Ep 174: SPORTS CORNER: The ins and outs of climbing, with Dr Carrie Cooper

[00:00:00] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research

[00:00:10] to quality practice. I'm Claire Ardern, the editor-in-chief of the Journal of Orthopaedic

[00:00:15] and Sports Physical Therapy. It's great to have you listening today.

[00:00:22] This week on JOSPT Insights we are here with another sports corner series. This week

[00:00:27] we are covering rock climbing with Dr. Kerry Cooper. I am very excited about this one as

[00:00:32] a mediocre to poor climber myself. I have a lot to learn not only about climbing but

[00:00:36] rehabilitating these injuries. Dr. Kerry Cooper is a doctor of physical therapy specializing

[00:00:41] in climbing injuries based in Salt Lake City, Utah. She has over 30 years of climbing

[00:00:46] experience underneath her belt along with multiple publications related directly to rehabilitating

[00:00:51] climbers. We will have the descriptions of those in the show notes so check them

[00:00:55] out. She also works as an educator and a consultant to international climbing teams,

[00:00:59] US national team members as well as other elite level climbers and outdoor athletes.

[00:01:04] My name is Dan Chapman. I'm a US-based physical therapist and owner of Chapman PT in Baltimore,

[00:01:08] Maryland. And I'm Chelsea Kuhlman, a physical therapist

[00:01:11] and athletic trainer at Stanford University Athletics.

[00:01:13] Dr. Cooper, thank you so much for joining us on JOSPT Insights. As I mentioned,

[00:01:20] I'm a climber myself and I'm very much looking forward to this.

[00:01:23] Thank you so much for having me. It's an honor.

[00:01:25] Oh, well the honor definitely goes both ways. Before we get started though, can you just

[00:01:30] give us a 50,000 foot view for those PT's listening who don't know much about rock

[00:01:35] climbing? What should they know?

[00:01:36] Rock climbing is a fairly young sport. This is rock climbing's second Olympics. It is

[00:01:46] comprised of several different individual disciplines. You can think of it a little bit

[00:01:52] like running. So there are sprinters, there are short distance runners, there are long distance

[00:01:57] marathon runners and the rock climbing equivalent to that would be bouldering sport climbing

[00:02:05] and trad climbing. And these disciplines are basically defined by their type of protection

[00:02:11] that's used. You can further divide those into indoor and outdoor climbing. From a movement

[00:02:20] standpoint, there is a lot of crossover and especially from the kinds of demands that are

[00:02:25] put on the body. But in practice, they feel very different depending on your level of fear

[00:02:34] and comfort with gear. From an injury perspective, there are trends that we are starting to see

[00:02:41] that go with these subdivisions. If we speak about rock climbing in general, there are

[00:02:46] absolutely a lot of like I said, there's crossover and movement. So there are crossover

[00:02:53] in the injuries that we see. What are these demands? What is required from the climber

[00:03:00] to be able to complete these tasks? People and I'm going to assume here that people are

[00:03:05] thinking of climbing as an upper extremity sport, which is true. We certainly use our hands

[00:03:12] differently than any other sport or activity on the planet basically. But really climbing is a

[00:03:21] points of contact sport. So what that means is you have three points of contact that you're

[00:03:28] hoping are on the wall while you are advancing a fourth. And there is dynamicism with those movement

[00:03:36] requirements. There's a ton of tension dispersal that happens through the body in order to keep

[00:03:44] those points of contact. So if we want to draw some comparisons with other sports, maybe you'll

[00:03:53] think of gymnastics when it comes to the dynamicism, jujitsu, we get ourselves in really strange

[00:04:02] positions. And even baseball, mostly because of the types of shoulder injuries that we see,

[00:04:09] we are required to have a ton of shoulder range of motion. And also rugby, because

[00:04:17] it's a high impact sport sometimes. Oh, okay, wait, is it supposed to be a high impact sport?

