987 to January, 199 1, five traumatic injuries have been reported: one fractured wrist, two rope burns (from improper belaying technique), and two dislocated shoulders (both a result of chronic shoulder instability). Since May, 1977, there has been a cumulative registration of 1,526 climbers. The current number of climbing wall users is not available. Ninety-six climbers attending the Outdoor Pursuits Centre climbing wall during the survey period responded to the questionnaire. Records of attendance were not available, so there was no method to estimate the response rate in this group. Of the 200 mailed surveys, 52 (26%) were returned completed, and 18 (9%) were returned because the person had moved. Therefore, a total of 148 climbers responded to the questionnaire, including 1 15 males and 33 females. Thirty-five respondents competed in sport climbing. Figure 2 illustrates the distribution of ages, which ranged from (mean age 28 years). Years of climbing experience ranged from <1 year to >10 years, with a median of 2 years (Figure 3). Climbers reported the frequency and intensity of their climbing activi-. ties. The median quantity of current and off-season activity was in the 1-3 hours category, and the median of peak-season activity was in the 4-6 hours category. Peak season hours were greatly extended, with many of JOSPT Volume 16. Number 2 August 1992

---. 30 FIGURE 2. Frequency of age distribution as a percent of respondents. a <I I I 4 h 7 V 10 I? 13-15 16-10 >I0 Current Hours $2" 3.- 9.5 lo I-- 1 b 0 $?

Number of years of rock climbing experience as a percent of respondents. the respondents climbing over 18 hours per week (Figure 4). The median difficulty most often attempted was 5.

3 FIGURE 2. Frequency of age distribution as a percent of respondents. a <I I I 4 h 7 V 10 I? >I0 Current Hours $2" lo I-- 1 b 0 $? O Hcad Nsk Shoulder Arm Elhow Wnst Hand V X 0 l Ovrmse Injuries 5 e3 Traumatic Injuries Peak Seawn Houn Years Experience FIGURE 3. Number of years of rock climbing experience as a percent of respondents. the respondents climbing over 18 hours per week (Figure 4). The median difficulty most often attempted was 5.8, and the median highest level of difficulty was (Figure 5). Climbers reported a total of 124 injuries occurring within the past year (Figure 6). No altitude injuries (such as pulmonary edema) or exposure injuries (such as frostbite) were reported. Climbers described 22 traumatic injuries: three occurring to the head, seven to the upper extremity, one to the back, and 11 to the lower extremity. The most common traumatic injuries were ankle sprains (4% of all injuries), impact to the knee during a fall (3%). and hand injuries (3%). In addition, respondents reported 102 overuse injuries (Figure 6). Injuries to the hand were most common and accounted for 34 injuries (28% of all injuries). Elbow inju- Off Season Houn FIGURE 4. Hours of rock climbing activities per week. C 30 I $ 20 e: cp I5 w. E 10 s E s % 5' Level of Difficulty Moct Often Auemptcd H~ghesl Level of D~fficulty Attempted FIGURE 5. level of difficulty most often attempted and highest level attempted. ries and shoulder injuries accounted for 19% and 8% of injuries, respectively. Lower extremity overuse injuries were of lesser frequency, and 4% of all injuries were overuse injuries of the knee. Upper extremity in- FIGURE 6. Region of injury as a percent of all injuries. juries often occurred in combination. Of the 69 respondents with overuse injuries, 23% of these had a combination of shoulder-elbow, shoulder-hand, or elbow-hand injuries, the most common being combined hand and elbow injuries. The injuries reported were generally not severe. The typical injury could be described as moderately painful, of 2 weeks to 1 month in Respondents reported 102 overuse injuries. Hand injury was the most common duration, and resulting in limitations in some activities (Figure 7). DISCUSSION Traumatic injuries in this sample of rock climbers occurred at onefifth of the rate of overuse injuries. However, trauma-such as falls, friction injury to the belayer, and impact with falling objects-does pose a relative risk since 15% of 148 re- Volume 16 Number 2 August 1992 JOSPT

-.- RESEARCH STUDY ----.-------------,-------- - ---- -.- -. - - - -, 0.e 5 U c %@' ir: LL 50 40 30 20 10 Pain Duration Level of Disability FIGURE 7.

While lower extremities, especially the ankle and knee, were involved most frequently with the impact of a fall, hand injuries occurred at nearly the same rate.

