Cover photo by Federico Rimembrana – @fede.ri_91
Preface by Dr. Jared Vagy – The Climbing Doctor
Elbow injuries can start as a mild nagging discomfort and develop into a debilitating pain that makes it difficult to train and climb. They involve a complex differential diagnostic process and can often be challenging to treat. Historically there has been limited research evidence on how best to manage elbow pain. However, there is new evidence now emerging that supports various intervention techniques. Jędrzej has done the hard work for you in this article by reviewing and summarizing the current research on elbow tendinopathy. The article is very comprehensive and goes in-depth into every aspect of the elbow. You will learn the anatomy of the elbow, how to diagnose your elbow pain, and a step-by-step process to treat it. The hope is that you can use this article as a reference to guide you through the rehabilitation process.
Dr. Jared Vagy PT, DPT
Doctor of Physical Therapy
Board Certified Orthopedic Clinical Specialist
Elbow Pain – The Ultimate Guide for Rock Climbers – Quick summary
- Preface by Dr. Jared Vagy – The Climbing Doctor
- Elbow pain for rock climbers – Introduction
- Quick guide to Climber’s Elbow healing
- Injuries in rock climbing
- Anatomy of the elbow
- Symptoms and diagnosis of elbow epicondylitis
- Pathology of elbow tendinopathy
- Tendon healing phases
- Elbow tendinopathy treatments
- Selected manual therapy techniques for elbow pain
- Selected exercises for elbow pain
- Elbow pain for rock climbers – Conclusions
- References
Elbow pain for rock climbers - Introduction
Chronic elbow pain is one of the most common injuries among climbers, yet it is also one of the toughest to heal. I should know - I suffered from elbow epicondylosis for over five years! I was lucky to identify the root cause of my elbow issues and solve them, but many climbers are not as fortunate. The generally available climbing resources provide some information on preventing and healing chronic elbow injuries, but the picture is often incomplete, and the advice is rarely helpful. If applied haphazardly, remedies found in books and on climbing fora can often make things even worse and lead to unnecessary aggravation of the condition.
Because of my long-year struggle, since long I have wanted to write a post about elbow epicondylosis. Recently, I got in touch with Dr. Jared Vagy, who is well recognized in the climbing community as The Climbing Doctor. Jared is an accomplished Doctor of Physical Therapy and a University Professor specializing in climbing injuries [1][2]. He also runs a successful climbing site theclimbingdoctor.com and appeared multiple times on the TrainingBeta podcasts, where among other topics, he thoroughly explained elbow pain causes and treatments [3][4].
I thought it would be an excellent opportunity to team up and write the article together, and Jared very kindly agreed! I hope you will enjoy this post and find it helpful if you are struggling with elbow pain!
Quick Guide to Climber's Elbow healing
Here is a quick step-by-step guide if you are not interested in reading a long article but want to fix your Tennis or Golfer's Elbow pronto.
Phases of the healing process
There are three main phases of the tendon healing process:- Inflammation - lasts about 7 days after the injury. Necessary for the initiation of the healing process
- Formation - takes up to 3 weeks after the injury.
- Remodeling - starts 3 - 6 weeks after the injury, can take up to 1 year.
The challenge is that if your condition is chronic, it might be impossible to tell at which stage of the healing process you currently are. Moreover, different parts of the tendon could be at different healing phases concurrently. There could be places where constant micro-tearing causes inflammation or areas where the formative or remodeling stage was failed, has stagnated and needs a reset. That vicious cycle of inflammation and degeneration makes recovering difficult and needs to be stopped if you want to get better for good.
Understanding the above healing stages is critical because it will let you apply the correct treatment mode at the right time and help you evaluate your progress. You will be able to tell where you currently are and what to expect in the coming weeks.
Step-by-step elbow healing procedure
If tendinosis indeed lies at the root of your elbow pain, which is often best ascertained by a competent physiotherapist, an effective healing strategy is as follows:- Depending on the severity of your condition, either take a week or two or two of complete rest or significantly reduce the training volume and intensity. However, do not take a complete break from climbing for more than a few weeks.
- Perform forearm massage and gentle stretching to start releasing muscle tension (video massage).
- Use Myofascial Release to continue loosening muscle tone and scar tissue adhesions (video MET)
- Apply Deep Transverse Friction techniques (DTF) to break down the degenerated tendon tissue and reinitiate the inflammation phase necessary to trigger tendon healing.
- Focus on stretching to release the muscle tension further and start realigning the collagen fibers.
- After about 2 – 3 weeks, begin to slowly introduce rehabilitation exercises to remodel the tendon and strengthen it by triggering hypertrophy.
- Focus on strengthening the antagonist muscles using appropriate exercises to prevent reoccurrence of the issue.
- Change climbing habits, crimp less, improve technique, climb more dynamically, avoid locking off all the time.
- Warm up thoroughly before each training or climbing session. You will find everything you need to know about why you should warm up in this article [5].
Releasing muscle tone and scar tissue adhesions in the forearms
If your condition is not very severe yet, it might be enough to release the tension in your forearms. Take about two weeks off from climbing. During that time, massage and gently stretch your forearms to relieve any passive tension and eliminate scar tissue adhesions in your muscles and tendons. Start by performing massage once or twice a day for 15 minutes. You may later increase the frequency and administer it multiple times a day or whenever you feel like your forearms are tight.
Once you start noticing improvement after a couple of days, slowly introduce the exercises listed in the exercise section. You may continue the routines if they cause you discomfort but be sure to stop if the pain becomes disabling.
After about two weeks, gradually return to climbing, taking notes of your condition. If it keeps improving, then you are in the clear. Keep massaging and stretching your forearms, and add the strengthening exercises into your daily routine to prevent the issue from reoccurring.
If the pain comes back and keeps getting worse, you might need to stop climbing for a bit longer and focus on your elbow rehabilitation. Do not cheat yourself – you will not climb through this. It will only keep getting worse, and you will never unleash your full climbing potential.
Rest and initiate inflammation to restart the healing process properly
If massage, stretching, and exercising of the forearms do not help, it means that the degenerative process is quite advanced, and you need to take some additional measures to get it fixed. You need to reinitiate the inflammation process to make sure that you restart and resynchronize the healing process in the whole of the affected tendon.
Start by performing gentle massage and stretching to promote blood circulation in the forearm and begin releasing scar tissue adhesions. After about 5 minutes of massage, begin the Deep Transverse Friction procedures (DTF) directly on the painful area. It could be precisely at the center of the epicondyle or in its direct proximity.
You will likely start experiencing a tingly or burning sensation in the massaged area and a temporary flare-up of the condition. That is because you are breaking down the disorganized scar tissue that failed to heal correctly. Do not go too hard - it is enough to start breaking down the scar tissue gently. Continue the DTF procedure for about 10 minutes, alternating it with massage and stretching of the flexor and extensor muscles. You want to address the tendon and muscle tightness in the entire forearm.
As explained before, the DTF administered on the degenerated tendon tissue will likely lead to a brief flare-up, which may initially last a day or two. It is not easy to give one-size-fits-all directions here, but you should generally wait until the aggravation starts to subside before you repeat the DTF. In the meantime, you can perform gentle massage and stretching once or twice a day.
Stretching and loading to remodel the tendon structure
After about five days of DTF, the inflammation process should be in full swing, and the formative phase will begin. It is now time to shift your focus to forearm stretching. Please continue with the DTF procedure as long as it keeps aggravating the epicondyle area, but make sure that you incorporate systematic stretching of the tendons into your program to stimulate proper realignment of the collagen fibers. After another week, you should slowly begin to feel better, and it is likely the right time to introduce some light strengthening exercises into your routine.
After a few weeks of treatment, DTF should stop irritating your tendons. Keep massaging and stretching your forearms, and ensure that you perform the agonist and antagonist strengthening exercises. You may slowly return to climbing activities. Constantly monitor your condition and take a step back if it starts getting worse again. Be patient and enjoy the process.
Injuries in rock climbing
In rock climbing, injuries are frequent, and most of them are related to the upper limbs, repeatedly subjected to very high forces. And so, 42.6% to 71.4% of all climbing injuries occur in the shoulders, elbows, forearms, wrists, and hands - the highest of any anatomic region [6].
After five years of climbing, 89% of people suffer some sort of injury
In 1995, Rooks examined 39 recreational rock climbers to determine the incidence and pattern of injuries sustained after climbing for five years on average. Thirty-five of the studied climbers (89%) suffered at least one significant injury in their career.
- 50% of the injuries involved the hand or wrist.
- Eleven of them (26%) had suffered a major injury from a fall.
- Seven climbers (19%) had a pulley injury.
- Four climbers (11%) had evidence of carpal tunnel syndrome.
- Twenty climbers (50%) had tendinitis in an upper limb!
The above shows that the most common injury pattern seen in climbers seems to be overuse of the upper extremities [7].
| Area of injury | Incidence |
|---|---|
| Shoulders | 17.2 % |
| Elbow epicondylosis | 5.4 % |
| Wrists | 13.1 % |
| Fingers | 52.0 % |
About 25% of my clients report having had elbow pain at some point in their careers.
In climbers, most elbow pain comes from chronic overuse injuries, often referred to as the infamous Climber’s Elbow, another name for epicondylitis or epicondylosis. And while traumatic injuries are usually easily managed, chronic elbow injuries tend to persist for years. I got particularly interested in elbow pain because I used to suffer from climbers’ elbow myself. And while I sustained an entire plethora of injuries during my climbing career, including fingers and shoulders, most of them would subside after a while. However, that pesky elbow pain would not go away!
Many articles and resources are available on the web on dealing with elbow issues, but very few are reliable and helpful. It is tough to understand why specific exercises are recommended and what results to expect. People end up randomly trying different treatment routines, unable to evaluate if they are improving. Their condition often worsens because they chose the wrong exercises or could not get the volume and intensity right.
In fact, despite actively looking for information on elbow pain treatments, it took me five long years before I finally resolved my issue. By that time, I had the Golfer’s Elbow in both my arms and the beginnings of the Tennis Elbow in my right arm. I think the main reason it is so difficult to deal with elbow pain is that it is a rather complex condition, and it may have a variety of underlying causes. However, in climbers, it is usually a chronic degenerative state of the tendons attaching to the lateral or medial epicondyle. Still, even if the issue is correctly diagnosed as tendinosis, it may have various causes, including:
- Failed healing process
- Tight/weak/strong agonist muscles
- Tight/weak/strong antagonist muscles
- Cervical and thoracic spine issues (C6 – C7)
- Ulnar nerve entrapment
- Poor movement patterns
Crazy right? No wonder it is so difficult to find a one size fits all therapy! In this article, we will examine elbow epicondylosis in detail. Still, it is essential to realize that elbow pain causes may be diverse. When in doubt, it is best to be diagnosed by a specialist and not waste time on treatment strategies that might turn out unhelpful at best and harmful at worst.
Anatomy of the elbow
To understand the nature of elbow pain, we need to first talk a bit about the anatomy of the elbow joint and the tendon structure around it. The elbow is a complex hinge joint formed between the distal end of the humerus in the upper arm and the proximal ends of the ulna and radius in the forearm [11]. The humerus ends with two protrusions, called the medial and lateral epicondyle. These bony knobs are where the tendons of the forearm muscles attach and where the pain is often located (see Figure 1).
Figure 1: Bone structure around the elbow joint.
The ulna extends past the humerus to form the tip of the elbow, known as the olecranon. The olecranon is where the tendons of the triceps attach, and if we are dealing with triceps tendinopathy, this area can also be painful and tender (see Figure 2).
Medial side of the epicondyle
On the medial (internal) side, five muscles are attaching to the epicondyle (see Figure 2).
Figure 2: The five muscles attaching to the medial epicondyle.
The tendons of these five muscles form the so-called flexor-pronator mass, and they attach to the medial epicondyle at the sites marked in Figure 3.
Figure 3: Origins of the flexor-pronator mass tendons.