[00:04:23] Or is that when things go wrong? Both actually. So high impact meaning that you can fall

[00:04:31] in bouldering and I fall all the time. Boulders, we are champion-fallers. Occasionally it does

[00:04:39] go wrong. And so you have to be able to handle that impact. And sometimes you could land at

[00:04:46] a sideways angle. And nine times out of 10, it's fine. But that one time that you're a little bit

[00:04:53] tired, you can't handle the impact. The same thing goes if you are leaping from one hold to another,

[00:05:01] so you're catching it with maybe one arm. And say you've only got your distal fingers that

[00:05:07] you're dangling off of. That's a ton of tension through your shoulder, your clavicle,

[00:05:14] your neck. There's a lot that's going on there that that's where we kind of draw those comparisons

[00:05:21] to rugby. We get clavicle injuries. We get like SCM dislocations and shoulder dislocations, full

[00:05:28] dislocations. So it is high impact, but mostly we can manage it. So a lot of climbing is managing

[00:05:38] the forces that are being put through your body. That reminds me a little bit of wrestling almost

[00:05:43] too. Like a ton of range of motion, but then also you are meeting the forces put on you. So it's also

[00:05:49] a ton of strength at all of those ranges of motion, which again is that like gymnastics portion of it

[00:05:54] as well. So you said range of motion of the shoulders. Anywhere else that like is is the most

[00:06:01] important to have either range or strength in a certain way? Well, we need a lot of strength

[00:06:07] in our hips. We tend to have more knee motion. So the muscles that sort of hug the knee and allow

[00:06:17] for that stability to happen while you're putting force through, say the side of your foot, while

[00:06:23] your hip, knee, ankle are all externally rotated and flexed and you're trying to drive

[00:06:29] through that combination of joints. There is a lot of strength that needs to happen

[00:06:38] in those areas as well as rotator cuff, the deltoid tricep, lat bicep. I mean, climbers tend to,

[00:06:48] we have not actually huge muscles, but we're really strong. Yeah, I think also

[00:06:56] not only a rock climber is really strong, but something that surprised me a lot too is

[00:07:01] I mean it differs a little bit depending on, you know, if you're doing more of the like endurance

[00:07:05] climbing or the bouldering. But regardless, you need to have a wide range of endurance,

[00:07:10] but also rate of force development and power, right? The ability and then eccentric strength

[00:07:14] as well. What would you say are like the top three to five injuries that you see

[00:07:20] in climbers that come to see you? I hate to hone in on the hand,

[00:07:24] but I'm going to mention it really quick because those are the top three injuries that we see

[00:07:30] are actually all in the hand. So they are flexor pulley strains and ruptures, that's flexor

[00:07:38] tendinopathies and joint related injuries. Aside from the hand, shoulder slap tears,

[00:07:48] but also less severe shoulder pathologies. So most of the injuries that we see in the clinic

[00:07:58] are not severe, they're actually overuse injuries. And so they're not a full slap tear or they are

[00:08:05] a asymptomatic slap tear. It's something else that's going on. Also, we see knee and meniscal

[00:08:14] injury. So those are basically, I would say the top three areas.

[00:08:19] And so the meniscus is that falling or is that just like torquing that knee in those

[00:08:23] weird positions trying to produce force? So here's where we get into some of the emerging trends.

[00:08:29] We are getting a lot more meniscal tears from heel hooking and when I say heel hook,

[00:08:36] I'm going to describe it a little bit. It's where you have a hold, you know,

[00:08:40] you can imagine a climbing hold and you stick the side of your foot on it. So I'm talking about

[00:08:45] the outside of your foot and your heel is mostly on it. Like that is the point of your foot that

[00:08:51] you're mainly putting the pressure on. And then you're going to use that heel like a hand

[00:08:56] and you're going to try to pull yourself upward. So regardless of what direction your knee is

[00:09:02] facing, it could be facing directly up towards the ceiling. It could be towards the door over

[00:09:09] in the corner, way far to the right of you. It can really be located anywhere. But as you start to

[00:09:15] put that pressure on your heel and drive your body upwards, sideways, you can rest like that.

