Injury in traditional and sport rock climbing

Wilderness and Environmental Medicine, 9,2-7 (1998)

ORIGINAL ARTICLE

Injury in traditional and sport rock climbing TODD E. PAIGE, MD; DAVID C. FIORE, MD; JEFFREY D. HOUSTON, MD From the University of Connecticut, Integrated Residency in Emergency Medicine, Hartford, CT (Dr Paige); University of Nevada School of Medicine, Family and Community Medicine, Reno, NV (Dr Fiore); and Department of Radiology, University of New Mexico Health Sciences Cell1er, Albuquerque, NM (Dr Houston).

The objective of this study was to compare patterns of injury found in traditional rock climbing with those found in sport climbing. A questionnaire was administered to rock climbers by mail, in person, and via the World Wide Web. Injuries that occurred while rope-protected climbing on rock were analyzed regarding the anatomical location and the mechanism and activity at the time of injury. Ninety-four climbers reported sustaining an injury while rope-protected climbing on rock. Most injuries occurred while leading and involved the upper extremity, especially the fingers. Falling was the predominant mechanism of injury on traditional climbs, and stress over a joint while attempting a difficult move was the most common mechanism on sport climbs. Potential for injury prevention lies in teaching climbers to recognize the limitations of the fingers as weight-bearing structures. Key words: rock climbing, mountaineering, traditional climbing, sport climbing

Introduction

Rock climbing is a rapidly evolving and increasingly popular sport. Many factors are contributing to this evolution, including improved safety equipment, the development of "sport climbing," and the growth of indoor Climbing gyms. Climbers can now train during any season, at any time, without traveling to the mountains or even leaving home. Along with these changes, the number of climbers is growing rapidly. In 1997, the number of climbers was estimated at 7.5 million [1]. In addition, rock-climbing images are commonly seen on television and in the print media. There are also many Internet and World Wide Web (WWW) sites devoted to climbing. Owing to this great increase in popularity, it is likely that more climbers will be consulting their physicians with climbing-related injuries. Not only has climbing soared in popularity, but the nature of the sport is changing as well. A new style of climbing, sport climbing, has been introduced and is quickly becoming popular. Sport climbing focuses on the development of athletic ability and on making the most difficult moves possible. The mental distractions of danger and placing safety equipment while climbing are minimized through the use of permanently placed equipReprint requests to Hartford Hospital, Residency in Emergency Medicine, 80 Seymour St, PO Box 5037, Hartford, CT 06102-5037 (Dr Paige).

ment. Sport climbing takes place both indoors on climbing walls and outdoors on natural rock. Traditional climbing, which has been practiced for many years, generally uses natural weaknesses in a cliff face, such as a crack, that provide opportunity to place safety equipment, which is later removed. The challenge of engineering a safety system plus the psychological challenge of dealing with the danger of a long fall are central elements of traditional climbing. Traditional climbing only takes place outdoors on natural rock. Sport climbing is distinct from traditional climbing in a number of other ways. It is highly gymnastic in nature; it relies heavily on permanent, preplaced safety equipment to protect the climbers from frequent but minor falls; and the climbs tend to be shorter and more severely overhanging than traditional routes. The nature of sport climbing demands that the upper extremities support much more body weight than they would on a typical traditional climb, where most of the weight is supported by the lower extremities. Many climbers participate in both forms of climbing, while some prefer to specialize. Climbing injuries are commonly perceived to be the result of a long fall or of a falling object such as a rock striking the climber. This perception has been supported in several publications describing mountaineering injuries; however, these reports do not accurately reflect rock-climbing injuries, because they include injuries that occurred on snow and ice as well as on rock [2-4]. Of

Injury in rock climbing the reports limited specifically to rock-climbing injuries, one described injury patterns by anatomic location [5], but most have been case studies [6-12]. Some papers describe rock climbing but do not discriminate between injuries occurring on natural rock and those occurring on artificial surfaces [13-17]. The term "artificial surface" is used in this report to describe any structure constructed to simulate rock climbing on a natural cliff. These structures are built indoors and outdoors, in a great variety of shapes and sizes, to simulate climbing on different types of terrain. Large walls (30-50 feet high) are housed in indoor gyms devoted to climbing. Artificial hand and foot holds made of wood, plastic, ceramic, or rock are bolted onto the surface of these walls. This study compares the patterns of injury found in traditional rock climbing with those found in the new discipline of sport climbing on natural rock in the outdoor setting. Design

