Climbers

Clarifying the Role of Pain in Injuries

First Appeared in TheClimbingDoctor.com

For a long time I dropped things, mostly smaller items like car keys. I also suffered from phantom pains. The tip of my finger itched even though it wasn’t there.
— Tommy Caldwell, The Push
 Image from www.quora.com

Image from www.quora.com

It wasn’t that far ago that phantom limb pain was a complete mystery. This is a sensation that someone experiences in, say their finger, after it’s been amputated. The finger no longer exists yet the person can still feel it. This is possible because sensations, such as pain, are experiences created by both your body AND your mind.

When a finger is amputated you lose the nerves that were part of the finger. You don’t lose the nerves that connect your finger to your brain, or the part of the brain dedicated to that finger. What remains are crucial components for the production of pain, and are sufficiently powerful to create pain in a limb that doesn’t exist. This is why phantom limb pain is possible.

This phenomenon has allowed us to learn a lot about how pain works. Unfortunately, misconceptions around pain are abundant, some of which dampen our ability to recover from injury. Clarifying the purpose of pain and how it works can go a long way in helping us overcome the most stubborn of injuries.

_ _ _

You’ve got a week left of training before you set-off for your fall climbing trip. You put your time in this year with the hopes of finally sending your long-time project. You’re feeling strong but will occasionally get an ache at the base of your left ring finger with hard bouldering sessions. It usually settles within a couple of days and you think nothing of it.

_ _ _

Pain is meant to protect you

When you experience pain, it is first and foremost a warning system meant to protect you from potential harm. If you take a finger and slowly start to pull back on it, you’ll experience pain before you cause tissue damage. This is meant to prevent you from going further so you don’t cause injury, and it happens in everyday life.

If you sit on a cold rock at the crag for too long your bum will get sore. This is meant to remind you to move around. You wouldn’t have caused harm to the tissue – it’s resilient! On the other hand, if you ignored the signal to move you may eventually sufficiently restrict blood flow to your bum and cause injury to the skin, known as pressure sores.

Perhaps a more pertinent example happens with training. If you’re pushing hard and nearing your body’s limits, you’ll start to get muscle soreness, mild pain, or straining in and around the joints. If you stop the session when the warning signs show up, there’s a good chance your tissues will settle within a few days and you’ll be good to start training again. The pains you experienced acted as a warning to tell you to back off so that your tissue can recover. Not heeding the warning is a good way to get injured.

_ _ _

This is your second day climbing and your third and final go at your project. It’s a gentle approach into a progressively crimpier pumpfest. It finishes with a deadpoint before locking-off to grab a jug. The terrain eases off significantly afterwards. Things are going well – your beta is clean and you’re moving quickly. Your left hand hits the edge of the deadpoint and you manage to curl your fingers into a full crimp. You pull into your lock-off and release your right hand. “POP” goes your left ring finger. You’re committed and finish the move. Only ten more feet of climbing. You think to yourself “that wasn’t painful” and finish the climb. As you lower you start to feel an ache in your finger. The next day, your finger is swollen, painful and difficult to move.
_ _ _

If you’re lucky, you’ll see an injury coming before it’s too late. We’re not all lucky and warnings don’t always present themselves. Pain is almost always associated with fresh injuries but when we experience the pain isn’t always consistent. Why are injuries painful, and why isn’t the timing of pain always consistent?

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Photo Credit: Lauren Watson

A noxious stimulus sets off the alarm

In the example above, the “pop” was a sprain to the A2 pulley of your ring finger, a fairly typical climbing injury. You only start to feel an ache after you finish the route, though damage would have occurred with the pop instantaneously. Inflammation ensues. If there’s enough inflammation, nociceptors are triggered.

Nociceptors are nerve endings meant to detect a noxious stimulus. Once the nociceptor is triggered, it sends a signal up to the spinal cord. The spinal cord will then relay that message to the brain. If the brain determines that the nociceptive signal poses a threat, you will experience pain in your finger. By the time you come off the route, you’re starting to feel an ache and thinking “something is wrong”, all thanks to the inflammatory process that triggered your nociceptors.

