Heel Hook Injury

In a recent study done by Schoffl et. al., during a 4-year period, 836 patients with a total of 911 independent climbing injuries were prospectively evaluated using a standard questionnaire and examination protocol. Of all injuries, 833 were on the upper extremities, 58 on the lower.

Lower extremity injuries are relatively uncommon compared to other climbing injuries such as finger and shoulder injuries, but they still happen and can be just as debilitating.

In this article, I will discuss the mechanisms of a hamstring injury and my general approach to rehabbing this type of injury.

HAMSTRING ANATOMY

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 common mechanism behind this injury is usually a combination of pelvic flexion and knee extension, such as jumping, kicking a ball, falling with your leg extended. An eccentric mechanism of injury.

Heel hooking injuries tend to be a little different.

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. Though most heel hook injuries tend to be a concentric mechanism of injury.

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, usually a stretch or eccentric injury) and some tear the distal portion (closer to the knee, concentric injury).

Some probable causes of hamstring tears:

Underpreparedness  (the hamstrings were not properly trained to handle the load or repeated load)

Improper heel hook technique

Mobility issues in the hips, low back or the hamstrings themselves

Traumatic (falling while foot gets stuck in a bomber heel hook or heel-toe-cam)

Fatigue


SYMPTOMS


Most climbers (but not all) report a “pop” followed by pain and cramping behind the thigh. Some will not notice until after the climbing session or the next day. 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.

All strains are muscle tears. There are different grades of strain traditionally used to differentiate these injuries.

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.


DIFFERENTIAL DIAGNOSIS

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 joint 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 may be 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. Don’t waste time trying to self-diagnose.


TREATMENT STRATEGIES


***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 and some guidance first before attempting self-treatment.***

Most hamstring injuries 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 ad other factors that may influence treatment (like beliefs about the injury pain, prior experience etc.). This is why you need a professional opinion before proceeding.

Here is a general overview of my approach:  

PHASE 1


Anywhere from 24 hours up to 2 weeks post-injury depending on the climber and the injury presentation.

Goals: Decrease pain and restore range of motion.

You don’t need to ice it. Why?


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. 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. You don’t need to hinder it with icing.

RESTORING RANGE OF MOTION


I use a high volume exercise 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 works to minimize scar tissue formation and helps the tissue heal normally. I do this using light squats or Romanian deadlifts starting anywhere from immediately to a few days after initial injury depending on severity and presentation and can be done daily.

In some cases, I will recommend a high-dose anti-inflammatory regimen to bring the pain down enough so that we can begin the rehab process. This will inhibit the inflammatory process but it can be worth it if it allows for rehab to begin sooner.


PHASE 2

This can begin anywhere from 48 hours to a few weeks post-injury, again, depending on the climber and the presentation of the injury.

Goals: build strength

High intensity/low-moderate volume training. General strengthening and specific exercises depending on tolerance.

EXERCISES

Here are some examples of the exercises I recommend for strengthening and rehabbing hamstring injuries. I do these 3-4x per week with at least 1 day off in between.

Squats : Squats 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. Proper coaching is necessary.

Deadlifts: 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 proper loading strategies are applied. Proper coaching is necessary.

Romanian Deadlift (RDL): This is an alternative I use for climbers who need a more targeted hamstring exercise. Most 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.

Glute bridges: Glute bridges are a little bit less of strength exercise and a little bit more of a sport specific drill but I’ll use them in this phase sometimes. 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. You can change your foot position for a different feel. The feet can be elevated for added challenge. Weight can also be used on the hips.

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. Nobody ever got better at climbing without trying something more difficult than the last time, right? Heavy isn’t dangerous as long as you progress up to it in a systematic way.

I highly recommend seeking out professional advice on how to perform these exercises from a qualified coach, PT or rehab specialist in your area.

Climbing can be resumed in this phase for some people. I usually move to phase 3 after 6-12 weeks.  

MANUAL THERAPY/TISSUE WORK/STRETCHING

Manual therapy (MT) work can be started in Phase 2 if you like it, know how to do it and want to do it. I don’t think it’s necessary for healing especially because it tends to impart temporary changes in sensation and range of motion and doesn’t actually “fix” the issue.

I do not prescribe stretching to any of my patients for the same reasons as MT. Passive stretching can also sometimes aggravate some people’s injuries. Eccentrics and isometrics are better and that’s what we are doing with the exercises mentioned above. Stretch if you want to

PHASE 3

In this phase the climber has been cleared to heel hook again, symptoms are gone and the climber has done at least 6-8 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 sport specific hamstring isolation work to prepare the climber for heel hooking at full capacity again.

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.

*Heel hooking technique post to come

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 the injury, the presentation of the injury on an 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 injuries and it is possible other structures could be damaged with the same mechanism of injury. This may or may not change the treatment approach. 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, especially if surgery is potentially involved. Don’t just talk to your general practitioner or an orthopedic surgeon, talk to physical therapists and other rehab specialists who work with climbers as well. Don’t forget to ask a lot of questions. Be your own advocate.



Resources

Schöffl, V., Popp, D., Küpper, T., & Schöffl, I. (2015). Injury Trends in Rock Climbers: Evaluation of a Case Series of 911 Injuries Between 2009 and 2012. Wilderness & Environmental Medicine,26(1), 62-67. doi:10.1016/j.wem.2014.08.013

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

Hubbard, TJ, Denegar, CR. Does Cryotherapy Improve Outcomes with Soft Tissue Injury? J Athl Train. 2004 Jan-Mar; 39(1): 88–94.