Knee Injuries

Now, with knee injuries in rock climbing, there are no specific injuries that climbers get due to our sport – we get “normal” knee injuries, such as meniscus problems and ACL ruptures. The only thing that differs is the mechanism of injury, such as falls from doing an “Egyptian” or heel hooks, phrases your standard doctor or sports physiotherapist may not understand!

But first, as always, to discuss the anatomy of the knee, to aid your understanding of what's going on in your joint:

Knee anatomy

Now, the knee is a lot simpler to understand compared to those joints with more movement such as the shoulder, as it predominantly is a hinge joint, so moves forwards and backwards only.

However, there is a slight degree of rotation and translation (moving forwards and backwards of the bones without gross movement of the leg), and it's mainly these movements that cause damage to the structures of the knee.

Bones

Ligaments

Within the knee, there are 4 main ligaments, two on the outside edge of the knee called the collateral ligaments, and two on the inside of the knee called the cruciates; and two sections of cartilage called the menisci.

Muscles

The muscles of the knee provide the gross flexion / extension movements, which is provided by the hamstrings for flexion, and the quadriceps to extend the knee.

Movements

As previously discussed, the gross movement of the knee is flexion and extension of the knee, however there is a degree of lateral translation of the knee and some rotation.

Cause for injuries

Eqyptian / Drop Knee

These moves tend to stress the hamstrings and therefore can cause muscle strains or tears. They also put pressure on menisci and ACL/MCL which, in conjuction with a fall from these moves, can cause rupture and injury due to the unusual orientation of the knee.
This is caused by passively ‘sitting’ on the medial collateral ligament (MCL) that runs down the inner side of the knee.

Heel hooks

Falls

Especially when bouldering, falls onto an uneven surface can cuase damage and rupture to ligaments and muscles around the knee. This can even cause a cascade effect when one ligament fails, it shock loads the next and causes multiple injuries.

Common injuries

Common climbing injuries related to the above movements, as already mentioned, are:

Meniscal tears

Anterior Cruciate Ligament / Medial Collateral Ligament

Patella Dislocation

Hamstring and other muscular tears

I could go into much more detail, but then this post would turn into an essay and you'd be asleep by about....now! Further information on any specific injury can be provided, or as future posts.

Symptoms

Symptoms of a knee injury will depend on the degree of damage and the structure damaged, however, you will tend to find one or more of the following symptoms:

• Locking of the knee
• Localised swelling/tenderness/pain
• Inability or difficulty in weightbearing
• Clicking/grinding

Symptoms of an injured muscle will be the following:

• Tightness
• Swelling/Bruising/Redness
• Weakness
• Pain
•  Inability to fully stretch

Treatment

The treatment to a specific knee injury depends on the injury, the extent of it, and whether a surgical intervention is required. However, much of the rehab will focus on training those muscles around the knee, so below are some sample exercises discussed.

Exercises: open and closed exercises

Simulated loading cases: A, closed kinetic chain
or squatting (WB, body weight). B, open kinetic chain leg
extension (WT, tibia weight). C, open kinetic chain loaded
(WT, tibial weight; M, external moment on tibia)

In a closed chain the end of the chain farthest from the body is fixed, such as a squat where your feet are fixed and the rest of the leg chain moves. In open chains the end is free, such as in a seated leg extension - See more at: http://www.afpafitness.com/research-articles/closed-chain-exercise-for-legs-and-knees/#sthash.pEvSRn4h.dpuf

In a closed chain the end of the chain farthest from the body is fixed, such as a squat where your feet are fixed and the rest of the leg chain moves. In open chains the end is free, such as in a seated leg extension
Closed chain exercises are better, as they provide more stability to the joint, less shearing forces therefore less chance of injury, increase stability, engages more muscles, and are more functional.
Some evidence says closed improve strength, however open chain exercises maybe nessecary if you are unable to weight bear on the injured knee.
To increase difficulty of these exercises, fix proximal point on unstable surface e.g. stand on a gym ball to increase stability and control

See some more sample exercises listed below.

