All posts by Mike Gable

Tennis Elbow

Anatomy and Injury

common extensor tendon
common extensor tendon

Tennis elbow (lateral epicondylitis) is an irritation of the outer layer of the bony lateral epicondyle (bone on the outside of the elbow) as well as of the common extensor tendon, specifically the extensor carpi radialis brevis.1-4  This injury is typically due to repetitive use of the muscles of the common extensor tendon that extend the wrist (bend it backwards) and that help stabilize the wrist during gripping motions.  Specifically for climbing, it can also occur through repeated finger flexion and gripping movements such as with face climbing, finger jams, the use of ice tools, and rope maintenance.  This is due to the wrist extensor muscles working to keep the wrist in a neutral position as the fingers are flexing.5,6         Tendon overuse injuries (especially when they have been around for 3+ months) are now more accurately called tendinosis, or in this case epicondylosis, rather than the previous label of tendinitis, or in this case epicondylitis, due to studies that have been done on the cells and tissues.  Instead of inflammatory cells, which would be found for tendinitis, the problem has been seen as a disorganization of the tendon tissues.  The disorganized tissues resemble a clump of cooked spaghetti on a dinner plate as opposed to healthy tissues organized in a parallel fashion like uncooked spaghetti noodles in a bag.  All of this is important because the treatment changes from targeting inflammation, which may not be present, to targeting the tissue disorganization.2,4,7-13

This is a very painful disorder that is felt with any gripping or grasping motions as well as with resisted wrist or middle finger extension and passive wrist flexion.  The pain is felt on the lateral epicondyle (outside of the elbow) and can radiate pain down the back of the forearm.  Grip strength is also typically decreased.7,8,14-16

Prevention

The keys to preventing this injury are:
1. Warming up properly:  For climbing specifically, roughly 120 moves or 4 routes/8-12 boulder problems of easy climbing is recommended before attempting climbing near your maximum level of climbing difficulty.17,18.  

2. Gradually ramping up training:  Has the climbing, or other related activity, increased significantly from normal frequency or difficulty?

3. Maintaining good flexibility by stretching the muscles that are being used:  Static stretching after climbing (or repetitive gripping motions) is the best time.  Hold the stretch for 30 seconds for 2-3 repetitions, 2-3 times throughout the day.

wrist flexor stretch
wrist/finger extensor stretch

4. Trigger Points/Myofascial restrictions:  Check for any trigger points (spots that feel tight or tender) at the end of the climbing day or after any activities requiring repetitive gripping/grasping motions.   Hold direct pressure on those spots for 2-3+ minutes.  Below are some options but feel for other spots in the surrounding area.

extensor carpi radialis brevis trigger point
extensor digitorum trigger point

5. Body awareness:  Is there any pain on the outside of the elbow during or after climbing or after any activities requiring repetitive gripping/grasping motions?  If so, consider modifying your activities so as not to continue to aggravate the injury.

 

Treatment

Much time and frustration will be saved, not to mention pain, by addressing the above symptoms as soon as possible.  A challenging aspect of tendon injuries is that they typically take longer to heal than muscle injuries.19  Due to the decreased blood supply to tendons in comparison to muscle and bone, tendons receive less “contractors and workers” to repair the damaged area.  This is a reason to not let this get out of hand and to cultivate awareness of any activities throughout your day that may be contributing to the symptoms.  A massage therapist once told me that switching from a squeeze bottle to a pump for her massage lotion/oils almost immediately cleared up a long bout of her tennis elbow symptoms.  Its amazing how seemingly minuscule activities can produce huge effects when they’re repeated a hundred times or more per day.

There have been 40 or so treatments studied for this injury!8,14,15  A few of the treatments that have shown the best results, are the most common, and can be performed at home will be discussed and described.  In the initial phase of healing, it is important to avoid making the injury worse.  This means listening to the signals the body is sending (pain) and allowing the natural inflammatory process to do its job of removing dead tissue, repairing damaged tissue, and laying down new tissue.  Crosier, Foidart-Dessalle, et al state that creating increased pain has been noted to slow healing progress with this injury.  They further note, “Our position is that pain must be interpreted as an alarm signal and that if the injurious effects of the repetitive motion continue, tendinous suffering may persist or even worsen.”20  On the other end of the spectrum, not using the arm at all, or immobilization, has been shown to decrease the healing progress as well, because it slows new tissue formation.20  Listening to the body and using pain as a guide will increase the ability to find the balance.  The first goal is to maintain range of motion in the elbow and wrist.

Some of the treatments that have been successful with this injury are:
1. Static stretching of the wrist extensors: 1,8,21  This stretching helps the new tissue being laid down during the healing process to line up in the proper way to allow the elbow joint to move without restrictions.  Hold the stretch for 30 seconds for 2-3 repetitions, 2-3 times throughout the day.

wrist/finger extensor stretch

2. Myofascial release: 4  (see “trigger points/myofascial restrictions” section above) Although the common extensor tendon and muscles coming from those tendons were specifically targeted in the research, it may help to also check for trigger points of the muscles of the common extensor tendon, extensor carpi radialis longus, triceps brachii, brachioradialis, supinator, and supraspinatus. Trigger points in these muscles can refer pain to the outer elbow.  The goal is to find any area that feels tight or tender and to hold direct pressure on those spots for 2-3+ minutes.

3. Eccentric strengthening of the wrist extensors:  It is suggested to start this after the acute phase (10 to 14 days) when the damaged tissue has been removed and the new tissue has been laid down. 1,8,15,20,22   With eccentric strengthening, as opposed to concentric strengthening, the muscle is actively contracting while it is lengthening. This type of strengthening is thought to increase tendon strength and, due to the muscle lengthening aspect, help the new tissue fibers that are being laid down during the healing process to line up properly.  Furthermore, the type of collagen found in healthy tendon (Type 1 collagen) has been found to increase and excessive tendon thickness found to decrease with eccentric strengthening.3,8,10,23,24

eccentric wrist extensor strengthening start
eccentric wrist extensor strengthening end

 

Concentric strengthening of a muscle is actively contracting the muscle while it is shortening.  This type of strengthening has been shown to be beneficial as well 3,7,8 however, the lengthening or stretching aspect does not occur as with eccentric strengthening.  Furthermore, eccentric contractions have been found to produce more force while requiring less oxygen and energy than concentric contractions and therefore will produce increased strength of the tendon with less waste products as opposed to concentric strengthening.11,25

4.  Other:  Various types of joint mobilizations/manipulations and taping have been suggested, some of which may be performed at home:9,16,26  Healthcare practitioners such as physical therapists, chiropractors, and osteopaths can evaluate the injury and provide instruction for these services, if appropriate.  Furthermore, other areas (shoulder, neck, etc) can contribute to elbow symptoms, which can be evaluated by a physical therapist or other practitioner familiar with optimal alignment and movement strategy evaluations.

An interesting note with this injury is that it typically resolves on its own within one year’s time.  Furthermore, although corticosteroid injections significantly decrease symptoms initially (the first 6 weeks or so), symptoms have been found to actually worsen and recurrence rates are higher compared to no treatment at all from 12 to 52 weeks.26,27

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

References:

