Category Archives: Blog

Beyond Tape Donations – Wild Iris

After writing Beyond Tape, I made a commitment to donate all of my net proceeds to local and global non-profit service-oriented organizations.  I’m excited to finally start passing those proceeds along and plan to write articles describing where that money is going and why I’m choosing each organization.

Thanks to all the folks who bought the book as well as the numerous people who donated their pictures, knowledge, and time to help me make Beyond Tape much better than it would have been with just me at the wheel.

My goal with the donations is to shine a light on people and organizations who are working hard to make meaningful and positive changes in their communities, both locally and globally.  It often seems we’re being constantly reminded of how hurtful we can be as human beings, but there are many more true heroes out there doing the tough job of preventing and cleaning up the messes in order to show us there are ways out of the darkness.  My intention is to strive to be more like the light creators.  I hope you’ll join me!  Giving money is great and, taking it a step further, people who volunteer for roughly 100 hours/year with 1-2 organizations tend to live longer and healthier lives.1-4 If the extent of the problems you see in the world seem overwhelming and you don’t know where to begin, start at home.  It’s often easiest to see the tangible good that is being done in your backyard.

Wild Iris is an obvious choice for a donation, in my opinion.  Here are 3 reasons why:

  1. They’ve been helpful to me personally.  In my line of work, I’m fortunate to have people trust me enough to tell me some pretty heavy things that happen in their lives.  I encourage this openness because physical problems are rarely, if ever, only physical.  Sometimes the things people share with me are beyond the scope of my ability to help them and Wild Iris has been an invaluable referral source since the time I moved to Bishop fourteen years ago.
  2. We can all agree domestic violence is a problem and we should do what we can to decrease it.  It’s a problem that affects all of us, whether directly or indirectly.
    •  “Children who witness or are victims of emotional, physical, or sexual abuse are at higher risk for health problems as adults. These can include mental health conditions, such as depression and anxiety. They may also include diabetes, obesity, heart disease, poor self-esteem, and other problems.”5
    • Kids who grow up in abusive households are 3-4X more likely to repeat the cycle in adulthood, whether by becoming an abuser or being abused.6,7   “The single best predictor of children becoming either perpetrators or victims of domestic violence later in life is whether or not they grow up in a home where there is domestic violence. “8
    • “A boy who sees his mother being abused is 10 times more likely to abuse his female partner as an adult. A girl who grows up in a home where her father abuses her mother is more than six times as likely to be sexually abused as a girl who grows up in a non-abusive home.”9

    It’s said that “hurt people hurt people”.  With the help of folks like Wild Iris, we can work to stop the cycle of violence.

  3. Wild Iris is an organization that focuses on treatment as well as prevention.  Aside from their direct client services, they offer the following programs and services (see their website for more information):
  • Parenting and Co- Parenting Classes: Wild Iris offers a FREE 6-week series of parenting and FREE 8-week series of co-parenting classes.
  • Supervised Visitation Monitoring: We provide neutral, professional third parties who can enforce effective safety measures during a child visitation with a non-custodial parent.
  • Youth Violence Prevention: Wild Iris offers a curriculum to students in the local schools that helps the faculty and staff meet their educational standards in areas of mental, emotional and social health, violence prevention and safety, and sexual health.
  • CASA (Court Appointed Special Advocate): Our CASA program provide foster youth with professional volunteer advocate in order to objectively gather information and provide a voice for the child in court as well as provide the child with a consistent adult in their life while in foster care.
  • Groups: Wild Iris offers A Window Between Worlds and Art For Healing programs. Hands-on workshops offer a safe environment for self-expression and self-exploration while using art as a way to heal from trauma, pain, grief, fear or stress.
  • 52- Week Court Ordered Parenting: Wild Iris offers the 52-week Court Ordered Parenting course. Those interested do not need to have a court order to attend classes.

 

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for information about warming up, stretching, and other climbing (and non-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 Konrath S, Fuhrel-Forbis A, et al. Motives for volunteering are associated with mortality risk in older adults. Health Psychol. 2012 Jan;31(1):87-96.
2 Sneed R, Cohen S. A prospective study of volunteerism and hypertension risk in older adults. Psychology and Aging, Vol 28(2), Jun 2013, 578-586.
3 Anderson ND, Damianakis T, et al. The benefits associated with volunteering among seniors: a critical review and recommendations for future research. Psychol Bull. 2014 Nov;140(6):1505-
33.
4 https://www.nationalservice.gov/pdf/07_0506_hbr.pdf
5 Monnat SM1, Chandler RF2. Long Term Physical Health Consequences of Adverse Childhood Experiences. Sociol Q. 2015 Sep;56(4):723-752.
6https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/peoplewhowereabusedaschildrenaremorelikelytobeabusedasanadult/2017-09-27
7 https://southbaycommunityservices.org/domestic-violence-awareness-month/
8 https://www.unicef.org/media/files/BehindClosedDoors.pdf
9 Vargas, L. Cataldo, J., Dickson, S. (2005). Domestic Violence and Children (link is external). In G.R. Walz & R.K. Yep (Eds.), VISTAS: Compelling Perspectives on Counseling. Alexandria, VA: American Counseling Association; 67-69.

Critical Decision Making and the Healing Process: Part 1

Image caption:  Crashpads and appropriate spotters are climbing critical decision making 101…double fail!

Critical decision making is one of the most important aspects, and oftentimes the key component, for the prevention and treatment of injuries.  Our bodies (and beings) have the amazing ability to heal themselves in most cases, aside from cases of severe trauma such as displaced fractures.  Its our job to create the environment to allow our bodies to do what they know how to do…heal.