Nociceptors can also be triggered by changes in temperature (e.g. a hot stove) and mechanical stresses (e.g. an aggressive stretch). The “pop” you felt would have triggered the mechanical nociceptors yet it wasn’t painful, an all too common occurrence. You were lucky enough to feel the ache immediately after completing the route. Some people won’t feel it until the next day, or in extreme examples, until they climb again a few days later. How can this be?

Nociception can be stopped at the spinal cord

The brain has a remarkable ability to lessen or even stop the noxious stimulus from making it all the way up to the brain. It can send a signal to the spinal cord that in essence says “we’ve got more important things to worry about (red-pointing this route!!), so don’t bother me with your nociception. I’m not interested right now.” This is why you don’t always feel pain with a very clear “pop”, and why climbers will often times finish a route before noticing their finger pain. This is also why you can run a marathon with a sprained ankle, and even win the race!

The brain listens to the danger signals

What happens when nociception makes it to the brain? The brain has the difficult job of interpreting all of the thousands of signals that come from the body at any given time. It needs to understand the signal before making a decision. Based on all of the information available to it, if it deems the signal to be dangerous to the tissue, and there aren’t more pressing matters, you will experience pain, whether it’s an ache, throb, sharp, lancinating, piercing, burning, stabbing, or (insert any pain descriptor) type of pain.

Now we know why we don’t always feel pain at the moment of injury, and we can explain the throb that occurs shortly after an injury. Let’s take a closer look at the alarm system as the healing process begins.

_ _ _

The rest of the trip was a bust. The finger progressively got worse. You could barely close your hand, making it impossible to climb. Thoughts about a long-haul recovery have taken over. It’s been two weeks since your injury and you find yourself sitting on your couch. You notice that the swelling and pain have finally started to settle. You decide to test it by lightly crimping your coffee table. BAM! “That *@#$ing hurt! This finger is totally messed.”

_ _ _

The alarm system sensitizes

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For simplicity’s sake, it’s easiest to think of two systems working together to help you recover from your recent injury. You have a system designed to heal your injured tissue and one to protect the tissue while it heals. Broadly speaking, the first consists of the inflammatory process, and the second creates your pain experience. Both are intricately connected and work together to get you back to health. While the inflammatory process repairs damaged tissue, the nervous system warns you against potentially harmful situations. Think of it as a smoke detector. If a sufficient amount of smoke is detected (nociception) it will sound the alarm (pain).

After an injury, your smoke detector is more sensitive. It will sound the alarm at the faintest hint of smoke, even if a fire (harm/ further injury) is far from a reality. This is your mind and body’s way of protecting the injured tissue so you don’t hinder or aggravate the healing process. You’ll experience pain far before you cause more harm. Remember that pain is meant to protect you.

During the coffee table incident, it’s far more likely that you triggered the alarm system without causing further harm. The pain typically settles relatively quickly without a significant increase in swelling, aching, or stiffness. Your warning system sounded the alarm to protect the already injured tissue.

The alarm system can be a helpful tool in the recovery process. It reminds you to drop into a lower gear and slow down. As the injury heals, and you begin to gradually load the tissues, the system will begin to desensitize and you’ll find yourself able to do more with less pain.

_ _ _

It’s been four weeks since the injury and the finger doesn’t seem to be improving much. The coffee table incident really freaked you out. It was quite sore for a few days afterwards. You went to grab a milk jug out of the fridge and even though it wasn’t as bad as the coffee table, you still felt pain. You wonder whether it needs more rest so you decide it’s best to avoid using the finger with other tasks – no milk jugs, no opening doors, light use with brushing your teeth and cutting food. Eight weeks out and it almost seems to be getting worse. Lifting a milk jug out of the fridge is more painful than it was three weeks ago. “What gives?!!” Four months out and lifting a milk jug out of the fridge is unthinkable. “Something must be seriously wrong.”
_ _ _

The alarm system can remain sensitized past healing

The experience of pain and the process of healing, though intricately connected, can diverge. It’s possible that as the healing subsides, the alarm system remains sensitive or even continues to sensitize. For instance, during the coffee table incident, your alarm system may have created a sufficiently noxious stimulus that you decided to avoid using the finger all together. Every time you use your finger your alarm system goes off and you go back to protecting the pulley that’s not healing. We often think that pain relates to tissue harm and that we should avoid anything that is painful. Remember that pain is meant to protect you and is a poor indicator of harm being done to your tissues.