  1. Wen DY, Schultz BJ, Schaal B, Graham ST, Kim BS. Eccentric strengthening for chronic lateral epicondylosis: a prospective randomized study. Sports Health. 2011 Nov;3(6):500-3.
  2. Nagrale AV, Herd CR, Ganvir S, Ramteke G. Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: a randomized clinical trial. J Man Manip Ther. 2009;17(3):171-8.
  3. Raman J, MacDermid JC, Grewal R. Effectiveness of different methods of resistance exercises in lateral epicondylosis–a systematic review. J Hand Ther. 2012 Jan-Mar;25(1):5-25.
  4. Ajimsha MS, Chithra S, Thulasyammal RP. Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals. Arch Phys Med Rehabil. 2012 Apr;93(4):604-9. doi: 10.1016/j.apmr.2011.10.012. Epub 2012 Jan 10.
  5. Rooks MD. Rock climbing injuries. Sports Med. 1997 Apr;23(4):261-70.
  6. Moore K, Dalley A. Clinically Oriented Anatomy, 4th edition. Lippincott Williams and Wilkins, Baltimore, 1999. p. 746.
  7. Peterson M, Butler S, Eriksson M, Svärdsudd K. A randomized controlled trial of exercise versus wait-list in chronic tennis elbow (lateral epicondylosis). Ups J Med Sci. 2011 Nov;116(4):269-79. doi: 10.3109/03009734.2011.600476.
  8. Waseem M, Nuhmani S, Ram CS, Sachin Y. Lateral epicondylitis: A review of the literature. J Back Musculoskelet Rehabil. 2012;25(2):131-42.
  9. Shamsoddini A1, Hollisaz MT. Effects of taping on pain, grip strength and wrist extension force in patients with tennis elbow. Trauma Mon. 2013 Sep;18(2):71-4. doi: 10.5812/traumamon.12450. Epub 2013 Aug 13.
  10. Murtaugh B, Ihm JM. Eccentric training for the treatment of tendinopathies. Curr Sports Med Rep. 2013 May-Jun;12(3):175-82. doi: 10.1249/JSR.0b013e3182933761.
  11. Skjong CC1, Meininger AK, Ho SS. Tendinopathy treatment: where is the evidence? Clin Sports Med. 2012 Apr;31(2):329-50. doi: 10.1016/j.csm.2011.11.003.
  12. Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J. Bone Joint Surg. 2005; 87:187Y202.
  13. Bass, E. Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters. Int J Ther Massage Bodywork. 2012; 5(1): 14–17. Published online 2012 March 31.
  14. Stasinopoulos D, Johnson MI. Cyriax physiotherapy for tennis elbow/lateral epicondylitis. Br J Sports Med. 2004 Dec;38(6):675-7. Review.
  15. Viswas R, Ramachandran R, Korde Anantkumar P. Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial. ScientificWorldJournal. 2012;2012:939645. doi: 10.1100/2012/939645. Epub 2012 May 2.
  16. Vicenzino B. Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Man Ther 2003;8:66-79.
  17. Schweizer A. Sport climbing from a medical point of view. Swiss Med Wkly. 2012;142:w13688.
  18. Hockhoelzer T, Schoeffl. One Move Too Many… Druckerei Sonnenschein, Ebenhausen, 2003. p. 109.
  19. Holtzhausen LM, Noakes TD. Elbow, forearm, wrist, and hand injuries among sport rock climbers. Clin J Sport Med. 1996 Jul;6(3):196-203.
  20. Croisier JL, Foidart-Dessalle M, Tinant F, Crielaard JM, Forthomme B. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med. 2007 Apr;41(4):269-75. Epub 2007 Jan 15.
  21. Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med. 2013 Nov;47(17):1112-9.
  22. Tyler TF, Thomas GC, Nicholas SJ, McHugh MP. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. J. Shoulder Elbow Surg. 2010; 19:917Y22.
  23. Woodley BL1, Newsham-West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med. 2007 Apr;41(4):188-98; discussion 199. Epub 2006 Oct 24.
  24. Alfredson H1, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998 May-Jun;26(3):360-6.
  25. Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin Orthop Rel Res 1986;208:65–8.
  26. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: r andomised trial. BMJ. 2006 Nov 4;333(7575):939. Epub 2006 Sep 29.
  27. Smidt N, Van Der Windt DA, Assendelft WJ, Deville WL, Korthals-De Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002; 359:657–62.

Sleep And Healing

Having 2 and 4-year-old kids has me thinking a lot about sleep lately.  I’ve been interested in how sleep loss affects the healing process though for a long time since I became fascinated with chronic pain conditions early on in my career.  There’s research going back to before I was born linking sleep deprivation and what we know today as fribromyalgia.1,2  Since then, there has been an incredible amount of research linking sleep deprivation with a myriad of health issues.  At the end of this article, I break down each of the many aspects of health that are affected by sleep and some of the research that has been done on each topic.  Many of the references are mentioned in the fascinating book Why We Sleep by Matthew Walker while many are additional articles I found through my review of the current literature.  This post is a greatly expanded version of the information I wrote about in Beyond Tape.

The potential causes of sleep loss are vast but seem to be able to be broken down into 2 categories , behavioral and medical, which can be linked in many cases.  Medical causes including obstructive sleep apnea, hormone imbalances, medication-related, and psychological disorders, which should be ruled out first by a qualified health care professional.3,6,9  Behavioral causes can be changed by modifying a person’s behavior, such as avoiding screens before bedtime.  Oftentimes, the causes are more on the behavioral end, which is where treatments like cognitive behavioral training and sleep hygiene techniques come into play.  Cognitive behavioral training (CBT), when performed by an expert in this field, has been found to be the most effective (even more so than sleep medications in some studies).  Sleep hygiene tips, one aspect of CBT, have been shown to be helpful as well.4-11  Check out my evidenced-based handout for sleep hygiene tips if you or someone you know suffers from sleep problems.

As a physical therapist, I’m mostly fascinated with the effects of sleep on injuries and the healing process.  Growth hormone is produced during stage 3, a deeper stage which is considered slow-wave non REM sleep, of the sleep cycle.12-14  This hormone helps to facilitate the healing process.  It takes roughly 90 minutes to get into this stage of the sleep cycle.15  Inadequate sleep has been shown to decrease growth hormone production.  Sleep disturbance can also contribute to myofascial trigger point formation, another contributor to chronic pain.  Psychological stress is a major cause of sleep loss.  This is a double-whammy, as stress causes an increase in production of the hormone cortisol (as does sleep deprivation), which has a negative impact on healing.  Laughter, meditation, and yogic breathing each have been shown to decrease the negative effects of stress.13,14

Aside from the affects on the healing process, sleep loss is linked to all kinds of problems which are described in the summary below.  Some big ones that are being talked about in the research are the link with metabolic syndrome (increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels — that occur together, increasing your risk of heart disease, stroke and diabetes), obesity and type 2 diabetes, both in adults and kids.16  This is thought to be due to the effects on hormones that play a major role in control of appetite and energy expenditure.  Hunger increases with poor sleep.  

Here is a summary of the health issues associated with poor sleep quality and quantity:

      • Cancer – Night shift work is associated with breast, prostate, and endometrial Cancers.17-19
      • Cognitive impairments – Cognitive functioning has been found to be impaired in all age groups, from children to the elderly, when restricting sleep by as little as 1 hour over 5 nights or 1 night of sleep deprivation.20-22
      • Alzheimer’s – Sleep fragmentation (repetitive short interruptions of sleep) and insomnia are found to be associated with Alzheimer’s and an increased rate of cognitive decline.23,24  Treating obstructive sleep apnea has been shown to improve cognitive function in Alzheimer’s patients.25
      • Cardiovascular disease and blood pressure – Poor sleep quality and insomnia are associated with increased blood pressure and vascular inflammation (C-reactive protein, a stable marker of inflammation that has been shown to be predictive of cardiovascular morbidity, has been shown to be elevated in subjects with total and partial sleep deprivation).26,27  People who get more sleep have been shown to have lower coronary artery (blood supply to the heart) calcification incidence.28  All these problems increase the risk of heart attacks and strokes.
      • Common cold and upper respiratory illness – Sleeping for less than 7 hours of sleep per night has been shown to be associated with an increased incidence of developing the common cold.29-31
      • Chronic pain and fibromyalgia – Sleep deprivation, especially of stage 3 in non REM sleep, has been shown to produce fibromyalgia-like symptoms of muscle tenderness and central sensitization.  This is where the nervous system becomes overly reactive, requiring less and less of a stimulus to create the sensation of pain and the pain is maintained even after the initial injury has healed.32-34  And as I mentioned above, stage 3 is when growth hormone is released which helps to facilitate the healing process.  Sleep hygiene education has been shown to decrease pain and fatigue in patients with fibromyalgia.35  Sleeping less than 6 hours has been associated with increased cortisol release and increased sympathetic nervous system activity, which contribute to central sensitization.36  Sleep disturbance is also thought to be a factor in the perpetuation of myofascial trigger points.37
      • Low back pain – Improvements in sleep quality are associated with improvements in low back pain and disability. 38 
      • Obesity – Sleep deprivation in both the short and long term is associated with increased obesity, body mass index, and weight gain in adults and children (including infants).  This is due to several factors including decreased glucose tolerance and carbohydrate metabolism, decreased insulin sensitivity, increased evening concentrations of cortisol, increased levels of ghrelin, decreased levels of leptin and increased hunger and appetite.  Ghrelin and leptin sound like Lord of the Rings’ characters, but they’re actually crucial hormones for regulating appetite.  Grehlin is an appetite stimulant and leptin an appetite suppressant.39-45  
      • Type 2 Diabetes – Sleep deprivation and poor sleep quality are associated with an increased prevalence of type 2 diabetes.  This is due to decreased carbohydrate metabolism and glucose tolerance, leading to insulin resistance and diabetes.46-49  
      • Sports injuries and performance – Decreased sleep is associated with a significantly increased prevalence of injury.  In one study, the likelihood of having an injury was 75% for 6 hours of sleep versus 18% for 9 hours in high school kids and 65% of kids were injured who slept less than 8 hours versus 31%  who slept longer than 8 hours.  This is thought to be due to the findings in other studies showing an association between sleep loss and impairment of psychomotor performance,  motor function, mood, and cognitive functions.50  Exciting research regarding performance shows that  basketball players who increased their sleep to at least 10 hours sprinted faster, shot more accurately, and noted improved physical and mental well-being.51  Decreased sleep is also associated with decreased performance, especially with “sports-specific skill execution and submaximal sustained exercise bouts”.  Increasing sleep showed an increase in “sports-specific skill execution and cognitive related tasks, such as reaction time and shooting accuracy”.52
      • Bone loss – Bone loss has been shown to occur after 3 weeks of sleep disruption, due to bone formation being decreased while bone resorption stays the same.53
      • Sleep medications – As a physical therapist, its beyond my scope of practice to give recommendations on medications.  That being said, sleep medications such as Restoril and Ambien have been shown to significantly reduce slow wave activity during non REM sleep.  Again, this is also called deep sleep and is the phase when growth hormone is released for healing of damaged tissues, glial cells in the brain are restored with sugar to provide energy for the brain, and synapses in the brain which are formed from learning and memory during wakefulness are regulated.54 Other factors that you may want to consider are that in some studies, sleep medications were no more effective than behavioral treatments55 and sleep medications have common, and often significant, side effects.54,56,57

