Author Archives: Justin Hensley

Assistant Professor of Emergency Medicine at Texas A&M Health Science Center/Christus Spohn.

Are you using the heel hook? Should you?

As climbing has progressed from simple vertical faces to more complex topography of the rock wall, largely brought on by recreational bouldering, so too have the techniques. One of these is the heel hook. It’s as if the first climber said to him or herself, “hey, that’s like an extra pair of hands down there. Let’s use those!”

And so began at least the documented use of the heel hook, specifically using the back of the heel to put pressure on a hold using your hamstrings. When climbers tell you that you should be using your legs more, they generally didn’t mean this. At least not with gusto, because this paper is a case series of 17 injuries from using this technique.

Heel hook in action

Now, I know what you’re saying. Lower extremity injuries are a small subset of climbing injuries (~5 to ~13%), and most of those are from falls instead of from using the heel as a climbing implement. But this should be looked at more closely, as the authors of this paper state that nearly 2/3rds of their patients were coming for a second opinion due to initial misdiagnosis.

So what injuries do you get from this? All of the climbers in the case series state that while using the heel hook, they had sudden dorsal pain in the knee, thigh, or pelvis. Seven reported a snapping sound as if a ligament had torn. All had a noticeable limp immediately, and point tenderness on exam. With US and MRI, the authors discovered 8 strains, and 9 torn muscles or ligaments. Of note, only 2 required surgery, and the rest were treated conservatively.

Interesting enough is that 6 of the tears were in the pelvis (5 in the biceps femoris alone) in a pattern more common with soccer (football) players,. The 2 knee injuries were similar to those of martial arts injuries from a similar but different heel hook. The velocity there leads to more ACL injuries however.

Prevention is obtained (in the words of the authors) by thorough stretching and flexibility exercises, and a good warmup routine. They also note that people should not use the heel hook ambitiously, as knowing their own limits will prevent injury. They also feel that MRI is not necessarily overkill for pelvic injuries and professional climbers.

The “Heel Hook”—A Climbing-Specific Technique to Injure the Leg
http://www.wemjournal.org/article/S1080-6032(15)00467-6/pdf

No really, snakes can hurt you after they’re dead

Even though we have all (hopefully) been taught that dead snakes can still envenomate people, apparently it hasn’t been reported much in the literature. I say this because this case report is in press as of 18 Nov 2016.
Southern Copperhead
In this instance a young man killed a copperhead by cutting it into three pieces. While holding the piece containing the snake’s head, “his right index finger brushed against the fang and was inadvertently punctured.” I’m sure all of us think that is exactly how this happened. Pain and swelling followed, so the patient went to his local hospital where he received 4 vials of antivenom.
There was further progression of the swelling and ecchymosis, so another 4 vials were administered. The patient was then transferred to a tertiary center “with concern for compartment syndrome of his hand.” Another 2 vials were given and the hand was elevated, and no operative intervention was done. Of note, his labs showed he did not have a bleeding diathesis, but readers of this blog already knew that.
I wish I didn’t have to say it, but sadly some people out there still believe that fasciotomies are required after snake bites. Truthfully, based on the evidence, the best treatment is antivenom and elevation, not surgeries that can cause complications and haven’t been shown to give benefit.
This paper does note that there have been multiple case reports of envenomations by dead rattlesnakes or rattlesnake heads. One even had been freeze-dried, bought at a gift shop, and used as a tie tack. Almost all of those required antivenom. This is an interesting thought, as recently deceased snakes likely retain the ability for the venom gland to contract reflexively. Envenomation from a freeze-dried snake has to be retained protein on the fang itself, as the ducts aren’t functioning anymore. This particular episode is the first documented case involving a copperhead that required antivenom.
So it is more than just an old wives tale. Dead snakes can still evenomate you, even if they’ve been dead for quite a while. So stay away from the pointy ends of snakes, and stop killing them for crying out loud.

Clinically Significant Envenomation From Postmortem Copperhead (Agkistrodon contortrix)
http://www.wemjournal.org/article/S1080-6032(16)30225-3/abstract