Jarem Frye with a specialized prosthetic knee at El Capitan in Yosemite Park. Courtesy of Craig DeMartino
Adaptive Rock Climbing
As a sport, rock climbing is increasingly popular in both the recreational and competitive world. As of 2015, up to 9 million Americans climb a year . The sport offers a physically demanding outlet that is easily accessible for many different groups, including adaptive climbers. Many rock climbing gyms are now equipped with adaptive climbing equipment. It is the combination of the access to these gyms and the desire for the athlete with a disability to challenge him-/herself which is leading to its increase in popularity.
The International Federation of Sport Climbing (IFSC) Paraclimbing has strict categories in order to ensure equal opportunity during competitions. As a standardization method, a medical panel assesses each competitor to determine the category they fit in. They have a customized examination method to calculate the ability coefficient of those with a neurophysical disability. Additionally, any artificial aids that are used must be presented to the medical panel for evaluation.
Styles of Climbing
There are various styles of climbing that can be utilized by the adaptive athlete as well as the able-bodied climber. Climbing utilizes a belayerthe person on the ground who secures the climber. It is the belayer’s duty to keep an eye on the climber’s progress and let out slack to the line by releasing the belay. The belay is a special device that locks the rope a little at a time as the climber slowly ascends. The two major categories that climbing is broken down into is free climbing and aid climbing. Free climbing relies on the natural holds of the course with equipment used to prevent falls. It includes, but is not limited to, bouldering, top roping, and lead climbing. In contrast, aid climbing relies on the use of devices that affix to the course that act as artificial holds. This allows the climber to ascend more safely.
Bouldering can be done indoors or outdoors. It is a low height course where the climber ascends without a safety rope or aid. Safety is dependent on the height and a crash pad that is placed underneath the climber to cushion any falls that may occur.
Top roping can be done indoors or outdoors. The belayer is on the ground with the rope anchored at the top of the course. The rope runs through the harness of the lead climber to ensure maximum safety for both belayer and climber. Typically the climber will use pre-existing grip holds to ascend the wall without the use of aids.
Lead climbing can be done indoors or outdoors. This is a style where the lead climber is attached to a rope that runs through anchors. The rope is connected to the belayer. Progress is achieved by the lead climber ascending beyond the anchor point to attach rope to the next point. In contrast to top roping, the rope is not anchored to the top of the course. As a result, this is a riskier style of climbing that results in larger injuries.
Aid climbing is performed outdoors. The climber ascends by utilizing specialized equipment not typically seen in free climbing. The equipment can be used to create artificial holds in the natural rock surface of a course. Some of these holds or anchors are permanently placed by the climber to mark the course for a future climber. These holds are called fixed protection. Other equipment used by the aid climber attaches to the fixed protection to allow for ascent. A typically safer method of climbing, aid climbing is used for the tougher courses where free climbing (bouldering, top roping, lead climbing) is dangerous or not easily achieved.
Rules of Competition
The rules of the World Paraclimbing Championships are set forth by the International Federation of Sport Climbing (IFSC). The organization defines three types of paraclimbing competition. They are lead, boulder, and speed. Competitors are placed in a specific disability category as referenced in Table 28.1. If there are not enough competitors to be placed in a category, the entrant may opt to compete in the next higher category.
Disability classifications in the IFSC World Paraclimbing Championship 
Neurological/physical disability (NPD)
NPD1: Assessed ability coefficient ≤1.4
AA1: One arm amputee
WS1: Competitors normally requiring a wheelchair
NPD2: Assessed ability coefficient >1.4
B2: Visual acuity up to 2/60 and/or visual field <5%
LA1: One/two leg amputee (with/without prosthesis)
B3: Visual acuity between2–6/60 and/or visual field 5–20%
In the lead competition, an artificial wall with purposeful design is used. The wall is a required minimum height of 12 meters (m), length of 15 m, and width of 3 m. There are two rounds, a qualifying and final round. Competitors that are in category B1–3 are allowed to receive instruction from a coach with regulation communication equipment.
In the boulder competition, an artificial wall with purposeful design is used. However, this wall must not put the lowest part of the climber’s body greater than 3 m above the landing mat. There are two rounds, a qualifying and final round.
In the speed competition, an artificial wall with purposeful design is used. This wall is 10–15 m in length. A minimum of two parallel lanes allow for a side-by-side race. The type of climbing in these speed competitions is top-rope.