A retrospective survey using an anonymous questionnaire was administered during 1995 and 1996 using the following three methods: 1) face-to-face administration by one of the authors in indoor climbing centers; 2) mailed distribution to indoor climbing centers in the Western states, with questionnaires returned to the authors by mail; or 3) A WWW site containing a HyperText Markup Language version of the questionnaire, announced to climbers on the rec.climbing newsgroup. Five hundred hard copies of the questionnaire (see appendix A) were distributed, and data were collected from the WWW for 9 months from August 1995 to May 1996. Questionnaires solicited data on a climber's injury history over the last 5 years, and each completed questionnaire represented the history of one injury event. Individuals who had experienced more than one injury event during the last 5 years were asked to use one questionnaire for each event. Injuries sustained while climbing on traditional routes were compared with injuries sustained while climbing on outdoor sport routes. Data concerning injuries that occurred while bouldering were excluded because bouldering shares attributes of both sport and traditional climbing. "Bouldering" is classified as neither sport nor traditional climbing. It is a unique style of climbing that occurs on small boulders, 10 to 20 feet high. Many climbers use this form of climbing to practice difficult moves, which may be used for either traditional or sport climbing, while fairly close to the ground so that they can jump down if necessary. Bouldering has historically been practiced on natural

3 rock, but has become popular on artificial surfaces as well. Injuries occurring on artificial surfaces were excluded to avoid the confounding variable of different climbing surfaces. Traditional climbing only occurs on natural rock. Categories of comparison included the type of climb on which the injury occurred, anatomic location of injury, activity at the time of injury, mechanism of injury, and severity of injury. Results

Three hundred ninety-eight questionnaires were completed (50 from face-to-face collection, 209 by mail, and 139 from the WWW). Forty-nine questionnaires were excluded owing to incomplete or uninterpretable data (5 from face-to-face collection, 38 from mail, and 6 from the WWW). The average age of respondents was 29 years, with a range of 11 to 63 years. Eighty percent of the respondents were male and 20% were female. The mean number of years of climbing experience was 7 years (range 0.25-40 years). Ability ranged from 5.0 to 5.14 on the Yosemite Decimal System scale. The Yosemite Decimal System is a numeric scale used to rate the difficulty of climbing routes. It was developed in Yosemite Valley, and ratings are expressed using a decimal point to separate the general class of a climb from a more specific difficulty rating. For example, a climb rated 5.8 would be read as "five eight." The "5" indicates a climb of the fifth class, being those climbs difficult enough to require a rope, as opposed to class 4, which would not require safety equipment. After the decimal point, a more specific number is given, which indicates the difficulty of the climb compared with other fifth class routes. These ratings range from 5.0 to 5.14. The latter is read "five fourteen," not "five point one four." 5.14 is currently the maximum level of difficulty. Of 251 climbers reporting an injury (98 had no injury) within the last 5 years, 120 reported sustaining their injury on natural rock, while 131 were injured on an artificial surface. Twenty-six of those injured on natural rock were injured while bouldering. Ninety-four reports of injury on natural rock while sport or traditional climbing were used in this analysis. Fifty-one percent (48/94) were injured while climbing on a sport climb, and 49% (46/94) were injured while on a traditional route. The average age of injured climbers was 31 years. Eightysix percent (81/94) were male, 14% (13/94) female. Several injury events resulted in more than one anatomical site of injury. The 48 climbers injured on sport climbs reported 64 anatomical sites of injury, while the 46 climbers injured on traditional climbs reported 53 sites. The sites of injury are listed in Table 1.

