"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