It may seem strange for your physical therapist to be concerned about your sleep patterns, but I find (as does the research) that addressing all aspects of a person’s health leads to better and longer-lasting outcomes.  This is the purpose of my handouts for evidence-based sleep hygiene tips and evidence-based wellness topics.  Poor sleep quality and quantity is not just a normal part of the aging process and there are things you can do.  

Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

1Moldofsky H, Scarisbrick P. Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. Psychosom Med. 1976 Jan-Feb;38(1):35-44.
2Moldofsky H, Scarisbrick P, England R, Smythe H. Musculosketal symptoms and non-REM sleep disturbance in patients with “fibrositis syndrome” and healthy subjects. Psychosom Med. 1975 Jul-Aug;37(4):341-51.
3Bloom HG1, Ahmed I, et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc. 2009 May;57(5):761-89.
4Sharma MP1, Andrade C. Behavioral interventions for insomnia: Theory and practice. Indian J Psychiatry. 2012 Oct;54(4):359-66.
5Orlandi AC1, Ventura C, et al. Improvement in pain, fatigue, and subjective sleep quality through sleep hygiene tips in patients with fibromyalgia. Rev Bras Reumatol. 2012 Oct;52(5):666-78.
6Zhou ES1, Gardiner P2, et al. Integrative Medicine for Insomnia. Med Clin North Am. 2017 Sep;101(5):865-879.
7Ye YY, Chen NK, et al. Internet-based cognitive-behavioural therapy for insomnia (ICBT-i): a meta-analysis of randomised controlled trials. BMJ Open. 2016 Nov 30;6(11):e010707.
8Kozasa EH1, Hachul H, et al. Mind-body interventions for the treatment of insomnia: a review. Braz J Psychiatr. 2010 Dec;32(4):437-43.
9Maness DL1, Khan M1. Nonpharmacologic Management of Chronic Insomnia. Am Fam Physician. 2015 Dec 15;92(12):1058-64.
10Siebern AT1, Suh S, et al. Non-pharmacological treatment of insomnia. Neurotherapeutics. 2012 Oct;9(4):717-27.
11MacLeod S1, Musich S2, et al. Practical non-pharmacological intervention approaches for sleep problems among older adults. Geriatr Nurs. 2018 Sep – Oct;39(5):506-512.
12Cauter E, Leproult R, et al. Age-related changes in slow wave sleep and REM sleep and relationship with growth hormone and cortisol levels in healthy men. JAMA. August 16, 2000 – Vol 284 No 7 pp. 861-868. 
13Robles TF1, Carroll JE.  Restorative biological processes and health. Soc Personal Psychol Compass. 2011 Aug;5(8):518-537. 
14Adam K, Oswald I.  Sleep Helps Healing. British Medical Journal. Volume 289, 24 November 1984. 
15Davidson J, Moldofsky H, et al.  Growth Hormone and Cortisol Secretion in Relation to Sleep and Wakefulness. J Psychiatr Neurosci, Vol. 16, No. 2, 1991. 
16Van Cauter E, Spiegel K, et al.  Metabolic consequences of sleep and sleep loss. Sleep Med. 2008 Sep;9 Suppl 1:S23-8.
17Pahwa M1, Labrèche F, et al.  Night shift work and breast cancer risk: what do the meta-analyses tell us? Scand J Work Environ Health. 2018 Jul 1;44(4):432-435.
18Viswanathan AN1, Hankinson SE, et al. Night shift work and the risk of endometrial cancer. Cancer Res. 2007 Nov 1;67(21):10618-22.
19Salamanca-Fernández E1, Rodríguez-Barranco M, et al.  Night-shift work and breast and prostate cancer risk: updating the evidence from epidemiological studies. An Sist Sanit Navar. 2018 Aug 29;41(2):211-226.
20Volkow ND1, Tomasi D, et al.  Hyperstimulation of striatal D2 receptors with sleep deprivation: Implications for cognitive impairment. Neuroimage. 2009 May 1;45(4):1232-40.
21Yaffe K1, Laffan AM, et al.  Sleep-disordered breathing, hypoxia, and risk of mild cognitive impairment and dementia in older women. JAMA. 2011 Aug 10;306(6):613-9.
22Sadeh A1, Gruber R, et al.  The effects of sleep restriction and extension on school-age children: what a difference an hour makes. Child Dev. 2003 Mar-Apr;74(2):444-55.
23Osorio RS, Pirraglia E, et al.  Greater risk of Alzheimer’s disease in older adults with insomnia. J Am Geriatr Soc. 2011 Mar;59(3):559-62.  
24Lim AS1, Kowgier M, et al.  Sleep Fragmentation and the Risk of Incident Alzheimer’s Disease and Cognitive Decline in Older Persons. Sleep. 2013 Jul 1;36(7):1027-1032.
25Ancoli-Israel S1, Palmer BW, et al.  Cognitive effects of treating obstructive sleep apnea in Alzheimer’s disease: a randomized controlled study. J Am Geriatr Soc. 2008 Nov;56(11):2076-81.
26Aggarwal B1, Makarem N2, et al.  Effects of Inadequate Sleep on Blood Pressure and Endothelial Inflammation in Women: Findings From the American Heart Association Go Red for Women Strategically Focused Research Network. J Am Heart Assoc. 2018 Jun 9;7(12).  
27Meier-Ewert HK1, Ridker PM, et al.  Effect of sleep loss on C-reactive protein, an inflammatory marker of cardiovascular risk. J Am Coll Cardiol. 2004 Feb 18;43(4):678-83.
28King CR1, Knutson KL, et al.  Short sleep duration and incident coronary artery calcification. JAMA. 2008 Dec 24;300(24):2859-66.
29Prather AA1, Janicki-Deverts D2, et al.  Behaviorally Assessed Sleep and Susceptibility to the Common Cold. Sleep. 2015 Sep 1;38(9):1353-9.
30Cohen S1, Doyle WJ, et al.  Sleep habits and susceptibility to the common cold. Arch Intern Med. 2009 Jan 12;169(1):62-7.
31Prather AA, Janicki-Deverts D, et al.  Sleep Habits and Susceptibility to Upper Respiratory Illness: the Moderating Role of Subjective Socioeconomic Status. Ann Behav Med. 2017 Feb;51(1):137-146.
32Moldofsky H, Scarisbrick P.  Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. Psychosom Med. 1976 Jan-Feb;38(1):35-44.
33Moldofsky H, Scarisbrick P, et al.  Musculosketal symptoms and non-REM sleep disturbance in patients with “fibrositis syndrome” and healthy subjects. Psychosom Med. 1975 Jul-Aug;37(4):341-51.
34Simpson NS, Scott-Sutherland J, et al.  Chronic exposure to insufficient sleep alters processes of pain habituation and sensitization. Pain. 2018 Jan;159(1):33-40.
35Orlandi AC1, Ventura C, et al.  Improvement in pain, fatigue, and subjective sleep quality through sleep hygiene tips in patients with fibromyalgia. Rev Bras Reumatol. 2012 Oct;52(5):666-78.
36Spiegel K1, Leproult R, et al.  Impact of sleep debt on metabolic and endocrine function. Lancet. 1999 Oct 23;354(9188):1435-9.
37Dommerholt J, Bron C, et al.  Myofascial Trigger points: an evidence-informed review. Journal of manual and manipulative therapy. Vol. 14 No. 4 (2006), 203 – 221.
38Kovacs FM, Seco J, et al.  The association between sleep quality, low back pain and disability: A prospective study in routine practice. Eur J Pain. 2018 Jan;22(1):114-126.
39Chen X1, Beydoun MA, Wang Y.  Is sleep duration associated with childhood obesity? A systematic review and meta-analysis. Obesity (Silver Spring). 2008 Feb;16(2):265-74.
40Van Cauter E, Spiegel K, et al.  Metabolic consequences of sleep and sleep loss. Sleep Med. 2008 Sep;9 Suppl 1:S23-8.
41Leproult R1, Van Cauter E.  Role of sleep and sleep loss in hormonal release and metabolism. Endocr Dev. 2010;17:11-21.
42http://teacher.sduhsd.net/mrall/ap%20bio/AP%20Bio%20classwork/sleep.pdf
43Spiegel K1, Tasali E, et al.  Brief communication: Sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. Ann Intern Med. 2004 Dec 7;141(11):846-50.
44Taveras EM1, Rifas-Shiman SL, et al.  Short sleep duration in infancy and risk of childhood overweight. Arch Pediatr Adolesc Med. 2008 Apr;162(4):305-11.
45Kohatsu ND1, Tsai R, et al.  Sleep duration and body mass index in a rural population. Arch Intern Med. 2006 Sep 18;166(16):1701-5.
46Gottlieb DJ1, Punjabi NM, et al.  Association of sleep time with diabetes mellitus and impaired glucose tolerance.  
47Spiegel K1, Leproult R, et al.  Impact of sleep debt on metabolic and endocrine function. Lancet. 1999 Oct 23;354(9188):1435-9.
48Nilsson PM1, Rööst M, et al.  Incidence of diabetes in middle-aged men is related to sleep disturbances. Diabetes Care. 2004 Oct;27(10):2464-9.
49Knutson KL1, Ryden AM, et al.  Role of sleep duration and quality in the risk and severity of type 2 diabetes mellitus. Arch Intern Med. 2006 Sep 18;166(16):1768-74.
50Milewski MD, Skaggs DL, et al.  Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. J Pediatr Orthop. 2014 Mar;34(2):129-33.
51Mah CD, Mah KE, et al.  The effects of sleep extension on the athletic performance of collegiate basketball players. Sleep. 2011;34:943–950.
52Bonnar D1, Bartel K1, et al.  Sleep Interventions Designed to Improve Athletic Performance and Recovery: A Systematic Review of Current Approaches. Sports Med. 2018 Mar;48(3):683-703.
53Swanson CM1,2, Shea SA, et al.  Bone Turnover Markers After Sleep Restriction and Circadian Disruption: A Mechanism for Sleep-Related Bone Loss in Humans. J Clin Endocrinol Metab. 2017 Oct 1;102(10):3722-3730.
54Arbon EL, Knurowska M, et al.  Randomised clinical trial of the effects of prolonged-release melatonin, temazepam and zolpidem on slow-wave activity during sleep in healthy people. J Psychopharmacol. 2015 Jul;29(7):764-76.
55Smith MT1, Perlis ML, et al.  Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry. 2002 Jan;159(1):5-11.
56MacFarlane J, Morin CM, et al.  Hypnotics in insomnia: the experience of zolpidem. Clin Ther. 2014 Nov 1;36(11):1676-701.
57Kripke DF1, Langer RD, et al.  Hypnotics’ association with mortality or cancer: a matched cohort study. BMJ Open. 2012 Feb 27;2(1):e000850.

