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Abstract and Figures

Rock and ice climbing are widely considered to be 'high-risk' sporting activities that are associated with a high incidence of severe injury and even death, compared with more mainstream sports. However, objective scientific data to support this perception are questionable. Accordingly, >400 sport-specific injury studies were analysed and compared by quantifying the injury incidence and objectively grading the injury severity (using the National Advisory Committee for Aeronautics score) per 1000 hours of sporting participation. Fatalities were also analysed. The analysis revealed that fatalities occurred in all sports, but it was not always clear whether the sport itself or pre-existing health conditions contributed or caused the deaths. Bouldering (ropeless climbing to low heights), sport climbing (mostly bolt protected lead climbing with little objective danger) and indoor climbing (climbing indoors on artificial rock structures), showed a small injury rate, minor injury severity and few fatalities. As more objective/external dangers exist for alpine and ice climbing, the injury rate, injury severity and fatality were all higher. Overall, climbing sports had a lower injury incidence and severity score than many popular sports, including basketball, sailing or soccer; indoor climbing ranked the lowest in terms of injuries of all sports assessed. Nevertheless, a fatality risk remains, especially in alpine and ice climbing. In the absence of a standard definition for a 'high-risk' sport, categorizing climbing as a high-risk sport was found to be either subjective or dependent on the definition used. In conclusion, this analysis showed that retrospective data on sport-specific injuries and fatalities are not reported in a standardized manner. To improve preventative injury measures for climbing sports, it is recommended that a standardized, robust and comprehensive sport-specific scoring model should be developed to report and fully evaluate the injury risk, severity of injuries and fatality risk in climbing sports.
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Evaluation of Injury and Fatality Risk in
Rock and Ice Climbing
Volker Scho
¨ffl,
1,2,3
Audry Morrison,
3
Ulrich Schwarz,
4
Isabelle Scho
¨ffl
5
and Thomas Ku
¨pper
3,6
1 Department of Sportorthopedics, Orthopedics and Trauma Surgery, Klinikum Bamberg, Bamberg,
Germany
2 Department of Trauma Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen,
Germany
3 Medical Commission of Union Internationale des Associations d’Alpinisme, Bern, Switzerland
4 Private Practise, Oberstdorf, Germany
5 Department of Anatomy 1, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
6 Institute of Occupational and Social Medicine, RWTH Aachen Technical University, Aachen, Germany
Contents
Abstract................................................................................. 657
1. Retrospective Data Collection and Climbing Participation Time Calculation . . . . . . . . . . . . . . . . . . . 659
2. Description of Rock Climbing Sub-Disciplines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660
2.1 Sport Climbing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660
2.2 Bouldering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660
2.3 Traditional (Alpine) Climbing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660
2.4 Indoor Climbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
2.5 Ice Climbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
3. Injury and Fatality Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
3.1 Traditional, Sport Climbing and Bouldering. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
3.2 Indoor Rock Climbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 670
3.3 Ice Climbing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
4. Comparison of Climbing to Mountaineering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672
5. Injury Risk Compared with Other Sports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673
6. Is Climbing a High-Risk Sport? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 674
7. Limitations of the Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 674
8. Conclusions........................................................................... 675
Abstract Rock and ice climbing are widely considered to be ‘high-risk’ sporting
activities that are associated with a high incidence of severe injury and even
death, compared with more mainstream sports. However, objective scientific
data to support this perception are questionable. Accordingly, >400 sport-
specific injury studies were analysed and compared by quantifying the injury
incidence and objectively grading the injury severity (using the Nation-
al Advisory Committee for Aeronautics score) per 1000 hours of sporting
participation. Fatalities were also analysed. The analysis revealed that fatal-
ities occurred in all sports, but it was not always clear whether the sport itself or
pre-existing health conditions contributed or caused the deaths. Bouldering
REVIEW ARTICLE Sports Med 2010; 40 (8): 657-679
0112-1642/10/0008-0657/$49.95/0
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(ropeless climbing to low heights), sport climbing (mostly bolt protected lead
climbing with little objective danger) and indoor climbing (climbing indoors
on artificial rock structures), showed a small injury rate, minor injury severity
and few fatalities. As more objective/external dangers exist for alpine and ice
climbing, the injury rate, injury severity and fatality were all higher. Overall,
climbing sports had a lower injury incidence and severity score than many
popular sports, including basketball, sailing or soccer; indoor climbing
ranked the lowest in terms of injuries of all sports assessed. Nevertheless, a
fatality risk remains, especially in alpine and ice climbing. In the absence of a
standard definition for a ‘high-risk’ sport, categorizing climbing as a high-risk
sport was found to be either subjective or dependent on the definition used. In
conclusion, this analysis showed that retrospective data on sport-specific in-
juries and fatalities are not reported in a standardized manner. To improve
preventative injury measures for climbing sports, it is recommended that a
standardized, robust and comprehensive sport-specific scoring model should
be developed to report and fully evaluate the injury risk, severity of injuries
and fatality risk in climbing sports.
Rock climbing originated as a skill practice for
difficult sections of a mountaineering ascent in
the 1960s and was practiced by a small group of
dedicated climbers. By the mid-1980s its popu-
larity spread globally and diversified to include
new categories such as ice climbing (climbing iced
rock faces and frozen waterfalls),
[1]
bouldering
(ropeless climbing to low heights), speed (com-
petition climbing where two climbers climb si-
multaneously on identical routes against each
other) and aid climbing (climbing with artificial
aid and gear).
[2,3]
In 1991, only a few countries
participated in the first World Championships
but by 2005, some 500 athletes from 55 countries
competed.
[2-4]
The International Federation of
Sport Climbing is currently seeking recognition
as an Olympic sport.
[3,5,6]
All of these climbing
activities are regulated by national and interna-
tional climbing organizations to promote safe
participation, competitions
[2,3,7]
and to meet the
needs of the rapidly rising club memberships.
Learning to climb has never been easier with
the advent of indoor artificial climbing walls
found in many cities.
[8]
In some schools it forms
part of the sport curriculum.
[4,5]
Rock climbing
participation is accessible to all ages, toddler to
pensioner,
[4-7]
and is enjoyed by many over a
lifetime. There is little doubt that climbing as a
sport has both diversified and grown in popu-
larity, and has even become a spectator sport.
However, with any sporting participation, there
will be some risk of injury that must be weighed
against the benefits of this exercise. To date, no
known study has demonstrated that rock or ice
climbing are high-risk sports, a commonly held
perception.
Epidemiological analysis of sport-specific in-
juries helps to provide preventive measures that
can target the incidence and reduce their severity.
Extensive studies on injuries in general rock
climbing,
[4,9-22]
indoor climbing
[8,10,23]
and com-
petition climbing
[5]
exist, including analysis of the
injury risk per 1000 hours. Severe injuries during
indoor or competition climbing are rare, but do
happen.
[5,8,10,12,16,17,19,21-33]
Most injuries in rock
climbing occur on the upper limbs, notably the
fingers, and generally result from overstraining
rather than acute injuries.
[28,31,34-39]
To date, no
known study has objectively demonstrated that
ice or rock climbing are high-risk sports, or that
those climbing higher grades are more prone to
experience severe injuries compared with those
climbing lower grades. Nevertheless, the media’s
lurid depiction of elite rock and ice climbers has
helped to create a perception of climbing as being
a hazardous and high-risk sport.
[1,40]
For ex-
ample, a 1999 Time Magazine cover featured a
sport climber with the headline ‘‘Why we take
658 Scho
¨ffl et al.
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risks’’ with a subtitle stating ‘‘From extreme
sports to day trading thrill seeking is becoming
more popular.’’
[40]
Other ‘thrill seeking’ activities
cited in this magazine’s feature article included
having unprotected sex when AIDS was pre-
valent.
[41]
UK government statistics from around
this time counter such titillating journalism by
calculating the annual risk of death as a con-
sequence of climbing to be 1 in 320 000 climbs, 1
in 200 000 dives if scuba diving, and 1 in 116 000
flights for hang gliding.
[42]
Many European accident and disability in-
surance policies either limit or exclude rock and
ice climbing participation. In contrast, an estab-
lished British policy
[7]
offers global coverage for
different forms of climbing. This suggests that
both the popular public and professional assess-
ment of the actual risks associated with climbing
may not be fully informed.
To objectively analyse and compare injuries
from different sports, a common scoring system
for the grading of injuries is essential. In general,
when assessing whether a sport presents a high
risk of injury or death, a distinction between
overstrain (overuse) injuries and acute injuries or
accidents should be made. The reasons being,
overstrain injuries are generally less severe and
can generally be avoided with informed training,
whereas an examination of the injury rate for
acute sport-specific injuries, especially their se-
verity, is crucial. In any case, an analysis of both
overuse and acute injuries in climbing has been
presented in this review.
Although many studies and alpine clubs have
recorded climbing accidents and injuries for over
100 years, two studies around 1990
[20,21]
pio-
neered the use of a scoring system (Injury Severity
Score [ISS]) to grade registered climbing injuries
and calculated the injury risk in correlation to
climbing days
[21]
or climbing time.