There can be blockages to the healing process so we first have to figure out what those blockages are and then remove them.  This takes having a keen awareness of the things that are limiting the healing as well as those that are promoting it.   Listening to the signals that our bodies send, such as pain, depression, and anxiety, help us find the path that leads to healing.  This awareness ultimately gives us the power to make decisions that allow us to return to the life and activities that we wish for.  Pain and inflammation (discussed below) are important, albeit uncomfortable, parts of the healing process.

Understanding the healing process from a physiological perspective is a helpful start to show that healing is in fact a process, not an event.  For a more in depth description, check out the first chapter of Beyond Tape or the references below.1-11 Simply put, there are three main phases:

 Phases of the healing process
  1. Inflammation (roughly days 0-7):  When an injury occurs, the body sends an increased supply of blood to the area which bring in cells that remove dead or damaged tissue.   When those cells are finished, they call in a new group of cells to come in to lay down new tissue.  In addition to the cells, various chemical messengers are released, some of which signal danger (or pain) that prevent the person from continuing to touch the hot stove, for example.
  2. Proliferation (roughly days 7-21):  New tissue gets laid down.  Initially, the new tissue is disorganized, like a clump of cooked spaghetti.
  3. Remodeling/maturation (roughly day 21-weeks/months):  The disorganized tissue realigns in a more functional way so we can return to normal activities.  This realignment occurs from finding the balance of stressing the tissues (range of motion, stretching, strengthening, functional activities) enough to create healthy adaptation while not stressing them enough to cause more injury.

Now that we have the physiology out of the way, here are some other common themes that hold people back.  I think these topics are fascinating and shifted my personal mindset from seeing my own unhealthy decisions as “bonehead Mike decisions” to ways that I as a human being have a tendency to sabotage myself.   Having the awareness that we’re all subject to things like cognitive biases, allows us to think more critically about a decision before it takes us down a hard and unnecessary road.  Check out the lecture series “The Art of Critical Decision Making” with Michael Roberto from the Teaching Company and Daniel Kahneman’s book Thinking, Fast and Slow for a more in-depth discussion of these types of topics.

1. Sunk Cost Effect

The “sunk cost effect” is a term typically used in economics that applies to many other areas of life as well (we’ll use rock climbing as an example). It is “an irrational economic decision to invest more future resources after a prior investment has been made (costs are sunk) compared to a similar situation
without a prior investment”.12

For climbing, this is exemplified by making the decision to continue climbing when there is an injury present because of the desire to avoid wasting all the time, effort, and possibly money that has been spent training to reach a goal. This may involve working toward specific goals of boulder problems, red points, or summits. The climber finds herself in a situation where there are obstacles to those goals in the form of an injury, illness, or uncooperative weather. The rational decision would be to back off in order to return to climbing in a healthy
state. The irrational decision would be to ignore the obstacles and continue digging further into the hole. These irrational decisions are often easy to see in hindsight, but we are all capable of justifying unhealthy decisions when the sunk cost effect is present. Making the rational decision could mean the difference between returning
to climbing after a sprain or strain heals in a couple weeks versus doing serious damage that eventually puts the climber out for months or a year.

For mountain climbing, the difference could be aborting the mission in order to make another attempt on a later date versus continuing on and risking serious injury or death. The sunk cost effect was thought to be a major factor in the Mt. Everest tragedy in 1996 where 5 climbers died, including 2 experienced expedition leaders.13 Sticking to turn around times and acknowledging approaching ominous weather becomes more difficult the more prior investment has been made. Try to step back and see the bigger picture before ignoring the signs.

2. Good Pain Versus Bad Pain

Most of us were told some form of “no pain, no gain” over and over starting from a young age.  Is this a true statement?  As with most other things in life, it depends.  There is injurious pain (pain signifying injury or danger) and therapeutic pain (discomfort that leads to beneficial results).  Take a person who is training for a race and doing speed work at the track.  It’s hard and is becoming mentally painful to continue, but they know if they do a couple more sprints it will help their performance (therapeutic pain).  If that person broke their ankle, they hopefully wouldn’t continue to run because it will not help their performance (injurious pain).  That’s an extreme example, but you get the point.

This concept also comes up when talking about performing self body work at home.  I practice and teach people to perform myofascial release on themselves, which is sinking into an area that feels tight and tender and holding direct pressure on the area for 2-3 or more minutes of time to release restricted areas.  People often describe this a “good hurt”.  The idea is to work with your body rather than to beat it into submission.

This is a part of what is probably the most important message from this article…listen to the body, as well as to the environment, and to the signals they are sending. As they say, “if you listen to your body when it whispers, you won’t have to hear it scream”. Paige, Fiore, et al describe this perfectly: “Climbers should be encouraged to immediately stop climbing when they feel sharp pain. This is especially true of finger pain and if symptoms appear while “working” a move. This seems obvious, but successful climbers, like other successful athletes, have often conditioned themselves to ignore discomfort and to push through difficulties. Climbers must learn to differentiate between pushing oneself despite exhaustion and muscular fatigue and pushing oneself into a serious connective tissue injury.” 14

3. All or None Versus Modification

A crucial aspect of healing is determining aspects of our lives that either help the healing process or slow it down.  I think it helps to just start with concrete aspects without worrying about how you might modify those aspects.

For example, take a person who loves gardening, which is an activity that increases their pain.  People are often reluctant to even start this conversation, stating, “well I have to garden!” (or work or take care of my kids, etc.).  Starting from a place of either gardening or not gardening prevents us from considering the possibility of modification, or finding the balance between doing what we want but not in a way that causes further injury.  Once we have the aspect (gardening in this case), we can look at variables that might be modified. For example, length of time performing the task.  Instead of gardening for 4 hours straight, is it possible to try 1 hour blocks with a 30 minute rest break in between?  This not only might help the body heal, but it also allows a person to assess their progress over time (start with 1 hour for the first week, increase to 1.5 hours for the next if it feels ok, then 2 hours, etc.).

