National Trends in Rock Climbing Injuries

Abstract

Background:

Rock climbing participation in the United States has grown markedly, yet recent epidemiologic data are limited. This study characterizes national trends, injury patterns, and risk factors for severe injuries among climbers treated in US emergency departments from 2014 to 2023.

Methods:

Rock climbing-related injuries were identified in the National Electronic Injury Surveillance System database. Injuries were analyzed by type, body region, mechanism, and demographic group. Weighted logistic regression assessed fracture and hospitalization risk by age and fall height.

Results:

From 2014 to 2023, an estimated 47,251 injuries occurred. Fractures (26.8%) were most common, followed by sprains/strains (20.4%), soft tissue (10.2%), and lacerations (8.0%). Lower extremities were most frequently injured (50.6%), followed by upper extremities (26.7%) and torso (14.9%). Falls (58.8%) were the leading mechanism; falls >20 ft carried 52% higher fracture risk (odds ratio = 1.52, [1.41-1.63]). Adults 21 to 45 years accounted for 63.1% of cases. Climbers >45 years had 45% higher fracture odds compared with those 7 to 20 years. Hospitalization occurred in 9% of cases.

Conclusion:

Fractures and lower extremity injuries are the most common presentations in US rock climbing Emergency Department visits. Older age and higher fall height were associated with increased severity of the injury.

Level of Evidence:

Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction

Rock climbing is an increasingly popular sport in the United States, with an estimate of over 10 million individual participants in 2022 and an annual growth rate of 6.6%¹. This trend is likely to continue with the inclusion of rock-climbing events in the Tokyo 2020 and Paris 2024 Summer Olympics. Therefore, a corresponding rise in the incidence, severity of injuries, and injury burden may be anticipated due to the rise in newer and less experienced climbers.

Climbing includes various disciplines—bouldering, sport, traditional, and speed climbing—each with unique equipment.² Advances in technology have led to the development of lighter, more durable, and more reliable safety equipment, contributing to improved climber protection and performance.³

Several studies have indicated that 50% to 82% of rock climbers report sustaining at least one climbing-related injury annually, with approximately 40% of these injuries requiring surgical intervention^4-6. Upper extremity injuries are the most common, accounting for 42.6% to 71.4% of cases, followed by lower extremity injury at 12.7% and spine injury at 7.1%^5-8. However, previous studies have primarily focused on competitive rock climbers rather than the general population.

Earlier National Electronic Injury Surveillance System (NEISS) studies demonstrated increasing Emergency Departments (EDs) visits. Between 1990 and 2007, cases increased from 1,617 to 2,637, representing a 63% rise⁹. A subsequent study noted injuries nearly doubled between 2008 and 2016, from 2,500 cases to nearly 5,000¹⁰.

This study extends the timeline to 2023, evaluating injury trends, mechanisms and demographics to compare to studies describing previous decades.

Methods

Cases of rock-climbing–associated injuries between 2014 and 2023 were retrospectively exported from the NEISS database, a database maintained by the US Consumer Safety Commission that collects information on patients that presented to the ED.

Injuries involving multiple diagnoses, body parts, or mechanisms were counted in all applicable categories. The database collects information from 100 hospitals. Probability weighting enables the sample to extrapolate national estimates for the roughly 5,000 EDs in the broader United States. Probability weights are assigned to each based on stratum-level weights, which is the inverse probability of hospital selection within each stratum, adjusted for nonresponse and mergers. Annual calibration, in which weights are recalibrated yearly using total ED visit volumes and dynamic sampling, means if a hospital leaves the sample, it is replaced by the highest-ranked hospital in the same stratum. The data are deidentified.

Variable

Product code 1,258 identified injuries related to “mountain climbing (activity, apparel, or equipment)” in the NEISS data set between 2014 and 2023 was exported to Microsoft Excel. Each case narrative was reviewed by JL and JK, and if there were any disagreements, NK served as the tiebreaker. We excluded cases involving children aged ≤6 years as well as injuries not directly related to rock climbing, including those sustained during mountaineering, ice climbing, or other nonclimbing activities, even when these occurred at climbing gyms or outdoor climbing sites. Children ≤6 years were excluded as these injuries are typically playground injuries.

