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!

Long QT Syndrome and Sudden Cardiac Deaths

So, a slight deviation from the norm, but I figured I write something on this topic following on from my recent physiotherapy in-service training I did on cardiology.

So, Long QT Syndrome became well known in the press in 2012 when Fabrice Muamba of Bolton Wanderer's collapsed on pitch during a FA Cup football match against Tottenham Hotspur.

It's one of the main reasons now that all sporting clubs should have defibrillators as standard, and why there are more being used in public places such as shopping centres.

Long QT is a disorder that is associated with the umbrella term of "Sudden Cardiac Death", which is described as "non-traumatic, unexpected event that occurs due to sudden cardiac arrest".  In order to be clinically considered SCD, the event must occur within 6 hours of previously witnessed typical health (Pugh, Bourke, & Kundian, 2011), and also includes such conditions as Wolf-Parkinson-White Syndrome and Myocarditis.

The "QT" in "Long QT Syndrome" is related to the electrical impulses transmitted within the heart. The QT interval on an ECG is the time taken for the ventricles to repolarize (return to their normal electrical status in preparation for the next impulse/heart beat). This timing should be approx 1/3 of each heart beat cycle for the QT interval, and when this is longer than it should be, it could trigger abnormal heart rhythms called arrhythmias, which can lead to sudden cardiac arrest/death.

 

Long QT Syndrome is a congenital condition, and the first symptoms clinically could be that of sudden cardiac arrest, however, some may experience sudden faints, seizures or arrhythmias. 

It affects roughly 1 in 2000 people, and causes roughly 1-2 deaths per 100,000 athletes per year.

Those who are thought to have Long QT can be diagnosed via ECG, genetic testing or stress test.

Long QT is thought to be caused by lack of ions or ion channels, such as sodium, calcium or potassium ions in the heart that when move across the heart cell boundaries, they stimulate the electrical impulses within the heart.

If Long QT Syndrome is confirmed,  certain lifestyle changes should be incorporated to avoid strenuous activity, such as removal from competitive sport, and some are advised to purchase an external defibrillator as part of their standard kit, or smaller changes such as adding more potassium-rich foods to dietary intake (such as bananas). 

Treatment may also consist of beta blocker medication to slow down the heart rate, to reduce the risk of Long QT causing sudden cardiac death.

Surgery may be required, either to fit a Implantable Cardiac Defibrillator (ICD - see below) or to regulate the nerves of the heart to maintain a normal rhythm.

ICD 

An implantable cardiac defibrillator is much like a pacemaker, and can actually do the same job, providing regular electrical impulses (NOT shocks) to ensure the heart stays in the correct rhythm. The additional bonus of an ICD is that, when required, if an abnormal heart rhythm is detected and is unable to correct with pacing, can provide an electrical shock to the heart to restore normal rhythm.

They sit just under the collarbone on the left and are around the size of a matchbox. They have electrical wires that feed down the blood vessels into the heart. 



Post ICD Insertion

Normal post-surgical precautions
No contact sports incase of dislodging wires or implant
Take care around other devices/objects that omit electrical pulses which may confuse the device

Living with Long QT Syndrome

If Long QT is confirmed, it may be worth taking precautionary steps, such as having a plan in place if sudden fainting or cardiac incident occurs, which involves letting colleagues, friends, family know about your condition.

However, Long QT doesn't mean all has to change, athletes such as Dana Vollmer, an American swimmer who won a gold medal at 2012 Olympics. She was diagnosed with Long QT at 15 years old, but still continued to compete with a debrilliator on the sidelines, and has still had a successful career.

Read more here

If anyone has any experiences of this condition, I'd love to hear about it, via email (thomasbond.physio@gmail.com), Twitter (@Tombondphysio) or just comment below!

References

O'Connor A 2012 Overcoming a heart condition to win Olympic gold. New York Times Blog

Pugh, Andrew, John P. Bourke, and Vijay Kunadian. Sudden cardiac death among competitive adult athletes: a review. Postgraduate medical journal 88.1041 (2012): 382-390.

National Heart, Lung and Blood Institute 2011 What is Long QT Syndrome?

Heart and Stroke Foundation 2011 What is Long QT Syndrome?