[00:09:24] When the muscles that help to support the stability of that position start to fatigue,

[00:09:30] we lean into those inert structures. And that's when we get the injuries.

[00:09:34] Some of the things that lead to the most success in a climber are really what leads to

[00:09:39] can lead to failures as well. So is that kind of what you're alluring, like alluding to there?

[00:09:42] Like your ability to kind of create these force and these funky positions, but then once

[00:09:46] those stabilized structures are fatigued, it goes, that applies to the shoulder, I'm guessing.

[00:09:51] How does that apply to the hand? I would say more in the joints of the hand in that case.

[00:09:56] So as humans, we tend to grab things with our thumb. It's like a sideways hand position

[00:10:02] where you're like using your, your palm and your thumb and you're gripping with your fingers.

[00:10:07] Think about like grabbing a cup, you know, and I'm going to try to describe this to your listeners

[00:10:13] because it's very visual. Imagine that you're grabbing that cup and then start to put pressure on

[00:10:19] your fingertips. You notice that there's a force that's produced through the system.

[00:10:26] And say you add like, I don't know, half your body weight to that. You start to feel that force.

[00:10:34] It's more of a vertical force coming down through your joints, which creates torque.

[00:10:41] Okay. So we have our common injuries and kind of the demands of the sport. So

[00:10:46] if someone, if a climber is coming into your clinic with any of these injuries or something

[00:10:50] else, what are some key things that clinicians should keep in mind when we're rehabbing

[00:10:55] these athletes? I think the most important rehab concept to consider when treating climbers,

[00:11:02] even if you don't know climbing is that almost any activity can be modified based on the

[00:11:09] limitations of specific injuries. Climbers and I would argue most athletes don't

[00:11:18] respond well to advice to just not climb. They want to know exactly what is your reason behind

[00:11:26] that? How is that going to help them and why is that your primary suggestion for the wellness

[00:11:35] of that person or injury? As a clinician, be curious. Help the climber figure out what

[00:11:41] they can do because they are probably telling you what they can't do already.

[00:11:47] And it's nice to think about or to listen to what an athlete is telling you that they can't do

[00:11:55] because that helps to fill in the gaps of your knowledge. As you say, okay, I can't do a gaston.

[00:12:00] Well, what is a gaston? Show me. And they'll show you a sideways hand position. You go,

[00:12:05] oh, that is a lot of internal rotation on the shoulder. I get that. They want to talk about

[00:12:11] rock climbing? Let them. And I would say aside from that, climbers are really strong in their big

[00:12:18] muscles. So they can make your tests look normal. But if they're coming to see you,

[00:12:25] there's definitely something wrong. And you've got to kind of parse that out a little bit.

[00:12:30] And most of the time it comes from those smaller intrinsic or stabilizing muscles.

[00:12:36] And if you isolate out the rotator cuff, for example, there will be imbalance. The upper trap

[00:12:44] will take over immediately. You'll notice that it just gets huge. And then suddenly you're like,

[00:12:50] oh, wait a minute, let me really hone in on these tiny little things because these guys are

[00:12:55] really strong and they can cheat. They'll cheat all your tests.

[00:13:00] It seems to me that there's a couple of different climbers that come into the clinic.

[00:13:03] You have the overuse injuries, the people that got really into climbing. They never climbed

[00:13:07] before. They're climbing three, four, five days a week and then six weeks later, they're

[00:13:12] by substantive and screaming. And that's one category of climber that's going to be

[00:13:17] coming into your clinic. But then you also have the really advanced level climbers

[00:13:21] that are getting into these wild positions and producing a ton of force in these crazy

[00:13:25] positions on the wall. And I can imagine that before we get them back on the wall,

[00:13:30] before they're actually really ready to climb again, we need to make sure that they can

[00:13:33] produce forces in these wild positions. But can you really talk about the,

[00:13:38] how important it is to dial in the easy movements, the simple movements and find out where these

[00:13:44] deficits really lie? I would argue that it's when you isolate out these little things,

[00:13:51] that's when you find the weaknesses. So that sideline external rotation,

