Injury Patterns in Rock Climbing

Sasha DiGiulian climbs the Platinum route on El Capitan in Yosemite National Park, California, USA on November 7, 2025. // Pablo Durana / Red Bull Content Pool.

Rock climbing is one of the fastest-growing sports worldwide. The expansion of indoor facilities has made what was once a sport for intrepid athletes accessible to casual weekend warriors. Now an Olympic event, climbing participation increased by 7.1% from 2019 to 2021 and continues to trend upward⁽¹⁾. Every sport has inherent risks of overuse and traumatic injuries. Still, climbing has unique risks compared to other activities, primarily due to the height and the extreme stress placed on the fingers. While athletes and facilities both take precautions to avoid injury by modifying the environment and using safety equipment, climbing has a higher injury rate than in years past, likely due to lower barriers to entry today. 

There are several disciplines within climbing that sports medicine clinicians should be familiar with, as each entails distinct risks and injury patterns (see table 1). 

1. Bouldering is climbing short routes on boulders or walls without ropes, using crash pads for fall protection.
2. Top rope climbing is common in indoor facilities and involves a harness that connects the athlete to the top of the wall with a rope. 
3. Lead climbing involves the climber placing a rope that they are carrying into pre-existing protection points on the wall as they climb higher. 
4. Trad (traditional) climbing, primarily done outdoors, is where athletes place their own safety devices into natural rock faces and clip a rope to them. 

Table 1: Differences between climbing modalities

Injury Incidence

Bouldering athletes have 1.47 injuries per 1000 hours of climbing, compared with top-rope climbers, who have 0.29 injuries per 1000 sport hours⁽²⁾. Furthermore, bouldering injuries are more common, likely due to shorter routes that require more intense athletic movements that can stress joints and connective tissues. Indoor climbing gyms commonly offer bouldering as a lower barrier to entry activity. In contrast, top-rope climbing often requires a safety course to demonstrate competence with safety equipment, given its potential for more severe injuries. This policy leads many entry-level climbers to bouldering alone, which can increase injury rates.

Another theory researchers propose to explain why advanced bouldering athletes have higher injury rates is that bouldering-specific shoes often have a more aggressive toe curvature, which can alter the vectors of force during falls onto the ground, resulting in unnatural landing positions⁽³⁾. 

Upper-extremity injuries are the most common among climbers. While proper climbing technique requires nearly equal use of the lower and upper extremities, climbers often place excessive stress on the upper extremities, particularly the fingers, elbows, and shoulders. 

“There appears to be clear sex-based differences in injury patterns...”

Injury Patterns

Finger injuries
One of the most common injuries in climbing, and colloquially known as "climbers’ finger," is the flexor pulley injury⁽⁴⁾. The flexor tendons of the upper extremity digits run across the palmar surface of the hand with transversely orientated fibrous tissue sheaths or pulleys running over them (see figure 1). Climbers place the tendons and overlying ligaments under stress with eccentric loading of the digits during flexion. This mechanism of injury occurs in all climbing disciplines while holding onto "crimps," small outcroppings of rock that are only large enough to hold with the fingers (see figure 2). These outcroppings can extend just millimeters from the wall, requiring climbers to rely on their most distal muscles to support their weight.

While there are five annular pulleys in each digit except the thumb (which has two), the second and the fourth are the most common sites of injury (see figure 1). In a flexor pulley injury, "bowstringing" can occur, in which the affected digit cannot flex to its full range of motion and is associated with local edema and pain. Clinicians grade them on a scale of one to four. 

1. Grade one: Presents with local tenderness and pain with flexion.
2. Grade two: Partial rupture of A2 or A3, or a complete rupture at A4, and involves local pain at the pulley in question, while also having pain with extension of the digit.
3. Grade three: A complete rupture of the pulley at A2 or A3, often accompanied by local tenderness, a crack or popping noise, edema, and pain with both flexion and extension.
4. Grade four: Multiple ruptures are present or a single rupture with concurrent lumbrical muscular trauma⁽⁵⁾. 

Clinicians may request hand or finger radiographs to rule out fractures. However, standard radiographs have poor sensitivity and specificity for pulley injuries. Ultrasound and magnetic resonance imaging have similar sensitivities for detecting complete ruptures of the pulley system. Still, clinicians often prefer ultrasound as it is cost-effective, accessible, and can provide dynamic views of the injury. They manage grade one and two injuries conservatively with initial immobilization and early functional therapy, but complete ruptures of A2 or A3 usually require surgical repair⁽⁴⁾.