Tendon Pain - Could your diet be a problem?

Since publishing my climbing injuries book Make or Break earlier this year, this is the first important paper released into the scientific field during the year which has really caught my attention. Co-authored by professor Jill Cook (one of the tendon pain research big guns worldwide), it reinforces the idea I put across in Make or Break that looking at tendon injuries simply as ‘overuse’ injuries may at best blinker us to other important causes, and at worse be plain wrong.

In this review, Cook explores the possibility that your cholesterol profile could possibly cause tendon pain. The evidence available shows association, not causation. Nevertheless, we shouldn’t ignore the data. Not only is it known that cholesterol accumulates in tendons, that people with the disease ‘familial hypercholesterolemia’ have much more tendon pain, but several studies show that various cholesterol parameters are associated with tendon pain.

Influences such as this, if causation could be ultimately demonstrated, help to explain the apparently unpredictable individual variability in tendon injury, if you are looking at the problem solely as a result of training errors.

So if we can’t ignore the data, we get to what we should do to improve our cholesterol profile. The paper points out that increased tendon pain is associated with the same cholesterol profile as cardiovascular disease, namely a lack of HDL cholesterol and an excess of LDL and blood triglycerides. Unfortunately, the world of medicine and public health is in a big fat mess when in comes to providing evidence based recommendations for how to improve our cholesterol profile. 

If you want to learn just how messed up the situation is, read Nina’s book. Apart from teaching you a few seriously important lessons about trusting both science and government, it might even save your life if it turns out to be right. No joke. 

Unfortunately the low fat, high carbohydrate diet (as well as the problem of the oils used in processed foods) that sportspeople are still widely recommended to eat may well cause just the bad cholesterol profile we are talking about (low HDL, high LDL, high triglycerides). Diet is not the only input of course.

My personal hunch is that this line of enquiry will continue to yield evidence we should listen to. At a basic level, the idea that human tissue is unbelievably plastic, responding to training with precisely regulated growth and maintenance responses could go so frequently awry simply by doing some training does not add up. It seems likely to me that there are some things missing from the picture. This could be one of those things.

I would urge anyone serious about their tendon health, their sport performance and their long term health to go right back to basics when it comes to diet and nutrition. It’s fair to say that the whole world of nutrition and health has been blown to bits in the past five years, and pieces are still falling back to earth. Meanwhile, some of the medical world and much of the public have yet to notice. And many vested interests are desperately trying to keep it that way. Personally, I have finally wriggled free from the paradigms I learned in University about sports nutrition and stand in a confused state of optimism mixed with distrust and scepticism. The problem is, we can't wait for better evidence - I have to eat something, in two hours time! So what to eat? I’m cautious about publishing my observations on my own diet and performance just yet. I will do when I feel a bit more comfortable and educated about what the hell is going on. But, I will tell you that I feel like I’m on an exciting journey!

Make or Break: Don’t let climbing injuries dictate your success

For the past 4 years or so, I have been working on a book about climbing injuries. It spells out in detail how to treat them once you have them, based on the evidence from high quality scientific research and practice. More importantly, it discusses all the things we do in our climbing routine that cause our future injuries and prolong those we have already caused.

I have titled the book ‘Make or Break’. This is because becoming an expert in understanding the causes and treatments of climbing injuries will be make or break for your climbing career. As Wolfgang Gullich said, “getting strong is easy, getting strong without getting injured is hard”. In my first book, 9 out of 10 climbers make the same mistakes, I suggested that many aspects of training for climbing are not rocket science. Keep showing up, pulling on small holds, pushing the limits of your motivation and learning from others and you will get stronger fingers and get better at climbing.

It will be injuries that will get in the way of your progress, and if you let them, they will dictate how far you get in climbing. The research suggests that nearly all climbers get injured at some point. Finger injuries are most likely, followed by elbows and shoulders. Of course there are countless bits of our anatomy that can break if suitably mistreated. When you get one of these injuries, you need to be the expert, because unfortunately you cannot rely on anyone else to make sure you recover. This is not because doctors and therapists fail to do a good job (although they sometimes do). It is because there is no single source of advice on the vast array of things you must do to make sure you recover well and prevent future injuries. The climbing coaches, physiotherapists, otrhopaedic surgeons etc. that you will see will all give you pieces of the jigsaw puzzle, but it is you who must put them together.

Claire MacLeod dispatching our pre-orders the other night.

During the process of writing the book, I have discovered many pieces of hard scientific information and subtle concepts I wish I’d known when I was 16. They would have saved me so much of the pain and psychological torment of injuries that climbers everywhere share at some point in their career. There are many strands of information in the book. It is a handbook on how to take care of yourself as a lifelong climbing athlete. In this blog post, I will briefly outline three messages that will give you a flavour of what you will find in the book:

1. Tendons don’t like rest, or change.

Surprisingly, sports medicine research still has a lot to learn about tendons and how they heal and respond to training. However, there have been several big steps forward in the research over the past decade or two. The only problem is, new knowledge in sports medicine takes years or even decades to filter through to the advice you receive. Consider the following quote: 

“In general, it takes approximately 17 years to get 14% of research findings adopted into practice. Moreover, only 30–50% of patients receive recommended care, 20–30% receive care that is not needed or that is potentially harmful and 96% may receive care with the absence of evidence of effectiveness.”

