[rosmat]

Does that mean I should do lots of it? Most thingd online just say something like 3 sets of 10 a day, I'm happy to do plenty more than that if it might help, but obviously dont want to do too much and make it worse in any way.

I spoke to Dave Mac about this exact topic. As you probably know already Dave is writing a book on climbing injuries at the moment, and so has been researching this in depth. As part of his research he visited the top "tendinopathy" specialist in the UK (London I think he said) who advised:

Repetitions:
Current thinking on best protocol for tendonopathy is 180 - 220 repetitions per day. (Obviously not all at once - I think the idea here is lots of sets throughout the day to constantly stimulate the tendon).

Intensity:
The weight used must be suffiecient to cause discomfort during the exercise. On a "pain scale" of Zero to 10 (where zero is no pain and 10 is agony), the intensity should be around 3-4.

Note: the discomfort should subside within approx. 30 mins following exercise - if it doesn't then reduce the weight. Work up to what is the right intensity - don't just dive in.

However....
You should definitely see a good physio and obtain a correct diagnosis prior to starting any remedial exercise program. Tendonopathy (previously Tendonosis) has become the "go to" self-diagnosis for elbow problems. There are other problems which can produce the same symptoms - so get a proper diagnosis.

Regarding your other question:

seems really strange that aggravating it then makes it hurt less, anyone know how that works?

Very basically, you are using mechanical stimuli to promote re-generation (as opposed to just healing). See here for more information: http://rheumatology.oxfordjournals.org/content/47/10/1444.full


It's very important to point out though that such injuries are often (almost always) a result of either:
a.) Other biomechanical problems such as issues with your shoulder / back (again see a physio).
b.) Poor training methods / technique

Ideally you need to address these underlying issues if you really want to resolve the problem in the long term. Invariably programs to correct these things take much longer (and are f**king boring), maybe months or even years. It really comes down to how committed you are.

I hope you find the above useful, best of luck.

R

[abarro81]

Good knowledge, thanks

[masonwoods101]

whens the book out? any idea? and cheers

[spinmaster]

Same as me that. Thought I had golfers but now tahts pretty much gone and now I'm left with nerve pain... Been climbing today and now my elbow feels like I wacked my funny bone too hard... Load of neck stretches and a kind of Egyptian dancing hand movement to 'floss' the nerves! Still hurts everyday for the last 4 months... If you find a cure tell me please hahaha

Sounds like ulna nerve entrapment. Get a physio to check the origin in the neck for tightness and then the full pathway through the shoulder (and pec minor), tricep and forearm for any areas where it may be sticking. If you have golfers elbow the forearm may be where the entrapment is.

[rosmat]

whens the book out? any idea? and cheers

Sorry I don't know. It was meant to be finished this summer - but I hear it's taking longer than expected.

[masonwoods101]

thanks anyway and yeah man it is a trapped nerve... hot bean bags on the neck are working so guess its there.... f**king sucks

[rosmat]

So much of clinical advise around tendon injuries has taken an about turn in the last 15 years it's really worth obtaining the most up-to date information from a good physio (e.g. FASIC).

Examples are:

1.) Old advise was extended period of rest - Current advise is to exercise (following correct protocols not hitting the campus!).

2.) Old thought was that pain caused by inflammation - Now we know that tendonopathy is non inflammatory (so ditch the ibuprofen!).

I sometimes feel like we (climbers) are obsessed with self diagnosis - I don't understand it. We happily spend £100 on new pair of climbing shoes but we seem reluctant to spend £35 on a session with a physio to get a proper diagnosis.

Again FASIC are extremely good - but I'm sure there is an equivalent at Sheffield Uni. (and there definitely is at Loughborough Uni.)

It'll be the best £35 you can spend.

[duncan]

For those who have/have had golfers: when you do the eccentric curls (the wrist pronator ones particularly) and you get it to hurt a bit do you find all pain then disappears for a while? This happens for me, seems really strange that aggravating it then makes it hurt less, anyone know how that works?

The hypothesis behind eccentric exercising is that you are overloading the area to provoke a healing response. 

