"Climber's elbow" - Brachialis Tendonitis

So this post is to explore the other problems with elbows – specifically "climber's elbow" – a differential elbow pain to that of tennis or golfers elbow. Less common than biceps brachii injuries but quite common in climbers.

Climber's elbow is caused by tendonitis of the brachialis muscle. The brachialis muscle lies deeper than the biceps brachii muscle and originates on the upper humerus and attaches to the ulna.

Brachialis is a true flexor of the elbow as it attaches to the ulnar (rather than attaching to the radius which rotates over the top of the ulnar during pronation and supination. N.B. Biceps brachii attaches to the radius)

Therefore, because of the broad origin on brachialis and it's only function is to flex the elbow, the brachialis can be considered the strongest elbow flexor.

This injury, if a gradual onset, is most likely to be tendonitis. If there is pain in this area of the elbow after a specific incident/fall, it could be a rupture of ligaments or muscle tendons. 

N.B. Pain in this area of the elbow, could be, as mentioned above, could be from biceps, from brachialis, or even from problems with the proximal ulna-radial ligament. Always worth getting these kind of problems checked out.

Also needing ruling out would be shoulder / wrist / finger injuries or muscular imbalances.

Palpation

To try and identify the injured structures, you can try and palpate the painful area. 

The brachialis tendon must also be palpated for tenderness during elbow flexion, as both the biceps and brachialis flex the elbow. 

The brachialis muscle and its tendon are palpated where they insert at the tuberosity of the ulna and the coronoid process of the ulna. 

Like the biceps, the distal end of the muscle and/or the insertion of the tendon would be tender with injury. 

Supination of the hand would not necessarily affect the brachialis tendon, helping to further differentiate between the two muscles.

Symptoms

• Deep elbow pain (not superficial like tennis/golfers elbow generally is)
• Pain on anterior (front) elbow (note, this could be due to a biceps brachii injury)
• Swelling around the elbow or above the elbow (in the cubital fossa)
• Inability to bend elbow comfortably

Cause

Brachialis tears normally occur during a forceful contraction or a forceful hyperextension while climbing. Complete tears are associated primarily with elbow dislocation.

Tendonitis is normally caused by strain from sudden increase in training, overuse or repetitive elbow bending or forced, excessive elbow straightening (hyper-extension).

Treatment

Full rupture = surgical intervention would be required.

For a partial tear:

• Control inflammation in the acute phase – see POLICE Principles
• Rest
• Dep tissue frictions / Massage
• It has also been suggested that traversing may irritate the brachialis, so consider limiting this.
• If a tendonitis, the research suggests eccentric biceps curls (lowering of a weight in the curl position), however, I've found anecdotally that in the hammer position with your thumb pointing upwards works better.
• Exercise progression from isometrics to eccentric to concentric strengthening, ensuring all are pain free, progress from isometrics once full range of movement around the elbow is achieved

Prevention

As usual, warming up is a key prevention method

Ensure adequate recovery time between climbing days

All-round strengthening of rotator cuff, biceps and brachialis can maintain a good strength all round to correct any kind of muscle imbalances.

Triceps can also need stretching/strengthening depending on the imbalance.

Stretching of lattimuss dorsi and biceps

Technique when performing pull-ups etc or when climbing i.e. making sure you lock with your lats by keeping your elbow close to your body. Try not to chicken-wing (see below)

In the bottom row of pictures, you can see the correct form for pull-ups, with the elbows tucked in

In the top row, the elbows are "winging", which makes you more prone to injury

Also note, don't snap your elbows straight when lowering from a pull-up, control the movement down.

  

Avoid:

• pull ups with weights – your working to body strength – why do you need to be able to do pull-ups with weights?!
• descending bachar ladder
• down climbing campus board
• no snapping back of elbows during climbing/pull ups

And if your wondering where I got the lovely t-shirt, go to climberagainstcancer.org 

References

Live Strong article

Miller KJ 2013 Climber's Elbow: Diagnosis and Conservative Treatment Protocols. Dynamic Chiropractic Vol. 31, Issue 01

Memorial healthcare system 2013Brachialis or Anterior Capsular Elbow Strain with Rehab mhs.net 

Hochholzer T, Schoffl VR 2006 One Move Too Many. Lochner-Verlag, Germany

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.......

You decide! Comment below on the next topic you would like me to write about, email or tweet me!
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!

And if you want updates of when I write a new post, use to "Follow this blog by Email" function, or subscribe to RSS feeds using the options on the right-hand side.

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