Khan 2014 Introduction to Long QT Syndrome: A Cause of Sudden Cardiac Death in Athletes. BMJ Group

 British Heart Foundation Implantable Cardiac Defibrillator Patient Leaflet

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

"Climber's elbow" - Brachialis Tendonitis

So this post is to explore the other problems with elbows – specifically "climber's elbow" – a differential elbow pain to that of tennis or golfers elbow. Less common than biceps brachii injuries but quite common in climbers.

Climber's elbow is caused by tendonitis of the brachialis muscle. The brachialis muscle lies deeper than the biceps brachii muscle and originates on the upper humerus and attaches to the ulna.

Brachialis is a true flexor of the elbow as it attaches to the ulnar (rather than attaching to the radius which rotates over the top of the ulnar during pronation and supination. N.B. Biceps brachii attaches to the radius)

Therefore, because of the broad origin on brachialis and it's only function is to flex the elbow, the brachialis can be considered the strongest elbow flexor.

This injury, if a gradual onset, is most likely to be tendonitis. If there is pain in this area of the elbow after a specific incident/fall, it could be a rupture of ligaments or muscle tendons. 

N.B. Pain in this area of the elbow, could be, as mentioned above, could be from biceps, from brachialis, or even from problems with the proximal ulna-radial ligament. Always worth getting these kind of problems checked out.

Also needing ruling out would be shoulder / wrist / finger injuries or muscular imbalances.

Palpation

To try and identify the injured structures, you can try and palpate the painful area. 

The brachialis tendon must also be palpated for tenderness during elbow flexion, as both the biceps and brachialis flex the elbow. 

The brachialis muscle and its tendon are palpated where they insert at the tuberosity of the ulna and the coronoid process of the ulna. 

Like the biceps, the distal end of the muscle and/or the insertion of the tendon would be tender with injury. 

Supination of the hand would not necessarily affect the brachialis tendon, helping to further differentiate between the two muscles.

Symptoms

• Deep elbow pain (not superficial like tennis/golfers elbow generally is)
• Pain on anterior (front) elbow (note, this could be due to a biceps brachii injury)
• Swelling around the elbow or above the elbow (in the cubital fossa)
• Inability to bend elbow comfortably

Cause

Brachialis tears normally occur during a forceful contraction or a forceful hyperextension while climbing. Complete tears are associated primarily with elbow dislocation.

Tendonitis is normally caused by strain from sudden increase in training, overuse or repetitive elbow bending or forced, excessive elbow straightening (hyper-extension).

Treatment

Full rupture = surgical intervention would be required.

For a partial tear:

• Control inflammation in the acute phase – see POLICE Principles
• Rest
• Dep tissue frictions / Massage
• It has also been suggested that traversing may irritate the brachialis, so consider limiting this.
• If a tendonitis, the research suggests eccentric biceps curls (lowering of a weight in the curl position), however, I've found anecdotally that in the hammer position with your thumb pointing upwards works better.
• Exercise progression from isometrics to eccentric to concentric strengthening, ensuring all are pain free, progress from isometrics once full range of movement around the elbow is achieved

Prevention

As usual, warming up is a key prevention method

Ensure adequate recovery time between climbing days

All-round strengthening of rotator cuff, biceps and brachialis can maintain a good strength all round to correct any kind of muscle imbalances.

Triceps can also need stretching/strengthening depending on the imbalance.

Stretching of lattimuss dorsi and biceps

Technique when performing pull-ups etc or when climbing i.e. making sure you lock with your lats by keeping your elbow close to your body. Try not to chicken-wing (see below)

In the bottom row of pictures, you can see the correct form for pull-ups, with the elbows tucked in

In the top row, the elbows are "winging", which makes you more prone to injury

Also note, don't snap your elbows straight when lowering from a pull-up, control the movement down.

  

Avoid:

• pull ups with weights – your working to body strength – why do you need to be able to do pull-ups with weights?!
• descending bachar ladder
• down climbing campus board
• no snapping back of elbows during climbing/pull ups

And if your wondering where I got the lovely t-shirt, go to climberagainstcancer.org 

References

Live Strong article

Miller KJ 2013 Climber's Elbow: Diagnosis and Conservative Treatment Protocols. Dynamic Chiropractic Vol. 31, Issue 01

Memorial healthcare system 2013Brachialis or Anterior Capsular Elbow Strain with Rehab mhs.net 

Hochholzer T, Schoffl VR 2006 One Move Too Many. Lochner-Verlag, Germany