Tendonosis - develops slowly with oversuse rather than down to a specific incident - is thought to be a degeneration in the tendon rather than inflammation.  Repeated overload causes microtrauma.  This is usually A Good Thing because repair occurs and the  tendon is strengthened.  If the microtrauma is occurring faster than the repair process can cope with, the tendon eventually breaks down in places. This is tendonosis. Because there is little or no inflammation (the usual healing process) no healing occurs.  Rest is not helpful.   

Most of the successful tendonosis treatments involve stirring things up a bit (through heavy exercise or injecting something that irritates the area) to deliberately cause a little inflammation in order to kick-start healing.  So the exercises should hurt a bit but feel better after.

There are probably also neurophysiological effects with exercise, which is why sometimes the response is quicker than you might expect, but I'm hedging my bets a little here!

[abarro81]

Most of the successful tendonosis treatments involve stirring things up a bit (through heavy exercise or injecting something that irritates the area) to deliberately cause a little inflammation in order to kick-start healing.  So the exercises should hurt a bit but feel better after.

Ok, so should I not be icing after these exercises then, since I want that inflammation?

[duncan]

Ok, so should I not be icing after these exercises then, since I want that inflammation?

In theory, no you should not.  In practice I would experiment with and without. 

My uninformed speculation is that ice will have more of a neurophysiological effect than anything here as the amounts of inflammation are tiny.  It's not like we are dealing with a big, red, swollen knee  (I'm a big fan of ice and have been known to carry a thermos of the stuff to the crag but I'm not sure if it is more curative than paracetamol much of the time).

[rosmat]

Hi Duncan,

I don't mean to be critical but what you have written is out of date / and or factually incorrect. I think it's important to point this out to anyone reading it.

The hypothesis behind eccentric exercising is that you are overloading the area lengthening the tendon under load to provoke a healing response. 

Tendonosis develops slowly with oversuse rather than down to a specific incident - is thought to be a degeneration in the tendon rather than inflammation.  Repeated overload causes microtrauma.  This is usually A Good Thing because repair occurs and the the tendon is strengthened.  If the microtrauma is occurring faster than the repair process can cope with the tendon eventually breaks down in places.  This is tendonosis. Because there is little or no inflammation (the usual healing process) no healing occurs. Rest is not helpful.

This isn't aligned with current clinical thought. This used to be the understanding but it has been proven not to be the case. The term Tendonosis is now redundant and was replaced with "Tendinopathy" to get away from this school of thought.
Tendonopathy is not a degenerative repsonse - it is a failed healing response.

Most of the successful tendonosis treatments involve stirring things up a bit (through heavy exercise or injecting something that irritates the area) to deliberately cause a little inflammation in order to kick-start healing.

This is incorrect. Firstly - "heavy exercise" isn't thought to be what causes a response. Clinical thought is that is the pattern of tendon loading, with its force fluctuations, rather than the magnitude of the force, which is responsible for the therapeutic benefit.

Secondly - "injecting something" I assume you either mean salt water or Corticosteroid. Neither are recommended anymore, and the therapeutic benefit of Corticosteroids is not due to "stirring things up".

Lastly, Tendonopathy is non inflammatory.

Again, sorry if this seems critical - it's not. I can point you in the direction of the current research and clinical papers if it is something your intersted in.

Cheers

R

[rosmat]

Hi Duncan,

I don't mean to be critical but what you have written is out of date / and or factually incorrect. I think it's important to point this out to anyone reading it.

The hypothesis behind eccentric exercising is that you are overloading the area lengthening the tendon under load to provoke a healing response. 

Tendonosis develops slowly with oversuse rather than down to a specific incident - is thought to be a degeneration in the tendon rather than inflammation.  Repeated overload causes microtrauma.  This is usually A Good Thing because repair occurs and the the tendon is strengthened.  If the microtrauma is occurring faster than the repair process can cope with the tendon eventually breaks down in places.  This is tendonosis. Because there is little or no inflammation (the usual healing process) no healing occurs. Rest is not helpful.

This isn't aligned with current clinical thought. This used to be the understanding but it has been proven not to be the case. The term Tendonosis is now redundant and was replaced with "Tendinopathy" to get away from this school of thought.
Tendonopathy is not a degenerative repsonse - it is a failed healing response.