Some other examples of variables that can be modified might be the various activities (digging vs. watering vs. weeding vs. planting), time of day (does the pain tend to be worse first thing in the morning or in the evening?), the possibility of having someone else temporarily perform some of the more strenuous activities, body position (standing and bending over versus using a stool or bench).  The goal is to create the environment that allows your body to heal itself by making logical, rational decisions.  It helps to see these modifications as temporary, while you’re allowing your body to heal. I often suggest that if a person is having trouble deciding if they should perform a certain activity, pretend a loved one is telling them about this exact situation happening to that loved one.  What advice would you give them?

4. Real versus perceived threat 

I see lots of folks who haven’t tried a certain activity because they think it will hurt.  Oftentimes when we try the activity in the clinic, they find that its either not painful, or we’re able to modify it so they can start to ease into the activity.  Its a powerful feeling to realize that you may be capable of things you thought you were not and that there is at least the possibility you can return to your life.

There are many understandable reasons why we all avoid things that we think will hurt.  Sometimes people are told they shouldn’t do certain things (you should stop running, lifting, squatting, bending, etc.).  There can be important reasons for these suggestions (avoiding bending over or prolonged slouched positions with an acute spinal compression fracture, for example) but that’s not a long term plan.  In most cases, people should be able to return to their normal daily lives after an injury.

Problems that show up on imaging (Xrays, MRIs, etc.) can be disconcerting.  A lot of folks are under the impression that once damage is done (disc herniation, meniscus tear, arthritis, etc.) then it will be there forever.  In reality, these injuries heal the majority of the time15-27,   or may not actually be the cause of the pain.28-39  There are certainly times when your body may require some outside help (surgery, etc.), such as a herniated disc stopping the nerve signal to the area it controls which can cause significant and specific weakness, lack of sensation, or bowel/bladder problems.  Again though, most of the time the body can heal.

What you can do:  Gain greater and greater awareness into the meaning the signals your body sends.  See pain as a crucial tool to help you heal yourself.  Ease into activities in a controlled manner, initially avoiding forceful movements using momentum (starting a lawn mower, for example).  Consider how your body feels during the activity, immediately after, and the next day.   Assume you can heal, you may just not have figured out how yet.  People who believe they can heal make different decisions than those that don’t, which will be discussed further in Part 2.

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-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:

