Heel Hooks and YOU.

This topic is for those of you who have been asking for heel hooking advice...

Photo Rights: Elsevier. 2016. School's Article Photo Rights: Elsevier. 2016. Schoffl's Article Here.

1. Heel Hook Basics for Newbies:

Most notably seen in Bouldering, the heel hook attains this classic position…

The knee is bent and above the body while the toe is pointed outward while the heel is pressed firmly into the hold.


AVULSION: əˈ-vəl-SHən "The act of pulling away"

Felt at the knee or up in the hamstring-hip region, heel hook injuries are on the rise. Back in the day, climbers didn't use this move as much as we are now... As this becomes more mainstream- Its bringing with it a few overuse injuries and a few aches and pains that we'd rather not see. Here's a bit of education and theory on the dreaded heel hook-

Clinical Note: The saddest thing I've seen as a clinician is an athlete who refuses to take time off and then, years or months later, he/she cannot climb at his/her desired level. With this info below, you can be observant for TRUE injuries and ensure proper self-care and return to climbing.


As physios, therapists and docs- These are our bread and butter. These symptoms are EVERYWHERE, especially in the climbing community.

Unlike a true injury, these knots and sore spots reside most commonly within the muscles themselves. We only feel them with pressure, overuse, or fatigue. Little demons that lay in wait of being provoked, they can be well managed with self-care to eliminate them. A few times a week with your favorite self-care tool and you should be ready to go without fear of injury. A tennis ball and a few good mobility drills will go a LONG WAY (coming in PART 2 Next WEEK!!)


Roughly only 6-12% of climbing injuries have traditionally been seen below the knee (1). Now that we’re using more heel hooks, research studies point to watching the risks and learning anatomy to protect ourselves from injury (2).

Some injuries will need time off and recovery, such as a hamstring tendon that has AVULSED or pulled off a bit of the bone. Others, such as a lateral collateral ligament, can get back to climbing in just 6 weeks time…if the title of ‘world champion’ is on the hook- Regardless of the injury, you might hear a “POP” which could be just pressure being released from the joint, or a tendon losing a bit of its width while it tears. Lets cover the position, the structures that can be damaged, and the goals for recovery.

Structures involved in a Heel Hook Gone Wrong:

The common injuries we see while heel hooking include injuries to the upper thigh and hip as well as to structures around the knee. Broken down into region/design, here is a list of structures at risk with aggressive heel hooks…

Image 1: Heel Hook Injury Meniscus, collateral ligament, and PCL injury anatomy

Local Knee Stabilizers:

-Lateral collateral ligament (LCL)

-Posterior cruciate ligament (PCL)

-Popliteus tendon

The PCL and LCL prevent backwards and sideways motion of the knee itself.

Image 2: Heel Hook Injury Anatomy Knee and ITB

The popliteus muscle wraps around the back of the knee and is responsible for the first 5 degrees of locking and unlocking of the knee.

It also weakly stabilizes the knee in terms of rotation.

Deep Knee Structures:

-lateral (outer) meniscus

-back of the joint capsule itself

The medial and lateral meniscus are like little rubber pads that provide shock absorption. The edges are weaker and most commonly tears occur as ring lines in the tissue, much like topo lines on a map.

Image 3: Back of the hip anatomy- High hamstring tears, piriformis, heel hook injury diagnosis

Regional Knee, Thigh and Hip Stabilizers:

-IT Band attachment at the knee

-Hamstring tendons (Rectus femoris)

-The lower external hip rotator muscles and tendons (low buttock muscles) including

The most commonly injured muscle in heel hooks is the Rectus Femoris... Felt usually at the 'sits bones' attachment on the bottom of the pelvis (AKA the ischial tuberosity)... This tendon can actually pull off from or avulse from the bone. This will take longer to heal. A partial avulsion is nonsurgical in the non-runner. Most athletes heal up fine without surgery however medical 'success' for the treatment of this area often includes recurring pain in this region as a side effect. Platelet cell therapy is the next step in my office for failure to heal and a more conservative non-surgical intervention. If THIS fails, then we consider surgery. If FULLY avulsed, I highly recommend visiting your local orthopedic surgeon for his recommendations. Reattachment, if possible, is the next step.

