In this post I will discuss what the basic structure of a potential program might look like if we applied some of the ideas we have talked about previously. I will outline a rough training plan that will help bring the concepts together for many of you reading.
Concepts for managing training stress for intermediate and advanced climbers.
Why you need a training program.
Why training needs to be structured differently for novice, intermediate and advanced climbers.
Why easy to moderate climbing is just "junk mileage" for climbers and not useful for training.
Why traditional periodized programs don't work for climbers.
Why climbers should be having "limit" sessions every session and only manipulating volume.
In climbers, residual fatigue is one the most common obstacles to improving one’s overall baseline level of ability. Not being able to recognize and identify when the body is sufficiently recovered makes it extremely difficult to know when it’s productive to physically stress the system again. Without stress there is no adaptation but without proper recovery there is insufficient resources to sustain both neurological and structural improvement.
Hamstring injuries are very common among climbers, right up there with knee and ankle injuries. Because of the hamstring intensive nature of some of the techniques we use in climbing–namely, heel hooking–hamstring injuries are something I see with increasing frequency in my clinic. In this article I will discuss some of the ways we injure our hamstrings and my general approach to rehabbing this type of injury.
The general term “hamstrings” technically refers to the posterior thigh muscles, namely the semitendinosus, semimembranosus and biceps femoris (which includes both a long and a short head). These muscles begin at the pelvis and end at the lower leg, crossing both the hip joint and the knee.
Mechanism of Injury
A strain is a stretch injury or tear to a muscle or a tendon (side note: a sprain is an injury to a ligament). A hamstring strain happens when the hamstring muscle is pushed past its physiological limits and is stretched or torn.
Because the hamstring crosses both the hip joint and knee joint, the mechanism behind this injury is usually a combination of rapid pelvic flexion and knee extension, such as jumping, kicking a ball, falling with your leg extended or…heel hooking!
Heel hooking is a very effective and efficient climbing technique, but it is also extremely hamstring intensive. Because it’s so hamstring intensive, it’s usually the mechanism of injury for hamstring strains in climbing.
In my experience the biceps femoris is the most commonly injured hamstring muscle in climbers. This is probably due to the nature of heel hooking. Depending on the exact mechanism of injury, some climbers tear the proximal portion (closer to the hip) and some tear the distal portion (closer to the knee).
Some common causes of hamstring tears:
Improper heel hook technique
Flexibility issues in the hips or the hamstring itself
Extremely high heel hooks
Falling while foot gets stuck in a bomber heel hook or heel-toe-cam
Heel hooking in extreme knee flexion (sometimes also involves meniscal tears)
Most climbers report a traumatic event followed by pain and cramping behind the thigh. The majority of hamstring strains will be associated with mild to moderate pain behind the thigh or knee. It is common to experience mild swelling and slight discoloration of the skin at the site of injury. Depending on the amount of damage inflicted on the muscle, spasm and bruising may accompany a hamstring strain. In more serious cases a climber with a complete rupture, or grade III strain, may experience severe pain, significant blood pooling with a large palpable ball of muscle protruding behind the leg. These climbers may not be able to walk without intense pain and should be evaluated by a professional.
Grade I muscle strain: Mild muscle strain. The muscle or tendon is overstretched. Small tears to muscle fibers may or may not occur. You may have mild pain with or without swelling.
Grade II muscle strain: Moderate muscle strain. Grade II strain occurs when the muscle or its tendon is overstretched with some of the fibers torn but not completely. Symptoms may include marked pain with swelling. The area of injury is tender. Bruising may occur if small blood vessels at the site of injury are damaged as well. Movement may be difficult because of pain.
Grade III muscle strain: Severe muscle strain. Grade III is the most serious among the three grades of muscle strains. Most of the muscle fibers are torn. In some cases, the muscle is completely torn or ruptured. Pain, swelling, tenderness, and bruising are usually present. Movement is usually difficult.
