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elbow injury confusion

Original Post
kenr · · Unknown Hometown · Joined Oct 2010 · Points: 16,608

Seems like there's a diversity of opinion about the causes and treatments of pain around the medial epicondyle -- the usual location for climbers to feel it, though it's popularly called "golfer's elbow".

When I look at respected mainstream web medical info sources (as opposed to climber-specific websites and forums) I find lots of ideas like this:

Causes of medial epicondyle pain:

  • strain of wrist and finger flexors, often related to gripping, often repetitive.
  • pronator muscle/tendon strain is possible, but not frequent.

not mentioned in mainstream:
  • imbalance of antagonists: e.g. extensor versus flexor, supinator versus pronator.
  • tendon strength versus muscle strength

Treatment:
  • main idea is to (safely) restore strengh and range-of-motion of wrist flexor and finger flexors.
The strengthening needs to be carefully progressive, like first static isometric, then eccentric only -- and then several sources advocate concentric strength training once the flexors are ready for it.

little mentioned:
  • strengthening or stretching of wrist supinators or pronators.

not mentioned in mainstream:
  • strengthening of antagonists: extensors for wrist or fingers
  • eccentric exercise for the reason of focusing more on tendons rather than muscles. (I suspect rather that eccentric training is advised initially because it's more controllable for avoiding high force intensity at the initiation of the motion).

climber-specific opinions ...
I contrast those mainstream ideas above with climber-specific websites, videos, forums - which often focus on these concerns:
  • extensors as antagonists
  • pronation/supination
  • eccentric exercise as especially appropriate
  • tendon versus muscle

So now I'm starting to wonder if I've been mostly wasting my time carefully performing those reverse wrist curls (antagonists) and wrist pronate/supinate asymmetrically-weighted rotations.

Ken
kenr · · Unknown Hometown · Joined Oct 2010 · Points: 16,608

Since I posted those confusions, I've come across two new climbing-specific publications about elbow injury, one in a recent issue of a climbing magazine, the other in Dave MacLeod's book, Make or Break.

Both offered similar procedures for diagnosis and treatment, and both were much closer to mainstream (non-climbing-specific) sources, and avoided lots of the "old coaching lore" in other climbing-specific websites and publications.

Muscle versus Tendon:
I think I remember the magazine article (but not MacLeod) still holding onto the "old coaching lore" about climber's tendon strength not developing in balance with climber's increasing muscle strength. (No well-controlled scientific study is offered to support this claim).

Some thoughts about this:

  • pain location is sometimes (often?) an unreliable indicator of the location of the actual tissue damage. So possibly in some cases, the climber reports sensation of pain around a tendon attachment point, while most of the damage is actually in one of the muscles.

The possibility of "referred pain" confusion gets especially complicated for "golfers elbow", because there are three different muscles that attach to the medial side elbow bump (wrist flexor, finger non-distal-joint flexors (FDS), and wrist pronator).
. (note that FDS muscles and tendons tend to get load from both Crimp grips and from holding on a Jug).

  • tendon tissue is generally way stronger than muscle tissue. One source I found said that the two "normal" tendons (that attach each end of a muscle to the bones or joints at each of its two ends) can sustain roughly 4 times the force of the muscle they are attaching. So even if a climber develops their muscle 50% or even 100% stronger, there should be plenty of strength in a "normal" tendon. If the tug-of-war between muscle and tendons is a "fair fight".

So Dave MacLeod devotes a lot of careful analysis (and speculation) to how it could be that climber's elbow tendons ever get injured (page 120, with more detail pages 70-72).

  • slow onset. One idea MacLeod offers is that the experienced elbow tendon injury (if it really is a tendon injury) was preceded by longer-term degradation of tendon strength which the climber did not notice.

Coming up with a convincing mechanism for this degradation in otherwise healthy climbers is not obvious. I will only add the idea that most tendons have fewer nerves than muscles. And that perhaps our unconscious mental perception networks have not gotten "practice" in recognizing the neural-firing patterns that accompany tendon damage.

