That Aching Elbow!

Managing and preventing one of climbing's most common afflictions

 

An undercling move you tried again and again and again. A deep ache in both elbows that one day became sharp and stayed that way for three days, then came right back after a week off.

It’s Sendtember and you’re … hosed. Elbow injuries are near ubiquitous among climbers of every level: the most common injuries after fingers and shoulders. Despite the names “golfer’s elbow” for inside-elbow pain and “tennis elbow” for outside-elbow pain, as a climber you are at risk when cranking on slopers or throwing for edges.

Yet, fear not if you’re one of the many suffering nagging elbow pain. The road to recovery will require active attention, but you can be back on your proj soon enough.


Symptoms

Elbow tendon pain usually appears as tenderness at the bony attachment at the elbow. For golfer’s elbow the pain is on the inside of the elbow. Pain can occur when you bend your wrist down or up. It can also hurt when you engage the muscles that attach to the bony site. For the inside of the elbow, those muscles are the wrist and finger flexors and pronator muscles. Climbing moves that may be aggravating include gastons, slopers, compressions, or dynamic moves to edges.

For tennis elbow, tenderness occurs on the outside of the elbow, right above the crease. You may feel pain while engaging the wrist, finger extensors or supinator muscles against resistance. Triggers may include sidepulls and crimping. In some cases, pain arises during or after climbing but may improve after light climbing. When the injury gets bad, you may feel pain when simply lifting a pot of water.


Tendinitis Vs Tendinosis

Tendinitis usually occurs from overuse or sudden trauma, causing an inflammatory response. I tend to see this reaction with climbers “overdoing it” by lack of rest and increasing climbing/training volume or intensity too quickly. Overuse can also be due to abnormal movement, not just doing too much. Tendinitis is more likely to occur in the younger population, in their 20s and below, than those above 30.

Tendinosis, on the other hand, is a chronic, degenerative condition that occurs from recurring bouts of repetitive (as opposed to traumatic) stress and inflammation. Tendinosis affects climbers in their 30s and above. It is important to differentiate between the two as each behaves differently and the treatments for each differ. With tendinitis, pain and symptoms usually increase when you are climbing, and will respond well to anti-inflammatory measures. With tendinosis, symptoms may improve during climbing but can worsen after climbing, depending on the session.


Treatment

Before starting any treatment program, make sure to consult your physician or physical therapist for a proper diagnosis.


For golfer’s elbow, do the “hammer” exercise by loading a dumbbell with a weight on just one side, then lower the weight until your palm faces up, then raise the weight. You can substitute an iron skillet for the dumbbell.

Tendinitis—Rest and Reload

For TENDINITIS, rehab initially includes short-term rest, activity modification, and anti-inflammatory measures. As physios, we first aim to reduce pain, and the best way is to manage the load by avoiding aggressive stretching and compression to the tendon, meaning no dynamic moves or bearing down on slopers and crimps. Resting for 72 hours after painful activities lets the body work through the inflammatory phase.

We then want to introduce submaximal tendon loading through isometric contractions, meaning to create muscle contractions without movement (e.g. through deadhangs). These tendon-loading exercises can be performed in a mid range (meaning neither in a fully stretched nor fully contracted position) using free weights or resistance bands. Aim for holding the contraction for 45 seconds and repeat five times, two to three times per day. Light isometrics have even been shown to reduce pain.

Once pain has settled during even normal daily activities, progress to isotonic exercises (moving through a range of motion) that produce minimal  pain. Isotonic exercises include eccentric-strengthening exercises (slowly lowering weight) with moderate resistance for the wrist and finger flexors and pronator teres, performing three sets of 10 to 15 reps, four to five times per week. Exercises for golfer’s elbow include wrist and finger curls and a “hammer” exercise, rotating a hammer or dumbbell with weight on just one side until the palm is facing up, (Figures 1 and 2) for the pronator teres (the muscle that turns your palm down). For tennis elbow, therapy would include finger and wrist extensions with a resistance band and dumbbells, and the hammer exercise for the supinator (the muscle that turns your palm up).


Tendinosis—Load to Remodel

In treatment for tendinosis, we can skip the anti-inflammatory measures due to the absence of inflammation. In fact, we want to create a little inflammation to stimulate a healing response and remodel disorganized tissue. I recommend slow-resistance eccentric training. Eccentric
exercises have been shown to reduce neovascularization, which is new blood-vessel and nerve-ending growth that can increase pain sensitivity.

Eccentric exercises also promote collagen synthesis to aid in remodeling. Unlike with tendinitis, we want to use heavier loads that stimulate a familiar pain level. I usually recommend three to five out of 10 pain level. As above, we use the wrist and finger curls, pronator hammer exercises with free weights or resistance bands for golfer’s elbow. For tennis elbow, perform the wrist and finger extensions and supinator hammer exercises.

Emphasize the exercises that recreate the familiar pain the most. Gradually progress from three to four sets of 15 repetitions, ideally at 70 percent of one repetition maximum (ORM), three times per week, up to 85 percent ORM for three to four sets of six to eight reps, three times per week. I do not recommend trying to perform a one-repetition maximum if you are dealing with an injury. Start with a lighter weight, then gradually add more, staying within the recommended pain tolerance.

In your climbing, initially avoid excessive loading, meaning no campusing, manteling or big moves to bad holds. For tendinitis, you should definitely rest from climbing until daily activities and easy climbing become pain free. To begin more intense climbing would depend on your tolerance for your current climbing level. Your current climbing intensity and volume need to be pain free before you can progress. Never increase volume and intensity simultaneously, as this is a recipe for disaster. For tendinosis, it can be a tricky balance.

You can continue climbing as long as you avoid the moves previously mentioned. However, your climbing progression depends on meeting the criteria set by your PT, which includes being able to perform certain exercises correctly and climbing at a modified level without pain. Be patient with tendinosis. Remodeling may take up to three to four months. Consult your local PT to discuss these progressions.

Feature Image by Jan Novak


Also Read

Dodgy Elbows

  • Zack DiCristino is the lead physical therapist the for USA Climbing Team. He travels to both Open and Youth competitions to ensure the safety and well being athletes. DiCristino currently lives in Salt Lake City and conducts research on climbing-related injuries.

    • Show Comments

    • M

      Is it also possible that these symptoms can be referred from the shoulder or thoracic region in some cases? Ive dealt with these symptoms- including numb fingers. Physios have always directed me to do rotational and flexion work on the wrist but I’ve not found it a complete fix. I have started working on my range of motion in shoulders and thoracic and that seems to benefit me more

    • Atene Karauria

      There is no mention for the use of deep muscle massage, on a regular basis, to release the tension in the muscle fibres. With the interconnectedness of the whole body, for conditions like tennis elbow i.e. the muscles from the hands, forearms, upper arms, and the masses of muscle groups in the shoulder complex are ALL affected. Similarly for the legs, with the back and spine linking the two.

      Through regular treatment by releasing the tension in the muscles, the corresponding tendons, and the chronic pain induced, are greatly reduced, and allow healing in the tendon structures.

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