SHOULDER INJURIES IN ROCK CLIMBERS

SPORTS INJURIES

Richard Clarke & Lennard Funk

Rock climbing has become a professional competitive sport with its own bi-annual international world cup and an estimated 25 million climbers involved in the sport in 140 countries (Danger 2013). The International Federation of Sport Climbing (IFSC) has been officially recognised by the International Olympic Committee and has been shortlisted alongside eight other sports as a possible new event for the 2020 Olympics (Danger 2013). Recreational rock climbing continues to grow in popularity in the UK with five million visits to indoor climbing walls every year (Gardner 2013). Membership of the British mountaineering council (BMC) has grown from 25,000 in 1990 to over 75,000 in 2014 and the number of indoor climbing walls has increased from 40 in 1988 to over 350 in 2013 (Giles et al. 2006, Gardner 2013).

Injuries are common and between 30% and 67% of climbers have sustained a climbing related injury. 33% to 93% of these are overuse injuries and the majority involve the upper limb (Backe et al. 2009, Paige et al. 1998, Maitland 1992, Wright et al. 2001, Pieber et al. 2012, Jones et al. 2008).

Repetitive loading of the shoulder in overhead positions combined with dynamic and static loads involving full body weight means climbers are prone to developing shoulder pathologies including shoulder impingement syndrome (SIS) rotator cuff tendinopathy, rotator cuff tears, labral tears and biceps tendinopathy (Peters 2001, Schweizer 2012). Epidemiological studies have shown that the increased risk of injury is associated with:

1. male gender
2. climbing at higher grades of difficulty
3. climbing frequency
4. More than 10 years of climbing
5. Lead climbing or bouldering

(Backe et al. 2009, Wright et al. 2001, Pieber et al. 2012, Jones et al. 2008).

Several studies have examined physiological properties of rock climbers and have shown associations between strength and endurance of the hand, finger and shoulders and high levels of climbing performance. None of these variables have been associated with an increased injury risk. A study of climbers specialising in bouldering found that injuries were associated with a previous history of injury but were unrelated to climbing experience, gender or body mass index (Josephsen et al. 2007)

Rotator Cuff Disorders:

Rotator cuff tendinopathy, rotator cuff tears, SIS, labral lesions and biceps tendinopathy are common patho-anatomical diagnoses for shoulder pain reported in the climbing literature (Peters 2001, Schweizer 2012). Rotator cuff tendinopathy is proposed to develop through compressive and tensile loading of the tendons at a level exceeding their physiological capacity (Lewis 2010). A continuum of tendinopathy has been proposed where tendon overload leads to a reactive tendon characterised by a non-inflammatory proliferative response, acute pain, thickening and increased activity of tendon cells. If overload continues a state of tendon disrepair develops with collagen fibre changes followed by irreversible tendon degeneration with partial or full thickness rotator cuff tears (Lewis 2010, Cook 2009).

Internal impingement:

Internal impingement involves compression of the articular side of the rotator cuff tendons between the humeral head and the glenoid labrum (Kibler et al. 2013). Internal impingement was first observed in throwing athletes during the late cocking stage of throwing when the gleno-humeral joint is in end range abduction and external rotation (Heyworth & Williams 2009). Since then internal impingement has been recognised in non-athletic populations who regularly participate in overhead activities (Castagna et al. 2010). The exact aetiology of internal impingement remains unclear although several factors including gleno-humeral instability and gleno-humeral internal rotation deficit (GIRD) caused by increased posterior shoulder tightness and scapula dyskinesia have been implicated (Heyworth & Williams 2009). Gleno-humeral internal rotation deficits (GIRD) have been reported in overhead throwing athletes with and without shoulder symptoms (Mihata et al. 2013). The restriction of internal rotation is usually accompanied by an increase in external rotation and increased tightness of the posterior shoulder capsule and rotator cuff musculature (Thomas et al. 2010, Michener et al. 2003). Simulated GIRD in a cadaver study has been shown to cause altered scapula mechanics of decreased upward rotation and increased inward rotation (Mihata et al. 2013) which are also commonly seen in patients with SIS (Ludewig & Cook 2000). SLAP Lesions:
Superior labrum anterior posterior (SLAP) lesions are common in climbers (Haddock & Funk 2006). SLAP lesions can be caused by compression as in a fall onto an outstretched arm or through traction to the long head of biceps. Traction in a superior direction is commonly seen during normal climbing movements especially on overhanging routes if the climber loses their footing and has to take their full body weight through one arm. The repetitive nature of sport climbing and bouldering involves high climbing loads with relatively short rest periods in-between routes. Inadequate rest periods between episodes of tendon loading may not allow a tendon time to adapt and could lead to rotator cuff or biceps tendinopathy in climbers (Cook 2009).