Swimming and/or cycling are good later stage activities - non-weight bearing strengthening

Prevention

Again, much of the prevention work for knee injuries is strengthening of the muscles around the knee, and below is a sample of exercises from Climbing.com. Much of the other preventative work is repetitive information, but again is listed!

1. Strengthening work

Three Exercises That Protect Your Knees

Note: Ramp up gradually — building connective tissue can take two years.

1. Hamstring Curl on a Physioball

How: Lie on your back with heels on the ball, knees straight. Tighten your abdominals and bridge your hips up, and then bend your knees to roll the ball toward you. Try two sets of eight reps with good form; work up to three sets of 15. Advanced challenge: single leg atop the ball!

Why: The ACL prevents forward movement of the tibia. Your hamstrings assist in preventing that motion (particularly in this exercise).

2. Floor Touches

How: Stand on one foot with your knee slightly bent. With the opposite hand, touch the ground outside your standing foot. Keep your back straight. Repeat on the other leg. If tight hamstrings restrict your reach (and your lower back rounds), bend your knee more and reach only halfway. Begin with two sets of 12 slow, controlled reps, and work up to holding a three-to-10-pound weight in the hand reaching the fl oor. Advanced options: reach to the front, then inside your standing foot.

Why: Multi-joint proprioception and eccentric hip control. This exercise enhances the body’s positional awareness, to improve protective reflexes, and strengthens the hip muscles that maintain knee alignment.

3. Sidestepping with a Theraband

How: Place both feet atop a Theraband and hold opposite handles, with your arms crossed. Slightly bend your hips and knees, and then step left with your left foot, stretching the band. Lift (don’t drag) the right foot, and then step it left to narrow your stance slightly, keeping your feet greater than hip width apart — use core muscles to steady your shoulders, with your feet forward. Begin with 15 to 30 steps in each direction (depending on the band’s tension) and work up to 100.

Why: ACL injury can also occur when the knee is forced into a valgus (knock-kneed) position; your hip abductors and external rotators can minimize this vulnerability. Traditional exercises and day-to-day activities don’t strengthen these muscles, making the ACL injury-prone in certain climbing positions.

Thomas Rosenberg, Stacy McCooey, http://www.climbing.com/skill/injury-proof-knees/

Also, performing the moves will help train and strengthen the ligaments and joint in question, however start easy and simple and build up with repetition.

2. Correct any muscular imbalances

Personally, I know my hamstrings are quite strong, however this means my quads may not be as strong, therefore I perform cross-training, I run to ensure equal training of my lower limb muscles.

3. As always, improve technique to avoid falls and stressing your knee in strange positions because you have rubbish technique!

4. Down climbing to prevent falls / look at stable landings
Including using bouldering mats to protect landings.

5. Ensure good lower limb mobility
Make sure you have good range of movement at the ankle, knee and hip to limit damaging specific structures.

6. Stretching
Ensure muscles are correctly stretched, not overstretched, to aid performance at their optimal range

7. Listen to feedback from your knee
If it starts to hurt, or ache, or twinge, stop doing the move that's aggravating, or else something may well go pop!

8. Warm up!
Tendons and ligaments are stiff when cold, more elastic and better proprioception when warm.

Sample warm up for knees

 Try the following before climbing: •10 lunges on each leg, to open your hips and warm up your legs •10 floor touches (exercise No. 2 above) •Single-leg balance on the ground for 20 seconds — close your eyes •Two 30-second quad stretches (hold your foot in your hand and bend your knee, with your heel touching your behind)

COMING SOON: a post on lower limb amputations, as I'm currently treating a gentleman and learning lots in the process!
References

http://www.afpafitness.com/research-articles/closed-chain-exercise-for-legs-and-knees/#sthash.pEvSRn4h.dpuf

Jewell DV. Guide to evidence - based physical therapy practice: Jones & Bartlett Learning; 2008

Witvrouw E, Danneels L, Van Tiggelen D, Willems TM, Cambier D. Open versus closed kinetic chain exercises in patellofemoral pain: a 5-year prospective randomized study. Am J Sports Med 2004;32:1122-30