There are a lot of structures in and around the knee that share similar symptoms as a hamstring tear when injured:
- Meniscus tear
- PCL sprain/tear
- MCL sprain/tear
- LCL sprain/tear
- Popliteus muscle injury
- Fibularis muscle injury
- Proximal tibiofibular head injury or dislocation
- ITB subluxation to name a few things…
This is why it is important to get a professional diagnosis so you know what you are dealing with. The treatment is different for some of these injuries so you really need to get a proper diagnosis to understand what is going on and how to proceed. I can’t stress this enough in all my articles.
***This information is for educational purposes only and not meant to be medical advice. If you believe you have a hamstring injury seek professional help! At least get a solid diagnosis first before attempting self treatment.***
Most hamstring tears are simple by nature and do not require serious medical intervention or surgery. Even severe tears with a lot of swelling and bruising can be resolved with conservative care as long as avulsion fractures and retraction of the hamstring muscle can be ruled out via imaging.
I break down treatment into phases depending on how recently the injury occurred, how severe, and how the initial exam turns out. This is why you need a professional opinion before proceeding. Here is a general overview of my approach.
This is where I start for acute or severe hamstring tears. This can be anywhere from 24 hours up to 3 weeks post injury depending on the climber and the injury presentation.
First of all…DON’T ICE IT!!! Why? Read my last TrainingBeta article HERE on why.
I do not perform soft tissue work or stretching in this stage or recommend the climber do any on themselves as it can cause too much inflammation and interfere with healing at this point.
I subscribe to the Starr Rehab Protocol. It’s a high volume protocol with the goal of flushing blood to the injury site and throughout the whole body. It will NOT feel comfortable and it may hurt. You need to be able to distinguish the difference between what is ok and considered “rehab pain” and what is not ok and might be considered “re-injury” or aggravation. If you can’t tell the difference you need to work with a rehab professional. This method works to minimize scar tissue formation and helps the tissue heal normally. I do this using squats, deadlifts or Romanian deadlifts starting anywhere from immediately to a few days after initial injury depending on severity and presentation. These can be done daily.
I also prescribe heat or contrast baths to flush blood to the injured area. The more blood you can get to the injury the faster it will heal.
In rare cases, if pain is severe and complications have been ruled out (such as avulsion fracture and retraction of the muscle), I will recommend a high-dose anti-inflammatory regimen. 800mg 3x/day with food for up to a week. The purpose of this is to bring the pain down enough so that we can begin the rehab process.
The goal is to proceed to Phase 2 ASAP!
Phase 2 is the strengthening phase. This can begin anywhere from 48 hours to several months post injury, again, depending on the climber and the presentation of the injury. Most climbers have weak hamstrings and the goal here is to strengthen the hamstrings, hips and core so that climbers can heel hook properly without getting injured.
Weight Gain Side note
A quick side note on lower body strengthening and weight gain (because I know what you are thinking):
Gaining muscle is hard to do.
Muscle is metabolically expensive and if you are not eating a surplus of calories it is impossible to gain mass even while you are strength training.
In my experience most climbers do not eat ENOUGH during strengthening phases and end up LOSING weight (not necessarily a good thing).
The type of strengthening I prescribe is high intensity/low volume (heavy weight, 1-5 reps, 1-3 sets) and results in a mostly neurological strength adaptation. As a result, your muscles get better at recruiting more muscle fibers at one time during a muscular contraction. That’s where the strength gains come from.
As a rule of thumb, if you are not eating a surplus of calories you will not gain any weight.
Phase 2 Exercises
Here are some of the exercises I recommend for strengthening and rehabbing hamstring injuries. I do these 3x per week with at least 1 day off in between.
The Low-Bar Back Squat
The LBBS is a powerlifting style squat that emphasizes the low back muscles, abdominals, hips and hamstrings. It’s a functional way to get the hamstrings stronger and also all the muscles that keep you on a steep wall. This is different than the type of squat you see most gym goers performing. Unless they have been coached otherwise, most people you see in the gym are using a “high-bar” style squat, which is more of a quad dominant style of squat and does not stress the hamstrings as much as a LBBS. The difference is in the placement of the bar on the back. Very safe as long as good form is used. Proper coaching is necessary.
The conventional deadlift is a narrower stance deadlift with the hands placed outside of the legs. It emphasizes the whole posterior kinetic chain, lats, back, abdominals, glutes, and hamstrings. Ideal and functional for climbers since these are the muscles that keep you on a steep wall. Also, very safe as long as good form is used. Proper coaching is necessary.
