Hooper’s Beta Ep. 56

Intro

I’m just going to come right out and say it, this is a complicated and deep subject, BUT we’re going to break it down into digestible pieces in this video because it’s such a massively important topic for climbers. We’re going to find out how to FINALLY fix that lingering hand or finger injury you got months ago from climbing that “just won’t heal”. We will go deep into understanding pain science and how to USE that knowledge to rehab our injuries. We will go into a Proper Pain Protocol to help guide your process. AND, we are making this episode extra special by bringing in not 1, but 2 special guests.

For our two interviews, we will have a pain science discussion with Dr. James Lee, a physical therapist in Chicago who has been treating climbers there for years (and is of course, also a rock climber). And, we will have an interview with our friend Marcel, who is a rock climber himself who found himself in a similar situation uttering those same words to me while climbing one day: “I hurt my A4 a year ago, and it still hasn’t healed”. 

We are going to start off with an interview with Marcel, but before we call him up, let’s give a little more background. Marcel is an awesome dude and a strong climber who experienced an A4 pulley injury about a year ago. In his words: “I was climbing at Tramway, it was cold, and of course i spent all of 10 minutes "warming up". I got through the slopey crux and grabbed a huge incut crimp with my left hand and as soon as I put my weight on it I heard a loud pop and my finger instantly went tingly and funny feeling. surprisingly no pain but suddenly I lost all power with that finger. It was never diagnosed but I believe a a4 injury on the middle finger.”

Now, it’s been long enough since the injury so the tissue should be healed at this time. But he is still experiencing discomfort. We will talk to him about his rehab process and check in on how he has been doing. 

Interview with Marcel

Question: What did you do for your rehab?

 Answer: It was maybe 12 plus weeeks of no climbing and then from there I slowly started what I call crack rehab. I’ll just go out to Woodson and Tahquitz and just climb easier cracks. I just that that kind of motion wasn’t going to hurt it as much. I started bouldering again obviously but the pain, although it wasn’t the same, I had power back, but the pain lasted and still lasts. I’ve been climbing more but the confidence is definitely still lower with that hand, especially that finger.

Question: What do you think is causing you to not be confident in the hand still.

Answer: I’m not entirely sure. I think the memory of the injury or the pain of the injury is just so recent it’s still there.

Interview with James: Pain Science

Question: When can we be confident that our healing is complete.

Answer: Even at it’s longest, the connective tissue may take a max of 4 months to heal.

Question: So, what exactly is happening when we have pain despite the fact that the tissue should be fully healed?

Answer: We actually don’t have dedicated pain receptors. There is no specific nerve that’s just saying this is painful. We have a lot of different sensory receptors: temperature which differentiates temperature, pressure, stretch [and chemical]. But, when you get injured your brain makes a switch from experiencing those sensations and it interprets it as painful. in normal cases this is very advantageous because you want to protect what you ended up hurting but even that system can malfunction which leads you to become hypersensitive to a certain movement and this is a big deal because when injuries become chronic it has very little to do with tissue damage but it’s more of the inability of your brain to restore that system. So, it freaks out because it’s trying to still protect you form a stress it still perceives as dangerous.

Question: Do you have any specific techniques or tips or anything that you can tell us that you do in particular?

Answer: Easy climbing will help to promote the restoration of your injury. Tendons actually do very poorly when you’re completely resting. The physiological makeup is that it actually thrives on load. So, out of that 10 points pain scale, 0 being no pain and 10 is excruciating, I always tell my patients to work within a range of zero to three, just to be on the conservative side. [You] can feel that pain, but make sure it doesn’t go past a three out of ten. If you completely rest a tendon for several months and you’re not helping to train to restore that tension within the tendon, so that you’re almost conditioning the brain to say it’s OK to pull at this level and it’s this constant feedback of those signals. If you’re not doing that and you’re just completely resting it’s no wonder your having pain again in that same flexor tendon.

Thank you again to @leephysicaltherapy for joining us in this episode! If you're in the Chicago area and need PT advice, please check out https://www.leeptchicago.com/ for more information!

Etiology

So, what’s actually happening when we still have pain with a lingering injury? Well sometimes it’s more simple than you may think. What’s likely happening is two fold: the tissue physically is not fully retrained to be able to handle the stresses of rock climbing, and the neurological component comes into play as the body no longer knows / understands what a safe amount of load is, so the neurological systems may be hyperactive in order to help protect you. 