Bakhtiary AH, Fatemi E. Open versus closed kinetic chain exercises for patellar chondromalacia. British Journal of Sports Medicine 2008;42:99-102


http://ptrehab.ucsf.edu/sites/ptrehab.ucsf.edu/files/documents/Open%20versus%20Closed%20Kinetic%20Chain%20Exercises%20for%20Patellofemoral%20Pain%20Syndrome_Tsai.pdf

Cohen, Hrvoje Roglic, Grelsamer, Henry, Levine, Mow, Ateshia 2001 Patellofemoral Stresses during Open and Closed Kinetic Chain Exercises An Analysis Using Computer Simulation Am J Sports Med July 2001 vol. 29 no. 4 480-487 

Dave Macleod; Injury case study, knee ligament tear

Helmet or not to helmet?

So, the idea of this blog is to discuss injuries and injury prevention, so I thought I'd share some discussion on helmet wearing within rock climbing, as that clever piece of brain matter is quite vital!

The author climbing "Looning the Tube" E1 5b in the Dinorwic slate quarries, helmet in situ.

Now, there are plenty of sports that wear helmets, horse riding and cycling are the immediate sports that spring to mind.

Yet, out on the crags, we see climbers choosing not to wear helmets, yet a lot of them will wear helmets when they are involved in other sports such as cycling.
I understand that there are no rules and regulations that require climbers to wear helmets, that it is a personal choice (unlike, for instance, horse riding competitions), so I just thought I'd share ideas about wearing helmets.

Below is the BMC video from last year that canvassed opinions from climbers out on the Eastern Grit about helmet wearing.

Some people do have the opinion that a helmet limits visibility, impairing balance and cause overheating, however, modern helmets nowadays reduce this, and from a personal point of view, my helmet does not limit my climbing!
Sometimes, I think it's vanity, but luckily this is starting to change, with rock climbing magazines and guidebooks proudly displaying pictures of hard climbing/climbers wearing helmets! Helmets now also fit better and look slightly more aesthetically pleasing.

Also, some people only think that helmets protect you from falling objects, so some that will choose to only wear a helmet at crags that are classed as "unstable", such as quarries such as Horseshoe Quarry, however, most head injuries I've seen have been from falls have been where the climber has inverted by catching their leg behind the rope (such happened to a friend at Pen Trywn - luckily, he only had minor concussion and was right as rain after a few days), or from swinging underneath an overhang or round awkward corners (seen this a few times on the grit, fortunately no serious injuries).

In contrast to this, in Paul Pritchard's recovery from his head injury from a rock fall in Tansania , on the Totem Pole, which resulted in his hemiplegia, the doctors who initially assessed the extent of his injury reported that if he had been wearing a helmet, the angle at which the rock hit his head could have resulted in him being killed outright instead of resulting in a recoverable (albeit long!) head injury.

And statistically speaking, head injuries account for 12.2% of accidents in the US (similar figure acquired by UK Mountain Rescue Teams), and the majority of these being lacerations rather than serious injuries. There is a higher likelihood of a fracture or overuse injury. But it's still 12.2%!

From a personal point of view, I don't wear my helmet when bouldering or indoor climbing, although some will argue that there is a place for helmets in these environments. From my point of view, it's a calculated risk, as I'm generally not high balling routes when bouldering, and most indoor routes are straight lines and well thought out for clipping etc. When soloing, I don't wear a helmet, as it's not going to be much use if I fall off!
When I'm out trad or sport climbing, the helmet is always in the bag, and the decision is made on arrival at the crag to wear it or not, dependant on the crag and route. I generally wear a helmet sport climbing in the Peak, on the limestone, do to the nature of the rock, whereas trad on the grit is normally a route-by-route decision. 
I took my helmet out to Kalymnos, and rarely wore it, and at times wish I did, due to some routes still being loose and friable (especially on Telendos), but when you come back without incident, it gives you time to reflect and ensure you do so next time.

So there you have it, take from it what you will, but do remember, recovery from a head injury such as a bleed or hemiplegia is much longer than from a finger injury, and much more serious (if anybody knows someone who's had a stroke will know it can be a long road to recovery).