Stiff Leg Deadlift
This is an alternative I use for climbers who need a more targeted hamstring exercise. 95% of the time a conventional deadlift will get the job done but I have had a few climbers that really needed some targeted hamstring work to really stress the injured area. These are usually climbers who don’t get symptom relief with only the squats and conventional deadlift. These are performed similarly to a conventional deadlift except starting from the top and without any knee bend. Your hamstrings will get very sore the first couple times these are done. Don’t say I didn’t warn you if you try them. As with all these lifts, proper coaching is needed.
The strength work will start to get heavy as we progress over the course of a few weeks and it has to if we actually want to get stronger. So don’t be afraid of heavy weights. With good form you’ll be fine. Nobody ever got better at climbing without trying something more difficult than the last time, right?
I highly recommend seeking out professional advice on how to perform these exercises from a qualified coach, PT or rehab specialist in your area. I also recommend checking out the book Starting Strength by Mark Rippetoe for further reading on the biomechanics of performing these movements.
Soft tissue work can be started in Phase 2 as well. I recommend using a lacrosse ball on a hard surface to massage into the hamstring for a few minutes everyday. The foam roller just doesn’t get into the deeper parts of the muscle like we need it to. This can also be done with a baseball, small kettlebell or other similarly sized round object.
I do not prescribe stretching to any of my patients at any point because none of the research shows that stretching is effective in and of itself. Eccentrics and isometrics are better and that’s what we are doing with squats, deadlifts and stiff leg deadlifts. Climbers can stretch if they want but I don’t find it as effective as some of the other things described in this article.
Climbing can be resumed in this phase with no heel hooking until cleared to do so. Move to phase 3 after 6-12 weeks.
In this phase the climber has been cleared to heel hook again, symptoms are gone and the climber has done at least 6 weeks of strengthening. Most climbers are good to start heel hooking at full strength again in this phase and no other treatment or steps are necessary. A small percentage of climbers will start to experience pain or discomfort when they start heel hooking intensively again. In these cases, I will add some intense hamstring isolation work to prepare the climber for heel hooking at full capacity again.
The single leg glute bridge works the hamstring in a more isolated way while exposing the injured muscle to similar forces it would experience during a heel hook. The farther out you place the heel the more hamstring involvement. The feet can be elevated for added challenge. Weight can also be used on the hips.
Technique work for proper heel hooking at the gym with a coach is warranted in the case of a novice-intermediate climber or climbers with poor heel hooking technique. If you fall into these categories, I would recommend that you sign up for technique classes at your local climbing gym or seek out professional coaching from a high quality coach who can work with you in person.
Here are some helpful articles on heel hook technique:
Putting It All Together
As I mentioned above, this is just a general outline of how I would approach a hamstring injury. This isn’t everything. The details, technique and progression are highly dependent on the climber, the severity of injury, the presentation of the injury on exam as well as other factors. Hamstring injuries are relatively easy to treat and generally heal very quickly if rehabbed properly. The key is talking to someone who works with climbers, understands how we use our hamstrings, and knows how to rehab them properly.
The most important thing is to get a proper diagnosis as the symptoms can mimic other pathologies and it is possible other structures could be damaged with the same mechanism of injury. You want to know what you are dealing with before trying to self-diagnose and treat.
It is also wise to seek out multiple opinions. Don’t just talk to your general practitioner or an orthopedic surgeon, talk to physical therapists and other rehab specialists as well. Don’t forget to ask questions. Anecdotally, I have had patients told they tore a meniscus and needed surgery when the imaging was negative and I have had patients told to just rest and they would be fine and they were not. Be your own advocate.
As overhead athletes who do a disproportionate amount of pulling down, it’s important for climbers to keep the shoulders strong and well balanced.
When I was in my late twenties I suffered from a few different shoulder injuries ranging from supraspinatus impingement, bicipital tendinopathy, bursitis (you don’t want this one…10/10 pain! ouch!!!) as well as posterior impingement and a possible labral tear from a shoulder subluxation.