[20]
However,
this ISS score showed a weak validity for injury
self recall,
[43]
and so future studies used the Na-
tional Advisory Committee for Aeronautics
(NACA) score
[44]
(see table I) for grading.
[1,45]
The NACA score is the most commonly used
emergency score in Germany and is also part of
the nationwide standard pre-hospital emergency
physicians report form.
[46]
It is also recom-
mended and used internationally for alpine trauma
evaluation.
[47]
Therefore, this review sought to objectively
compare different sports for their sport-specific
injury risk by quantifying and grading the injury
severity, and fatality rates per 1000 hours of sport-
ing participation. The question as to whether
any, or all, climbing activities should be considered
high-risk sports was also examined.
1. Retrospective Data Collection and
Climbing Participation Time Calculation
An electronic PubMed search was conducted
using the following search terms: ‘rock climbing’
(138 hits), ‘ice climbing’ (10 hits), ‘mountaineer-
ing’ (1821 hits), ‘sport injuries risk’ (5021 hits),
‘sport fatalities’ (243 hits), ‘epidemiology sport
injuries’ (5102 hits) and ‘NACA score’ (13 hits).
All studies on rock climbing and ice climbing
were gathered and completely analysed. For
mountaineering, all the abstracts were read and,
if relevant, the full paper was accessed. A similar
method was used for the other search terms once
the relevant abstracts were identified. Additional
information was sought by personal commu-
nication (with the German Alpine Club Safety
Commission) and by an Internet search to obtain
alpine club publications from Germany, Canada
and America.
From 400+studies on climbing, mountaineer-
ing and other sports that supplied detailed in-
formation on sport-specific injuries, the injury
risk per 1000 hours was either extracted directly
Table I. The National Advisory Committee for Aeronautics (NACA)
scoring system
[44]
Patient status Score level
Not an acute life-threatening disease or injury 1
Acute intervention not necessary; further
diagnostic examination needed
2
Severe but not life-threatening disease or injury;
acute intervention necessary
3
Development of vital (life threatening) danger
possible
4
Acute vital (life threatening) danger 5
Acute cardiac or respiratory arrest 6
Dead 7
Rock and Ice Climbing 659
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or calculated from the data of the selected study.
If climbing days were reported and not the injury
risk per 1000 hours of sports performance, a
single rock climbing day was calculated using
4 hours for sport climbing, 8 hours for alpine
climbing, 2 hours for indoor climbing,
[5,8]
6 hours
for ice climbing
[1,5,8]
and 16 hours for an expedi-
tion day. The rock climbing ability grade was
transferred into the Union Internationale des
Associations d’Alpinisme (UIAA) scale and then
into the metric scale.
[48]
The injury definition and
grading from the selected studies were initially
evaluated by the independent analysis of the
injuries using the NACA injury scoring system
followed by a complete re-evaluation of these
injuries in an identical manner by the consensus
of three experienced trauma surgeons or sport
physicians who were also experienced climbers.
The fatality rate and case fatality were also ana-
lysed. In order to compare climbing with other
sports, the injury risk per 1000 hours of sport
participation was either given or calculated.
2. Description of Rock Climbing
Sub-Disciplines
Rock climbing is a multi-disciplined sport.
Depending on the sub-discipline examined, the
climber’s experience and skills, grade of route
difficulty, equipment, climbing surface (type of
rock or ice, artificial indoor wall, scree), remote-
ness of location, altitude and weather will im-
plicate different levels of risk. In addition to these
variables, many climbers regularly participate in
more than one climbing sub-discipline. Designing
scientific studies that can accurately reflect all
these injury variables exclusively for outdoor
climbing is difficult,
[49]
as many of these variables
are common to anyone who engages in outdoor
activity. Injuries at indoor climbing walls have
more controlled sport-specific variables and are
better documented.
[5,8,23]
Another variable con-
sidered when analysing climbing literature was
careful interpretation of the origin of the study
and geographical climbing area, as climbing
terms and conditions differ among the continents
(i.e. rock type, climbing grades, likely equipment
used especially in older studies, likely climbing
sub-disciplines practiced), and this was reflected
in tables IIV. Therefore, some climbing sub-
disciplines will be briefly described, followed by
an analysis of injury data for climbing and other
sports.
2.1 Sport Climbing
Sport climbing (figure 1) or free climbing re-
quires gymnastic-like strength, flexibility, finger
strength and strength endurance when climbing
each unique and graded route. The climbing is
slightly prescriptive as the climber ascends to-
wards mostly permanently fixed anchors, such as
bolts to clip their rope into for protection. The
route length can range from 10 to 100+m with
fixed anchors generally around 25 m apart. Falls
are frequent, trained for and are mostly harm-
less.
[11]
Physical hazards (rock fall, weather
changes etc.) are small and the neglect of wearing
a climbing helmet is widely accepted.
[4,64]
In
contrast, fixed anchors will be very minimal when
‘free climbing’ and a helmet is recommended.
2.2 Bouldering
Ropeless climbing involves a short sequence of
powerful and technical moves to complete the
graded route on large rocks, occasionally up to
10+m high.
Bouldering (figure 2) can be done without a
partner and with minimal equipment (climbing
shoes and crash pad). Falling onto one’s feet or
body is a normal part of bouldering, whether a
route is completed or not.
2.3 Traditional (Alpine) Climbing
Traditional (alpine) climbing (or trad climb-
ing) emphasizes the skills necessary for estab-
lishing routes in an exploratory fashion outdoors.
The lead climber typically ascends a section of
rock while placing removable protective devices
where possible along the climb. Falls can there-
fore be longer than those experienced when sport
climbing. Unreliable fixed pitons may occasion-
ally be found on older established routes. As
physical hazards are likely, the use of a helmet is
considered mandatory.
[65]
Above approximately
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Table II. Injuries and fatalities in traditional and sport climbing
Study (year) Type of climbing
(geographical
location)
Study profile Cause of injury;
body location
Injuries per 1000 h
sport performance
Injury severity Fatality Risk evaluation
Bowie
et al.
[21]
(1988)
Traditional
climbing,
bouldering some
rock walls 1000 m
high (Yosemite
Valley, CA, USA)
Data collection in the
ER of the central
hospital within the area
Mainly lead climbing
falls; mostly lower
extremity
37.5
a
Majority of
minor severity
using ISS
score; 95%
ISS <13; 5%
ISS 1375
13 of 220
subjects had
severe
injuries, of
which 11 were
fatal (5.9%);
case fatality
rate 6%
Bias of injuries presented
may reflect more serious
injuries requiring ER
treatment
Addiss and
Baker
[22]
(1989)
Mountaineering
and traditional
climbing, includes
snow and ice (US
National Parks;
includes snow and
ice terrain)
127 rock climbing
injuries that were
reported to US National
Park services (19812)
75%falls NS 28%NACA
seven (fatal)
b
36 (28%);
injuries on
snow and ice
were more
likely to be
fatal
Potentially high-risk activity
Schussmann
et al.
[20]
(1990)
Mountaineering
and traditional
climbing (Grand
Tetons, WY, USA)
Data collection through
National Park
registration from 1981
to 1986, representing
43 631 climbers, 108
accidents for all
mountaineering
activities
More mountaineering
accidents than rock
climbing
0.56 for injuries;
0.13 for fatalities;
incidence 2.5
accidents/1000
mountaineers/yor
5.6 injuries/10 000 h
of mountaineering
23%of the
injuries were
fatal (NACA 7)
b
25 fatal,
23%case
fatality rate;
fatality rate
0.13/1000 h
Author concluded
mountaineering was of a
higher risk than pure rock
climbing; climbing education
and experience were
considered preventative
factors in accidents and
injuries
Rooks
et al.
[18]
(1995)
Recreational rock
climbers,
(GA, USA)
39 recreational
climbers
Six climbers climbing
beyond the sport level
sustained a major injury
from a fall, 35 sustained
at least one significant
injury; mostly to upper
extremity
NS NS Six (15%) had
a major injury
from a fall
NS
Paige
et al.
[19]
(1998)
Traditional
climbing, sport
climbing (NS)
94 rock climbers
completed a
retrospective
questionnaire on
overstrain injuries by
mail, in person and via
the Internet
Mainly lead climbing,
falling when alpine
climbing, injuries from
hard moves in sport
climbing; upper
extremity, fingers
especially affected
NS NS None as
retrospective
questionnaire
No major difference between
alpine and sport climbing
Continued next page
Rock and Ice Climbing 661
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Table II. Contd
Study (year) Type of climbing
(geographical
location)
Study profile Cause of injury;
body location
Injuries per 1000 h
sport performance
Injury severity Fatality Risk evaluation
Rohrbourgh
et al.
[31]
(2000)
Competition rock
climbers at US
National
Championships
(NS)
42 elite rock climbers;
only overuse syndromes
were studied
Mostly in upper limbs NS NS None No significant relationship
between overuse injuries and
years of climbing or difficulty
level
Scho
¨ffl
et al.
