Feet and rock climbing

So you're out climbing, and you pull your climbing shoes out the bag. What size are they? One size smaller than your normal shoes? Maybe two? Well, this post is to discuss the links between feet, footwear and climbing, and other foot injuries/problems.

Do remember, however, that we aren't the only sport or hobby to do this to our feet.....

In a study of 104 rock climbers, Killian et al (1998) found that 81% suffered from an acute or chronic pain or pathology in the foot and/or ankle during or after rock climbing. They suggest that this is in relation to the biomechanics of wearing small rock shoes.

First, as always, I will discuss the anatomy of the foot.

Ligaments

Muscles

Tibialis anterior is also the main dorsiflexor of the ankle.
The gastrocnemius, soleus and plantaris are the plantarflexors of the ankle (there are more muscles involved with platarflexion due to needing to lift the entire body weight, whereas dorsiflexion only consists of lifting the foot.)

Movements of the foot

Feet position within climbing shoes

Arches of the foot

Forces through feet when climbing

Robert Bradshaw-Hilditch and Gary Gibson (yes, THAT Gary Gibson) are both podiatrists who have been conducting some brilliant studies in collaboration with Staffordshire University regarding the forces that are exerted through climbing shoes, and where. 

Their research has found that the forces when front pointing on the hallux (big toe) during climbing causes more force through the metatarsal head, and puts the plantar fascia under tension.

During edging, the forces through the hallux again puts most of the force through the hallux metatarsal head, and stresses the plantar fascia, but also places the foot in a supinated position.

This is just the tip of the iceberg for this research, and Rob and Gary are looking at expanding this much further, as this was only looking at the plantar aspect of the foot in an indoor climbing situation.

But what does it mean?

This means that the feet are more prone to ankle injuries due to the supinated position (see below), and this increase in pressure on the plantar fascia could cause plantar fasciitis (see below as well). The forces being placed through the metatarsal head will change the biomechanics of the foot through the strength of certain muscles, and could cause problems with the arch of the foot (see below) and these problems will surpass what happens on the rock alone. 

So what can be done? 

Read on...

Problems with the feet

Hallux-Abducto Valgus (commonly known as bunions)

Hallux valgus is defined as a 20 degree difference between the axis of the first metatarsal and the axis of the proximal phalanx of the toe, and was noted in both feet in 53% and in one foot in 20% of climbers participating in the sport for more than 5 years and climbing UIAA degree IX. (Peters 2001)

Bunions are not actually caused by wearing tight shoes, but climbing shoes can worsen the deformity. Bunions are most often caused by an inherited faulty mechanical structure of the foot. 

Treatments include wearing bunion pads, orthotics or different footwear and pain killers, or there is the surgical route if the pain is severe. There is no physiotherapy intervention that can help here, therefore prevention is the best cure, by avoiding wearing tight shoes and decreasing the effect of escalating the problem. 

Vessel Compression

65% of sport climbers have found to have tingling and/or pins and needles in their feet, thought to be caused by medial to lateral compression of blood vessels and nerves of foot by smaller climbing shoes. This usually dissapates quite quickly once the shoes are removed. If it doesn't, I'd get it checked out by a professional fairly quickly.

Arch Disorders

Rock climbing has been found to have a beneficial impact on longitudinal arch of the foot (due to strengthening), but does cause an increase in frequency in transverse arch disorders such as tansversal platypodia (flat foot),and an increased frequency of abnormal toe-to-surface adhesion.

Both these problems affect the frontal areas of foot, caused by climbing footwear - changes in the biomechanics of the foot, can cause weakness in muscles controlling 1st metatarsal head extension.

Ankle sprains

Ankle sprains are an injury that don't just affect rock climbers, as you may well realise. They are much more likely to affect other sports persons such as fell runners, however, with climbing, due to the already supinated/inverted (turned inwards) position of the foot means that there is an increased risk of an ankle sprain, normally due to jumping/falling off (this has happened to a few friends, one bouldering in Font, the other trad climbing at Stanage – and both those walks out seemed to take forever!) Hochholzer & Schöffl (2006) found that 24% of climbers have suffered from an ankle sprain.

Ankle sprains are normally caused because the muscles around the ankle don't act quick enough to stop the ankle surpassing it's normal range of movement and the ligaments have to take the brunt of the force.It is normally when the ankle is inverted.

