Golfer's elbow (medial epicondylitis)

[PT-David]

Hi guys,

I've been working out for sometime now but developed Golfer's elbow and receive treatment for this by a physiotherapist.

My workout exists as follows: warm-up: the 60sec holds as suggested in one of the stickies

(60s plank, 60s reverse plank, 60s perfect hollow hold with hands over your head, 60s arch hold in the superman flying position, 60s Parallel Bar support, 60s chin up grip dead hang).

My workout: 3 sets/5reps of Decline Push-up on a swiss ball, pull-up, V-up and deck squats and this 3 x a week (M, W, F).

I do this in a steady state cycle. This for primarily for gaining the necessary strength needed for the more advanced exercises/movements.

I also warm-up and cool down by doing static and dynamic stretching.

Before training like this, I used to train in a "functional" manner (a combination of bodyweight training, lifting movements, strongman, plyometrics,...).

Anyone any idea how I can continue from here because I can't perform any pulling movements right now. Should I just drop the pull ups and continue or should I reconsider my entire training?

[scottmo]

Medial Epcondylitis is difficult to heal. Time off exercises that exacerbate the condition as well as fish oil and vitamin c has been recommended on this forum by Coach Summer. A very interesting presentation pertaining to tendonopathy can be found here http://www.authorstream.com/Presentatio ... owerpoint/. Which was found by forum member Mbern. Interesting to note Eccentric loading of the tendon has been shown to be effective in some pts. Many articles have been written pertaining to this- http://faculty.fullerton.edu/gnoffal/Co ... e/iso2.pdf. I am glad this topic was brought up and I was wondering if Coach Summer has any experience with Eccentric Loading for tendonitis. I personally have tried NSAIDS, Voltaren gel, Vit C and increasing fish oil. I have been trying eccentric loading for medial epondylitis and have noticed a marked improvement with this method. I hope this info helps.

[Cole Dano]

Nice to hear that its been working for you, hadn't thought of applying the eccentric idea to the elbow.

What specifically have you been doing with eccentrics?

The net does have quite a lot of good info available on treating this problem.

Some things that i've found helpful are, wrist roller work, and rotating an off center weight (i use a 2 pound indian club, but anything will work, for example a litter bottle of water). To do this with a bottle, hold it by the neck, at arms length and rotate it in both directions as far a possible without moving your arms.

[scottmo]

Mr Brady, In the article I attached you can see the study was pertaining to achilles, patellar and epicondylar tendons. Improvement outcome was similiar for all. I personally do rope climbing with a heavy emphasis on a slow controlled decent allowing each single arm to extend to its fullest. I have also done heavy chins with weight attached again controlling the decent and full extension. And yes, it does hurt, but as the time has passed the strength is increasing and the pain is decreasing. Again, I was hoping Coach Summer could comment on this topic as this type of training seems counterintuitive but it is effective.

[Cole Dano]

Rope climb negatives, good idea!

I suppose weighted negatives would also be good to add to that list, and maybe easier to get into than the chin depending on your set up of course.

[PT-David]

Perhaps Coach Sommer could elaborate his findings or his point of view on this condition?

Great stuff, Scottmo. Eventhough I cannot perform any pulling motion or negative for the moment.

MrBrady, prior to this workout I did use a forearm roller and rotated an offcenter weight to strenghten my muscles.

According to my fysiotherapist (also specialized in manual therapy and neuro manual therapy), I can workout but when it hurts I have to stop. So for now, all pulling motions (even deadhangs or negatives) are out of the question since they hurt. It doesn't bother me with the other exercises which is lucky for me. So I can keep my current level of fitness.

I think I got this condition by doing deadhangs and chin ups. However, I'm baffled by this because I'm no stranger to training and training techniques and used these exercises aswel prior to me following this workout. It is a RSI so perhaps I was doing too much at once. But I say this without any conviction because 15 reps of chin ups and 180 sec deadhang a week is less then what I was doing before this workout (when I was still working out with weights etc.).

[Milos]

I had been working 3*5 pulls from a complete dead hang to pulling as high as I could (i.e. trying to get chest to bar height) six days a week before. After a few weeks of this I started getting tendonitic pain. Since then I've been working the prerequisites like you, except I haven't been doing chin/pull work. What I have been doing that it looks like you haven't is chin/pull flex hangs. For me, the main areas I felt my elbows getting destroyed was a little at the bottom (dead hang, full extension) but mostly at the top (flex hang, full flexion). To me, this seems to suggest that you or I have no business regularly going through the full range of motion under stress for reps until the body can effectively exert strength (as measured by handling the static holds for time) throughout that range of motion. Note also that while working no chins/pulls and even playing around less with trying muscle-ups (although having worked jumping pullovers) than on the chin/pull program, I gained after only a few weeks my (admittedly very, very sloppy) first muscle-up.

So my suggestion to you is to work dead hangs and then flex hangs as an FSP as soon as you are able to. When you have mastered these (I would expect this to probably take at least two SSC's, very likely more), tentatively move on to chins/pulls. But bear in mind that even if improvements are seen due to stabilising muscles strengthening, the tendons will take much longer to strengthen. In my case I seem to have been able to compensate for the slowness of tendon growth with improvements in muscle/neural efficiency; this could be more the case or less the case with you.

(Edit: Regarding experience: My elbows started getting tendonitic after a year of very climbing-intensive freerunning--i.e. after thousands upon thousands of coincidental chins, pulls and dips. But recently even this relatively very low volume of static work has improved the stability and strength of these very same movements)

[PT-David]

Hey Milos,

Thx for sharing your experience on this. Glad to hear that someone has had a similar problem (although it's a little bit strange to state this :? ).

