Shoulder and elbow: the climbing injuries you're not watching

A pulley warns you. There’s a pop, a pain that stops the session dead, and an athlete who messages you that same night. Unpleasant as it is, the warning arrives, and it arrives with a date.

The shoulder does none of that. It aches a little during the warm-up, settles, comes back on the overhangs, settles again. The athlete never stops climbing, so the event that would make someone write it down never happens. Two years later, that athlete’s file doesn’t have a single line about the shoulder, and the shoulder has quite a history.

That asymmetry is what this article is about. It’s not about rehab: it’s about why these two injuries are invisible to whatever logging system you have in place, and what needs to change so they stop being invisible.

The numbers, which are worse than they look

In the cohort by Lutter and colleagues on sport climbing injuries after the sport entered the Olympic programme, with 633 treated cases, fingers are still the top area at 41.2% of injuries. The shoulder is second, at 20.2%. Forearm and elbow add up to 7.7%.

The interesting part is the time series from the same research group. The share of shoulder injuries went from around 5% in the 1998-2001 cohort to 17.2% in 2009-2012 and 20.2% in 2017-2018. In twenty years, the shoulder’s share of all injuries has quadrupled, in step with the rise of bouldering, volumes and steep overhanging climbing.

If you look at complaints instead of treated injuries, the scale changes. In one-week prevalence studies, around half of climbers report something in the fingers or hand, and roughly a third report something in the shoulder. And in an MRI study of elite climbers with more than twenty-five years of practice, lifetime prevalence of shoulder pain was 77%, with considerably more labral changes than in the control group.

The detail from that study that says most about your job: all of them described the pain as mild, and none had had to stop climbing because of it.

Why they don’t get logged

That’s the explanation. Your incident system, formal or not, is almost always event-driven: someone writes it down when something happens. And the shoulder and elbow don’t produce events. They produce a slope.

The three conditions that make an injury invisible:

• It doesn’t interrupt. The athlete keeps training, so there’s no failed session to explain.
• It comes and goes. It aches at the start and calms down once warm. The athlete concludes it’s nothing, and for a while they’re right.
• It has no start date. When you ask since when, the honest answer is “I don’t know, it’s been like this for a while”.

A system that only captures what interrupts will capture pulleys and nothing else. Capturing a slope takes something different: a periodic, short, boring question, asked whether the athlete is fine or not. One line a week about niggles, whether or not anything is going on. Without that question, the first entry about your athlete’s shoulder will be the day they can no longer climb.

The elbow: the early sign is very specific

What climbers call climber’s elbow is almost always a tendinopathy of the flexor-pronator insertion at the medial epicondyle, the inside of the elbow. That’s where the muscles that flex the fingers and wrist attach, along with the one that pronates the forearm, which is exactly what a climber does all the time. There’s also the lateral version, the classic tennis elbow, and anterior pain from the brachialis and biceps, much more specific to our sport because of the combination of elbow flexion with repeated pronation and supination.

Two things worth being clear on:

It isn’t inflammation, it’s tendon degeneration. Histopathology studies describe fibroblast proliferation, collagen disorganisation and neovascularisation, not an inflammatory process. This matters because it changes what you can reasonably expect: it doesn’t resolve with rest and anti-inflammatories, it resolves with well-dosed load and time.

It settles in without an event. It appears gradually, with no identifiable moment, and the athlete describes it as a dull ache on the inside that gets worse when gripping, flexing the wrist or pronating.

The early sign, and the only one you’ll be able to use in practice: discomfort at the start of the session that goes away once warm. If an athlete tells you that, they’re not telling you they’re fine. They’re describing the typical onset of a tendinopathy, and it’s the point at which you can still adjust load instead of losing months.

There’s also a mechanical explanation that helps make sense of why it hits the athletes who are progressing best: tendon adapts more slowly than muscle. A climber who gains grip strength quickly can generate forces their insertion can’t tolerate yet. The problem isn’t that they train badly; it’s that one part of the system is running ahead of the other.

The shoulder: the movement punishes one specific position

Among the shoulder injuries in that cohort, the most frequent were SLAP labral tears, ahead of subacromial impingement.

That fits what a climber does: deep lock-offs, arms overhead under load, pulling on overhangs with the body hanging off one rotated arm, and dynos where the shoulder takes force in poorly controlled positions. It’s high load at end range with little active stability, repeated for years.