  • unfair fight 1 (range + time). My suggestion (and MacLeod says similar things) is that it's easy to set up situations where a normal attaching tendon is put at an "unfair" disadvantage relative to its muscle. One way is since the muscle has much larger range-of-motion than the tendon, the muscle apply a smaller force through a long range and build up lots of momentum / kinetic energy. Then if that momentum is suddenly ended through a short-distance short-time impact, the force on the tendon in the stopping impact could be much larger than the force on the starting push.
. (and guess what: elbow problems are seen lots in two sports that feature high impacts: gold and tennis).
. (climbers can do it by unexpectedly blowing off a hold)

  • unfair fight 2 (angle): Muscles get to do most of their pulling in roughly a single line. Tendons can get bent and stretched at odd angles, and some layers might even get compressed instead of extended. So you could have a wide gradient of conflicting strain forces over the cross-section of a tendon. So it's easy to guess that a tendon might need a few days or weeks of careful progressive training and recovery+rest cycles to adapt to handle new strange stuff like that. And some climbers' physiology might be much better at handling that strangeness than other climbers.
And that some climbers might not give some tendons time and careful progressive stimulus to achieve that adaptation (especially if they're not experienced at getting or recognizing pain/injury signals from some tendons).

-> This is not about muscles developing faster than tendons. It's about climbers allowing (perhaps Non-developed) muscles to apply "unfair" stresses on a tendon in two different ways (without allowing the tendon any reasonable time to develop to adapt).

Anyway ...
I doubt it's all that important to distinguish whether an elbow injury is muscle versus tendon -- or (likely?) some blend of the two.
What is important is Not putting new impacts or new angles on them too much too soon.

Happy to get corrections or more suggestions or experiences about these confusions and speculations.

Ken
kenr · · Unknown Hometown · Joined Oct 2010 · Points: 16,608

A point where both the magazine article and MacLeod agree (against some mainstream sources) is in recommmending eccentric exercises for rehab.

The magazine article gives a simple reason eccentric (rather than concentric or isometric) which I find unconvincing.

Dave MacLeod in Make or Break is careful to say while many studies have found that eccentric helps with tendon rehab -- that the physiological justification for this is not obvious (page 73). And that the rehab results for using it for elbow injuries not as convincing.

Still he definitely recommends eccentric for rehab of golfers elbow (page 122). I think there's a very understandable reason (page 201) for this choice (but it's not convincing for me).

Anyway some mainstream sources recommend the concentric version of the same exercises that MacLeod and the magazine article offer in eccentric form. And one mainstream source suggests a rehab progression from isometric to eccentric to concentric.

My thoughts:

  • concentric exercise normally includes eccentric contraction (in the phase of recovering the motion to the initial position to start the next concentric contraction).
  • regrowth really happens nearly automatically in a normal healthy athlete's body -- the body really wants to heal, and is designed to regrow -- provided some relevant training stimulus is provided, and re-injury is avoided. So there's no harm in a climber restricting their rehab exercised to eccentric.
  • eccentric seems like a good choice in the early stage of rehab, just because the peak force load is more controllable than concentric (but isometric is even more controllable). So recommending eccentric early helps avoid re-injury. And just seems easier to people unaccustomed to special exercises, so let's then actually get started (which might be the most important thing).
  • placebo effect of doing eccentric might be stronger for some people. Because performing it is different from "normal" exercise, and a bit more complicated -- so feels more "special".
  • myself I did lots of concentric exercises for recovering from my golfer's elbow and it worked just fine. And I did lots more concentric since then to prevent future recurrences, and that worked just fine too.

Glad for corrections and more suggestions and experiences.

Ken
kenr · · Unknown Hometown · Joined Oct 2010 · Points: 16,608

Some important finger flexor and wrist flexor muscles attach to the shared tendon that attaches to the "golfers" medial elbow bump.

The FDS (flexor digitorum supercialis) muscles + tendons are used in all grips, and get special focus in crimping (and also grabbing jugs in a certain size range, or hanging on a pull-up bar, also with some pinch grips). Wrist flexor muscles and tendons get special focus in supporting crimp grips.

It's not that "everything" around fingers + forearm + elbow is connected -- but that some of your specific injured components are connected ... like finger joints with medial elbow bump.

So Yes it's likely that a rehab program to address problems with finger and wrist gripping is going to need to go together with resolving the elbow problem. The new Dave MacLeod book has very helpful specific diagnosis and treatment steps for that.