1Kannus P1, Parkkari J, Järvinen TL, Järvinen TA, Järvinen M. Basic science and clinical studies coincide: active treatment approach is needed after a sports injury. Scand J Med Sci Sports. 2003 Jun;13(3):150-4.
2Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J. BoneJoint Surg. 2005; 87:187Y202.
3James R1, Kesturu G, et al. Tendon: biology, biomechanics, repair, growth factors, and evolving treatment options. J Hand Surg Am. 2008 Jan;33(1):102-12.
4Hess GP, Cappiello WL, Poole RM, et al: Prevention and treatment of overuse tendon injuries. S p o r t s M e d 8 : 371–384, 1989.
5Järvinen TA1, Järvinen TL, et al. Muscle injuries: biology and treatment. Am J Sports Med. 2005 May;33(5):745-64.
6Bondesen BA1, Mills ST, et al. The COX-2 pathway is essential during early stages of skeletal muscle regeneration. Am J Physiol Cell Physiol. 2004 Aug;287(2):C475-83.
7Schleip R1, Müller DG. Training principles for fascial connective tissues: scientific foundation and suggested practical applications. J Bodyw Mov Ther. 2013 Jan;17(1):103-15.
8Lu H1, Huang D, et al. Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury. FASEB J. 2011 Jan;25(1):358-69.
9Arnold L1, Henry A, et al. Inflammatory monocytes recruited after skeletal muscle injury switch into antiinflammatory macrophages to support myogenesis. J Exp Med. 2007 May 14;204(5):1057-69.
10Smith C1, Kruger MJ, et al. The inflammatory response to skeletal muscle injury: illuminating complexities. Sports Med. 2008;38(11):947-69.
11Wren TA, Yerby SA, et al. Mechanical properties of the human achilles tendon. Clin Biomech (Bristol, Avon). 2001 Mar;16(3):245-51.
12Strough J1, Karns TE, Schlosnagle L. Decision-making heuristics and biases across the life span. Ann N Y Acad Sci. 2011 Oct;1235:57-74.
13Roberto, M. The Art of Critical Decision Making. The Teaching Company. 2009.
14Paige TE, Fiore DC, Houston JD. Injury in traditional and sport rock climbing. Wilderness and Environmental Medicine, 9,2-7 (1998).
15Benson RT1, Tavares SP, et al.  Conservatively treated massive prolapsed discs: a 7-year follow-up.  Ann R Coll Surg Engl. 2010 Mar;92(2):147-53.
16Saal JA1, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. An outcome study. Spine (Phila Pa 1976). 1989 Apr;14(4):431-7.
17 Yukawa Y1, Kato F, et al. Serial magnetic resonance imaging follow-up study of lumbar disc herniation conservatively treated for average 30 months: relation between reduction of herniation and degeneration of disc. J Spinal Disord. 1996 Jun;9(3):251-6.
18Masui T1, Yukawa Y, et al. Natural history of patients with lumbar disc herniation observed by magnetic resonance imaging for minimum 7 years. J Spinal Disord Tech. 2005 Apr;18(2):121-6.
19Matsubara Y1, Kato F, Mimatsu K, Kajino G, Nakamura S, Nitta H. Serial changes on MRI in lumbar disc herniations treated conservatively. Neuroradiology. 1995 Jul;37(5):378-83.
20Komori H, Okawa A, et al.  Contrast-enhanced magnetic resonance imaging in conservative management of lumbar disc herniation. Spine (Phila Pa 1976). 1998 Jan 1;23(1):67-73.
21Autio RA1, Karppinen J, et al.  Determinants of spontaneous resorption of intervertebral disc herniations.  Spine (Phila Pa 1976). 2006 May 15;31(11):1247-52.
22 Anakwenze OA1, Namdari S, et al. Athletic performance outcomes following lumbar discectomy in professional basketball players. Spine (Phila Pa 1976). 2010 Apr 1;35(7):825-8.
23Hsu WK1. Performance-based outcomes following lumbar discectomy in professional athletes in the National Football League. Spine (Phila Pa 1976). 2010 May 20;35(12):1247-51.
24Mochida K1, Komori H, Okawa A, Muneta T, Haro H, Shinomiya K. Regression of cervical disc herniation observed on magnetic resonance images. Spine (Phila Pa 1976). 1998 May 1;23(9):990-5; discussion 996-7.
25Lee DY1, Park YJ2, et al. Arthroscopic meniscal surgery versus conservative management in patients aged 40 years and older: a meta-analysis. Arch Orthop Trauma Surg. 2018 Dec;138(12):1731-1739.
26Sihvonen R1, Paavola M2, et al.  Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial.  Ann Rheum Dis. 2018 Feb;77(2):188-195.
27Azam M1, Shenoy R2.  The Role of Arthroscopic Partial Meniscectomy in the Management of Degenerative Meniscus Tears: A Review of the Recent Literature.  Open Orthop J. 2016 Dec 30;10:797-804.
28Boden SD1, Davis DO, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8.
29Deyo RA. Magnetic resonance imaging of the lumbar spine. Terrific test or tar baby? N Engl J Med. 1994 Jul 14;331(2):115-6.
30Brinjikji W1, Luetmer PH2, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6.
31Bedson J1, Croft PR.. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskelet Disord. 2008 Sep 2;9:116.
32Beattie KA1, Boulos P, et al. Abnormalities identified in the knees of asymptomatic volunteers using peripheral magnetic resonance imaging. Osteoarthritis Cartilage. 2005 Mar;13(3):181-6.
33Guermazi A1, Niu J, et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ. 2012 Aug 29;345:e5339.
34Schwartzberg R1, Reuss BL, et al. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthop J Sports Med. 2016 Jan 5;4(1):2325967115623212.
35Kälin PS1, Crawford RJ, et al. Shoulder muscle volume and fat content in healthy adult volunteers: quantification with DIXON MRI to determine the influence of demographics and handedness. Skeletal Radiol. 2018 Oct;47(10):1393-1402.
36Nakashima H1, Yukawa Y, et al. Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015 Mar 15;40(6):392-8.
37Register B1, Pennock AT, et al. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. Am J Sports Med. 2012 Dec;40(12):2720-4.
38Alyas F1, Turner M, Connell D. MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. Br J Sports Med. 2007 Nov;41(11):836-41; discussion 841.
39Videman T1, Battié MC, et al.  Associations between back pain history and lumbar MRI findings.  Spine (Phila Pa 1976). 2003 Mar 15;28(6):582-8.

 

 

 

 

 

 

Find Your Balance to Prevent Falls and Boost Confidence

About a third of people 65 years and older fall at least one time each year.1-3  Falls account for over half of all injury-related hospitalizations for the elderly.2

As a community, we can help  our friends and family members by assisting them with the exercises and helping them address any external factors noted below.  As individuals, we can boost motivation by exercising with a friend or taking a class.  Additionally, a common message that is conveyed to older folks is that they are frail and that inactivity and falls are an inevitable part of aging.6 As with many other things in life, its easy to take an aspect of truth and swing our pendulum in an extreme direction.  Its true that sarcopenia, the term given to the loss of muscle mass related to age, occurs.3,6  About two percent of muscle mass is lost per year after the age of 50.6 This loss in muscle mass is one of the main contributors to decreased function, such as rising from a chair, walking, making turns, and balance at rest and while performing activities.3,6,7  However, strength training has been shown to greatly mitigate this decline.5,6  Perhaps even more exciting is that exercises and educational programs have been shown to significantly improve balance and decrease the risk of falls as well as injuries caused by falls.1-13

Aside from the exercises mentioned below, Tai Chi2,14, Pilates21, and Yoga22 have been shown to improve balance and decrease the risk of falls.  If you live in the Bishop area, we’re blessed to have Tai Chi classes taught by Andy Selters and Deo Santos, Pilates at Bishop Yoga and Pilates Center and FlowMotion Pilates, and yoga at Bishop Yoga and Pilates Center, FlowMotion Pilates, Sabine Elia at Inyo Council for the Arts, and Sierra Shanti.

