Suddenly Highly Susceptible to Tendon Problems: Suggestions or Advice?

For the past 5 months I have been highly susceptible to tendon disorders and I am at my wit's end about it. I have been following the advice and suggestions of specialists, but every time I wait, rest and return to easy climbing following their suggestions, I accrue a new injury. I am 28 and have been bouldering seriously since 2019 without incident other than spraining my thumb and my hamstring by doing dumb things (smashing my hand into a hold and missing a match and getting caught in compromising heel hook), but since the end of April, as if some switch has been turned on, I am now suddenly unable to avoid tendon issues in my fingers, wrist and forearm, even with light bouldering or hang boarding with lots of rest and breaks. 

The specialists I have seen have not been able to give me any answers and the MRI I had done was negative for any pulley injuries other than displaying marrow edema around the proximal phalanx of my left middle finger (they said to me it is high traffic area and it could have been some other ligament that snapped). Thankfully nothing has been serious yet in the sense of warranting surgery. I consider myself to be generally in-tune with my body, and the specialist I saw suggested that may be why I've avoided serious injury—I'm pushing things close to the point of failure and backing off as needed. 

For the interested reader, I will provide a timeline of what I have done and of the various problems I have had at the bottom of this post. I will highlight the various injuries, when I got them and how I got them if you want to read cursorily. It's not necessary to read the timeline, but I believe it will explain why I'm here and it may be useful.

Let me begin, then, with my questions. I have one lead on what may be happening and it is related to my second question and it will likely be more difficult to address than the first, so feel free to address just one or the other if you are so inclined. Here is the first:

Has anyone ever experienced something like this before? If so, how did you resolve this? If not, do you have any suggestions or advice based on experiencing something vaguely similar?

It may be too early to tell if it is the culprit, but one possibility is that medication is causing me these problems. First, I should say that standard inflammation markers in body are low—I've had the blood work done recently. So despite contracting COVID on May 11th (my case was mild; I was symptomatic for about 3 days), the only really relevant thing that has happened to me before I got either my first injury or any of the succeeding injuries is that I started a new medication, 15mg of Mirtazapine (I was also on 30mg at some point but moved back down to 15mg) for sleep. I would have reached the therapeutic serum dose in about 4–6 weeks after starting it, which is exactly when my first injury occurred. The FDA monograph for Mirtazapine claims that an infrequent side effect of the medication is tenosynovitis and a rare side effect is tendon rupture.

I quit Mirtazapine mostly cold turkey about 3 weeks ago; I've only taken it one time since. The withdrawal is pretty bad, but it is not worse than anything I've had to deal with recently. If Mirtazapine is the culprit, I cannot find literature about time-to-recovery for the tendons involved. Toxic tendinopathy appears to be confirmed only with statins and certain classes of antibiotics. What I have seen for those drugs suggests something on the order of magnitude of a year for the tendons to mostly recover, but information about these two side effects are not otherwise extant within the literature I have access to through my uni library.

This brings me to the second question:

If indeed medication is the culprit, do you have any idea what I should expect in terms of recovery time? I will gladly take any advice on this point, but I understand if no one is able to answer this admittedly more abstruse question. A little more precisely, I was on the medicine from mid-March to around 3 weeks ago, so let us say August 22nd.

Here is the promised timeline. Like I said, this may or may not be useful and you shouldn't feel obligated to read it (even cursorily).

--------------------------Timeline--------------------------

• This may or may not be relevant, but in February—as one does—I had somewhat acrimonious ending to a relationship, which was difficult for me.
   
• Around the middle to the end of April I noticed some pain on slopers in the A4 region of my left middle finger. I took two weeks off to see if it would resolve and then was referred to a hand specialist when this didn't resolve. They suggested a pulley sprain and I took a break from climbing for a little over a month.
  
  
• While abroad at conferences at the end of May, I noticed I had pain in the A2 region of my left ring finger. At the time, I dismissed it as something I got from lugging around my luggage at the various airports I was at over that period of about two weeks, and that I wouldn't have noticed it if I wasn't so in-tune with my fingers. This seemed to mostly go away on its own after some time (unfortunately, this will return later).
  
  
• After getting the OK to do some easy climb again in the middle of June, I entered the gym, climbed a ladder—had no issues—rested for a couple minutes, and then started a problem the next step up from a ladder and immediately heard something pop in my left middle finger—loud enough to hear through my headphones—when I went for a hold. The pain was localized to the A2 region of my left middle finger and was sensitive to touch. It swelled up a little later that night. I followed up and the hand surgeon suggested some sort of rupture and I stopped climbing again.
  