 

Evidenced-Based Wellness Recommendations

Healing is a multifaceted process.  When someone comes to me with back pain, for example, there are often other topics that come up.   “How does it feel to be injured?  How are you sleeping?  How does the injury affect your job, family, recreation?  How’s your diet and hydration?”  I’ve often wondered about the evidence behind some of the recommendations that are suggested from various experts or we see in articles or on the internet.  I’ve put together a handout, with citations included, for my patients about some common topics that come up in my clinic.  Below, I’ll briefly discuss my reasoning for adding each topic but here is the handout if you want to just skip to the business.

The Healing Process:  I think its crucial to have a basic understanding of what happens in our bodies when we have an injury.  This knowledge helps us understand that healing is a process, not an event.  It also helps us make decisions when trying to decide if and how a given intervention (exercise, manual therapy, surgery, medication, injections, anti-inflammatory modalities, etc.) will meet our goals both in the short and long term.

Sleep:  We spend roughly a third of our lives asleep.  Its easy to look at sleep as a waste of our waking lives and something we should try to fight (“Joe Shmoe is successful because he gets 4 hours of sleep a night”).  An overwhelming amount of research shows the incredible importance of sleep for all aspects of our lives.  A fascinating and in-depth read about this topic is Why We Sleep by  Matthew Walker (I hope Joe Shmoe checks this out).  Some people have been dealing with disrupted sleep for so long they think its normal or that nothing can be done.  Not so!  A psychotherapist with expertise in cognitive-behavioral therapy for insomnia can be of great help.  And here’s a list of evidence-based sleep hygiene tips.

Nutrition:  We’re learning more and more about how foods affect our beings and the healing process.  Recommendations change based off of new information and proper nutrition for each individual is often based on many factors that are unique to that person.  I frequently urge people to consult with an expert in nutrition.  Ask them questions about what you’ve heard or read about.  That’s what they’re there for.

Hydration:  Have you ever wondered if there’s evidence behind the recommendation to drink eight eight-ounce cups of water a day?  I have.  Turns out there’s not, but there has been research done regarding this topic.  I provide this information in the handout, and there are also lots of individualized caveats to consider.

Stress:  The fight or flight response is hugely important if you come face to face with a mountain lion while on a previously enjoyable jog in the mountains (that’s pretty extreme I know, but you get my point).  Many of us are living in a low-level fight or flight situation throughout each day, whether it be due to less-than-ideal relationships, work, or prior unresolved conflicts or traumatic events.  Hormones are released which are beneficial in short-term situations but wreak havoc on our bodies and lives when they’re constantly in our systems.

Volunteering:  I joined the Rotary Club (there are an infinite number of similar organizations who’s goal it is to serve their communities in meaningful ways) many years ago because I thought it would be a productive way to try to balance out the horrible things that we sometimes do to each other as human beings.  That’s why I continue to be a member.  The benefits I reaped (learning how to organize, speak publicly, work with people of differing views, gain the confidence to do things out of my comfort zone because I realize I’m a part of something bigger than myself, etc.) far outweigh my capacity to give back.  I was also pleased to see the solid evidence that volunteering benefits the helper in concrete physical ways as well.

Flexibility:  This topic got the ball rolling for me with the writing of Beyond Tape.  I was starting to see internet musings conveying the pointlessness of stretching and felt it would be beneficial for me to compile the actual evidence.  There are many benefits of stretching for both young and old.

Strength:   In my experience, many older folks are under the impression that strength training is a young person’s activity.  Not so!  This mindset tends to be a major player in the downward spiral that can, but doesn’t necessarily have to, happen as we age.  “If you don’t use it, you lose it” is for real.

Aerobic Activity:  It’s hard to make a lifestyle change and starting a walking, biking, or swimming program is nearly impossible without concrete goals.  We’re fortunate to have research that gives us solid guidelines to go by.  It’s important to see these guidelines as long term goals rather than something we should be doing right now.  I frequently suggest a person leave their front door, walk 5 minutes, and come back.  Add 5 minutes next week if it feels right to you.  Pat yourself on the back, you’ve made a start, and that’s the hardest part.