Paige, Fiore, and Houston

4 Table 1. Number of injuries according to anatomic location and type of climb

Table 2. Number of injuries according to mechanism of injury and type of climb

No. (%) of injuries Body region Axial Head Spine Ribs Total Upper extremity Shoulder Arm Elbow Forearm Wrist Hand Finger Total Lower extremity Hip Knee Leg

Ankle Foot Total

Traditional climbing

2 (4) I (2) I (2) 4 (6) 4 I

(8) (2)

8 (15) I (2) 6 (II)

No. (%) of injuries

Sport climbing

Other

20 (43) 6 (12)

5 (II) 4 (8)

15 (33) 30 (62)

6 (13) 8 (17)

Traditional Sport

6

pulley system and stop the fall. The term belay refers to the activity of holding the rope while another climbs. If a fall should occur, the belayer secures the rope and stops the fall. Top-rope climbing refers to a system of rope work in which the climber is protected by a rope secured to a belayer at the top of the climb. Data relevant to the severity of injury revealed no differences between traditional and sport climbing in the amount of time taken off from climbing, perceived outcome after recovery, or the number of climbers who sought medical attention.

o

o

(9) (0)

7 (II)

4 (6)

II (21) 33 (62)

49 (76)

I (2) 2 (4)

(0)

I (2) 4 (6) 2 (3)

II (21) I (2) 16 (30)

4 (6) I (2) 12 (19)

o

Stress on a joint

2 (3) I (2) (0) 3 (5)

(6) (5) 25 (33)

2 (4)

Falling

Hit by falling object

Type of climb

4 3

On traditional climbs, the ratio of finger injuries to all other sites of injury combined was 1:3.8 (n = 11:42); on sport climbs this ratio was 1:1.6 (n = 25:39). The most commonly injured finger on traditional climbs was the middle finger (45% of finger injuries, n = 5). On sport climbs the most commonly injured fingers were the middle (36%, n = 9) and ring (32%, n = 8) fingers. Falling was the predominant mechanism of injury on traditional climbs, and stress over a joint while attempting a difficult move was the most common mechanism on sport climbs. Table 2 shows the distribution of injury by mechanism. Climbers were engaged in different activities at the time of injury. The number of injuries that occurred during each activity are shown in Table 3. Definitions for the activities are provided below. Lead climbing is the process of placing safety equipment during an ascent to protect the climber in case of a fall. The climber is attached to a rope that is laced through the equipment. As the climber ascends, he places ever higher pieces of equipment, forming a pulley system between himself and a partner (belayer) on the ground. If the lead climber should fall, the belayer would hold the rope, which would become taut through this

Discussion

The results of this study suggest that the types of injuries sustained on traditional and sport climbs are different with respect to anatomic location and mechanism. These findings are helpful in developing strategies for injury prevention. When injuries are considered by body region, upper extremity injuries predominate in both sport and traditional climbing. The ratio, however, of upper extremity to lower extremity injuries is greater in sport climbing, with a ratio of 4:1 (n = 49:12) for sport climbing and 2: 1 (n = 33: 16) for traditional climbing. Among upper extremity injuries, the fingers are the most commonly injured structures. This is especially true in sport climbing, where the ratio of finger injuries to all other injuries far exceeds that seen in traditional climbing. On sport climbs, the ratio of finger injuries to all other sites of Table 3. Number of injuries according to activity at the time of injury No. (%) of injuries Type of climb

Leading

Top rope

Belaying

Traditional (n = 46) Sport (n = 48)

31 (67) 38 (79)

11 (24) 8 (17)

3 (6) 2 (4)