Flexor Carpi Ulnaris (FCU)
Actions: Flexion and adduction of the wrist
Exercise: Wrist Curls, stretching, manual therapy
The FCU is the big muscle on the internal surface of the forearm. It is involved in wrist flexion and adduction, which means moving the wrist towards the pinkie side (see Figure 2).
For climbers, the tendon origin of the FCU muscle can cause many issues since it is highly involved in crimping. If you are experiencing medial elbow pain and tend to crimp a lot, you might want to focus on the FCU muscle and its origin. You should also consider climbing more with the open hand grip and see if that relieves the symptoms.
Pronator Teres (PT)
Actions: Pronation of the forearm
Exercise: Internal Hammer Rotations, stretching
The function of the pronator teres is to rotate the forearm, so the palm faces down (see Figure 2). This muscle is highly loaded when you turn the inside of your hand towards the wall. That means pretty much all of the time when you are climbing. If you are experiencing pain when shaking someone’s hand, trying to rotate your palm inwards, you know that the PT is likely one of the muscles contributing to your condition.
Unfortunately, direct massage of the PT can be tricky because of the median nerve piercing through the belly of the muscle (see Figure 2). To some limited extent, a tight PT can be released through stretching, but any issues are usually addressed by eccentric exercises, such as Internal Hammer Rotations.
Flexor Digitorum Superficialis (FDS)
Actions: Flexes the metacarpophalangeal joints and proximal interphalangeal joints at the four fingers. It also flexes the wrist.
Exercise: Resisted Finger Extensions (antagonist training), stretching
The FDS is typically not addressed when discussing medial epicondylitis, yet Jared finds it a common cause of elbow pain in rock climbers. The FDS is the muscle primarily responsible for crimping as it flexes the interphalangeal joints. Since one of its two origins is part of the flexor-pronator mass, it may heavily contribute to the condition (see Figure 2). The FDS splits into four tendons at the wrist. The tendons travel through the carpal tunnel and attach to the middle phalanges of the four fingers.
Since the FDS is hidden under the muscles of the anterior superficial compartment of the forearm, it is difficult to massage directly, and tightness can be released mainly through stretching.
Flexor Carpi Radialis (FCR)
Actions: Flexion and abduction of the wrist
Exercise: Wrist Curls, stretching, manual therapy
The FCR is another big muscle that can be involved in medial epicondylosis (see Figure 2). It is engaged in wrist flexion and abduction, which means moving the wrist towards the thumb side. The FCR can be easily massaged and stretched to relieve excess tension caused by scar tissue adhesions.
Palmaris Longus (PL)
Actions: Flexion of the wrist
Exercise: Wrist Curls, stretching, manual therapy
The PL muscle is a funny one, it has no impact on grip strength, and on average, 15% of the population do not even have it. Nonetheless, it does originate at the medial epicondyle and can potentially contribute to Golfer’s Elbow. The PL is located between the FCU and the FCR, and it can be released and exercised together with the other two muscles (see Figure 2).
Figure 4: Muscles attaching to the lateral epicondyle. ECRL removed to reveal the supinator (left), ECRL shown (right).
The sites of tendon attachments to the lateral epicondyle are marked in Figure 5.
Figure 5: Attachments of the muscles around the lateral epicondyle.
Actions: Extension and abduction of the wrist
Exercise: Reverse Wrist Curls, stretching, manual therapy
The ECRB muscle is situated on the lateral side of the forearm. Its function is to produce abduction and extension of the wrist - see Figure 4. The ECRB is the primary muscle associated with lateral elbow tendinopathy [12]. It can easily be massaged, stretched, and released through manual therapy.
Actions: Extends medial four fingers at the MCP and IP joints.
Exercise: Resisted Finger Extensions, stretching, manual therapy
The EDC is the primary extensor of the fingers, and it is the most common secondary cause of LET [12]. Similar to the ECRB, the EDC can be easily massaged, stretched, and released - see Figure 4.
Actions: Supinates the forearm
Exercise: External Hammer Rotations
The supinator is impossible to access directly. It lies in the deep compartment of the forearm, beneath the brachioradialis and the extensor muscles - see Figure 4 (left). According to recent research, the supinator is one of the significant contributors to LET. Strengthening of the supinator is an essential aspect of many LET treatment programs [13].
The supinator cannot be massaged directly and is not easy to stretch. The best way to address issues related to the supinator is exercise.
Actions: Extension and abduction of the wrist
Exercise: Reverse Wrist Curls, stretching, manual therapy
Similar to the ECRB, the function of the extensor carpi radialis longus is to produce abduction and extension of the wrist. The muscle is situated on the lateral side of the forearm, just next to the brachioradialis and above the supinator - see Figure 4 (right). Although it does not attach directly to the lateral epicondyle, the tendon of the ECRL passes above the origin of the ECRB, and scar tissue adhesions between the two tendons may form [14]. The ECRL can easily be massaged, stretched, and released through manual therapy together with the ECRB.
Anconeus
Actions: Extends and stabilizes the elbow joint and abducts the ulna during pronation of the forearm.
The anconeus is another muscle attaching to the lateral epicondyle – see Figure 4. Although it is rare, it may be a site of pain and discomfort. If so, it is possible to release it using the Press-and-Stretch technique, as explained in the manual therapy section.
Extensor Digiti Minimi (EDM)
Actions: Extends the little finger and contributes to extension at the wrist
Exercise: Reverse Wrist Curls, Resisted Finger Extensions, manual therapy
The EDM muscle is rarely listed as a contributor to elbow pain. That is likely because it is only responsible for extending the little finger and supporting wrist extension. Nonetheless, it can be easily massaged, stretched, and strengthened together with the other extensor muscles – see Figure 4.
Extensor Carpi Ulnaris (ECU)
Actions: Extension and adduction of the wrist
Exercise: Reverse Wrist Curls, stretching, manual therapy
Although attached to the lateral epicondyle, the ECU goes along mainly along the medial side of the elbow – see Figure 4. It is rarely listed as a factor contributing to lateral epicondylosis. It can be easily accessed for stretching and manual therapy, as it lies on the surface of the forearm, between the EDM and FCU muscles.
Anterior side of the elbow
Brachialis, Brachioradialis, Biceps BrachiiActions: Flexion of the elbow joint
Exercise: Resistance Exercises, stretching, manual therapy
The front of the elbow can also become painful due to tendon degeneration caused by repetitive flexion while in the pronated position. Tenderness and discomfort can be caused by tendinosis in the attachments of one of the three elbow flexor muscles, the biceps brachii, the brachioradialis, or the brachialis (see Figure 6). The brachialis is particularly predisposed to injury, as it is practically isolated when you bend your elbow with the palm facing the rock wall).
Brachialis tendinopathy is a lengthy subject in itself, which Kurt Vo has thoroughly addressed in his post [15]. Since problems in the surrounding muscles can contribute to lateral and medial tendinopathy, it is always good to perform massage, stretch and strengthen the elbow flexors, as explained in Kurt's article.
Figure 6: The three elbow flexor muscles.
Posterior side of the elbow - olecranon of the ulna
Triceps Brachii (TB)Actions: Extension of the elbow joint
Exercise: Resistance Band Extensions, manual therapy
Although it is not very common, elbow pain can be located at the posterior (back) side of the elbow, an area which is known as the olecranon. The olecranon is the spot where the triceps tendons attach to the ulna (see Figure 3 and Figure 4). Excess tension in the triceps or weakness compared to the biceps can lead to triceps tendinopathy and contribute to medial and lateral epicondylosis.
The triceps can be released by manual therapy, but you need to be careful not to press on the ulnar nerve, which runs through the cubital tunnel and is very vulnerable in this area (see Figure 7). Eccentric strengthening of the triceps muscle and tendon can be done using resistance band exercises, as explained in the exercise section and by Jared in his article [16].
Figure 7: The arrangement of muscles and nerves around the elbow joint.
Ulnar nerve
The ulnar nerve runs unprotected along the ulnar bone. It might become compressed, entrapped, and irritated as it passes through the elbow, particularly in the area between the two heads of the flexor carpi ulnaris muscle (see Figure 7). The nerve might become pinched as the surrounding structures swell because of repetitive strain and overuse.
When at rest, the condition often manifests itself by numbness and tingling in your ring and pinky finger, weak grip, and medial elbow pain. In some severe cases, it might even lead to atrophy of some of the muscles. The condition is further aggravated during climbing when trying to grip hard.
Ulnar nerve entrapment is typically treated with physical therapy, which involves unloading and mobility exercises. If physical therapy fails, doctors may resort to surgery. If you are interested in more details regarding ulnar nerve entrapment, Derrick discussed the topic in detail on theclimbingdoctor.com [17].
Median Nerve
The median nerve travels along the inner side of the forearm, through the pronator teres, between FDS and the FDP muscle, and enters the carpal tunnel in the wrist (see Figure 2). If the wrist is repetitively flexed, the median nerve can become compressed underneath the carpal tunnel tendons, causing numbness, pain, and weakness in the hand. Movements on slopers, underclings, and sidepulls pose a particular risk of triggering issues with the median nerve. All these movements flex the wrist into extreme positions and can increase the pressure in the carpal tunnel.
The carpal tunnel syndrome symptoms include pain in the front of the wrist, numbness and tingling in the fingers, increasing at night while sleeping, and weakness in the hand [18]. As Jared explained in his article, the issues related to nerves in the upper body are often treated using the so-called nerve glides [19].
Radial Nerve
The posterior interosseous nerve (PIN), also often referred to as the radial nerve, passes through a space located behind the radius bone in the proximity of the elbow, called the radial tunnel [20]. The tunnel is formed on the lateral side by the space between the brachioradialis (BR), the extensor carpi radialis longus (ECRL), and the extensor carpi radialis brevis (ECRB) muscles, and on the medial side by the biceps tendon and the brachialis. The tunnel's floor is formed by the capsule of the radiocapitellar joint [21][22].
Radial tunnel syndrome (RTS) is a painful condition that is presumed to be caused by PIN compression. Patients with RTS usually feel pain along the radius bone, close to the elbow. The pain may radiate up and down, and it tends to increase as the forearm is rotated [22]. The pain may lead to muscle weakness, but the condition is not associated with specific muscle dysfunction or denervation [23]. There are also no sensory symptoms associated with RTS.
As the PIN crosses the elbow, it passes beneath several structures which may cause excessive compression, namely the [24][25][26]:
- edge of the supinator (also known as the arcade of Frohse)
- edge of the extensor carpi radialis brevis
- radial recurrent blood vessels
- superficial layer of the supinator muscle
The arcade of Frohse is the most frequent site of entrapment of the PIN, responsible for up to 80% of cases [26].
Passive stretching of the supinator muscle significantly increases the pressure inside the radial tunnel [27]. Erak and colleagues found that the pressure inside the radial tunnel increased when the wrist was moved from neutral to a flexion-pronation position. That increase in pressure was reduced by lengthening the supinator. However, lengthening the extensor carpi radialis brevis or the extensor digitorum communis had no effect [28].
Conservative treatment of the RTS may include low-intensity ultrasound, steroid injections, cryotherapy, pain-free stretching, muscle strengthening, and improvement of movement patterns. In addition, the patients should avoid prolonged elbow extension with forearm pronation and wrist flexion [29][30].
If conservative treatment fails to relieve the symptoms, then surgical treatment is required, which is in general considered effective. However, many investigators suggest caution before proceeding with surgical intervention, and as always, it should be regarded as a last resort [31][32].
Symptoms and diagnosis of elbow epicondylitis
I'm sure many of you know the feeling. It starts with a bit of itching and irritation that goes away after a few minutes of climbing, only to return with a vengeance as soon as you cool down and manifest itself the following morning with a feeling of stiffness, pain, and tenderness around the bony elbow protrusion called the epicondyle (see Figure 1).