My shoulders have been through hell and back but now that I’m in my thirties and I can say that my shoulders have never felt better!
What finally fixed them? A lot of tissue work and learning the barbell overhead press!
A correctly performed overhead press is the single most useful strength training exercise for shoulder health in climbers.
What is so awesome about pressing?
Unlike other pressing variations it does not isolate one muscle or one joint, it uses the full kinetic chain to transmit force from the ground all the way up to the hands to press the bar overhead.
Since a correct press is done in a standing position it works all the muscles in the body.
Everything between the bar in the hands and the feet balancing against the floor participates in the exercise. Legs, abs, and back muscles, as well as the obvious shoulder and arm muscles, all work together in a correctly performed press.
The press is a functional, full range of motion, multi-joint movement that can be progressively loaded over time to strengthen the shoulders. In other words, more bang for your buck!
Overview of the shoulder muscles involved in the press from StartingStrength.com
Why use barbells over dumbbells or kettlebells?
- At a certain point dumbbells and kettlebells become too large and too awkward to press.
- Using a barbell with two arms allows you to lift more weight. If strength is our goal (which it is) then more weight is always better than less weight.
Why is a heavy barbell press more ideal than other press variants or band exercises?
Since more muscles are involved in performing the press we can use more weight and therefore get stronger.
How strong can you really get from an exercise that isolates the rotator cuff? It’s self-limiting.
“There is no single muscle group in the entire human body that works in isolation as its normal function. Not even your tongue. It therefore makes no sense to train muscles in a way in which they do not function. Physical Therapists may be able to isolate your rotator cuff muscles, but you may have noticed that this motion is not a normal part of your day.
If the cuff muscles work during a press (they do), and if they are aided in their function by all the other muscles in the shoulder (they are), then as the progressively heavier press makes the shoulder stronger, it makes the rotator cuff muscles stronger too. It is much better to strengthen the cuff muscles while their shoulder-muscle friends help lock out a press, than when they are made to work all alone, all by their skinny little selves in the PT clinic.” -Mark Rippetoe (Starting Strength Article, The Overhead Press)
Band and single arm exercises become inefficient because they are too difficult or awkward to progress for very long and because they force the rotator cuff to work in a way that it does not normally function.
If you start pressing correctly with a light weight and add a little weight each time you train, you will get progressively stronger and all the muscles you use in the press get stronger, not just the rotator cuff.
Why is pressing so ideal for climbing?
- Pressing is a true antagonistic movement to all the pulling we do in climbing.
- As mentioned above it trains the entire body much like climbing.
- It keeps the shoulder balanced by training all the muscles around the shoulder including the rotator cuff.
The Press as explained in Starting Strength by Mark Rippetoe. Notice how the bar stays balanced over the middle of the foot.
If there is one exercise you do for the health of your shoulders make it the standing barbell overhead press!
***You must learn how to do this exercise with proper form, if you’re doing it correctly it shouldn’t hurt your elbows or shoulders!***
Invest in this book if you re serious about getting stronger!
Some useful videos on pressing:
In my clinical experience, most of these elbow injuries and some of these shoulder injuries are likely tendinopathies.
Mention the word “tendinitis” to any climber who has been at it for a while and they will most likely be very familiar with the nagging pain it causes or will know someone who has.
It’s a common occurrence for climbers to come into my office and complain about “tendinitis” issues. What many of these athletes don’t realize though is that they don’t have tendinitis, they have tendinosis.
So…what is the difference between tendinitis and tendinosis?
Tendinitis is an inflammatory condition of the tendon that results from micro-tears that happen when the musculotendinous junction is acutely overloaded with a tensile force that is too heavy and/or too sudden.
Tendinosis is a degenerative condition of the tendon’s collagen in response to chronic overuse. When overuse is continued without giving the tendon time to heal and rest (think repetitive stress) tendinosis results.
The current thinking is that tendinitis occurs secondary to an underlying tendinosis. If you have a tendinitis going on then you probably had/have an underlying undiagnosed tendinosis.
Too often athletes get diagnosed (or in some cases self diagnosed) with tendinitis when their condition is actually more of a tendinosis.