Injury in rock climbing

injury combined is 1: 1.6 (n = 25:39); on traditional climbs this ratio is 1:3.8 (n = 11:42). This pattern of injury has also been reported by Bollen, who found the hand and wrist to be the most frequent sites of injury among "extreme rock climbers," with the proximal interphalangeal joints of the ring finger and middle finger being the most common [13-15]. It is not clear whether the injuries reported by Bollen were sustained on sport or traditional routes. Shea et al previously reported that half of climbers surveyed had suffered an injury to the hand or wrist and half had also experienced distal or proximal interphalangeal joint pain [11]. The differences in injury patterns between sport and traditional climbing are due to style-specific mechanisms of injury and to the fact that sport climbing places greater stress on the upper extremities, especially the fingers. The body movements necessary on sport climbs are often explosive and dynamic. Lunging from one very small finger hold to another is common, and these movements generate tremendous stress on the fingers. Injured climbers may have exceeded the strength of the fingers' connective tissue during a ballistic movement. This sort of movement is common on sport climbs and uncommon on traditional climbs. Another aspect of sport climbing that may lead to injury is the common practice of working on a difficult sequence of moves many times over. This is done to master the movements required on a particular section of a climb. This process is known as "working the route" and exposes the sport climber's fingers to a repetive strain and rapid overuse. Not only do the locations of injury differ between traditional and sport climbing, but the predominant mechanisms of injury differ as well. On traditional climbs, injury is usually the result of a fall. On sport climbs, stress over a joint while attempting a move is the most common mechanism. This mechanism has been reported previously by Largiader and Oelz, who described "overstrain" injuries to the fingers and elbows [16], and by Bollen and Gunson, who described injuries due to "pulling up on a small hold with one or two fingers" [15] and "sprains of the collateral ligaments of the PIP joints" [13]. Robinson also discussed similar upper extremity injuries [18]. Comparison of our data with those of previous studies suggests that the pattern of injury in traditional climbing may also be changing. Our study found an upper extremity to lower extremity injury ratio of 2: 1 in traditional climbing. This is a much different result than that reported by Bowie et al in 1988, who found a ratio of 1:4.4 (n = 29:127) [5]. Bowie et al did not label their work as a study of traditional climbing, but in their study area, Yosemite National Park, at the time of data collection, 1984-1987, sport climbs were very rare. The dif-

5

ference in patterns may be explained by improvements in safety gear since 1987, which allow climbers today to place safety equipment at more frequent intervals, thereby avoiding long falls. In addition, advancements in climbing standards may playa role. The more difficult climbs today tend to be steeper, thus placing more stress on the upper extremity, while offering cleaner falls. On a climb that is less than vertical, a falling climber is more likely to strike a lower extremity on a ledge before being stopped by the rope. On a vertical or overhanging climb, a climber falls into the air and travels away from the rock before being stopped by the rope. Alternatively, patterns of injury may be specific to the type of rock being climbed. In this case, the data of Bowie et al would reflect injuries that occurred on granite, whereas our data are not specific to any rock type. To our knowledge, no study has compared injuries based on rock type. The generalizability of this study has several limitations. First, our methods of questionnaire distribution may not have captured a cross section of climbers representing the population of all climbers. However, our use of three different methods for distributing and collecting the questionnaires should have provided a better population for sampling than if we had only used one method. The average age of injured subjects in our study (31 years) was similar to previously published averages, which have ranged from 25 to 31 years [2,3,5,19,20]. The percentage of injured female subjects in our study (14%) was slightly higher than the number in other reports, which have ranged widely (4%-12%) [2,5,20]. The methods of survey administration prevented rate determination because nothing is known about the climbers who chose not to participate in the study. The ability of this survey to estimate the severity of injuries was also limited, because information on fatal and career-ending injuries was not collected. Even hand and finger injuries that appear to be minor have the potential to keep a climber away from the rocks for prolonged periods of time. Largiader and Oelz [16] described healing times from months to years after overstrain injuries, and Moutet et al [10] prescribed 45 days of rest and physical therapy prior to a slowly progressive return to climbing after rupture of the A2 pulley. The greatest potential for injury prevention lies in teaching climbers to recognize the limitations of the fingers as weight-bearing structures. Adequate recovery, appropriate training, and taping of fingers before maximal efforts may also contribute to injury prevention. Climbers should be encouraged to immediately stop climbing when they feel sharp pain. This is especially true of finger pain and if symptoms appear while "working" a move. This seems obvious, but successful climbers, like other successful athletes, have often conditioned