  
• At the end of June I was cracking the fingers of my left hand individually when I felt something funny when I did it to my left ring finger. The next day that finger was sensitive and painful like it was in the 3rd bullet point. I messaged the specialist I was seeing and they ordered an MRI for me.
  
  
• After 3 weeks since the injury of the 4th bullet point, I started following some hang boarding protocols on the internet for pulley injuries. I started on July 1st or so and I had the MRI on July 7th. My reasoning was that I had tried what the hand specialist suggested, now I'll try a conservative approach suggested by people who actually climb. I was very conservative and always did it with assistance from pulleys.
  
  Unfortunately, while hang boarding, I still had pain in my left ring and my middle finger where I had done something to them before. The middle finger pain was more tolerable than that in my left ring finger.
  
  
• The MRI on July 7th was negative for everything according to the technician except the presence of marrow edema around my left middle finger where I had pain. The pulley was intact. The specialist confirmed this to me on July 20th and sent me to a different specialist on August 9th who suggested that I had some sort of injury but not a pulley rupture and suggested all my other finger issues were overuse tenosynovitis.
  
  
• The evening of July 7th, after I had the MRI, I started to experience the same pain in my right ring finger as I did in my left ring finger while hang boarding.
  
  I stopped climbing again at this point. At this point I had pain while climbing in all of the fingers except for the initial injury. 
• 
  Between this time my fingers started to feel better because I wasn't using them again. I normally do quite a bit of swimming (I've fallen off on this since my injuries) but while I was swimming with a friend, I pulled on the side of the pool while we were social kicking to get closer to the side (small lanes) and I must have aggravated the right ring finger again because the pain returned as soon as I did this and persisted for a bit.
  
  Both hand specialists said they didn't know why I am so susceptible to these tendon issues. The second hand specialist told me I had two choices—climb through the pain or stop climbing; I think his reasoning being that tenosynovitis can't progress to something worse and everything basically looked fine on the MRI besides the marrow edema.
• I waited a couple weeks and started climbing cautiously again. Warming up with easy hang boarding and as I gained confidence throwing in days that were more difficult. I also kept my sessions short. I still had pain in all of the fingers except the left middle finger A4 region. I did this for about 3 weeks before I stopped again, as I will explain in the last point.
  
  
• Not long after starting, I developed new pain in my right hand localized to top of my thumb and the webbing between my thumb and index finger, and additionally pain on both the radial and ulnar side of my right hand near my wrist. The pain on the ulnar side was both on the top and underside of my forearm near the wrist whereas the pain on the radial side was on the top. I figured I'd tried to climb through like the surgeon suggested but eventually it got to a point where I recognized the (maybe FCU?) problem was seriously interfering with my ability to write, chop vegetables and play the piano, so I stopped because I was worried pushing through it would lead to something worse.
  
  
• This leads us to today, where I had a referral appointment to one the two specialists I've seen before and was diagnosed with tendonitis of the ECU and whatever's going on with my thumb. The real kicker for me right now is the FCU, which was not addressed during my visit—I think at this point the specialists I've been seeing think I'm some sort of hypochondriac and I was hurried out of the office, so in the appointment where this ECU issue in my right hand was diagnosed, the communication between the specialist and myself I think was suboptimal. I suppose it doesn't really matter because I can be conservative and treat it like tendonitis of the FCU without a formal diagnosis.

I had a similar experience at about the same point in my climbing years ago. For me, I had flexor and pulley tendon issues that persisted for a while and was constantly injuring them.

I went to a climbing specific PT in Boulder who did some testing. The gist of the diagnosis was that there was so much fascia and scar tissue built up in my forearm that the tendons had lost their “stretchiness” and ability to glide normally. I started to use a mini foam roller and wave tool for my forearms which helped immensely. I still have issues here and there but that was a game changer for me.

The other thing that happens with pulleys is the scaring and pain last a long time. Even if the tendon is intact, residual pain can last for months. Scraping scar tissue and stretching can help reduce the pain but discomfort tends to stick around for a while.

Hope you get it figured out!

oof sounds rough. probably just keep taking it easy until your tendons feel right again.

I'm the same age as you and I just got through about a year of constant debilitating tendon issues. I'm finally feeling healthy again and back to full climbing, but there were some dark times for sure. I've been climbing and training for more than a decade (I've rehabbed a few pullys over the years too).