Why is it important to know the difference?
The treatment approach, treatment goals and timelines for each of these conditions are quite different. If the difference between these two conditions is not differentially diagnosed and the appropriate treatment is not applied then the athlete will not improve and could suffer from chronic pain.
For example, if a climber thinks they have a tendinitis then they will likely ice, take NSAIDS and sometimes even get a corticosteroid injection from their doctor to reduce inflammation. This could be a problem if they actually have more of a tendinosis because some treatments to reduce inflammation are contraindicated with tendinosis. Ibuprofen, a nonsteroidal anti-inflammatory (NSAID), is associated with inhibited collagen repair and studies have shown that corticosteroid injections inhibited collagen repair prolonging healing times and were found to be a predictor of later tendon tears.
Treatment approaches can vary slightly depending on the specific injury. In general though most treatments will follow the guidelines below.
For tendinitis we want to reduce inflammation. Ice, NSAIDS, and rest are common treatment approaches.
The healing time for tendinitis is several days to 6 weeks, depending on whether treatment starts with early presentation or chronic presentation. If an athlete has a tendinitis it is important to treat the underlying tendinosis after the initial inflammatory phase.
For tendinosis we want to stimulate fibroblast activity and collagen production.Massage, Active Release techniques (ART), Graston/Gua Sha, Cup Therapy, eccentric loading of the tissue are common treatment approaches.
Treatment for tendinosis recognized at an early stage can be as brief as 6–10 weeks. However, once the tendinosis has become chronic treatment can take 3–6 months.
It is important to get an accurate diagnosis from a professional using assessment techniques and knowledge of the relevant condition in order to have the best possible outcome. Knowing the difference between these two conditions and their respective timelines is part of creating an effective treatment plan.
- Chronic tendon injury (tendinosis) is degenerative in nature and NOT inflammatory.
- Anti-inflammatory medications (NSAIDs) and/or corticosteroid injections can actually accelerate the degenerative process and make the tendon more susceptible to further injury, longer recovery time and may increase likelihood of rupture.
- Heavy load eccentric strength training helps to increase the tensile strength of the tendon and soft tissue treatment modalities increase collagen production and helping restore the health of the tendon.
I have said this a lot in previous posts and it’s worth repeating: Get a professional diagnosis! Know what you are dealing with before wasting time Googling symptoms and trying to self treat. Trust me. It will save you time, money and suffering in the long run.
“The body is extremely complex and it is rarely possible for a non-medic to confidently exclude possible diagnoses. An example of this is nerve compression syndromes of the back and neck which mimic exactly the symptoms of elbow tendon pain.”
Want to know more about how nerve impingement issues in your neck could be the cause of your elbow pain? READ HERE.
Book your next appointment HERE or by emailing firstname.lastname@example.org
*Featured image Tara Kerzhner
Khan KM, Cook JL, Kannus P, et al. Time to abandon the “tendinitis” myth: Painful, overuse tendon conditions have a non-inflammatory pathology [editorial] BMJ .http://www.bmj.com/content/324/7338/626.full. Published March 16, 2002.
Khan KM, Cook JL, Taunton JE, et al. Overuse tendinosis, not tendonitis—Part 1: A new paradigm for a difficult clinical problem. Physician Sportsmed. 2000 28(5) http://www.massagebyjoel.com/downloads/OveruseTendinosis-PhysSptsmed.pdf.
Heber M. Tendinosis vs. Tendinitis. Elite Sports Therapy. http://www.elitesportstherapy.com/tendinosis-vs–tendonitis.
Tsai WC, Tang FT, Hsu CC, et al. Ibuprofen inhibition of tendon cell proliferation and upregulation of the cyclin kinase inhibitor p21CIP1 [abstract] J Orthopedic Research. http://onlinelibrary.wiley.com/doi/10.1016/j.orthres.2003.10.014/abstract.
Most of our time climbing is spent with our arms above our head reaching, grabbing, twisting and pulling down on holds. This type of overhead movement puts great demand on the shoulders. As a result of this demand, the shoulders are one of the most commonly injured areas in climbing athletes.