[15]
(2003)
European
climbers (NS)
604 injured climbers
were seen
prospectively over 4 y
Upper extremity 67%NS Mostly NACA
12, only
0.8%severe
injuries
(NACA 4 or 5)
None Severe injuries were rare
Logan
et al.
[29]
(2004)
Rock climbers,
(UK)
545 members of the
Climbers Club of Great
Britain completed a
questionnaire, which
examined the prevalence
of hand injuries
NS Mostly NACA
1 and 2
b
None reported
as it was a
retrospective
survey on
hand injuries
Climbing intensity score
higher in injury group
(including overstrains)
(p <0.05) although paper
said intensity, grade is what
is meant and clearer
Gerdes
et al.
[16]
(2006)
Rock climbing
(NS)
1887 subjects
completed an
anonymous Internet
survey. There was a
total of 2472 injuries,
which included overuse
syndrome injuries
Upper extremity 57.6%NS 20%no injury;
60%NACA 1;
20%>NACA 1
b
None reported
as it was a
retrospective
survey
Traditional (p <0.01) and
solo climbing (p <0.01) had
more injuries (acute and
overuse injuries). Injuries
were fairly evenly distributed
between indoor and outdoor
climbing
Smith
[12]
(2006)
Review on alpine
climbing injuries,
(NS)
Review Falls are the most
frequent injury cause
NS NS NS Falling injuries are more
severe in alpine climbing
German
Alpine
Club
[50]
(2006)
All climbing
disciplines (NS)
Reports on all climbing
accidents were
reported to the DAV
insurance cover
provider (20045)
NS NS NS 12%of all accidents in
mountain sports are from
rock and ice climbing: 48%of
these from alpine climbing,
29%sport climbing, 9%
indoor climbing, 6%ice
climbing, 1%bouldering
Josephsen
et al.
[51]
(2007)
Bouldering, indoor
and outdoor
(CA, USA)
Prospective, cross-
sectional cohort study
(n =54) of 152 subjects
who completed the
year-long study
NS NS None Few differences between
injuries experienced between
indoor and outdoor
bouldering
Continued next page
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2500 m, physiological altitude-induced adapta-
tions must also be factored into the climbs.
2.4 Indoor Climbing
Indoor climbing (figure 3) is performed on
artificial structures that try to mimic climbing
outdoors but in a more controlled environment.
As physical hazards are almost totally eliminated,
such climbing became an extra-curricular sport in
many countries.
[6]
National and international
competitions are held on such walls and involve
three major disciplines: lead climbing (i.e. sport
climbing), speed and bouldering. Bouldering is
performed above thick foam mat flooring.
2.5 Ice Climbing
Ice climbing (figure 4) normally refers to roped
and protected climbing of features such as ice-
falls, frozen waterfalls, and cliffs and rock slabs
covered with ice refrozen from flows of water.
Equipment includes ice axes for hands and
crampons for feet. Physical hazards such as ava-
lanches, rock and icefalls are present.
3. Injury and Fatality Risk
3.1 Traditional, Sport Climbing and Bouldering
Very few climbing injury studies differentiate
between the sub-disciplines
[51]
of outdoor rock
climbing, and many climbers participate in a few
sub-disciplines, so traditional, sport climbing and
bouldering will be examined together. Un-
fortunately, a high number of scientific climbing
articles present case studies of common hand in-
juries
[11,13-15,28,38,66-72]
and are therefore not
suitable for injury risk analysis, but they help to
inform of overuse injury trends and preventative
training. Nevertheless, most studies agree that the
most (5867%)
[15,16]
injured body region is the
upper extremities.
[15-19]
In contrast, in their hospital and emergency
room study based in the Yosemite Valley, USA,
Bowie et al.
[21]
found that the lower extremity was
most affected. The Yosemite area is famous for
its 1000 m high walls, few bolts and mostly tra-
ditional climbing. Falls here can be quite long
and may result in rock-hit trauma
[4,27,73]
as the
Table II. Contd
Study (year) Type of climbing
(geographical
location)
Study profile Cause of injury;
body location
Injuries per 1000 h
sport performance
Injury severity Fatality Risk evaluation
Jones
et al.
[52]
(2007)
Rock climbers,
indoor and
outdoor (NS)
Retrospective cross-
sectional study of 201
rock climbers
10%acute through falls,
33%overuse injuries,
28%acute through
strenuous move
NS NS None reported
as it was a
retrospective
study
Climbing frequency and
difficulty are associated with
incidence of overuse injuries
Nelson and
McKenzie
[53]
(2009)
Rock climbing
injuries, indoor
and outdoor (NS)
846 cases treated at
US NEISS hospitals
were collected
and 40 282 injuries
for the US were
estimated from
1990 to 2007
Lower extremity mostly
affected
Measures of
participation and
frequency of
exposure to rock
climbing are not
specified
Mostly NACA
12
b
, 11.3%
hospitalization
None reported
as it was a
retrospective
study
Over-exertion injuries more
likely on the upper body
a Injuries/fatalities per 1000 h calculated by the authors according to the information given in the study.
b NACA score graded by the authors according to the information given in the study.
DAV =German Alpine Club; ER =emergency room; ISS =Injury Severity Score; NACA =National Advisory Committee for Aeronautics; NEISS =National Electronic Injury
Surveillance System; NS =not specified.
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Table III. Injuries and fatalities in indoor and competition climbing
Study (year) Type of climbing
(geographical location)
Study profile Cause of injury;
body location
Injuries per
1000 h sport
performance
Injury severity Fatality Risk evaluation
Limb
[23]
(1995) 90 indoor climbing walls
(England, Wales and
Scotland)
Postal survey of climbing
walls; 55 accidents reported
with 1.021 million visits
Mostly upper limb 0.027
a
All >NACA 1
a
;
none NACA 7
None Climbing walls seem to be
associated with a very low
injury rate; injury rate not
related to any identified wall
design or safety feature
Scho
¨ffl and
Winkelmann
[8]
(1999)
Indoor climbing walls
(Germany)
Prospective study of 25 163
registrants to indoor climbing
walls
0.079 3 NACA 2;
1 NACA 3
None Indoor climbing is a very low
risk sport for acute injuries
Wright et al.
[10]
(2001)
Overuse injuries in
indoor climbing at World
Championship (Munich,
Germany, 1999)
Semi-supervised
questionnaire for 295
spectators and competitors
44%had overuse
injuries; mostly fingers
NS NACA 12
b
None Climbing harder routes was
correlated to overuse injuries
(p <0.01)
Scho
¨ffl and
Ku
¨pper
[5]
(2006)
Indoor competition
climbing, World
Championships
(Munich, Germany)
443 climbers (273 M; 170 F)
from 55 countries
18 acute injuries of
which four were
significant
3.1 16 NACA 1;
1 NACA 2;
1 NACA 3
None Indoor rock climbing has a low
injury risk and a good safety
profile
Josephsen
et al.
[51]
(2007)
Bouldering, indoor and
outdoor (CA, USA)
Prospective cross-sectional
cohort study n =54 of 152
subjects who completed the
year-long study
Overuse injuries NS NS None Few differences between
indoor and outdoor climbing
German Alpine
Club
[50]
(2006)
All climbing disciplines
(NS)
Reports on all climbing
accidents reported to the
DAV insurance cover
provider (20045)
NS NS NS 12%of all accidents in
mountain sports are from rock
and ice climbing: 48%of these
are from alpine climbing, 29%
sport climbing, 9%indoor
climbing, 6%ice climbing and
1%bouldering
Jones et al.
[52]
(2007)
Rock climbers, indoor
and outdoors (NS)
Retrospective cross-
sectional study of 201 rock
climbers
10%acute through falls;
33%overuse injuries;
28%acute through
strenuous moves
NS NS None Climbing frequency and
difficulty are associated with
incidence of overuse injuries
a Injuries/fatalities per 1000 h calculated by the authors according to the information given in the study.
b NACA score graded by the authors according to the information given in the study.
DAV =German Alpine Club; F=females; M=males; NACA =National Advisory Committee for Aeronautics; NS =not specified.
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Table IV. Injuries and fatalities in ice climbing
Study (year) Type of
climbing;
(geographical
location)
Study profile Cause of injury;
body location
Injuries per
1000 h sport
performance
Injury severity Fatality Risk evaluation
Mosimann
[45]
(2006)
Ice climbing
(Switzerland)
Outcome of 46 ice climbers
rescued by Swiss mountain
rescue service over 6 y
Most frequent injury
causes were falls
(55%), but no fatal
injuries were
sustained through
falls
NS 31%NACA 0;
42%NACA 23;
8%NACA 4; 6%
NACA 5; 13%
NACA 7
Case fatality rate
13%
Fatality rate in ice climbing is
higher than in mountaineering
and rock climbing
Scho
¨ffl et al.
