Short Descriptions of Risk Factor Research

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Research > Syntheses > Risk Factors > “Risk Factor Descriptions”

Short Descriptions with Physiotherapist and Researcher Expert Opinion Provided

Green = Brazil [RV]: Renato Vilella
Blue = Norway (GG]: Gudmund Grønhaug – Gudmund’s contributions are primarily as a researcher discussing methodological issues – see the end of the document (in BLUE) for his observations on how researchers are calculating risk factors.
Red = Japan (RT): Ryuichiro Tomizawa

NOTE: It’s incumbent upon *YOU* to think critically about each of these risk factors.  I am balancing brevity and access to bring you information, which means I’m not including caveats.  For example, if an article says that taping is a risk factor, you should consider whether taping causes injury, injury causes taping, or it’s merely a correlation with some common factor between the two.

Additional note: many of these factors are associated with very specific populations.  It’s really important to read the research itself since a simple summary can never do the nuance associated with these studies an appropriate amount of justice.

The Effect of Increased Climbing Opportunities on Injury Status
No Link – Paper sent by Author
Risk Factor: Compared data from before 2010 with data after 2011 which showed the “drastic surge” of climbing in Japan is leading to a shorter time period between the start of climbing and the onset of injury.

No Pain No Gain: a survey of use of healthcare and reasons not to seek healthcare by Norwegian climbers with chronic injuries
Link
Risk Factor: Survey of 667 Norwegian climbers, 385 of which had chronic injuries.  70% of injured climbers don’t think their injury is serious enough to seek healthcare.  60% of climbers do not believe a healthcare professional can help them.  Male climbers and climbers with finger injuries are less likely to seek healthcare than female climbers and those with non-finger related injuries.

The epidemiology of rock-climbing injuries
https://www.ncbi.nlm.nih.gov/pubmed/18065444
Risk Factor: the authors found that climbing frequency and technical difficulty were associated with climbing injuries both inside and outside, particularly through a repetitive accumulation of trauma in the upper body. Frequency and difficulty were also associated with shoulder injuries in boulderers.

Epidemiology of injuries and pain in rock climbers – A review of the literature and new epidemiological data.
Link 
Risk Factor: Climbers that climb medium’s degree of difficult have more chances to feel pain. Climbers that climb outdoor and indoor are more likely to feel pain.
Brazil [RV]: As pain is a sign of the body, the onset of it can be an indicative of the onset of a stress injury.  Injury Rates: 0.02/1000 climbing hours (adult, non-elite climbers), 4.44/1000 climbing hours (11-19 years old, non-elite climbers), 22.59/1000 climbing hours (adult, elite climbers).

A stress fracture of the phalanx from rock climbing: a case report
https://www.wemjournal.org/article/S0953-9859(94)71142-6/pdf
Risk Factor: case report of pain which began with (1) finger jams and finger locks, then spread to (2) first jams and hand jams, and then eventually (3) normal climbing grip handholds.  Authors suggest repetitive “compressive” (reducing size) and “tensile” (elongating size) stress on the fingers places climbers at risk for stress fractures of the fingers.

 Climber’s Finger
https://www.worldscientific.com/doi/abs/10.1142/S0218810407003420
Risk Factor: Description of the mechanism which leads to “climber’s finger” is when the finger forms a “hook” and places the highest point of stress between the first cruciform pulley and the second annular pulley (using the middle joint on the palm side as a reference, move slightly back toward the palm).
Norway (GG]: I do believe this is not recognized as a diagnosis?

Lean and mean? Associations of level of performance, chronic injuries and BMI in sport climbing
Link 
Risk Factor: The author found no association between climbing level, chronic injuries, training volume, and/or BMI.

Radiological changes and signs of osteoarthritis in the fingers of male performance sport climbers
https://www.ncbi.nlm.nih.gov/pubmed/21904290
Risk Factor: Being a climber is a risk-factor for osteoarthritis, a degenerative joint disease that occurs with a wearing down of cartilage.

Indoor rock climbing: who gets injured
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724320/
Risk Factor: climbing for more than 10 years, climbing harder routes, and bouldering / leading more than top roping.

Performance-enhancing Osteopathy in Sport Climbers with Finger Injuries
Masters Thesis an der Donau-Universität Krems
Risk Factor: Very extensive work on finger injuries.  Authors suggest that “continuity of training”, or interruptions in continuity, may be a significant risk factor for any injury.

