Manual demands and consequences of rock climbing Types of rock climbing, hand-grip techniques, and training practices used by rock climbers are described. A survey was completed by 46 climbers. Three fourths of the climbers reported a climbing-related injury; of these injured climbers, almost one half reported a hand or wrist injury. More than half of the injured climbers had been treated by a physician for their injury. More than half of all climbers reported distal interphalangeal or proximal interphalangeal joint pain while climbing. Case reports of three climbers with acute hand injuries are presented to illustrate the minimal effects of their residual deficits on their climbing abilities. A wider understanding of the manual aspects of rock climbing and an awareness of the patterns and incidence of injuries in this sport will facilitate prevention, treatment, and rehabilitation. (J HANDSURC 1992;17A:200-5.)

Kevin G. Shea, Los Angeles,

Human

MD, Owen F. Shea, BA, and Roy A. Meals, MD,

Calif.

beings evolved

from aboreal creatures that spent thousands of years in trees aided by opposable thumbs for gripping. Now, for sport, people again lift themselves off the ground as rock climbing continues to gain in popularity. The climber’s hands are the tools for hanging on ledges as shallow as 5 mm and for locking into cracks of varying dimensions. Great forces are transmitted through the tissues of the hands, and climbing-induced injuries tend to be chronic because of repetitive use of the holds and because of many climbers’ unwillingness to rest adequately. Although reduced function may not be noted on the routine physical examination, minor injuries or disabilities can seriously compromise the hand’s use as a climbing tool and severely reduce the climber’s overall ability and security. This article introduces medical personnel to the manual demands and consequences of rock climbing.

From the Division of Orthopaedic icine, Los Angeles, Calif. Received for publication July 18, 1991.

Oct.

Surgery,

UCLA School of Med-

10, 1990; accepted

in revised form

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Roy A. Meals, MD, 100 UCLA Medical Suite 305, Los Angeles, CA 90024-6970. 311133282

200

THE JOURNAL

OF HAND

SURGERY

Plaza,

Terminology Bouldering is climbing on large rocks; it is usually done within 5 m of the ground. Bouldering allows the climber to develop strength and to practice difficult maneuvers without risk of serious injury. This type of climbing tends to be very stressful on the hands because the climber may repeatedly attempt very difficult movements. In faceclimbing the climber uses small, often unapparent, knobs, edges, pockets, and flakes on bare rock faces for hand- and footholds; in extreme cases, this is done hundreds of meters off the ground. Buildering involves climbing on office towers and other manmade structures. Bouldering, buildering, and climbing involve the use of four basic grip techniques. The open grip (Fig. 1) is used on large handholds. Frequently, holds that begin as open grips become cling grips (Fig. 2) as the climber pulls and then pushes the body upward, the shoulder moving above the hand. The distal interphalangeal joint (DIP) now becomes hyperextended as the climber exerts downward force on the hold to push the body higher. The physical characteristics of most climbing obstacles (either manmade or natural) necessitate frequent use of the cling grip. The pocket grip (Fig. 3) involves the insertion of one or two fingers into a small hole; this is an extremely stressful maneuver because the flexor tendons of one or two fingers hold much, if not all, of the climber’s body weight. The pinch grip is used when a projecting hold is squeezed between the thumb and fingers.

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Fig. 1. DIP joints are held in some degree of Aexion during open grip

Crack climbing uses the fingers, hands, and feet as wedges in cracks of varying widths (Fig. 4). Crack climbing often requires less finger flexor strain than face climbing because the fingers are held into the crack by wedging and twisting them until they are locked into the crack. Torque on the finger joints can be very high. Digital avulsion amputations are a recognized consequence of crack climbing. Frequent sustained positions of wrist and finger flexion predispose to carpal tunnel syndrome. In addition to being very abrasive to the skin, crack climbing can irritate the extensor tendons because of sparse padding between the tendons and the rock. Hypertrophic scar tissue may form on the dorsal surface of the hand from frequent crack climbing. Some climbers wear thin rubber pads on the dorsal surfaces of the fingers and hands to protect these areas during crack climbing. Gobies are rock-induced skin abrasions and are commonly observed on the fingers and dorsal surfaces of the hands (Fig. 5). The physician can roughly gauge the amount of climbing a person does by inspection of these areas. Gloves are not used during climbing because they interfere with tactile sensation and prevent secure handholds. Climbing ability is quantitated by the Yosemite Decimal S_ysrem (YDS). Climbs rated 5.1, 5.2, . . . , 5.8 are for beginners; 5.9 and 5.10 are for intermediate; 5.11 are for advanced; 5.12, 5.13, and 5.14 are for expert climbers. YDS leading abiliry refers to the rating

Table I. Profile of surveyed

climbers

Average age Average number of years of climbing Average number of days of climbing or bouldering per year Percent seen by physician for climbing-related injury Percent injured while climbing Percent with hand or wrist injury from climbing Percent reporting DIP and/or PIP pain with climbing Average number of painful joints per climber Percent using anti-inflammatory medication due to climbing injury