And the trend over time fits too: bouldering and steep overhangs make up a larger share of training today than in the nineties, and that’s exactly the style that exposes the shoulder most.

The signal is in the load, not the complaint

This is the part that lets you get ahead of it.

Both are load progression injuries. They set in when volume or intensity rises faster than the tissue can tolerate, and that’s almost always in your data before it’s in the athlete’s mouth: a new block, a week with one session too many, the return after a break, the start of the rock season with five days of climbing in a row.

One figure from the descriptive injury study worth keeping in mind: around 77% of injuries happened while climbing at or below the person’s usual level. They don’t get hurt on the hardest move of their life. They get hurt on the third day of a week that was already loaded.

That’s why detecting these two isn’t about watching technique, it’s about watching the slope of the load, which is the same thing we said in quantifying training load and in when to cut the load for finger injuries, applied to two tissues that warn you even later than a pulley.

What actually has evidence

Here’s some little-known good news. A 2023 systematic review on risk factors and prevention of overuse injuries in adult climbers includes two randomised controlled trials, on the same cohort, in which a programme of strength and closed-chain eccentric exercises, done three to four times a week for a year, reduced the likelihood of shoulder and elbow injuries.

Two practical implications, both uncomfortable:

• The dose is high. Three or four times a week. Not the ten-minute shoulder block on Thursdays.
• The timeframe is long. A year. This isn’t a prevention mesocycle: it’s something that lives in the plan permanently, in and out of season.

It is by far the best-supported intervention available today for these two areas in climbing. And it’s the first thing to drop out of the plan when the calendar gets tight.

The same review lists among the risk factors for overuse injury higher climbing intensity, bouldering, use of the crimp grip, previous injury and, rather counterintuitively, lower grip and finger strength. In other words, the reading of “train your fingers less so you don’t get hurt” runs exactly opposite to what the evidence points to. Strength, progressed well, protects.

What to log

The minimum for these two to stop being invisible:

• A periodic niggle question, with area and side, that always gets answered, including when nothing is going on. That’s what turns a slope into a series.
• Intensity and trend, even if only in three levels: same, worse, better. What’s useful is the sequence, not the precision.
• Which movement triggers it. For the elbow, whether it comes on when gripping, pronating or flexing the elbow. For the shoulder, whether it’s in deep lock-offs, overhead or on dynos. That’s the first lever you’ll pull, before intensity.
• Whether it eases once warm. The cheapest question and the most informative of all.
• Whether there’s an active restriction and since when, so you don’t assign the painful movement without realising.

And the initial shoulder and elbow screen goes into the first session, as we covered in what to measure on day one. Not to diagnose, but so that the day something shows up you know whether there was a history.

Where your job ends

Same as with fingers, and it bears repeating: diagnosing is not your job. Pain that doesn’t ease with load adjustment within a few weeks, that wakes them at night, that comes with loss of strength or with the shoulder catching, gets referred to a healthcare professional. Your role is to detect early, adjust, log and refer in time.

What is your job, and nobody else is going to do it, is making sure there’s a history the physio can read when the time comes.

Common mistakes

• Waiting for the event. With these two there isn’t one. Either you ask periodically or you don’t find out.
• Taking “it goes away once I’m warm” as a good sign. It’s closer to the opposite.
• Treating shoulder work as end-of-session filler. What has evidence is three or four days a week sustained for a year, not ten minutes when there’s time left over.
• Cutting finger load to protect the elbow. The flexor insertion gets irritated by poorly dosed progression, not by strength training. Reducing strength over the long term makes things worse.
• Not logging the side. A history that says “shoulder” without saying which one is a useless history.

Where this breaks

All of the above comes down to a thirty-second weekly question per athlete.

With four athletes, you ask it in the chat and remember the answers. With eighteen, that’s eighteen questions to send, eighteen answers arriving on different days through different channels, and a comparison with the previous four weeks, which is where all the information is and which nobody does. Because “shoulder, same” means nothing on its own, and means a lot when it’s the fourth week in a row it says same.

That’s the real reason the shoulder isn’t in your athletes’ files. It’s not that you don’t care: capturing a slope takes consistent logging, and manual consistency breaks in exactly the same way the spreadsheet broke. A niggle that never interrupts is never going to win priority over the fourteen things that do interrupt you.

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In ClimbrLab every athlete has an incident history with area, side, triggering movement and trend, and active restrictions stay visible when you assign sessions. We’re opening early access for coaches.