24 April 2007

Elbow injury - lessons from tennis

Here is an interesting wee link to some summary data about rehab of Tennis Elbow on the Sports Physiotherapy For All website. Tennis elbow in climbers is pretty rare (I think, but there is no data on it!), but does sometimes happen. Where it does happen I suspect its most likely caused by a discrete event such as a sudden tear, or due to a very unusual climbing technique. The main reason I posted about the link was to draw attention to the comments about late stage rehab of this type of injury. In climbers this will more likely be medial epicondylitis or problems with brachioradialis, although it applies to any sports injury. The article stresses the importance of good technique and relying less on strength and making more fluid and efficient movements. This is most often the underlying cause of overuse injury in the first place, and the reason why certain people are plagued with repeated injury of the same type. In climbing, key risk factors for finger and eblow injuries are probably poor footwork, a 'rushed' climbing pace and a habit of locking off and pulling up to initiate moves rather than initiating movements with your feet. Of course, there are risk factors in the areas of training practice, nutrition and lifestyle and genetics as well, but these may be less significant that movement technique.
So, the message is clear - to prevent injury occuring or recurring, look at your movement technique.


Richard said...

I'm in the final phases (hopefully) of recovery from medial epicondylitis in my left elbow. I thought my experience might help others who develop a similar injury.

The problem began with the opening of the first dedicated climbing wall in Aberdeen – the 11 metre RGU wall. Prior to this I’d trained exclusively on bouldering walls or by climbing outdoors. Although I’ve had an assortment of muscle tweaks I’d never suffered a serious tendon injury due to training. Needless to say my warmup routine consisted of chalking up and starting to climb. Over a period of several months I’d raised my grade and was aiming for F7a. I noticed that my elbows had started to hurt when I climbed, but the pain always vanished after I’d done a few routes. It wasn’t a sharp pain, more of a background level, but it was becoming noticeable. I put it down to regular and harder training so wasn’t too concerned. However, I was climbing a route on an overhanging section of the wall last October, my left arm locked off on a small crimp, and a 90 degree bend at the elbow. Suddenly I felt a very sharp pain in the elbow, all the strength drained from my fingers and forearm and I fell off. After resting for 10 minutes the pain had subsided so I started climbing again, but on easier routes. I returned a week later thinking a week off would have allowed the injury to heal. Although I didn’t have the acute pain any more, I had very little lock-off strength in my left arm and didn’t feel confident loading it. After a couple of weeks I decided complete rest was the best option.

I stopped all climbing for 6 weeks, but I didn’t go to a doctor or physio, thinking this was plenty of time for the injury to heal. The first session back seemed alright, climbing only up to 6a. Again I limited training to once a week but after the 3rd visit the pain had returned to my elbow and it felt very weak again. After doing a little reading on golfer’s and tennis elbow I decided to take a 2 month layoff before returning, again not consulting with a doctor or physio. This time I limited my climbing to 5+ grades, and again after a few sessions the pain had returned. If anything it seemed worse! Finally, I relented and sought the advice of a sports physiotherapist.

After a very painful physio session I learned I’d torn the tendon in my elbow. The tear was made almost inevitable by the fact that I’d been stressing the tendon over a long period but ignored the tell-tale background pain. There was a large build-up of scar tissue preventing the tear from healing properly. I’ve had 9 physio sessions, consisting of direct and forceful massage of the lump of scar tissue to break it down (this really hurt!), followed by ultrasound and laser treatment to promote blood-flow in the tendon. I’ve also been following a stretching and icing regime every day. I’ve started bouldering again, in a progressive fashion, gradually building up the grade. The elbow is starting to feel strong again and I’m looking forward to a good Summer.

Lessons Learned
1. Warmup and stretch properly before every climbing session.
2. Develop the antagonistic muscles as well as developing your “climbing” muscles.
3. Use an open hand grip as much as possible, crimping only where you have to.
4. If you start to experience constant background pain during/after climbing seek medical advice.
5. If you experience acute pain stop climbing immediately. Ice the affected area as soon as possible to prevent swelling and seek medical advice.
6. A planned recovery programme is essential, with the help of a physio if required.
7. Unlike me, don't assume you know best! You might prevent an injury in the first place, and certainly reduce your recovery time substantially...

titifrig said...

I've got an elbow injury by pulling to much on my arms and forgetting about my feet.

As Richard said, it' s important to "develop the antagonistic muscles as well as developing your “climbing” muscles".

For this, I do the exercise explained in the tennis article at fig.4. A load of 2.5kg, 30 repetitions on each hand, twice a day. Other exercises could be done but this one seems to me that is the most efficient.

If I stop doing it and keep climbing, the pain comes back in a 2-3 days and disappears in max 2 days of re-exercise.

Of course the other stuffs are important: warm-up, stretch, use your feet, drink water, pay attention to the rest periods.

Have fun!

Anonymous said...