Scapula Dysfunction in Climbers:

Clinically subjects with shoulder and arm symptoms are commonly observed with poor dynamic scapulo-thoracic and gleno-humeral control (Kibler et al. 2013). Scapula positioning on the thorax is important in order to create a stable base for shoulder movement and maintain the humeral head in the centre of the glenoid (Mottram 1997). The lateral tip of the acromium has been shown to upwardly rotate, posteriorly tilt and externally rotate during elevation in the scapula plane in asymptomatic subjects (McClure et al. 2001). This pattern of scapula movement is thought to help maintain the size of the sub-acromial space and prevent impingement of the sub-acromial bursa and rotator cuff (Michener et al. 2003). This viewpoint is supported by ultrasound and MRI studies that have shown increased anterior scapula tilt reduces the sub-acromial space in healthy individuals altered scapula kinematics (Silva et al. 2010, Solem-Bertoft et al. 1993). Altered scapula kinematics have also been linked with decreased isometric shoulder elevation and rotational strength in subjects with SIS and healthy individuals (Smith et al. 2003, Smith et al. 2006, Tate et al. 2008, Akyol et al. 2013, Wassinger et al. 2012). Roseborough & Lebec (2007) measured end of range static positions of the scapula and humerus to determine gleno-humeral to scapulo-thoracic ratios for climbers and non-climbers. Climbers had a significantly higher gleno-humeral to scapulo-thoracic ratio (3.6:1) compared to non-climbers (2.8:1). The authors concluded that this increased ratio may represent an increased risk of rock climbers developing SIS (Roseborough, Lebec 2007).

Altered thoracic posture has also been linked with changes in scapula kinematics and alterations in shoulder ROM and strength (Kebaetse et al, 2003). The fact that changes in thoracic position affect scapula kinematics and shoulder strength is not surprising given the extensive muscle attachment between the thoracic spine and scapula (Mottram 1997). Increases in thoracic kyphosis have been linked with increased age (Culham, Peat 1993) and shortened pectoral muscles (Borstad 2006).

Movement Patterns and Prevention:

Poor performance during movement control tests has been associated with an increased risk of future injury (Roussel et al. 2009, O’Connor et al. 2011, Kiesel et al. 2007). Several studies have been able to identify differences in movement patterns between patients with lumbo-pelvic pain and healthy controls during movement control tests and functional positions (Luomajoki et al. 2008, Dankaerts et al. 2009, O’Sullivan et al. 2003), but nothing similar has been done for the shoulder.

As part of an MSc Dissertation, Richard Clark, undertook a study to examine movement dysfunction of the shoulder and trunk in recreational rock climbers with and without a previous history of shoulder injury using low and high load movement control tests.

We found that there were significant differences between injured and uninjured climbers for low load movement control tests. Climbers with a history of shoulder injury displayed movement dysfunctions of scapula anterior tilt and internal rotation (winging). Self-reported injury severity was significantly correlated with poor performance during the movement control tests. Therefore, rock climbers with a history of shoulder injury display patterns of movement dysfunction during the performance of low load movement control tests.

Summary:

Shoulder injuries are common in rock climbers, with the majority being overuse and fatigue injuries. Rotator cuff pathology is most common with SLAP tears also being common in younger climbers. Chronic scapula and trunk dysfunction can develop and can increase the risk of injury. Movement control tests may be beneficial in screening and identifying shoulder dysfunction and pathology in rock climbers.

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