"Elbows" - an introduction (http://climbingphysio.blogspot.com/2013/03/elbows-introduction.html)
24 March 2013, 7:21 pm
Climbers' elbow, Font elbow, tennis elbow... the perennial, unresolving bain of many a climber causing pain, limited training, years passing by. Sound familiar?
Disclaimer: self-diagnosis and treatment via the internet is not a recommended way of solving your problems. If you have on-going, persistent, or any sort of troublesome injury, you should seek face-to-face professional advice. You'd do it for your car, do it for your body.
This post is meant to be "educational", and perhaps give you an understanding as to why self-diagnosis of "tendonitis" (the default self-diagnosis from what I can tell), and the resultant mis-treatment, unsurprisingly, leads to non-resolution of a seemingly simple problem.
Furthermore, this stuff is NOT evidence-based - it is my theory as to the common cause of 'Font elbow'. Anecdotally it seems to hold some water, and the advice on how to prevent it is good advice anyway, and ought not to do you any harm!
It is a huge subject: the complexity of the physiology of the cervical & thoracic spine, the shoulder girdle, the actual shoulder (gleno-humeral) joint and the arm means that problems breed problems - biomechanics veer away from 'normal', resulting in compensations, altered movement patterns and structural changes. I'm going to try and tackle the subject as a series of short posts - please feel free to comment/ask questions, which I can try to answer as we go along...
The aim of this post is to introduce my thoughts on "cause", and provide some basic anatomy. I hope it makes sense and isn't too laborious.
OK, as far as climbers are concerned, I believe there are two main causes of lateral (outside of the) elbow pain. There is genuine lateral epicondylitis (Tennis elbow). This is characterised by a definite point of tenderness (pain) on the lateral, bony point of the elbow. The pain may extend down into the posterior (rear) portion of the forearm, and will be acutely exacerbated by resisted wrist/finger extension. This, I believe, is RARE in climbers. There is a definite, evidence-based treatment programme for it, and you should seek professional help to have this outlined for you.
The other type of lateral elbow pain is a diffuse deep ache that affects the lateral part of the elbow and upper arm/lateral bicep. It may extend down into the forearm, but does not have a definite 'point' of pain. It usually comes on with squeeze-type bouldering moves, or manteling - hence its nickname of Font elbow. If you suffer with this, just the thought of topping out on classic Fontainebleau 'blobs' will bring tears to your eyes!
It is my belief that this type of problem is brought about by instability at the shoulders: the use of pecs when doing these types of moves pulls the head of humerus forwards in the 'socket', and it impinges on the structures running over its anterior (front) aspect. This leads to referred pain further down the arm. Classic impingement occurs with overhead activities, causing impingement of supraspinatous, but that is not applicable here. It is why, however, this type of anterior impingement is rarely diagnosed - it does not fit a commonly observed picture. Like many sportspeople, climbers put unique strains on the body, but there is virtually no research, literature and therefore understanding of these unique problems.
The main aim of this series of posts is to give you some idea about normal movement at the shoulder joint. What you have in the body is movement muscles and stabilising muscles (and some muscles that do a bit of both). For normal movement, what you need is correct alignment (posture, if you like) at ALL joints, and dynamic control of ALL joints (i.e. maintenance of alignment through movement). The classic 'agonist/antagonist' model does not fit. Again, knocking out a few intermittent press-ups to "even yourself out" is not going to help you much.
The shoulder complex can be split into 2 main 'joints' - the 'scapula-thoracic junction' and the 'gleno-humeral joint'. Very simply, the scapula is a 'floating' docking point for the arm. I shall deal with scapular stability in the next post, but it's a very complicated thing to achieve, and (if it's an issue) unlikely that you can do it without professional help. I shall mainly outline what can go wrong, and how to identify if yours are not working quite as they should.
The gleno-humeral joint is what you think of as your shoulder. The humerus is the bone that forms the upper arm, the glenoid is the 'socket' that the humerus attaches to. The glenoid is part of the scapula.
(http://saptstrength.com/wp-content/uploads/2011/06/glenohumeral-joint.jpg) (http://saptstrength.com/wp-content/uploads/2011/06/glenohumeral-joint.jpg)
OK, so what are the likely problems that climbers will get suffer from with the gleno-humeral joint? Fundamentally, problems at the shoulder can basically be split into 2 main catergories - stiffness or instability, although often these will occur simultaneously. My view is that instability at the gleno-humeral joint is a very common, and very debilitating problem for climbers. I think it is the MAIN CAUSE of climbers' elbow problems, i.e. NOT tendonitis.