[1]
(2008)
Ice climbing
(international)
Retrospective questionnaire
of 88 experienced ice
climbers who evaluated their
injuries over previous 3 y
95 injuries, overuse
syndrome
4.07 for
NACA 13
2.87/1000 h
NACA 1;
1.2/1000 h
NACA 2/3; none
>NACA 3
None reported as
this is a
retrospective study
Ice climbing is not a sport with a
high risk of injury; 61%of injuries
occurred while leading, 24%
while following
American
Alpine Club
[54]
(2006)
All climbing
accidents
(US)
Alpine club records from
1951 to 2003 reported 6111
accidents (5931 unharmed)
from 11 089 mountaineers
NS 53%NACA 0
a
;
12%NACA 7
a
;
4%NACA
a
accidents on ice
1373 fatal accidents NS
German
Alpine Club
[50]
(2006)
All climbing
disciplines
(NS)
Reports on all climbing
accidents reported to the
DAV insurance cover
provider (20045)
NS NS NS 12%of all accidents in mountain
sports are from rock and ice
climbing: 48%of these are from
alpine climbing, 29%sport
climbing, 9%indoor climbing, 6%
ice climbing and 1%bouldering
Canadian
Alpine Club
[55]
(2005)
All climbing
accidents
(Canada)
Alpine club records from
1951 to 2003 reported 958
accidents involving 2003
mountaineers; 715 injured,
163 occurred on ice
NS NS Of 292 fatal injuries,
30 were fatal ice
climbing injuries,
which occurred over
a 30 y period
NS
a NACA score graded by the authors according to the information given in the study.
DAV =German Alpine Club; NACA =National Advisory Committee for Aeronautics; NS =not specified.
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Table V. Injuries and fatalities in mountaineering
Study (year) Type of climbing;
(geographical
location; includes
snow and ice
terrain)
Study profile Cause of injury;
body location
Injuries per
1000 h sport
performance
Injury severity Fatality Risk evaluation
Addiss and
Baker
[22]
(1989)
Mountaineering
and traditional
climbing (US
National Parks)
127 rock climbing
injuries that were
reported to US
National Park
services (19812)
75%falls NS 28%NACA 7
(fatal)
a
36 (28%) injuries
on snow and ice
were more likely to
be fatal
Mountaineering was
potentially a high-risk activity
compared with rock climbing
Schussmann
et al.
[20]
(1990)
Mountaineering
and traditional
climbing (Grand
Tetons, WY, USA)
Data collection
through National
Park registration,
108 accidents
More
mountaineering
accidents than
rock climbing
0.56 for
injuries; 0.13
for fatalities
23%of the
injuries were
fatal (NACA 7)
b
25 fatal cases;
fatality rate 23%
Author concluded
mountaineering was of a higher
risk than pure rock climbing;
climbing education and
experience were considered
preventative factors in
accidents and injuries
Malcom
[56]
(2001)
Mountaineering
(Mt Cook, New
Zealand)
Fatality analysis of
deaths on Mt Cook
NS NS 0.12 for fatalities
a
or 1.87/1000
mountaineering
days
Mountaineering was
associated with a high risk
compared with other leisure
activities
Stephens
et al.
[57]
(2005)
Unknown
(Washington State
Park, USA)
Retrospective,
recreational
injuries
NS NS Hiking was the most
common activity
during time of death
with 58%fatalities.
Mountaineering
was 26%
NS
Monasterio
[58]
(2005)
Mountaineering
and alpine rock
climbing,
maximum altitude
4000 m
(New Zealand)
Prospective
questionnaire
regarding injuries
over 4 y among
44 mountaineers
(40 M; 4 F)
NS NS 5 NACA 7 (fatal)
[8.7%]; one death
was unrelated to
climbing, two fell
into crevasses, two
died by climbing
misadventure (one
climber was
climbing alone)
Mountain climbing was
associated with a high risk of
serious injury and mortality;
baseline climbing experience
was 57y
Continued next page
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Table V. Contd
Study (year) Type of climbing;
(geographical
location; includes
snow and ice
terrain)
Study profile Cause of injury;
body location
Injuries per
1000 h sport
performance
Injury severity Fatality Risk evaluation
Firth et al.
[59]
(2008)
Mountaineering
(mountaineers,
Sherpas and
climbers
attempting to climb
Mt Everest,
8850 m, highest
point in the world)
Search of
Himalayan
database and other
records from 1921
to 2006; analysis of
mortality among
n=28 276 where
192 deaths
occurred
113 died from
objective falls or
hazards; 52 non-
traumatic (sudden
death, altitude
illness, hypo-
thermia); 27 body
never found
NS NS Mountaineers had
a mortality rate of
1.3%
Debilitating symptoms of high
altitude pulmonary oedema
associated with descent from
the summit; subsequent
deaths were commonly
associated with late arrival
times to summit and profound
fatigue
German Alpine
Club
[50]
(2006)
All climbing
disciplines that
were covered by
the insurance
provider for the
German Alpine
Club
Reports on all
climbing accidents
reported to the
DAV insurance
cover provider
(20045)
NS NS NS 12%of all accidents that occur
in mountain sports are from
rock climbing: 48%of these
are from alpine climbing, 29%
sport climbing, 9%indoor
climbing and 1%bouldering
American Alpine
Club
[54]
(2005)
All climbing
accidents (US)
Alpine club records
from 1951 to 2003
reported 6111
accidents (5931
unharmed)
from 11 089
mountaineers
NS 53%NACA 0
b
;
12%NACA 7
b
;
4%NACA
b
accidents on
ice
1373 fatal
accidents
NS
Canadian Alpine
Club
[55]
(2006)
All climbing
accidents
(Canada)
Alpine club records
from 1951 to 2003
reported 958
accidents involving
2003 mountaineers;
715 injured, 163
occurred on ice
NS NS 292 fatal injuries;
30 fatal ice
climbing injuries
occurred over a
30 y period
NS
Continued next page
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Table V. Contd
Study (year) Type of climbing;
(geographical
location; includes
snow and ice
terrain)
Study profile Cause of injury;
body location
Injuries per
1000 h sport
performance
Injury severity Fatality Risk evaluation
Hearns et al.
[60]
(2006)
Mountaineers who
were patients at a
specialist spinal
hospital (Scotland)
Retrospective
study; 21 of 1400
patients identified
with spinal injuries
from mountaineer-
ing over 10 y; the
21 patients were
followed up with
questionnaires
Four rock climbing,
six winter climbing,
one other
NS NS No fatalities
reported. Study
was of survivors
with spinal
injuries from
mountaineering
Incidence of spinal cord injury
was less than in the overall
group of spinal injury patients.
Most of the 21 patients studied
had other significant and
potentially distracting injuries
McIntosh
et al.
[61]
(2007)
School teaching
outdoor training
and wilderness
skills taught at the
National Outdoor
Leadership School
(Lander, WY, USA)
Retrospectively
evaluated medical
incidents and
evacuations from
National Outdoor
Leadership School
from 2002 to 2005;
mean age of
participants was
22 y
0.071 NACA
1
a
; 0.074
NACA 13
a
;
0.0056%
NACA 23
a
92%NACA 1
b
;
7.6%NACA
23
b
; none
>NACA 3
b
None NS
McIntosh
et al.
[62]
(2008)
Mountaineering
(Mt McKinley [or Mt
Denali] in Alaska,
6194 m)
Retrospectively
reviewed fatalities
from 1903 to 2006
0.063 for
fatalities
a
NS 3.08/1000 summit
attempts, or 100/
1 million exposure
days on Mt Denali
Fatality rate is declining
McLennan and
Ungersma
[63]
(1982)
Mountaineering
(Sierra Nevada,
Columbia; peaks
up to 5700 m)
Retrospectively
reviewed 5 y of
accidents and their
possible causes
when climbing
Class V routes
215 mountaineering
accidents; 94
involved ankle
and lower tibia,
17 deaths mostly
involved head
injuries
NS NS 17 deaths, mostly
from head injuries
Poor acclimatization with
acute mountain sickness and
hypothermia found in 104
patients, resulting in poor
judgemental errors
a Injuries/fatalities per 1000 h calculated by the authors according to the information given in the study.
b NACA score graded by the authors according to the information given in the study.
DAV =German Alpine Club; F=females; M=males; NACA =National Advisory Committee for Aeronautics; NS =not specified.
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body swings into the wall with outstretched legs
typically absorbing the impact.
[4]
More recently,
Nelson and McKenzie
[53]
analysed American
hospital emergency room records from 1990 to
2007 using data from the National Electronic
Injury Surveillance System (NEISS) of the US
Consumer Product Safety Commission. These
reviewers also found that most of the climbing
injuries were located on the lower extremities.
However, this study was unable to determine
what style of climbing, time of year (i.e. winter vs
summer) or where exactly the accident took place
(i.e. big walls). The falls were coded by mechan-
ism (i.e. felt a ‘pop’, overexertion, sprain), by any
descriptive narrative of the accident if available,
and by whether the fall was £6m or 6m.