As overhead athletes it is very important to understand shoulder mechanics as well as the strength and range of motion demands that overhead movement has on the shoulders. Especially if we want to maintain healthy shoulders for the duration of our long climbing careers.
There is very little information out there that is written with the climbing athlete in mind. I’m writing this post with the intention of helping climbers and coaches understand the finer points of shoulder mechanics for climbing.
Proper scapular motion is crucial to a healthy shoulder in the climbing athlete. A lot of climbers have been told to “Keep the shoulder blades down and back” while climbing or dead-hanging. But this is potentially injurious advice. If you lock the shoulder blades down while you raise the arms upward, then your humeral heads are on a collision course with the roof of your tightly compressed AC joints. Tendons, bursa, and your supraspinatus wait helplessly to be impinged. When the arms are raised overhead to reach, lift, or pull down, the shoulder blades need to rotate upwards with them. The scapula are designed to roll with the arms, in a coordinated process known as scapulohumeral rhythm. Bottom line, THEY NEED TO MOVE.
If you’ve ever been victim to the “down and back” cue read on to find out what you should actually be doing with your shoulders to keep them healthy.
WHAT IS NORMAL MOVEMENT OF THE SCAPULA?
Normal scapular movement involves the coordination of four key motions:
- Abduction of the glenohumeral joint.
- Upward rotation of the scapula.
- Posterior tilting of the scapula.
- External rotation of the scapula.
Normal range of motion (this can vary slightly person to person) is considered to be 120 degrees of glenohumeral abduction and 60 degrees of upward rotation of the scapula (about a 2:1 ratio of movement between the glenohumeral joint and the scapula).
WHY SHOULD YOU CARE ABOUT SCAPULA MOVEMENT?
- Stronger more efficient shoulders. Proper, coordinated movement preserves optimal length-tension relationships of the glenohumeral muscles so they can sustain their force production through a larger portion of the range of motion.
- Injury prevention of the shoulders. Proper, coordinated movement prevents impingement of the shoulder. Because of the difference in size of the glenoid fossa and the humeral head subacromial impingement can occur unless relative movement between the humerus and scapula is limited. They should move together.
“Pinch your shoulder blades.” “Squeeze your scaps together.” “Retract your shoulders back.” “Pack your scapula.” These are all common coaching cues given during climbing training and during scapular exercises that climbers do for shoulder health. The goal of all of these cues is essentially to get the climber into better posture/positioning.
As I explained above, if you lock your shoulders into position while your arms elevate you are likely limiting the normal protraction and upward rotation that occurs with arm elevation and the tendons, bursa, and your supraspinatus underneath your acromion process are going to be impinged.
Here is what that would look like:
The space between the top and bottom arrows is the subacromial space. You can imagine that if this person raised their arm over head that would reduce the space between these two arrows and would cause pinching of the rotator cuff muscle.
The truth is, you actually cause impingement every time you move your arm. Impingement itself is normal and happens in all of us. When it becomes excessive is when injury occurs.
Thing about this though, how many moves do you do at the climbing gym per week with your scapula potentially in the wrong position? That starts to add up.
WHAT IS THE SOLUTION?
Given that the goal of these cues is better posture/positioning I would argue that a better cue would be to encourage thoracic extension. Extending the thoracic spine or cuing “chest up” during a pull-up, dead hang or climbing will help the climber achieve a better posture/position and an active shoulder.
Why? We must realize that scapula position depends on rib position, rib position depends on spine position (spine position also depends on pelvic position, but that is a whole separate post I’m saving for another day).
It’s all connected.
The alignment of the scapula will determine how much subacromial space we have. The less subacromial space we have the higher our chances of developing impingement over time.
Not picking up what I’m putting down?
Slouch in your chair and try to raise your arm above your head. Now sit chest up and raise your arm above your head. Get it now?
Below are some examples of how these cues would look when applied to the climbing while. Courtesy of the climbing Sensei himself, Rob Mulligan.
In the left photo you can see how Rob is keeping his shoulder in a good position by keeping his right leg turned out, driving through his right foot, keeping the core engaged and keeping his chest up and in thoracic extension, not by packing the shoulder.