My advice is to ease back in way slower than you think you need to. When you've just recovered from an injury and you're getting back into shape, it's really easy to over do it. You're so excited and your muscles are strong enough to pull really hard. Your tendons need more time. Take an extra rest day. Find something else fun to do.

Also, if you like sport or trad at all, try mixing in some days on a rope. Bouldering is harder on your tendons. I've found that keeping my bouldering to once or twice a week (even if I'm climbing 4 days a week) helps me stay healthy. 

We're getting older man. You gotta be kind to your body and have plenty o' compassion when it tells you "no."

Climbing places unique stresses on the body. Connnective tissue takes MUCH longer to adapt to these stresses than the rest of your body. If you're like me, your stoke and determination will far outstrip your tendons and ligaments' ability to keep up, and you'll get hurt. Unless you have a solid foundation (talking years here) of other activities that placed very similar demands on your connective tissues that was progressive, I'd recommend taking it slow. Yes there are some mutants who fly from V0 to V9 in a year, but your story seems to indicate that that ain't you. There are a myriad of things to counteract the stresses climbing places on your connective bits, from sub maximal hangboard routines and rice bucket training to contrast baths and massage. This site is a wealth of information if you take some time to wade through it. Good luck! 

What is your weekly climbing/training/all other physical exercise activity schedule? For each day: how many hours? what do you do, in term of both quantity and difficulty?

Any chance you've recently taken quinolone antibiotics ?

I see this has received quite a bit of attention recently! I am extraordinarily grateful for the attention this has received so far and your various messages. I am still keeping an eye on this post and will likely continue to do so for a while, so I'll see your replies and such.

Let me try to address some of what's been said above in reverse chronological order.

Tim Schafstall wrote:

Any chance you've recently taken quinolone antibiotics ?

No. I am aware that certain classes of antibiotics may cause tendinopathy, but it is rare for me to get sick with anything other than a cold, so I'm virtually confident I haven't been on any antibiotics within the past year. 

Jake Foster wrote:

What is your weekly climbing/training/all other physical exercise activity schedule? For each day: how many hours? what do you do, in terms of both quantity and difficulty?

I climb at most every other day for about an hour and half. I generally have an extra day or two off every other week. Other than climbing, I occasionally lift with a friend or go to a swim practice. I think I should clarify that I didn't climb all of 2020, so when I returned to bouldering in the summer of 2021, I went at it pretty hard initially but I backed off as time went on—mostly in the intensity with which I would climb but also the frequency.

Leading up to my first injury, I was only climbing for about an hour and at a much lower intensity. I had a lot going in my life at that point. During this time, I'd occasionally climb two days in a row, but I was cautious about the intensity I climbed at when I did this.

In terms of difficulty, the hardest grade I climb at the gym I frequent is a V6. They tend to set harder for the grade than is typical, but I don't have a feel for whether that's a difference of several standard deviations or something more modest. I prefer crimpy and technical stuff, but I always mix it up so that I'm never doing the same sorts of problems on two consecutive days that I climb.

It's been such a long time since I've climbed, I couldn't tell you what my typical day used to look like at this point, unfortunately :(. My feeling is that it'd depend on the day. I always warm up on V2s and V3s. Occasionally I'd project something or limit boulder and other times I'd just climb problems I knew I could send and maybe give a couple cracks at problems that I know I could project. I think at the time I got my injury I was mostly doing this third thing.

Andy Bennett wrote:

Climbing places unique stresses on the body. Connnective tissue takes MUCH longer to adapt to these stresses than the rest of your body. If you're like me, your stoke and determination will far outstrip your tendons and ligaments' ability to keep up, and you'll get hurt. Unless you have a solid foundation (talking years here) of other activities that placed very similar demands on your connective tissues that was progressive, I'd recommend taking it slow. Yes there are some mutants who fly from V0 to V9 in a year, but your story seems to indicate that that ain't you. There are a myriad of things to counteract the stresses climbing places on your connective bits, from sub maximal hangboard routines and rice bucket training to contrast baths and massage. This site is a wealth of information if you take some time to wade through it. Good luck!

I will be taking it more slowly when I come back to climbing once these pesky wrist tendons (FCU, ECU) calm down again, and it's been 4 weeks since I injured them, so I was thinking about dipping my toes in the water again soon. And I agree it's totally plausible that I might be throwing myself at it too hard—I've been out of it for so long at this point too, I'd imagine it's possible my muscles are too strong for my tendons. 