If we continue to avoid using the finger in fear of causing harm, we may further sensitize our alarm system to the point that previously non-painful tasks become unthinkable. It’s possible that the healing process will finish and for the alarm system to remain sensitized. Rather than simply the pulley, your whole finger may become tender to touch. It may progress to your whole hand, forearm and upper arm weakening. This can be an incredibly frustrating, demoralizing, depressing, and for some a life altering experience. The good news is that the human body is adaptable no matter your age, and pain is changeable, no matter how long you’ve had it or the severity of your injury.

Desensitizing the Alarm

A sensitized alarm system needs desensitization, and one of the best ways of doing this is by understanding how pain works. We now know that pain is meant to protect you. We also know that pain is a poor indicator of tissue harm, and can occur even when no harm is being done to your tissue. We also know that pain can persist past healing.

Armed with this knowledge the next logical step is to say “Hell! If my alarm is overactive I may as well ignore and push through the pain”. False! This can be a good way of making the situation worse. Remember that you may have avoided exposing your tissue to stresses such as lifting a jug of milk. Not only does your nervous system need desensitization, your tissues need to adapt to the load you’re exposing it to. In other words it may need some time to adapt to lifting a milk jug again. When re-introducing movement and activity, I typically have my clients ask themselves two questions:

1. Is this safe for me to be doing?

To phrase it differently, am I exposing my tissues to a safe load? When I lift the jug of milk out of the fridge, I may experience a bit of pain, but can my tissues handle this load? Remember that pain is not an indicator of tissue harm, and with a sensitized system you’ll experience pain before you cause harm. If you don’t know the answer to this question it’s best to start more conservatively. Can my finger handle holding a phone despite some pain? Chances are yes, but for some this might still be too much to start with. Can I bend my finger despite mild pain? Lightly moving your finger through its available range of motion is typically a very safe bet if you have any doubt. The next thing I ask is:

2. Will I be OK tomorrow?

There are a lot of reasons for why pain may not always present itself immediately after a stressor. This is why it’s important to ask yourself whether you’ll feel pain later. Take comfort in knowing that pain that lasts a couple of days, though irritating and perhaps demoralizing, is unlikely to cause any more harm to the injured tissue. We refer to these as flare-ups of the nervous system, and are perhaps not surprisingly relatively common. This is normal, and provides an opportunity for evaluating how hard you’re pushing. When a flare-up happens we typically need to pull back to rest the nervous system. Once the pain has calmed down we then try a similar activity at a lesser intensity. The idea is to build your activity levels gradually and systematically.

In his book The Push, Tommy Caldwell describes exactly this process when he was overcoming a sensitized finger stump and experiencing phantom limb pain. Although an extreme example, the process is the same. He gradually and systematically exposed his new finger to more aggressive exercises and tasks to the point of climbing the Dawn Wall.

Overtime you’ll find yourself using your finger with everyday tasks, lightly crimping coffee tables, and even starting to try easy rock climbs. Eventually you’ll start bearing down on crimps and building the confidence to try your old projects. Gradually building your tolerance to movement and activity, while simultaneously pacing your activities to avoid delayed pain are great tools in helping you overcome a sensitized alarm. If you need help getting there, look for a physical therapist well versed in the latest pain science and exercise physiology. If we stick to the finger, the end-stage rehab usually consists of fingerboarding. If your therapist is recommending more soft tissue work three months post injury, it’s time to look for someone else. Remember that gradual loading and pacing is your best bet no matter the injury.

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_ _ _

It’s been a year since your finger injury and you find yourself looking at the old project that started it all. You strap on your shoes, tie into your harness and begin making your way up the gentle approach leading to the crux. You can feel your heart pumping in your chest. The nerves are mounting. You take a few deep breaths before starting the long and pumpy crux. The finger feels great – not an inkling of pain or discomfort. You hit the deadpoint with the left hand, curl your fingers into a crimp, release the right hand and reach for the jug leading to easy terrain. You don’t even feel pumped as you’re lowered to the ground.