I remember once overhearing a conversation at a climbing gym, where a client told his coach that he had chronic pain and stiffness in his elbows and was asking for advice. The coach just shrugged his shoulders and said to him that he could probably climb through it. That shows that the knowledge of elbow injuries and how to heal them is still scarce in the climbing community.
The signs and symptoms of elbow epicondylitis are clear, and the diagnosis is relatively straightforward, but no ideal treatment has emerged to date. Many conservative therapies have been used, and over forty different methods have been reported in the literature [33]. These treatments have various theoretical mechanisms of action, but all aim at reducing pain and improving elbow function.
The variety of treatment options suggests that the optimal treatment strategy is not known.
The elbow is a complex joint designed to withstand a wide range of dynamic forces. In terms of location, elbow pain can generally be classified as anterior, medial, lateral, or posterior. Lateral and medial epicondylitis are two of the more common diagnoses. Patients have pain and tenderness over the affected tendon, aggravated by specific movements [34].
For climbers, the condition can be particularly debilitating. Epicondylosis not only causes pain but also manifests itself by the weakness of the entire kinetic chain, including grip, wrists, and shoulders. In 2007 British researchers found that compared to the control (C) group, the Tennis Tennislbow affected group (TE) experienced:
- 25% weaker grip strength
- 25 - 35% lower strength in all shoulder movements
- 30% weaker wrist flexion and extension
- 36% weaker knuckle (metacarpophalangeal) joint flexion (but not extension)
The sum of all upper limb strength measurements in the affected limbs was reduced by about 30% in the Tennis Elbow group
Figure 8: Total upper limb strength (¼ sum of all upper limb strength measurements) in affected (dominant) and unaffected (nondominant) limbs shown as mean SEM in the TE and C groups. Total upper limb strength is reduced ( p<0.05) in TE on the affected side [35].
Interestingly, Alizadehkhaiyat and colleagues found that the extensor carpi radialis (ECR) muscle activity was significantly reduced in the TE group. They suggested that restoration of normal ECR function should be a treatment goal in Tennis Elbow rehabilitation.
Diagnosis of Tennis Elbow (LET - lateral elbow epicondylitis)
In Tennis Elbow, the most commonly affected structure is the origin of the extensor carpi radialis brevis (ECRB) [36]. In about 50% of the cases, it also involves the EDC (extensor digitorum communis). Sometimes pathological changes are seen on the undersurface of the ECRL (extensor carpi radialis longus) [37]. Finally, it has been shown that strengthening the supinator enhances recovery [13][38].
To diagnose Tennis Elbow, a therapist will usually try to reproduce elbow pain by performing the following tests:
- Digital palpation on the facet of the lateral epicondyle
- Resisted wrist extension or resisted middle-finger extension with the elbow in extension
- Getting the patient to grip an object
A more thorough physical examination may be required to identify (or rule out) coexisting conditions or other reasons for their pain [39]. The examination should include the elbow, wrist, and forearm range of motion to look for any movement restrictions. Evaluation of the cervical and thoracic spine and radial nerve function is also necessary, especially if the patient suffers from neck pain, diffuse arm pain, or unusual skin sensations, such as tingling, pricking, chilling, burning, or numbness (paresthesia). Reproduction of lateral elbow pain during manual palpation or movements of the cervical spine could indicate radicular or referred pain [40].
Video 1: Test for lateral elbow epicondylosis by Dr. Jared Vagy.
Diagnosis of Golfer's Elbow (MET - medial elbow epicondylitis)
Since medial epicondylosis is much less common in the general population than lateral elbow tendinopathy, significantly less research is published on the topic. However, MET has been described as a condition analogous to lateral elbow tendinopathy, and so the healing and treatment principles are similar [41].
Still, certain groups are particularly affected by MET, including carpenters, plumbers, and of course, climbers. The condition is often caused by repetitive movement, including a combination of pronation of the forearm and wrist flexion [42].
In MET, the flexor-pronator mass is typically affected, close to the origin of the muscle in an area where the flexor carpi radialis (FCR) and pronator teres (PT) fuse [41][43]. In addition, larger diffuse tears can also take place in the palmaris longus (PL), flexor digitorum superficialis (FDS), and flexor carpi ulnaris (FCU) [44][45].
To diagnose MET, the examiner will run a series of movement tests while applying resistance to the elbow and the forearm. Patients with medial epicondylitis experience pain during resisted wrist flexion or forearm pronation. However, additional radiographs may be helpful to rule out other causes of medial pain [46][47]. For instance, medial elbow pain can be caused by ulnar or medial antebrachial cutaneous nerve (MABCN) problems [48]. On top of that, issues with the cervical spine may lead to weakness and dysfunction of the forearm muscles, causing imbalances and triggering the onset of the Golfer's Elbow [12][49].
Video 2: Test for medial epicondylosis by Dr. Jared Vagy.
Other elbow pain causes
If lateral and medial epicondylitis treatments are unsuccessful, ulnar neuropathy and radial tunnel syndrome are typically considered. Ulnar collateral ligament injuries often occur in athletes participating in sports that involve repeated overhead throwing.
Another cause of elbow pain to be considered is the biceps, brachialis, or brachioradialis tendinopathy, which causes pain in the anterior elbow. Climbers are at a particular risk here because they perform repeated elbow flexion with forearm supination and pronation. Pain in the back elbow can be triggered by triceps tendinopathy. Finally, olecranon bursitis is a common cause of posterior elbow pain and is often accompanied by swelling [34].
Imaging techniques
In the case of acute injuries, plain radiography is the initial choice for the evaluation. Radiography is very useful for showing bony injuries, soft tissue swelling, and joint effusions. For chronic elbow pain, magnetic resonance imaging (MRI) is preferred. Musculoskeletal ultrasonography allows for an inexpensive dynamic evaluation of commonly injured structures [34].
Figure 9: Coronal T-2 weighted MRI image of a right elbow showing an injury of the insertion of the extensor muscles at the lateral epicondyle [50].
However, ultrasound and MRI are sensitive but not very specific techniques in detecting structural abnormalities in tendinopathies [51][52]. MRI studies found signal changes in 90% of affected and 50% of unaffected tendons [53]. The similar goes for ultrasound, where the examiners found tendinopathic changes in 90% of patients with elbow tendinopathy and 53% of asymptomatic controls [54].
Figure 10a: Ultrasound appearance of a healthy Achilles tendon. White arrowheads indicate margins of a healthy Achilles tendon, and white arrows indicate a regular vessel [55].
Figure 10b: Ultrasound appearance of tendinopathy of the Achilles tendon. White arrowheads indicate local thickening of the Achilles tendon structure, and white arrows indicate pathological capillary vessels formed in the process of neovascularisation [55].
Still, negative ultrasound findings can be used to confidently rule out tendinosis and let the clinician focus on other possible causes of pain [56][54]. MRI can be used to detect other pathologies, such as loose bodies, articular cartilage damage, ligament injury, or elbow synovial fold (plica) syndrome [57][58].
Ultrasound can help diagnose nerve compression, hypoechogenicity of the nerve or cysts [59][58]. Finally, nerve conduction testing may be used to detect slowed conduction velocity of an entrapped nerve [60].
Symptoms and diagnosis summary
Determining the source of elbow pain can be difficult because of this joint’s complex anatomy and the broad possibilities for diagnosis. Each case may be different, and it is necessary to identify the underlying cause accurately before you can eliminate the injury once and for all. That is why typically, the best idea is to stop reading this article and to see a competent PT, like Dr. Vagy 🙂
If unsure, get a competent PT to examine your elbow - it'll save you time and prevent your condition from worsening.
Pathology of elbow tendinopathy
In the beginning, doctors and researchers thought that elbow epicondylitis is mainly an inflammatory process. Later, practitioners changed their minds and turned to believe that the pathological process is, in fact, not inflammatory but solely degenerative [12]. The subject is still a matter of debate, as it was recently found that chronic tendinopathy does incorporate elements of the inflammatory response [61].
Degenerated tendon tissue has a characteristic appearance. It consists of immature fibroblasts and disorganized, nonfunctional vascular elements. This granulation-like tissue is called angiofibroblastic hyperplasia, which is abnormal, propagates through the adjacent normal-appearing tendon fibers, disrupting them. The tendon affected by tendinosis differs significantly from a normal one. It appears gray, friable, and often swollen (see Figure 11) [12][62].
Figure 11: Normally organized collagen (lower right) and disorganized collagen showing separation, fragmentation, and disorientation of finers (upper left of image) [62].
The doctors suspect that the angiofibroblastic hyperplasia, meaning the pathologic alterations seen in the tissue of patients diagnosed with tendonitis, may result from a failed healing response to microtears. Healing cannot take place because of the poor vascularity of the pathological tendon origins. Also, the normal fibroblastic repair response may be disrupted by the continuing injury, and the degenerative tendinosis itself may be detrimental to the process of tissue repair [63].
The degree of tendon degeneration correlates with the intensity of the experienced pain and the duration of symptoms, according to Table 2 and Table 3 below [12]:
Table 2: Staging systems of tendinosis [12].
| Stage | Description |
|---|---|
| I | Temporary irritation (chemical inflammation?) |
| II | Permanent tendinosis - less than 50% tendon cross-section |
| III | Permanent tendinosis - greater than 50% tendon cross-section |
| IV | Partial or total rupture of the tendon |
Table 3: Pain phase systems of tendinosis [12].
| Phase | Description |
|---|---|
| I | Mild pain after exercise activity, <24 hours |
| II | Pain after exercise activity, >48 hours, resolves with warm-up |
| III | Pain with exercise activity, does not alter activity |
| IV | Pain with exercise activity that alters activity |
| V | Pain caused by heavy activities of daily living |
| VI | Intermittent pain at rest that does not disturb sleep; pain caused by light activities of daily living |
| VII | Constant rest pain and pain that disturbs sleep |
Causes of failed healing and degeneration
A wide array of theories have been proposed to explain the root causes of lateral and medial epicondylitis. The majority of research results suggest that repetitive contractures of the forearm muscles lead to microscopic tears and eventually degenerative tendinosis [12][64][65][36][37].
In climbing, tendons are often subjected to rather extreme loads, which results in micro-tears that need time to heal. The recovery rate of damaged tendons is relatively slow compared to bones and muscles. That is because tendon cell metabolism is relatively slow (the oxygen consumption is 7.5 times lower than in muscles), but that allows them to endure stress during long-term loading [66][67][68].
Figure 12: Load-deformation relationship chart. In the physiological range, there is an energy absorption and elastic deformation of fibers. However, when the load exceeds the physiological capabilities, microtears of fibers appear, and the curve enters the non-physiological range. Further, progressive load results in partial and complete rupture of fibers [55].
Tendon healing phases
According to medical literature, tendon repair consists of three main phases, essential for soft tissue healing. Understanding these stages is key to designing a successful tendinosis treatment protocol, so let us analyze them in detail.
Phase 2: Formation
The inflammatory cells found in the hematoma begin releasing cytokines and growth factors in the injured area and slowly initiate the second healing phase. These inflammatory cells initiate the release of mediators, which increase the proliferation of tenocytes from undamaged tendon fragments [70][71]. That means that a certain degree of inflammation is necessary to initiate the formative phase.
Initial inflammation is necessary to start the tendon healing process.
That is why taking NSAIDs can be detrimental to tendon healing. The second phase typically lasts up to three weeks after the injury, and it is divided into the proliferation and differentiation periods [55].
Phase 3: Remodeling
The last phase — remodeling, begins 3–6 weeks after injury, and it can be as long as a year before the tendon is fully healed [66]. During this phase, the number of cells, vascularity, and collagen fiber density slowly decrease, while the tendon's elasticity and strength improve [68].
Suppose that during any of the three phases of the healing process, the damaged tendon is repeatedly subjected to loads that exceed the threshold of possible adaptation or reparability. That is how degeneration begins [66]. The tendon structure's arrangement becomes chaotic and disorganized, and a random expansion of new capillary vessels (so-called neovascularisation) occurs. Consequently, the mechanical strength of the tendon is compromised. What is more, the newly formed degenerated tissue is prone to further injury, and a vicious circle is created, leading to tendinopathy [55].