Data regarding everyone’s age, diagnosis, injured body part, and disposition were reclassified into categorical variables. Three age groups were formed: 7 to 20 years, 21 to 45 years, and >45 years. Diagnoses were characterized as fracture, sprain/strain, laceration (included laceration, puncture, and avulsion), soft tissue (included contusion, abrasion, crush, hematoma, nerve damage), dislocation, and others. Normalized injury rates were calculated using US Census population estimates as denominators for each age group, as age-specific rock climbing participation data was unavailable at the time of the study. Injuries were graded using the Union Internationale des Associations d'Alpinisme (UIAA) scale to allow comparison with other studies with Grade 2 including sprains/strains and Grade 3 including fractures/dislocations (Table I)⁹.

TABLE I.

Union Internationale Des Associations D'Alpinisme Injury Classification¹¹

Grade	Description
1	Mild injury or illness, no medical intervention necessary, self-therapy (e.g., bruises, contusions, strains)
2	Moderate to severe injury or illness, not life-threatening, prolonged conservative or minor surgery, outpatient therapy, doctor attendance within a short time frame (days), injury-related work absence, heals without permanent damage (e.g., undisplaced fractures, tendon ruptures, pulley ruptures, dislocations, meniscal tear, minor frostbite)
3	Major injury or illness, not life-threatening, hospitalization, surgical intervention necessary, immediate doctor attendance necessary, injury-related work absence, heals with or without permanent damage (e.g., dislocated joint, fractures, vertebral fractures, cerebral injuries, frostbite with amputations)
4	Acute mortal danger, polytrauma, immediate prehospital doctor or experienced trauma paramedic attendance if possible, acute surgical intervention, outcome: alive with permanent damage
5	Acute mortal danger, polytrauma, immediate prehospital doctor or experienced trauma paramedic attendance if possible, acute surgical intervention, outcome: death
6	Immediate death

Injured body parts were categorized as lower extremity, upper extremity, torso, head and other (refer to Supplemental Material). Dispositions were organized as not hospitalized (left without being seen, treated, and released or held for observation for <24 hours) or hospitalized (admitted or transferred to another hospital). Each case narrative was reviewed and, where applicable, the fall height was categorized as ≤20 ft or >20 ft^9,10. This distance was used because patients who fell from >20 ft were 10 times more likely to be hospitalized and 3.24 times more likely to sustain fractures⁹. The mechanism of injury was classified as overexertion, being struck by an object, patient striking their limb or body part against another object, fall, or other.

Analysis

All analysis was performed using MATLAB (version 2023a) with the Statistics and Machine Learning Toolbox. The data were imported as a text file exported from Microsoft Excel. Cases flagged that met the exclusion criteria as listed above were removed before analysis. A total of 1,457 cases were extracted, and 1,306 met inclusion criteria.

Weight estimates (accounting for survey sampling weights in the weight column) and 95% confidence intervals (CIs) were calculated using nonparametric bootstrapping with 1,000 resamples. For each analysis, a summary statistic (e.g., total weighted cases, subgroup proportions) was computed on resampled data sets, and percentile-based CIs were derived from the empirical distribution of bootstrapped estimates. Proportions were calculated using weighted sums with case-specific masks generated by diagnosis. The narrative column was mined for keywords to extract the mechanism of injury. Similarly, the bones were mined through the narrative column associated with the fracture diagnosis. Injuries were classified at UIAA grade 2 (sprains, strains) or grade 3 (fractures, dislocations) with weighted proportions reported. A weighted logistic regression (fitglm) was implemented to estimate fracture risk by age group, with sampling weights.

Age Groups' refers to a patient's inclusion in an age group as a logical variable (yes = 1, no = 0). A Bonferroni correction was applied to account for multiple comparisons (21-45 years and >45 years groups vs.7-20 years as reference). A similar weighted logistic regression was used to compare fracture risk between falls ≤20 ft and >20 ft.