As always, let me know if you have questions or if you’d like to see additional topics added.  And please always feel free to let me know if I’ve missed anyone that you think should be on a list of practitioners I’ve provided (see the nutrition section of the handout).

Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

 

 

 

 

Plantar Fasciitis

Anatomy and Injury

calf muscles – gastrocnemius and soleus

The plantar fascia is a thick band of connective tissue that runs along the bottom of the foot from the heel bone to the ball of the foot.  Along with many tendon injuries that have long been called tendinitis and are now labeled as a tendinosis, this diagnosis is now thought to be more accurately termed plantar fasciosis.  This is due to studies of the tissues where disorganized fibers within the tissues are found rather than inflammatory cells.  What does this mean in the real world?  Treatments targeting inflammation, although questionable even if inflammation was present, are pointless as there are no signs of inflammation after the first couple of weeks of this injury.  Thus, the key to resolving this issue is helping the disorganized fibers in the plantar fascia on the bottom of the foot to become more organized.1,2,3,4 Although this injury can be caused by a single traumatic event (stepping on a hard object, such as a stone…or walking in ill-fitting shoes around the LAX airport parking lots for 4 hours because you forgot where you parked, which was a good reminder for me about the iphone camera), its typically a repetitive use injury such as walking, running, or hiking farther than normal. Other factors like old or poor footwear, walking on different surfaces than normal, injuries “further up the chain” (knee, hip, low back) causing gait abnormalities, and a lack of flexibility can play a role.

Symptoms

Significant pain is typically noticed on the bottom of the heel when getting out of bed and upon standing after prolonged sitting.  Pain is also noticed with walking and prolonged standing.

Prevention

1. Footwear: Replacing walking, hiking, or running shoes every three months or 500 miles has been recommended to prevent this injury.5 Being properly fitted at a reputable shoe store (we’re lucky to have Sage to Summit and Eastside Sports in Bishop) for your specific foot type is also a good idea.
2. Stretching:   Plantar fascia and calf stretches are key to keeping a normal length to these structures so they do not irritate the attachment point on the bottom of the heel.1,2,6 (See pictures for stretches below in the treatment section)
3. Preparation:   Get the body ready for unusually long walks, hikes, or runs by gradually increasing distance and elevation gains or losses.  Using appropriate footwear, such as shoes with good arch support for people with low arches, can help prevent irritation of the plantar fascia.
4. Trigger points/myofascial restrictions:   Periodically check for any trigger points/myofascial restrictions in the gastrocnemius, soleus, and muscles on the bottom of the foot.2  The goal is to find any spot that feels tight or tender and hold direct pressure for 2-3+ minutes while feeling for a release (you may notice the pain lessen or the tissues soften).  See the treatment section below for pictures of treatment examples.

gastrocnemius trigger points

gastrocnemius trigger point referral to the foot

Treatment

This injury can turn into a very long rehabilitation process if it is ignored (months or even years!).  The areas on which to focus include:
1. Avoid any activities that increase the pain as much as possible.  Consider temporarily switching your walking/running routine to cycling or swimming and avoid walking barefoot.  Walking, hiking, or running shoes should be replaced after roughly 500 miles.6
2. Range of motion:  Pump your ankles (bring your toes towards your nose and then push them towards the floor) 10 times prior to standing after you have been lying or sitting for prolonged periods.

pull your toes towards your nose

push your toes towards the floor

3. Stretching:   Plantar fascia, gastrocnemius, and soleus stretches will help the disorganized fibers to line up properly to heal the area.1,6,7  Hold the stretches for 30 seconds and repeat 2-3 times, 2-3 sessions per day.

gastrocnemius stretch (stretch is felt in the calf of the back leg)

soleus stretch (stretch is felt in the calf of the back leg)

4. Trigger points/myofascial restrictions: Assess for trigger points in the gastrocnemius, soleus, and muscles on the bottom of the foot.2,4,8

gastrocnemius sefl trigger point release

soleus self trigger point release

5. Night splint:   This is a splint worn at night to keep the plantar fascia and calf muscles stretched out.  Research has shown that they can be beneficial.  It was previously difficult for some people to wear through the night due to discomfort trying to sleep with the foot wrapped in a brace, however they have greatly improved in comfort over the last several years.1,6,7,8

6. Other:  Additional variables (joint mobility, footwear, posture/alignment, workplace or daily activity contributions, deficits in other areas of the body such as the knee/hip/low back etc.) can contribute to these symptoms and having an evaluation from a knowledgeable physical therapist can be beneficial.

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for further information and tips specific to climbing and plantar fasciitis as well as other foot disorders.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

References:

1. Schwartz EN, Su J. Plantar Fasciitis: A Concise Review. Perm J. 2014 Winter;18(1):e105-7.
2. Renan-Ordine R1, Alburquerque-Sendín F, de Souza DP, Cleland JA, Fernández-deLas-Peñas C. Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2011 Feb;41(2):43-50.
3. Bass, E. Tendinopathy: Why the Difference Between Tendinitis and Tendinosis Matters. Int J Ther Massage Bodywork. 2012; 5(1): 14–17.
4. Ajimsha MS1, Binsu D2, Chithra S2. Effectiveness of myofascial release in the management of plantar heel pain: A randomized controlled trial. Foot (Edinb). 2014 Jun;24(2):66-71.
5. Glazer JL. An approach to the diagnosis and treatment of plantar fasciitis. Phys Sportsmed. 2009 Jun;37(2):74-9.
6. Davies C. The Trigger Point Therapy Workbook. New Harbor Publications, Oakland, 2004. pp.223-226.
7. Chinn L, Hertel J. Rehabilitation of ankle and foot injuries in athletes. Clin Sports Med. 2010 Jan;29(1):157-67, table of contents.
8. Beyzadeoğlu T, Gökçe A, Bekler H. [The effectiveness of dorsiflexion night splint added to conservative treatment for plantar fasciitis]. Acta Orthop Traumatol Turc. 2007;41(3):220-4. Turkish.

Kids and Climbing Injuries

As coaches, parents, and healthcare providers, we have the opportunity to look after the best interests of our kids and to influence their decision-making processes toward a sustainable and healthy climbing career and life.  Important and helpful research has been done about various topics of avoidable dangers to kids who climb, especially at an elite level.

  1. Growth plate fractures

growth plate
growth plate

What is it?

Fractures at the growth plates of bones of the fingers, especially the middle and ring finger appear to be increasing.  Growth plates are places within the long bones of the body (fingers, humerus, femur) where growth of the bone continues to occur until the body is fully developed. If the growth plate is fractured, the bone may not develop properly, and deformities can occur.  The growth plates typically close between the ages of 13 and 17 years.  During this period before growth plate closure, the skeletal mass increases significantly, which is a problem for climbers because the growth spurt adds more weight to the body, which in turn makes it more difficult to pull oneself up the rock.  Additionally, the growth plates are two to five times weaker than the surrounding connective tissues.  Therefore, during this developmental stage, there is a combination of the weak point in the fingers, the growth spurt, which increases weight, and a subsequent increase in finger strength training intensity to counter the increased weight.  All of these factors lead to the increased incidence of fractures in kids, which can potentially have long term consequences on their climbing careers and other finger related activities in the future.  The fractures are not typically due to a single traumatic incident but rather occur over a period of time due to repeated micro-traumas.

What can we do?

Educating kids about the importance of notifying their parent, caregiver, trainer, or coach of any pain they notice in their fingers is crucial so they can be evaluated by a medical professional who is preferably familiar with climbing-related injuries.  Morrison, Shoffl, et al state that “Climbers who delayed reporting joint pain, ignored medical advice and continued to train intensively, especially on the ‘‘Campusboard’’, experienced permanent deformity of the affected finger with some loss of range of motion.”4  A further training recommendation is to focus on more volume (higher reps with less intensive climbing) and technique with a variety of climbing types rather than intensity and strength.  The more efficient the climber, the less strength and brute force is needed.  Furthermore, there are suggestions to consider avoiding intensive finger strengthening and boulder competitions for kids 16 and under.1,2,3,4

  1. Eating Disorders

In climbing, it is easier to propel yourself upward if there is less weight working to keep you on the ground.  However, for kids who are not yet fully developed, trying to maintain a body weight that is below their natural level can negatively affect the development of their skeletal and neuroendocrine systems as well as their metabolism and even the changes that occur during puberty.  This desire to maintain a lean physique, especially when below one’s natural weight, also has the potential to lead to the development of eating disorders.  Eating disorders are typically more prevalent in women, however, they occur in both sexes in the general and climbing populations.4  Progressing to an eating disorder usually occurs gradually and can have serious long term, potentially fatal effects which may include osteoporosis and/or cardiovascular, digestive, and kidney disorders.  Furthermore, the psychological effects of eating disorders are devastating and long lasting.  The primary tool for prevention of eating disorders is education, and it is recommended to begin educating kids on this subject as early as 9 to 11 years of age.  Additionally, red flags signaling unhealthy methods of weight loss include “starvation, fasting, frequently skipping meals, overeating, and binge-eating followed by purging, as well as the use of diet pills, laxatives, diuretics, and even excessive exercise” as mentioned in an excellent article by Coelho, Gomez, et al.5  If any of these signs are noticed, getting the climber professional help as soon as possible can help prevent potentially irreversible consequences.