I was shocked too when I read that. I was aware through my own experience that the advice I’d been given to recover from my own climbing injuries was often at odds with research I’d read. But to discover the extent of the lag between research findings and advice given to sportspeople is depressing. We only have one life and we cannot afford to receive outdated advice. Unfortunately, the internet hasn’t made the task of unearthing reliable advice any easier. Scientific journals remain hidden to most behind a paywall, while the same poor quality, outdated and non-specific advice drowns out the few reliable sources.

One of the shifts in understanding from the past decade is that slow-onset tendon injuries such as golfer’s elbow do not respond well to complete rest. In fact, it often makes the condition worse. Moreover, many of the adjunct treatments often offered - stretching, massage, ibuprofen may do little to contribute to healing, and only affect pain. Instead, the most promising treatment has been large volumes of exercise of a specific mode (eccentric) and at a level which causes some pain. Much of this seems counterintuitive at first sight, which is why a detailed understanding of what happens in injured tendons is so important. 

Some practitioners in sports medicine are still working to a pre-1990s concept of tendon healing and will advise you to heal your injured tendons by resting them completely. In contrast, modern research has found that the best way to heal injured tendons is to use them, but only in a way that is specific to the nature of the injury. Tendons do not like rest or change. The successful formula is to provide constant stimulus to tendons to maintain their health. But if you want to change that stimulus, such as by training harder, you must do so very carefully, using all the cues from the body that you can listen to.

Section 1 of the book discusses in detail the limitations of the sports medicine industry and how to get the most out of it, and section 4 details the modern understanding of tendon injuries and how to successfully treat them.

2. Know pain, or no gain

Above I hinted at the difference between the pain level and the healing status of an injury - a crucial concept for any sportsperson to understand. Understanding of the nature of pain has been another area of science that has advanced hugely in sports medicine. It is not enough to be able to listen to your body. You need to be able to decode the messages and see the patterns in them. This is both a science and an art.

Climbers need to be able to differentiate between healthy soreness from training and activity, and damage that demands action. They need to be able to take understand how various treatments affect pain from their injuries and what this means for their daily decisions on how much activity to expose them to. They need to understand how many aspects of their environment and psychological state amplify or suppress pain sensations from their daily activities. Pain sensations are an essential measure for climbers to monitor, but without detailed knowledge of how it works, it is very easy to interpret those messages from pain wrongly.

Section 2 of the book is entirely devoted to understanding pain.

3. The luxury of doing sport badly will not last

A young body can withstand a surprising amount of abuse. But the relentlessness of sport and training amplifies the effect of small imbalances or errors, and it doesn’t take long before these accumulate to the point of injury. Balance is the key word here. One area of sports medicine that has come on a fair bit in recent years has been the recognition that athletes need to develop strength in a balanced way, taking care to strengthen muscles on both sides of joints. That is a good development, but it is not enough.

Balancing of the stress imposed by training for climbing needs to come in several other ways too. Matching increases in training intensity with improvements in the quality of rest is one way. Improving technique and the design of the training progression to spread that stress is another. 

Sections 1, 3 and 4 deal with these concepts and the specific details that climbers should be aware of which commonly result in climbing injuries.

Repeated forceful internal rotation of the arm (the right arm on this move) is a big part of climbing. So it is no surprise that the internal rotators of the arm at the shoulder become dominant. You may well get years out of a healthy young shoulder without feeling a thing. But the resulting impingement syndrome affects so many climbers. If you'd rather prevent it, it's not hard to do a little work to keep the shoulder joint working well. And if you are already suffering, you may be able to reverse it quite quickly, unless you've really tried to ignore it for too long!

Maintaining awareness of the foot during hand movements is a core skill in climbing injury awareness. Slipping feet are a important cause of many finger and shoulder injuries. Do your feet slip too often? Do you know what to do when they do slip? Correct your climbing technique and you can push your body a lot harder before it starts to complain.

Finally, there is the psychological challenge of injuries which is hugely underestimated by both climbers and their friends and families. In sections 1 and 5 of the book, I present the idea that we should see the injuries we suffer as a crucial message that something must change in our way of approaching climbing. By seeing the injury as an opportunity to go back to basics, to understand what must change and make that change, we can not only improve our climbing, but enjoy the process rather than endure it.

I hope the book will help many climbers prevent their future injuries or overcome existing ones. You'll find the book in our shop here, dispatching worldwide.

My climbing injuries book is up for pre-order!

Readers of this blog will of course know that I have been working on a book on climbing injuries for some years. It has turned out to be a much bigger book than I originally envisaged. It has been a huge project, but in a few weeks I will reach the finish line. The book is currently with the printers and some time in the next few weeks, many boxes of copies will arrive at my house. The final stages were a rather exhausting process, but I’m excited to release it and potentially help healthy climbers stay healthy and injured climbers to get back to the fray.

I’ll write a more detailed post about the content of the book when the stock arrives in early February. If you want to make sure you get a copy as soon as you can, we’ve put it up for pre-order in the shop here, and it’ll be in the post to you as soon as it arrives. I’ve also added the table of contents below so you have an idea of the breadth of the areas covered.

My aim was to write the manual on how to stay healthy as a climbing athlete that I wished I’d had when I was 16. The first priority was to base my writing on the cutting edge of sports medicine research, wherever it was available. The second was to include all the diverse aspects of injury prevention and recovery, and then present them in a way that allows you to see them in the whole context of your efforts to stay injury free. As with the world of training, too many injury texts focus on or overplay the importance of just one aspect of sports medicine.