As mentioned in the last part of that interview with Dr. James Lee is particularly important. People are discovering how just resting during quarantine isn’t magically restoring their function and healing their injuries or issues. Part of that is absolutely the neurological component we talked about, but, we need to discuss the physical component of an injury as well.

BONUS STORY: A runner goes for their normal run. They get close to some bushes, and feel a scratch. They think nothing of it and keep running. After a few minutes, the pain starts to build and they inspect the tissue. Turns out, it was a snake bite. Months later, the runner is fully healed and they go for another run. They get close to some bushes and feel a little nervous. But, the trail is narrow so they run on.  Now, they feel a scratch again and immediately inspect the skin, thinking that they have been bitten by a snake when it was in fact just a scratch. 

Physical component

From a physical standpoint, when we injure a pulley, we reduce the threshold of the tissue to withstand forces. Basically, we reduced how much force it can hold up to before it breaks. Example: a pre-injured pulley may be able to withhold 450 newtons of force. But, after an injury it may be lowered to 350N due to the damage to the tissue. Because of this lower threshold, the body is going to be more quick to “protect” it from exceeding the threshold. Because as you can imagine, exceeding the threshold equals a re-injury. The remaining fibers holding it together are not as strong and thus more prone to injury. 

The same goes for your hands with climbing. The tissue will heal back to a natural level to handle your everyday activities, but that level is not going to be high enough to handle the stress of climbing. So, you may have done a wonderful job resting, going through a range of motion and performing your initial rehab, but if you have not done any retraining, you have quite a gap there that you are going to be unable to bridge. The threshold of that pulley is going to be quite low compared to the forces of climbing.  Hence, you go to climb, and the body warns you that you are getting too close to that threshold and potentially another injury so it sends you a pain signal.  

*quick side note here, if you want to learn a whoollllleee lot about the A2 pulley and haven’t yet, I highly recommend checking out our MEGA A2 video. It’s 40+ minutes of information all about the A2 pulley, anatomy, causes of injury, treatment, and more*

So you may be asking, how do I retrain the pulley and bridge the gap then if it is painful when I climb? Didn’t you just mention that the body is warning you that you are getting close to another injury? Well, yes, and that’s where the proper pain protocol comes in place. 

Proper Pain Protocol

The proper pain protocol is the program I use to help teach people how to place SAFE loads on the tissue, in order to trigger the body to adapt and reinforce the injured tissue, INCREASING the working threshold we mentioned earlier to bring the gap between rest and climbing in a SAFE manner. 

Now, there are multiple ways of doing this, but early on, I recommend doing “farmer crimps”. These are a safer way to load the tissue in a similar manner to which you got injured, while being able to control the weight and very SLOWLY increase the weight. It allows your body the chance to say “hey this is too light” or “hey knock it off, we aren’t Hercules over here”. It’s much safer, in my opinion, than just starting to generate the force on a hangboard or on a climbing wall. If you have a decent injury, your may need to take a lot of force off of the hangboard which means a large counter weight. And just “pulling on the hangboard until it hurts” without lifting your feet off the ground, is not tracking anything. Can you really tell if you are loading 20 vs 25 pounds on your fingers on a hangboard just by pulling? Definitely not. So, until you can safely handle your body weight without pain, you’ll want to start with farmer crimps. 

On the wall climbing should be the second step, before hangboarding, because you can use your feet to keep the stress on your fingers lower. The reason this is riskier than farmer crimps is because you can’t always predict how a hold is going to feel until you grab it. That “jug crimp” may look like a jug but not be as incut as you predicted. The medium crimp with the solid looking foot chip, may actually be at the wrong angle and you don’t feel secure on the foot, so you place too much weight in your hands. OK, you get the idea. 

So, to safely load the tissue in a controlled manner, I recommend farmer crimps initially, then light climbing until you can tolerate hangboarding with 2 hands but feet off the ground, THEN you can start adding weight to your hangboarding again as appropriate. 

For more information about farmer crimps, check out our other video here.

Understanding The PPP and Pain

So we now know why we need to retrain the tissue and how to go about it, but how do we incorporate the proper pain protocol into our rehab? 

The proper pain protocol involves creating low levels of discomfort that will quickly return to normal after removing the force created the discomfort *cut scene:pain*

Sounds simple right? Our two measures we will track are level of discomfort, and time. 