_ _ _

Is it possible to come out stronger than you started? It sure as hell is.

REHABING A BROKEN PHYSIO

If you've ever wondered how a physio goes about rehabing their injuries, this is your chance. Here’s a glimpse into my recovery process after busting my ankle at the start of the climbing season:

Week 1 (May 17th)

I busted my ankle on Super Dyke. For those of you familiar with the climb, you'll guess exactly where: between the boulder and the tree. My foot blew off the slab quite unexpectedly (I was feeling invincible that night!) and went crashing down onto the tree root below me. My left foot landed flat and my knee proceeded to continue moving forward. For you anatomy buffs, I hyperdorsiflexed my ankle. I did a couple of quick tests which told me I should get an x-ray to rule out a fracture…

 

No fractures!

 

The next day I woke up with a very swollen ankle, unable to put very much weight through my foot. It was clear this wouldn't exactly be a quick recovery.

Swollen ankle

At this point most people would think about RICE. Ever hear of it?

REST.

ICE.

COMPRESS.

ELEVATE.

DID I REST?  

I sure did! I avoided anything that was painful. In fact it's the only thing I could do. That's the beauty of pain and inflammation - it stops you from causing further harm when the system is weak and trying to repair itself.

DID I ICE?

I did NOT. Here's why:

Ice is thought to help slow or even prevent the effects of inflammation. It turns out the inflammatory process plays a very important role in healing. In fact this is exactly what HEALS your injuries, so why would you want to take it away? You shouldn’t take it away. Trust your body to heal itself - it does a great job!

To add insult to injury, when we look at the research, it turns out ice probably doesn’t even penetrate deep enough to have an effect on the inflammatory process. There is no strong evidence to suggest that icing an injury will accelerate your healing time.

Some will say we should use ice to help manage pain. While ice may help reduce your pain, I would argue that pain is very useful and a natural part of the healing process, especially in the acute phase. It tells you to back off! I chose not to use ice for pain management mostly because I could adequately control my pain by resting and protecting my ankle. If you push through the pain and use ice as a management strategy you’re not doing yourself or your injury a favour. In fact pushing through your injury at an early stage may in fact prolong your recovery period.

DID I COMPRESS?

This one isn't as clear cut as icing. Some studies have shown positive results on healing time and pain, while others have shown it to be ineffective. So what did I do? I wore tight ski socks and wrapped it with a tensor for a couple of hours here and there. I could visibly see a decrease in swelling with aggressive wrapping but it's questionable as to whether it had an effect. Just because the swelling is temporarily reduced, doesn't mean this accelerates healing time.

As far as pain goes, I experienced more pain immediately after removing the dressing. This would lead me to think that compression is helpful in controlling pain. What's more likely is that I experienced a temporary increase in pain as the ankle returned to its more natural swollen state. In other words, the ankle wants to be swollen because of damaged blood vessels and permeable cell membranes. The body will repair this over time and swelling will come down naturally with a little help from specific exercises.

DID I ELEVATE?

Surprisingly, this is the least studied of the RICE recommendations. Intuitively, it makes sense to elevate for swelling control, especially if it helps with pain.

Did I elevate it? Yes! I elevated it whenever it was throbbing or aching. Having it high above my heart was the most comfortable position. If it wasn't bothering me, I had it resting on the coffee table or planted on the ground. This is arguably the equivalent of resting my ankle.

What did I do?

If I didn't ice, or do much compressing, and wasn't religious about elevating it, it doesn't sound like I did much, does it? To the contrary, I did quite a bit.

 

Protection and Optimal Loading

I moved my ankle and toes as much as I could through it's available pain free range. I did so in non-weight bearing positions, but also with my foot planted on the ground. I used the help of a belt to move it around, but also did so actively with my ankle and foot muscles. I let pain be my guide. I would avoid anything that brought on an increase in pain, trusting that when I felt pain it was more so a warning sign as opposed to an indication that I was causing more harm (see video below).

I practiced walking as normally as I could using crutches. I also started moving my left knee, hip and back to help avoid the effects of disuse. I used my physio stool to load my left hip, which helped a lot with work! I was even able to get into the pool and tread water lightly. In essence, I tried to be as active as possible without aggravating my ankle.

