You chalk up below the bouldering wall. The crux on your project revolves around a hard heel hook. Today’s the day, you tell yourself. You start climbing. You set the heel—yes, I got it!—and inch up closer, but in the raw excitement you hear a small pop above the back of your knee. Ugh. Unfortunately, you just got one of the most common climbing injuries.
In today’s climbing and gym world, I am seeing two injuries—heel-hooking injuries and lumbrical strains—more often than ever before. Climbing gyms provide a canvas for imagining and developing moves that require unique solutions. These moves are undoubtedly effective, and really fun, but can place us at risk for injury.
Performing a heel hook can create high forces at the knee due to the biomechanics involved. The upper leg and lower leg (femur and tibia/fibula) create long moment arms (the length between a joint axis and the line of force acting on that joint), with your knee caught in the middle. When the toe is turned out, high tensile and shear stress can occur at the lateral collateral ligament (LCL), lateral meniscus, proximal tibiofibular ligament, popliteus tendon, dorsal joint capsule, iliotibial band, and lateral hamstring tendons. The medial knee can undergo shear and compression as well. Therefore, our possible injury list includes: meniscus tears, LCL and proximal tibiofibular sprains, hamstring strains, hamstring avulsions (where the tendon fractures the bone where it attaches), among others. So yeah, it’s quite a list.
Heel-hooking injuries are not fully preventable given the biomechanics, but we can at least decrease the risk through proper warm-ups and preventative exercises.
Climbers often report a snapping or popping sound at the time of injury. The sound may indicate a ligament sprain or the iliotibial band snapping over the boney part of the lateral knee. Mild to moderate swelling may occur quickly with low-grade sprains or partial tears of the LCL and proximal tibiofibular ligaments. The climber may also feel “unstable” at the knee with an LCL sprain. With a meniscus injury, swelling may appear more gradually over the next day, but persist if the tear does not heal itself. Moderate or severe strains at the hamstrings may result in discoloration, pain and guarding (spasms or tightness) when straightening the knee, and possible weakness with actively bending the knee. The strain may occur in the muscle belly (more mid-thigh) or higher, where the muscle meets the tendon (aka “high” hamstring strain). Hamstring avulsion injuries usually occur at the ischial tuberosity (your sit bone) and tends to appear during explosive movements.
Getting the right diagnosis is paramount. Start with a physical examination by a medical professional. If signs and symptoms hint of a meniscus or ligament injury, then you may need diagnostic imaging to confirm the diagnosis. Diagnostic ultrasound may not be able to rule in/out some injuries such as hamstring avulsion injuries, so an MRI is recommended for those. Different types of meniscus tears and degrees of ligament sprains require different treatment approaches (surgery versus conservative treatment, how long to brace, what movements/activities to avoid, etc.).
Physical therapy can begin as soon as your physician clears it. For LCL, proximal tibiofibular sprains and meniscus injuries, treatment initially includes pain and swelling management through icing and compression for up to 72 hours after the injury. Knee range-of-motion exercises, and low-load muscle activation exercises of the quadriceps and gluteals can begin immediately.
If an LCL sprain is present, a stable hinged brace can provide protection. The later phases of rehab (in two to four weeks depending on the severity of the sprain) focus on restoring functional strength and neuro-muscular control, to prevent reinjury. Take care in performing isolated hamstring strengthening (e.g., leg curls) if an LCL and/or proximal tibiofibular ligament sprain are present given the attachment of the lateral hamstring tendon at the fibula, where these ligaments also attach.
This initial phase of rehab is also the time to assess whether you are activating muscles (specifically the gluteals) in the correct sequence. These muscles aid in heel-hooking, taking stress away from the hamstrings and knee by involving the hip. These exercises can include simple prone hip extensions to learn the proper firing pattern, then applying the strategy to “bridges” with variations that mimic heel-hooking maneuvers. Once you can perform the exercises without pain and you demonstrate proper strength, you can reintroduce heel hooking.
If you suspect a high-hamstring strain or an avulsion (pain will be closer to your sit bone), DO NOT stretch your hamstrings or start any strengthening exercises yet. High-hamstring strains need to be treated more conservatively and gradually than mid–hamstring strains.
For hamstring strains, perform dynamic stretching as part of your warm up. Forward leg swings can improve mobility as well as activate the hamstrings and gluteals. Also, single-leg deadlifts warm up the gluteals and hamstrings, as well as your overall balance. Performing bridges is also a good way to activate the gluteals, especially if you plan to do some steep routes/problems.