Elbow tendinopathy treatments
In climbing books and resources scattered all over the internet, we can find many tips and suggested treatments for the climber’s elbow. Unfortunately, very few of them provide a complete picture. Some of the advice could be helpful, but it needs to be applied at the correct stage of the healing process. Otherwise, mistimed therapy is likely to aggravate the condition. We will now discuss some of the most popular elbow tendinopathy treatments to see which of them are confirmed as effective by proper scientific research.
Rest
I think rest and withdrawal from climbing is a critical aspect of the therapy to touch on. First of all, how long should you rest? In his article, Eric Horst suggests that after the injury, one should rest anywhere from two weeks to a month or two months, depending on the severity of the condition. That could be good advice in an acute tendon injury, such as finger tendon rupture. We would then want to rest during the initial inflammation phase. However, elbow tendinopathy is a chronic injury, and once you start experiencing pain, you are probably well into the failed formative and remodeling phases.
Indeed, some authors postulate that theoretically, the chronically injured tendon would heal in much the same way as the acute tendon injury. However, this theory has not been proven, and it is difficult to know the stage of healing of the tendon because the precise time of injury is unknown [72]. What is more, it is generally accepted that mechanical stimulation improves tendon repair. More precisely, the lack of mechanical stimulation is detrimental to the healing process [66].
The lack of mechanical stimulation is detrimental to the healing process.
Furthermore, how can you tell that you have rested enough? Should you rest until the pain goes away completely? That's not necessarily a good idea. In 2009 I took an entire year off from climbing because I had medial epicondylitis in both elbows. After a year, I felt better, but guess what, when in 2010 I returned to climbing, my tendinosis quickly came back with a vengeance.
In his article from 2003, Nirschl writes: "Rest and medication may result in temporary comfort but at the expense of further deconditioning and further delay of the rehabilitative process. Rest should be understood as the absence from abuse, not as absence from activity. Only activities that aggravate the condition should be eliminated. This does not necessarily mean abstaining from work or play if the injured tissue can be protected through a reduction in playing time or intensity" [12].
I think this is sound advice, and it means that as long as you are mindful of your condition, you can and should maintain light climbing activities. This way, you will learn which movements to avoid, and you may have the chance to develop healthier climbing habits, which will allow you to keep that elbow tendinosis at bay in the future.
Ice
Applying ice helps alleviate the pain by constricting the capillaries, decreasing blood circulation in the affected area, and numbing the nerve endings. Although icing is still sometimes recommended as a treatment for elbow tendinopathy, there is hardly any evidence of its effectiveness for long-term healing. Still, even Dr. Saunders recommends icing the elbow for a few minutes after the evening exercises [73].
Steven Low explains that ice is best used for reducing inflammation, so it could be helpful if the tendon is in the reactive tendinopathy stage. If we are dealing with chronic tendon degeneration, ice will not be beneficial [74]. What is more, Willette argues that using ice could do more harm than good by stopping the inflammation and healing process, which might lead to stagnation and degeneration [75].
Ice as a supplement to an exercise program offers no benefit to patients with LET.
Finally, Stasinopoulos concluded in his article that icing made no difference to recovery when combined with an eccentrics-based exercise program [76].
NSAIDs and cortisone injections
Now here is an exciting topic - the famous "Vitamin I"! Does it help treat elbow tendinopathy? Let us take a quick look at how doctors tackled elbow tendinosis in the past.
Before the 1990s, pain arising from tendons was referred to as tendinitis, which meant that inflammation was responsible for the pathological process. This view was widely accepted in the medical literature [61]. Back then, treatment strategies were heavily based on the administration of anti-inflammatory drugs (NSAIDs) and corticosteroids [77][78]].
However, during the 1990s, this approach was challenged since no study revealed inflammatory cells in the affected tendons [12]. The medical community agreed that chronic tendinopathy had a different root cause than inflammatory conditions such as Rheumatoid Arthritis (RA). Researchers emphasized that traditional strategies such as corticosteroid injection and NSAIDs do not adequately address the pathology [61].
This "degeneration without inflammation" paradigm prevailed until the late 2000s. As a result, physicians focused on physical therapies. In that vein, practitioners found eccentric exercises to help effectively manage mid-portion Achilles tendinopathy [79]. However, in subsequent studies, the astonishingly high success rate reported for eccentric exercises has not been repeated [80]. Furthermore, this technique's efficacy has not been satisfactorily demonstrated for other tendons [81][82][83]. Other popular treatments from the early 2000s included:
- Treatments using blood and blood products that aim to improve tendon healing and remodeling
- Treatments aiming to reduce the pain associated with tendinopathy rather than heal the tendon itself (such as sclerosant or high volume injections)
- Extracorporeal shock wave therapy (ESWT) [61]
Unfortunately, with the possible exception of mid-Achilles tendinopathy, none of the above techniques ultimately proved ineffective. A question arose whether it is certain that inflammation is not involved in the development or progression of tendinopathy? Or maybe something has been overlooked?
In recent years there have been significant advances in immunohistochemistry and gene expression analysis. Several studies have discovered some inflammatory reactions in humans and animal models, both in established tendinopathy and early overload response. Currently, there is a growing body of evidence indicating that ongoing tendon degeneration is an active process involving inflammation [61]. That makes sense because if the degenerated tissue is constantly irritated and torn before it is adequately healed, some inflammation should always be present. But does that mean that NSAIDs or corticosteroids are a viable way of treating tendinosis?
As far as corticosteroid injections are concerned, their effect on tendon pain is unclear. What is more, the benefits are generally short-term, and that there is the potential for weakening the structural integrity of tendons in the long run [84][85].
Corticosteroid injections should be considered as a last resort with careful control on the dosages.
The use of corticosteroids may increase the risk of spontaneous ruptures, and it was demonstrated that they negatively impacted cell viability, proliferation, and matrix synthesis [86][87]. The challenge is to develop more advanced future therapies without the long-term increased risk of symptom recurrence [61]. Still, for the time being, corticosteroid injections should be considered as a last resort with careful control on the dosages [86].
Compared with corticosteroids, NSAIDs have a more specific anti-inflammatory role and remain in everyday clinical use. As it stands now, some weak evidence was found of NSAIDs' moderate effect on acute tendon pain [88]. Both beneficial and harmful effects of NSAIDs on tendon healing were reported.
What is more, there are still concerns that NSAIDs may negatively affect the normal matrix remodeling, which may contribute to the failed tendon healing [86]. This is perfectly logical because, as explained before, a certain amount of inflammation is necessary to initiate the formative phase of tendon healing.
NSAIDs likely contribute to tendon degeneration by preventing the proper healing process.
In my opinion, the most considerable risk related to the use of NSAIDs and cortisol injections to treat the climber’s elbow is that they mask the problem and prevent healing. You begin feeling better, start climbing hard again, and end up worsening the condition. So, if you think that a couple of pills or shots will be a quick fix for your elbow pain – think again.
Rehabilitative exercise
According to Nirschl, the goal of the formative and remodeling phases is to enhance the growth of blood vessels and fibroblasts, followed by collagen deposition and the final maturation of the healed tendon structure. These goals are accomplished by:
- Rehabilitative exercise.
- High-voltage electrical stimulation.
- Central aerobics and general conditioning exercise.
- Absence from abuse.
Let us focus on rehabilitative exercise. As mentioned before, mechanical loading is critical for tendon healing. Appropriate training increases the diameter and tensile strength of tendons, with tendon fibroblasts increasing the production of collagen type I [89]. Unfortunately, we know very little about how to dose mechanical stimulation. To achieve the best results, we would need to precisely determine the amplitude, frequency, duration, and the appropriate time point during the repair process for loading to start while avoiding overload [66].
Concentric strengthening exercises
In their article, Alizadehkhaiyat and colleagues found that in patients with Tennis Elbow, the ECR muscle was weak compared with the control group. They suggested that strengthening the ECR muscle and restoring its normal activity should be a treatment goal in Tennis Elbow rehabilitation. Naturally, concentric exercises are the first thing that comes to mind when thinking of muscle strengthening. Indeed, programs involving concentric exercises have proven effective at reducing pain and improving function in patients with elbow tendinopathy [90].
In his book "training for climbing" and articles, Eric gives some general guidelines regarding stretching and strengthening exercises for the climber's elbow, including the concentric version of the well-known pronator teres exercise with the hammer [91]. Other concentric exercises for elbow pain may include Wrist Curls, Finger Extensions, Bicep Curls, and Thumb Abduction (the rubber band exercise) [92].
I believe that these concentric strengthening routines can indeed help in the later stages of the maturation phase, but they can do more harm than good if introduced too early. In fact, when I started developing elbow issues back in 2008, I religiously performed concentric elbow rehab strength exercises, which made things even worse because I executed them haphazardly and without any plan. I exercised too often, did too many reps, and used too much weight. It is also important to realize that strengthening exercises are rarely effective as a standalone treatment modality and that other therapies should accompany them, such as stretching or massage.
Eccentric-concentric training with isometric contractions
In recent years, the efficacy of isometric exercises in tendon pain management became a subject of investigation [93][94][95]. Climber's elbow is often related to forceful grip activities requiring isometric contraction of the wrist flexors and extensors. It was hypothesized that isometric contractions would be more beneficial than eccentric ones in the treatment of lateral epicondylitis [90]. Indeed, a case study showed that the combination of eccentric training with isometric contraction had positive effects in LET [94].
In 2017, Stasinopoulos published the results of a study where he compared the efficacy of three different exercise protocols in LET treatment [96]. The participants were divided into three groups, A, B, and C. All three groups performed Reverse Wrist Curls in three different exercise modes. Group A performed only eccentric contractions, Group B did eccentric-concentric contractions, and Group C combined eccentric, concentric, and isometric contractions.
The exercise protocol in Group C was the following (see the exercise section). The elbow was placed on the bed in full extension. The forearm was in pronation, the wrist was in an extended position (as high as possible), and the hand was hanging over the edge of the bed. From this position, patients flexed their wrist slowly while counting to 30, then returned to the starting position (extension). In the starting position, the patient performed an isometric contraction of wrist extensors for 45 seconds. When the isometric contraction was completed, the patient again performed the eccentric-concentric contraction, starting the next repetition.
In all groups, 3 sets of 15 repetitions of slow progressive exercises (eccentric, concentric, and isometric, respectively) of the wrist extensors at each treatment session were performed, with a 1-minute rest interval between each set. All three treatment groups additionally performed static stretching exercises of the wrist extensors 3 times before and 3 times after the exercises. The stretch position was held for 30 - 45 seconds, with a 30-second rest interval between repetitions.
This investigation showed that eccentric-concentric training combined with isometric contractions produced the most significant treatment effect at the end of treatment and follow-up. Based on their findings, the authors postulated that the eccentric-concentric training combined with isometric contraction should be the first treatment option for therapists when managing LET.
Eccentric strengthening exercises
According to the definition, an eccentric (lengthening) muscle contraction occurs when a force applied to the muscle exceeds the momentary force produced by the muscle itself, resulting in the forced lengthening of the muscle-tendon system while contracting [97]. Thus an eccentric training program strengthens the muscle-tendon complex while lengthening the complex [98]
As already mentioned, in the 1990s, eccentric exercises became "the thing" when it comes to tendon injury management [61]. Although the mechanisms in which eccentric loading could be superior to other modes of loading are not fully understood, researchers believe that the active lengthening of the muscle-tendon unit during eccentrics is essential. Therefore, it is hypothesized that the effect of eccentric training might:
- Lead to tendon hypertrophy and increased tensile strength [99][100].
- Have a significant favorable influence on the tendon's elastic characteristics, owing to the elastic stretching component of the eccentric exercises [99][79].
- Have a sclerosing effect on neovascularization [101].