Therefore, the preventative measures you can do to improve the acting of your muscles around the ankle would be to improve the proprioception of the ankle (knowledge of where your body is in space).

To do this, you can use the use of a wobble board or wobble cushion. Stand on the board/cushion on one leg until you can do it for 1 minute. Then close your eyes and try to reach one minute. This can also be used as late stage rehab for an ankle sprain.

 

 Early stage treatment for an ankle sprain would be to follow the management of acute injuries, along with maintaining range of movement in a non-weight bearing manner.

Taping can also be used to support the ankle if injured, such as the technique below, to prevent further inversion:

To read more about ankle sprain and preventative measures, check out Global Therapies recent blog.

Plantar Fasciitis

Plantar fasciitis is heel pain that is caused from an inflammatory process of the connective tissue, the plantar fascia. 
It is commonly caused by long periods of weight bearing and flat feet, as well as poor footwear, poor biomechanics, high arches, and/or running/walking long distance on hard surfaces.
The treatment is normally rest, ice, reduce inflammation and swelling, calf stretches, and finally, correcting what caused the problem in the first place, be that poor footwear, muscular imbalances etc.

Achilles Tendinopathy

This has already been covered by a separate post here.

Ankle fractures

So, an ankle fracture, as you'd have guessed, is when a bone involved in the foot or ankle gets broken. There is no real preventative measure for this, and will normally occur from a fall. Therefore, the approach for a fracture is surgical intervention, or conservative treatment (which normally involves just casting the foot and ankle in plaster and waiting it to heal).
The time frame and approach is entirely dependant on where the fracture etc is, and what other structures are involved.
Post op/plaster, you should be referred to physiotherapy for rehab anyway.
So I'm just going to leave you with a tasty X-ray of an ankle fracture and repair!

Other problems

There are also other non-musculoskeletal problems hat can occur with the foot, such as corns, cuts, toe infections etc which just needs you to look after your feet!

Prevention

Just a few tips to try and prevent foot and ankle problems:

As previously mentioned, use of the wobble board or cushion can help prevent some ankle injuries.

Ensuring you have appropriate sized climbing shoes, or if not possible, remove them at all opportunities, or alternate your shoes for different routes

Parallel training to strengthen the muscles around the foot and ankle

Appropriate sized normal footwear

Foot hygiene

If you are a diabetic, please please please avoid tight shoes!! This is because of change in the sensation in the feet (neuropathy) that can be caused by diabetes, and can cause much more serious foot problems!

To avoid some ankle injuries, have some (decent!) spotters when bouldering, and try to have dynamic belay techniques when roped climbing, to avoid clattering into the rock and giving you time to slow down the motion with your upper legs rather than at the ankle!

However, the main take home message is that with footwear, pain is insane! here possible, make your climbing shoes fit properly, feel comfortable, and look after your feet!

Kids feet and climbing shoes

This will be covered in the next post, just to break up the amount of information I'm giving you! 

References

Peters P 2001 Orthopedic problems in sport climbing. Wilderness and Environmental Medicine, 12; 100-110

Morrison A 2009 Climbing shoes: is pain insane? BMC

Killian RB, Nishimoto GS, Page JC 1998 Foot and ankle injuries related to rock climbing. The role of footwear. J Am Podiatr Med Assoc. 88(8):365-74.

Morrison AB, Schoffl VR 2007. Physiological responses to rock climbing in young climbers. Br J Sports Med 41;852-861.

Hochholzer T, Schöffl V. 2006. One move too many… (2nd edn). Lochner Verlag: Ebenhausen.
Killian RB, et al. 1998. Foot and ankle injuries related to rock climbing. The role of footwear. JAPMA 88(8);265-74.

DrJulian Saunders 2009 Ankles Away

E. Demczuk-Włodarczyk, E. Bieć, T. Sipko, E. Boerner, R. Jasiński 2008
ASSESSMENT OF MORPHOLOGICAL ARCHITECTURE OF FEET IN ROCK-CLIMBERS
Biology of Sport 25(1)

"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

Physiological response to injury and hot/cold

So, this post originally started off as a post to review the evidence behind contrast baths, however, I realised it would be best to explain the physiological effect of hot and cold on the body, and discuss healing times while I'm at it, due to the overlap.

So, here it goes, I will begin with healing times and process.