Paul Pritchard's craniotomy in 2012
Copyright Paul Pritchard

So next time you go to the crag, will your helmet be packed? Personally, I know mine will. 


References/Further Reading

Paul Pritchard 1999 Totem Pole

BMC articles: 
Head Case 
Keeping a head; a head injury case study 
Tech skills; why wear a helmet 

Personal experience!

Youngsters: Epiphyseal Plate Injuries

Getting children involved in climbing is fantastic, especially as climbing can be viewed as a life-long sport. However, we'd like to keep it that way, and the process to do this is prevent any injuries that will impact the kids in the future.
The main problem with injuries in children is any damage to the growth plates of any kind, and the most likely growth plate to injure is those that are sustaining high stress forces through them, such as the fingers. This post will aim to explain what growth plates are, the incidence of these injuries, and how best to avoid them.

Remember, children are children, not just “mini adults”!!!

What are growth plates?

As a child grows, all their bones start of as cartilage, and develop into bone as they get older. This is why a child's rib cage is much bouncier than an adults (please don't test this out!). This is why children are more likely to get greenstick fractures than pure fractures (this is where the bone bends and splinters, rather than a pure breakage – try this out with a freshly cut tree branch and try and snap it). As these bones develop, there are areas where the bone needs to grow.

The epiphyseal plate (or growth plate) is where new bone is formed to make the bone grow in a longitudinal direction, and on the otherside of the plate, the new bone growth becomes calcified. There is one of these growth plates at either end of the growing bone.

When this growth plate is damaged, the growth of the bone can be changed, from direction, to rate of growth or even stop growth altogether.

Whilst growth plates are still growing, they are the weakest area of the growing skeleton, 2 to 5 times weaker than adjacent ligaments. This is due to the connective tissues needing to allow for the growth of the bones.
Once growth has stopped, the epiphyseal plate is replaced with solid bone through calcification, and ceases to be an area of weakness.

Obviously, weight bearing is key for bone development and growth, however, it is the overuse and over-stressing of these structures that we are concerned about.

Time line of growth plates

If I remember correctly, during the closure of growth plates, the larger bones will fuse first, then the smaller joints. Also, the dorsal aspect of the growth plate closes last. 

This means that the fingers are susceptible to injury longer than larger bones such as the femur or humerus, and the dorsal aspect of the epiphyseal plate is usually where an overuse injury will occur in a child’s finger.

The picture above demonstrates this area of weakness, with a grade 3 Salter-Harris fracture.

Fingers stop growing at a biological age of 17 years old, but key timings to note is that of growth spurts, occurring from around age 12-13 for girls, and 13-15 for boys.

Especially for boys, this is key to note, as growth spurt plus testosterone = temptation to train harder due to the ease in which muscle bulk is put on in this period.

Incidence of growth plate injuries

Amongst junior competition climbers studied within the German National Junior Team by Volker Schoffl and friends found two-thirds who trained regularly on the campus board got fractured growth plates in a finger.
Shigeo Omori and Hajime found over 3 years, 182 junior competition climbers aged 7 to 19 had their fingers medically examined and 77.6% of these climbers had abnormalities, mostly deformation and light flexion contracture (can’t place hand flat on table).


In general, non-climbing public:
Growth-plate injuries comprise 15 percent of all childhood fractures. They occur twice as often in boys as in girls, with the greatest incidence among 14- to 16-year-old boys and 11- to 13-year-old girls. Older girls experience these fractures less often because their bodies mature at an earlier age than boys. As a result, their bones finish growing sooner, and their growth plates are replaced by stronger, solid bone.
Approximately half of all growth plate injuries occur in the lower end of the outer bone of the forearm (radius) at the wrist. These injuries also occur frequently in the lower bones of the leg (tibia and fibula). They can also occur in the upper leg bone (femur) or in the ankle, foot, or hip bone.