You can perform most of the exercises mentioned in the concentric exercise section in the eccentric mode. Typically, as in the Wrist Curls and Hammer Rotations cases, you use an assisting hand to lift the load and limit yourself to lowering the load with the affected hand. However, some rehabilitation tools, such as the FlexBar, are explicitly designed for eccentric training, and they can be very effective, as we will explain in the following sections.
Although eccentric exercises have been proven effective in treating elbow and rotator cuff tendinopathy, it is still unclear whether they are significantly better than other loading protocols [102][103]. In fact, it was found that eccentric training alone is not adequate for many patients with tendinopathies [104][105]. Therefore, eccentric training should be combined with other treatment methods [106].
Antagonist training
Weakness and imbalance in the elbow flexor and extensor muscles can contribute to an onset of medial epicondylitis. Tendinopathy may occur because the muscle that attaches to the affected tendon is forced to work overtime to compensate for the weakness of the other muscles.
In medial and lateral elbow tendinopathy cases, it is common that the opposing forearm muscles require strengthening. And so, a person suffering from Tennis Elbow may benefit from strengthening the flexor muscles with Wrist Curls. Similarly, a person with the Golfers Elbow may successfully introduce Reverse Wrist Curls and Resisted Finger Extensions into their rehabilitation program.
Still, the issue does not always lie in the forearms. Weak rotator cuff, back, abdominal and hip muscles all can contribute to the onset of elbow pain. It is essential to realize that elbow pain is often the last link in a long chain of cause and effect. Addressing the entire kinetic chain may be required to heal the injury completely and prevent it from reoccurring [75].
With that in mind, it is also easy to understand that muscle imbalance training should not be random, as we could be addressing the wrong set of muscles, further worsening the condition. For example, on climbing forums and climbing books, push-ups are often recommended as a general for the Climber's Elbow. However, strengthening the triceps can only help if it is the elbow flexors that cause the condition. Likewise, if the wrist flexors cause the issues, it may be reasonable to strengthen the wrist extensors.
Unfortunately, if the elbow pain is related to the forearm muscles, push-ups may only aggravate epicondylosis. Actually, my real problems started when I began doing push-ups to resolve my condition. As explained by Jared, when you are doing push-ups, you are contracting the FCU and FCR at the wrist to push your palm into the ground. Because the muscles are elongated over the wrist joint, they are put into in a poor length-tension position. The tensile load from the muscle lengthening over the wrist joint combined with the active flexing and extending of the elbow joint can cause strain on the wrist flexor tendons as they insert into the medial epicondyle. Therefore, it is better to exercise with elastic bands or low weights in the earlier healing stages to prevent unnecessary elbow irritation. Alternatively, you may do fist push-ups to avoid contracting the FCR and the FCU at the wrist.
Training the antagonists is an excellent measure to stop the condition from recurring once it is healed [49]. However, you should carefully select the exercises to best address the situation. What is more, similar to other strengthening exercises, antagonist exercises should not be introduced at the beginning of the recovery plan. Otherwise, you will only cause further destruction of the tendons. Finally, if the degenerative process is already quite advanced, sole antagonist muscle training is unlikely to reverse the condition.
Stretching
Stretching is generally considered essential in treating elbow tendinopathy, but it is rarely used as a standalone therapy. When discussed, it is usually done in relationship to eccentric loading, although programs based solely on stretching have been proven effective in some cases [90]. In any case, stretching is one of the standard components of any tendon rehab program, as it is thought to encourage proper tissue alignment during healing so that the injury does not recur [107].
The primary role of stretching is to restore the normal tendon flexibility, help break the scar tissue adhesions in the muscles and tendons, and promote proper realignment of collagen fibers [107][75]. According to Cyriax, tissue should not be allowed to heal in a shortened position as this may predispose the patient to recurrence of the condition [108]. When the inflammatory phase is over, mechanical stimulation of the healing tendon has a critical influence on tissue mechanobiological properties and structure arrangement. Collagen, which is not under stress during the proliferative and remodeling phases, is weaker, and its structure is disorganized [109].
Although there are many known stretching techniques, simple static stretching is considered a practical and straightforward procedure [107][110][111]. According to Stasinopoulos, static stretching should be applied slowly, with the stretch position held for 30–45 seconds. However, Willette argues that this style of stretching is too aggressive and risky when you have Tennis Elbow or Golfer's Elbow. Instead, he recommends short, gentle, progressively harder stretches that he considers much safer and equally effective [112].
Apart from its positive impact on the structure of the healing tendon, stretching can help release some of the tightness trapped in the forearms. Still, if your condition is already advanced, it is unlikely to be enough to relieve the chronic tension caused by scar tissue adhesions formed in the muscles [75][90].
“The Stretch”
Staying true to his motto "Don't expect anything normal," in 2012, Tom Randall published a post where he explained how he cured his two-year-long elbow tendinosis condition in just two weeks with an exercise he had learned from a fellow climber, Drew Haigh [113]. The drill, which he called "The Stretch," essentially means laying on your belly and stretching your arms by pressing on them with your body weight.
In his reply to Tyler Nelson's post on elbow tendinosis, Tom reported that the exercise has helped 500+ people solve their elbow issues in just 1 - 2 weeks. However, no physiotherapist he had asked could explain why the method was so powerful [114][115].
If it’s helping you, then keep it up.
A discussion on Tom's post started on r/climbharder, where Steven Low, in a similar tone to Tyler's, explained that if "The Stretch" helps, the cause of the pain is likely not primary tendinosis but rather a joint mobility issue [116].
Manual Therapy
Manual therapy plays a crucial role in elbow tendinosis recovery. Indeed, transverse or deep friction massage, myofascial release, and trigger point therapy are often used by physical therapists for treating lateral and medial epicondylitis.
Deep Transverse Friction (DTF)
Dr. James Cyriax believed that therapeutic massage helped prevent random binding of newly formed collagen fibers, which, left untreated, led to tendinopathy [117]. In 1936, he reported substantial success in treating Tennis Elbow using Deep Transverse Friction (DTF) [108]. DTF is a specific type of connective tissue massage applied precisely to soft tissue structures such as tendons. The Cyriax method is currently used extensively in rehabilitation practice [107][110][118][119][120].
Unfortunately, the technique has developed a reputation for being very painful [120][121][122]. However, pain during friction massage is usually the result of a wrong indication, a wrong technique, or an excessive amount of pressure. If this form of massage is applied correctly, it quickly results in an analgesic effect over the treated area, and it is not at all painful [108][119][123].
It is a common clinical observation that DTF leads to immediate pain relief. The patient experiences a numbing effect during the session, and reassessment immediately after shows a reduction in pain and increase in strength and mobility [124].
The application of DTF breaks down the cross-links or adhesions that have been formed in the degenerated tendon. That results in softening the scar tissue and mobilizes the cross-links between the mutual collagen fibers and the adhesions between repairing connective tissue and surrounding tissues [119][123][125][126]. Moreover, clinicians claim that the rhythmical transverse stress of DTF stimulates fiber orientation to enhance tensile strength [119][120].
Finally, DTF produces vasodilatation and increased blood flow to the area, which may facilitate the removal of chemical irritants and boost the transportation of endogenous opiates, resulting in decreased pain [119][123][125][126].
Although DFT seems to work well in practice, the clinical evidence of its efficacy is still lacking, and more studies are needed to validate it [127]. It is also important to remember that if your elbow pain is not caused by tendon degeneration, but, e.g., ulnar nerve entrapment, DTF massage may not help.
Myofascial Release
In the late '80s, Chop suggested that elbow tendinopathy could be caused by myofascial trigger points (MTrP) that forearm muscles (myofascial pain syndrome) [128]. A trigger point is a hyperirritable spot in the muscle, associated with a palpable nodule in a taut band that is painful on compression [129]. A taut band is an internally localized contracture within the muscle, present without motor activation [130]. In other words, it is a chronic involuntary shortening of a muscle without EMG activity [129]. An MTrP can trigger local or referred pain and cause muscle stiffness and restricted range of motion [131].
MTrPs have been identified with nearly every musculoskeletal pain problem, including [129]
- joint dysfunction [132],
- disk pathology [133]
- tendonitis [134]
- carpal tunnel syndrome [135]
- neck pain [136]
Several possible mechanisms can lead to the development of MTrPs. These mechanisms include [129]:
- low-level muscle contractions
- uneven intramuscular pressure distribution
- direct trauma
- unaccustomed eccentric contractions
- eccentric contractions in unconditioned muscle
- maximal or submaximal concentric contractions
All these can lead to chronic tension in the muscles and, in consequence, potentially tendinopathy. However, the relationship between MTrPs in the forearm muscles and LE is still uncertain [137].
Myofascial trigger points are treated with [129]:
- manual techniques
- spray and stretch
- dry needling
- injection therapy
Several studies have shown that manual therapy treatment focusing on myofascial components effectively reduces pain and improves function in patients with lateral epicondylosis [137]. Therefore, manual therapy is one of the primary treatment options, and the role of orthopedic manual physical therapists cannot be overemphasized [138].
Study 1: [139]Patients treated with myofascial release (MFR) manual therapy group reported a 78.7% reduction of pain and functional disability (PRTEE score) in week four compared to baseline and a 63.1% reduction in the follow-up at week 12. Control patients reported only a 6.8% reduction in PRTEE at week four and an increase of 2.2% in PRTEE at follow-up.
Study 2: [140]In a second double-blinded RCT, Nourbakhsh and Fearon investigated the effect of oscillating-energy manual therapy (OEMT) on 23 subjects with chronic LE. The OEMT is a manual osteopathic technique originally used to treat tender points and MTrPs. This method involves inducing a gentle oscillating movement through specific hand placement over the tender spot being treated.
The treatment group showed statistically significant improvement in grip strength, pain intensity, functional level, and limited activity due to pain compared with those in the placebo group. Patients in the treatment group significantly improved their grip strength, pain intensity, functional level, and limited activity due to pain. None of these variables showed a significant change in the placebo group. A follow-up showed that 91% of subjects maintained improved function, with 73% remaining pain-free for at least six months.
Study 3: [141]The third RCT conducted by Blanchette and Normand evaluated the effect of augmented soft tissue mobilization (ASTM) in the treatment of LE while determining the feasibility and appropriate sample size for a future study.
The results showed a significant decrease in post-treatment pain and functional disability compared to the stretching exercise group. These results, however, must be treated with caution due to the non-blinded design and small sample size [141]
According to the three interventional studies included in this review, treatments focusing on myofascial components seem to reduce pain and improve function in patients with LE effectively. However, additional, large, and high-quality RCTs are essential to formulate a solid conclusion.
Combined exercise programs
So far, we have discussed various standalone management strategies for elbow pain. All these treatment methods have been reported helpful, but it was impossible to determine if any of them is significantly superior. Hence an idea emerged to combine the interventions to increase the chance for recovery. The results of such combined programs are compared in the following sections.
Eccentric - concentric training (static stretching vs. supinator strengthening)
In 2013 Malliaras and colleagues conducted a systematic review of tendinopathy loading programs. They found some potential mechanisms related to neuromuscular performance, where the eccentric-concentric rehabilitation programs could be superior to isolated eccentric loading [142].
A recent study conducted by Padasala et al. compared the effects of two different eccentric-concentric Tennis Elbow treatment programs [143]. The participants were divided into two groups. Group A was treated with eccentric-concentric training of wrist extensors with static stretching, while Group B was treated with eccentric-concentric training combined with supinator strengthening (think External Hammer Rotations).
The study results showed that both groups experienced significant function and grip strength improvements after 6-month treatment. However, the supinator strengthening group had better outcomes for all variables in comparison to the stretching group.
Heavy-Slow Resistance Program
The Heavy-Slow Resistance (HSR) Program, proposed by Stasinopoulus, consisted of concentric-eccentric and isometric exercises, combined with forearm extensors stretching. Furthermore, the program included rotator cuff strengthening and supinator strengthening exercises. The researchers found that the HSR program reduced pain and improved function at the end of the treatment and at the follow-up [144][145].