Having spent around 4 years researching, thinking and writing the book, I do feel that if I’d had access to the information contained in it when I was a teenager, my health and climbing achievements over the past 20 years would have been significantly better. I hope the book can make this difference both for both youngsters who have yet to experience injury, and battle scarred climbers like myself.

Below is the table of contents, so you can get idea of the scope of the book. You’ll find the book in the shop here. 

Section 1: Make or break

Why the treatments you have tried aren’t working, and what to do about it.

How to use this book

The real reasons you are injured

Stress and injury

The reason you are still injured

The language problem

The practitioner problem

The sports medicine problem

The missing link

Exceptional use: the luxury of doing your sport badly

Prevention

Your visit to the doctor’s

Summary

Section 2: Know pain, or no gain

Pain and how to read it

Seeing the patterns in your pain

What is healthy soreness?

Understanding your pain

Going beyond reading only pain

Summary

Section 3: Removing the causes of injury for prevention and treatment

Are you only treating symptoms?

What was the real cause?

The big four: technique, posture, activity, rest

Correcting technique

Correcting posture

Activity

How to rest

Warm-up and injury

Lifestyle

Nutrition

Section 4: Rehabilitation of climbing injuries - treating both causes and symptoms

Acute rehabilitation

When to move beyond acute care

Goals of mid-late rehabilitation

Modern understanding of tendon injuries and recovery

Therapeutic activity - basic exercises

Therapeutic activity - climbing

Proprioceptive training

Walking the line of rehab ups and downs

Therapeutic modalities

Surgery

Drug and other emerging treatments

When to stop rehab?

Summary

Section 5: Psychology of injuries: dealing with the anguish of injury

Face it: it really is that bad!

Take heart

Finding motivation

Section 6: Young climbers

What young climbers should know

Too much, too young: a warning

What parents and coaches should do

Section 7: The elbow

Golfer’s and tennis elbow

Brachioradialis/brachialis strain

Other elbow injuries

Section 8: The fingers

Different grips in climbing and consequences for injury

Pulley injuries

When and how to tape the fingers

Painful finger joints

Flexor unit strains

Dupuytren’s contracture

Ganglions

Other finger injuries

Section 9: The wrist

Triangular fibrocartilage injury

Carpal tunnel syndrome

De Quervain’s tenosynovitis

Other wrist injuries

Section 10: The shoulder

Shoulder impingement/rotator cuff tears

Biceps tendon insertion tears

Labral tears

Shoulder dislocation

Frozen shoulder

Thoracic outlet syndrome 

Shoulder and neck trigger points

Section 11: Lower body injuries

Foot pain in climbers

Plantar fasciitis

Heel pad bruising

Ingrown toenails

Sesamoid injuries

Hallux valgus

Morton’s neuroma

Ankle injuries in climbers

Cartilage/joint injuries

Ankle impingement syndrome

Achilles tendon pain

Knee injuries in climbers

Meniscus tears

Anterior cruciate ligament tears

Medial collateral ligament tears

Hamstrings tear

Hernia

Section 12: Further reading

Further reading and references

Getting access to good care

The author’s tale of woe and hope

Glossary of key terms

Thanks

References

Hyperhidrosis and climbing

Over the years I’ve heard from a few climbers who suffer from hyperhidrosis (excessive sweating) of the hands. For obvious reasons, the condition is a major hindrance for rock climbing and causes much torment for sufferers who love the activity but are constantly hampered by severely sweaty hands.

I do not have the condition myself, but I definitely have more sweaty hands than average and I find that my indoor climbing performance has always lagged as much as a number grade behind my outdoor climbing grade. I cannot imagine how difficult it would be to deal with the condition as a climber, having dripping hands with the slightest exertion. 

Hopefully, most sufferers will already know about iontophoresis, but in case not, I thought I should write this post.

I am grateful to Bob Farrell who got in touch last year to let me know that discovering the treatment had completely transformed his climbing. He went from a state of despair about how to enjoy rock climbing to being able to enjoy good friction and dry hands on small holds, both indoor and outside in warm weather.

The treatment involves passing a small electrical current, supplied by an iontophoresis machine through the hands, for 15-30 minutes or so. The hands (or feet) have to be placed in a water bath to apply the current. Despite its remarkable effectiveness, its mechanism of action is still unknown. But it blocks the sweat glands in some way, temporarily. Several treatments are required to see the benefits, and top-up treatments are needed every few days or weeks (with individual variability) to maintain the effects.

But those effects appear to essentially solve the problem for a great majority of sufferers. Although I have not tried the treatment myself, it sounds from Bob’s experience and the evidence from other non-climbing sufferers, that all affected climbers should definitely try it.

It is available, at least in some places on the NHS. But most sufferers who try the treatment and have good results seem to just purchase their own iontophoresis machine and do their top-up treatments at home. Machines cost £3-400 for a standard model. 

There seem to be few side effects, although if you have cuts in your fingers from climbing, these will burn during the treatment, with the workaround of just excluding the cut finger from the iontophoresis bath during treatment

I hope this post provides some help to sufferers who have yet to hear of the treatment.

The difficult question of sports injuries and disillusionment in youngsters

This good website has some interesting information on the size of the problem of young sportspeople getting injured. Injury rates are going up, to uncomfortably high levels. A serious sports injury is not just a short term issue for a young climber, runner or other sportsperson. It’s one of a few important reasons why so many youngsters drop out of sport before they even finish their teens.