If you're farther down the road with repeated injury and scar tissue and complicating stuff, likely need to get face-to-face professional diagnosis.

Ken

Rob Gordon · · Hollywood, CA · Joined Feb 2009 · Points: 115

TL:DR

But... I don't care if it makes sense or not, the reverse wrist curls have all but cured my elbow tendonitis. I do them very slowly with no weight and fingers straight. Hold them for five seconds. Do like 30 reps till upper forearms burn.

I say it's the imbalance thing (forearms too big - opposing top of forearm too small) but I don't know if that's true. I just know it works.

Rui Ferreira · · Boulder, CO · Joined Jul 2003 · Points: 903

Not to add more confusion to this topic, but as referenced by Mike Reinold on "Functional Stability Training for the Upper Body" some degree of cervical dysfunction may also result in elbow pain. Research studies show that 54% of subject with C6, C7 radiculopathy had medial elbow pain (Lee, Sports Health, 2010). The results are even more compelling for lateral epycondilitis

71% of subjects with lateral elbow pain had pain in cervicothoracic junction on exam – Berglund: Manual Therapy, 2008

Cervical manipulation increases pain free grip in subjects with lateral epicondylitis – Fernandez, Carnero: Journal of Manipulative Physical Therapy, 2008

Lateral Epicondylitis
•  Reduced grip strength w/ lateral epicondylitis
•  Grip produced 7/10 in pain scale
•  Grip improved with scapular positioning 26kg to 34kg with no pain
•  10 week scapular program reduced pain and increased grip strength to 42kg
 Bhatt: JOSPT,2014

Difficult to conclusively state which is the cause and which is the effect, but addressing cervical dysfunction results in increased grip strength and reduced elbow pain.

Reinold's protocol is to eliminate forward head posture and reduce other alignment issues (thoracic, scapular, etc.), recover kinetic chain mobility up-stream from the elbow in combination with soft tissue work, and then introduce a strengthening program.

On one of the Reinold's lab videos (in Functional Stability Training for the Upper Body), a subject is able to increase grip strength by 15% on the side exhibiting chronic medial elbow pain after a simple forward head posture reduction.

Reinold also distinguishes between three different stages of epycondolitis:
Phase 1:
•  Acute reversible inflammation
•  Minor aching, after heavy activities
•  Sometimes sore initially with activity but “warms up” and feels better
•  Local rehabilitation, NSAID,rehab generally successful

Phase 2:
•  Partial angiofibroblastic invasion
•  Some healing present
•  Pain with activity & after rest helps
•  Rehab promotes healing, gradual strengthening

Phase 3:
•  Extensive angiofibroblastic invasion (absence of inflammatory cells: tendinosis instead of tendonitis)
•  Significant functional defects
•  Pain)during/after activity,night pain
•  Condition is difficult to rehab& treat

This may account why some persons experience relief with some protocols and not others, as it depends whether the condition is acute or chronic and where it is in that time scale.

kenr · · Unknown Hometown · Joined Oct 2010 · Points: 16,608
Rob Gordon wrote:reverse wrist curls have all but cured my elbow tendonitis.
If you mean the usual tendon problem for climbers - the "golfers" medial elbow problem - the muscles that attach are flexors.

Some popularly-linked climber websites and videos (and articles + books) indeed recommended reverse wrist curls -- which strengthen the extensor tendons and muscles (not the flexors). The old theory was that lots of climber non-traumatic injuries were caused by muscle imbalances between primary agonist flexor muscles over-powering the antagonist extensor muscles. So the rehab strategy was to strengthen the antagonist extensors.

But the two most recent climber sources, and most mainstream sources (including another recent 2014 medical journal article) recommend instead training the primary flexor tendons and muscles -- often specifically using normal (non-reverse) wrist curls as a key rehab exercise.

My non-expert guess is that for this kind of elbow problem, most of the medical experts now think that antagonist imbalance is usually not relevant.

So how come the old antagonist strategy works for some climbers? My non-expert guess is ...
(a) A healthy athlete's body wants to heal, and is designed to re-grow tendons and muscles in response to any training stimulus that roughly progressively approximates toward normal use.
(b) Placebo effect really works: If you really believe something will heal you, often that will help healing.
(c) in a few special cases, strengthening the antagonist is actually needed.