It might sound wild, but doing sub-bodyweight hang board stuff is how I got one of my funky finger problems! That should be in the timeline somewhere. It's the primary reason I suspect something else may be at play here.

Marshall W wrote:

I had a similar experience at about the same point in my climbing years ago. For me, I had flexor and pulley tendon issues that persisted for a while and was constantly injuring them.

I went to a climbing specific PT in Boulder who did some testing. The gist of the diagnosis was that there was so much fascia and scar tissue built up in my forearm that the tendons had lost their “stretchiness” and ability to glide normally. I started to use a mini foam roller and wave tool for my forearms which helped immensely. I still have issues here and there but that was a game changer for me.

The other thing that happens with pulleys is the scaring and pain last a long time. Even if the tendon is intact, residual pain can last for months. Scraping scar tissue and stretching can help reduce the pain but discomfort tends to stick around for a while.

Hope you get it figured out!

Let me say that I find Marshall's suggestion about scar tissue extremely attractive—it's an explanation that would dovetail perfectly with my MRI being largely negative but with my tendon problems persisting, and would explain those problems as a sort of referred pain thing.

Marshall W wrote:

I had a similar experience at about the same point in my climbing years ago. For me, I had flexor and pulley tendon issues that persisted for a while and was constantly injuring them.

I went to a climbing specific PT in Boulder who did some testing. The gist of the diagnosis was that there was so much fascia and scar tissue built up in my forearm that the tendons had lost their “stretchiness” and ability to glide normally. I started to use a mini foam roller and wave tool for my forearms which helped immensely. I still have issues here and there but that was a game changer for me.

The other thing that happens with pulleys is the scaring and pain last a long time. Even if the tendon is intact, residual pain can last for months. Scraping scar tissue and stretching can help reduce the pain but discomfort tends to stick around for a while.

Hope you get it figured out!

I'm going to try this out too. It's been a year since I did the A2 on my pinky and I still have pain/crunchiness even though I'm fairly sure it's rehabbed.

I saw the title of this post and my very first thought is that the cause was a drug side effect.  In my work (in the pharma industry) I've run across issues with tendon rupture relating to antibiotics, so I immediately thought of this as a cause.

Sounds like you too have identified a potential drug-related connection here.  

A "low risk" of tendon rupture in the general population would likely be much higher in a climber who regularly stresses his tendons.  

I'd be willing to bet money that this was the cause of your initial problems.  

Dave MacLeod wrote about a period of frequent tendon injuries he went through in his book 9 out of 10 Climbers. I imagine his other book, about injuries specifically, would go into more depth on it.

Kai Larson wrote:

I saw the title of this post and my very first thought is that the cause was a drug side effect.  In my work (in the pharma industry) I've run across issues with tendon rupture relating to antibiotics, so I immediately thought of this as a cause.

Sounds like you too have identified a potential drug-related connection here.  

A "low risk" of tendon rupture in the general population would likely be much higher in a climber who regularly stresses his tendons.  

I'd be willing to bet money that this was the cause of your initial problems.  

I've thrown multiple levers at once so it's unclear to me which one is working or not working, but I seem to be having fewer problems bouldering now. I have some issues where marrow edema showed up on my MRI in my left middle finger and still have some issues in my right ring finger, but the former is what I would expect and the latter is a sort of intermittent thing that bothers me some days and doesn't other days. I'm still being cautious, but, tentatively, the combination of changes I've made seem to be mostly working. I plan to post an update to this later when I'm confident enough to say this without any reservations—at the moment I'm still wary.

J C wrote:

Dave MacLeod wrote about a period of frequent tendon injuries he went through in his book 9 out of 10 Climbers. I imagine his other book, about injuries specifically, would go into more depth on it.

I'll definitely check it out! By his other book, you must mean Make or Break, is that right?

Are you taking some form of steroid?  I was chatting with another climber yesterday and the conversation touched on steroid use and how it can adversely decrease tensile strength of tendon. Just a thought.

Steroid use, or even prednisone(for poison ivy) weakens tendons over years, so it seems unlikely that would be the culprit. 

You should read both of Dave's books, the treatment for tendon injury is not rest, it's active recovery. I've rehabbed two complete pulley tears using his methods. Make sure you're eating more than enough protein and nutrients for your activity level.

Have you been tested for Lyme?