As a former high school and college wrestler, I find that eating disorders are much more prevalent then the general population realizes.  In the beginning, there’s a slippery slope involved, rather than big flashy red flags.  You skip a meal here or there, you start exercising intensely without proper hydration or nutrition, you experiment with eating a big meal and purging it afterwards, and on and on.  If the person is fortunate, its an experiment that leads to the realization that these methods aren’t healthy, decrease performance, and just aren’t worth it.  But sometimes it leads down a long hard road of struggle and misery.  Our kids need us to be aware and to guide them on their paths.

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing injury related topics.  Subscribe here to get the latest posts and like my facebook page for updates and more information.  My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

1 Schöffl V, Morrison A, Schöffl I, Küpper T.  The epidemiology of injury in mountaineering, rock and ice climbing.  Med Sport Sci. 2012;58:17-43.

2 Schöffl V, Popp D, Küpper T, Schöffl I.  Injury trends in rock climbers: evaluation of a case series of 911 injuries between 2009 and 2012.  Wilderness Environ Med. 2015 Mar;26(1):62-7.

3 Woollings KY, McKay CD, Kang J, Meeuwisse WH, Emery CA.  Incidence, mechanism and risk factors for injury in youth rock climbers.  Br J Sports Med. 2015 Jan;49(1):44-50.

4 Morrison AB, Schoffl VR.  Physiological responses to rock climbing in young climbers.  Br J Sports Med 2007;41:852–861.

5 Coelho GM1, Gomes AI2, Ribeiro BG2, Soares ED1.  Prevention of eating disorders in female athletes.  Open Access J Sports Med. 2014 May 12;5:105-113.

 

Finger Flexor Tendon Pulley Injuries

Anatomy

The flexor tendons (flexor digitorum superficialis and flexor digitorum profundus) that run along the front of each finger are encased in a continuous sheath of connective tissue.  Along this sheath, there are five thickened areas that create annular pulleys (A1, A2, A3, A4, and A5) as well as three to four cruciform pulleys.  These pulleys keep the tendon close to the bone when flexing the fingers and provide stability as well as allow forces to be transferred from the muscles in the forearm to their tendons in the fingers.1-5

finger and wrist flexors

finger flexor pulley system
finger flexor pulley system

The crimp grip increases the risk of pulley injury because of the increased forces that are able to be exerted.  The force is especially high on the pulleys, especially the A2 pulley.  A closed crimp grip (using the thumb) exerts even more force, which is why it is used so often especially with smaller holds.1,6,7

open crimp grip

closed crimp grip – thumb is added

Injury

Damage to the flexor tendon pulleys is the most common climbing injury.8-14  The grading scale regarding the severity of flexor tendon pulley injuries is as follows:  1. Pulley strain 2. Complete A4 or partial A2, A3 tear/rupture 3. Complete A2 or A3 tear/rupture 4. Multiple ruptures or a single rupture with lumbricalis muscle or collateral ligament trauma.  A grade 4 injury requires surgery to prevent long term damage, such as a flexion contracture (the inability to fully straighten the finger).15,16

Often a “pop” is heard followed by significant swelling and pain (at the base of the finger for A2) when trying to extend (straighten) the finger.8,11,13,17-19  Pain is also noted when trying to flex (bend) the finger and bowstringing may be able to be detected by resisting finger flexion at the distal phalanx (fingertip) if A2-A4 are ruptured.1,13

torn pulleys with bowstringing tendons in a crimp grip

Prevention

  1. Static Stretching – Holding a stretch for at least 30 seconds after a climbing session and on rest days helps to decrease injuries. (For references and more information, see my article titled “Static Stretching for Rock Climbing”.)

wrist flexor stretch
wrist/finger flexor stretch

  1. Warm up – This is a combination of an aerobic warm up (hiking, jogging, cycling, etc.), dynamic stretching, and the sport specific warm up of easy climbing for 100-120 moves (8-12 boulder problems or 3-4 routes).17,20,21 (For more information, see my article titled “Rock Climbing Warm Up”.)
  2. Taping (H taping) – This way of taping has been shown to decrease the risk of reinjury when a pulley tear or sprain has occurred previously.10 

1. Tear a 4-inch piece of athletic tape from the full width of the roll. 2. Tear from each end to leave a 1/2″ bridge connecting the two ends.

3. Place the middle section along the palmer side of the joint in the middle of the finger. 4. Wrap the section of the finger closer to the hand first.

5. Bend the taped joint to 30 degrees and wrap the other section of the finger.

Ready to rock.

  1. Climbing technique and body awareness – Proper footwork technique and avoiding intense dynamic movements may help to decrease the risk of pulley injuries by reducing excessive grip force and thus placing less stress on these structures.22 Listening to your body and allowing an injury to fully heal before returning to climbing helps to prevent reinjury.

Treatment

Having the grade of tear diagnosed medically helps to determine the treatment as well as to rule out damage to nearby structures.  Grades 1 to 3 pulley ruptures do not typically require surgery.  Surgical repair is recommended for Grade 4 ruptures due to the increased risk of fixed flexion contractures (an inability to fully straighten the finger).1,6,8,11,12,23,24  Some authors have also recommended surgical repair for grades 2 and 3 especially for elite-level climbers.25

Initially, one to two weeks of immobilization with a finger immobilization splint or a “pulley protection splint” is recommended for grades 2 and 3 pulley injuries (no immobilization is required for grade 1).4  After the immobilization period, H taping (see picture in prevention section above) is recommended to protect the pulley while gentle range of motion exercises are begun.

finger flexion – bend the finger until a stretch is felt, hold for a second or two, and repeat 10 times

finger extension – straighten the finger until a stretch is felt, hold for a second or two, and repeat 10 times

The taping is recommended for three months with grades 1 and 2 injuries and six months for grade 3 injuries.  Once full and pain free range of motion of the finger has returned (usually one to two weeks after beginning these exercises), gentle strengthening can be initiated with a hangboard or other strengthening device that allows for controlled movements and the ability to modify the force on the injury site if pain is noted (use the feet to decrease the force on the fingers when using a hangboard).   A crimp grip should be avoided for at least six weeks after the injury.  Movements or exercises causing pain at the site of injury should be avoided as this is the body’s way of indicating that it is being re-injured.  A gradual return to climbing can be initiated when no pain is noted with any of the gripping positions you plan to use.  These can be tested on the hangboard or chosen device.  Full return to activity is realistic in six weeks for grade 1 and 2 injuries.  For grade 3 pulley injuries, a gradual return to climbing may be able to be initiated at six to eight weeks and full functional return by three to four months minimum.6,8,11-13,18,26

Some additional treatments are:

  1. Checking for trigger points in the wrist/finger flexors as well as gentle massage to the flexor tendons and pulleys to prevent scar tissue formation

Flexor digitorum superficialis/profundus trigger points 1 – apply direct pressure to any tight or tender spots close to the X and hold for 2-3+ minutes

Flexor digitorum superficialis/profundus trigger points 2 – apply direct pressure to any tight or tender spots close to the X and hold for 2-3+ minutes

  1. Ester Smith, DPT at grassrootsphysicaltherapy.com goes over a solid treatment protocol for this injury on her blog (also featured in trainingbeta.com). This is a great research option for a grad school thesis in areas with high populations of climbers – hint, hint to the students out there.