The right photo is an example of how the shoulder and body position should NOT look:
-Relaxed mid back
-Lack of thoracic extension
-Overactive upper trapezius
-Loss of turnout
-Lack of core engagement.
Below is a good example of what this would look like as a static position while system training, resting, clipping, chalking etc.
Notice Robs turnout in the left photo and how he keeps his chest square with the wall by maintaining thoracic extension and core engagement. He is not exaggerating the shoulder position by packing the shoulder but rather using his mid back muscles to maintain thoracic extension.
The photo on the right highlights how this position should NOT look:
-Shoulder are not square with the wall
-Body sagging away from the wall
-Loss of turnout
-Lack of thoracic extension
-Lack of core engagement
Here is a side view of the same position to give you a better idea of how it would look.
***For more on these photos and to learn about one of the best ways to train these positions, check out Rob Mulligan’s excellent 3 part article on System Training. It’s the the ONLY good post written anywhere on the actual method of System Training and I highly recommend it. Two months of this type of training twice a week took my climbing from projecting V7/V8 to flashing or sending V10 in a few goes.***
Next time you are at the gym training or doing shoulder exercises think of the “chest up” cue and feel for yourself the difference it makes in your shoulder positioning.
If you have shoulder pain you need to SEEK PROFESSIONAL HELP to figure out where the dysfunction is that is causing your pain.
At the very least get a diagnosis so you know what you are dealing with before wasting time googling symptoms and trying to self diagnose. It will save you time, money and suffering in the long run.
“The body is extremely complex and it is rarely possible for a non-medic to confidently exclude possible diagnoses. An example of this is nerve compression syndromes of the back and neck which mimic exactly the symptoms of elbow tendon pain.”
Ankle sprains are one of the most common injuries among climbers following finger, shoulder and elbow injuries. Here is how I approach the initial treatment of an acute ankle sprain.
DO YOU NEED IMAGING?
Although most patients with ankle sprains who present to emergency departments undergo radiography, less than 15% have a fracture.
My suspicion is that this number is slightly higher in climbers due to the fact that most sustain ankle sprains during a fall from a significant height rather than on field or during normal walking or running activities, but this is just speculation.
Ankle sprains should be evaluated using the Ottawa ankle rules, which are well-established clinical guidelines used to determine the need for radiography.
According to the Ottawa ankle rules, ankle radiography is needed if any of the following are true:
There is pain in the malleolar zone, plus either bone tenderness over areas of potential fracture which are the posterior edge or tip of the lateral or medial malleolus.
An inability to bear weight for four steps immediately after the injury and in the emergency department or physician’s office.
If there is pain in the midfoot zone, plus either bone tenderness over areas of potential fracture which are the base of the fifth metatarsal or the navicular bone of the midfoot.
Multiple studies have demonstrated that the Ottawa ankle rules are nearly 100 percent sensitive for detecting fractures in adults and children as young as five years. Therefore, negative findings eliminate the need for radiography. However, because specificity is low (30 to 50 percent), positive findings do not necessarily indicate that a fracture is present, but do indicate that radiography is needed to confirm or rule out fracture.
If you have any of the above positive findings according to the Ottawa ankle rules seek medical attention immediately and get imaging to rule out fracture.
*Disclaimer: This post is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read online.
Ok, I don’t have a fracture. What next?
DON’T ICE THAT ANKLE SPRAIN!!!
According to a 2012 study in the British Journal of Sports Medicine, ice is commonly used after acute muscle strains, but there are no clinical studies of its effectiveness. Some studies say icing could be counterproductive in the long run because it seems not to improve but, rather, delay recovery from eccentric exercise-induced muscle damage.
Inflammation is normal and beneficial to the healing process. You must allow the inflammatory process to take place. Don’t hinder it with icing.
Ice can relieve pain but will cause a congestion of the tissue. It causes a backflow of the interstitial space, shuts off the signal between the muscles and nerves, and does not help the evacuation of deoxygenated blood and waste. Therefore, ice is counterproductive!
Ibuprofen is worse because it actually stops the signal of the inflammatory response, not just prevents it. The body’s natural inflammatory response is not a mistake!
Here is a great article listing 10 reasons icing injuries is wrong.
