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 reviews coming through

Many of you have emailed to let me know that you found Make or Break to be very useful for dealing with your climbing injuries. Thanks for sending those, it’s good to know the effort of writing it was worth it.

There are now a couple of reviews of the book around and below are a few comments from those and links to the full reviews. As ever, you can get the book in our shop here.

Neil Gresham, writing in Climb Magazine:

“...a modern bible for avoiding injuries...anyone who owns a pair of rock shoes owes it to themselves to get a copy...at last,there’s no longer an excuse for doing climbing and training wrong and getting hurt, now that this fantastic book exists.”

“No stone has been left unturned and advice is given on everything from supportive nutritional strategies to sleep positions, non-sporting injury contributors and so on. I particularly like the chapter on managing injuries from a psychological perspective. Again, this is delivered with empathy from someone who clearly understands how demoralising it can be to have your climbing goals dashed on the rocks. But the most revealing section is surely the one on proprioception and correction of technique. I can’t think of many climbers who won’t need to take a rain check after reading this.”

The full review was in Climb Magazine issue 122 (May 2015)

Duncan Critchley, Physiotherapist, lecturer and pain researcher, Kings College London, writing for UKbouldering.com

“This is the best book on climbing injuries by a large margin. The section on tendon injuries is one of the best I've read anywhere, clearly presenting what we know and don't know. It suggests specific treatment ideas but is happy to acknowledge when we don't know the best treatments or why treatments work. Many medical practitioners would benefit from adopting this humility. Make or Break is well designed and attractively produced. It even has an index. At £30 it is exceptionally good value for a medical text-book.”

“Pain specialists know tissue damage is one factor of many contributing to pain and how we deal with pain. Mood, beliefs about pain and injury, health behaviours and social circumstances are important in determining who gets injured, which bit hurts and how much, and speed and extent of recovery. It is great to see the 'Know Pain' chapter start to acknowledge this, explaining how to interpret pain, and why pain is rarely an honest witness of damage. This is common knowledge in pain management but unusual to see it recognised so clearly in the world of sports and sports injuries.”

The full review is on UKB here.

There is also a review by Steve Crowe on Climbonline.co.uk here.

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