Goals and Cross Training

Now, I apologise for the lack of posts recently, it appears life has gotten in the way, but I'm going to try and kickstart these posts again.

One reason why life has got in the way, is that I've just returned from a week's long climbing trip in Kalymnos. 
Now, over the week, I climbed harder, more routes and longer routes than when I first visited the island 2 years ago.
Yet I've been climbing less than I was prior to the first visit.
So, what's changed?

Firstly, I think knowledge of the island helps and the style of routes, therefore I was able to pace myself better and set some clear goals for the trip - of which I achieved.
Why did I achieve them? Because they were clear, concise, and realistic.
Secondly, I'm cardio-vascularly fitter than I was last trip, due to doing a little more running and cycling of late. This has meant that a) the walk-ins haven't knackered me out before I've even started and b) I've recovered quicker and easier on those longer routes
This, combined with bouldering more, I've been able to complete harder moves on routes by viewing them as boulder problems and then making use of the rests on the routes. 
Utilising all these methods also meant I didn't get injured, meaning I could climb every day and succeed in achieving my goals, and have a good holiday!

So, in summary, I think it's important in climbing, as with lots of other sports:
1. Set clear goals, make them SMART (Specific, Measurable, Achievable, Realistic, Timed)
2. Cross-train; i.e. do other activities/sports, not just climbing to ensure an all-round fitness. This applies to climbing different disciplines too, i.e. bouldering can help succeed on the harder moves on trad routes, etc

That's all I have to say this week, but there will definitely be two posts coming very soon, one on amputees in sport, the second will follow the next BMC Climbing Injuries Symposium

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

Mirror Neurons: How we learn by watching

You here it all the time, don't you....

Watch better climbers and you'll learn to climb better

And it seems to work, we see someone shift there body position slightly, maybe twist into the wall a bit more, and can then reach that elusive hold. Then we can recreate it.

But how does it actually work?  

Well, I went to a very interesting lecture last week on mirror neurons, with the thoughts that there are a certain set of neurons within your brain that fire whilst you are doing a task, and whilst watching someone do the task, for instance, you reach for an object, XY and Z neurons fire. You watch someone else reach for the object, XY and Z neurons fire again.

This is a new concept, as previously it was thought that when learning (or relearning) a new task, the brain observes, analyses, breaks down step-by-step, then recreates the new task. 
But it's much more of an instinct as that.

With one provision:

There must be a goal, a purpose to the task

 If there is no goal, say, just a hand making a fist shape, then the mirror neurons get bored, and therefore don't fire. The task has to be purposeful, like reaching for food or an object (or climbing a route!)

The brain sees the initiation of the movement, understands the task in hand, and almost figures out the "filler" bit in the middle of how to achieve it. 

This helps us understand lots about how we learn new tasks, and can be used in a context of a child's learning, or in the re-learning of tasks, for instance, after an acute brain injury.

It also helps explain how we feel empathy, as when we watch someone fall off a problem, miss a hold, miss a penalty, whatever the analogy, then it's like we are the person doing it, the same neurons in the brain are firing.

The lecture I went into went into a lot more detail, however, I'm going to leave you here, further reading is available below, or some TED talks that are always worth a watch! 

Any questions, comment below!

References

Harriss JP 2014 Mirror Neurons. Presented at Annual Brain Lecture

http://www.pbs.org/wgbh/nova/body/mirror-neurons.html

http://blogs.scientificamerican.com/guest-blog/2012/11/06/whats-so-special-about-mirror-neurons/

Papers

Franceschini M 2010 Mirror neurons: action observation treatment as a tool in stroke rehabilitation. Eur J Phys Rehabil Med.

Rizzolatti G 2008 Mirror neurons and their clinical relevance. Nature Clinical Practice Neurology


Further watching:

Ramachandran 2009 The Neurons that shaped civilization. TED Talks

And a heart warming story to end, to show that it does work:

R D'Angelo, F Fedeli 2013 In Our Baby's Illness: A Life Lesson. TED Talks

Fingers: Ganglion Cysts

So, I've noticed a few posts on certain climbing websites discussing ganglion cysts within the fingers, and so decided that I would write a post about them, considering there were one problem I omitted from the original finger injuries post.

What is a ganglion cyst?

A ganglion cyst is a liquid filled area within a joint capsule or tendon sheath that has bulged out to a particular side.
These cysts are caused by a congenitally weaker part of the capsule or sheath that cannot handle the extra pressure of over-creation of synovial fluid, which is created by over use and chronic stressing of joints. 
They can vary in size from pea to golf ball sized, and can occur anywhere in the body but most commonly in wrists and fingers. The size is often related to the amount of stress placed on the joint, therefore more stress = larger cyst, and this is why they most commonly occur in flexor tendon sheaths of climbers, just before the first finger joint.
Ganglions are normally harmless but can cause pain, especially if they irritate a nerve. 


Symptoms

• Pain
• Visible swelling of a lump
• Decrease in mobility around the joint

Treatment

The old adage of "smack it with a book" doesn't really work for cysts, no matter how much someone encourages you! As, even if it works and gets rid of the cyst for a little while, it will only refill.

Common treatments involve aspiration, steroid injection, or surgical removal of the cyst, however, some have suggested ultrasound as a treatment for the pain caused by the cyst.

Some people have steroid injections into/around the cyst to relieve the pain, however it is worth noting that steroids have been known to weaken tendons and tissues and so could cause further problems with the cyst. 
Varley et al (1997) found that there was equal success rate of removing a ganglion cyst (33%) with aspiration (insertion of a needle and draining the fluid, as depicted above) compared with aspiration and injection of steroid.

The other option is to have the cyst surgically removed, which has a re-occurrence rate of the cyst of only about 5%.