Tendon Injuries of the hand
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377907/
Risk Factors: Tendon tearing can happen due to chronic degenerative damage in climbers, and four factors affect post-surgical outcomes: extent of the retraction of the tendon, remaining blood supply, the time interval between trauma and surgery, and the presence and size of a bone fragment.

Incidence, mechanism and risk factors for injury in youth rock climbers
https://www.ncbi.nlm.nih.gov/pubmed/25385168
Risk Factors: Older age (even between 11-14 and 15-19); injury in a sport other than climbing; preventive taping
Brazil [RV]: Injury Rate: 4.44/1000 climbing hours

Previous injury as a risk factor for reinjury in rock climbing: a secondary analysis of data from a retrospective cross-sectional cohort survey of active rock climbers
Link 
Risk Factors: Previous injury, high incidence in fingers; Technical difficulty in bouldering and sport climbing is associated with repetitive overuse injury; wrist extension in crimp position increases finger flexor leverage but also increases injury risk.  There were associations between “acute” injuries and outdoor sport climbing and bouldering grades.  There were also associations between chronic injuries and both indoor and outdoor sport lead climbing grade as well as bouldering grade and frequency.

Pregnant Women in Sport Climbing – Is there a Higher Risk for Preterm Birth?
https://www.ncbi.nlm.nih.gov/pubmed/28103619
Risk Factor: climbing is not likely to be a risk factor for pre-term birth.

Common Musculoskeletal Injuries in Rock Climbers
Link
Risk Factors: Small climbing shoes and use of the crimp grip appear to be risk factors.

Epiphyseal stress fractures in the fingers of adolescents: Biomechanics, Pathomechanism, Risk Factors, and Ultrasound
IRCRA Conference Paper – 2018
Risk Factors: 22 injured fingers of adolescents, 95% are middle finger, 64.3% concern crimp grip and was preferred handhold in 71.4% of climbers.  Half occurred during bouldering competitions.  Most adolescents were male (75%).  Adolescents at high risk generally.

Prevalence of Disordered Eating Among International Sport Lead Rock Climbers
IRCRA Conference Paper – 2018
Risk Factors: Prevalence of Disordered Eating among sport lead climbers is 9%.  Females had higher prevalence (17%) than males (6%).  Disordered Eating significantly higher in advanced female sport lead climbers (43%) compared to lower grade climbers (7%).

Is the ratio between finger/wrist flexor and extensor strength the same in climbers as in healthy non-climbers?
IRCRA Conference Paper – 2018
Risk Factor: A study of climbers and non-climbers had the same ratio (3.0775 vs. 3.0825 respectively) of extensor to flexor strength in the fingers and wrists, suggesting that climbing trains both.

Knee injuries in Rock climbing and Bouldering – An Update
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5954325/
Risk Factor: Dorsal pain in the knee during a heel hook may be associated with LCL, PCL, lateral meniscus or distal hamstring injuries.

The “Heel Hook”-A Climbing-Specific Technique to Injure the Leg.
https://www.wemjournal.org/article/S1080-6032(15)00467-6/pdf
Risk Factor: Heel hooks may be a risk factor for dorsal-sided pain in the knee, thigh, or pelvis.  This could occur with or without outward rotation of the knee.
Brazil [RV]: The heel hook is used more with lateral rotation of the knee. This means that the Femoral Biceps muscle has the advantage of activating the other two posterior thigh muscles (Semitendinous and Semimembraneous). So, we should not think about preventing the hamstring injury but rather think about preventing muscle-specific injury (Femoral Biceps).

Rock Climbing-Related Bone Marrow Edema of the Hand: A Follow-up Study.
https://www.ncbi.nlm.nih.gov/pubmed/28696958
Risk factor: high traction to the wrist area (distal radius, distal ulna, and carpal bones) may be a stress reaction to high intensity climbing training due to traction (stretching) forces.
Brazil [RV]: Edema and stress fracture probably occurs because there is not adequate force transmission in the region. If the fascia is treated, local muscles properly trained (activation training for those who stabilize and strength training for those who mobilize) and tendons have a good progressive adaptation, these injuries may not appear.

Circular wrist tape – How to correctly use this technique in climbing and bouldering
https://www.sciencedirect.com/science/article/pii/S0949328X17302028
Risk Factor: authors suggest poor wrist taping habits may not be helpful for climbing, and recommend options for improved taping protocol.
Brazil [RV]: …but if performed correctly can add some benefit, like a feeling of increased stability and “strengthening” of the wrist and hand. Finger taping is not recommended because other papers showed that it can be a risk factor for injuries.