Mechanism of injury

Can be acute injury such as a fall, or can be a chronic onset caused by intense training, campus boarding or over-use of the crimp hold grip which causes compression or shearing of the growth plate.
It has been found that these injuries normally occur in climbers within the training scenarios rather than competitions.
Crimping or campus boarding has been found to be a cause of growth plate injuries due to the high loads put through the fingers, therefore causing an overload of growth plate (repetitive stress).

Signs and symptoms

Lack of mobility in fingers
Constant pain
Chronic swelling
Lack of crimping ability due to pain/swelling

The old mandate of “No pain, no gain” is crazy! If it hurts, get it checked out!

Diagnosis of injuries

The diagnosis and classification of a growth plate injury is normally via x-ray, and is classified as 1 to 5 Salter-Harris fracture.

Treatment

As with all fractures, this depends on the severity of the fracture, but will probably comprise of:
Immobilization
Manipulation or surgery
Strengthening/Range of movement exercises

Implication of these injuries

Rotation/shortening of finger
Incomplete growth
Deformity
Some papers suggest there is a link between climbing from an early age and early degenerative changes later on in life such as arthritis.
These will all obviously affect the child later on in life.

How to avoid these injuries?

• Avoid campus boarding under 18 years of age. Many famous climbers never touch a campus board – Steve Mclure, Tyler Landman so why does the kid?!
• Excessive Crimping – try and promote versatile grip strengths
• Long / intense training sessions
• No need to train strength pre-pubescent – due to motor skills still need to catching up with growth spurt.
• Avoid additional weight when climbing
• Dynamic moves – limit
• When training, try to discourage competition, as it will inevitably lead to someone getting an injury
• Train other areas, such as core, antagonists, balance, movement technique
• Respect growth spurts.
• Maintain good nutrition

No campus boarding (feet-off or dynamically) for under 18's! (to allow margin of error for late developers) UIAA approved advice!


References


Swiss medical weekly


Hochholzer T, Schoffl VR. Epiphyseal fractures of the finger middle joints in young sport climbers. Wilderness Environ Med. 2005;16:139–42.


One Move too many


http://www.medicinenet.com/growth_plate_fractures_and_injuries/article.htm



http://www.thebmc.co.uk/should-u18s-use-campus-boards?s=1



http://www.dpmclimbing.com/articles/view/kid-crushers-training-youth-climbers

Injures in Indoor Rock Climbing: New Research

Now the winter is fast approaching, all but the most tenacious of climbers will scurry indoors. But just how "safe" is indoor climbing?

Well, a new paper has been published this year by Schoffl, Hoffmann and Kupper in Wilderness and Environmental Mecicine has reported on the rate of injuries reported in an indoor climbing wall in Germany.


This study was performed over a 5 year period and was performed prospectively, rather than retrospectively as previous studies have. This meant that less bias could be introduced to the study, due to the events not having already occurred and the results unknown.


This study also had the advantage that climbing time could be monitored exactly due to an electronic entry and exit system at the climbing wall used.


There was a large number of participants registered in the study (515, 337), but this could of been higher due to those involved in group sessions not being counted separately.


Demographic data of the study found 63.6% of climbers were male, the remaining female, with ages between 8 and 80 years old (median being 34 years old). Average climbing time was 2 hours 47 minutes.
The authors reported 30 injuries in total over the 5 year period; 6 cases whilst bouldering, 16 lead climbing, 7 toproping, and in 1 case as a third person (not climbing or belaying) while watching another climber. Bouldering injuries were mostly the result of falls onto the mat, whereas in lead and toprope climbing various scenarios happened, but mostly resulting from belaying mistakes. Fifteen (50%) injuries were UIAA MedCom grade 2, 13 (43%) were grade 3, and 2 (7%) were grade 4, with no fatalities.

Injuries happened in beginner climbers in 5 (16.7%), in intermediate climbers in 16 (53.3%), in experts in 6 (20%), and in professionals in 3 (10%) cases.


In studies such as this, the safety aspect of a sport is given as a number of injuries per 1000 participation hours. The authors concluded that this study had 0.02 injuries per 1000 hours of climbing time, (similar to previous studies) and also much lower than other sports, such as surfing (13 per 1000 hours of competitive surfing (Nathason et al 2007)) and rugby (91 injuries per 1000 player hours (Brooks et al 2005)).