4 -.- RESEARCH STUDY , , 0.e 5 U c %@' ir: LL Pain Duration Level of Disability FIGURE 7. Severity of overuse injury as a percent of respondents reporting overuse injuries. spondents reported this category of injury. While lower extremities, especially the ankle and knee, were involved most frequently with the impact of a fall, hand injuries occurred at nearly the same rate. Sudden, uncontrolled forces, such as when a foot slips, can result in sudden rotational torques on the interphalangeal joints or high forces on the finger anatomical pulleys (1 4). Overuse injuries were common in this sample of climbers (48%). and the pattern found during this study clearly demonstrates that the upper extremities, especially the hands and elbows, are subject to high levels of stress. The pattern of injury found in this study is very similar to the survey of soft tissue injuries reported by Bollen (3). He reported on 1 15 injuries in 86 climbers. Eighty-nine percent involved the upper limb, 50% were associated with the hand, and 17% occurred in the region of the elbow. Confirmation of these earlier results by the current study seems to indicate a pattern of overuse injuries unique to rock climbing. Indoor climbing wall environ- ments probably contribute to the frequency of overuse injuries. The relatively safe environment of an indoor climbing wall lends itself to increasing a climber's level of skill, confidence, and endurance. Climbers surveyed in this study regularly achieved a high level of difficulty (5.9 and above). Even though the years of climbing experience of these respondents indicated that they were, on average, relative novices, they appeared to achieve high levels of relative difficulty because of the controlled environment. Difficulty is increased by minimizing the horizontal area of hold; the harder routes have finger-holds that only support a portion of one distal phalanx and foot-holds that only support a small fraction of the More diffiult climbing routes have a vertical angle over 90'. distal foot. As the routes get progressively harder, the hand structures are placed in a position of mechanical disadvantage. Thus, increasing magnitudes of torques are exerted on the anatomical components of the hand, which acts as a lever, and on the forearm. Of special importance are anatomical pulleys of the fingers (3, 4). Climbers are also at risk for multiple overuse injuries. The coincident elbow and finger injuries can be explained by the continuity between finger flexor tendons and their muscular origin on the medial epicondyle. Other combined injuries may be explained by stresses affecting the entire upper limb as the distribution of forces is carried through the anatomical linkages. For example, Figure 1 illustrates that to minimize muscular fatigue, the elbow is frequently in full extension, and just prior to moving up, the shoulder would have been fully flexed. In these positions, passive restraints are providing most of the support. Another common method of increasing the level of diff~culty is to increase the vertical angle. The steepness of easiest routes on a climbing wall may have a vertical angle of less than 80" while the more difficult climbing routes have a vertical angle over 90". As a consequence, body weight is shifted from the lower extremities to the upper extremities. Increased weight bearing by the upper extremities will, therefore, increase the relative risk of sustaining upper extremity injuries as the difficulty is increased. As a consequence of climbing wall architecture or the structure of natural rock, climbers often use movements that produce complex resultant forces on the anatomical structures of the upper extremities. For example, placing the fingers in a fissure can hold the entire body weight because the metacarpal-phalangeal joints or the proximal interphalangeal joints are "jammed". Yet, these holds produce high levels of rotational torque on the fingers, wrists, and elbows. Proximal interphalangeal joints are often chronically swollen and stiff as a result of repetitive climbing in this manner. Long reaches or foot placements at the limit of range of motion place the muscles at a mechanical disadvantage. In the lower extremity, common positions are with the hip fully flexed and knee fully flexed, or alternatively, with the hip flexed and knee fully extended. Accounts of muscular strains as the climber attempts to raise his or her body weight are common. The limitations of this study are a result of the imprecise nature of data collection associated with surveys. The responses are not from a random sample of climbing wall users. Therefore, one can expect that the respondents may be self- JOSPT * Volume I6 * Number 2 * August 1992