Prevention

Unfortunately, there is no current way of preventing a ganglion cyst, however they could be caused by unnecessary stresses on your joints, so avoiding or adapting the effect of these stresses could help, for instance, adapting / changing your climbing style, climbing more efficiently.

Ensuring full range of movements within your joints will also reduce the stresses put on the joint.
 
As usual, ensuring proper warm up/cool downs and eating well will aid the prevention of injuries.


References

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

NHS Choices

Varley GW,  Needoff M, Davis TRC, Clay NR 1997 Conservative management of wrist ganglia: Aspiration versus steroid infiltration. Journal of Hand Surgery 22(5): 636-637

Compartment Syndrome

So we all get pumped when we are out climbing, in our forearms. This is natural, but we expect this pump to ease after the route, or at the very most the next day.
So what happens when it doesn't go the next day, our even gets worse? Then it's quite possible that you're suffering from functional compartment syndrome of the flexor muscles, otherwise known as chronic exertional comparment syndrome (CECS).

Chronic exertional / functional compartment syndrome is much more common in the tibialis anterior muscle compartment in runners and walkers, but has recently been reported in the forearms of those requiring strong grip, such as climbers, motocross riders and rowers.

Physiology and Anatomy


Within the forearm, all the muscles are surrounded by a thin sheet of fibrous tissue called fascia, which holds all the muscle fibres together in their bundle.

CECS occurs when there is an increase in muscle mass but not in fascia that envelops the muscle tissue, which happens with high intensity training resulting in hypertrophy of the muscles) i.e. muscles grow quicker than the surrounding fascia).
The only space left is veins and arteries and so the vessels become constricted by the muscle mass and creates a back flow of blood and an "instant pump" The muscle still creates lactic acid, but the blood supply cannot remove it, resulting in the pump/burn, that can take days to recover. 

This process can also occur after infectious disease compromises an athletes immune system, but much less common.

Acute compartment syndrome normally occurs post fracture or crush injury, and requires urgent medical attention. This is not the focus of this post.

Symptoms

Pain in forearms during and after stress
Pumped sensation that does not decrease in the usual time frame
Pump reached way lower than your normal peak levels

Diagnosis

Diagnosis of CECS is using inter-compartmental pressure measurement during the sport specific stress (i.e. climbing) using the devices similar to below.

Schoffl et al (2004) set an algorithm as below for diagnostic of CECS dependant on the pressure found within the muscle compartments.

Differential diagnosis for the symptoms of CECS could be ulnar stress fracture or nerve entrapment

Treatment

• stress reduction i.e. cease to perform the activity, but I know climbers, and they won't stop climbing!
• stretching
• massage
• ice
• anti-inflammatories
• activity modification - analyse your climbing, change your climbing style, crimp less etc.
• surgical procedure - fasciotomy

Fasciotomy

A fasciotomy is one of the surgical options to reduce CECS. It consists of two incisions into each of the different forearm compartments to reduce the pressure within the compartments. They may require a skin graft if the muscle bulk is still too large to close the skin around it.

Outcomes

Painful sensations in the forearm were reduced from 53 to 7 VAS, and more than 95% (23/24) of the motocross patients were satisfied with the postoperative result of a fasciotomy after 5  follow-up. (Winkes et al 2011)

Post fasciotomy of 12 patients reported percentage improvement after surgery was 88%. Median time to return to full activity was 9 weeks.
(Brown et al 2011)

In 8 post fasciectomy patients, all had resumed their sport in the 6 weeks after the surgery, and 3 returned to their previous level, 5 improved their level. No complications and no recurrences were reported during an average 2-year follow-up. (Croutzet et al 2009)

Physiotherapy post operatively would be to follow the post op guidelines to regain range of movement and strength.

Although surgery is highly effective for most people, it's not without risk. Complications of the surgery can include infection, permanent nerve damage, numbness and scarring.

Pre and post fasciotomy

Prevention

Unfortunately, there is no real prevention for CECS except to remember that it is really important to build up training and intensity slowly and steadily to ensure all structures within your body adapt to the changes at the same rate, as muscle bulk grows quicker than tendon strength, fascia; and this can lead to problems, imbalances and injuries.

This doesn't mean that all the usual advice doesn't apply, such as warming up and cooling down properly, keeping well fed and hydrated, and "no pain, no gain" is a myth, if your in pain, stop!

References

Am J Sports Med. 2012 Feb;40(2):452-8. doi: 10.1177/0363546511425647. Epub 2011 Oct 26.
Long-term results of surgical decompression of chronic exertional compartment syndrome of the forearm in motocross racers.
Winkes MB, Luiten EJ, van Zoest WJ, Sala HA, Hoogeveen AR, Scheltinga MR. 

Br J Sports Med. 2004 August; 38(4): 422–425.
doi:  10.1136/bjsm.2002.003996
PMCID: PMC1724897
Evaluation of physiological standard pressures of the forearm flexor muscles during sport specific ergometry in sport climbers
V Schoeffl, S Klee, and W Strecker

J Hand Surg Eur Vol. 2011 Jun;36(5):413-9. doi: 10.1177/1753193410397900. Epub 2011 Feb 21.
Chronic exertional compartment syndrome of the forearm: a case series of 12 patients treated with fasciotomy.
Brown JS, Wheeler PC, Boyd KT, Barnes MR, Allen MJ.

Tech Hand Up Extrem Surg. 2009 Sep;13(3):137-40. doi: 10.1097/BTH.0b013e3181aa9193.
Mini-invasive surgery for chronic exertional compartment syndrome of the forearm: a new technique.
Croutzet P, Chassat R, Masmejean EH.

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!