 

WEEK 2:

 

It turns out my ankle was in fact broken... and I needed surgery.

 


 

To be continued...

 

Wrist and Elbow Training for Climbers: Part 3 - Warm-Up and Projects

If you've learned anything from our prior 2 videos, we hope that it's the importance of training your wrist extensors to help prevent wrist and elbow injuries, and improve performance. We can take this a step further by applying these principles to your warm-up, and if need be, to your projects. Check out the video to find out how! 

Wrist and Elbow Training for Climbers: Part 2 - Hangboarding

If you're lazy like me, you'll want to know how you can train both your climbing muscles and your opposition muscles at the same time. You've come to the right place! We'll show you how to keep your opposition muscles engaged while training your principle gripping muscles on the hangboard. Have a look and share your thoughts!

Wrist and Elbow Training for Climbers - Part 1

In this series, we'll explore how to get our wrists and forearms strong so that we can avoid pesky wrist and elbow injuries, and improve performance on crimps, slopers and pinches. The first video explores wrist positioning in a farmer's carry. The principles we discuss here can be applied anytime you lift a weight off the ground. In our upcoming videos we'll discuss how you can apply this to other typical climbing exercises, like pull-ups and hangboarding. 

Have a look, share your thoughts, and spread the word! 

 

 

Core Stability: Progressing the Posterior Chain

My last video introduced the concept of stability in the posterior chain. We used the bridge exercise as a means of training static stability in the posterior chain. As a refresher, static stability refers to stability around the joints of the body without movement around any other joint. When training core stability, we typically start with static stability and progress to dynamic. We used the push-up and pull-up as a means of training dynamic stability of the anterior chain.

This week we’ll progress the bridge exercise by making it into a dynamic stability exercise.

To help illustrate, allow me to share a few examples of when this muscle group comes into play. The most obvious example is a climber on overhanging terrain using his heel to prevent a barn door. Your posterior chain is doing much of the work anytime you heel hook.

Now picture a climber desperately reaching for a crimp. They first get their middle finger on the crimp, then somehow their index finger, and finally the ring finger. They can now bear down on the crimp, and steady themselves to bring their right foot up to a large foothold. The crux is over. What got them there? Their posterior chain. As the climber reached for the hold, their low back and glutes kept the bulk of their body close to the wall, their hamstring helped drive the pelvis into the wall while also helping the foot maintain tension on the hold. Finally, their calf pushed the heel up, and their mid-back extended their spine so that they could reach the hold.

Now consider the climber reaching for a far off foot hold. The moment the foot lands on the hold she needs the posterior chain to drive the foot into the hold so it doesn’t peel back off the wall. Her calf and hamstring are doing most of that work. If she wants to make her life easier, she’ll drive her pelvis and low back closer to the hold to get more of her weight over the foot. The muscles in her low back are doing much of this work. These are all muscles found in the posterior chain.

In other words, you use your posterior chain just as much as you would any other muscle group. If you want to avoid injury (think low back, knee, hamstring) and generally climb harder, training the posterior chain is key.

 

Core Stability Series Part 3: The Push-Up

In my two prior posts, we talked about how to integrate your core stabilizers into exercises used to train for climbing. The first looked at how to integrate your shoulders and anterior trunk muscles into your deadhang - see here. This can be a great tool to help you train static stability.

We then progressed by incorporating stability into our pull-up. The pull-up is a great way of training dynamic core stability (i.e. stability through movement) - see here.

In both of these exercises the feet are doing absolutely nothing. This is contrary to how we usually climb: we want to maintain foot contact as much as possible. We need a way of progressing anterior trunk and shoulder stability with both hand and foot contact. The push-up can help you do this.

Check out the video below to learn how to integrate anterior trunk and shoulder stability in the push-up.  

All of the exercises we’ve discussed have emphasized anterior trunk engagement. These exercises are great at getting your feet high on the wall, or preventing them from pulling you off the wall when they cut. What about maintaining tension when your feet are on the wall, or pulling your hips into the wall? This requires a whole new set of muscles. Check out next week’s article and video to find out more.