Most of the successful tendonosis treatments involve stirring things up a bit (through heavy exercise or injecting something that irritates the area) to deliberately cause a little inflammation in order to kick-start healing.

This is incorrect. Firstly - "heavy exercise" isn't thought to be what causes a response. Clinical thought is that is the pattern of tendon loading, with its force fluctuations, rather than the magnitude of the force, which is responsible for the therapeutic benefit.

Secondly - "injecting something" I assume you either mean salt water or Corticosteroid. Neither are recommended anymore, and the therapeutic benefit of Corticosteroids is not due to "stirring things up".

Lastly, Tendonopathy is non inflammatory.

Again, sorry if this seems critical - it's not. I can point you in the direction of the current research and clinical papers if it is something your intersted in.

Cheers

R

[rosmat]

Ok, so should I not be icing after these exercises then, since I want that inflammation?

abarro81: tendonpathy is non inflammatory, you don't need to use either ice or ibuprofen after exercise.

However....you might want to try and use ice / ice water more generally to promote increased blood flow as a result of reverse vaso constriction ("Lewis reaction"). Which has been observed to result in increased healing:

Use ice water for this treatment for approx 30 mins. You will need to use enough ice so as is required to promote 'Lewis Reaction' after 5-10 mins (the area of submerged will turn pinky / red).

Too much ice and your elbow will look white and be extremly cold.

Ideally the water will be cold but your elbow should feel warm by the end of the treatment.

Hope that's helpful.

[tj]

Hi rosmat,

I'd be interested in some links to the current research (bit lazy of me to ask for them on a plate, but since you've offered  )

Cheers

[rosmat]

Hi rosmat,

I'd be interested in some links to the current research (bit lazy of me to ask for them on a plate, but since you've offered  )

Cheers

Hi,

My pleasure - glad your interested.

*Note: the majority of studies into Tendinopathy have focused on the Achilles tendon, in part because this an issue experienced by people in high participation sports such as footballers / runners. There has been limited research into tendons which insert at the elbow - but the underlying principles remain the same.

Here you go:

Conservative management for tendinopathy: is there enough scientific evidence? (2008)
http://rheumatology.oxfordjournals.org/content/47/4/390.full


Management of Tendinopathy (2009)
http://ajs.sagepub.com/content/37/9/1855.full


The mechanism for efficacy of eccentric loading in Achilles tendon injury; an in vivo study in humans. (2008)
http://rheumatology.oxfordjournals.org/content/47/10/1493.full


Eccentric Loading, Shock-Wave Treatment, or a Wait-and-See Policy for Tendinopathy (2007)
http://ajs.sagepub.com/content/35/3/374.full

I hope that is of help,

R

[tj]

Cheers for that, something to keep me entertained inbetween drinking coffee and gazing forlornly out of the window at the incessant rain...

[masonwoods101]

Brilliant thanks

[tj]

Hmmm... As with most research of this type, it doesn't seem very inspiring... The answer to the question posted by the first article would (unsurprisingly) seem to be "No". I do use eccentric loading programmes but it does seem to be based more on the hint of "promise", rather than data obtained from high-quality RCTs;

Kearney R, Costa ML. Insertional achilles tendinopathy management: a systematic review. Foot and Ankle International 2010; 31 (8 ) : 689-694

The article by Rees et al (2008) whilst interesting, did strike me as being flawed (small number of subjects (yawn), healthy subjects (i.e. not necessarily representative of diseased tendon)).

Rompe et al (2007) demonstrated that eccentric loading is about as effective as shock-wave therapy, again not massively inspiring?

http://publications.nice.org.uk/extracorporeal-shockwave-therapy-for-refractory-tennis-elbow-ipg313/guidance

I can't comment on the second link as I couldn't access it.

The studies are also a little older than I was hoping (lazy and ungrateful!  ).

Overall, none of this strikes me as especially good quality evidence, but as I've already stated, I'm a bit lazy today (it is friday afternoon) and there may be a wealth of stuff out there that I don't know about. Maybe.

[rosmat]

I agree that there is still a wealth of research that needs to be done.

However, one thing I find positive is that the majority of the studies in the last 5 years do generally agree on at least the following:

1.) Eccentric loading is successful as a therapeutic intervention for Tendinopathy (although the mechanics are not yet fully understood).