Lumbrical muscle tear: clinical presentation, imaging findings and outcome.
https://www.ncbi.nlm.nih.gov/pubmed/29591320
Risk Factor: Climbing on pockets with one or two fingers may be associated with a rare injury of the lumbrical muscle.

Pediatric and adolescent injury in rock climbing.
https://www.ncbi.nlm.nih.gov/pubmed/30431364
Risk Factor: Epiphyseal stress fractures may be a major concern for youth, especially during the pubertal growth spurt.
Brazil [RV]: The risk of growth plate fatigue fractures correlates with puberty, which most often will occur at an age of 13–15 years. High intensity sports training requiring leanness in a young climber can result in altered and delayed pubertal and skeletal development, metabolic and neuroendocrine aberrations, and trigger eating disorders. The only factors with a higher risk of injury were previous injury and the regular use of tape.

The role of self-efficacy in the Antecedents of Climbing Related Injury: a critical review
IRCRA Conference Paper – 2018
Risk Factor: self-efficacy (belief in success) may both (a) buffer the effects of stress and thus reduce likelihood of injury, but also (b) create a loop between (i) success and (ii) more climbing which may result in chronic or overuse injury.

A critical review of the incidence and risk factors for finger injuries in rock climbing
Link 
Risk Factor: Fingers are most common injured – specifically pulleys, and growth plates may be rising in adolescent climbers; previous injury is a significant risk factor for reinjury. Additionally, review suggests that indoor sport climbing has a lower injury rate than outdoor climbing. 

Sport Climbing: medical considerations for this new Olympic discipline
Link 
Risk Factor: The authors discuss some of the newer trends in climbing injuries, such as heel hooks and bone marrow edema (excess watery fluid collection in certain areas of the body) injuries.

Descriptive epidemiology, medical evaluation, and outcomes of rock climbing injuries
https://www.ncbi.nlm.nih.gov/pubmed/28755819
Risk Factors: the authors found that 80.1% of all climbers who seek medical treatment for an injury get referred to a specialist, half of all climbers were not fully healed when returning to climbing, and a similar percentage developed chronic pain after injury, and the factors affecting return to climbing were: smoking, fractures, age, and surgery.

Survey of hand and upper extremity injuries among rock climbers
https://www.ncbi.nlm.nih.gov/pubmed/28644933
Risk Factors: The authors found that females were both more likely to report shoulder injuries than males and also more likely to report surgery.

Injury Trends in Rock Climbers: Evaluation of a Case Series of 911 Injuries Between 2009 and 2012
https://www.ncbi.nlm.nih.gov/pubmed/25712297
Risk Factors: A4 Pulley Injuries, bone or “growth plate” fractures, and (probably) shoulder injuries are increasing. More A4 than A2 pulley injuries are being seen, a change since previous study which noted A2 over A4 – suggesting change in biomechanics of grip. More shoulder injuries are being seen as well – likely a cross between rising shoulder injuries and sample bias. Bone or “growth plate” fractures increased by 600%, likely due to increasing interest in adolescents.

The Roles of Experience, Participation Rates and Judgment in the Injury Rates of Weekend Warriors
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4309770/
Risk Factors: This article seeks to refute the idea that people are more likely to get injured on weekends due to lack of experience, and suggests that increased injury rates are seen because of overall increased participation.  It’s a response to “The ‘weekend warrior’…” paper below.

The “weekend warrior”: fact or fiction for major trauma
https://www.ncbi.nlm.nih.gov/pubmed/24869618
Risk Factors: Individuals who participate in physical activities on weekends tend to become injured more often than those who participate in activities during the week from 1995 to 2009. 

Injury risk evaluation in sport climbing
https://www.ncbi.nlm.nih.gov/pubmed/21913158
Risk Factors: years of climbing experience, difficulty level, and climbing time per week during the summer and winter months were associated with injury.

The Influence of Concentric and Eccentric Loading on the Finger Pulley System
http://www.ncbi.nlm.nih.gov/pubmed/19646704
Risk Factor:  Ruptures of pulley tendons occurred at lower loads in eccentric (lengthening of muscle) loading.
Brazil [RV]: When a tendon or pulley tendon injury occurs, independent of the injury mechanism, it’s probably because of a bad / asymmetric muscle transmission of force. Ideally, the tendon should receive at most 30% of the force transmitted.  If the fascia, the same muscle, and other tissues are not prepared or if they have a “problem,” the force transmitted to the tendon will rise and result in injury.