Therefore, the bias of this study may report more
falls 6 m where lower extremity injuries are more
likely to result from big swings into the wall or big
falls. The authors claim that the discrepancy
between their finding of mostly lower extremity
injuries and most other studies finding mostly
upper extremity injuries may be partially explained
by the minor nature of many rock climbing re-
lated injuries recalled by participants in the other
surveys. Another study using a similar NEISS
analysis
[74]
on American golf cart injuries from
1990 to 2007 found significantly more golf cart
injuries resulted in emergency room admissions
than from climbing an estimated 147 696 in-
juries versus 40 282, respectively. The NEISS
data do not permit access to information re-
garding patient outcomes over time, or more
personal data. Addiss and Baker
[22]
and Schuss-
mann et al.
[20]
combined data from rock climbing
and mountaineering when analysing injuries in
US National Parks. Both studies found moun-
taineering to be of a higher risk than pure rock
climbing. Addiss and Baker
[22]
also found that
falls on snow or ice were longer than falls on rock,
and injuries on snow or ice were more likely to be
fatal. The injury rate per 1000 hours can only be
found in two studies and varied markedly from
37.5
[21]
to 0.56.
[20]
For alpine climbing (traditional climbing), a
death rate (fatality rate) was documented by
Bowie et al.
[21]
13 from 220 injured climbers
died a case fatality rate of 6%. This case fatality
rate was much smaller than older US records
Fig. 1. Modern sport climbing, protected with bolts.
Fig. 2. Boulderer and protection (for protection a spotter [who
works to direct the climber’s body toward the crash pad during a fall,
while protecting the climber’s head from hazards] and a bouldering
mat [crash pad] is used).
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from 1951 to 1960 that recorded 41%,
[75]
19%for
the Grand Tetons
[20]
in 1982 and 8%for Sierra
Nevada.
[63]
Schussmann et al.
[20]
calculated an
incidence of 2.5 accidents/1000 mountaineers/
year or 5.6 injuries/10 000 hours of mountain-
eering. The 25 fatalities calculated to a fatality
rate of 0.13/1000 hours or a case fatality rate of
23%. The Yosemite results from Bowie et al.
[21]
are in accordance with the results of Hubicka
[76]
for European climbing areas. As most of the
analyses performed in these climbing injury stu-
dies were conducted retrospectively through
questionnaires, the fatality rate is frequently
biased. The ‘older’ studies (20 years ago)
[20-22]
reported the most severe injuries and the highest
fatality rates, while recently, a prospectively con-
ducted study on bouldering
[51]
reported no fatal-
ities. The few bouldering injuries recorded in this
latter study,
[51]
also found few injury differences
between indoor and outdoor bouldering, which is
in accordance with the data by Gerdes et al.
[16]
In summary, Schussmann et al.
[20]
already
concluded in 1990 that rock climbing has a lower
injury risk than football and horse riding, but
with the obvious difference that latter sports
rarely result in fatalities although this is a ne-
gotiable argument concerning horse riding.
[77]
Climbing frequency and difficulty were asso-
ciated with the incidence of overuse injuries
[29,52]
in some studies, while others could not find an
association.
[31]
Most injuries occur when lead
climbing,
[12,19,21,22]
with falls being the most
common source of acute injuries.
[12,19,21,22,53]
Performing hard moves was the most common
cause for overuse injuries.
[52]
In traditional
climbing, falls lead to the most injuries, while in
sport climbing performing strenuous moves ten-
ded to be the cause.
[16,19]
Overall, the majority
of all injuries in these climbing studies was of
minor severity (NACA 1 and 2),
[15,16,18,20-22,29,53]
with a fatality rate ranging from 0%to 28%.
[22,51]
The vast span in between these numbers must be
further evaluated through ongoing studies, and
may reflect the bias of injuries recorded in the
study.
3.2 Indoor Rock Climbing
Several studies explored injuries and injury
rates in indoor and indoor competition climbing.
Wright et al.
[10]
evaluated the frequency of over-
use injury during the indoor 1999 World Cup
Championship (n =295) where 44%of the re-
spondents had sustained an overuse injury, 19%
at more than one site. Wright et al.
[10]
found
Fig. 3. Indoor bouldering.
Fig. 4. Ice climbing.
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an independent correlation to increased injuries
(p <0.01) when (i) climbing harder routes;
(ii) bouldering or leading versus top rope climb-
ing; and (iii) climbing for more than 10 years.
Multivariate analysis removed the effect of sex as
an independent predictor.
Jones et al.
[52]
similarly found increased num-
bers of overuse injuries or injuries caused by stren-
uous moves and less from fall-related injuries
than in traditional and outdoor sport climb-
ing.
[12,19,21,22]
Two large-scale studies
[8,23]
ana-
lysed indoor climbing injuries. Limb
[23]
reported
55 accidents from 1.021 million climbing wall
visits and no fatalities. Scho
¨ffl and Winkelmann
[8]
prospectively surveyed 25 163 registrants at ten
climbing walls. Only four significant injuries
(NACA 3) were found and no fatalities; the
injury risk per visit was 0.016%or 0.079 in-
juries/1000 hours of performance.
[8]
A higher in-
jury risk rate of 3.1/1000 hours was found at the
2005 World Championships,
[5]
where 18 acute
medical problems were treated (including 13
cases of skin bruising (see table VI).
In summary, these indoor climbing studies
demonstrated a very minor injury risk and se-
verity compared with traditional climbing and
various other sports.
[5,8,23]
Overuse injuries were
commonly reported in upper limbs, with the fin-
ger most affected.
No study reported a fatality rate, even though
fatalities do occur when climbing indoors. Cau-
sation of these rare fatalities need to be addressed
in future studies to distinguish whether climbing
misadventure or pre-existing co-morbidities con-
tributed most to any death.
[50]
3.3 Ice Climbing
Although ice climbing is a popular sport, very
little data on injuries and accidents exist. Schin-
dera
[99]
reported on general 12 general glacier
injuries where six patients fell into glacial cre-
vasses and the other six slid down a glacier ice
field. Patterson
[100]
reports about ice climbing in
prose style. Mosimann
[45]
evaluated 46 rescued
ice climbers for a non-peer-reviewed journal
Bergundsteigen, a risk-management magazine for
the German, Swiss and Austrian Alpine Clubs.
Scho
¨ffl et al.
[1]
evaluated 88 ice climbers using a
retrospective questionnaire where both ice-
climbing frequency and risk behaviour were
evaluated, and injuries and accidents were rated
using the NACA score. In these latter two stu-
dies, most of the injuries were of minor severity.
Scho
¨ffl et al.
[1]
found mainly open wounds
(55.2%) and haematomas (21.9%), 71%were
NACA 1, and no injury scored above NACA 3.
The injury incidence was 4.07/1000 hours for
NACA 13 with 2.87/1000 hours in NACA 1, and
none in NACA 47.
Of 46 ice climbers rescued over 6 years,
Mosimann
[45]
found 31%had no injury (NACA 0),
42%had NACA 23 injuries, 8%had NACA 4,
6%NACA 5, and 13%(6 climbers) had a fatal
injury (NACA 7). The most frequent cause of
injury was falls (55%), although no fatal injury
was caused by a fall. The percentile death risk
(fatality rate), which the author defined as the
percentile portion of deaths in reference to the
sum of all known emergencies, was reported as
13%for ice climbing. The author claimed the
fatality risk was higher for ice climbing than in
mountaineering (8%), ski mountaineering (7.5%)
and rock climbing (4%), but gave no reference for
these data.
Since 1951, the American
[54]
and Canadian
Alpine Clubs
[55]
recorded details of all mountain
accidents in their respective climbing areas up to
2005. The American Alpine Club report
[54]
recorded 6111 mountaineering accidents. The
Canadian Alpine Club
[55]
recorded 958 accidents
and then separately analysed ice-climbing acci-
dents over a 30-year period to reveal 92 moun-
taineers were injured while ice climbing, 30 were
fatal. The German Alpine Club recorded ice-
climbing accidents that were reported to their
insurance cover provider. From 2004 to 2005, 150
climbing accidents were recorded, with 12%of all
accidents occurring in mountain sports.
[50]
Al-
pine mixed climbing was recorded in 8%of all
accidents, water ice-climbing was 6%.
In summary, these studies demonstrated a
small percentage of accidents had occurred on ice
terrain. The limited data specifically on ice-
climbing injuries showed a minor injury risk and
some fatalities.
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4. Comparison of Climbing to
Mountaineering
As the collective skills of all forms of rock and
ice climbing are required when mountaineering a
comparison with mountaineering activities is
important. Mountaineering may include hiking,
expeditions and mixed and Alpine climbing, to
climbing the highest point in the world Mount
Everest (8850 m). All these activities present dif-
ferent physiological demands and involve different
risks from altitude-induced illnesses (begin-
ning from around 2500 m) to diagnosing and
managing all medical problems in the wild-
erness.
[12,19-22,28,54,60,62,99,101-113]
Most studies on
mountaineering fatalities and accidents present
the fatality/accident number per 1000 climbers or
per 1000 summits, making direct comparison
with sporting studies reporting injuries 1000 hours
of sports performance difficult.
McIntosh et al.
[61]
evaluated medical incidents
at a US outdoor/wilderness school. Injuries oc-
curred at a rate of 1.18 per 1000 programme days.