It’s so obviously ironic that parents and coaches both take satisfaction from encouraging kids to take part in sport to foster a lifelong habit of activity and enjoyment. Yet overdoing that encouragement is one of the main reasons behind them ultimately dropping out or getting injured. The number one reason youngsters give for deciding to quit their sport is pressure from parents, coaches or the setup of their sport. So, whatever we are doing, it’s wrong.

Lots of coaches are still wrestling with the idea of whether formal competition in sport is a good idea for kids. There doesn’t appear to be any straightforward answer to that question. The best answer might be ‘it depends’. If the environment is optimal, competition in sport may be quite healthy, if unnecessary. However, it rarely is optimal. There are potential sources of problems everywhere. Therefore, being realistic, maybe no competitive sport until beyond adolescence is better? That is definitely still an open debate.

It’s difficult for parents even to realise how pivotal their role is. For instance, who can blame parents for subconsciously rewarding competition results instead of effort, balance, maturity, sportsmanship and science based training in sport? The very best coaches in professional sport can hardly seem to achieve this, even though they should know better. It’s a tough challenge for parents to assume the role of sports philosopher, role model, coach, sports scientist and sports medic. On the other hand, if you are going to invest time, effort and expense in encouraging your child’s path in sport, you might as well do it properly, in a way that doesn’t leave them either injured or disillusioned and out of sport for good at 13 or 14.

It’s difficult for coaches too. Reliable and useful information on training program design and injury prevention is extremely hard to come by. Moreover, coaches often don’t have enough time with youngsters to provide individually tailored training. In this situation, I think it’s important that they emphasise to both parents and youngsters that the advice they give has limitations, and if they want to make sure they are training safely, they should consider  training themselves to be informed self-coaches, or hire in some more personalised coaching.

In climbing, we are about to enter a dangerous period (in the UK at least) since some new coaching qualifications are coming on-stream. Qualifications, generally speaking, are of course a good thing. However, there can be problems if parents see the word ‘qualified coach’ and don’t think any more about what the qualification means. It’s possible to be a qualified coach in many sports on surprisingly little experience, and unfortunately, depth of knowledge. Parents should be careful to make themselves aware of the level of skill and experience of those coaching their children. Start from the assumption that the coaches are not suitably experienced or resourced to prevent injuries in youngsters, and that you’ll need to consult a range of sources to ensure the best chances of avoiding injury and ensuring youngsters have a good range of influences on their development in sport.

I must say, with my own child, I’d be equivocal at best about encouraging them to get involved in regular competitive sport before adolescence. Non-competitive sport offers so many of the benefits, if not more, without the inherent problems that competition brings. Taking injury risk in particular, non-competitive sports offer the opportunity for more variety and spontaneity in the yearly diet of training, important both physically and psychologically. They also push the focus of performance inwards, to messages coming from the body, rather than outwards, just doing the same training as your peers or trying to keep up with others unrealistically. In other words, they are often healthier all round.

I see advice for youngsters in competitive sport to take breaks in the year from competition. Good advice, although not if they simply stop training completely. Complete rest falls foul of one of the fundamental laws of tendon injuries: “tendons don’t like rest or change”.

I’m talking about parents, coaches and the youngsters themselves so far. They have the immediate responsibility to improve the outcome for the youngster as they move forward with their own life. But what about those higher up, who are in charge of leading sport, spending our money to make sure the potential benefits for all of us are realised? What is the point in promoting sport if it is so hampered by a massive early dropout rate and millions (3.5 million in the US) of injured kids? The idea is that we foster lifelong involvement in sport and physical activity and that sport is something youngsters enjoy over the long term. It’s pretty clear that it doesn’t nearly meet these aims for a big chunk of the participants.

This is a big, serious question, that needs leaders of sport to go right back to basics. When we promote sport, how should it be done? What sports, or sporting practices are healthy in the long term? Should we be promoting entirely different sports and ideas around sport? Probably. I’d like to see data comparing dropout rates between competitive sports and non-competitive sports, such as those based around the outdoors and training. My hunch is that if sporting culture was less centred around rankings or winning/losing and more centred around simple fun, effort, resourcefulness and dedication, that dropout rate would go down.

What specifically should change? It’s a deep cultural change, so no single or simple thing can be targeted. I’d certainly like to see that a session at the gym/leisure centre/sports facility should always be cheaper than a can of cider. Getting an exercise high should always be cheaper than a drug high like alcohol for so many kids who have limited money. Unhealthy goods like cigarettes and alcohol are taxed more heavily to take account of their effects. Why not services? It seems a shame that new sports facilities are not given a more favourable financial climate in which to flourish. At big multi-activity centres, the pizza and cinema tickets could be £1 more expensive so that the indoor snow slope or climbing wall can be cheaper. The many threads of enjoyment of exercise and training for it’s own sake should be promoted over winning and losing. More could be made of urban spaces. Good incentives should be set up for running, cycling, parkour, skateboarding etc clubs to use these spaces. Everyday exercise and sport should be as conspicuous as possible. ‘No ball games’ signs could be banned. If the NHS is going to save money by encouraging us all to be involved in sports, at least some provision is going to be needed to offer proper sports medical care, in recognition that sports injuries do happen and are career ending if left untreated. Surely it’s cheaper to correctly diagnose and repair the ACL tear now than treat the arthritic patient in a couple of decades?