6 themselves to ignore discomfort and to push through difficulties .. Climbers must learn to differentiate between pushing oneself despite exhaustion and muscular fatigue and pushing oneself into a serious connective tissue injury. The potential for injury while "working a route" seems especially high at the upper levels of difficulty, as the degree of climbing skill has been shown to be a risk factor for injury, with more injuries seen at high levels of skill and difficulty [16,21]. Training the fingers to handle the stress of modern climbing may involve a long period of time to strengthen tendons and ligaments, as opposed to the relatively short period of time to strengthen muscle. Adequate rest between maximal efforts will allow recovery from microtrauma and will help prevent overuse injury. Fortunately, the modern training concept of periodization has become popular among climbers and allows for periods of recovery between periods of intense effort. Flexibility training may also be important. This aspect of physical fitness has not been systematically studied among climbers, but is known to be beneficial in other sports and is popular among climbers. The most specific injury prevention strategy is the development of good climbing technique. A smooth and precise style helps climbers avoid out-of-control forces and sudden unexpected loading of joints. Finally, when a climber does expect a maximal effort, circumferential taping of the fingers with athletic tape may augment the annular connective tissue pulleys and help prevent injury. The long-term consequences of frequent climbing and training are not known, and climbers often wonder if they will develop arthritis because of these activities [22]. Bollen and Wright [23] have examined radiographic changes in the hands of rock climbers and have found some unique changes not seen in controls. These changes include subchondral cysts, cortical thickening, and scalloping of the necks of the proximal phalanges at the site of attachment of the A2 pulley. Fourteen of the 36 climbers studied had osteophytes or bony spurs. The authors concluded that these findings are worrisome for the development of osteoarthritis among climbers [23]. Heuck et al also reported "hypertrophic changes in the muscles, tendons, ligaments and bones of top-level rock climbers" seen on magnetic resonance images of hands and wrists [24]. Rock climbing is a vigorous and rewarding activity. As the number of climbers increases and standards become more demanding, healthcare providers will be called upon more frequently to provide treatment and guidance when injuries occur. Familiarity with these injuries and with the sport of climbing will help providers develop rapport with their patients and improve compliance with therapy.

Paige, Fiore, and Houston References 1. KPMG Peat Marwick LLP. 1997 State ofthe Industry Report. Boulder: Outdoor Recreation Coalition of America and the Sporting Goods Manufacturers Association, 1997.

2. Addiss DG, Baker SP. Mountaineering and rock-climbing injuries in the US national parks. Ann Emerg Med. 1989;18: 975-979. 3. McLennan JG, Ungersma J. Mountaineering accidents in the Sierra Nevada. Am J Sports Med. 1983;11:160-163. 4. Schussman LC, Lutz D. Mountaineering and rock-climbing accidents. Physician Sportsmed. 1982;10:53-61. 5. Bowie WS, Hunt TK, Allen HA. Rock-climbing injuries in Yosemite National Park. West J Med. 1988;149:172-177. 6. Bannister P, Foster P. Upper limb injuries associated with rock climbing. Br J Sports Med. 1986;20:55. 7. Bollen SR. Injury to the A2 pulley in rock climbers. J Hand Surg. 1990;15B:268-270. 8. Cole AT. Fingertip injuries in rock climbers. Br J Sports Med. 1990;24:14. 9. Lewis RA, Shea OF, Shea KG. Acute carpal tuunel syndrome, wrist stress during a major climb. Physician Sportsmed 1993; 21:103-108. 10. Moutet F, Guinard D, Gerard P, Mugnier e. Subcutaneous rupture of long finger flexor pulleys in rock climbers: 12 case reports. Ann Chir Main Memb Super. 1993;12:182-188. Abstract. 11. Shea KG, Shea OF, Meals RA. Manual demands and consequences of rock climbing. J Hand Surg [Am]. 1992;17: 200-205. 12. Young CC, Raasch WG. A stress fracture of the phalanx from rock climbing: A case report. J Wild Med. 1994;5:413-416. 13. Bollen SR. Soft tissue injury in extreme rock climbers. Br J Sports Med 1988;22:145-148.