Just my guesses.

Ken
Rob Gordon · · Hollywood, CA · Joined Feb 2009 · Points: 115

Actually I think what I have/had is tennis elbow. The outside/top of the elbow pain. Isn't that what most climber's get?

ClimbHunter · · Reno, NV · Joined Nov 2013 · Points: 15

Great post and thanks for sharing your findings. It's hard to dig up climbing-specific info on this topic, and I feel like so many climbers experience it at one time or another. I don't have much research or personal expertise to back my 2 points below, but this has been my experience with elbow issues:

- I noticed significant improvements in recovery when I started using a 'wide-grip' when doing wrist/forearm exercises instead of the 'closed' grip of an empty hand or small-diameter dumbbell handle. Currently I use a weighted rubberized ball (~softball sized) or a 3" pvc pipe to do wrist/forearm exercises. To my eye this more closely resembles my grip position while climbing. I also found that using an antagonist finger trainer to strengthen the 'opening' finger muscles (I use the GripSaver Plus by Metolius) seems to activate areas in my elbow as well.

- Maybe it's the 'chicken-wing'? After a year of wrist & elbow joint pain on the left (weak) side and unsatisfactory results from wrist/forearm exercises, I was about ready to just 'wait for it to heal'. Then I dislocated my right (strong) shoulder kayaking, and decided to work out both sides during recovery. I was surprised that my left shoulder was still weaker than my recently-injured right shoulder. Once I returned to climbing after getting both shoulders back in shape, I found that my left-side elbow issues were almost non-existent. Maybe it was just the time off, but my theory is that my weak shoulder strength was putting undue stress/torque on my elbow. This imbalance scenario may not apply to most people, but it was certainly eye-opening to me!

On a related note, I have had multiple people (climbers and non-climbers) swear by joint supplements like 'Glucosamine Chondroitin' and others, citing that the body has a harder time repairing cartilage and tendons than muscle. Can anyone confirm or derail this train of thought?

sachimcfarland · · Edenbridge, Kent · Joined Nov 2014 · Points: 0

I think the experiences of people here and elsewhere above all demonstrate there really isn't a one-size fits all approach to overcoming 'overuse' injuries in the limbs. The most important thing is to try all approaches (properly) and do what works.

I had/have severe tennis elbow in both arms, especially the right, and also persistent soreness around the medial epicondyle in my left arm (is it possible to have golfers and tennis elbow in the same arm? who knows!). I tried stretching exercises, then stretching exercises alongside massage with a lacrosse ball but this didn't work. I then tried massage, stretching and eccentric reverse wrist curls (lowering the weight from the 'up' position) and it STILL didn't work. My forearms felt like a mass of knotted up tissue and the muscle and tendon areas were rock hard to the touch.

I've basically cured my tennis elbow doing the Tyler Twist exercise with a green flex bar and massive amounts of extremely painful massage with an Armaid (thing is seriously worth the steep cost IMHO). Stretching doesn't really seem to 'do' anything and I don't bother anymore. Likewise other forms of massage with lacrosse balls, hard surfaces, thumbs etc. These can't seem to apply enough pressure to the exact areas I need.

IMHO the Tyler Twist exercises were the thing that did it. Initially I was only doing the exercises for my right arm as it was the worst and noticed really quick results. Right arm was completely pain-free most of the time soon after starting wheras left still hurt like heck. I've been doing both my arms for a few weeks now and I feel like it's a miracle. I was thinking I was going to have to give up climbing completely the pain was so bad at one point.

On the glucosamine thing I'm not sure I would bother. I think studies only show benefit for people with osteoarthritis, and no benefit for other conditions. Dave Mac talks about it in his book a bit and thinks it's a waste of money. I tried taking it seeing if it would help with finger recovery/elbow recovery/any effect and I didn't notice any at all. Snake oil in my opinion.