Some background. The upper limbs are evolved for relatively low-load, large range activity - scratching your neck, wiping your bum, picking fruit from trees, throwing spears. Fortunately, our ancestors did a lot of climbing in and, swinging from, trees, so our shoulders can adapt back to this, but fundamentally, our shoulders are designed to allow large range of movement. They are inherently unstable. The muscles we use to stabilise them are much smaller and weaker (and tire more quickly) than the muscles we use to move our arms. The muscles we are talking about are the much talked about, but little understood, rotator cuff.
The rotator cuff is made up from 4 muscles: supraspinatus, infraspinatous, teres minor and subscapularis. The best way to decribe their action is as 'guy lines'. The shoulder is described as a ball and socket joint. It is, in fact, a beach ball and saucer joint. The humeral head is huge, the glenoid is a small, flat plate. Unlike the hip, with its deep socket, it has minimal structural stability.The large muscles that move the arm - deltoid, pectoralis major, latissimus dorsi are pulling the humerus out of the glenoid. The tiny rotator cuff is working like stink to not let that happen. Needless to say, it's a losing battle.
In the picture below, imagine you are looking at somebody lifting their arm sideways. The black arrows show the action of deltoid. Unopposed, this would cause the head of humerus to 'roll' upwards out of the glenoid. The red arrow shows the action of the inferior rotator cuff (infraspinatous & teres minor). The act as guy lines, providing a downward force, and causing the head of humerus to 'spin' in the socket - maintaining alignment.
[tr][td](http://2.bp.blogspot.com/-8WaxjpCtHis/UUiDZBRNXlI/AAAAAAAAAiQ/-WkViei7LP8/s320/IMG_4339.JPG) (http://2.bp.blogspot.com/-8WaxjpCtHis/UUiDZBRNXlI/AAAAAAAAAiQ/-WkViei7LP8/s1600/IMG_4339.JPG)[/td][/tr][tr][td]Schematic diagram showing action of rotator cuff[/td][/tr]
[/table]So what can we do about it? Firstly, those theraband exercises that you see people doing are the first line of defence against gleno-humeral instability. See the videos below. They should be an essential part of any climber's training regime. As with all exercises, you need to do some high load sessions to build strength, but also using low load as part of your warm up to get the muscles activated and ready to go. These exercises are primarily for infraspinatous & teres minor (the inferior cuff), which are the key muscles that maintain humeral head position.
?The other element that is important is the role of the posterior capsule in gleno-humeral alignment - and this is likely to be something that you haven't encountered before. There are 2 elements to it.
No 1: capsule length. The capsule is a piece of fibrous connective tissue that surrounds the joint. It helps with stability. In fact the ligaments are thicker parts of the capsule (a ligament is a non-stretchy piece of connective tissue that prevents excess movement at a joint).
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The posterior capsule is quite prone to shortening, and this will cause the head of humerus to sit too far forwards in the glenoid. The video below will show you how to work out if yours need stretching, and how to do it. A quick word on stretching. You must differentiate between stretching to warm up, and stretching to increase range. When warming up, you don't want to overstretch the muscles/soft tissues - it will increase the likelihood of instability and make the muscles less efficient (muscles must be under tension). When warming up, you are just getting the muscles ready to work in their available range (i.e. gentle stretches, not trying to push past the current maximum range).
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?No 2: Rotator cuff trigger points. Trigger points are sections of the muscle belly that go into spasm, usually from prolonged or excessive work. If you have a prod around in the areas indictaed below, you may find some points that are "exquisitely tender" (as the textbooks say) when you press into them. They probably indicate that your rotator cuff are working pretty hard. This section of the muscle becomes 'non-contractile', making the muscle weaker. They also produce pain when the muscle contracts, so will further decrease the muscle effectiveness by a phenomenon called 'pain inhibition'. Get rid!!
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To alleviate them, just press into them for 10 seconds or so (you may feel them relax), and then do the stretch in the above video (scarf stretch). They will come back, but with time and plenty of trigger point massage and stretching, they should improve.
The video below shows a way to begin to understand the 'correct' position of the scapula. I will attempt to undertake a more detailed post on the scapula and scapula stability, but this little exercise is important, and will allow you to start to gain control of your scapulae.
The video below gives some advice on resting position of the shoulders, in terms of lateral rotation. Many climbers stand with their shoulders protracted and inwardly rotated, which also causes the elbows to hang in a slightly flexed position. Now imagine the position of your arm when climbing - often the shoulder is laterally rotated, raised above the head and the elbow is straight, i.e. the opposite extreme. By standing with the shoulders laterally rotated, the elbows extended, you can help to lessen the difference between these 2 positions.
Hopefully, this will give you a basic understanding of the gleno-humeral joint, and how to try and keep it more stable. Next time we will look at the role of the scapula, and after that I would like to talk about the implication that shoulder instability has on the nerves of the upper limb.
Source: Physiotherapy for Climbers (http://climbingphysio.blogspot.com/)