[00:13:57] if you put them in the perfect position and you ask them to hold it there,

[00:14:02] it's like the hardest thing on the planet. But if they're allowed to show up, be like,

[00:14:07] I can put my arm out here, I can grab onto this, they're going to recruit all kinds of other

[00:14:11] muscles. But you're going to lose those tiny little nuances that really need to be online

[00:14:18] for them to be able to do these hard movements. And this is for your recreation athlete

[00:14:26] all the way to your elite athlete. I think that's exactly where the difference lies,

[00:14:33] is that usually we don't need to really isolate it out. But in these cases, I think it is prudent.

[00:14:40] You said like modification is key, which we love. And maybe that's modifying a field

[00:14:45] athlete is slightly different than modifying a rock climber. So for those who are less

[00:14:50] used to that, what are some key considerations when you're returning someone to climb? Is there

[00:14:57] a volume component, an intensity component? Is doing a V1, is that going to be worth it

[00:15:03] for someone who's typically on a V10? Something like that. What kind of considerations are

[00:15:08] you making when you're doing a return to climb? Depending on the severity of the injury,

[00:15:13] if you don't know how to appropriately prescribe climbing back into their program,

[00:15:20] it's nice to start with percentages. So say you've got a V6 climber and we'll use for your listeners,

[00:15:28] it's V0 to V17 is the hardest currently. And so you take a V6 climber and they come to you

[00:15:36] with the shoulder pain and they're like, well, can I climb? And say you don't really know,

[00:15:42] but you can think of it as, okay, do you have pain just sitting there? If they have pain just

[00:15:48] sitting there, they probably shouldn't be climbing until they can modify that pain. But then if they

[00:15:54] start out at 0 to 25%, that's a great place to start. At least they can climb and it's educating

[00:16:03] them about maybe what some of their habits have been in the past. Maybe they didn't warm up.

[00:16:08] Maybe they don't know how to warm up. Maybe they only climb a certain level or a certain inclination.

[00:16:16] So start with vertical, start with 0 to 25% of their normal climbing grade and their normal climbing

[00:16:24] time. So if they normally climb for four hours and you're putting them at a 0 to 25%,

[00:16:31] I would recommend not going beyond 45 minutes in that case. It's not a perfect equation.

[00:16:37] It's at least enough for them and for you to start to delineate out exactly, is it a volume problem?

[00:16:46] Is it an intensity problem? Is it a tissue problem? What's the issue here?

[00:16:52] That's really helpful. Typically, a recommendation wouldn't be switched to bouldering or something

[00:16:58] because usually they're in one of their categories. It would be just the percentage of what they were

[00:17:05] in the same category. Is that correct? Correct. Although I would say if someone was really severe

[00:17:11] and this gets into a little bit of nuance of climbing, bouldering as a discipline is graded

[00:17:22] when you start bouldering. It's harder than the easiest sport climbs. So if they tell you,

[00:17:31] no, I don't feel comfortable bouldering right now. Okay, that's fine. Start with some top roping and

[00:17:37] 5'6 to 5'9. A V0 is about an 11A, I think, or a 10D somewhere in there. I've got a cheat sheet for this.

[00:17:49] I'm looking on the spot. It would be fair to say though that like, please correct me if I'm

[00:17:55] wrong on this, that if you have a boulder and you're trying to still get them on the wall,

[00:17:59] bouldering is not in the cards for them, but you're trying to get them back on the wall.

[00:18:02] They might be able to do some lower level top roping, but if you have a top roper

[00:18:06] who cannot really do anything on the wall, you're not going to send them over to do bouldering.

[00:18:10] I think that's fair.

[00:18:12] Carrie, is there anything else that we missed that you really want to impart on the world of

[00:18:15] rehab about climbing? Because you freaking love treating climbers. You love climbing. So

[00:18:20] this is your chance. You know, I think because climbing is so new and we're still

[00:18:25] learning so much about the injuries, just listening and trying to, even if you're not a climber,

[00:18:33] just trying to level with the climber and think stability. Stability, stability, stability.