But I think you're right. I will try to work something out like you and see where it's get me.

In the meanwhile I heaven't worked on pull/chin-ups or deadhangs for a week now and my elbows are less sore.

I'm thinking of reincorporating some weight training to strenghten my arms and forearms.

But yeah, the muscles really the problem. The only thing we can do is gradually build strength to our tendons.

I will try to follow your tips. Can you elaborate a bit more over your handling about this?

[Milos]

As you are recovering from an injury, I would suggest a very light workload, adding additional volume to the joint only as you are sure you can handle each preceding increment. These hangs will probably already be enough to challenge your grip by themselves. (It is very likely that your grip will be the limiting factor in achieving 1*60s holds.)

Make your priority on each workout day to do these as essential prehab before any other optional elbow-intensive work:

Monday: 60s pull hang, 60s chin flex hang

Wednesday: 60s chin hang, 60s pull flex hang

Friday: 60s pull hang, 60s chin flex hang

then

Monday: 60s chin hang, 60s pull flex hang

Wednesday: 60s pull hang, 60s chin flex hang

Friday: 60s chin hang, 60s pull flex hang

***

Or something like that. (You might find three days a week too much in terms of tendonitic pain or simply feeling too fatigued/burned out to complete every workout. In this case, reduce to two days a week.)

I recommend initially holding the chin directly over the bar during flex hangs. This will not only allow you to break the 60 seconds into fewer and longer chunks by reducing the intensity but also ensure that you really are maintaining the chin above the bar--you'll soon find out if it drops! As you become stronger and more able to honestly judge your chin height, you can begin holding further back away from the bar if you wish.

You can add other (non-pulling & non-grip) exercises in between hangs as a rest period between exercises. This will allow you to complete the statics/prerequisites/prehab work before seeing if you are ready for additional work such as FBE's. If you do continue, they will be a good warm-up.

I should note that I have been feeling a lot of stress during the flex hangs. So far my elbows haven't become tendonitic, but it is possible that these flex hangs in particular might be too advanced at this point, leading to tendonitis over a longer term. Proceed with caution.

[Joshua Naterman]

Guys, strength is an issue and there is a great deal of good advice in this article but the base cause is missing entirely.

Excessive passive tension in the muscles is the major problem here, not strength itself. THis could come from scar tissue, hypertonicity (too much passive tension in the muscle), localized contractions (trigger points) or a combination of some or all of the above. If it's just hypertonicity then progressive stretching is all you need, but combining that with Active Release stretches and Gua Sha/Graston Technique/IASTM/ as well as extended duration cross-frictional massage will allow the tension in the muscles to be rebalanced, which will allow the tendon to heal. This is why so many sports clinicians and osteopaths and chiropractors learn some or all of these techniques, and this is also why people are thrilled with their treatments (particularly with ART, as it it is effective for the widest range of these issues out of any single treatment option).

TO properly use crossfrictional massage you will need to use only moderate pressure and you will need to massage the area for 15-20 minutes without stopping. It will take 5-10 minutes sometimes to begin noticing the releases, but you will see a major, major change in the tissue quality. It is slow, but when ART-type methods are either difficult to use for an area or are not quite doing the whole job this is the way to go.

Graston is essentially instrument assisted cross-frictional massage. There are different pressure levels that are used and certain advantages to using instruments in many cases but the basics are the same.

Read about these and why the work, and how to do them. Google has many of the answers, and your local therapists have the rest.

If you do not fix excess tension you will always have a repeating condition. Directly working on this is the most sure way to put these problems behind you forever.

[Nic Branson]

Slizz is on the ball again. Just trying to continue increasing strength is more then likely to make the problem worse and not better. Proper massage to increase circulation area, will vastly help with the inflammation and tissue quality. Try some massage work on the bicep as well. Also work mobility on both sides of the joint.

If there is pain do not train that area yet.

[Milos]

That's interesting. I have been massaging my arms, but much less often than I've been doing the static holds and have so far avoided reinflammation. I had assumed that was due to the lower volume + conditioning avoiding the problem and that the effect of the massage was minimal but it sounds like maybe I've just delayed it and had it the wrong way round!

[Joshua Naterman]

Keep in mind that inflammation only lasts for a short period of time, 2-3 weeks at most. After that, apparently our bodies actually grow NEW sensory nerves along with new blood vessels to feed them, and this is what is responsible for the continued painful sensation we feel in chronic injuries.

Think about it: You've got an injured area, what's the best way to remind yourself not to wreck it completely? Build a more sensitive alarm system and keep it until you finally heal, of course! It actually makes sense, as crappy as it feels for us.

I don't know if these nerves disappear or are just "unwired" or "deactivated" when excess tension is removed, but that is what appears to be causing prolonged pain. NOT inflammation. Inflammation is what you WANT, because it means there's more blood moving. More blood = more nutrition = more healing. This is part of what massage accomplishes. The other part is stimulating the formation of type 1 collagen, which is pretty neat. That's the stuff you want. Mechanical loading, whether it's ART or Graston-style or old-fashioned cross-friction massage, helps stimulate the breakdown of type 3a scar tissue collagen and cause it to be replaced with the good stuff!

It doesn't take much to keep the healing ahead of the damage once you've fixed the original problem! If you can remember to massage regularly and maybe graston the area once a week or so you'll really be in great shape.

I've got a powerlifter friend that I lent my homemade graston tool a few weeks ago... I gave it to him for his left shoulder and tricep along with instructions and how it worked, and he ended up using it on his hamstrings as well! Now he's putting palms on the ground with a flat back. Three weeks ago he couldn't get past mid-shins no matter how hard he tried. Pretty crazy... his back pain is apparently gone now. Simple stuff like this works well for a lot of issues!