There are many exercise programs geared towards improving balance and decreasing fall risk.  They all tend to have the common themes of addressing strength, flexibility, and balance.  The general consensus recommends one hour sessions three times per week.  The bulk of the program below is taken from the Otego Exercise Program.  This program has been studied extensively and has been shown to decrease falls and the injuries caused by falls by over a third.5,10-12  In addition to the exercises, a discussion of the internal and external factors related to falls will be addressed first as many of these can be modified to greatly decrease a person’s risk of falling.1,4 

 

Internal Factors Affecting Balance:

  1. Vision – Make sure you have the correct prescription for eye wear.
  2. Vestibular system – This is the sensory system in your inner ear that communicates with your brain to tell it where your body is in space.  BPPV and Meniere’s Disease are examples of vestibular system disorders.
  3. Proprioception – These are the sensors in your joints that tell your body where it is in space.
  4. Strength – Weakness in the ankles, knees, hips, and low back/core region have been shown to affect balance and will be addressed below.5,8
  5. Flexibility – Decreased flexibility in the ankles, hips, and spine have been shown to affect flexibility and will be addressed below.5,8
  6. Dual tasking – Walking while adding another task, such as talking, turning your head to look at objects, or reacting to hearing or seeing something that is happening in your environment, is considered dual tasking.  This is a fascinating and overlooked topic that I did my grad school thesis on.  Older folks tend to have a decreased ability to dual task while walking which can increase the risk of falls.  One easy way of determining if you should be working on balance is if you stop walking when you begin talking.15-18
  7. Medical Conditions – Some examples are poor general health, diabetes, arthritis, osteoporosis, stroke, incontinence, medication use, and cognitive/mental health issues (memory, inattention, dementia, depression). Many of these issues can by improved greatly by exercise, nutrition, and lifestyle changes.
  8. Lifestyle Choices – Some examples are exercise, footwear, alcohol use, nutrition, hydration, and fear of falling.4

External Factors Affecting Balance:

  1. Throw rugs and cords or other obstacles
  2. Lack of nightlights for bathrooms/hallways
  3. Lack of handrails
  4. Objects that are out of reach
  5. Uneven ground
  6. Alcohol
  7. Decreased activity level
  8. Fear of falling
  9. Dehydration – The recommendation is about twelve eight ounce glasses of water per day for men and nine for women.19,20
  10. Lack of sleep – See my evidenced-based handout for sleep hygiene tips.
  11. Medication issues
    – Did your balance issues begin around the same time as a medication change?  Talk with your doctor.
    – Lightheadedness/dizziness with a change of position (lying to sitting or sitting to standing) can indicate a blood pressure issue.  Talk with your doctor.
  12. Pets – high energy dogs, for example

Exercises

I. General Guidelines – click on the underlined areas for video demonstrations

  1. A person should be evaluated by a healthcare practitioner familiar with balance disorders and training before performing the exercise program below.  All of the exercises can be modified to be made easier or more challenging and every person’s deficits will be somewhat different.  The best exercise program is one specifically tailored to the individual.  Safety is the most important aspect of any exercise program.
  2. Performing any of these exercises is better than none.  If the program is taking too much time or effort, have your physical therapist remove the exercises that are not as necessary for you.  It is much better to start off doing less than you are capable of and add to that program rather than starting with too much and hurting yourself or hating the program and throwing it in the garbage.
  3. Do not push through pain with any of the exercises, even if it feels like you are “not doing anything”.  Try to avoid having expectations about being able to perform a certain number of repetitions or move in a certain range.  Progress will come with consistent practice.
  4. Notify your physician if you experience dizziness, chest pain, or shortness of breath (ie., you are unable to speak because you are short of breath).
  5. Do not hold onto an object for support that may move (use your kitchen sink rather than a chair for example).
  6. Look ahead when walking on even surfaces or performing the exercises instead of looking down.
  7. Try to add walking into your daily activities as much as possible. For example, park farther away from the entrance when going to the store. Use the stairs when possible instead of an elevator.

II. Warm Up

  1. Walk for 20-30 minutes if time permits (stationary cycling is a good alternative if walking is too unsteady)
  2. Neck rotation – stand tall and turn your head to the side until you feel a stretch, repeat on the other side 5-10X each
  3. Chin tucks – stand tall and tuck your chin as if you are creating a double chin while imagining your spine stretching towards the ceiling, repeat 5-10X
  4. Trunk extension – place your hands on your low back and bend backwards until you feel a stretch, repeat 5-10X
  5. Trunk rotation – keeping your hips and pelvis stationary, rotate your trunk until you feel a stretch, repeat on the other side 5-10X each
  6. Seated ankle range of motion – bring your toes towards your nose, then push your toes down towards the floor, repeat 10X in each direction

III. Strengthening
use a kitchen counter for support for safety and to focus on your technique, as needed

  1. Seated knee extension – straighten your knee and pull your toes towards your nose, feel free to add ankle weights to make more challenging, repeat 10X for 2-3 sets
  2. Standing knee flexion – bend your knee by bringing your heel towards your buttocks, feel free to add ankle weights to make more challenging, repeat 10X for 2-3 sets
  3. Toe/heel raises (double or single leg) – raise up onto the balls of your feet, lower back down and raise up onto your heels, repeat 10X for 2-3 sets
  4. Hip abduction – stand tall and raise your leg out sideways away from your other leg, repeat 10X for 2-3 sets on each side
  5. Marching – stand tall and raise a knee towards your chest, repeat 10X for 2-3 sets on each side
  6. Squatting – keeping a neutral spine position with your chest pointing forwards and your eyes looking straight ahead, squat down until you feel pain or unstable and return to standing (you may want to use a chair to simulate standing up from a seated position and squatting back down until your buttocks barely touches the chair before returning to stand), repeat 10X for 2-3 sets
  7. Lunges (more advanced)
  8. Single leg quarter squats (more advanced)

IV. Static (not moving) Standing Balance
*use kitchen counter for support for safety as needed
*there are 4 progressively more challenging foot positions (1. feet as wide as your hips 2. feet together 3. tandem stance 4. single leg stance) and 4 progressively more challenging variables for each foot position (1. eyes open on an even surface 2. eyes closed on an even surface 3. eyes open on an uneven surface, such as a balance board, dyna disc, or pillow 4. eyes closed on an uneven surface)
*hold all positions for 30-60 seconds and repeat 2-3X