Climbers endure significant strain to their body and risk serious falls. As a result, the equipment used needs to be rugged and reliable. There is equipment that is utilized by all climbers regardless if they are able bodied or have a disability. Not all adaptive climbers require special equipment and augment their prostheses or residual limb with standard equipment. We will review the standard climbing equipment as well as some adaptations for athletes with a variety of disabilities.
The most basic of climbing equipment used in all types of climbing is the climbing shoe. It typically has a thin vulcanized rubber layer to provide a higher coefficient of friction and, therefore, better foot grip. To improve handgrip, climbers will apply a fine layer of chalk to reduce sweat and increase friction. An overapplication of chalk will reduce friction and therefore, grip.
A harness is the core for safety in top roping, lead climbing, and aid climbing. It typically is designed to wrap around the waist and is what fastens the climber to a safety rope. The rope is hooked to an anchor, runs through a loop in the harness, and attaches to a belayer at the bottom. The belayer uses a belay device to help lock a climber in place if they start to fall. It is also used to help the climber descend at a safe and paced rate.
The courses in aid climbing have very few climbing holds. As a result, a variety of equipment is used in aid climbing and is what differentiates it from free climbing. Protection devices are equipment used to provide temporary anchor points. Ascenders are used to ascend a rope without necessarily using climbing holds. Aiders are short ladders that can be fixed to an anchor point to allow for difficult courses to be more navigable. This short explanation is by no means exhaustive as there are many types of aid climbing equipment.
Adaptive climbers in the neurological/physical disability (NPD) and seated category have a variety of specialized equipment available to provide safety in the climb. A chest harness can be used in place or in conjunction with a standard waist harness. This is used to secure the climber and to help keep them upright. There are other types of custom harnesses that modify the standard waist harness to better hold and distribute weight for the adaptive climber.
Pullup bars (Image 28.2) are utilized by climbers with disabilities such as lower limb paralysis to ascend a wall. The bar is fixed to a pulley system that allows the climber to ascend the route through a locking mechanism. Several famous adaptive climbers have used this equipment to climb tough routes such as El Capitan in Yosemite, one of the world’s largest exposed granite monoliths. Many rock climbing gyms are now adaptive climber friendly and have custom pulley systems that can accommodate different harnesses, wheelchairs, and pullup bars.
A climber utilizing the pullup bar to ascend a course. Courtesy of Paradox Sports
Most limb-deficient climbers do not require specialized equipment to climb. They may choose to use their regular prosthesis to help achieve balance and traction. However, several companies are now developing specialized climbing prosthesis and equipment to allow for more rigorous and difficult climbing.
Athletes with upper limb deficiencies due to amputation or congenital deficiency may use terminal devices, such as a hand or hook, that are built to withstand environment factors and the stresses that come with climbing. The prosthetic socket can use a vacuum suspension to prevent the prosthesis itself from detaching while under strain. An alternative cable system is available to allow for better grip by modifying the standard open and closing motions.
The athlete with lower limb deficiency may also use terminal devices which can be a climbing foot or knee. The climbing foot (Image 28.3) comes in different varieties, but the general design intent is to shorten and contour the foot from a standard prosthetic foot. This decreases the torque and allows the foot to better utilize small crevices. A climbing shoe or climbing sole is placed around the foot for traction. The climbing knee (Image 28.1) is designed with lightweight metal and shock resistors—a coil and air. It is built to withstand not only the large amount of pressure exerted when climbing but the environment it may be used in.
Chris Prange-Morgan with a prosthetic limb climbing Birch Tree Crack at Devil’s Lake. Courtesy of Able Outdoors
Injuries are overwhelmingly common in both the recreational and elite rock climbers. It has been reported that 75% of these athletes will suffer from either a traumatic or overuse injury . Up to 93% of injuries are an overuse injury while the remainder are due to a traumatic injury . The types of injuries tend to be sprains, strains, chronic overuse, lacerations, dislocations, and fractures. As the sport grows, initial research demonstrates several risk factors associated with injuries:
The risks with climbing compared to paraclimbing are similar. However, there are additional risks of adaptive climbing related to the type of disability, equipment used, and the additional compensatory force required to overcome certain physical disabilities.