This article was first published in Squamish Climbing Magazine on Sept 28th, 2016

Core Stability Series Part 2: Pull-Ups

Last week we discussed how you can start to integrate your core stabilizers with a basic exercise like the deadhang. Check out this article for a quick recap. In integrating your shoulder and anterior trunk muscles within your deadhang you’re training static core stability.

Consider static stability to be any exercise that engages your stabilizers without additional movement generated by your prime movers (the larger muscles in your body responsible for moving your limbs). Another example of a static stability exercise would be the classic plank exercise. You move your body into a neutral posture and hold that position. The stabilizers stay on for as long as you hold that position.

In climbing, you need both static and dynamic stability. Dynamic stability is your ability to control the joints in your body while the prime movers are carrying you up the wall. In other words, stability through movement. Holding a plank or simply training your stabilizers on a hangboard isn’t enough.

Consider last week’s climber who has just thrown for a dyno and their hands have landed on the finishing holds. As their body falls back towards the ground, the prime movers are working to slow the momentum of their body while the stabilizers are working to keep the joints safe. This is an example of dynamic stability. You train dynamic stability by keeping your stabilizers engaged through movement-based exercises.

The pull-up is a great place to start and a good means of progressing the hangboard exercise. Check out the video below to better understand how you can start to train dynamic core stability through pull-ups.

This article was first published in Squamish Climbing Magazine on Sept. 12, 2016.

 

 

Want to learn about Prehab and Climbing? Join me in Colorado at the CWA!

I'm excited to announce that I'll be presenting at the Climbing Wall Association conference this May in Boulder, Colorado. I'll be covering strategies to incorporate prehab and injury prevention into your climbing and training programs . If you're in the area and keen to learn  more, visit the website below. 

http://climbingwallindustry.org/page/2016_CWS_Sessions

Stay tuned for upcoming prehab and injury prevention seminars in Squamish. They'll be coming up soon at Ground Up Climbing

 

 

Breathing while Climbing

Has anyone ever told you to BREATH while cruxing out on your project? There's a very good reason for it, and this video helps explain why. A lot goes into answering this question effectively. I've tried to keep it simple and focus on the physiological side of things. Your breathing has a large role to play in your mental game but I'm going to avoid that can of worms for now. Have a listen and share your thoughts. I've highlighted 2 tips you can take away. 

Thanks to the viewer who asked this question. Hope this video sheds some light.


Releasing the Hips

As requested, this one goes out to everyone with tight hips.  Check out these exercises to help release common areas of tightness. Give them a shot and share your thoughts. When rolling out  it's normal to feel tenderness. If you experience significant or lingering pain talk to a professional.

Thanks to Michael Apps for demonstrating the exercises. Check him out at Highland Sport and Spine Physiotherapy for injury prevention tips for skiers. 

Preventing and Managing Belayer's Neck

If you've ever experienced headaches, neck pain, or muscle tension after belaying, this video is for you. Have a look for pointers on how to maintain good posture while belaying, and a quick stretch to prevent tension from building in the neck. As always, you should avoid this exercise if you experience any pain doing it. See a professional to help determine the source of the pain. 

 

I appreciate your feedback. Post your thoughts below. 

Editor's note: No climbers were hurt or left free soloing in this video. 

By William Bateman 

2 Key Shoulder Exercises for Climbers

Climbers prone to shoulder injuries have two things in common: a stiff ribcage and weak shoulder stabilizers. Check out the video below for 2 exercises to help address these issues. You can incorporate these as part of your dynamic warm-up or before starting your training program. 

A word of caution: if you experience pain doing any of these exercises they’re not appropriate. Seek the help of a professional to understand the source of your pain. 


By William Bateman 

Shoulder Form for Climbers

I see countless shoulder injuries in climbers. Most of them can be attributed to weaknesses in their external rotators and scapular stabilizers, and over developed internal rotators. A simple way of thinking about this in your climbing is to keep those elbows IN! If you're winging, you're hurtin'.

Check out the video bellow to get an idea of what I'm talking about. It's not meant to be a training video simply a demonstration of good shoulder form. See whether you can apply this to your training so that it becomes more natural on the sharp end.  

By William Bateman