The Influence of the Crimp and Slope Grip Position on the Finger Pulley System
http://www.ncbi.nlm.nih.gov/pubmed/19665129
Risk Factor: Ruptures of A4 tendon mostly occurs in the “crimp” position, while multiple other injuries are more common in the “slope” position.

The “Newbie” Syndrome
https://www.wemjournal.org/article/S1080-6032(17)30207-7/abstract
Risk Factor: Authors suggest that beginner climbers do not have the muscle stability to stabilize their body during a fall nor do they have the body control to orient their positioning during a fall.  Case study includes an incomplete burst fracture of the first lumbar vertebra.

Rock climbing injury rates and associated risk factors in a general climbing population.
https://www.ncbi.nlm.nih.gov/pubmed/19508652
Risk Factors: Overuse injuries reflected 93% of all injuries to Swedish sample.  Authors are concerned about the potential risk of being overweight and bouldering, a higher re-injury rate for male climbers, and a lower risk among older climbers.
Norway [GG]: 4.2 injuries per 1000 climbing hours.  606 participants from cross-sectional survey.

Incidence and Risk Factors for Upper Extremity Climbing Injuries in Indoor Climbers
Link
Risk Factors: Recreational Climber focused – found an association between higher risk for injuries and higher age (though it remains unclear given other studies), performing a cool-down (which the authors suggest is a proxy for another variable not measured in the study), climbing with a campus board, finger strength in the middle finger, and previous injuries. 

Recovery of rock climbing performance after surgical reconstruction of finger pulleys
https://journals.sagepub.com/doi/pdf/10.1177/1753193415623914
Risk Factors: Authors found a strong association between climbing level recovery and the amount of flexor bowstringing correction after surgery.
Norway [GG]: Addition.

Foot overuse diseases in rock climbing: an epidemiologic study
https://www.ncbi.nlm.nih.gov/pubmed/23536501
Risk Factors: Male sex, the use of high-type [high degree of asymmetry between the outer and inner part of the foot] shoes, high degree of climbing difficulty, and competitive level were often related to onset of foot diseases.  The authors suggest smaller shoes “favor lateral [outer side] instability” and the back of the shoe where it opens above the heel “produces increased pressure on the heel.”
Norway [GG]: Addition.

First overview on chronic injuries in sport climbing: proposal for a change in reporting of injuries in sport climbing
https://bmjopensem.bmj.com/content/2/1/e000083
Risk factors: Identifies discriminating features between lead climbing and bouldering – relative intensity of movement.  Bouldering – shorter paths with concentrated difficulty.  However, possible similarity includes degree of repetitive movement.  Hypothesizes (but doesn’t test) that tendency to spend longer time ‘planning’ a route or boulder might possibly be a leading factor for chronic injury.
Norway [GG]: Addition.

Self-reported chronic injuries in climbing: who gets injured when
https://bmjopensem.bmj.com/content/4/1/e000406
Risk Factor: Respondents who prefer outdoor climbing are more prone to injury than others.
Norway [GG]: Addition.

Risk Factors of hand climbing-related injuries
https://www.ncbi.nlm.nih.gov/pubmed/26105683
Risk Factors: Higher skill climbers and climbers with BMI at or above 21 kg (46.3 lbs) per meter (3.3 ft) were more likely to have tendon (re: pulley) injuries.  Authors do not recommend climbers climb easier routes or drop their weight to address these risk factors.
Norway [GG]: Addition.

Footwear in rock climbing: Current practice
https://www.ncbi.nlm.nih.gov/pubmed/26261058
Risk Factor: Climbers at higher levels seek tighter shoe fits, and foot pain was found in 91% of their data set of 56 rock climbers.
Norway [GG]: Addition.

Risk Factors for Injury in Sport Climbing and Bouldering: A Systematic Review of the Literature
Link
Risk Factors: a systematic review of the studies.  They broke their findings up into “intrinsic” (internal to the body) risk factors and “extrinsic” (external to the body) risk factors.  Intrinsic include: Studies on a person’s gender had conflicting results – six studies found no difference between sexes, while four found differences, and two found differences in injury patterns based on gender and competition.  Age too had conflicting results, but appears likely to be associated with injury.  Years of experience had conflicting results, with three finding no impact and four finding climbing experience as a significant predictor.  One study found an association between experience and medial epicondylitis.  Of the eight studies analyzed, three found no association between injury and skill level, while five found that higher skill levels were.  While no study found an association between body weight and injury, one study which scored high on methodology found that higher BMI was associated with both higher risk of injury and of reinjury.  Grip strength was not associated with injury in a lock-off but had a mild-to-moderate association with a straight elbow (when the arm is straight out in front of you).