Of course there are countless possibilities along these lines. The cumulative effect would be that youngsters who we do manage to encourage into sport will have enough variety in their activity, so they don’t grow to hate their own sports before they are 15. Moreover, they’ll be less likely to feel the need to enter into serious competition until later, when they are ready. Their parents will be less likely to ‘hang’ their encouragement on success in one sport as well as measuring that success along different lines. And, the youngsters might become more physically conditioned from a longer background in sports before they launch into serious training and hence lower their risk of injury.

Young climbers I’ve met who have been involved in the competitive side of climbing are the only ones I’ve ever seen stop climbing at a young age. I don’t think I can recall ever seeing a climber who was focused on the other aspects of the sport decide to give up. That’s not to say I conclude that competition is bad. It’s just that it can tend to drown out the other reasons for doing sport and become a demotivator after a while.

Whatever is suggested as solutions, the first stage is to really recognise that the injury and dropout rates among youngsters in sport means that what we are doing now is not enough.

The individuality of injury treatment

Yesterday, I was having yet another conversation about golfer’s elbow with a fellow climber and sufferer of the condition (it happens pretty much every time I go to a climbing wall or popular crag). The climber was a highly experienced and skilled ‘lifer’ in the sport with extensive working knowledge of physiology and sports science.

It struck me afterwards how personalised advice about sports injuries needs to be, depending on where the sufferer is ‘at’ with their knowledge and approach. I’m trying to weave this idea into my injuries book Rock ‘til you drop (now finished writing and currently redrafting).

One of the fundamental points of my book is that everyone needs to make themselves an expert in as many of the relevant corners of sports medicine as we can. I’ve provided a road map to achieve this for climbers in the book. 

However, the potential ‘weaknesses’ in your ability to successfully achieve recovery, as with performance weaknesses, are highly individual. In the discussion I was having the other day, the problem I anticipated with golfer’s elbow rehab is being too scared of the pain required for success in the rehab protocol. I don’t mean pain as in the ability to suffer. Almost the opposite. Someone with a good knowledge of sports medicine would quite rightly be wary of rehab exercises that caused any noticeable pain. Doesn’t pain mean overdoing it? 

It depends on the injury, the stage of the rehab and the individual. In the case of golfer’s elbow (and other tendonosis conditions where large volumes of eccentric loading is the rehab protocol of choice), some moderate pain is desirable. The stumbling block for an experienced climber may be backing off due to even mild pain before the loading really has a chance to work. For someone less experienced, it might be the opposite problem; they may not be sufficiently tuned in to their pain signals and patterns to avoid overdoing it.

The subtleties of tracking pain signals and adjusting both your sensitivity to them and the loading placed on the body is both a science and art. All of this underlines the need to seek out expert opinion of the highest possible quality and preferably from more than one source. 

PS While I’m on the subject of golfer’s elbow, I note that a lot of climbers are following a protocol outlined in a homemade video popularised by this article on UKC. Rather predictably, I've talked many climbers are not having success, since this protocol is appropriate when the tendon of Pronator Teres is causing the pain at the elbow, rather than the more commonly injured wrist flexor muscles. Before you use this protocol, make sure you get a specialist (i.e. Not your GP!) diagnosis to make sure you aren’t busying yourself with the wrong rehab program. 

Video: Training during recovery from injury

What’s your excuse?

PS. This programme might well not be the best for everyone. But the level of commitment definitely is.

Injury case study: Knee ligament tear from drop knee

Watch the video below with Dave Graham (which is entertaining anyway) and check out the knee ligament injury he suffered while doing a deep drop knee move.

This injury does happen from time to time in climbers without much warning, so all climbers should read this for prevention’s sake.

One month ago I suffered a very similar injury in an almost identical scenario while training on my climbing wall at home. The striking thing about the injury was that there seemed to be very little I could have done to foresee the injury. I’d just performed the same move several times (falling higher up the problem). The only difference was that my foot didn’t hit the foothold at the perfect angle. But this didn’t feel dangerous or painful until the moment of injury. So was it actually preventable? Well, thats debatable.

Prevention of sports injuries has two main strands. Firstly, by preparing the body for the demands of the sport, usually by strengthening the relevant areas and making sure they are the correct length (stretching muscles to make them longer is not always good). Secondly, by learning about the scenarios that cause the tissue to fail. In some injuries, like the one I’m describing, that’s acute tearing of otherwise symptom-free tissue. In others, it’s degeneration that builds up over years and gradually shows progressive symptoms. 

Taking these strands in turn, is there anything that climbers can do to strengthen the knee to protect it from injuries in drop knees? I’d say it’s pretty difficult. The muscles most forcefully activated during a drop knee depend largely on the exact positioning of the foothold and leg. Moreover, much of the force on the foothold is generated by passively ‘sitting’ on the medial collateral ligament (MCL) that runs down the inner side of the knee. Ligaments are strengthened by general use of the joint. Thus, the best way to strengthen them against the stress they are placed under during drop knees would be to do a lot of drop knees. Albeit less aggressive ones.

The simple maxim when it comes to prevention of tendon and ligament injuries is “tendons don’t like rest or change”. When they are rested, they become weaker. When you increase the demands placed on them, they take a long time to adapt. So perhaps the best protection would be to keep the leg musculature and knee ligaments strong with regular climbing involving this type of move for as much of the year as possible. Supplementation with basic leg exercises with weights or body weight may be a good idea if a specific weakness has been identified that is relevant. But at least some of the time, these exercises are so much of a shot in the dark that they may have little real effect in such specific movement patterns as demanded by climbing. Only a really good physiotherapist or an expert in stability and functional exercises is realistically going to be able to identify these weaknesses through manual testing of an individual. Are you about to go and track down an expert and book a session based on this blog post? Thought not.