2.) Tendinopathy is not de-generative - it is a healing response failure.

3.) Tedinopathy is not inflammatory.

Speaking from a personal perspective I have found eccentric loading to be very effective, and I've been surprised by the rate of improvement observed.

Lastly, apologies about the second link it did used to be viewable as full text. I would recommend signing up as there are some very good (and generally aligned) papers.

[tj]

Cheers for your reply. It's your first point that interests me most. I'm not disagreeing that studies demonstrate fair potential with eccentric loading, it's just that I've yet to see a well conducted RCT or systematic review that demonstrates a significant positive effect. I make this statement with the massive proviso that the last time I did a proper literature search on this was as a student in 2005, but I have done some less comprehensive searches since.

I'm hoping you can point me in the direction of something a little more concrete! 

Like I said, I do use eccentric loading in my practice, but there's an inner sceptic in me that's not fully satisfied. Especially since a friend lent me a copy of Bad Science by Ben Goldacre, but that's another story!

[Fiend]

Intensity:
The weight used must be suffiecient to cause discomfort during the exercise. On a "pain scale" of Zero to 10 (where zero is no pain and 10 is agony), the intensity should be around 3-4.

Note: the discomfort should subside within approx. 30 mins following exercise - if it doesn't then reduce the weight. Work up to what is the right intensity - don't just dive in.

Okay so I have been wondering about this. I'm doing eccentrics for my right elbow, and recently have been doing 3 sets of 20 reps at 12-14kg (alternating with 2 sets on my left). This generally produces no discomfort except for a mild ache in my wrist.

Over the weekend I went bouldering in the cold and my elbow got pretty sore (I should have taped earlier and kept my elbow warm). I was still sore today. At the gym I did 3 sets of 15 reps, at 14, 16, and 20kg. Again pretty hard work on my wrist, but only the mildest of discomfort, 1-2 on pain scale at the most.

Too little weight? I don't think my wrist can take much more. Too few reps? Too few sets? Or am I doing it wrong? I'm tending to have my upper arm at 120' rather than 90' as it feels like it's stretching and stressing the tendon more that way. I've tried other angles but just can't get enough discomfort.

I can certainly up the sets in a day. What is the best weekly schedule for this exercise??

P.S. Please change your avatar, I like your elbow advice and the useful depth you've gone into, but the avatar bugs me 

[duncan]

Cheers for your reply. It's your first point that interests me most. I'm not disagreeing that studies demonstrate fair potential with eccentric loading, it's just that I've yet to see a well conducted RCT or systematic review that demonstrates a significant positive effect. I make this statement with the massive proviso that the last time I did a proper literature search on this was as a student in 2005, but I have done some less comprehensive searches since.

The definitive, well-designed, properly powered RCT on eccentric exercise is yet been done. It would cost upwards of £600K but it might well get funded as it is a question that really needs to be nailed. Unfortunately researchers in this area seem to prefer to do mediocre quality underpowered trials on new'n'sexy interventions.

(So someone prove me wrong  ). 

At the gym I did 3 sets of 15 reps, at 14, 16, and 20kg. Again pretty hard work on my wrist, but only the mildest of discomfort, 1-2 on pain scale at the most.

Too little weight? I don't think my wrist can take much more. Too few reps? Too few sets? Or am I doing it wrong? I'm tending to have my upper arm at 120' rather than 90' as it feels like it's stretching and stressing the tendon more that way. I've tried other angles but just can't get enough discomfort.

It should hurt more than this.  Sounds like you are not quite hitting the spot. Have you tried eccentric supination?



(or, dare I ask, has anyone who knows what they are doing assessed it properly?)

[Fiend]

Haven't tried supinators, so I will try that. I need a stick.

As for assessment, no, but it's identical to my previous golfer's elbow that was assessed by 3 physios (2 climbing physios) and is responding in the same way.

[Andy W]

I'm finding that I have mild pain when I start the eccentric exercises, which passes by the second set and by the third set I can use more weight.  What does this mean, am I cured?

[Paul T]

Haven't tried supinators, so I will try that. I need a stick.

I do mine with a dumbell loaded on one end only. Gripping the threaded bar might not be everyone's cup of tea though!