Of the injuries that occurred, the authors report that many of them were preventable, such as belaying or knot tying mistakes.


However, this study did have some flaws, of which are discussed below:

1. This study was only performed in one climbing gym, which may have been a particularly well run gym, and therefore have a better safety record, which the study recognises
   
2. Climbing time less than 30 mins and over 5 hours was omitted (due to probability of less than 30 mins not going to have been a climbing visit, or over 5 hours someone forgetting to log out). However, how many of us pop in to our local wall for a lunch time session, or spend the whole day there and stop for lunch etc?!
   
3. Only injuries that occurred while at the wall that required medical attention then and there were recorded. No overuse/chronic injuries, or those that may have been discovered after the climbing session were recorded.

But there you are, relative to other sports, indoor rock climbing has a much lower risk of injury. 

This article is also available on the BMC website, along with information on preventing becoming an indoor wall injury statistic yourself!

References


Brooks JHM, Fuller CW, Kemp SPT, Reddin DB 2005 Epidemiology of injuries in English professional rugby union: part 1 match injuries. Br J Sports Med 39:757–766


Nathanson A, Bird S, Dao L, Tam-Sing K 2006 Competitive surfing injuries: a prospective study of surfing-related injuries among contest surfers.A m J Sports Med. 35(1):113-7.


Schöffl VR, Hoffmann G, Küpper T 2013 Acute injury risk and severity in indoor climbing-a prospective analysis of 515,337 indoor climbing wall visits in 5 years. Wilderness Environ Med. 24(3):187-94

IFSC International Paraclimbing Cup

So I've just returned from a very busy weekend, volunteering at the Westway Sports Centre as a physiotherapist for the GB Paraclimbing Team, as part of the IFSC International Paraclimbing Cup.

It was a fantastic weekend, with teams from USA, India, Italy, France and Spain, along side the GB climbers. The competition was hosted by the BMC and the IFSC. 

Over the weekend, I got to meet Mark Wilkinson, of Paragon Physiotherapy, who specializes in spinal injuries and had done some previous work with the GB Paraclimbing Team. We did some joint assessments on a couple of the Team who required some guidance on their rehab, such as an ankle, wrist, and the obvious finger injuries. This was great learning as we got to brainstorm different theories and share knowledge.

Then, the climbers got on with the two qualifying routes. It was really inspiring to see climbers who were visually impaired, had a neurological physical disability, or had an amputated limb climb hard routes with such style and finesse, you wouldn't think they had a disability once they were on that climbing wall. 

Lower limb amputees warming up

Fran Brown (GB) on the qualifiers

Sianagh Gallagher (GB) on the qualifiers

The following day, the climbers entered isolation and proceeded to exit one by one to compete in the final. The hardest of these routes, on a steep, overhanging wall, were up to F7c+ and it was impressive, and inspiring to see the climbers work the way up these. 

Ronnie (USA) on the qualifiers

Tom Perry (GB) on qualifiers

One of the French visual impaired climbers on qualifier

Over the weekend, I got to meet many people just as invested in paraclimbing as the paraclimbers themselves, such as Graeme Hill (GB Team manager), Andy Colbart (GB Team assistant manager and IFSC Paraclimbing President),  John Ellison (of Climbers Against Cancer), the family, friends, supporters, spectators, photographers, route setters....just too many to mention. 
It was fantastic to meet some of the athletes themselves, such as the USA climbers Ronnie and Jon, GB Team Fran Brown, Tom Perry, Sianagh Gallagher and Reanne Racktoo. 

One of the French climbers on the final route

Spanish finalist being lowered from his high point

I also thoroughly enjoyed watching the skill and balance that these climbers demonstrated and the mature attitude shown by all the climbers involved. It was also brilliant to see the comradeship of those competing with each other, with all athletes cheering each other on.

I came away awed, with more knowledge than I had previously, and I am very much looking forward to future work with the GB Paraclimbing Team.
Hopefully more pictures will follow as they surface!
Check out the BMC report on the competition.

Lower limb amputee podium