(n = 46) 26 ir II 8k7 118 t 37 58% 74% 48% 547r 2.1 t 0.7 58%

of the climb that a climber is capable of leading; the YDS follow abilip refers to the rating of the climb in which a climber is capable of following another climber who leads the ascent. In addition to boulders, buildings, and natural walls, climbers use man-made walls and training boards. These constructions have different-sized knobs, pockets, and ledges designed to simulate natural rock formations. Climbers also train by doing cling grip fingertip pull-ups on door jambs or training boards. An extreme exercise is performing one- and two-finger pull-ups. ’

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with the cling grip, most commonly in the DIP and PIP joints of the index and long fingers; these climbers reported an average of two painful finger joints while climbing (Table I). More than half of the climbers had seen a physician about a climbing-related injury, and more than half had used anti-inflammatory medication for pain relief. Half of the climbers continued to climb while injured, and half responded that they would continue to climb even if a physician told them that continued climbing would produce permanent damage in their hands. A third of the respondents using training boards reported that the board resulted in some type of finger injury; most of these injuries resulted from repetitive fingertip pull-ups. Case reports

Fig. 2. DIP joints are hyperextended during cling grip.

Materials and methods Forty-six climbers, representing a wide range of abilities from beginner to expert, were surveyed by questionnaire. The survey contained 60 questions regarding

various aspects of climbing, training, injuries, and number of days of climbing and bouldering per year. It included drawings of the hands and of climbing holds; the use of these drawings allowed the climbers to indicate which joints were painful during climbing and which climbing holds caused pain. Three climber-patients who had been treated by one of us (R. A. M.) for acute hand injuries were interviewed to ascertain the effect of their residual deficits on their climbing ability. Results Of the respondents, there were 8 beginner, 20 intermediate, 11 advanced, and 7 expert climbers. The climbers averaged 118 days per year of climbing and bouldering. Three fourths (35 of 46) reported a climbing-related injury, and almost one half of the injured climbers (17 of 35) reported an injury to the hand or wrist. Fifty-four percent of the climbers reported pain

Case 1. A 15year-old right-handed student sustained a home chemistry blast injury to the face and left palm. The ring finger was blown completely off, and the long finger was stripped of skin and neurovascular bundles over its proximal segment. Vein grafting restored circulation to the long finger, and nerve grafts harvested from the ring finger were used to span the defects in the long finger. The fourth metacarpal base was removed, and the fifth ray was transposed laterally. Split-thickness skin grafting covered the exposed areas in the palm and the base of the long finger. By 13 months after injury the patient had recovered protective sensation and full active motion, except for a 20-degree DIP extensor lag in his long finger. Eighteen months after the injury he reported difficulty in using his left hand for the cling grip while climbing and difficulty in manipulating rock-climbing equipment with his left hand. Although his overall climbing ability had increased since the injury, he thought that this injury had considerably limited his improvement. He reported that he must rely more on his right hand for difficult maneuvers. Before the injury, his YDS lead and follow abilities were 5.6. Eighteen months after the accident, his YDS lead ability was 5.8, and his follow ability was 5.9. Case 2. A 4%year-old man ruptured the primary repair of a frayed flexor digitorum profundus laceration to his dominant right index finger 3 weeks after surgery. Over the ensuing 10 months he recovered full active PIP joint motion but noted a change in his lead climbing ability from 5.9 to 5.7 and in his ability to follow from 5.10 to 5.9. He was not disabled from other activities. After a thorough discussion of the alternatives and risks, he chose to undergo two-stage grafting of the flexor digitorum profundus tendon. Twenty-five degrees of active DIP joint motion was restored, and PIP joint motion remained normal. Two years after the tendon reconstruction the patient reported that his finger was totally functional. His lead ability was 5.9 and his follow ability was 5.10. He thought that this injury had limited his improvement as a climber. Case 3. A 21-year climber sustained a crush injury to her right hand while shielding her head from a falling rock during a night climb. She remained on the rock until she was evacuated by helicopter at dawn. Radiographs revealed an outertable skull fracture and an open fracture of the middle phalanx

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Fig. 3. Pocket grip puts great strain on flexor tendons.

of the right ring finger. At surgery a scalp laceration was closed, the phalanx fracture was pinned, and the frayed dorsal tendon mechanism was repaired. When contacted 6 years later, the patient had no sensation distal to the old fracture site, and her DIP joint was stiff in full extension. She reported no impairment in her climbing ability from this injury. Before the injury, her lead ability was 5.8 and her follow ability was 5.9. At follow-up, she reported lead and follow abilities of 5.10 and 5.11, respectively.