The healing process consists of 3 different phases, and these are:

1. Inflammation (0-48 hours)
2. Proliferation (5 days – 4 weeks)
3. Maturation (4 weeks – 2 years +)

Now, I've put the time frames up here as a guide. A popular misconception is that these time frames are distinct and seperate, as shown below:

When actually, each of these areas overlap, as one area is winding down, the next is building up it's response, as shown below:

Now, here I will discuss what each area does physiologically, in as brief and simplest way possible:

Inflammation

We are all familiar with this process. This is when the injured area, swells, become red in colour, with associated warmth, pain, and loss of function. In this stage, the initial bridging of collagen fibres begins.

The normal response in this stage is to apply the POLICE principles.

Now, I must point, at this stage, we all panic about swelling, and try our best to get rid of it. Swelling is a natural part of the healing process and we should let it take it's course, as the swelling is needed to get fresh nutrients to the area, and to remove cellular debris.

Chronic swelling, so swelling that is still present maybe a week after the injury is not necessarily good, as this will start to impact on the optimisation of the healing process, and this is where we would want to remove excess inflammation.

Swelling upon exercise of the injured area, at this stage, would still be normal.

Proliferation

This stage shows the signs of inflammation beginning to decrease, and pain levels decreasing too.

Collagen fibres are being laid down at the injured site at the peak rate at this stage and will progress to orientate themselves in line with imposed stresses.

Maturation

This stage should so no signs of inflammation and a huge decrease in pain, with pain only at end range. This stage should focus on restoring function and strength, and optimising collagen alignment.

Collagen fibre deposits peak around 3 months post injury, but will continue to lay down up to 2 years after an inujry (depending on the severity of the injury).

Maturation is more focussed on return to normal, with excess collagen fibres removal, optimisation of the collagen matrix to accommodate imposed stresses, and return to normality of the vascular supply.

This video discusses the three stages of healing in much more
detail, if that interests you, and you can stand the accent!

N.B. Pain is not synonymous with healing. Pain levels will decrease quicker than structural integrity of the injured site improves, so the risk of re-injury is still high, even if the pain has subsided.

This graph shows that after the injury, the pain levels drop
below the threshold quicker than the tendon recovery

It is also worth mentioning a few stats on the temperature of tissues.

Optimal tissue temperatures:
resting = 36.5ºC – 37.2ºC,
aim when exercising = 38ºC – 40ºC (as tendons exhibit plastic deformation at 39ºC, collagen at 40ºC)

Hot and Cold response

So, now I'll move onto the effect of hot and cold physiologically:

Hot and cold can increase or decrease symptoms of inflammation, and here's how:

Cold

Glenn ice climbing in cold conditions!
Copyright Glenn Manifold

Symptom	Response	How?	Additional info:
Pain	↓	Reduces nerve conduction velocity and increases the firing threshold	Considerations Rewarming after icing can take 3-4 hours With a muscle at 4cm depth from skin surface will have a 4ºC fall in 1hr Contraindications: Raynauds, Cold hypersensitivity, Open wound, Sensory defect, heart disease Precautions: Cardiac disease/hypertension, pelvis/groin area (bone marrow production/blood cells), left shoulder+neck area (proximity to heart)
Spasm	↓	Automatic protective response, prevents increase demand for O2
Metabolism	↓	Reduces need for O2 in surrounding tissue so less damage via hypoxia and reduces total debris. Less O2 means less secondary damage to other tissues
Blood flow	↓	Vasoconstriction of the blood vessels
Inflammation	↓
Oedema	↓	By vasoconstriction of blood vessels and increasing blood viscocity
Tissue extensibility	↓

Heat

The author bouldering in sunny,
warm Fountainebleau

Symptom	Response	How?	Additional info:
Pain	↓	By reducing the nerve conduction velocity and increasing the firing threshold	Precautions/contraindications: Diabetes mellitus Multiple sclerosis Peripheral vascular disease Spinal cord injuries Rheumatoid disease Possible side effects: skin burns
Spasm	↓	Automatic protective response, prevents increase demand for O2
Metabolism	↑	More energy to cells, increasing there productivity, plus increase in blood flow meaning more oxygen to area
Blood flow	↑	Vasodilation of the blood vessels
Inflammation	↑
Oedema	↑	By vasodilation of blood vessels and decreasing blood viscocity
Tissue extensibility	↑

I hope this post has given you a little more understanding around the healing process and the physiological effects of hot and cold, and hopefully this will aid understanding for future posts, such as the evidence behind contrast baths, that I'm currently working on.