Medial and Lateral Epicondylitis (Golfers and Tennis elbow!)

Sorry this one has taken a while - but here is goes: lateral and medial epicondylitis.

Lateral epicondylitis = tennis elbow
Medial epicondylitis = golfers elbow
I will use the different terms synonymously throughout this post.

This is a problem that seems to plague more climbers than I originally first thought. Apparently, medial epicondylitis affects climbers more than lateral does, but I haven't found any statistics on this. However, it makes sense that it should as climbing requires a lot of use of the flexors to maintain grip. 
I did find that tennis elbow affects 1-3% of the population, and peak incidence is between 40 and 50 years of age. It affects men and women equally and the prognosis is between 6 months and 2 years.


Anatomy

Causes

The causes of epicondylitis in general is generally one or a combination of:

• Over gripping or over use of flexors
• Muscular imbalance between flexors and extensors
• Not enough rest
• Climbing too hard
• Climbing too often
• Repetitive movements

This is because epicondylitis is inflammation that is caused by repetitive microtrauma to the insertion points of the flexor and extensor muscles at the medial and lateral epicondyles respectively.

It is important to note the anatomy of the biceps and pronator teres, as the biceps turns the palm inwards (supination), whereas for climbing we want the hand to be palm outwards (pronation), and so pronator teres will battle with the biceps to maintain pronation, and can also cause microtrauma to this usually undertrained muscle of pronator teres, and cause medial epicondylitis.

Symptoms

Symptoms of medial and lateral epicondylitis are usually pain in the region of the forearm muscle attachments (the epicondyles) which is exacerbated by active and resisted movements of wrist extension for lateral and wrist flexion for medial.

Do remember though, that the pain could be caused from a neck issue, from the shoulder, arthritis, or carpal tunnel. If you are concerned, see a professional.


Treatment

Unlike previous posts where I've directed you to my "Management of Acute Injuries" post, this time, I will not, as the most important initial treatment is REST, as the cause is from repetitive use of those muscles without adequate time for them to rest. and recover. Therefore:

• Eliminate all pain-causing movements, including activities such as climbing
• Ice and ice massage over the area
• Non-steroidal anti-inflammatories if required, but only short term (Green 2001)

 If no swelling is evident and pain is reduced, mild stretching and deep tissue friction massage can be implemented (stretches described below).
Then, gentle strengthening exercises and gentle return to climbing. If in doubt, a delayed return to climbing is preferred due to epicondylitis recurrence rates being quite high.

If you go to see a physiotherapist, they may also use techniques such as ultrasound (Dingemanse 2012) of which the evidence is good. Physiotherapy exercises have been shown to have a faster and greater regression of pain compared to a wait-and-see approach (Peterson et al 2011).

Corticosteroid injections are a common approach sought, and studies have found that they are successful in the short term, but physiotherapy exercises have a better intermediate and long term outcome for lateral epicondylitis (Barr et al 2009)

And seeing as I reviewed some kinesio taping studies recently, Chang et al (2012) found that kinesio tape may improve pain, but has no significant results for baseball pitchers with medial epicondylitis (baseball pitchers chosen due to the overhead activities performed).

Please note: Do not return to climbing activities too soon, as epicondylitis has a high recurrence rate.

Exercises

Flexor stretch (for golfers) and extensor stretch (for tennis)

Remember to hold any stretch for at least 30-45 seconds, and always warm up first.

Pronator strengthening (for golfers)

Extensor strengthening (for golfers)

For a unorthodox stretch that may aleviate your golfers elbow, click here

Flexor strengthening (for tennis)

Eccentric exercises for lateral epicondylitis (Tyler 2010)

Or eccentric supination as suggested in the UKC article about medial epicondylitis

Tape/Brace

The idea of these braces or clasps is to change the insertion point the muscles are pulling from, to try and reduce the strain on the epicondyles. You can also tape around this area if required to try and perform the same function, but you will probably find that it will hinder your climbing more than help it, so I wouldn't recommend it.
The evidence for elbow clasps for tennis elbow has weak evidence, especially after 6 months and a year (Callaghan 2007). This doesn't mean that it won't help for short term alleviation and the anecdotal evidence using the clasp in conjunction with exercises is positive, but it's your choice.


Prevention

To prevent epicondylitis from reoccurring, or from occurring in the first instance, there are several courses of action. starting with the ever recurring advice of:

• Ensure adequate warm up
• Stretch regularly (perform both the stretches demonstrated above after each climbing session)

Along with:

• Ensure adequate rest between climbing sessions - listen to your body
•  Any new activities should be performed gently and controlled, such as starting fingerboarding
• Any deadhangs should be performed with elbows slightly bent
• Correct any muscular imbalances (this can be done by performing the muscle strengthening exercises above, generally I'd do the extensor and pronator ones, as predominantly climbers will have strong flexor muscles)
• Climbing technique - lateral epicondylitis can be caused by poor technique, as your grip strength is strongest when your hand is extended - hence why your arms "chicken wing" from the rock when you're trying to crimp a small hold, and the extensor muscles facilitate this, and this constant extensor muscle strain can lead to lateral epicondylitis - again, an old message - vary the grip you use, don't crimp everything!

Good luck!

Coming soon.......

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I have ideas, such as healing times of tissues, epiphyseal plate injuries, elbow compartment syndrome, or maybe another shoulder pathology? Let me know what you want!

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References

 UKC article about medial epicondylitis

Hörst 2007 Elbow Injuries

NHS Clinical Knowledge Summaries

Chang HY, Wang CH, Chou KY, Cheng SC  2012 Could forearm Kinesio Taping improve strength, force sense, and pain in baseball pitchers with medial epicondylitis? Clin J Sport Med 22(4):327-33

http://rockclimbinguk.co.uk/category/performance-improvement/injury-prevention-and-treatment/

Barr S, Cerisola F, Blanchard V 2009 Effectiveness of corticosteroid injections compared with physiotherapeutic interventions for lateral epicondylitis: A systematic review. Physiotherapy 95: 251–265

Dingemanse R, Randsdorp M, Koes BW, Huisstede BMA 2012 Evidence for the effectiveness of electrophysical modalities for treatment of medial and  lateral epicondylitis: a systematic review. Br J Sports Med

Peterson M, Butler S, Eriksson M, Svardsudd K 2011 A randomized controlled trial of exercise versus wait-list in chronic tennis elbow (lateral epicondylosis). Upsala Journal of Medical Sciences; 116 269–279

Callaghan M, Holloway J 2007 Tennis elbow and epicondyle clasp: Best Evidence Tpoic Report. Emerg Med J 24: 296-297

Green S, Buchbinder R, Barnsely L 2001 Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults (Cochrane Review). The Cochrane Library. Issue 4. John Wiley & Sons, Ltd
 
Tyler TF, Thomas GC, Nicholas SJ,  McHugh MP 2010 Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: A prospective randomized trial. J Shoulder Elbow Surg 19: 917-922