So that leaves mitigation of the injury scenario itself. It’s probably fair to say I use drop knees more than most. I’m weak and it allows me to climb things that I otherwise couldn’t touch. I previously irritated my right MCL by trying the crux drop knee on Ring of Steall (8c+) too many times in a row. You can see it in the video in BD's new catalogue here (page 9) Bizarrely, the altered movement I was forced to do because of the pain led me to find the beta tweak I needed and it tipped the balance for success on the route. Most injuries have an upside, somewhere.

I think I’ve got away with only two fairly minor knee injuries in 20 years despite all those drop knees because I learned to take them seriously as a dangerous move. I always take great care to concentrate and ‘feel’ the feedback from the knee to see if I’m properly and safely set before making the hand movement. Also, as I make the hand movement, I remember to keep thinking about the knee so I’m ready to react and let go if the ligament starts to strain or tear. Finally, if it’s a really deep drop knee and and on a redpoint project, I’ll make sure and have a couple of non-committal tries at the move to get a feel for it before fully committing.

Fast movements in such a dangerous position as a deep drop knee are probably more dangerous. Ligaments are ‘viscoelastic’. If they are stretched quickly, they are stiffer. When ligaments are injured at slow speeds, they tend to pull off a chunk of bone (avulse) at their end. When the movement is fast, it’s the body of the ligament itself that tears. So movements where you drop the knee and then move the hand all in one rapid motion are of particular concern.

Another issue pertinent to climbing is the cold. Especially in bouldering, hard ascents are often done in cold conditions with the core body temperature and especially lower limb temperature rather low. Probably dangerously low. In my board I train in just a pair of shorts and my favoured training temperature once warmed up is about -1, with the window wide open to let the highland winter winds in for maximum friction. Ligaments and tendons are stiffer when cold as opposed to being more elastic or compliant when warm. Moreover, joint proprioception (movement and position awareness) is poorer if the joint is cold. Keeping your knees warmer might be a good idea. If you’ve been getting colder for a while, put your shoes back on and run up and down the hill with your duvet jacket for a while. You’ll probably get on better on the boulder too!

Taking all this together, perhaps I injured my MCL because I was cold, I’d just taken a break from rock climbing to do some winter climbing for a month, I was having a good session and may have got a little overconfident. Lastly, it was late in the evening. That is usually my preferred time to train as I’m a night owl. But that particular day I’d done some manual labour moving rocks and mixing cement, followed by a 13 mile run at a good pace, followed by 3 hours of bouldering at my limit. I was probably getting tired and might have been better to stop the session 10 minutes earlier (it was pretty much my last problem before I was going to stop and go to bed). 

On the other hand, the tries immediately preceding the injury went without incident. This goes to show that we always tread a fine balance between training hard enough and injury. The right path is only impossible to see without hindsight.

I got away lightly, I had a partial tear of the MCL and a partial tear of the semimebranosus tendon (hamstrings) which I’ve already largely recovered from in just one month. A bigger concern in drop knees is that they often tear the knee menisci and or the ACL ligament with much more serious complications for the long term recovery and health of the knee. That little nightmare is too long for a blog post, but I’ve just finished writing about them for my injuries book Rock ‘til you drop. There will also be a little more on drop knee injuries in the book, since the MCL isn’t the only ligament hereabouts which can be injured by this move and some of the other ligaments are not so straightforward to rehabilitate.

In summary: Do drop knees, they are a killer climbing technique. But be careful. Concentrate, keep warm and do them year round to keep your knees strong.

Another good injury story

In the age of Facebook and Twitter, the good writing with some depth about our favourite subjects is sometimes a little less visible online than it was a few years ago. Here is a great story from Natalie Berry about her battles with a string of injuries over the past 12 years as a successful sport and competition climber.

I really felt for Natalie reading this, it brought back some of the worst moments from my own memories of ‘dark’ injury times. As I was reading, as a coach I was thinking “would there have been anything that could have been done differently?”. Possibly not if the design of the training progression was optimum, but the one thing on my mind was that a complete change of scenery while the appropriate rehab program was under way might help. Towards the end of her story, it turned out that doing just that seemed to improve the situation at least a bit. Nat's key quote of the blog was "The pain is telling me to change something". 

Like Natalie, I also went through a long (5 year) period of having one finger injury after another. As soon as one pulley healed, another went. If I could go back in time and tell myself the lessons I learnt the hard way, I’d say this:

The string of injuries were caused by poor technique, training planning and tactics. I’m not talking about seriously bad technical errors. I mean the kind of thing that’s so subtle only a very experienced coach would spot - slight systematic errors in control of movement, body position, the way I took the holds, my tactics for avoiding injury situations etc. I should have taken more time to clock up the hours climbing in more different situations, with different climbers and with less pressure to perform. Instead I should have concentrated more on basic climbing skills to develop the kind of movement and tactical awareness that only thousands of hours on the rock gives you.

When I got the injuries I should have taken complete time out from trying to perform. Not just the practicalities of trying to do it, but the impatient mindset that goes with it. I eventually went back to VS and went trad climbing all over the place and actually learned to be a solid leader. The result was coming back onsighting E7 instead of falling off E5s. I ought to have done it much earlier.

I changed my technique to move more dynamically, reducing the stress and risk for my tendons. I gained some openhanded strength and reduced my reliance on crimping. I learned that I needed to take care of my body better, and started eating and sleeping better. Finally, I thought tactically about what today’s climbing decisions meant for tomorrow, instead of just thinking about right now. A big part of this was simply being very careful climbing in warm or humid conditions when the risk of injury was much higher.