14. Bollen SR. Upper limb injuries in elite rock climbers. JR Coll Surg Edinb. 1990;35s:18-20. 15. Bollen SR, Gunson CK. Hand injuries in competition climbers. Br J Sports Med. 1990;24:16--18. 16. Largiader U, Oelz O. An analysis of overstrain injuries in rock climbing. Schweiz Z Sportsmed. 1993;41:107-114. 17. Limb D. Injuries on British climbing walls. Br J Sports Med. 1995;29:168-170. 18. Robinson M. Snap, crackle, pop. Climbing. 1993;138:141150. 19. Humphries D. Injury rates in rock climbers. J Wild Med. 1993;4:281-285. 20. Jones D. Injury survey report. Rock Ice. 1990;36:52-54. 21. Haas IC, Meyers Me. Rock climbing injuries. Sports Med. 1995;20:199-205. 22. MacDonald D. Crimp now, pay later: Can climbing give you arthritis? Rock Ice. 1995;67:32-35. 23. Bollen SR, Wright V. Radiographic changes in the hands of rock climbers. Br J Sports Med. 1994;28:185-186. 24. Heuck A, Hochholzer T, Keinath C. MRl of the hand and wrist of sport climbers: Imaging of injuries and consequences of stress overload. Radiologue. 1992;32:248-254. Abstract.

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Injury in rock climbing

Appendix A: Survey Questions 1) Have you been injured while climbing on rock or in a climbing gym during the last 5 years? [ ] Yes (please continue with question 2) (one injury per form please) [ ] No (please go to question lIon back)

2) Did your injury take place on a traditional climb or on a

sport climb? (please choose one) [ ] Traditional climb (a climb where the leader places most of the protection while leading or on which widely spaced bolts protect slab climbing) [ ] Sport climb (a climb where the leader is primarily protected by closely spaced bolts, or any climb on an artificial surface) [ ] Bouldering 3) Did your injury take place on real rock or on an artificial surface? [ ] Real rock [ ] Artificial 4) Which one of the following best describes your activity when the injury occurred? [ ] Leading [ ] Soloing [ ] Bouldering [ J On top rope or following [ J Belaying 5) How much time off from climbing did you take as a result of this injury? [ ] None [ ] Less than 1 week [ J Less than 1 month [ J Greater than 1 month 6) Please indicate the partes) of your body that was injured. [ ] Neck [ J Head ( ] Lower back [ J Upper back [ J Left rib [ J Right rib [ ] Left hip [ J Pelvis [ J Right hip [ J Left thigh [ ] Right thigh [ J Left knee [ ] Left shin [ J Right knee [ ] Left ankle [ ] Right shin [ ] Left foot [ ] Right ankle [ ] Right foot [ J Left shoulder [ ] Right shoulder [ ] Left upper arm [ J Right upper arm [ J Left elbow [ ] Left forearm [ ] Right elbow [ J Left wrist [ J Right forearm [ J Right wrist [ J Left hand: [ ] thumb [ J Right hand: [ ] thumb [ J index [ ] index [ J middle [ J middle [ J ring ( J ring [ J little t ] little

7) What was the cause of this injury? (may check more than one) [ ] Falling [ J Something falling on you [ J Stress on a joint while attempting a move [ ] Other (please describe) 8) Do you feel that overtraining may have contributed to this injury? [ ] Yes [ J No 9) Did you seek medical attention for this injury?

[ ] Yes [ J No

10) What was the outcome of this injury? [ ] Complete recovery with no related problems [ J Good recovery but some problems (please describe below) [ J Poor outcome (please describe below) 11) Please indicate the average number of days on which you climb over a I-year period. [ ] 5-7 d/wk [ ] 3-5 d/wk [ J 1-3 d/wk [ J 1-3 d/mo [ ] Less than 1 d/mo 12) Of the days above, how often are you climbing/training on real rock? [ ] 5-7 d/wk [ J 3-5 d/wk [ J 1-3 d/wk [ J 1-3 d/mo [ ] Less than 1 d/mo [ ] Never 13) How often on artificial surfaces? [ ] 5-7 d/wk [ J 3-5 d/wk [ J 1-3 d/wk [ J 1-3 d/mo [ J Less than 1 d/mo [ J Never

14) Please indicate your maximum climbing ability. [ J 5.00-5.7 [ J 5.12[ J 5.8 [ J 5.12+ ( J 5.9 ( J 5.13[ J 5.10[ J 5.13+ [ J 5.10+ [ ] 5.14[ J 5.11[ J 5.14+ [J5.11+ 15) Please indicate: Your age: Sex: (

1 Male

Years climbing:

[ J Female