Extrinsic risk factors include: Lead climbing does appear to be a risk factor for injury, as only one out of five studies did not find an association.  Data on climbing amount (volume) was conflicting, with two studies each suggesting that volume does and does not translate into a risk factor for injury.  A “climbing intensity score” was used in 2 studies to calculate “climbing stress” as measured by the average grade of climbing and the number of climbing days per year.  Both studies found an association with injury.  When looking at indoor vs. outdoor climbing:  One study found bouldering indoors to be at higher risk of fall-related injuries, and outdoors to be at higher risk of finger-related injuries.  A second study, however, found very little distinction – although the authors note that study may be biased.  Drugs and Alcohol: both studies analyzed finding different results – the study with better methods found no association with injury, while the study with more participants found that substance use increased risk of injury.

The review also looked at Prevention measures.  Data on stretching was mixed, as one study showed an association between static stretching and injury while a second did not.  Strangely, strictly regulating equipment use was not associated with decreased injury, nor was increasing instructor presence, the number of safety mats, and the number of spotters.  One study looked at multiple factors, and found the taping of wrists and weight training to be associated with a decreased risk of injury, but not glucosamine or other supplements, heating hands prior to climbing, taking time off to prevent injuries, corticosteroid injections, or finger taping.

Norway [GG]: Comments on the studies in general [Notes for Researchers and Interested Parties].

1. Most, if not all, of the studies are mixing chronic and acute injuries. That causes a problem for any statistical model. If the populations were divided in two, one for chronic and one for acute, numbers would look different.
2. Selection bias is a thing to consider for most, if not all, of the studies. The methodology used to get access to respondents are a serious problem in this research.
3. The grouping of respondents based on gender and/or ability is also a problem here. If we are to calculate and identify risk factors it is essential to first be able to recognize the generalizability of the results from the given population to the real population. I see a lot of the papers stating that doing harder routes is a risk factor.  Or is it so that those who are doing harder routes are a different population than those doing easier routes?  Here’s an example: let’s compare it to running for a moment.  Would you ask a person who is running 3km once a week about running related injuries? And then mix him up with some sprinters on a national level and a bunch of marathon runners who cover 50-70km a week?  It just doesn´t make sense!
4. Is it clinically plausible that the identified risk factor is an actual risk factor? As far as I can see all of these studies are cross sectional. That raises the overall problem: correlation does not imply causation.
5. Self-reported pain is not the same as an injury! As the studies are self-reported SYMPTOMS and not diagnosed injuries the difference is huge. This conclusion makes the presented results highly insecure.
6. Post hoc analyses. Most of the studies do not assess risk factors for injuries. They assess what the climbers with an injury are doing.  That could just as well have been done to get better from an injury as it was causing an injury…
7. Factors not assessed that we know from other sports have an impact on injuries:

• rate of loading VS rest during activity/training
• Duration of activity/training
• Relative load of stress compared with maximum level of achievement
• Nutritional status (this is mentioned in the paper on eating disorders)
• Hydration status during activity/training
• Time of menstruation cycle
• Sleeping status
• Other stressors in life
• Inner feeling of possible goal achievement in both short term (one given day or attempt on a climb) and long term (rate of training load VS recovery over time)
• Seasonal changes (going from indoor to outdoor or the other way changes the loading pattern and pattern of movement as well as the inner pressure to achieve goals) (this is partly and briefly discussed in my paper “who gets injured when” from last summer I found that the ones focusing on outdoor climbing to be the group with the highest rate of injuries. Given the short season in Norway and that most Norwegian climbers deem outdoor climbing to be the only real deal this puts a bigger inner pressure on achieving goals when it is possible to climb outside which again makes it plausible that they ignore signs of fatigue and pain)

 To sum up:
Methodologies give low generalizability and are not possible to conclude from!

There are a lot of factors known from other sports to predict the onset of an injury that are not assessed in the literature on climbing injuries that may be of bigger importance than the ones that have been assessed.  As long as these variables are not in the analyses the studies are inconclusive and risk factors should be interpreted as insecure suggestions.