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing injury related topics.  Subscribe here to get the latest posts and like my facebook page for updates and more information.  My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

1 Kubiak EN, Klugman JA, Bosco JA.  Hand Injuries in Rock Climbers.  Bulletin of the NYU Hospital for Joint Diseases • Volume 64, Numbers 3 & 4, 2006.
2 Bovard R.  Pulley Injuries in Rock Climbers (letter to the editor).   Wilderness & Environmental Medicine.  Allen Press Publishing Serv;Spring2004, Vol. 15 Issue 1, p70.
3 Schoffl V, Heid A, Kupper T.  Tendon injuries of the hand.  World J Orthop 2012 June 18; 3(6): 62-69.
4 Schneeberger M, Schweizer A.  Pulley Ruptures in Rock Climbers: Outcome of  Conservative Treatment With the Pulley-Protection Splint-A Series of 47 Cases.  Wilderness Environ Med. 2016 Jun;27(2):211-8.
5 Zafonte B, Rendulic D, Szabo RM.  Flexor pulley system: anatomy, injury, and  management.  J Hand Surg Am. 2014 Dec;39(12):2525-32; quiz 2533.
6 Warme WJ, Brooks D.  The effect of circumferential taping on flexor tendon pulley failure in rock climbers.  Am J Sports Med. 2000 Sep-Oct;28(5):674-8.
7 Schweizer A, Hudek R.  Kinetics of crimp and slope grip in rock climbing.   J Appl Biomech. 2011 May;27(2):116-21.
8 Crowley T.  The Flexor Tendon Pulley System and Rock Climbing.  J Hand Microsurg (January–June 2012) 4(1):25–29 DOI 10.1007/s12593-012-0061-3.
9 Schöffl V, Popp D, Küpper T, Schöffl I.  Injury trends in rock climbers: evaluation of a case series of 911 injuries between 2009 and 2012.  Wilderness Environ Med. 2015 Mar;26(1):62-7.
10 Schoffl I, Einwag F, Strecker W, et al.  Impact of Taping After Finger Flexor Tendon Pulley Ruptures in Rock Climbers.  Journal of Applied Biomechanics, 2007; 23:52-62.
11 Schöffl V, Hochholzer T, Winkelmann HP, Strecker W.  Pulley injuries in rock  climbers.  Wilderness Environ Med. 2003 Summer;14(2):94-100.
12 Schöffl VR, Einwag F, Strecker W, Schöffl I.  Strength measurement and clinical  outcome after pulley ruptures in climbers.  Med Sci Sports Exerc. 2006 Apr;38(4):637-43.
13 Schöffl VR, Schöffl I.  Finger pain in rock climbers: reaching the right differential  diagnosis and therapy.  J Sports Med Phys Fitness. 2007 Mar;47(1):70-8.
14 Pozzi A, Pivato G, Pegoli L.  Hand Injury in Rock Climbing: Literature Review.  J Hand Surg Asian Pac Vol. 2016 Feb;21(1):13-7.
15 Schöffl V, Hochholzer T, Winkelmann HP, Strecker W.  Pulley injuries in rock  climbers.  Wilderness Environ Med. 2003 Summer;14(2):94-100.
16 Smith LO.   Alpine climbing: injuries and illness.  Phys Med Rehabil Clin N Am. 2006 Aug;17(3):633-44.
17 Schweizer A.  Sport climbing from a medical point of view.   Swiss Med Wkly. 2012;142:w13688.
18 Rohrbough JT, Mudge MK, Schilling RC, Jansen C.  Overuse injuries in the elite rock climber.  Med Sci Sports Exerc. 2000 Aug;32(8):1369-72.
19 Merritt AL, Huang JI.  Hand injuries in rock climbing.  J Hand Surg Am. 2011 Nov;36(11):1859-61.
20 Hockhoelzer T, Schoeffl.  One Move Too Many…  Druckerei Sonnenschein,  Ebenhausen, 2003.  p. 109.
21 Schweizer A.  Biomechanical properties of the crimp grip position in rock climbers.  J Biomech. 2001 Feb;34(2):217-23.
22 Koukoubis TD, Cooper LW, Glisson RR, Seaber AV, Feagin JA Jr.   An electromyographic study of arm muscles during climbing.  Knee Surg Sports  Traumatol Arthrosc. 1995;3(2):121-4.
23 El-Sheikh Y, Wong I, Farrokhyar F, Thoma A.  Diagnosis of finger flexor pulley injury in rock climbers: A systematic review.  Can J Plast Surg 2006;14(4):227-231.
24 Klauser A, Frauscher F, Bodner G.   Finger Pulley Injuries in Extreme Rock Climbers: Depiction with Dynamic US.  Radiology. 2002 Mar;222(3):755-61.
25 Bouyer M, Forli A, Semere A, Chedal Bornu BJ, Corcella D, Moutet F.  Recovery of rock climbing performance after surgical reconstruction of finger pulleys.  J Hand Surg Eur Vol. 2016 May;41(4):406-12.
26 Holtzhausen LM, Noakes TD.  Elbow, forearm, wrist, and hand injuries among sport rock climbers.  Clin J Sport Med. 1996 Jul;6(3):196-203.

Static Stretching for Rock Climbing

The topic of static stretching is a prime example of why I wrote Beyond Tape.  I was starting to see more blog posts stating things like “there is absolutely no research that shows static stretching can help to prevent injuries”.  From time to time, we all regurgitate information that we believe to be true (whether it be related to health, politics, education, etc.) but do not always have clear examples of why we believe what we believe aside from hearing it from a source we trust (professor, coach, politician, news source, etc.).  I wondered, “Am I doing that?” and “Do these people know something I don’t?”  I went back through the research to organize the solid studies showing that a statistically significant decrease in musculotendinous injuries (sprains and strains) occurs when static stretching is used.1,2,3,4,5  There are also research results that call into question the benefits of static stretching for injury prevention.6,7,8  However, these conflicts are resolved in almost all cases when looking at the types of injuries and types of activities that are studied.   For example, stretching will most likely not prevent injuries such as dislocations or fractures that occur due to a traumatic event.  Another important point is that the research showing benefits of static stretching has been done with activities that require explosive movements or the athlete using the end ranges of movements, such as soccer.  In contrast, I think it is reasonable to argue that static stretching may not be beneficial for injury prevention for activities such as long distance running where end ranges and explosive movements are not typically used.  The bottom line is that static stretching is recommended for musculotendinous injury (strains and sprains) prevention with climbing due to the facts that these types of injuries are highly prevalent in the climbing population and that climbers are frequently testing end ranges of motion, especially in their shoulders and hips, as well as performing explosive movements especially with bouldering and sport climbing.

What is static stretching, how should I do it, and what stretches are best for climbers?

Static stretching occurs when a muscle is held at its end range for a prolonged period of time.  Research shows that a minimum of 30 seconds is best for muscle lengthening1,9,10,11 and holding for 1.5-3 minutes or more can additionally help release any myofascial restrictions that may be present.12,13,14,15

Check out my rock climbing warm up article for the reasons why static stretching is best used after climbing and on rest days, as opposed to before climbing.

The following are examples of important stretches for climbing specifically due to either the repetitiveness of some motions (finger/wrist flexors), the explosive nature of movements that use certain muscle groups (finger/wrist flexors, latissimus dorsi, hip extensors), and/or the likelihood of reaching into the end ranges of certain body parts on a regular basis (shoulder and hip joints).