  1. Feet hip width with eyes open (close eyes or stand on an uneven surface to make more challenging)
    feet hip width
  2. Feet together with eyes open (close eyes or stand on an uneven surface to make more challenging)

    feet together
  3. Tandem stance (tightrope) with eyes open (close eyes or stand on an uneven surface to make more challenging) – both sides
    semi tandem stance (easier)

    tandem stance (harder)
  4. Single leg stance with eyes open (close eyes or stand on an uneven surface to make more challenging) – both sides

V. Dynamic (moving) Standing Balance
*
use a wall or counter (hallways can be helpful) for support for safety as needed
*perform each activity for 10 steps (or better yet, measure out 10-15 feet so the dual task of counting while you are walking is not added, at least initially) and repeat 5X

  1. Tandem walking (tightrope) – walk forwards placing one foot directly in front of the other as if walking on a tightrope
  2. Walking with head turns – turn your head side to side as if you are checking out the food on either side of you in the grocery store aisle
  3. Walking backwards
  4. Sideways walking
  5. Figure 8 walking – walk in a figure of 8 pattern
  6. Heel walking – walk on your heels
  7. Toe walking – walk on the balls of your feet
  8. Backwards tandem walking – walk backwards placing one foot directly in front of the other as if walking on a tightrope
  9. Stairs – use one or two rails for support until you feel comfortable walking with no support

VI. Stretching
*
hold stretches for 30 seconds and repeat 2-3X on each side daily

  1. Calf stretches (standing) – a stretch should be felt in the calf of the back leg
  2. Hip flexor stretches (standing) – a stretch should be felt in the front of the hip in the back leg
  3. Single knee to chest (lying on back) – a stretch may be felt in the knee, hip, or back

    single knee to chest
  4. Trunk rotation (lying on back)

    low trunk rotation
  5. Child’s pose (start on your hands and knees and sit back on your heels while bringing your head to the floor)
    Childs Pose

     

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-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:

1Schwenk M, Jordan ED, et al. Effectiveness of foot and ankle exercise programs on reducing the risk of falling in older adults: a systematic review and meta-analysis of randomized controlled trials. J Am Podiatr Med Assoc. 2013 Nov-Dec;103(6):534-47.
2Sherrington C, Whitney JC, et al. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008 Dec;56(12):2234-43.
3Hamed A, Bohm S, et al. Follow-up efficacy of physical exercise interventions on fall incidence and fall risk in healthy older adults: a systematic review and meta-analysis. Sports Med Open. 2018 Dec 13;4(1):56.
4Florida Injury Prevention Program for Seniors (FLIPS) – https://slideplayer.com/slide/8680174/
5McMahon SK, Wyman JF, et al. Combining Motivational and Physical Intervention Components to Promote Fall-Reducing Physical Activity Among Community-Dwelling Older Adults: A Feasibility Study. Am J Health Promot. 2016 Nov;30(8):638-644.
6Papa EV1, Dong X2, et al. Resistance training for activity limitations in older adults with skeletal muscle function deficits: a systematic review. Clin Interv Aging. 2017 Jun 13;12:955-961.
7Gardner MM1, Buchner DM, et al. Practical implementation of an exercise-based falls prevention programme. Age Ageing. 2001 Jan;30(1):77-83.
8Emilio EJ1, Hita-Contreras F2, et al. The association of flexibility, balance, and lumbar strength with balance ability: risk of falls in older adults. J Sports Sci Med. 2014 May 1;13(2):349-57.
9El-Kashlan HK1, Shepard NT, et al. Evaluation of clinical measures of equilibrium. Laryngoscope. 1998 Mar;108(3):311-9.
10Shubert TE, Smith ML, Otago Exercise Program in the United States: Comparison of 2 Implementation Models. Phys Ther. 2017 Feb 1;97(2):187-197.
11Otego Exercise Program PDF – file:///C:/Users/Mike%20Gable/Documents/Originals/Articles/Balance/Not%20Read/Otago%20program%20PDF.pdf.
12Robertson MC1, Campbell AJ, et al. Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J Am Geriatr Soc. 2002 May;50(5):905-11.
13Sherrington C1, Fairhall NJ, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019 Jan 31.
14Taylor-Piliae RE1, Haskell WL, et al. Improvement in balance, strength, and flexibility after 12 weeks of Tai chi exercise in ethnic Chinese adults with cardiovascular disease risk factors. Altern Ther Health Med. 2006 Mar-Apr;12(2):50-8.
15Lajoie Y1, Teasdale N, et al. Attentional demands for static and dynamic equilibrium. Exp Brain Res. 1993;97(1):139-44.
16Wright DL1, Kemp TL. The dual-task methodology and assessing the attentional demands of ambulation with walking devices. Phys Ther. 1992 Apr;72(4):306-12; discussion 313-5.
17Chen HC1, Schultz AB, et al. Stepping over obstacles: dividing attention impairs performance of old more than young adults. J Gerontol A Biol Sci Med Sci. 1996 May;51(3):M116-22.
18Lundin-Olsson L, Nyberg L, et al. “Stops walking when talking” as a predictor of falls in elderly people. Lancet. 1997 Mar 1;349(9052):617.
19Sawka MN1, Cheuvront SN, Carter R 3rd. Human water needs. Nutr Rev. 2005 Jun;63(6 Pt 2):S30-9.
20http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=10925
21Pata RW1, Lord K2, et al. The effect of Pilates based exercise on mobility, postural stability, and balance in order to decrease fall risk in older adults. J Bodyw Mov Ther. 2014 Jul;18(3):361-7.
22Nick N1, Petramfar P2, et al. The Effect of Yoga on Balance and Fear of Falling in Older Adults. PM R. 2016 Feb;8(2):145-51.