Here is what Kelly Starrett, PT, founder of MobilityWOD and author of Supple Leopard has to say about using ice.
WHAT SHOULD I DO IF I DON’T ICE?!
Traction, movement and heat!
Traction will release the pressure and movement will encourage blood flow to the area which is rich with healing factors such as oxygen and white and red blood cells. The key is blood flow. If you want something to heal, it requires blood!
In addition, movement with traction reduces pain, enhances lymphatic removal of inflammation, improves flexibility, and restores normal joint alignment. The waste products are evacuated through the lymphatic system, not the circulatory system (the particles are too big). Therefore, muscle contraction via movement is necessary to move lymph and eliminate these chemicals, not immobilization!
Here are a few things you can do to get some traction and movement all at once with a little bit of compression to squeeze out some of the acute swelling.
Active range of motion with a voodoo band
Wrap a voodoo compression band starting midfoot working up over the ankle, then move the ankle thru its full range. This can be done actively by pointing your toes and then bring the back up as far as you can.
Resisted plantar flexion and dorsiflexion with traction
Loop a stretch band around the forefoot while the voodoo band is on to resist plantar flexion (pointing foot down) and hold onto the ends. Use another stretch band wrapped around the foot pulling the other direction to traction the ankle and resist the foot and toes in dorsiflexion (pointing foot towards you). Move ankle in plantar and dorsiflexion or in circles clockwise and counterclockwise Aim for 10-20 reps and 3-4 sets with a short rest in between.
Elevated dorsiflexion mobilization
Elevated dorsiflexion mobilization can be helpful as well for increasing dorsiflexion which typically gets restricted with an ankle sprain. This works with the voodoo floss wrapped around the ankle or with a stretch band looped around the lowest part of the ankle pulling posteriorly.
Here is how to perform it:
Place the involved foot on a plyo box or bench. Lean forward tracking the knee directly over the foot as far as possible while keeping the heel planted. A stick or PVC pipe can be used for balance. Repeat several times before taking the band off.
Light goblet squats with voodoo band
Hold a kettlebell at chest level. Stand with feet shoulder width apart with slight turn out in your toes (about 15° of turn out). Squat down to just below parallel with your thighs with knees tracking out over toes. Perform 10-20 reps for 3-4 sets.
Let pain be your guide on this exercise. Not everyone can handle this one with a fresh ankle sprain. If it’s more painful than a 2-3 out of 10 then hold off on this for a week or two.
Putting It All Together
There is a little more involved in fully rehabbing an ankle sprain than these exercises (although soft tissue work and more general/specific strengthening can be done for example). These are just some of the strategies that I use to get over the hump on an acute ankle sprain. These strategies can work very well on an old ankle sprain that did not heal properly too!
Hope these are helpful and I hope you enjoyed the article! If you are in San Francisco and have a climbing related injury come visit me at Motus Clinic and we can develop a strategy for helping you get over your injury. Book online HERE.
Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417.
Stiell, I. G. (1993). Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA: The Journal of the American Medical Association,269(9), 1127-1132. doi:10.1001/jama.269.9.1127
Ivins D. Acute ankle sprain: an update. Am Fam Physician. 2006;74(10):1719.
Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft tissue injury? J Athl Train. 2004;39(3):278–279.
Bleakley, C. M., Glasgow, P., & Webb, M. J. (2011). Cooling an acute muscle injury: can basic scientific theory translate into the clinical setting? British Journal of Sports Medicine,46(4), 296-298. doi:10.1136/bjsm.2011.086116
Tseng, C., Lee, J., Tsai, Y., Lee, S., Kao, C., Liu, T., . . . Kuo, C. (2013). Topical Cooling (Icing) Delays Recovery From Eccentric Exercise–Induced Muscle Damage. Journal of Strength and Conditioning Research,27(5), 1354-1361. doi:10.1519/jsc.0b013e318267a22c
Bekerom, M. P., Struijs, P. A., Blankevoort, L., Welling, L., Dijk, C. N., & Kerkhoffs, G. M. (2012). What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults? Journal of Athletic Training,47(4), 435-443. doi:10.4085/1062-6050-47.4.14