The authors concluded that eccentric exercises should be performed at a low speed in every treatment session to promote tissue healing. Avoidance of painful activities was found crucial for tendon healing. Eccentric exercises appeared to reduce the pain and improve function while reversing the pathology. The clinical improvement of the HSR group was accompanied by increased collagen turnover. However, they could not determine whether isometric contractions can reverse the pathology or solely reduced the pain [145]. Forearm stretching, rotator cuff strengthening, and supinator strengthening exercises were all found to be helpful in the management of LET.
"Dodgy Elbows" Program by Dr. Julian Saunders
In the climbing world, "Dodgy Elbows" and "Dodgy elbows Revisited" by Dr. Julian Saunders are among the most well-known articles on dealing with elbow tendinopathy, and eccentric exercises are the cornerstone of his program.
The general premise is that a muscle lowering a load (eccentric contraction) is roughly 40 percent stronger than a muscle lifting a load (concentric contraction). In practice, Dr. Saunders explains that, e.g., you may be able to lower yourself with one arm in a controlled fashion without being able to do a one-arm pull-up.
Why is that important? The article says that tendinosis comes from microtrauma inflicted by a muscle that is too strong in relationship with the tendon. So you want to strengthen the tendon without concurrently strengthening the muscle. What is more, you need to use high training resistance since low-weight programs are considered ineffective [73].
The claims by Dr. Saunders are generally in line with what we can find in other sources [103][109][107]. Needles to say, I tried Dr. Saunders's protocol back in 2008, but unfortunately, to no avail. The question is, why?
Towards the end of his article, Dr. Saunders writes that 100% of climbers attending his clinic for MANUAL THERAPY and monitoring IN CONJUNCTION WITH THE EXERCISE PROGRAM have recovered. Furthermore, Dr. Saunders gives remote consultations through email to climbers who cannot attend his clinic in person. Out of these, ONLY 60% recover. Also, the program must be individually tuned, involving correction of predisposing physical factors and elimination of lousy climbing habits. FINE-TUNING OF THE EXERCISES IS PARAMOUNT. The angle of your wrist and elbow can dictate success or failure.
Let us think about that for a minute - if only 60% of climbers receiving a personalized program over email recover, what would be the percentage of climbers who recover after only reading the article and trying to apply the exercises on their own? Probably around 30 - 40%.
What is even more critical, in the original article Dr. Saunders only briefly mentions the importance of manual therapy. However, in his subsequent article "Dodgy elbows revisited," where he writes that:
Soft-tissue work is imperative. Ten minutes of deep tissue massage a few times a week double the chances of success. Massage alone is ineffective.
Ok, now we're getting somewhere! After incorporating massage, we could be looking at 60 - 80% success rates again! Unfortunately, the importance of deep tissue massage can be very easily overlooked, particularly if we only read the original article. Yet, recent research shows that manual therapy is imperative for treating epicondylitis [124][137].
Don't get me wrong - I still believe that "Dodgy Elbows" and "Dodgy Elbows Revisited" are by far some of the best articles published on elbow tendinopathy for climbers. It is just that, particularly in the original article, the importance of massage is, in my opinion, not emphasized enough, and this is what can make the ultimate distinction between failure and success for many climbers - as it did for me.
Elbow surgery
If all non-operative options are exhausted, surgery is considered the last resort in treating tendinopathy. The most common procedure is open surgical debridement of the involved tendon or surrounding tissue, with potential repair of the tendon if necessary. Although good results can be obtained with debridement or decompression of chronic tendinopathies, the failure rates can be as high as 20 to 30% with some of these procedures [146].
Even the surgeons don't recommend this one!”
Elbow surgery is a topic that deserves a separate post, but to keep it short, as Dr. Saunders put it in his article, even the surgeons don't recommend it [73]!
Figure 12: Posterior interosseous nerve decompression. Radial recurrent vessels forming part of the roof of the radial tunnel. BR indicates brachioradialis; LH, Leash of Henry; RT, radial tunnel [147].
Acupuncture
Acupuncture is known to induce local vasodilation within human tissue. We can use this effect to enhance tendon blood flow, positively impacting tendinopathy treatment [148]. In a study from 2010, Kubo noticed a significant increase in total blood volume and oxygen saturation after acupuncture and heating in Achilles tendons [149]. However, 30 minutes after the therapy was administered, the total blood volume continued to increase, and oxygen saturation remained constant in the acupuncture group. In contrast, both values dropped abruptly in the heating group.
A separate study showed that acupuncture might promote an increase in collagen fibril diameter and reorganization [150]. Increases in tensile strength in tendons exposed to electroacupuncture were also reported [151]. Although further research is required, acupuncture might be an effective supporting therapy in elbow tendinopathy treatment [152].
Dry needling
Although it is similar to acupuncture, the term dry needling encompasses a wide array of techniques. Typically, the method involves passing a needle (20 to 23 gauge) in and out through the tendon about 20 to 50 times [153][154][155][156][157]. However, some authors suggest 3, 5, or 10 penetrations [158][159][160]. The number of needle passes may vary based on factors, such as patient characteristics, severity, and size of the tendinopathic area, presence or absence of tears, operator experience, comfort level, and needle gauge used [161].
In a recent trial, Uygur et al. evaluated the efficacy of dry needling therapy on LET. They concluded that dry needling is a safe and effective treatment method for lateral epicondylitis [162]. That view is confirmed by Stoychev, who states that current research provides initial support for the use of tendon dry needling as a stand-alone procedure for tendinopathy. However, he adds that studies comparing the different tendon dry needling protocols are still needed [98].
Low Level Laser Therapy
Among the various existing physiotherapeutic interventions, low level laser therapy (LLLT) is broadly used for treating musculoskeletal disorders. The treatment is particularly effective in modulating inflammatory mediators, contributing to tissue repair, thus helping resolve inflammatory conditions in general [163]. However, the results of LLLT therapy in the treatment of tendinopathy are conflicting [164][165][166].
In a very recent systematic review, Lopes et al. confirm that the results of using LLLT to improve pain and function in shoulder tendinopathies are controversial. Only 45% of the 11 examined studies showed a statistically significant decrease in pain. Furthermore, only 1 of the 6 studies that assessed functional outcomes observed a statistically significant improvement [163].
In 2013 Mamais and Stasinopoulos conducted a review where they investigated the influence of LLLT specifically on the effectiveness of LET treatment [167]. They concluded that the results generally showed poor LLLT effectiveness in the LET management. However, that does not mean that the modality should categorically be ruled out from the therapy list. Further research is necessary to investigate the effect of combining LLLT and exercise. The impact of laser wavelength and recommended dosages also require looking into.
Transcutaneous Electrical Nerve Stimulation
Transcutaneous Electrical Nerve Stimulation (TENS) is an inexpensive, safe, non-pharmacological analgesic technique. It is recommended as an addition to other treatments for musculoskeletal pain, enabling self-management by patients [168][169][170][171].
In 2013, Chesterton et al. published the results of an extensive trial in which they assessed the effectiveness of TENS for pain reduction in patients with lateral elbow pain. The study was conducted between 2009 and 2011 and included 241 patients. The patients were divided into two groups. One group received primary care management only, and the other group received primary care combined with TENS. A significant pain reduction was observed in both groups already in the first six weeks of the treatment, but no significant differences existed between the groups at any time point. Furthermore, no additional benefits from including TENS in the therapy were reported [169].
Later, in 2015, a systematic review on the efficacy of transcutaneous electrical nerve stimulation (TENS) for the treatment of rotator cuff tendinopathy was published by Desmeules. However, the number of available studies was limited, and their overall risk of bias was high, making it impossible to draw any solid conclusions. More studies are required to prove that the method is effective. Until then, the research team advised that clinicians should prefer other evidence-based and proven rehabilitation interventions [172]. In a nutshell, TENS does not seem to be an effective method for treating neither shoulder nor elbow pain.
Extracorporeal Shockwave Therapy and Pulsed Electromagnetic Fields
Mechanical stimulation using Extracorporeal Shockwave Therapy (ESW) and Pulsed Electromagnetic Fields (PEMF) showed some promising results in preclinical and in vitro studies. However, clinical evidence is still lacking, although its efficacy was demonstrated in treating calcific rotator cuff tendinopathy [173]. At the same time, PEMF seems to exert positive clinical effects towards shoulder and elbow tendon disorders only at a short-term follow-up [174].
Very recently, it was demonstrated that daily exposure to PEMFs generally provided an improvement in the fiber organization, a decrease in cell density, vascularity, and fat deposition, and a restoration of the physiological cell morphology compared to untreated tendons in rats [175]. Furthermore, another recent randomized clinical trial, combining Electromagnetic Transduction Therapy (EMTT) and Extracorporeal Shockwave Therapy (ESW), showed some promising results in rotator cuff tendinopathy management [176]. Finally, in 2020, Lin et al. showed that a single-pulsed electromagnetic field (SPEMF) enhances collagen matrix synthesis and reduces matrix degeneration [177].
While basic science research continues to show encouraging results, further in vivo human studies are necessary to confirm the clinical efficacy of PEMF and ESW for the treatment of tendon disorders [178]. As things stand, electromagnetic therapies remain controversial treatment options for tendinopathy management [146].
Ultrasound therapy
In the last decades, physiotherapists have commonly applied ultrasound therapy to treat musculoskeletal conditions such as LET [179][180]. Admittedly, there is strong evidence that ultrasound has positive effects on tendon healing, but it is based on animal models [181][182].
To date, several systematic reviews on the efficacy of USG in the treatment of Tennis Elbow were done. It was concluded that there is a lack of scientific evidence supporting physiotherapy treatments such as ultrasound in elbow tendinopathy [183][165][184][185]. However, it needs to be pointed out that the frequency of the USG used in the reviewed studies was 1 MHz, which is suitable for penetrating deep tissues. Since elbow tendinopathy is superficial, the ideal frequency to use would be 3 MHz, so the wave frequency used in the four mentioned studies was wrong [180].
In 2019 Hamza et al. performed a study where they compared the effectiveness of ultrasound therapy and kinesiotaping as adjunct therapies to a regular strengthening exercise program to treat recalcitrant elbow tendinopathy [186]. They have found that the treatment was successful in both groups, but, what is surprising, they also noticed that kinesiotaping yielded better effects than ultrasound.
It has to be mentioned that the team used 1 MHz USG waves, while 3 MHz would probably be more appropriate. What is more, they used continuous mode, while, according to Watson, pulsed mode would be better [171]. The treatment time was 5 minutes, which may be considered insufficient]. Further research is necessary to determine the treatment's optimum parameters and prove its efficacy [180][187].
Iontophoresis
Iontophoresis is a therapeutic technique that involves introducing ions, typically from a dexamethasone sodium phosphate aqueous solution, into the injured tissues through a direct electrical current [188]. The method has attracted much interest in the last 20-25 years, and it has been used for common musculoskeletal conditions, including Tennis Elbow [189].
In 2015 Akram conducted a study where he compared the effects of the Cyriax exercises with iontophoresis [108]. Both the iontophoresis and Cyriax groups experienced significant improvements in pain, grip strength, and patients' general well-being. Moreover, there were no significant differences between the groups one week after the last treatment session or at the follow-up at three months after treatment [189].
The above results were later confirmed in a double-blind RCT study done by da Luz, who showed that iontophoresis is an effective technique in reducing pain and improving strength and function in individuals with Tennis Elbow. Interestingly, iontophoresis gave superior results to galvanic current treatment, which also proved somewhat effective [190].
On the other hand, in their reviews, Stasinopoulos and McKivigan concluded that it is not clear whether iontophoresis should be recommended as a treatment approach for the management of epicondylitis. However, they both agreed that it is still too early for it to be ruled out and that more research is needed [191][192].
