Climbers' hands: injuries, treatment and prevention. Prevention is better than cure!
By Tim Halsey
Introduction: climbing styles
Climbing has experienced a huge growth in popularity recently with the exploits of Alex Honnold in the film Free Solo, numerous YouTube videos and the inclusion of climbing as an Olympic sport.
I live in Hathersage in the Peak District, close to Stanage Edge – the longest inland cliff in the UK and home to many climbing developments since the 1920s onwards. Rock climbing has progressed massively since and includes a wide array of sub-genres including bouldering, free climbing, roped climbing (‘trad’), sport climbing (bolts), via ferrata, aid climbing, mixed climbing and ice climbing.
Indoor climbing gyms initially developed as training facilities for outdoor adventures, but have developed in their own right to the point where some climbers only ever climb indoors and get extremely strong without ever using a rope or touching rock.
Lead climbing requires a rope and a belay partner. The rope is temporarily attached to the rock by the climber to protect against a fall and the ‘pro’ is either taken with you, leaving nothing behind (ethically pure ‘trad’ climbing) or relying on bolts pre-placed in the rock for safety (‘sport climbing’, which ironically is not considered very ‘sporting’ in purist circles). Competition climbing includes speed climbing, lead climbing and bouldering (climbing without a rope).
Climbing holds: open palm/crimp/half-crimp
Essentially climbing up a rock involves holding on to support yourself or to pull yourself up. A lot of the work is actually done with your legs and core, it is not just a string of pull-ups. But the way that the rock is held has an impact on the type of injuries sustained and may have an impact on injury prevention.
Finger flexion involves a complex interplay of intrinsic and extrinsic muscles, but we know that flexor digitorum superficialis (FDS) flexes the proximal interphalangeal joint (PIPJ) and the flexor digitorum profundus (FDP) flexes the distal interphalangeal joint (DIPJ). Three main types of grip are illustrated:
Figure 1: Climbing holds
A crimped grip involves significant PIPJ flexion, with a neutral DIPJ. A full crimp goes further, often with deep PIPJ flexion, hyperextension of the DIPJ, and pressure from the thumb on top of the index and middle DIPJs to reinforce the hold. An open palm grip takes some getting used to, as it can feel less secure, but involves both PIP and DIPJ flexion. The type of holds available do sometimes dictate how they are held. Gritstone in the Peak District classically has sloping holds, which require a more open palm technique, but there is an element of deliberate choice in how the climber holds on.
Pulleys
The digital pulley system serves to hold the flexor tendons close to the phalanges and is made of a series of rings (annular structures) numbered from A1-A5: A1 at the level of the MCPJ, A3 at the PIPJ and A5 at the DIPJ, with the crucial A2 and A4 in-between. These are important to prevent bowstringing. In a crimped position, there is a significant vector in towards the rock from the insertion of FDS. If the force exceeds the pulley strength, then a pulley rupture occurs, sometimes with an audible pop. These can occur when a foot slips, but sometimes are simply a case of pulling more force through the system than it is designed to cope with.
Figure 2: Pulley injury mechanism
Many climbers film themselves to help with their training and this has led to a number of pulley injuries being captured live and then shared on the internet https://vimeo.com/141411517 (best avoided if squeamish!).
Pulley injury categorisation and treatment algorithm
Climbers will often intuitively rest their fingers after a pulley injury, but it can be hard to know how long to rest for. The following algorithm developed by Volker Schöffl is helpful, but does depend on ultrasound to confirm diagnosis, which is very user-dependant.
Dave MacLeod has been climbing at the very highest level for several years and at one point put up the world’s hardest route (E13). He has a physiology degree, writes well and puts out a regular series of videos on climbing technique for anyone interested (www.davemacleod.com). He writes: “I used to be one of those who crimped too much and averaged about three serious pulley injuries a year for five years… Since I was forced to get strong open-handed, I have had one very minor pulley tweak… in the past five years”