All of these factors together worked. Better late than never. In the 8 years since I’ve had two minor pulley injuries that resolved in a short time. 

If you are going through the same sort of experience, it’s very challenging to know what to do without the benefit of hindsight. The contributing factors for your injuries will be slightly different for everyone. At the end of the day, although advice from experienced sources is priceless, only you will be able to process that advice and sense what you should do differently. You must make yourself the expert and be prepared to cut through your own hang-ups, deep set habits and prejudices. N.B. I've been writing down all the possible avenues to look at in my injuries book which I'm still making steady progress with.

No easy answers, but it can be done.

Any excuses?

Can’t climb for a while? Injured? No climbing wall nearby, no crags? Sure it’s rough not to be able to do the real thing for a while. However, it happens to almost all of us every so often. You can moan about that, but one thing you cannot moan about is getting weak. Have a look at this video. Do you really have any excuse? Thanks to Beastmakers for pointing at this.

Injuries: The problem with Lay-off

A traditional approach to a tendon injury such as commonly experienced by climbers is to include an extended lay-off of several weeks or even several months. There are several good reasons to consider a lay-off, and several not to lay-off at all, depending on the circumstances.

The basic rationale for lay-off is to allow the tissue some rest and a chance to recover from it’s severely compromised state. There are quite a few assumptions built into the decision to completely rest the tissue. First, that the tissue will really benefit from complete withdrawal from the sport. Unfortunately, this isn’t strictly true. 

In the earliest stages of injury rehab, where the tissue is extremely weak, inflamed and possibly swollen, even the lightest use risks further damage. However, this stage is extremely short - a few days or weeks at most. After this, lay-off is actually contributing to loss of tissue health. Even moderate activity tends to be enough to maintain strength in muscle or tendon. But inactivity causes it to lose strength rapidly. When the tissue is immobilised, the rate of atrophy is positively frightening.

A related assumption is that immature tissue that forms in those initial days and weeks after an acute injury will mature into tough tendon that will handle the forces you were asking of it when you were healthy. This isn’t true either. It was the training you were doing that made you strong. Only progressive training of the injured tissue will bring it up to the exceptional level of strength and toughness that you need for sport. If the lay-off is long enough for the tissue to mature without a good progressive rehab program, it will likely end up weak, the wrong length and vulnerable to re-injuring just as you start to get your momentum back.

Another dangerous assumption inbuilt into a lay-off program is that the painful tissue is the problem and that allowing this to recover will solve the problem. In a few cases this could be true, but in the majority, an underlying susceptibility forms a large part of the cause and lay-off will do nothing to remove it. For certain less severe injuries, simply addressing the underlying causes without any intervention to treat pain symptoms will be enough to put things right.

Who can help you identify those causes? Climbing, being such a technical sport needs an excellent coach with a thorough understanding of physiology, and the biomechanics of climbing movement to identify why your climbing movements are injuring you. Since your posture is probably contributing too, you need an excellent sports medic/physiotherapist who can thoroughly asses the mess of your wonky back and shoulders. If they are not too shocked by the horror of your shoulder movement, they will help you unload the stressed out muscles and tendons with proper alignment. Sounds like a lot of effort? Well, I guess you could always just hope the pain goes away by itself instead.

Now, what a heartening blog post I hear you think; forget lay-off, keep climbing and my injury will still recover? Be clear that despite it’s psychological challenge for keen sports people, lay-off is in fact the easy option compared to the work and discipline of recovering from an injury without lay-off. This is because changing habits is really hard and requires iron resolve that most people cannot sustain as long as they need to. Hence the high recurrence rate of injuries. People just try to do things as they always did (including the things that caused the injury). If you are ready to climb differently - at the level the injured part demands, working daily to correct your bad technique habits, tactics, postural faults and specific muscle weaknesses, then recovery without lay-off is the short cut to successful recovery. Most folk don’t have the discipline either to source the information on what they ought to change, or to put the work in and actually change it.

The detail of what things climbers should change has been my constant work over the last month as I continue to write my climbing injuries book Rock ‘til you drop. It’s been fascinating study so far.

Distracted from the task at hand

After my last post, Toby commented:

“I'm 25, been climbing for about two years, and am about to embark on a long road trip. I've quit my job and... ...I've had a whole spate of minor injuries crop up in the last eight weeks...It definitely helps to see you acknowledge the realities of being injured and managing those injuries. I look at some of my friends who train six days a week for months on end with no ill effects, and I curse my body for not being able to stand up to that sort of load... but the reality is we have to work with what we're given. Much as I would like to keep pushing it, I guess I have to view all these little injuries as signs from my body to take some time off, and be thankful they're not more serious.”

I wouldn’t take the message that this is a necessarily a sign that you cannot train as hard as others you observe, just that you cannot do it yet. Big difference. Injuries are much less often caused by a high training load per say, rather it’s sudden increases in the training load or where it is distributed across the body that is more important. 

It’s true that some respond differently than others to training stress, but I’d say this is a distraction from the real problem that people run into, which is failure to adjust training load carefully enough and failure to adjust the quality of the recovery to match the change in training load.

If you are used to sitting at a desk all day and training a handful of hours a week, getting stressed, not sleeping enough and drinking a couple of beers every night to forget about it, and then switch to full on climbing many more days on with intense work for elbows and fingers, no wonder the body gets a fright and isn’t able to catch up.