Ankle Sprains

What is it?

This is an overstretching or tearing of the ligaments on the outside of the ankle joint and foot.  The ligaments most commonly involved are the anterior talofibular ligament  toward the front of the ankle, the calcaneofibular ligament directly to the outside of the ankle, and less commonly the posterior talofibular ligament toward the back of the ankle.  This is the most common type of ankle sprain, noted as high as 85% of all ankle sprains, and occurs when the foot rolls to the inside with weight bearing activities.  This can occur while hiking on uneven ground especially with a heavy pack or when falling from a boulder problem and landing on the edge of the crash pad.1,2,3  Climbing shoes that are excessively small can also contribute to this injury.4  There has been an increased risk of ankle sprains with bouldering and sport climbing.5

What does it feel like (Symptoms)?

Significant pain and swelling is typically noticed on the outside of the ankle and it may be difficult to walk or bear weight on the ankle.

Prevention

There is a high rate of recurrence after the initial sprain so preventing this injury from occurring is key.  There are four key factors involved with preventing this injury:

  1. Range of motion and flexibility:  Assess and address as needed any differences between the left and right ankles for dorsiflexion, plantarflexion, inversion, and eversion range of motion as well as gastrocnemius and soleus flexibility. (See below)  A lack of dorsiflexion specifically has been shown to increase the risk of spraining the ankle.1,3
ankle dorsiflexion – pull your toes towards your nose
Repeat 10 times, 3-4 times/day in a pain free range.
ankle eversion – move your foot up and out
Repeat 10 times, 3-4 times/day in a pain free range.
ankle inversion – move your foot towards the big toe side
Repeat 10 times, 3-4 times/day in a pain free range.
ankle plantaflexion – push your toes down like you are pushing down on the gas pedal
Repeat 10 times, 3-4 times/day in a pain free range.
gastrocnemius stretch – keep the back knee straight and shift your weight forward until you feel a stretch in the back calf
Hold for 30 seconds and repeat 2-3 times, 2-3 times/day in a pain free range.
soleus stretch – bend the back knee and shift your weight down into the back foot until you feel a stretch in the back calf
Hold for 30 seconds and repeat 2-3 times, 2-3 times/day in a pain free range.

2. Strength:   Assess and address as needed any differences in ankle eversion, inversion, and plantarflexion as well as hip abduction and extensor strength (see below).1,3

ankle eversion strengthening – move your foot up and out
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range.
ankle inversion strengthening – move your foot towards the big toe side
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range.
single leg heel raise – raise up onto the ball of your foot
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range
hip abduction strengthening – move your leg out to the side and return to midline
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range. Feel free to add resistance.
hip extension strengthening – move your leg back and return to neutral
Repeat 10-15 times for 2-3 sets, 3 times per week in a pain free range. Feel free to add resistance or try a single leg bridge instead.

3. Balance and proprioception:   Proprioception is a joint’s ability to tell where it is in relation to the rest of the body.  Deficits with proprioception can cause the foot to land in a way that increases the chance of a sprain while walking, hiking, or landing from a boulder.6  The best exercises to address this issue are performed while standing on one leg.  The progression of these exercises from easiest to hardest is to stand on one leg on even ground with the eyes open for 60 seconds.  If this is easy, try either closing the eyes or standing on an uneven surface such as a wobble board, Bosu ball, or better yet: a slack line. As this becomes easier, stand on the uneven surface with the eyes closed.  Adding a single leg quarter squat to this can make it even more challenging.1-3,7-9

single leg stance – close eyes or stand on an uneven surface to make more challenging
Hold for 60 seconds, repeat 2-3 times, 3-5 times per week.
single leg quarter squat – stand on 1 foot and squat down in a pain free range making sure your knee is in line with your toes and your pelvis stays horizontal (doesn’t tip down when lowering)
Repeat 10-15 times, 2-3 sets, 3 times per week in a pain free range.

4. Crash pad positioning:   Spotters should always have a sense of where the climber will fall and to place the pad so the climber will fall in the middle of the pad as opposed to on the edge.  While in the gym or outside, make sure all the pads are connected and there are no spaces where the climber’s foot could land in between pads.

Treatment

This injury should be medically evaluated to determine the extent of the injury including any fractures or dislocations.  The Ottawa Ankle Rules were developed to determine if an X ray is necessary.20, 21   An X ray is indicated if any of the following are present:
1. bony tenderness along the back side of the bottom part of the fibula or lateral malleolus
2. bony tenderness along the back side of the bottom part of the tibia or medial malleous
3. bony tenderness at the base of the 5th metatarsal
4. bony tenderness at the navicular
5. Unable to walk at least 4 steps

bones of the foot and ankle

The use of crutches (or walker/cane) and functional support using a brace, wrap, or taping while gradually increasing weight bearing may be required if the pain is causing significant limping.  In an acute injury situation, pain is the body’s way of telling you what to do or not do in order to allow it to heal.  Inflammation is a crucial phase of the healing process, where dead or damaged tissue is removed and special cells are called on to lay down new tissue.  Research is showing that blocking the inflammatory phase of the healing process (with NSAIDS, for example) can actually slow the healing of bone and soft tissue.11-19  That being said, decreasing pain and inflammation should be considered for the first 3 days after the injury if 1. pain is preventing you from sleeping (check here for the importance of sleep) 2. pain is unbearable (stress hormones will be released which can slow the healing process) or 3. there is extreme swelling, theoretically damaging healthy tissue that wouldn’t have been damaged due to the injury.