4. Diagnosis... Pay the Big Bucks?!

This is where you and your doctor need to decide together… Do you need to spend the cash to get a MRI…OR is it a course of conservative care. In a high level climber, spend the cash and get the correct diagnosis. Regarding a ‘POP’ noise- If you heard a POP and felt weakness or if you have a high level of swelling or sensitivity in the region, then YES, I’d recommend getting an MRI. Only 7 of the 17 athletes in Dr. Schoffl’s case study heard a pop even though many of them had damage… Your physician will make the decision on if more diagnostics are a wise investment.

In those with high hamstring symptoms, it is hard to see the deep structures with Diagnostic Ultrasound. In these cases of pain in a deep region, MRI in my opinion is the way to go.

At $450-$600 for a cash case (with no insurance), this might alter your rehab and your return to climbing. If you are competing or heading out for a trip and this injury decides your fate, your doctor WILL be ordering an MRI.

For those of you who can take time off and don’t have symptoms that lead you to believe that you are truly injured, we often take a wait and see approach. The thing to keep in mind as an educated consumer on this is that IF there is an avulsion present, where the tendon pulls a bit of bone off the pelvis, then the only way to stabilize the region is to reattach it. With this said, we want to get in there and heal it sooner than later. If we skip the investment in imaging and instead months go by without proper treatment, your doctor may not be able to reattach the tendon. This is more rare with heel hooks but it does happen…This athlete would more likely have bruising immediately following the pain at the high hamstring and might feel a ball or knotted up muscle belly in their lower hamstring with a complete rectus femurs tear. For those of you who have knee pain, this is most likely NOT you. Each injury needs a different path for examination and treatment...


IF you heard a POP or felt immediate weakness or pain during/after a heel hook, please read on... Other health issues that can arise with heel hooks. To protect ourselves as a community, this is where a little research comes in (complements of Dr. Schöffl, a researcher and teacher in Bamberg Germany....Check out his case series Here.)

Lets learn more about the region and its vulnerabilities so we can avoid injury and learn how to prevent it. It all starts with education. I know, tedious but way cool!!

Now...Lets talk prevention.

Warmups are KEY.

We learn a cold structure, muscle, tendon, joint- isn’t as flexible as it should be and it is more prone to damage if we aggressively take it to end range with force.

Warm up nicely and be kind to your body with some gentle yoga stretches, get into some plyometrics, perhaps some bouncy deep squats, and ensure your body is ready to go before you push hard. And remember, our body is miraculous at doing what we ask when it is healthy, but if it is compensating for an injury, it is more likely to be injured…

READ Part 2 of HAMSTRING HEALTH coming soon for great self-care ideas and warmup images for the knee and hamstring.

My advice!? Patience, Persistence, and Planning to avoid risk or damage the stability of the region. I want you to be climbing at optimum for years to come.


1. V. Schöffl, D. Popp, T. Küpper, I. Schöffl

Injury distribution in rock climbers – A prospective evaluation of 911 injuries between 2009-2012

Wilderness Environ Med, 26 (2015), pp. 62–67

2. V. Schöffl, C. Lutter, D. Popp

Case Series: The “Heel Hook”—A Climbing-Specific Technique to Injure the Leg

Wilderness Environ Med, 27 (2016), pp. 294–301

3. Anatomy Images:

Figure 1: Wikipedia. Back of knee link.

Figure 2: Wikipedia. Front of Knee link.

Figure 3: Bartlby.com. Back of hip/thigh: link

#heelhook #hamstring #tendontear #climbinginjury #bouldering #climbing

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