Results

This study analyzed 47,251 estimated rock climbing-related injury cases between 2014 and 2023. The estimated number of cases per year is presented below in Fig. 1. There was a 48.5% decrease in 2020, presumably due to the COVID-19 pandemic. Since the pandemic, the number of injuries has rebounded and surpassed the 2014 estimation, a 17.2% increase between 2014 (5,106 cases, [3,937-6,157]) and 2023 (5,879 cases, [4,908-6,999]). The normalized injury rate was 5.18 per 100,000 in 2014, 2.55 per 100K in 2020, and 5.69 per 100K in 2023. The annual change in the normalized rate was −0.0154 per 100K (p = 0.654).

Fig. 1.

Estimated number of rock climbing injuries by year, 2014 to 2023 (Range 5,016-5,879).

Demographic Distribution, Fracture Risk, and Hospitalization

Within the NEISS Database, climbers aged 21 to 45 years accounted for the most injuries (63.1%, 29,836 cases), followed by adolescents aged 7 to 20 years (26.1%, 12,349 cases) and climbers >45 years (10.4%, 4,922 cases). The normalized injury rates were 2.095 per 100K population for individuals aged 7 to 20 years, 2.738 per 100K for 21 to 45 age group, and 0.372 per 100K for >45 age group. Fracture risk increased significantly with age: 21-45 years had 41% higher odds of sustaining a fracture (odds ratio [OR] = 1.41, [1.34-1.48] p < 0.001), and those >45 had 45% higher odds (OR = 1.45, [1.35-1.57] p < 0.001) of fracture compared with 7-20 y group. Most patients were not hospitalized (90.8%), compared with those who were hospitalized (9%) (Table II).

TABLE II.

Demographic Distribution and Fracture Risk

Variable	Estimated No. of Cases (95% CI)	% of Total	Fracture OR (95% CI)
Total injuries	47,251 (45,221-49,466)	100	—
Age group
7-20 years	12,349 (10,860-13,895)	26.1	Reference
21-45 years	29,836 (27,631-31,831)	63.1	1.41(1.34-1.48)*
>45 years	4,922 (3,880-5,995)	10.4	1.45 (1.35-1.57)*
Fall height (a total of 14,466 national estimate had fall data)
≤20 ft	10,187	70.4	Reference
>20 ft	4,279	29.6	1.52 (1.41-1.63)
Case disposition
Hospitalization	4,250	9.0	—
Not hospitalized	42,900	90.8	—
Fatality	101	0.2	—
Mechanism
Fall	27,772 (25,862-29,754)	58.8	—
Hit/Strike	6,001 (4,877-7,205)	12.7	—
Overexertion	499(184-888)	1.1	—
Struck by an object	188(3-436)	0.4	—
Other	16,633(14,809-18,406)	35.2	—

CI = confidence interval, and OR = odds ratio.

^*Bonferroni-adjusted p < 0.025 for age comparisons.

Fracture rates: 53.4% for >20 ft falls vs 43.1% for ≤20 ft.

Injury Diagnosis and Injured Body Part

Fractures (26.8%, 12,648 cases; [11,067-14,220]), strains and sprains (20.4%, 9,648 cases; [8,259-11,022]), soft tissue (10.2%, 4,806 cases; [3,621-5,984]), and lacerations (8.0%, 3,800 cases; [2,883-4,827]) were the most prevalent injury types. The lower extremities (50.6%, 23,888 cases; [18,510—29,223]), upper extremities (26.7%, 12,630 cases; [8,986-16,573]), and Torso (14.9%, 7,023 cases; [5,291-8,922)]) were the most frequently injured body regions (Table III) The ankle (30.8%), foot (18.4%), and wrist (8.2%) were the most fractured body part (Table IV). Of all the cases, 29.3% (13,858 cases; [12,238-15,508]) were UIAA Grade 2 and 33.78% (15,963 cases; [14,177-17,620]) were UIAA Grade 3.

TABLE III.