Sclerotherapy
Sclerotherapy relies on injecting a sclerotic agent into a blood vessel to degrade the abnormal vessels and sensory nerves within the tendinopathic tissue, which cause pain. Some limited evidence suggests that sclerotherapy may help patients with patellar or Achilles tendinopathies, lateral epicondylalgia, and shoulder impingement [193].
Nitroglycerin patches
There is some evidence that nitric acid (NO) promotes tendon healing and collagen synthesis [194]. However, the concurrent physiotherapy (eccentric and stretching exercises) that most participants received might have affected the cited study results. Thus, definitive conclusions on the exact role of NO in tendon healing are yet to be reached, but such therapy is not likely to be successful on its own.
Platelet-rich plasma
Platelet-rich plasma (PRP) therapies are considered a major breakthrough in the treatment of many medical conditions. They are one of the hottest topics in orthopedics owing to their presumed healing properties. A PRP therapy uses autologous activated platelets retained in fibrin matrices as a source of healing molecules [195]]. The goal is to inject a large quantity of signaling proteins such as growth factors and other cytokines into the degenerated area to drive the tissue regeneration mechanisms [196].
It is reported that after PRP, a temporary worsening of the symptoms may occur, with expected pain relief within a few days after injection [197]. First, however, an individual-specific rehabilitation program, based on eccentric training and strengthening, must be started, as mechanical stimuli seem to enhance PRP efficacy [198] [199].
Kinesiotape
Kinesiotape (KT) is a therapeutic taping technique developed in the mid-1970s by Dr. Kenzo Kase. Research has shown that taping may help treat conditions such as patellofemoral pain [200][201][202], carpal tunnel syndrome [203], and shoulder impingement syndrome [204][205].
Among other benefits, Kinesiotape is reported to relieve pain, improve ROM and help prevent injuries [206][207][208]. Some of these effects are explained by KT causing lifting of the skin over the underlying tissue. However, a psychological component regarding the support, comfort, and security perceived by patients may also be considered [209].
In a recent systematic review, Ortega wrote that there is limited evidence to support the application of KT to treat tendinopathy, especially for anything beyond the short term. Furthermore, improvements related to KT were not generally more significant compared with other treatment modalities [210].
What is even more interesting, in 2013, Chang and colleagues specifically investigated the efficacy of KT in the treatment of Medial Elbow Tendinopathy [211]. They found that KT did not influence the maximum grip strength. In any case, the evidence for the effectiveness of taping in the improvement of function and reduction of elbow pain is conflicted [212].
Vitamin C
Vitamin C plays an essential role in connective tissue healing and collagen synthesis enhancement [213][214]. It also acts as a powerful antioxidant, which neutralizes the deleterious reactive oxygen species (ROS), responsible for cell apoptosis during the inflammatory phase [215][216]. It was also reported that vitamin C could induce tendon-derived stem cell mobilization, osteoblast growth and differentiation, and fibroblast stimulation [217][218][219].
In 2018, DePhillipo and his team conducted a systematic literature review to summarize the current knowledge concerning the efficacy of vitamin C supplementation in treating musculoskeletal injuries. Their most significant finding was that there is preclinical evidence that vitamin C supplementation accelerates bone healing after fractures, increases type I collagen synthesis, and reduces oxidative stress. Unfortunately, they also stated that clinical evidence does not replicate the results seen in animal models to date. Because of the limited number of human studies, further clinical investigations are needed before implementing vitamin C as a postinjury supplement [220].
Collagen supplementation
Collagen is the primary structural protein in tendons, ligaments, skin, and bones. Consequently, dietary supplementation with gelatin or hydrolyzed collagen (HC) products has become a popular nutritional strategy to improve connective tissue collagen synthesis. Still, its efficacy is yet to be scientifically validated [221][222].
At this point, there are still practitioners who claim that collagen is simply a waste of money [223]. However, a growing body of evidence shows that oral administration of specific collagen peptides may enhance the benefits of a well-designed tendon strengthening program [224].
In 2016 Shaw demonstrated for the first time that consuming a gelatin and vitamin C–rich supplement increases the appearance of the amino acid components of collagen within the human serum. Furthermore, the accelerated rate of collagen synthesis was observed as early as four hours after the first bout of exercise (five hours after gelatin supplementation). Moreover, it was maintained throughout the 72 h of the study [225]]. Later, it was shown that vitamin C and the amino acid proline could increase collagen production and the mechanics of engineered ligaments. Increasing glycine intake was found to improve the mechanical properties of Achilles tendons after injury [226][227].
These results suggest that ingestion of supplements containing amino acid components of collagen combined with vitamin C an hour before exercise or adding gelatin to an intermittent exercise program improves collagen synthesis and could play a beneficial role in injury prevention and tissue repair. Unfortunately, these results were generally characterized by a large variability, which limited their statistical significance [225][222]. It is also unclear whether there is anything specific about collagen-based proteins for collagen synthesis within the body or whether ingesting a different type of protein, such as whey, would have the same effect as gelatin or hydrolyzed collagen [222].
Finally, research conducted on rats revealed no significant advantage in tendon healing after collagen supplementation. However, scientists noticed an activation of fibroblasts in the repair site through increased expression of proliferating cell nuclear antigen (PCNA) and transforming growth factor β1 (TGF-β1). The meaning of increased PCNA and TGF- β1 expression in the endotenon fibroblasts has yet to be discovered, and further research is still required to explain how this effect could impact long-term tendon healing. Still, it may have some potential benefits [228].
It seems that even if taking collagen supplements does help increase the rate of collagen synthesis in the degenerated tendon tissue, it has to be accompanied by a regular exercise program to ensure that the new collagen fibers are correctly aligned and form a healthy tendon. A random buildup of new collagen over the injured site will indeed not resolve the condition.
Collagen injections
Oral administration is not the only means by which exogenous collagen can be delivered to the injury site. For example, in 2018, Farkash et al. performed a study where they injected a gel composed of cross-linked bioengineered recombinant human type I collagen combined with platelet-rich plasma (STR/PRP). The gel’s function was to form a collagen-fibrin matrix that promoted cell migration and tissue repair.
As a result, the therapy was successful in 86% of the patients who failed to respond to conservative treatment. It was also reported that the mean grip strength among the patients increased from 28.8 kg at baseline to 36.8 kg at six months. In addition, noticeable improvements in the sonographic tendon appearance were found among 68% of patients. However, the authors admitted that double-blind, randomized controlled trials are necessary to determine the efficacy of this new treatment compared with other currently available injection treatments in chronic LE [229].
In a similar study, performed in 2019, Corrado et al. concluded that a series of five collagen injections, at weekly intervals, significantly reduced pain symptoms and improved function in just one month in a group of 50 patients with LE. Furthermore, continuous improvement was observed two months later. Although a randomized control study is necessary to confirm these results, the preliminary trials with collagen injection therapy seem very promising [230].
Selected manual therapy techniques for elbow pain
Basic forearm massage
In the early stages of elbow tendinopathy, it is often enough to release the excess tension in the forearms. You can achieve that through a simple massage. Look for lumpy and tender spots in your muscles and gently release them, as shown in the video.
Video 3: Forearm tightness release massage.
Forearm myofascial release
If simple massage and stretching do not improve the condition, you may incorporate some light myofascial release techniques into the rehab program. These techniques are known as the Press-and-Stretch and are recommended by Dr. Allan Willette [75].
To perform Press-and-Stretch, you need to contract the muscle, press it and extend it while maintaining pressure. The method makes it possible to break down scar tissue adhesions, which cause excess tension in the forearms and contributing to elbow tendinopathy.
In Golfer's Elbow cases, releasing the tight FCU can bring quick relief.
Video 4: Medial Elbow Pain – myofascial release.
Deep Transverse Friction (DTF) techniques
Suppose the simple tension release techniques fail to alleviate the condition. In that case, it might be necessary to break down the degenerated scar tissue directly in the tendons and reinitiate the healing process employing Deep Transverse Friction Massage. The basic DTF techniques for medial and lateral elbow tendinosis are explained in the sections below.
For any of the described methods, remember not to work on one spot for too long, or you might overdo it, cause bruising and swelling. The tendon structure might feel slightly granular, crystalline, and irregular to the touch. These are the scar tissue adhesions that you want to get rid of.
In the beginning, perform the DTF for only a few minutes every second day. The procedure is likely going to cause some irritation and flare-ups of elbow pain. That is generally a good sign because it means that you are breaking the stagnation in the healing process, but you might want to wait for the flare-ups to subside before you repeat the therapy. As your condition improves, you might be able to administer DTF even several times a day without experiencing an aggravation. However, the tendon healing process is relatively slow, so it might take weeks or even months before you reach that stage.
When applying DTF, it is good to perform some light stretching now and then, which helps break down the degenerated tendon tissue and release tension in the muscles. Some selected DTF techniques are demonstrated in the sections below.
Frequency of DTF application:- Initially, perform DTF once a day for a few minutes. In case of a flare-up, wait for it to subside before you continue the therapy.
- Increase the massage frequency to twice a day for 10 – 15 minutes, as your elbow gets better.
Basic cross-fiber massage
Use your fingers to massage the epicondyle directly using short back and forth motions across the painful area. Change the massaged spot frequently, moving towards the wrist to cover the entire affected area. As you do that, you will be focusing less on the tendon attachments and more on the tendons themselves.
The Press-and-Turn technique
The Press-and-Turn technique is used to apply DTF to the epicondyle effectively. The name comes from the simultaneous pressing on the epicondyle and pronating or supinating the forearm. The method enables deep cross-fiber massage of the tendon attachments.
When applying the Press-and-Turn massage to your medial epicondyle, make sure that you stay on the side that is closer to the wrist and not on the backside, or you might hurt your ulnar nerve, which passes through the cubital tunnel.
The Press-Turn-Stretch technique
The Press-Turn-Stretch technique is the most advanced of the methods described here, and it is a combination of the routines explained above. To execute this form of DTF massage, bend your elbow, press on the affected spot, and extend the elbow while turning it and maintaining the pressure at the same time. Try to do all this in one smooth movement.
Selected exercises for elbow pain
Whether you are suffering from LE or ME, exercises are necessary to promote proper collagen fiber realignment and stimulate healing. Below is a list of muscle and tendon strengthening exercises useful for the treatment. In the following sections, we briefly discuss some of the exercises that help heal elbow tendinopathy.
Stretching
Stretching is an essential part of practically all elbow tendinopathy treatment programs. Typically, static stretching between 30 – 45 seconds is recommended, but some authors claim that short duration stretches are safer and better [75]. Stretching can be done at the end of an exercise session or during myofascial release or DTF therapy.
Theraband Flexbar - eccentric strengthening of the forearm muscles
The Theraband FlexBar is often referred to as very helpful in treating elbow tendinopathy [231][232]. Page reported that patients who combined the FlexBar eccentric exercises with physiotherapy experienced a significantly better improvement than the control group, who received standard physiotherapy only. The standard therapy involved stretching, cross-friction massage, ultrasound, heat, and ice [233].
The pain level in the FlexBar eccentric exercise group was reduced by 81% vs. the mere 22% in the control group. Strength improvements were also significantly better in the eccentric group, reaching 79% vs. 15% improvement in the control group. The DASH (Disability of Arm, Shoulder, and Hand) score improved by 76% in the FlexBar group compared to only 13% in the control group. A prescription of 3 sets of 15 repetitions daily for approximately six weeks appeared to be an effective treatment in most patients [234].
FlexBar Twist for forearm extensor trainingCondition: Lateral Epicondylosis (Tennis Elbow)
Exercise mode: eccentric
Function: strengthening of the forearm extensor muscles
Frequency: 3 sets of 15 repetitions daily
Video 5: Flexbar Eccentric Twists by Dr. Jared Vagy.
FlexBar Twist for forearm flexor training
Condition: Medial Epicondylosis (Golfer’s Elbow)
Exercise mode: eccentric
Function: strengthening of the forearm flexor muscles
Frequency: 3 sets of 15 repetitions daily
Video 6: Reverse Flexbar Twists by Dr. Jared Vagy.