  1. Wrist/finger flexors – used to grip the rock with all types of holds

wrist flexor stretch
wrist/finger flexor stretch

2. Wrist/finger extensors – used to stabilize the wrist and oppose the wrist flexors

wrist flexor stretch
wrist/finger extensor stretch

3. Pectorals – pectoralis minor contributes to rolling the shoulders forward in the typical “climber’s back” posture

pec minor stretch
pectoral stretch

4. Latissimus Dorsi – used extensively in the pulling motions of climbing and also contributes to rolling the shoulders forward in the typical “climber’s back” posture

latissimus dorsi stretch

5. High step (hip adductors, extensors, internal rotators) – lack of flexibility can limit climbing ability and cause significant strain on the muscles in their most lengthened position

high step stretch – hip extensors, adductors, and internal rotators

6. Spinal twists with shoulder horizontal adduction – lack of spinal flexibility contributes to excessive motion at the shoulder and hip joints; this pose also stretches the muscles of the posterior shoulder which is used extensively in pulling

 

spinal twist with shoulder horizontal adduction stretch
spinal twist with shoulder horizontal adduction stretch

 

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing injury related topics.  Subscribe here to get the latest posts and like my facebook page for updates and more information.  My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

1 Woods K, Bishop K, Jones E.  Warm-Up and Stretching in the Prevention of Muscular Injury.  Sports Med 2007; 37 (12): 1089-1099.
2 Hartig DE1, Henderson JM.  Increasing hamstring flexibility decreases lower extremity overuse injuries in military basic trainees.  Am J Sports Med. 1999 Mar-Apr;27(2):173-6.
3 Cross KM1, Worrell TW.  Effects of a static stretching program on the incidence of lower extremity musculotendinous strains.  J Athl Train. 1999 Jan;34(1):11-4.
4 McHugh MP1, Cosgrave CH.  To stretch or not to stretch: the role of stretching in injury prevention and performance.  Scand J Med Sci Sports. 2010 Apr;20(2):169-81.
5 Amako M1, Oda T, Masuoka K, Yokoi H, Campisi P.  Effect of static stretching on prevention of injuries for military recruits.  Mil Med. 2003 Jun;168(6):442-6.
6 Pope RP1, Herbert RD, Kirwan JD, Graham BJ.  A randomized trial of preexercise stretching for prevention of lower-limb injury.   Med Sci Sports Exerc. 2000 Feb;32(2):271-7.
7 Arnason A1, Andersen TE, Holme I, Engebretsen L, Bahr R.  Prevention of hamstring strains in elite soccer: an intervention study.  Scand J Med Sci Sports. 2008 Feb;18(1):40-8.
8 Thacker SB1, Gilchrist J, Stroup DF, Kimsey CD Jr.  The impact of stretching on sports injury risk: a systematic review of the literature.  Med Sci Sports Exerc. 2004 Mar;36(3):371-8.
9 de Weijer VC1, Gorniak GC, Shamus E.  The effect of static stretch and warm-up exercise on hamstring length over the course of 24 hours.  J Orthop Sports Phys Ther. 2003 Dec;33(12):727-33.
10 Davis DS1, Ashby PE, McCale KL, McQuain JA, Wine JM.  The effectiveness of 3 stretching techniques on hamstring flexibility using consistent stretching parameters.  J Strength Cond Res. 2005 Feb;19(1):27-32.
11 Bandy WD, Irion JM, Briggler M.  The effect of static stretch and dynamic range of motion training on the flexibility of the hamstring muscles.  J Orthop Sports Phys Ther. 1998 Apr;27(4):295-300.
12 Ajimsha MS1, Binsu D2, Chithra S2.  Effectiveness of myofascial release in the management of plantar heel pain: A randomized controlled trial.  Foot (Edinb). 2014 Jun;24(2):66-71.
13 Barnes JF.  Myofascial Release:  The Search for Excellence.  Paoli, PA:  Rehabilitation Services, Inc., 1990.  Print.
14 Standley P.  In Vitro Mechanical Strain Modeling of Myofascial Release.  Date: 11/3/2011.  http://www.osteopathic.org/inside-aoa/events/annual-aoa-research-conference/2011-research-conference/Documents/10-30-2011/1—10-30-2011–BiomechanicalRegulation-of-Cell-Function—-Standley.pdf (presented at the 2011 Research Conference of the AOA).
15 Cao TV1, Hicks MR1, Zein-Hammoud M1, Standley PR2.  Duration and magnitude of myofascial release in 3-dimensional bioengineered tendons: effects on wound healing.  J Am Osteopath Assoc. 2015 Feb;115(2):72-82.

The Rock Climbing Warm Up

Maybe not the most exciting part of climbing, but one of the most important for keeping you on the rock and off the couch.  We’re all excited to get to our projects.  When warming up, many of us are hoping to hit that sweet spot between performing enough easier climbs to get us ready for more challenging routes/problems but not overdoing it on the warm up and blowing our chance to give a serious effort to the goals of the day.  Thankfully, Schweitzer provided us with a solid range of routes/problems to work off of.  His study from 2001 showed that roughly 100-120 moves, or 3-4 routes/8-12 boulder problems, were required for the finger flexor tendon pulley system to show an increased amount of pliability.  This means that the tendons are better able to tolerate the loads that are being placed on them.1,2,3  So, the recommendation is 3-4 easy routes or 8-12 easy boulder problems before attempting climbing near your upper limit. Warm up routines and their relation to injury prevention have yet to be researched specifically in the climbing community (hint, hint for any doctoral students out there looking for a thesis topic), however, the evidence  from sport-specific warm ups and warm ups with the three components listed below shows a correlation between warm ups and decreased injury rates for various sports such as soccer, basketball, football, as well as with military recruits.4,5,6  Furthermore, a basic aerobic warm up, such as light jogging for as little as five minutes, hiking to the climbing area or jumping rope in the gym, has been shown to increase flexibility and prepare the body for the upcoming activity.7,8

The Business:  3 parts to the warm up

  1. A mellow aerobic activity – light jogging or cycling for 20-30 minutes or the approach to the climbing area (although, even as little as 5 minutes has been shown to increase flexibility and prepare the body for the upcoming activity)7,8
  2. Stretching – dynamic stretching (stretching through motion), as opposed to static stretching (holding a stretch for prolonged periods), is best used during the warm up. Static stretching has gotten a bad rap as far as injury prevention and treatment, which I’ll discuss in a later post, but there’s some evidence that it decreases performance when used immediately prior to competition.9,10,11,12  There is however some evidence that dynamic stretching can help to improve immediate performance,13,14 which is why I recommend dynamic stretching during the warm up.  Dynamic stretching can be worked into #3 below, or here are 3 examples of helpful dynamic stretches for climbers:

High Step

Wrist flexors/extensors

Latissimus Dorsi

  1. An activity specific to the sport being perform – this is your 3-4 easy routes or 8-12 easy boulder problems

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment (currently sold locally in Bishop stores, on my website, and soon to be on Amazon) for more information about warming up, stretching, and other climbing injury related topics.  Subscribe here to get the latest posts and like my facebook page for updates and more information.  My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

1 Wright DM, Royle TJ, Marshall T.  Indoor rock climbing: who gets injured?  Br J Sports Med 2001;35:181–185.
2 Hockhoelzer T, Schoeffl.  One Move Too Many…  Druckerei Sonnenschein, Ebenhausen, 2003.  p. 109.
3 Schweizer A.  Sport climbing from a medical point of view.   Swiss Med Wkly. 2012;142:w13688.
4 Fradkin AJ1, Gabbe BJ, Cameron PA.  Does warming up prevent injury in sport? The evidence from randomised controlled trials?  J Sci Med Sport. 2006 Jun;9(3):214-20.
5 Woods K, Bishop K, Jones E.  Warm-Up and Stretching in the Prevention of Muscular Injury.  Sports Med 2007; 37 (12): 1089-1099.
6 Herman K, Barton C, Malliaras P, Morrissey D.  The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review.  BMC Med. 2012 Jul 19;10:75.
7 Samson M1, Button DC, Chaouachi A, Behm DG.  Effects of dynamic and static stretching  within general and activity specific warm-up protocols.  J Sports Sci Med. 2012 Jun 1;11(2):279-85.
8 O’Sullivan K1, Murray E, Sainsbury D.  The effect of warm-up, static stretching and dynamic stretching on hamstring flexibility in previously injured subjects.  BMC Musculoskelet Disord. 2009 Apr 16;10:37.
9 McHugh MP1, Cosgrave CH.  To stretch or not to stretch: the role of stretching in injury prevention and performance.  Scand J Med Sci Sports. 2010 Apr;20(2):169-81.
10 Winchester JB1, Nelson AG, Landin D, Young MA, Schexnayder IC.  Static stretching impairs sprint performance in collegiate track and field athletes.  J Strength Cond Res. 2008 Jan;22(1):13-9.
11 Gergley JC.  Acute effect of passive static stretching on lower-body strength in moderately trained men.  J Strength Cond Res. 2013 Apr;27(4):973-7.
12 Simic L1, Sarabon N, Markovic G.  Does pre-exercise static stretching inhibit maximal muscular performance? A meta-analytical review.  Scand J Med Sci Sports. 2013 Mar;23(2):131-48.
13 Little T1, Williams AG.  Effects of differential stretching protocols during warm-ups on high-speed motor capacities in professional soccer players.  J Strength Cond Res. 2006 Feb;20(1):203-7.
14 Myers, T.   Fascial Fitness: Training in the Neuromyofascial Web.    IDEA Fitness Journal, Volume 8, Number 4.  April 2011.