Injury Characteristics

Category	Subtype	Annual Estimated No. of Cases (95% CI)	Percentage (%)	Key Subgroups (No. of Cases)
Diagnosis	Fracture*	12,648 (11,067-14,220)	26.8	Ankle (30.8%), foot (18.4%), wrist (8.2%)
	Sprain/Strain	9,648 (8,259-11,022)	20.4	—
	Soft tissue	4,806 (3,621-5,984)	10.2	Contusion/Abr. (4,211), nerve damage (318), hematoma (196), crushing (81)
	Laceration	3,800 (2,883-4,827)	8.0	Laceration (3,591), puncture (208), avulsion (189)
	Dislocation	3,314 (2,445-4,263)	7.0	—
	Other	12,846 (10,734-15,051)	27.2	Other (9,303), internal injury (2,043), concussion (1,089), dental (123), derma/conjunct (113), radiation (64), amputation (37), foreign body (20), hemorrhage (17), burn (16), poisoning (16), ingestion (5)
Body Part	Lower extremity	23,888 (18,510-29,223)	50.6	Ankle (8,914), lower leg (3,196), knee (3,190), foot (3,122), upper leg (278), toe (428)
	Upper extremity	12,630 (8,986-16,573)	26.7	Shoulder (4,418), elbow (2,201), lower arm (1,193), wrist (1,458), upper arm (512), hand (2,099), finger (1,749)
	Torso	7,023 (5,291-8,922)	14.9	Upper trunk (3,542)
				Lower trunk (3,481)
	Head/Neck	6,462 (4,866-8,312)	13.7	Head (4,271), face (836), neck (740), mouth (244), eyeball (226), ear (15)
	Other	1,247 (582-2,131)	2.6	Pubic region (339), all parts, body (663), internal (5), not stated/unknown (131)
UIAA	Grade 2	13,858(12,238-15508)	29.3	Sprains, soft tissue injuries
	Grade 3	15,963(14,177-17620)	33.78	Fractures, dislocations

^*Refer to Table IV for complete fracture subcategories.

TABLE IV.

Fracture Distribution

Body Region	No. of Cases	Percentage (%)
Ankle	3,895	30.8
Foot	2,331	18.4
Wrist	1,037	8.2
Vertebra	1,030	8.1
Hand	905	7.2
Radius	897	7.1
Fibula	798	6.3
Rib	547	4.3
Clavicle	363	2.9
Humerus	338	2.7
Pelvis	170	1.3
Femur	116	0.9

Notes: No patellar or orbital fractures were observed.

Mechanism of Injury and Fall Height

Falls (58.8%) were the leading mechanism. Falls from heights >20 ft was associated with a 52% higher fracture risk (OR = 1.52, [1.41-1.63]) compared with falls ≤20 ft (43.1% fracture rate), followed by patients hitting an object, overexertion, and being struck by an object (Table II). In total, 35.2% of cases were categorized as other due to the narrative being incomplete or vague descriptions of mechanism of injury. Some descriptions include “Left 3rd finger swelling and pain for 2 to 3 days after he went rock climbing” or “Felt a twinge in the right side of the neck after rock climbing the night before”.

Discussion

This 10-year analysis demonstrates that rock climbing continues to carry a substantial risk of injury, with fractures—particularly of the ankle, foot, and wrist—being the most common injury type (26.8%). Lower extremities were most frequently injured (50.6%), reflecting the high impact of falls. Falls were also the leading cause of injury (58.8%), with falls >20 ft associated with a 52% higher fracture risk. Both the >45 years (OR = 1.45) and 21-45 years (OR = 1.41) age groups were associated with high odds of sustaining a fracture while climbing when compared with the younger age group. Although the severity of these fractures is not known based on these data, these findings still underscore the need for targeted prevention strategies for older climbers. As climbing continues to attract recreational participants across a broad age range, age-specific safety education will be increasingly important in reducing injury burden among older climbers, who are at higher risk of sustaining more severe injuries compared with younger climbers.

