Pain near the medial epicondyle is commonly called golfer’s elbow or climber’s elbow. Pain develops in the tendons connecting the pronator teres muscle and/ or the many forearm flexor muscles (responsible for finger flexion) to the knobby, medial epicondyle of the inside elbow.
In many cases medial tendinosis is caused by muscular imbalances of the forearm and an accumulation of microtraumas to the tendons that result from climbing too often, too hard, and, most important, with too little rest. Consider that all the muscles that produce finger flexion are anchored to the medial epicondyle. Furthermore, the muscles that produce hand pronation (that turn the palm outward to face the rock) originate from the medial epicondyle. This subtle fact plays a key role in causing this injury: Biceps contraction produces supination (turning of the palm upward), but in gripping the rock you generally need to maintain a pronated, palms-out position. This battle, between the supinating action of the biceps pulling and the necessity to maintain a pronated hand position (to maintain grip with the rock), strains the typically undertrained teres pronator muscle and its attachment at the medial epicondyle.
Given the above factors, it’s easy to see why the tendons attaching to the medial epicondyle are subjected to sustained stress and, inevitably, develop microtraumas. Just as muscular microtraumas are repaired to new level of capability, the tendons increase in strength and can withstand higher stress loads given adequate rest. Unfortunately, the repair and strengthening process occurs more slowly in tendons than in muscles. Eventually, the muscles are able to create more force than the tendons can adapt to—the result is injury.
Tendinosis will reveal itself gradually through increasing incidence of painful twinges or soreness during or after climbing. Tendinitis, however, is evidenced by acute onset of pain in the midst of a single hard move (or failed move), and is usually followed by inflammation and palpable swelling. Even in these cases cumulative microtrauma may be involved in making the tissue vulnerable to acute trauma.
As in treating other injuries, you can more easily manage tendinopathy (any tendon injury) and speed your return to climbing by early recognition of the symptoms and proactive treatment. The mature and prudent approach of attending to the injury early-on versus trying to “climbing through it” could mean the difference between six weeks and six months (or more) of climbing downtime.
Treatment of tendinosis and tendinitis has two phases: Phase I involves steps to relieve pain and reduce of inflammation (in the case of tendinitis); Phase II is engaging in rehabilitative and stretching exercises to promote correct alignment of collagen tissue and prevent recurrence.
Phase I demands withdrawal from climbing (and all sport-specific training) and commencement of pain-reducing and anti-inflammatory measures. Icing the elbow for twenty minutes, three to six times a day, and use of NSAIDs will help reduce inflammation and pain following injury; cease use within a few days to a week. A cortisone injection may be helpful in chronic or severe cases, though this practice is somewhat controversial among physicians and, in fact, may be detrimental to the healing process (Nirschl 1996). Depending on the severity of the injury, successful completion of Phase I could require anywhere from two weeks to two months.
The goal of Phase II is to retrain and rehabilitate the injured tissues through use of mild stretching and strength-training exercises. Since forearm-muscle imbalance plays a primary role in many elbow injuries, it’s vital to perform exercises that strengthen the weaker aspects of the forearm—hand pronation for medial tendinosis and hand/wrist extension for lateral tendinosis (more on this in a bit).
Always perform some general warm-up activity and consider warming the elbow directly with a heating pad before beginning the stretching and strengthening exercises. Stretch twice daily the forearm flexor, extensor, and pronator muscles as shown below. Once the stretching exercises have successfully restored normal range of motion with no pain, you can introduce strength training with the forearm pronator exercise (below). It’s important to progress slowly with training exercises and to cut back at the first sign of pain. Begin with just a couple of pounds of resistance and gradually increase the weight over the course of a few weeks. Use the stretching exercises daily, but do the weight-training exercises only three days per week.
After three to four weeks of pain-free training, begin a gradual return to climbing. Start with low-angle and easy vertical routes, and take a month or two to return to your original level of climbing. Continue with the stretching and strength-training exercises indefinitely—as long as you are a climber, you must engage in these preventive measures. Failed rehabilitation and relapse into chronic pain may eventually lead to a need for surgical intervention.
Finally, let’s take a look at the use of counterforce bracing, or circumferential taping of the upper forearm, as a curative (or preventive) measure for elbow tendinosis. A counterforce brace designed specifically for elbow tendinosis can provide some comfort by dispersing forces away from the underlying tissues. These braces are not a substitute for proper rehabilitation, however; they instead act only to help prevent recurrence after full rehabilitation. There is little evidence that supportive taping of the forearm provides the same benefit as use of a counterforce brace.
In a standing position, bring your arms together in front of your waist. Straighten the arm to be stretched and then make a tight fist; place the fist in the palm of your other hand. With your fist hand in the thumbs-up position, gently pull the fist inward to create a mild stretch along the back of the forearm. Hold this stretch for twenty seconds. Now release the stretch and rotate the fist until it’s in the awkward thumbs-down position. Again, use your free hand to flex the fist and hold for twenty seconds—hold a solid fist and keep your arm straight to best work this strange, yet important stretch (needed to stretch the brachioradialis). Repeat this stretch with your other hand.
In a standing position, bring your arms together in front of your waist. Straighten the arm to be stretched and lay the fingertips into the palm of your other hand. Position the hand of your stretch arm so that the palm is facing down with the thumb pointing inward. Pull back on the fingers of your straight arm until a mild stretch begins in the forearm muscles. Hold this stretch for about twenty seconds. Release the stretch and turn the hand 180 degrees so that your stretch arm is now positioned with the palm facing outward and the thumb pointing out to the side. Using your other hand, pull your fingers back until a stretch begins in the forearm muscles. Hold for ten seconds. Repeat this stretch, in both positions, with your other arm. Finish up with a minute of self-massage to the forearm flexor muscles using deep cross-fibre friction.
Sit on a chair or bench with your forearm resting on your thigh with the hand in the palms-up position. Firmly grip a sledgehammer with the heavy end extending to the side and the handle parallel to the floor. Turn your hand inward (pronation) to lift the hammer to the vertical position. Stop here. Now, slowly lower the hammer back to the starting position. Stop at the horizontal position for one second before beginning the next repetition. Continue lifting the hammer in this way for fifteen to twenty repetitions. Choke up on the hammer if this feels overly difficult. Perform two sets with each hand.
Summary Tips for Treating Elbow Tendinosis
1. Cease climbing and sport-specific training.
2. Apply ice to the injured area and take NSAID medications only if the injury produces visible or palpable swelling (most elbow tendinopathy does not). Cease use of ice and NSAIDs as soon as swelling diminishes—further use will slow healing.
3. Never use NSAIDs to mask pain in order to continue climbing while injured. Regular use of NSAIDS (and smoking) may actually weaken tendons!
4. If no swelling is present, begin mild stretching, light massage, and use of a heating pad (ten to fifteen minutes) three times per day. Most important is twice-daily use of the forearm stretches shown above.
5. If no swelling is present and if pain is minor, engage in rehabilitative exercises on an every-other-day basis. Perform some warm-up activities such as arm circles, finger flexions, massage, or use of a heating pad. Use Reverse Wrist Curls for lateral tendinosis and Forearm Pronators for medial tendinosis.
6. Cautiously return to climbing when your elbow is painfree and no sooner then after two to four weeks of strength training exercise. Begin with easy, foot-oriented climbing for the first few weeks and limit use of the crimp grip. Cease climbing if you experience pain while climbing and immediately return to Step 2.
Copyright 2007 Eric J. Hörst. All rights reserved.