So, how much discomfort do we want??? Well I mean, not a lot. Pain is there to protect you. It’s your warning sign, so we don’t want to trigger too much pain because then we are over loading the tissue in what it can handle, whether that be physical or psychological. It’s important to feel confident in what you’re doing. Overstressing it may hurt your confidence and you may not continue with the program. So, we want to have a 1-2 point increase while we are performing the hold. If you are at a 0/10 at baseline, don’t go to a 3 or higher, it’s that simple. If you’re at a 1/10, don’t go higher than a 4/10. Believe it or not, you WANT the slight discomfort to force the connective tissue changes, but you don’t want to push so far that you produce a warning signal for the aforementioned reasons. 

Note: if you’re already at like a 4/10 pain… be careful, you may not be ready for this, or you may only want to trigger an increase of ½ or 1 points so you don’t push too hard.  

OK so the level makes sense, what about the duration? How long should it last for? 

Once you have removed the force, the symptoms of discomfort should dissipate within 10 seconds. That is the ideal window. That basically is your body saying “hey, I get it, you're forcing an increased load to my tissue, I’m not sure if I love it yet, hence the discomfort levels increase to warn you, but it’s not more than I can handle. We good”. If your symptoms last between 11-30 seconds, that’s the first “yellow flag” so to speak that you may want to decrease the load because you are creating a lasting pain effect. If your symptoms last for >60 seconds, you should consider being done for that day to further evaluate your symptoms and make sure you don’t exacerbate the injury. You may have just overloaded the tissue by being too aggressive. Come back later (1-2 days later) and try again with less load and see if you can get it within the proper time frame.  

So in summary the two primary factors we will look for in this protocol: 

1. The level of pain on a scale of 0-10 with 0 being no pain and 10 being going to the emergency room

   1. No increase in pain = are you even loading the tissue or are you even injured?

   2. 1/10 increase in pain = good, you could maybe do a little more but be patient

   3. 2/10 increase in pain = the sweet spot, you’re doing just fine.

   4. 3/10 increase in pain = whoa, slow down there 

   5. 4/10 increase in pain = too much for sure, stop immediately, reduce your weight or force. 

2. The duration of the pain after you release the force or load until it completely dissipates or returns back to its prior level. 

   1. The ideal range + <10 seconds

   2. Moderate = 11-30

   3. You’ve done too much = >60 seconds 

Reps and Sets

What about reps and hold time?

You are going to want to perform about 4-6 reps (sets) of this, each hold should be for 10 seconds, each with at least 60 seconds in between. 

An ideal program would look something like this…

Say you are at 15 pounds or ~6.8kg on the farmer crimps. First, perform tendon glides to warm up. You do a quick self assessment and notice you have no pain with tendon gliding. So, at rest and with active range, you are at a 0/10 for pain. Fantastic. Then, you load your 15 pounds and you notice an increase in discomfort to a 2/10. You count your 10 seconds while the tissue is loaded, then unload the tissue (drop the weight). You notice immediately the pain drops to a 1/10, and then at about 10 seconds the pain is back down to a 0. This happens for all 6 of your reps. That’s awesome! That’s a perfect protocol. You have safely loaded and are forcing adaptations. 

The rest time can vary depending on how much load you’re placing. If it is lower weight, you may not need to wait as long. If it is higher weight, you should allow yourself up to 3 minutes in between to ensure proper return of blood flow and full strength of the tissue. 

Increasing weight

How do you know when it’s time to increase the weight? Well, it’s best practice to repeat that load until you have less discomfort. Say you have a 1/10 while the weight is loaded and then it drops down to a 0/10 immediately after you unload it, and you also notice on the 5th and 6th sets there is no pain at all. Those are good signs to increase. 

Now, if you increase too much and say go up to 25 pounds/~11kg  from 15 pounds/~6.8kg and then have a 4/10 when you load the tissue with that 25 pounds, you may be moving too fast and rather you should go to 20 pounds. Give the tissue time to respond to your new training rather than try and force the healing too quickly. 

Keep increasing the weight until you can safely do 25-35 pounds (based upon your body weight) without any pain! That’s a good indicator that you are ready to try more advance tissue loading techniques, ie. climbing. 

And that’s it! Hopefully now you better understand not only the physiological and neurological components of an injury, but you have a better understanding of how to work through those aspects utilizing the proper pain protocol to allow you to return to sport. 

Thanks for watching. Until next time, Train. Climb. Send. Repeat.

Disclaimer:

As always, exercises are to be performed assuming your own risk and should not be done if you feel you are at risk for injury. See a medical professional if you have concerns before starting new exercises.

Written and Produced by Jason Hooper (PT, DPT, OCS, SCS, CAFS) and Emile Modesitt

IG: @hoopersbetaofficial