[00:18:42] Go there first. And then if they're perfectly stable, choose the bigger muscles and test

[00:18:49] those. Talk to the climber about climbing. They would love to tell you what they can

[00:18:53] and can't do right now.

[00:18:55] Do you find in just anecdotally in your experience that proximal weakness, so this is say rotator cuff

[00:19:00] weakness leading to a higher incidence of distal injuries? So someone coming in with a hand injury,

[00:19:06] but you're finding for instance they have a lot of weakness when testing through the shoulder.

[00:19:11] Yeah, absolutely. And the same thing goes with side to side. So if they come in with a shoulder

[00:19:19] injury, what does the other shoulder look like?

[00:19:22] Oh, do you have any ways you recommend people testing hand strength? Different grip strength,

[00:19:26] things like that. With training for climbing, we have these things called edge blocks.

[00:19:32] There are different brands of this and they have different types of hand holds on them.

[00:19:37] And typically they have like a cordillette that you can either hang them from something or,

[00:19:43] you know, push your foot onto it to create tension. I set that up with a like a force.

[00:19:50] A green scale or something? Yeah, exactly. Yeah, green scale. Yeah.

[00:19:53] Yeah, exactly. Usually I don't do it as a strength measurement. I do it as a tolerance measurement.

[00:20:01] So what is their tolerance to load, especially for the hand is how much pressure can they create

[00:20:09] before they actually feel their pain or like right when they start to feel it.

[00:20:14] I do this actually with elbows as well. I've started to apply it to most of the climbing

[00:20:22] injuries that I see because I want to improve that tissue tolerance to load. So it becomes more

[00:20:31] compliant, more accepting of the forces that I really want to put through it.

[00:20:37] That is really great insight because we, I mean, I think most clinics now have some

[00:20:40] way to measure that, whether it is a hand held dynamometer that you press on or a crane scale

[00:20:44] that you pull on. So that can be another way of like not sure how to assess tolerance. That's great.

[00:20:50] Move some numbers behind that. Something I will say if you're going to measure grip strength,

[00:20:55] I think best practice these days is to do it, we call it a half crimp. So it's flexion at the

[00:21:02] PIP joint, roughly mostly extent or like relative neutral at the DIP joint and then relative neutral

[00:21:14] at the MCP joint. So it looks like a little hook and that is a really safe place to train,

[00:21:22] especially for the pulleys. And it's also a safe place to test because where if we're strong

[00:21:28] in a half crimp, you can either create strength through specific exercise in a full crimp or you

[00:21:35] can say, okay, it's really the open hand that's weak. We can draw a lot of information just from

[00:21:43] a half crimp and it's relatively safe to test and to train. It is very hard for me to get

[00:21:48] into that position. Oh my gosh, I'm not a climber. I'm just seeing your listeners could see

[00:21:54] the like hand dance that we've been doing today. Guys, listen to that part again and then try it.

[00:22:01] Like am I? Oh, it's not possible? Your MCP joints are in a little bit too much extension,

[00:22:08] but your right hand was... All I do is manual therapy with these, okay.

[00:22:12] You should have really strong grip strength. Okay, okay, now I'm shamed. All right, I'll

[00:22:17] work on it. Well, Carrie, thank you so much for joining us. This has been awesome.

[00:22:22] I am so excited for people to listen to this and be able to treat climbers better because you're

[00:22:26] right. They do love climbing and they love to tell you about climbing and they also do not

[00:22:30] want to stop climbing. So some great tips on being able to do that for our climbing athletes.

[00:22:36] We really appreciate it. I hope that the clinicians who are listening were able to

[00:22:42] get some nuggets of knowledge. If they have more questions, I would be happy to answer.

[00:22:49] Perfect. So if you do have more questions, please feel free to reach out to Dr. Cooper.

[00:22:53] Thank you so much, Dr. Cooper, for coming on the show. And as always, we want to thank all

[00:22:57] of you for listening to JOSPT Insights. Thanks for listening to this episode of

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