There is a high rate of recurrence after an initial ankle sprain and many people develop chronic ankle instability, so it is important to address any of the key factors that may be limited due to an ankle sprain including:2

  1. Range of motion/flexibility:    Assess and address as needed any differences between the left and right ankles for dorsiflexion, plantarflexion, inversion, and eversion range of motion as well as gastrocnemius and soleus flexibility. (See figures in the prevention section above as well as a figure below for a  stretch for the tibialis anterior muscle.)  Also, practice tracing the alphabet in uppercase letters with your foot.1-3  When these motions have been regained with minimal pain, strengthening can be initiated.
tibialis anterior stretch – point your back toes down and straighten your knee
Hold for 30 seconds, repeat 2-3 times, 2-3 times per day, 3-5 times per week

2. Strength:   Assess and address as needed ankle eversion, inversion, and plantarflexion as well as hip abduction and extension strength (See the figures in the prevention section above).1-3  Progress to the single leg stance and single leg quarter squats as seen in the prevention section above and add the following lunge.

Forward lunge – step forward, drop straight down, return to start, repeat on the other side
Repeat 10-15 times, 2-3 sets, 3 times per week in a pain free range

After these exercises can be performed pain free, squat jumps can be added with progressively increasing the height of the jumps and advancing from two legs to single leg as strength increases. These exercises will help the climber prepare for landing while bouldering.
3. Balance and proprioception: See details under the prevention section above
4. Trigger points:   Check for any trigger points, especially of the peroneal muscles as stated above

peroneal trigger points
peroneal self trigger point/myofascial release
Hold gentle-moderate direct pressure for 2-3+ minutes on any area that feels tight or tender and feel for a release
Repeat 2-3 times per day

 

5. Functional support:   Bracing and taping for stability have both been shown to decrease the risk of recurrence after the initial ankle sprain.2,3
6. Joint mobility:   Joint mobilizations, including mobilizations with movement, typically performed by a physical therapist, chiropractor, or osteopath, have been shown to be beneficial when range of motion is difficult to regain.1,3,10

 

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 Kaminski TW1, Hertel J, et al; National Athletic Trainers’ Association. National Athletic Trainers’ Association position statement: conservative management and prevention of ankle sprains in athletes. J Athl Train. 2013 Jul-Aug;48(4):528-45.
2 Chinn L, Hertel J. Rehabilitation of ankle and foot injuries in athletes. Clin Sports Med. 2010 Jan;29(1):157-67, table of contents.
3 Lin CW1, Hiller CE, de Bie RA. Evidence-based treatment for ankle injuries: a clinical perspective. J Man Manip Ther. 2010 Mar;18(1):22-8.
4 Buda R1, Di Caprio F, et al. Foot overuse diseases in rock climbing: an epidemiologic study. J Am Podiatr Med Assoc. 2013 Mar-Apr;103(2):113-20.
5 Schöffl V, Küpper T. Feet injuries in rock climbers. World J Orthop. 2013 Oct 18;4(4):218-228. eCollection 2013. Review.
6 Sefton JM1, Yarar C, et al. Six weeks of balance training improves sensorimotor function in individuals with chronic ankle instability. J Orthop Sports Phys Ther. 2011 Feb;41(2):81-9.
Herman K, Barton C, et al. 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. doi: 10.1186/1741-7015-10-75. Review.
Schweizer A1, Bircher HP, et al. Functional ankle control of rock climbers. Br J Sports Med. 2005 Jul;39(7):429-31.
McKeon PO1, Ingersoll CD, et al. Balance training improves function and postural control in those with chronic ankle instability. Med Sci Sports Exerc. 2008 Oct;40(10):1810-9.
10 Travell J, David S. Myofascial Pain and Dysfunction, Vol 1: The Trigger Point Manual. Williams and Wilkins, Baltimore, 1983. pp.355-367.
11 Skjong CC1, Meininger AK, Ho SS. Tendinopathy treatment: where is the evidence? Clin Sports Med. 2012 Apr;31(2):329-50.
12 Hess GP, Cappiello WL, Poole RM, et al: Prevention and treatment of overuse tendon injuries. S p o r t s M e d 8 : 371–384, 1989.
13 Bondesen BA1, Mills ST, et al. The COX-2 pathway is essential during early stages of skeletal muscle regeneration. Am J Physiol Cell Physiol. 2004 Aug;287(2):C475-83.
14 Lu H1, Huang D, et al. Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury. FASEB J. 2011 Jan;25(1):358-69.
15 Arnold L1, Henry A, et al. Inflammatory monocytes recruited after skeletal muscle injury switch into antiinflammatory macrophages to support myogenesis. J Exp Med. 2007 May 14;204(5):1057-69.
16 Smith C1, Kruger MJ, et al. The inflammatory response to skeletal muscle injury: illuminating complexities. Sports Med. 2008;38(11):947-69.
17 Mishra DK1, Fridén J, et al. Anti-inflammatory medication after muscle injury. A treatment resulting in short-term improvement but subsequent loss of muscle function. J Bone Joint Surg Am. 1995 Oct;77(10):1510-9.
18 Cottrell, and O’Connor, P. Effect of Non-Steroidal Anti-Inflammatory Drugs on Bone Healing. Pharmaceuticals, Vol 3, No 5, 2010.
19 Magra M, Maffulli N. Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe. Clin J Sport Med. 2006 Jan;16(1):1-3.
20 Kerkhoffs GM1, van den Bekerom M, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012 Sep;46(12):854-60.
21 Vuurberg G1,2,3, Hoorntje A, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med. 2018 Aug;52(15):956.

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 video demo) – 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.