Rui Ferreira · · Boulder, CO · Joined Jul 2003 · Points: 903

Not to belabor the point, but even if therapy is successful in treating the symptoms of elbow pain, you still should investigate for potential alignment and posture issues in the kinetic chain (shoulder, scapula, cervical/thoracic spine) in order to prevent reoccurrence of those symptoms.

kenr · · Unknown Hometown · Joined Oct 2010 · Points: 16,608
Rob Gordon wrote:Actually I think what I have/had is tennis elbow. The outside/top of the elbow pain. Isn't that what most climber's get?
Well that would explain simply why doing reverse wrist curls helped. It fits with mainstream recommendations for that injury.

But climbers mostly get golfers elbow.
kenr · · Unknown Hometown · Joined Oct 2010 · Points: 16,608

Rui Ferreira wrote:
> Reinold also distinguishes between three different stages of epycondolitis:
> ... ...
> This may account why some persons experience relief with some protocols
> and not others, as it depends whether the condition is acute or chronic
> and where it is in that time scale.

Good point.
Yet another complicating factor.
Which makes it tricky to know what to do with the experiences we share on this forum.

Also makes it more difficult and expensive for researchers to perform careful well-controlled scientific studies on these kinds of injury.
And more tricky for us when reading a nice-sounding journal article about a supposedly well-controlled study -- to know how carefully selected the subjects were regarding stage of injury and other key assumptions.

Ken

kenr · · Unknown Hometown · Joined Oct 2010 · Points: 16,608

Eccentric-contraction exercises for Rehab raises another complication:

Since the normal way to perform a Concentric-contraction exercise includes an equal number of Eccentric-contraction moves (in order to recover the body parts and resistance mechanism back to their starting position for the next Concentric repetition) -- then claiming that Eccentric is the best way
would imply that Concentric moves are somethat harmful to rebuilding healthy tendon tissue.

But if Concentric moves are harmful, that has big lifestyle implications for the rehab period, because all kinds of normal daily activities (notably grasping) make Concentric moves with muscles + tendons that attach to the Medial elbow bump. And of course almost any sort of active climbing normally includes Concentric finger-flexor contractions attaching to the Medial elbow bump -- (which is likely how the elbow injury got started).

So perhaps there's something odd about somebody recommending only Eccentric exercises for "climbers" medial elbow pain rehab, but not also recommending wearing a special splint or brace to prevent Concentric usage in normal life, or at least not also recommending completely stopping climbing.

Just an idea that hit me. Likely needs to be corrected or at least modified.

Ken

SM Ryan · · Unknown Hometown · Joined Jul 2008 · Points: 1,090

Ken
I have had elbow issues and it was prescribed to me to assist the weight through the concentric portion of the exercise with the other hand.

I am too lazy to find the actual article, but here is reference

“GAIT (Glucosamine/chondroitin Arthritis Intervention Trial) report” funded by the National Institutes of Health in 2006. Basically, the prospective, randomized trial reported that at 2-year follow-up, there was no difference in joint space narrowing among patients with osteoarthritis who received glucosamine chloride alone, took glucosamine chloride with chondroitin sulfate, or took a placebo.

aaos.org/news/aaosnow/sep12…
aaos.org/news/aaosnow/sep12…

Caden S · · Unknown Hometown · Joined Jun 2014 · Points: 0

You're right that there's not much said about strenghtening the finger / wrists and that this is essential (but must be done progressively). I posted an article I found a couple months ago on another thread here which talks about how to treat climber's elbow , but like you said Ken, i think that it is geared more towards standard golfers elbow. i've tried just about everything over the past few months, which makes it hard to say what is working and what is useless. i feel like the eccentric wrist curls and reverse wrist curls do help, along with the supplements, but the number one thing i've found to be helpful is myofascial (spelling?) release.

sachimcfarland · · Edenbridge, Kent · Joined Nov 2014 · Points: 0
Caden S wrote:You're right that there's not much said about strenghtening the finger / wrists and that this is essential (but must be done progressively). I posted an article I found a couple months ago on another thread here which talks about how to treat climber's elbow , but like you said Ken, i think that it is geared more towards standard golfers elbow. i've tried just about everything over the past few months, which makes it hard to say what is working and what is useless. i feel like the eccentric wrist curls and reverse wrist curls do help, along with the supplements, but the number one thing i've found to be helpful is myofascial (spelling?) release.
I had the same experience with tennis elbow. Nothing really worked till I started doing all the fancy massage techniques along with the other exercises
Guideline #1: Don't be a jerk.

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