5 RESEARCH STUDY selecting for certain attributes. However, this study is probably representative of general trends in rock climbing injuries because of the similar findings in other studies (3). Given the nature of the sport of rock climbing, preventing or moderating the effects of this repetitive, high torque activity is difficult. However, relative rest can be achieved in several ways. First, one can encourage the climber with upper extremity injuries to decrease the vertical angle or the level of difficulty. Also. there is both clinical experience and subjective evidence that would suggest taping can be very effective if applied in an appropriate manner (5). Climbers often apply tape to protect finger joints and finger pulleys. Some climbers use tape to prevent abrasions. In addition, analysis of the individual's training techniques and activity patterns relative to the factors described above may elucidate the mechanism of overuse injury and lead to modifications and rehabilitative steps. For example, climbers often use "chin-up" boards that only support the distal phalanx. These boards can exacerbate an existing injury or they may actually be the causative factor. CONCLUSION While severe traumatic injuries were rare, mild traumatic injuries and overuse injuries were common in the 148 rock climbers surveyed. Traumatic injuries, such as those that occur during a fall, most often affected the ankles and knees. However, hands were also affected by trauma as a result of sudden high forces because they are the climber's principle support. Overuse injuries most commonly occur to the upper extremities. The hands and elbows are particularly susceptible because of the effects of mechanical stresses of the sport on the innate anatomical structure. Recognition of the overuse injury patterns in these athletes may lead to methods to prevent injuries or provide for methods of rehabilitation. JOSPT ACKNOWLEDGMENTS Many thanks to Craig Dolick of ABL Photographic Studio, Calgary, for his tremendous effort in obtaining the climbing wall photographs. I would also like to thank The University of Calgary Outdoor Pursuits Centre staff for their assistance in gathering data. REFERENCES I. Addiss DC, Baker SP: Mountaineering and rock-climbing injuries in US national parks. Ann Emerg Med 18: , Bannister P, Foster P: Upper limb in- juries associated with rock climbing. Br I Sports Med 20:55, Bollen SR: Soft tissue injuries in extreme rock climbers. Br I Sports Med 22: , I Bollen SR: Injury to the A2 pulley in rock climbers. I Hand Surg 15B: , Bollen SR, Gunson CK: Hand injuries in competition climbers. Br I Sports Med 24: 16-18, Bowie WS, Hunt TK, Allen HA, Ir: Rock-climbing injuries in Yosemite national park. West I Med 149: , I The British Mountaineering Council: Development, design and management of climbing walls. A technical information manual for architects, leisure managers and climbers, pp London: The Sports Council, Cavaletti G, Caravaglia P, Arrigoni G, Tredici C: Persistent memory impairment after high altitude climbing. Int I Sports Med I 1: , Cole AT: Fingertip injuries in rock climbers. Br I Sports Med 24: 14, Ferris BC: Mountain-climbing accidents in the United States. New Engl I Med 268: , 1963 I I. Houston CS: Acute pulmonary edema of high altitude. New Engl I Med 263:478, McLennan )C, Ungersma I: Mountaineering accidents in the Sierra Nevada. Am Sports Med 1 1: , Schussman LC, Lutz Ll: Mountaineering and rock-climbing accidents. Phys Sportsmed 1 O:U, Tropet Y, Menez D, Balmat P, Pem R, Vichard P: Closed traumatic rupture of the ring finger flexor tendon pulley. 1 Hand Surg (Am) 15: , Williamson le (ed): Accidents in North American Mountaineering New York: The American Alpine Club, 1979 Volume 16 Number 2 August 1992 JOSPT

6 RESEARCH STUDY Appendix 1. Items Included in Survey Appendix 1. Questionnaire Items. Please note that the format presented here has been altered in order to be consise. The distributed questionnaire also included informed consent information and space for responses. 1. Do you compete in sport climbing? Yes No 2. Circle the numba of yean rock climbing < >10 Circle the number of hours pa week participating in rock climbing and related activities (eg. approaches, belaying, bouldering) but Q not include other sports (eg. weight training) during the following time periods: 3. Cumntly (hourshveek) < >18 4. At previous peak seawn fiourshveek) <l >18 5. At pmvious off season (hourshveek) <l >18 6. Cile the level of climbing most often attempted in the past year: Don'tKnow 7. Cile the highest level of climbing attempted in the past year: Don't Know 8. How many injuries did you have in the last year which were caused by rock climbing (iinone write O)? 9. How many of these injuries prevented or limited your climbing or working? 10. How many injuries were a result of a fall, impact, or a falling object? 11. How many of these injuries were a result of overuse, strains, exertion, repetitive movements or sustained position? 12 How many were the mult of exposure to the elements (eg. frostbite, pulmonary edema)? 13. How many occurred while climbing on artificial climbing walls or buildings? 14. How many occumd while climbing on natural rock? 15. Please demibe briefly how the injuryhnjuries occurred. 16. On the diagram below place an X at each position where you had an injury in the past year as a result of overuse, strains ~petitive movements, or sustained positions while rock climbing but not due to falls, impact or falling objects. Circle the X which was the worst A injury. &&u Cile the number below which indicates the level of severity of the worst injury on the diagram above. for each of the following: 17. Pain None Some Moderate Sevae 18. Duration <1 Week 2 Weeks-1 Month 2 Monthsdmonths % months 19. Level of 1 Could manage 2 Could not do some 3 4 Disability all activities hobbies or sports Unable to work Totally disabled 20.Name 21. Date of Birth 22. Gender M F 23. Signature 24. Today's Date JOSPT Volume 16 Number 2 August 1992

Epidemiology of Rock and Ice Climbing Injuries Boulder V. Schöffl

Epidemiology of Rock and Ice Climbing Injuries Boulder 2014 V. Schöffl Definitions: 5 major types of climbing mountaineering traditional (alpine) rock climbing sport climbing (incl. bouldering) indoor