Discussion To many climbers, they have developed

the sport the necessary

is an obsession;

once

upper body strength,

they are loath to cut back on their training despite acute injuries or aching joints. Previous studies have analyzed injuries secondary to falls and response to high altitude.‘-6 A recent survey of injuries of 460 climbers indicated that overuse injuries are more common than acute injuries (usually due to a fall).’ In our survey, approximately one half of the climbers reported DIP and/ or PIP pain with climbing. The cling grip, which places great strain of the fingertips, tendons, and flexor pulleys, was reported to be the most painful grip. Frequently, climbers will place their full body weight on one or two fingers while using the cling grip or pocket grip. Climbers commonly wrap tape around the proximal and middle phalanges to support the flexor tendons during training and actual climbing. Our survey and others show that hand and wrist injuries are the most commonly reported injuries, ac-

Fig. 4. Crack climbing mechanically rock.

locks appendage

into

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. Fig. 5. Gobies are rock-induced skin abrasions

counting for about 50%. There are several types of hand injuries that frequently occur in rock climbing: l Soft tissue injury to the fingertips is the most common hand injury. Virtually all climbers have experienced this injury, which is the result of a combination of severe and prolonged pressure and abrasion to the fingertips.’ l Digital avulsion injuries at the DIP or PIP have been observed in crack climbing. This occurs when a climber slips with one or two fingers wedged into narrow cracks. Sprains and tears of the collateral ligaments of the PIP joint also occur with crack climbing. l Injuries to the A2 pulley of the flexor sheath are common occurrences; in a recent study, which included a survey and examination of 67 professional climbers, 28 (42%) had evidence of this injury.’ This injury may be acute, or it may develop in a chronic, progressive manner. It is most commonly seen in the long and ring fingers, indicating the powerful forces they resist. . A fixed flexion deformity of the PIP is a common finding, usually involving the ring finger.” . Ruptures of the flexor digitorum superflcialis tendon at its insertion into the base of the middle phalanx have been reported. The cling grip places great stress on this tendon.” Tendon nodules of

the flexor digitorum superficialis, suggesting extreme strain, have been described in climbers.’ Sprains of the ulnar collateral ligament of the first metacarpophalangeal joint are associated with the pinch grip. lo

Carpal tunnel syndrome has been observed in rock climbers. One climber reported this condition after several days of crack climbing which required repetitive, sustained forced flexion of his wrist. An understanding of the manual demands of rock climbing leads to several recommendations for the rock climber. Climbers need to be informed of possible injuries, especially those associated with climbing maneuvers that place much if not all of the body weight on one or two fingers. Crack climbing involves a high risk of avulsion injuries, especially if the climber falls with one or two fingers wedged into a crack. Climbers should be counseled that repeated fingertip pull-ups are associated with injuries. Many climbers circumferentially tape their flexor tendons at the proximal and even the middle phalanges. Whether this is an effective means of reducing flexor tendon and pulley injuries is not known, but many climbers are ardent supporters of this practice. A major concern of climbers with hand injuries, sustained either while climbing or otherwise, is the effect the injury will have on their future climbing. In each

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of the cases reported here, the climbers were able to resume climbing at a level equal to their ability before their injury; two of the three climbers continued to improve their climbing ability despite their injuries. Some indication of the relative insignificance of single digits in climbing can be ascertained by the functional changes noted after acute injuries. Climbers rely mostly on the index and long fingers for tactile feedback and strength; the ring finger is also important, but its function in climbing is more of strength than of tactile feedback. As with other activities, alternate patterns can substitute for localized dysfunction, particularly when the user is highly motivated.” Compared with many other activities, in climbing the thumb has relatively less importance than the longer digits. Although the physician may not be able to persuade injured climbers to rest until their injuries completely heal, an awareness of the strains these persons place on their hands must serve as a starting point for improvement in methods of training, treatment, and rehabilitation. “-I’ REFERENCES 1. Robbins R. Basic rockcraft. Glendale, Calif: La Siesta Press, 1971. 2. Ferris BG. Mountain-climbing accidents in the United States. N Engl J Med 1963;268:430-1.

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3. Schussman 4. 5.

6.

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LC, Lutz LJ. Mountaineering and rockclimbing accidents. Physician Sportsmed 1982;10:53-8. McLennan JG, Ungersma J. Mountaineering accidents in the Sierra Nevada. Am J Sports Med 1982;11:160-3. Wilson R, Mills WJ Jr, Rogers DR, et al. Death on Denali: fatalities among climbers in Mount McKinley National Park from 1903 to 1976; analysis of injuries. illnesses, and rescues in 1976. West J Med 1978;128: 471-6. Bowie WS, Hunt TK, Allen HA Jr. Rock-climbing injuries in Yosemite National Park. West 3 Med 1988;149:172-7. Jones D, et al. Injuries survey report. Rock Ice 1990;36(March-April):52-4. Cole A. Fingertip injuries in rock climbers. Br J Sports Med 1990;24: 14. Bollen S. Hand injuries in competition climbers. Br J Sports Med 1990;24: 15-7. Bollen S. Soft tissue injuries in extreme rock climbers. Br J Sports Med 1988;22:145-7. Brown P. Less than ten: surgeons with amputated fingers. J HAND SIJRG 1982:7:31-7. O’Shea T. Exercise prescription for mountain climbing. Physician Sportsmed 1976;4:38-44. Editorial. Medical aspects of mountain climbing. Physician Sportsmed 1977:5:45-68. Robinson M. Get a grip on injury prevention and treatment. Climbing 1988:109:108-13.

Manual demands and consequences of rock climbing.

Types of rock climbing, hand-grip techniques, and training practices used by rock climbers are described. A survey was completed by 46 climbers. Three...
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