For the adaptive athlete, ambulatory athletes (visually impaired, amputee, cerebral palsy) are at increased risk for lower limb injuries . Lower limb-deficient athletes have a predilection for injury to regions proximal to their residual limb. This is due to increasing the necessary rotation, flexion, and extension of those groups to achieve increased excursion and propulsion . Additionally, the residual limb at the point of contact with prosthesis is at risk for increased skin injury. The contralateral intact limb will endure similarly increased forces as the groups proximal to the residual limb. It is at risk for chronic overuse injuries . There is always a risk for skin injuries at the point of contact with the prosthesis. Upper limb-deficient athletes are at similar risks as athletes with lower limb deficiency as with regard to residual and intact limb. Wheelchair athletes are at increased risk for upper limb injuries .
Adaptive climbers are still at risk for injuries experienced by the standard climber. Upper extremity injuries tend to compose anywhere from 57 to 82% of all injuries while lower extremities and trunk comprise the rest [7, 11]. Table 28.2 demonstrates the most common injuries associated by body part.
Most common injuries associated with body part 
Most common injuries
Sprains, strains, chronic overuse injury, lacerations
Chronic overuse injury
Lacerations, fractures, sprains, strains
Upper extremity injuries, acute and chronic, occur in about 75% of all rock climbers . About 60% of these injuries are at the hand or wrist [3, 7, 11]. The other 40% involves the shoulder or elbow.
Of the hand or wrist injuries, finger tendon injuries comprise of 52–57% of injuries [1, 11]. This is due to the reliance and incredible strain on the fingers. The different types of grips, hooked, open-crimp, closed-crimp, open-hand, and pocket grip can predispose the climber to these tendon injuries. The most common tendon injuries are the flexor digitorum superficialis (FDS) and profundus tendons (FDP) and sheaths  and annular tendon injuries [1, 11]. In general, climbers will exert 380 Newtons (N) of force on an annular tendon—a 70 kg climber could exert as much as 450 N of force when falling . The maximum tension that the strongest annular pulley, the A2 pulley, can withstand is 400 N . The proximal interphalangeal (PIP) joint collateral ligaments are also commonly injured—they are seen in up to 50% of elite climbers .
The other hand or wrist injuries typically consist of strains, lacerations, abrasions, fractures, and dislocations. These injuries can result in chronic disease that may impair the rock climber such as volar subluxation of the PIP joint, collateral ligament sprains and tears, contractures, and early osteoarthritis .
The shoulder is the second most common injured site and encompasses roughly 9–17% of all injuries [7, 11, 14]. Superior labral tears, impingement, anterior dislocations with labral tears, biceps tendon overuse injuries, tears or ruptures, and supraspinatus tendinopathies are the most self-reported injuries .
The elbow consists of around 8% of injuries in climbers . Climber’s elbow is one of the more culturally recognizable pathologies. Starting as a pain in the cubital fossa, it is a layman’s term for brachialis myotendinous junction strains. The brachialis muscle is utilized frequently as the typical motion for a climber to ascend is pronation and flexion. Golfer’s elbow, or medical epicondylitis, is also regularly seen.
Lower extremity injuries comprise anywhere from 6 to 27.6% of all injuries [7, 11]. However, when analyzing acute and traumatic injuries, almost 50% are lower extremity injuries . The typical mechanism is due to a fall from height. The most common knee injuries are the anterior cruciate, posterior cruciate, collateral ligament tears, and patellar dislocations . The most common foot injuries are contusions, calcaneus fractures, talus fractures, ankle fractures, and ankle sprain with lateral ligament injury . Modern climbing shoes force the foot into a concave shape with a majority of pressure on the big toe. As a result, there are many chronic injuries that can result such as hallux valgus deformity, subungual hematomas, nail bed infections, and neurological complaints . Acute injury to the superior peroneal retinaculum, while rare, can result due to the extreme pressure experienced by the big toe and foot .
Although the literature is still developing for rock climbing, modifying some of the risk factors listed in the above section may reduce the risk of injury. Low-weight, high-intensity training and general physical fitness and conditioning can reduce muscle fatigue and be protective against both acute and chronic injuries. Finger strengthening exercises are protective against the typical tendon injuries seen and are easily accomplished anywhere. There are a variety of equipment available as well as common household items that can be used to strengthen the fingers. Certain handheld devices that incorporate resistance against each finger are useful for improving flexor strength. A soft stress ball can replace this for grip strengthening exercises. Rubber bands placed across two fingers to provide resistance while extending a finger can be used to aid in improving extensor strength. There are multiple taping methods across the sport, but the only one to demonstrate significant difference is the H-tape method. This is a taping method shown to strengthen a finger with a pulley injury . However, it is not shown to be prophylactic for pulley injuries. There is no other taping method that has been shown to prevent injuries.