2 years of climbing is nothing. The body takes many years, like ten, for some just to get used to hard training. That is, just to get into full gear and then really start. There are no shortcuts. My advice to anyone in this situation is to use extra time they have to get out and climb in as many different laces as they can. The adjustment needed in the elbows and fingers to train harder will happen along the way, and meanwhile you will actually learn to be a good climber, a process that takes tens of thousands of routes under your belt. 

I’m sure Toby will have a good trip and come back a better climber.

Golfers/Tennis elbow etc - what eccentrics do.

I’ve been asked a lot about eccentrics which are a really big part of successful rehab from tendonosis, in climbers that’s usually Golfer’s or Tennis elbow. What to they do? How do they work to heal the tendon?

There are no definitive answers, in fact, right now the various teams around the western world researching such things are arguing more about this subject now than they were a few years ago. Here is a little discourse on where things are right now.

The protocol of eccentric wrist curls was first brought to prominence by two Canadian physiotherapists (Stanish and Curwin) who reported very impressive and consistent success rates with their tennis elbow patients using a protocol that stopped short of provoking pain in the tendon. Since then, lots of studies have followed over the past decade and a half, also generally reporting good or excellent results with various protocols. These days, the evidence is mounting that nearly everyone with elbow epicondyle tendinosis should be able to get rid of it without resorting to surgery, so long as they do the exercises (the hard bit!), do them right and eliminate the original cause (the other hard bit!).

Protocol - The various different research teams have, generally speaking, had success with three different protocols. One is to do 3 set of 10 reps daily, with a weight that stops just short of provoking pain throughout the exercise. A second is similar, but at an intensity that provokes a little pain in the final set. The third protocol, favoured in a string of papers by a Swedish researcher Hakan Alfredson and his team, is to do 3 sets of 15 reps daily at an intensity that causes mild pain throughout. Several other teams replicated good results using eccentrics only three days a week.

The allowance for pain during the rehab exercises runs counter to much of orthodox sports medicine, even from researchers in the same field. Far from being settled, it’s a question that is only just being opened in tendon research right now. However, the successful healing demonstrated by Alfredson’s protocol does speak for itself. Briefly, the idea behind it is that tendons suffering tendonosis (degenerative tissue changes) grow numerous and sensitive new nerve endings that serve as a protective measure to self limit the condition. In order to stimulate the tendon enough to grow new collagen and remodel immature scar tissue, the exercise must be a little painful. If the exercise progression is correct, a little exacerbation in the first few weeks should give way to steady pain ratings while the exercise intensity gradually goes up.

So why eccentrics only? Well a lot of researchers were unsatisfied with the rather simplistic explanation that this mode of contraction (lengthening under load) preferentially loaded the tendon rather than the muscle, preventing the muscle from getting strong ‘too quickly’. It’s true that muscles respond better to a combination of concentric and eccentric loading. What tendon strength responds best to is nearly impossible to research (would you let a man in a white coat train you for weeks, chop your bicep tendon out and pull it on a strain gauge until it snaps?).

One idea from Alfredson was that the eccentric loading breaks up the adhesions of disorganised scar tissue, as well as abnormal blood vessels and free nerve endings that proliferate in degenerative tendons, allowing both pain free stimulation and collagen maturation. There are various other ideas about how the tendon responds biochemically to eccentric loading related to growth factors, inflammatory processes and other very complicated processes of cellular messaging.

An intriguing new hypothesis is emerging that tendonosis might be down to underuse, rather than an overuse injury as it’s traditionally been perceived. Research into painful achilles and patellar tendons is suggesting that unequal distribution of loading exists within tendons that are chronically loaded at a certain joint range. Some areas are overworked and strained, other areas ‘stress shielded’ become atrophied and weak, and eventually strain as well. This lends weight to the importance of technique, training design and posture as being the direct causes of these injuries in at least a proportion of cases. There is some evidence that eccentric loading allows more even loading in the tendon, stimulating both the overused and underused portions in a way that allows them to recover normal collagen content and arrangement.

Whatever the underlying mechanism, there is quite convincing evidence that these exercises are the thing to do and seem to get through to even the most unresponsive tendons, except in a few extremely advanced cases where the tendon has been trashed so severely it literally turns to bone. Which protocol you choose largely comes down to experimentation I’m afraid, as no studies have compared the effectiveness of each in a reliable way. Personally, I’ve found that either pain free, or with a little pain worked on all three of my injured epicondyles (two now symptom free, one more recent injury well on the road to complete recovery).

People tend to fail at this by simply not disciplining themselves to do the exercises. Simple as that. I’ve read a couple of studies that demonstrated clearly that tennis elbow sufferers tended to recover much better on identical protocols if they were done with the physio there. 

Remember that doing these exercises, although a gift to climbers who are suffering chronically, are only one part of the response. Unless your technique, posture, training all change to remove the reason you got injured in the first place, it’ll probably come back the minute you start trying to push your grade or training volume again.

This post is just a snippet about one aspect of elbow rehab. The above discussion should reinforce that healing a tendon for sport is a massive field and way more than a few blog posts. There is much more you should know - about the stretching, fitting the rehab in with climbing, and the detail of the changes to make in your technique, posture, training, lifestyle. Hence I’m writing the book. I know, I know, it’s not out yet… I’m working hard on it, but couldn’t resist a moment out to write this as I’ve been asked so many times…

Happy curling