Wrist Curls
The flexor carpi radialis (FCR) and the flexor carpi ulnaris (FCU) tendons are typically strengthened using Wrist Curls (WCs). According to Saunders, in climbers, the FCU tendon may be particularly affected by the excess loads it is subjected to during crimping [73].
To do the eccentric version of the Wrist Curls exercise:- Place your wrist palm up (supinated) on the edge of a flat surface so that your hand has a free range of motion.
- Hold the dumbbell tilted so that your little finger is slightly higher than your thumb and your wrist is fully flexed.
- Tilting the dumbbell puts more emphasis on the FCU tendon, which is critical if your condition is caused by excess crimping
- Hold the dumbbell so that the thumb is on the same side of the bar as your fingers to prevent triggering other overuse conditions
- Lower the weight as far as you can, slowly counting to 5 or even 30.
- Relax your grip and use your other hand to lift the weight back into position.
After a few weeks of exercise, once your condition is practically pain-free, you may proceed with the eccentric-concentric-isometric version for final strengthening and remodeling of the muscles and tendons.
To do the eccentric-concentric-isometric version, points 1 - 3 stay the same.- Instead of using the assisting hand, slowly lift the dumbbell back up with the affected one (concentric contraction).
- Once the wrist is fully flexed (raised), hold this position for 45 seconds while pulling the inside of your palm towards your elbow (isometric contraction).
- When the isometric contraction is completed, start your next repetition by slowly lowering the dumbbell again (eccentric contraction).
- Perform 10 - 15 repetitions per set
- Rest 3 - 5 minutes between sets
For reference, you can take look at a demo video recorded by Dr. Saunders himself [235].
Video 7: Wrist Curls and eccentric External Hammer Rotations by Dr. Julian Saunders [235].
Equipment: Elastic band or free weights
Exercise mode: eccentric, concentric or eccentric-concentric-isometric
Main muscles targeted: flexor carpi radialis (FCR), flexor carpi ulnaris
Load: You should feel fatigued at the end of the last repetition. Typically 5 - 10 kg. You might need to use a lower weight for the eccentric-concentric-isometric version.
Frequency:
Reverse Wrist Curls
The Reverse Wrist Curls (RWCs) are commonly used for strengthening the extensor muscles. In cases of lateral elbow tendinopathy (Tennis Elbow), RWCs are usually the cornerstone of any treatment program exercise. RWCs can be performed in various modes, including concentric, eccentric, eccentric-concentric, or eccentric-concentric-isometric, with the last version being reported as the most effective [96].
To do the eccentric version of the exercise:- Place your wrist palm down (in pronation) on the edge of a flat surface so that your hand has a free range of motion.
- Hold the dumbbell so that your wrist is fully extended - raised as high as possible.
- Lower the weight as far as you can, slowly counting to 5 or even 30.
- Relax your grip and use your other hand to lift the weight back into position.
- Perform 10 - 15 repetitions per set
- Rest 3 - 5 minutes between sets
- Instead of using the assisting hand, slowly lift the dumbbell back up with the affected one (concentric contraction).
- Once the wrist is fully extended (raised), hold this position for 45 seconds while pulling your knuckles towards your elbow (isometric contraction).
- When the isometric contraction is completed, start your next repetition by slowly lowering the dumbbell again (eccentric contraction).
- Perform 10 - 15 repetitions per set
- Rest 3 - 5 minutes between sets
Equipment: Elastic band or free weights
Exercise mode: eccentric, concentric or eccentric-concentric-isometric
Main muscles targeted: extensor carpi radialis brevis (ECRB), extensor carpi ulnaris (ECU)
Load: You should feel fatigued at the end of the last repetition. Typically 1 - 5 kg. You might need to use a lower weight for the eccentric-concentric-isometric version.
Frequency: 3 sets of 10 - 15 repetitions daily or twice a day, 5 - 6 times a week.
External Hammer Rotations
Strengthening the supinator muscle has been shown to improve the healing of LET significantly [236][144][143]. Using a hammer for supinator strengthening exercises is common among climbers, but it can also be done using a rubber band. You can do the exercise either in the eccentric or concentric version. Stasinopoulos and Padasala recommend the concentric version in their articles, but Saunders favors the eccentrics [73].
To do the eccentric version of the exercise:- Place your arm extended on the edge of a flat surface.
- Hold the barbel or the hammer over the edge, in the vertical position, with the weight at the top.
- Slowly lower the weight to the horizontal pronated position (palm down), counting to 5 or even 30.
- Lift the weight to vertical again with the assisting hand to eliminate the concentric phase.
- Perform 8 - 15 repetitions per set
- Rest 3 - 5 minutes between sets
Finding the correct elbow angle is critical. Assess your pain for various elbow angles by bending your elbow and sliding your forearm toward your chest. The positions that elicit irritation or pain are the ones you should address. Keep the load low, but make sure that it is high enough to trigger some discomfort. If all angles are pain-free, you may need to increase the load slightly [235].
The eccentric version of the exercise should be your initial choice, but you may change to the eccentric-concentric version after several weeks as your condition improves. To do that, do not use the assisting hand for lifting the weight back to vertical, but slowly lift it with the affected arm. Also, remember that you may need to use a lower load if the exercise contains a concentric component.
I believe that the eccentric-concentric mode should best be used for the final muscle and tendon tissue strengthening phase and that it had better be avoided if your elbow still has any painful symptoms.
Condition: Lateral Epicondylosis (Tennis Elbow)Equipment: Elastic band, barbell, hammer, or a skillet
Exercise mode: eccentric, concentric or eccentric-concentric
Main muscles targeted: Supinator
Load: 0.5 - 2 kg at the end of the barbel. Depending on the intensity of the symptoms, you may adjust it by controlling the grip distance from the end of the barbel.
Frequency:
Resisted Finger Extensions
The Resisted Finger Extensions is what most people know as the "rubber band exercise." The routine targets pretty much all of the extensor muscles. Although it is not discussed in any research articles I found, it is often mentioned in internet posts [92]. The rubber band exercise could help restore the proper muscle balance in the forearms, but its primary application is to heal and prevent pulley sprains [237]. Also, keep in mind that this is an eccentric-concentric exercise, so if you suffer from Tennis Elbow, it might do more harm than good if used too often and too soon. Nevertheless, I believe that it is a valuable technique to have in your arsenal for keeping your fingers healthy. Still, it should not necessarily be the first choice for elbow tendinosis treatment.
To do the exercise:- Place a rubber band around the tips of your fingers while maintaining a straight wrist.
- Spread your fingers apart without bending your wrist.
- Slowly return your fingers to the starting position.
- Mainly finger pulley sprains
- Medial Epicondylosis (Golfer's Elbow) - as antagonist muscle-strengthening exercise
- Lateral Epicondylosis (Tennis Elbow) - as an eccentric-concentric strengthening exercise for the finger extensors
Exercise mode: eccentric-concentric
Main muscles targeted: wrist, finger, and thumb extensor muscles
Load: standard elastic band
Frequency: 3 sets of 15 repetitions with a 5-second isometric hold once per day [237].
Internal Hammer Rotations
The Internal Hammer Rotations exercise is used to strengthen and remodel the Pronator Teres (PT) tendon. Next to the Flexor Carpi Ulnaris (FCU) tendon degeneration, the microtears of the PT tendon attachment are the typical cause of medial elbow pain. The procedure for strengthening the PT is similar to the one used for the supinator. You can do the exercise either in the eccentric or concentric version. Stasinopoulos and Padasala recommend the concentric version in their articles, but Saunders favors the eccentrics [73].
To do the eccentric version of the exercise:
- Place your arm extended on the edge of a flat surface.
- Hold the barbel or the hammer over the edge, in the vertical position, with the weight at the top.
- Slowly lower the weight to the horizontal supinated position (palm up), counting to 5 or even 30.
- Lift the weight to vertical again with the assisting hand to eliminate the concentric phase.
- Perform 8 - 15 repetitions per set
- Rest 3 - 5 minutes between sets
As with the External Hammer Rotations, assess your pain for various elbow angles by bending your elbow and sliding your forearm toward your chest. The positions that elicit irritation or pain are the ones you should address. Again, keep the load low, but make sure that it is high enough to trigger some discomfort. If all angles are pain-free, you may need to increase the load slightly.
Similar to before, it is best to start with the eccentric version of the exercise and possibly shift to the eccentric-concentric version only after several weeks for final tissue remodeling and strengthening. To do that, do not use the assisting hand for lifting the weight back to vertical, but slowly lift it with the affected arm. For reference, you can look at the demo video recorded by Dr. Saunders himself (see Video 7) [235].
When I struggled with medial elbow pain, I excessively used the concentric version of the exercise, based on the directions I found in the book by Eric Horst [91]. Little did I know that it was much too early in the process. That only led to further degeneration of the tendon tissue, and I ended up quitting climbing for one entire year, which was another bad idea, and needless to say, it did not help either.
Condition: Medial Epicondylosis (Golfer's Elbow)Equipment: Elastic band, barbell, hammer, or a skillet
Exercise mode: eccentric, concentric or eccentric-concentric
Main muscles targeted: pronator teres (PT)
Load: 2 - 5 kg at the end of the barbel. Depending on the intensity of the symptoms, you may adjust it by controlling the grip distance from the end of the barbel.
Frequency:
Triceps Extensions
If you experience pain on the front or the back of your elbow, it might result from muscular imbalance or triceps tendinopathy. In such a case, strengthening your triceps could be a way to tackle the problem. That can best be done through the so-called Triceps Extensions, described by Jared in his article [16].
To do the exercise:- Wrap the resistance band around the palm of the opposing hand.
- Kneel and lift the opposing arm up and to the side.
- Grasp the other end of the band with the active hand and straighten your arm.
- Slowly bend your lower elbow until your hand reaches your chest. Make sure to keep your lower arm aligned with your upper arm.
If the condition is severe, it might be better to avoid the concentric phase of the movement and focus on the eccentric part only. To do that, you can bend the opposite arm each time you straighten the active hand so that you tighten the band with the unaffected arm.
Condition: Triceps tendinopathy, anterior elbow painEquipment: Elastic band
Exercise mode: concentric-eccentric
Main muscles targeted: triceps
Load: standard elastic band
Frequency: 3 sets of 10 repetitions once per day
Elbow pain for rock climbers - Conclusions
Elbow pain is a complex issue that can be difficult to resolve without a physiotherapist's help. Over the years, countless therapies for elbow pain have been developed. The views on the origins of chronic elbow pain and what it truly is have been changing over time. Currently, it is believed that it is a degenerative state with potentially some elements of inflammation during certain phases.
There can be many reasons for lateral and medial elbow pain. Issues may be caused by acute trauma, radial tunnel syndrome, biceps tendinopathy, and many other conditions [238][34]. That is why it is often best to be diagnosed by a specialist before undertaking self-therapy. However, when it comes to climbing, one of the most common causes is tendon tissue degeneration, caused by repetitive stress and excess tension caused by a buildup of adhesions in the forearm muscles.
There are a lot of remedies to be found on climbing websites and fora. Unfortunately, some of them are scams, and some help only a handful of people with a particular condition. Many of them are valid, but they can do more harm than good if they are mistimed. That could happen, e.g., if you introduce strengthening exercises too early. Therefore, the correct timing of the treatment modalities is critical.
A comprehensive elbow tendinopathy rehabilitation program should include exercises to strengthen the forearm flexors and extensors, which are the most commonly affected structures, and for the rotator cuff and scapular muscle strengthening [13][239]. Moreover, techniques to improve reduced proprioception caused by nerve compression are also recommended [93]. Finally, stretching has positive effects on the management of tendon injuries and should be included in any treatment program.
Although it is hard to find a 100% effective method to treat elbow tendinopathy on your own quickly, a good PT will generally know how to help you. If you are not getting better within a month or two, I suggest that you visit one. Don't waste your time suffering when you could be enjoying pain-free climbing days at your favorite crag!
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