Only 5%of the injuries resulted from the
programme’s supervised rock climbing; 44%re-
sulted from hiking with a backpack. Stephens
et al.
[57]
similarly found hiking (58%) was the
most common activity at the time of death in a
fatality and 26%in mountaineering.
McIntosh et al.
[62]
also reviewed mountaineering
fatalities on Mount McKinley, Alaska (6194 m).
More recently, fatality rates have declined to 3.08 of
Table VI. Injury risk per 1000 hours of sport performance of various sports
Sport Type of athlete studied Injuries per 1000 hours References
Rugby Amateurs, competition 283 78
Rugby Professionals, competition; summer/winter 150/52 79
Ice hockey Professionals 83 80
Rugby Youth 57 81
Handball F, competition 50 82
Soccer M, competition/training UEFA Champions League 31.6/3583
Traditional climbing 20 y ago NS 37.5 21
Motorbike Competition, professionals race course, cross, trial 22.4 84
American football German first league 15.7 85
Handball M, competition/training 14.3/0.6 86
Basketball Professionals and amateurs, M and F 9.8 87
Soccer M, professionals overall injury risk 9.4 83
Sailing Yacht sailing, professionals, competition and training 8.8 88
Polo Competition 7.8 89
Kite surfing NS 7 90
Volleyball School children, training 6.7 91
Ice climbing NS 4.07 1
Soccer F, German first league 3.1/1.4 92
Competition climbing NS 3.1 5
Triathlon NS 2.5 93
Boxing Amateur and professionals 2 94
Mountain biking NS 1 95
Ski/snowboard NS 1 96
Nordic walking NS 0.9 97
Mountaineering and traditional climbing NS 0.56 20
Surfing NS 0.41 98
Indoor climbing NS 0.079
0.027
8
23
F=female; M=male; NS =not specified; UEFA =Union of European Football Associations.
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1000 summit attempts. McIntosh et al.
[62]
found
this fatality rate to be 20 times higher than those
given for trekkers hiking in Nepal by Shlim and
Houston
[113]
andevenhigherthanthoseforEnglish
and Welsh mountaineers.
[114]
McIntosh et al.
[62]
adjusted denominators to allow comparison and
reported a fatality rate of 100/1 million exposure
days on Mount McKinley, or a calculated fatality
rate of 0.063/1000 hours.
Malcom,
[56]
reported mountaineering fatal-
ities on Mount Cook in New Zealand and found
it to be 1.87/1000 exposure days, or a calculated
0.12 fatalities per 1000 hours of mountaineering.
This figure seems extremely high and may have
been the product of estimated exposure days
based on hut night stays, rather than actual
climbing days.
[62]
Firth et al.
[59]
calculated a
mortality rate of 1.3%when examining causes of
mortality among those who climbed Mount
Everest from 1921 to 2006 (n =192 fatalities from
28 276). Altitude-induced illnesses with neuro-
logical dysfunction or co-morbidities may have
contributed to fatal falls (n =113) or body dis-
appearances (n =27), but could not be confirmed.
Pollard and Clarke,
[115]
similarly found that at
extreme altitude, 7080%of mountaineering
deaths were related to environmental factors.
Monasterio
[58]
prospectively surveyed 46 rock
climbers/mountaineers over 4 years to determine
the type and frequency of accidents. Monaster-
io
[58]
reported five deaths one unrelated to
climbing, two in avalanche and two from climb-
ing misadventure. Unfortunately, neither Mon-
asterio nor Pollard and Clarke reported climbing
frequency during the study period.
When summarizing the comparison of rock
and ice climbing to mountaineering, the latter
showed a higher injury and fatality rate. On 8000
m peaks, ascent success rates declined with sum-
mit height, but overall death rates, and death
rates during descent from the summit, increased
with summit height.
[59,105]
5. Injury Risk Compared with Other Sports
When comparing injury risk among different
sports, the relative injury risk per 1000 hours of
sport exposition is a useful and established para-
meter. Further subdivision within a specific sport
can also reflect important injury risk factors. For
example, the injury risk in soccer when com-
peting was much higher than for training
[83]
(table VI). Similar results were reported for
female soccer,
[92]
snowboarding,
[116]
handball
(male and female)
[82,86,117]
and indoor climb-
ing.
[5,8,23]
Sex differences also influence injury
risk.
[118]
For example, the injury risk for soccer
played by females was lower than for males when
training versus competing.
[83,92,118]
In rugby, im-
portant differences exist between amateurs and
professionals,
[78,79]
and between juniors and
adults.
[78,81]
A comparison of the same disciplines
performed either by school children or adults also
shows significant differences.
[119]
Comparing not
only the injury risk but also the seriousness of the
injuries between different sports is difficult, as no
standard score is present. Becker
[92]
evaluated all
female soccer injuries or accidents, which resulted
in a drop out of one playing or training unit and
further assessed this injury time out according to
<1, <3or>6 weeks. An analysis of American
Football injuries in the German First League
graded an injury as minor if there was a compe-
tition or training dropout of up to 1 week; longer
breaks or a hospital stay were graded as severe,
and intensive care unit therapy or persistent
neurological or orthopaedic damage was graded
as fatal.
[85,120]
Other studies,
[95,96,98]
including the
study by Neville et al.,
[88]
that evaluate injury risks
in sport disciplines do not grade the injuries at all,
even for combined injuries and diseases together.
Spinks and McClure,
[121]
reviewed 48 studies
that quantified the risk of injury from physical
activity in children aged 515 years. There was no
consistency in the injury definition among studies
and the wide variation in reported injury rates did
not necessarily represent actual differences in
injury risk between activities. It is difficult to
compare studies directly where a standardized
injury severity and rate per 1000 hours of sports
performance or equivalent is lacking, although some
insight into sport-specific injuries may be possible.
Fatality rates among sporting studies are even
more difficult to compare as natural deaths and
the influence of co-morbidities
[122]
on sporting fatal-
ities are up to 30%and are not often explored.
[122]
Rock and Ice Climbing 673
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In soccer, a consensus statement on injury defi-
nition and data collection procedures was a
greed under the auspices of FIFA (Fe
´de
´ration
Internationale de Football Association) Medical
Assessment and Research Centre.
[123]
A similar
statement is desirable in other sports. In sum-
mary, Schussmann et al.
[20]
already concluded in
1990 that rock climbing has a lower injury risk
than football and horse riding, but with the ob-
vious difference that latter sports rarely result in
fatalities which is a negotiable point when con-
sidering equine-related fatalities.
[77]
6. Is Climbing a High-Risk Sport?
Another aim of this study was to objectively
evaluate whether climbing was a high-risk sport.
Meyers encyclopaedia
[124]
defines extreme sports
as the performance of exceptional sport dis-
ciplines where the athlete deals with high mental
and physical stress. If the sport contains an ob-
jective or subjective sensed risk of damage to
health or life it is considered a high-risk sport.
Meyer’s definition is accurate but it does not de-
fine any real risk from the athlete’s perspective,
that is, an experienced and highly skilled athlete is
more likely to take and successfully manage
higher perceived sporting risks compared with a
novice. Kajtna and Tusak
[125]
define high-risk
sports as any sport where one has to accept the
possibility of severe injury or death as an inherent
part of the activity. In contrast, Backx et al.
[91]
characterized high-risk sports as those performed
mostly indoors with a high jump or contact rate,
as in volleyball or basketball.
Some authors substitute the terms ‘high-risk
sport’ and ‘extreme sports’ or these terms inter-
changeably. Young
[126]
included climbing under
the term ‘extreme sports’, together with inline
skating, snowboarding, mountain biking etc.
Young
[126]
stated that the category of extreme
sports was fluid and the definition was inexact. In
support of Young’s view, it is not known what
selection criteria were for an ‘extreme sport’ to be
included in the popular media event called the
X-Games, a commercial annual sports event in
the US. Climbing was occasionally represented in
this annual event.
Sport disciplines that are performed by a large
population are subjectively considered harm-
less.
[127]
Therefore, more mainstream sports such
as soccer, handball or rugby are not perceived or
characterized as high-risk sports, even though
they have a high risk of injury. A sport such as
kite surfing reported a modest injury rate (7/1000
hours)
[90]
in a 6-month prospective study (n =235).
However, the injury incidence and severity rate
was high and even recorded a fatality (124 in-
juries, 11 severe injuries and 1 fatal).
[90]
When assessing whether climbing should be
considered a high-risk sport it is obvious that
each climbing sub-discipline implicates different
levels and types of risk of injury and fatality.
When climbing outdoors, there are objective
dangers and physical hazards such as variable
rock and ice quality, extreme weather conditions,
weapon-like equipment (ice climbing), difficult
approaches and high mental and physical stress.
In mountaineering, additional environmental
factors can sometimes directly influence injuries
and fatalities (e.g. avalanches, crevasses, altitude-
induced illnesses with neurological dysfunction)
but these situations can still be avoided or some-
times successfully managed (e.g. using weather
forecasts, training in alpine climbing/rescue skills,
obtaining knowledge of local terrain, climbing
permits, acclimatization and awareness of alti-
tude-induced illnesses, access to helicopter
mountain rescue). In contrast, with indoor and
sport climbing, these objective and external dan-
gers are greatly reduced but, nevertheless, a risk
of a fatal injury is still given.
