Aims and Objectives: Rock climbing and bouldering is undergoing a worldwide “boom” and has recently been selected for the next Olympic summer games. Besides ground falls, an injury mechanism in this sport is the so-called heel hook position, which is used more frequently today due to changing training and competition modes, especially in indoor bouldering. With the rising number of knee injuries in climbing and bouldering, we now aimed to analyze this specific injury mechanisms and its underlying pathologies. Materials and Methods: Among 50 climbing athletes with unspecific knee pain, we identified 9 patients with injuries of the lower extremities after performing a heel hook. The outcome was evaluated at a minimum of 6 months after the injury and classified in a sport-specific score. After clinical examination and exclusion of the minor injuries we performed ultrasound and/or magnetic resonance imaging. Patients were treated conservatively with initial partial immobilization and early functional therapy with physiotherapy. Only one patient with a partial meniscus tear needed a surgical procedure. Results: All patients reported sudden dorsal-sided pain in the knee while performing the hook. Seven also reported hearing a snapping sound, similar to those reported in achilles tendon tears. Walking was difficult in all cases and all were limping. Five patients were diagnosed a strain of the lateral collateral ligament and two patients a lateral meniscus tear. The other patients had either a partial tear of the PCL, or a strain of the distal hamstring tendons. In 8 of 9 cases, we received “good” to “excellent” outcomes with a conservative approach. The popping sound at the time of injury may correspond to a change of the pivot of the tractus ileotibialis that then “jumps” over the condyle. While the hook is performed, there is frequently an active knee flexion involved, which thus changes the pivot of the tractus. Conclusion: In climbing and bouldering, injuries of the knee will further increase due to modern training and competition modes requiring the use of heel hooks. MRI shows the proper diagnosis and the proper therapeutic approach is conservative treatment. The outcome after heel hook injuries is good to excellent in most of the cases. Warm-up routine, an avoidance of muscular imbalances, and flexibility training can help to avoid injuries during heel hook.
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