I appreciate the great info on elbow repetitive stress injury. I'm about 8 weeks into the recovery process, but am concerned that I may not be on the correct path. I would very much like to hear from others who have recovered from this issue on what worked and didn't work for them. It's been difficult to miss out on most of the summer climbing season, and I'm hoping I can get back into shape before the end of the year.

After first noticing pain on the inside of my elbow, I took a few weeks off from climbing. I then resumed climbing at a lower level than before, and would ice the elbow and pop a few ibuprofen after a workout. I would only notice the pain when using certain grip positions. However, the pain didn't go away, although fortunately it didn't get any worse.

About 4 weeks after first noticing the pain I went to see the doctor. Unfortunately I don't think my doctor has a lot of experience with sports injuries, so I'm not sure how useful his advice is.

He recommended complete abstinence from climbing until the pain went away. He also said that popping a few ibuprofen pills wouldn't do anything for inflammation. He prescribed 800 mg tablets and recommended taking 3 per day. He also recommended continuing with the ice treatments. The doctor also mentioned breaking down scar tissue with massage, but wasn't very specific as to how to go about doing this (location, pressure, etc). He also gave me an adjustable band to wrap around my forearm. He said something about how it would either help distribute the load or change the direction of the load, so that it wouldn't stress the tendon connection as much as before.

It's been almost 4 weeks since the doctor visit, and I still haven't seen much change. I normally don't feel any pain, but there are certain motions or grips that do it. Using a knife to cut a slice of cheese is one of the worst!

I know tendon injuries can take a long time to heal, but I'm wondering what is reasonable?

- Do I really need to refrain from all climbing until the pain is completely gone? If I can limit myself to low level climbing might it actually stimulate the area and help promote healing rather than make things worse?

- Now that the initial inflammation is gone is there any reason to continue with the ibuprofen or icing? Would treatments with cool water baths rather than ice-cold water work better for promoting blood flow (as has been recommended for finger injuries)?

- Should I try to get a referral to a physical therapist who can help with the deep-tissue massage to break down scar tissue? Should I try to see a different doctor who has more expertise in sports injuries?

- The band I use around the forearm does seem to help -- motions that will typically cause pain cause less or no pain when wearing the band. However, I am concerned that the band might be reducing blood flow to the affected area. I try to leave it off when not using the affected arm. Is the band really helping (by reducing additional small tears to the tendon) or is it just masking the problem?

Dave MacLeod said...

Wow, lots of questions there anonymous, I'll try to answer some. Reasonable recovery times for tendon injuries depend entirely on what you do during the rehab process. Do nothing or stall recovery with inappropriate lifestyle, activity, nutrition and medication and it will remain chronic indefinitely. Seek out the detailed information you need, and follow it vigourously and the recovery may be less than one year. Within that, you may be able to support normal sporting activity within weeks with careful management of the injury. Most athletes have at least one injury in the process of recovery at any given time, but it may not be affecting their play if it they work hard and smart enough at the management of it. I've currently got 4 injuries, none of which are stopping me climbing due to careful daily monitoring and rehab.

GPs often have no knowledge of sports injuries rehabilitation and will generally advise you with no regard to sporting performance, only to relief of pain and return to 'normal' (in a non-sporting sense) function. If you want sound and specific advice but don't have time to become an expert in it yourself, always seek out advice from a recognised expert. It's worth the money because otherwise you are just blindly hoping you don't make a critical error in your rehab choices.

Ibuprofen can interfere with the inflammatory process in a way which leads directly and indirectly to further tissue damage. It is only indicated for tendon injuries in a very few situations and even then the specialists are still divided over this.

I would say that little change in your injury is to be expected after taking a layoff and ibuprofen. A program of rehab from an expert or researched by yourself will produce much better results, with steady and persistent effort over a long period.

good luck with it.

Anonymous said...

What about a tunnel syndrome of a cubital canal? I got it ( alas), and it seems to be basically different from epicondylitys.

Anonymous said...
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Anonymous said...

I think that too much emphasis is put on tennis elbow, and not enough on the other forms of injury that can be contracted through the sport.

Sprained ankle, calf strains and shoulder injuries are all more common forms of sports injury that can be contracted through tennis, not just elbow damage; and tennis players need to be aware of this and prepare for their matches adequately.

doug scown said...

Some great info on these problems at http://www.athlon.com.au/articles.htm

Grindelwald said...

After ignoring a niggling pain in my elbow I was diagnosed with tennis elbow. The physio via the GP gave me a brace to put on. I only had to wear it for about 1/2 dozen times and the elbow is now 100% However (!) I now have rotary cuff tendonitis in the same arm - is there a link here do you think? This is extremely painful but am hoping a weeks rest and I can slowly get back into climbing. Any longer and I will go mad :) Am I being too optimistic?
Thanks Dave, great site found via UKCF

Neil said...

Recently got a fingerboard up in my back porch and me and my son are having a great time on it, but I've developed a pain on the outside (bony part) of my left elbow. It doesn't hurt at all when working on the fingerboard. I only feel it when I fully extend my arm, and when I'm out cycling and have my arms bent on the bars I feel it.

Don't know what it is. Not a major problem though.

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