Between 2014 and 2023, an estimated 47,251 rock climbing injuries were treated in US emergency departments, with a 48.5% decline in 2020 presumably attributed to COVID-19–related reductions in participation and ED utilization^12,13. Postpandemic injuries rebounded in 2023 with a 17.2% increase from 2014, indicating renewed engagement as access resumed similar to other outdoor sports¹⁴. However, rock climbing continues to be a relatively high risk activity compared to other recreational sports. Of all patients who presented to the ED, 9% of rock climbing-related injuries required hospitalization. This rate is significantly higher than the average of all other recreational sports-related injuries reported in the NEISS database where only 2.3% of injuries required hospitalization¹⁹.

Age-related patterns were notable: adults aged 21 to 45 accounted for 63.1% of injuries (2.738 per 100K), adolescents 7 to 20 years old for 26.1% (2.095 per 100K), and those >45 years for 10.4% (0.372 per 100K), similar to previous studies^9,10. Although older adults represented a smaller proportion of injuries, their higher fracture risk may reflect physiological changes such as decreased bone mineral density^8,15.

Our findings on injury type and body region expand on previous literature^9,10. Fractures, sprains/strains, and lacerations were the most prevalent injuries, with the lower extremities disproportionately affected. This contrasts with elite sport climbers, where upper extremity injuries, especially finger injuries, predominate^16,17. These differences may be attributed to a broader population that encompasses various climbing styles and experience levels^6,8,16,17. In addition, climbers tend to undersize their climbing shoes by 2.3 sizes¹⁸. Cramped footwear may contribute to a higher rate of chronic ankle and foot injuries compared with other body regions; however, no study has directly examined the relationship between acute injuries and shoe downsizing^18,20.

Although this study focused on acute injuries, chronic overuse upper extremities injuries remain prevalent and often result from repetitive stress and improper technique. For instance, finger injuries, especially to the flexor tendon pulleys, are common due to the high demands placed on these structures during climbing^21,22. In addition, shoulder impingements and rotator cuff issues can arise from repetitive overhead movements^4,8,23. Comprehensive injury prevention strategies should address both acute and chronic injuries, emphasizing proper training regimens, technique refinement, and adequate rest periods to promote musculoskeletal health^4,5.

Overall, this study confirms that as rock climbing’s popularity grows, injury risk remains significant. By identifying high-risk populations, common injury types, and mechanisms, these findings provide critical guidance for targeted prevention, safety education, and further research.

Limitations

This study has several limitations. The NEISS database includes only injuries treated in US emergency departments, likely underestimating the true burden of rock-climbing injuries by excluding those managed in urgent care, outpatient clinics, injuries treated with home remedy and those not treated. Minor injuries, such as bruises and superficial skin abrasions, are likely underrepresented due to their lower likelihood of prompting emergency care. In addition, the database lacks detailed information on climbing type (e.g., bouldering, sport, traditional), indoor vs. outdoor setting, and climber experience level. Rock climbing participation is also geographically variable, and NEISS data may reflect regional biases based on the location of reporting hospitals relative to active climbing communities. It also does not capture the use of safety equipment, such as crash pads, helmets, or harnesses, which may have prevented or reduced injury severity in some cases. These unmeasured variables limit our ability to assess context-specific risks. Furthermore, some NEISS narrative data include a reported fall height, but these values are self-reported, not independently verified, and cannot be objectively assessed. Finally, injury diagnoses rely on ED and NEISS coding practices, which may introduce variability and human error that may affect classification accuracy.

Conclusion

This 10-year epidemiological analysis highlights the increasing burden of rock climbing-related injuries in the United States, with fracture—particularly of the ankle, foot and wrist, being the most common injury. Older climbers faced significantly higher fracture odds compared with younger groups. Lower extremities are the most frequently affected body region, likely due to high impact falls. While the study underscores the sport's risks, its ED-based database design may underestimate the true injury prevalence.

Appendix

Supporting material provided by the authors is posted with the online version of this article as a data supplement at jbjs.org (http://links.lww.com/JBJSOA/B80). This content was not copyedited or verified by JBJS.