The vast majority of climbers manage the
above inherent risks with their climbing experi-
ence and skills, thereby avoiding serious injuries
and even fatality. Sport and indoor-climbing,
including competitions, cannot be considered as
high-risk sporting activities.
7. Limitations of the Analysis
The heterogeneity of the data collected in the
various individual studies may limit the conclu-
sions. In some studies, the narrative or data pre-
sented on injuries did not always distinguish
whether the ‘climbing accident’ occurred while
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actively climbing or perhaps when walking or
hiking towards the route. Was the accident a
result of equipment failure or climbing misadven-
ture? It is mostly unknown whether any co-
existing health morbidities contributed or caused
many sporting accidents or deaths. There may
also be an underreporting of climbing injuries,
especially the deaths associated with the sport as
no mandatory reporting is required and the stu-
dies are often based upon retrospective survey
data. The survey-based studies may suffer from
recall bias of the participants, as well as mis-
classification bias by the investigators. Other
limitations include possible sampling bias of
these investigators (possibly not incorporating all
of the studies), and difficulties in abstracting and
manipulating data reported in previous publica-
tions. The calculation of climbing days into hours
may also contain miscalculations. Internationally,
there is no standardized method of recording climb-
ing accidents by representative climbing bodies or
otherwise. Such limitations may have resulted in
a more descriptive study being realized.
In addition, all the authors are experienced
rock climbers. This may have resulted in a bias,
but it was also important when interpreting data
(i.e. the specific geographical location of the
study will suggest climbing styles, the nationality
of climbers may also suggest climbing styles and
techniques). Many non-climbing people, includ-
ing researchers, do not differentiate among the
different climbing styles because they are un-
aware of such differences. Rock climbing is a
multi-disciplined sport. Depending on the sub-
discipline examined, the climber’s experience and
skills, grade of route difficulty, equipment,
climbing surface (e.g. type of rock or ice, artificial
indoor wall, scree), the remoteness of location,
altitude and weather will implicate different levels
of risk. In addition to these variables, many
climbers regularly participate in more than one
climbing sub-discipline. Such data need to be
understood in climbing injury studies.
The present authors have all experienced in-
juries when rock climbing and have had friends
die when climbing. We are also members of the
International Medical Commissions for the
UIAA providing advice to more than 7 million
climbers in 76 countries (V.S., T.K., A.M.) and
for the International Federation of Sport
Climbing (IFSC) [V.S.], and the Safety Commis-
sion of the German Alpine Club (V.S.). We deal
with climbing injuries and injury analysis on a
regular basis both in document form, and even
when medically treating patients (V.S., T.K.). We
are obviously aware of the risks involved when
climbing and wish to initiate a more comprehen-
sive sport-specific reporting of such injuries and
fatalities to objectively educate everyone about
the real risks associated with climbing sports, and
to promote evidence-based best practice with the
sport itself.
8. Conclusions
Scientific epidemiological analysis of sport-
specific injuries helps to inform preventative
measures that can target the injury incidence and
reduce their severity, even potential fatality. It
may even provide the robust criteria desirable in
an objective and standardized definition of a
‘high-risk’ sport, which is currently lacking. Ac-
cording to the above definitions, few sports
would qualify as not being a high-risk sport, in-
cluding basketball, mountain biking, handball,
soccer (contact sports) and horse riding (danger
of potential fatality). Sporting fatalities should
also ideally be assessed to determine whether co-
existing morbidities contributed or caused the
death, as opposed to sporting participation.
Of all the sports objectively analysed, indoor
climbing reported the fewest injuries per 1000
hours of participation, and no fatalities. Other
climbing sub-disciplines similarly reported a low
injury incidence relative to mainstream sports
assessed, along with a low injury severity grade.
However, overuse injuries of minor severity in-
volving the upper limbs, notably the finger, are
commonly reported in rock climbing studies.
Nevertheless, a small number of fatalities do oc-
cur in all climbing disciplines, mainly in alpine
and ice climbing. This must be further explored in
future studies, both in terms of organized and
individual sporting participation.
When determining the relative injury risk in
any sport, we suggest using the NACA injury
Rock and Ice Climbing 675
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severity scoring system, for accuracy and simpli-
city, to evaluate 1000 hours of sport exposition.
However, it is a pre-hospital score and lacks in-
formation about patient outcome specifically,
did a fatality ultimately result from a patient with
a NACA score of 4 to 6 during the hospital stay?
Therefore, additional information on how an
injury was sustained and the final outcome would
add completeness to sporting risk assessment. An
international consensus statement for climbing
and mountaineering is currently being drafted by
the Medical Commissions of the UIAA and
IFSC.
[2,3]
Acknowledgements
No sources of funding were used to assist in the prepara-
tion of this review. The authors have no conflicts of interest
that are directly relevant to the content of this review.
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... It relies on permanent anchors fixed into the rock, such as bolts, to protect climbers from falls. Traditional (Trad) climbing placing removable protection gear while ascending [2,3]. Alpine climbing: climbing in mountainous environments, often involving rock, ice, and mixed terrains [4]. ...
... Pulley injuries occur primarily due to the high forces generated during specific climbing grips, particularly the crimp grip. Explosive moves and falls can also contribute to pulley injuries [2,9,10]. ...
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Introduction Rock climbing has surged in popularity over the past few decades, attracting a diverse range of participants from recreational enthusiasts to professional athletes. While climbing offers numerous physical and mental benefits, it also presents significant injury risks. Rock climbing is a sport that imposes extreme stress on the fingers, particularly on the flexor pulley system. Injuries to these structures can severely impact a climber's ability to perform and progress in the sport. Understanding the anatomy, injury mechanisms, and treatment modalities is essential for effective management and prevention. Aim of the study The purpose of this narrative review is to comprehensively describe information on the anatomy, function, mechanism of injury, diagnosis, and treatment modalities of the finger flexor pulley system (FFPS). Materials and methods The methodology for the literature search involved using the keyword "pulley" and adding terms such as "treatment", "mechanism", "function", "anatomy", "diagnosis", and "symptoms". The search terms were entered into the PubMed and Google Scholar databases. The review works and clinical trials were taken into account. Conclusion Finger flexor pulley system (FFPS) strain is a common overuse injury in climbers, often caused by the crimp grip used in rock climbing. Pulleys A2 and A4 are particularly vulnerable. Diagnosis involves physical examination and imaging tests, such as ultrasonography and, if necessary, magnetic resonance imaging. Grade I to III injuries are typically treated conservatively, while surgical treatment may be necessary for grade IVb injuries. Using a splint or H-taping the fingers after an injury can help prevent further damage and provide support for the affected pulleys.
... Although climbing is considered a high-risk sport, the prevalence of severe injuries is low. 16 Importantly, the chronic injury rate is almost double compared with other Olympic sports, [17][18][19] and predominantly chronic injuries may be avoided with proper training planning. 16 In the past decade, climbing has changed dramatically regarding how the routes and boulder problems on the indoor walls and competitions are designed, 20 21 giving way to different movement patterns at different performance levels. ...
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Introduction Climbing has evolved from an obscure outdoor sport to a predominantly indoor sport with the rise of mainstream climbing on artificial walls. Reported climbing-related injuries were predominantly chronic and may be avoided with proper planning of training. All climbers, regardless of age and gender, are training on the same routes and perform similar movements; however, few studies have investigated gender-specific injuries in climbing. Objectives Assess the distribution of chronic climbing injuries in an international population with gender-specific analyses and assess the impact of the person’s training focus or aim of training on those injuries. Methods A cross-sectional survey using a web-based item-driven questionnaire was created and promoted using social media and several climbing media stakeholders. All climbers engaged in either sport climbing, bouldering or traditional climbing were included. Results The survey received 1513 responses (877 men, 427 women and 9 not reporting gender), of which 50.3% (n=665; 51.4% men and 48.0% women) had experienced an injury in the past 12 months. There were significant differences in injuries in feet/ankle (p=0.014), neck (p=0.03), head (p=0.0001), shoulder (p=0.001), elbow (p=0.021) and fingers (p=0.003). Conclusion Over 50% of the climbers experienced an injury in the past 12 months. The most common injuries were to the shoulders (women) and fingers (men). There were significant differences between the genders regarding injury site and prevalence. The gender differences may be affected by the aim for training and the style of climbing.
... Rugby is a close-contact sport where the objective is to ground the ball behind the opponent's try line. In rugby, concussions are a big problem among elite players [108,109]. Rugby is becoming increasingly popular among athletes, from high schools to colleges. The head and neck are the most injured body areas in rugby, with tackling being the most common cause of injury [110][111][112][113]. Injuries among men are 30% more frequent than in women [114]. ...
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Purpose The objective of the present study was to provide an update on the 16 sports with the highest incidence of brain injuries. Thereafter, its diagnosis, treatment, and management strategies are discussed. Methods The manuscript addresses the brain-related injuries individually in each of the 16 sports with the highest incidence. To simplify the reading, the mentioned 16 sports are sorted alphabetically. A subpart mentioning the management of brainrelated sports injuries, including pharmacological management, is also included in the manuscript. Results The incidence of sports-mediated brain injuries within hospital-based studies ranged between 3.5 and 31.5 per 100,000. One community-based study using multiple case ascertainment sources identified a higher incidence of 170 per 100,000. Brain injuries due to sports total 1.2–30.3% of all TBIs (traumatic brain injuries). Men have a higher prevalence than women (75.6% vs. 66.1%), and adolescents and young adults had the highest incidence of sports-mediated brain injuries. Almost 50% of head injuries reported during the practice of sports or recreational activities occur in bicycling, skateboarding, or skating incidents. More than 775,000 children, aged 14 and younger, are treated yearly in hospital emergency rooms for sports-related injuries. Conclusions Brain injuries are common in sports and difficult to manage, but athlete health and injury prevention should be the priority. Preventive measures should be stricter in sports with a higher incidence of brain injury. As for treatment, a comprehensive approach should be adopted.
... Ice climbing emerged as a U.S. climbing discipline when attention shifted to frozen waterfalls, facilitated by technological advancements such as reverse curve pick ice axes and crampons with front points (Lowe, 1979). Due to the presence of external dangers, alpinism/mountaineering, ice climbing, and trad climbing carry higher relative risks than many other forms of climbing (Schöffl et al., 2010), with the obvious exception of free soloing, which refers to climbing routes without a rope, harness, or other protection. Sport climbing is differentiated by lead climber protection in the form of pre-placed bolts drilled into rock walls. ...
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Background: Via ferrata (VF) climbing is an increasingly popular mountain activity in the European Alps. The purpose of this study was to determine the nature of injuries incurred by VF climbers and to understand the extent of their First Aid (FA) knowledge and training. Materials and methods: A questionnaire-based cohort study was performed at two alpine locations. Data included basic data (age, gender, climbing activities, exercise), 18 multiple choice questions with 5 answers each concerning First Aid (FA) knowledge and a self-rating of FA knowledge. Statistics were performed with non-parametric tests. Results: 391 questionnaires were completed. Sunburns (23.9%), contusions (17.7%), open wounds (13.1%), and exhaustion-related injuries were the most reported incidents. Exhaustion was the most common emergency call. Only 52% of climbers wore helmets and gloves, less than 25% had adequate physical conditioning, and 28.1% reported having no FA training. The most common causes of emergencies were weather conditions (19%), stumbles (18.6%), falls (13.4%), and fatigue and deficiency in concentration (13.4%). Only 11 of the surveyed climbers scored 75% on their FA knowledge questions. VF climbers showed significant less FA knowledge than alpine mountaineers. They scored quite high on questions related to general FA but low on questions related to high altitude sickness, back, and thoracic injuries. Conclusions: VF climbers should seek out FA training every two years with an emphasis placed on sunburns, contusions, open wounds, and exhaustion injuries. The training should also emphasize the prevention of back and thoracic trauma and developing rescue strategies.
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Since the 1970’s there has been a major increase in adventure sports participation but it seems that engagement in such sports comes with a stigma: adventure sports participants are often regarded as reckless ‘daredevils’. We approach the questions about people’s perception of risk and recklessness in adventure sports by combining empirical research with philosophical analysis. First, we provide empirical evidence that suggests that laypeople tend to assess the danger of adventure sports as greater than more mundane sports and judge adventure sports participants as more reckless than participants in non-adventure sports. We contextualise these findings within existing psychological risk perception paradigms and outline new philosophical explanations of the identified pattern in laypeople’s risk perception.
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Background Climbing is an intricate sport composed of various disciplines, holds, styles, distances between holds, and levels of difficulty. In highly skilled climbers the potential for further strength-specific adaptations to increase performance may be marginal in elite climbers. With an eye on the upcoming 2024 Paris Olympics, more climbers are trying to maximize performance and improve training strategies. The relationships between muscular strength and climbing performance, as well as the role of strength in injury prevention, remain to be fully elucidated. This narrative review seeks to discuss the current literature regarding the effect of resistance training in improving maximal strength, muscle hypertrophy, muscular power, and local muscular endurance on climbing performance, and as a strategy to prevent injuries. Main Body Since sport climbing requires exerting forces against gravity to maintain grip and move the body along the route, it is generally accepted that a climber`s absolute and relative muscular strength are important for climbing performance. Performance characteristics of forearm flexor muscles (hang-time on ledge, force output, rate of force development, and oxidative capacity) discriminate between climbing performance level, climbing styles, and between climbers and non-climbers. Strength of the hand and wrist flexors, shoulders and upper limbs has gained much attention in the scientific literature, and it has been suggested that both general and specific strength training should be part of a climber`s training program. Furthermore, the ability to generate sub-maximal force in different work-rest ratios has proved useful, in examining finger flexor endurance capacity while trying to mimic real-world climbing demands. Importantly, fingers and shoulders are the most frequent injury locations in climbing. Due to the high mechanical stress and load on the finger flexors, fingerboard and campus board training should be limited in lower-graded climbers. Coaches should address, acknowledge, and screen for amenorrhea and disordered eating in climbers. Conclusion Structured low-volume high-resistance training, twice per week hanging from small ledges or a fingerboard, is a feasible approach for climbers. The current injury prevention training aims to increase the level of performance through building tolerance to performance-relevant load exposure and promoting this approach in the climbing field.
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Injuries and overuse syndromes of the fingers are the most common problems in rock climbers. While injuries to the finger flexor pulley system and tenosynovitis are well known to be frequent problems, other syndromes like the lumbrical shift syndrome or flexor tendon ganglions are rather unknown. The differential diagnosis of finger pain in rock climbers involves more than 20 different diagnoses and can be quite difficult. After taking a history, clinical examination and radiography, the ultrasound is the most helpful diagnostic aid. As a safe and inexpensive examination, it provides plenty of information for further differential diagnosis. Additional MRI is only occasionally necessary. This article discusses the possible differential diagnoses for finger pain in rock climbers, showing their typical history, clinical picture and therapeutic approach.
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Rock climbing has become increasingly popular in the past decade. However, the increased participation exposes a greater number of climbers to potential injury. The risks involved with climbing increase in proportion to the skill-level of the climber: the higher the skill-level, the more hours are required for training and on more difficult routes. The hands are used as tools for the ascent, with much of the climber's weight placed upon the fingers and also distributed through the wrist, elbow and shoulders. The combination of repetitive climbing and the excessive weight-bearing demands of the sport result in cumulative trauma to the upper limbs. Prevention should begin with educating climbers on the potential risk for injury. Although adequate rest between climbs and decreased training when pain is first encountered would aid in alleviating numerous problems, additional research directed towards improving training, treatment and rehabilitation pro-grammes is warranted.
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Finger and hand injuries and overuse syndromes are most frequent in sport climbers. Among 604 injured sport climbers (1/98-12/01), three of the four most frequent diagnoses were related to the fingers (pulley injuries 20%, tendovaginitis 7%, joint capsule damage 6.1%). Often the differential diagnosis is difficult. The presented paper shows the pathologies as well as the diagnostic and therapeutic criteria.
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A retrospective study was undertaken in 2003 with surfers from 22 nations who were questioned as to injuries suffered. A trilingual paper and online questionnaire was used. The 471 surfers included in the analysis reported a total of 466 acute injuries. The computation of the injury incidence (number of injuries per 1 000 surfing hours) was 0.41. The majority of acute injuries was in the lower extremities (44.6%) and the head (27.8%), followed by injuries to the trunk (14.8%) and the upper extremities (12.2%). The foot outnumbered by far every other single injury location (19.6%). With regard to types of injuries suffered, cuts dominated significantly (37.4%). Contusions (11.7%) held second place. Strains (9.5%) and fractures (7.6%) were next in rank. The majority of the injuries was due either to collision with the own surfboard (52.4%) or with the seafloor (15.5%). The fin caused a total of 51.1% of all surfboard-related injuries and was thus the number one source of injuries. A large part of the acute injuries could be prevented by always using safety fins and noseguards, as well as wearing neoprene shoes and helmets. Strategic marketing by industry and professional sports is necessary to improve the image of such safety equipment. It would also contribute to a broader use of such equipment among surfers.
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Objectives: The purpose of this study was to understand the activity, recreational profile and the rate of hand/finger injuries among non-professional climbers Design: 23 young climbers (mean age 16 years) and 20 older climbers (mean age 29 years) participated in a questionnaire study. The data included sociodemographic variables, level of daily and recreational activities and climbing profile (experience, training frequency, past injuries, functional and medical diagnoses). Results: The results indicate that young climbers do not sustain hand/finger injuries as frequently as the older adults. Men sustain injuries and complain of pain more often than women. Conclusions: Overuse, lack of sufficient rest and a more challenging environment appear to be the main factors which contribute to hand/finger injuries among the older climbers.