In the previous article we presented the most current thinking about the cause of persistent climber’s elbow. Tendon pain is the most common elbow problem in athletes, especially in climbers. At risk populations also include those that are involved in activities which involve repetitive and /or forceful and heavy manual tasks. To recap, in our last article we questioned traditional ideas held by many climbers and healthcare professionals that the primary problem causing elbow pain was an inflammatory condition. We challenged this position with pioneering research suggesting that it is a degenerative problem caused by the tendons failure to repair after hard climbing and training.
So in this article we explain the preventative measures available to climbers and other athletes which can reduce the risk of developing this disabling condition
Prevention should be better than cure! 1. Why straight arm climbing will set you free?
Straight arm climbing is one the best investments you can make to prevent this condition from stopping you climbing. This important and often neglected aspect of climbing technique is critical for protecting your elbow tendons.
To understand why we first need to go back to our physical education class at school and anatomy class 101. What are the muscles and tendons responsible for flexing our fingers, the muscles that allow us to hold on to the rock? There are really two muscles that are notable requiring our consideration.
The forearm flexors include:
The Superficial flexors
The Deep flexors
The forearm flexor muscles are particularly important in relation to persistence elbow pain. The reason for this is because of their anatomical arrangement. The flexor digitorum superficialis is the more superficial of the two muscles and attaches to the medial epicondyle above the elbow joint on the arm. The flexor digitorum profundus muscle is the deeper of the two and attaches on the forearm below the elbow. This means that when the elbows are bent and we need to hold onto the rock, as we do by flexing our fingers, the tension on the entire group is huge. This information will be of no real surprise to many climbers, because, we can all appreciate that our finger flexors need to generate a lot of force to hold on to the rock. But this force from the muscles is transmitted to the tendons and then on to a very small area of bone on the forearm and above the elbow joint. To add insult to injury (no pun intended) when the elbow is bent this now means that the tendon now has to develop tension around a right angle turn or a corner (your elbow). So in actual fact, not only are you developing huge amounts of tension in your tendons, which is what they are supposed to do! But you are now also introducing a compressive force into the mix and squashing the tendon against the elbow bone. So is it any wonder that climbers often complain of pain in the superficial flexor tendon above the elbow joint. Still don’t understand, well then let’s use an analogy!!!
To visualize what is happening, imagine getting your finger caught in your belay device, while also getting it caught up in the rope and pulled a part! So it gets squashed and pulled apart at the same time. Would that hurt …? Hell yes! So when you are climbing with bent elbows, down climbing, repeating a sequence that needs a deep lock off with a bent elbow on a crimp over and over again.
It then becomes very obvious that this will eventually overload the tendon!
2. Why you need to worry about your finger extensors?
Many climbers talk about antagonist training but very few actually do it or know how to do it properly. The finger extensors are important muscles for helping to reduce the load on the elbow flexor muscles and its tendons.
Well it is very common for climbers to have a significant muscle imbalance between the forearm flexors and forearm extensors. Now, the flexor muscle group in all humans should be stronger than the extensor muscle group because we spend most of our lives gripping objects. However, when this imbalance moves away from an acceptable limit this can cause problems. By definition if you are a climber and who climbs more than 3-times per week it is very likely that you will have a muscle imbalance because of the extra gripping you do when you climb compared to the rest of the population.
Well, the so what is this!
Your extensor muscles in the forearm are responsible for positioning your hand in about 20-30 degrees of wrist extension during gripping activities. This is very important because the flexors muscles cannot generate optimal levels of force above or below 20- 30 degrees of wrist extension. So if your extensor muscles are significantly weaker than your flexor muscles they will fatigue quickly changing the wrist position. This will cause your flexors muscles to rapidly lose strength. But worse still,as your wrist position changes for the worse, you will naturally have to pull harder with your flexors muscles and this will lead to overuse of the muscles and tendons.
This can all be avoided by training the forearm extensors!
3. Why a clever and strong rotator cuff group is critical to climbing preformance
All climbers have heard of the rotator cuff muscles, but most don’t train these important shoulder muscles until they have injured their shoulder. The rotator cuff is made up of a team of four important muscles, the infraspinatus, supraspinatus, terres minor and subscapularis. These muscles can be found lying deep to all other shoulder muscles taking their attachment on the head of the humerus. In short, these muscles as a group provide close support for the ball and socket joint in your shoulder (glenohumeral joint). Their role is to control the positioning of the ball and socket joint at rest and during times of high load (e.g. when climbing). Research has shown asymmetrical levels of strength in the muscles of athletes with elbow pain of tendon origin. This finding is not surprising considering the important role these muscles play in supporting the shoulder joint during heavy physical activity.
4. The role of the scapular stabilizing muscles
There are not many climbers that need an excuse to train their finger strength, but ask them about the training they do for the scapular stability muscles and most of the time I will be met with a blank face. These muscles include the middle and lower trapezius muscles and posterior chain. These muscles are the power houses behind the scenes that provide the foundational support for the shoulder joint and help to position the shoulder blade on your rib cage and therefore your arm and elbow.
Why are the shoulder blade stabilisers important in climber’s elbow?
The shoulder blades are one of the forgotten heroes of the shoulder because they are not as sexy as the doing one arm pull ups or dead hangs. However, they help to positioning the shoulder blade to accept loads generated by the shoulder joint during all climbing and upper limb activities. They also act as an attachment site and base of support for the rotator cuff muscles and the many neck muscles during campusing, lunging and over hanging walls. So when you neck feels stiff and a bit sore the next day after a hard bouldering session, it may be because your neck muscles are compensating for poorly functioning shoulder blade muscles. Research has shown a relationship between weak shoulder blade muscles or the scapular stabilizers and elbow pain in tennis players that have tendopathic changes at the elbow. In fact, in recent research it has been shown that tennis players with elbow pain has a 25-35 % reduction in the lower and middle trapezius muscles when compared to players without elbow pain.
This therefore suggests that poorly functioning or weak scapular muscles contribute to tendon problems at the elbow. This is biomechanically plausible as a physiotherapist because if your scapular muscles are weak then they will fatigue quickly or not have enough strength to position the shoulder blade in an optimal position to support your shoulder. This then means that your elbow will be in a poor position to generate force which will affect your overall body position on the wall. This will also mean that your forearm flexors are required to work harder to keep you on the wall leading to overuse and strain. This is also supported with research as another study found that patients with poorly positioned shoulder blades also had reduced grip strength when tested electronically. More, importantly, when the shoulder blade position was optimized by coaching the patients to recruit specific muscles the grip strength improved to a significant degree. Consider, this practical climbing example, we have all seen the climbers with rounded shoulders and chicken wing arm positioning during hard problems who eventually fall off the wall. It is common to hear them blame their finger strength as the primary cause of their demise, but we now know better?
Alizadehkhaiyat O et al ( 2007) Upper limb muscle imbalance in tennis elbow : a functional and electromyographic assessment. Journal Orthopaedic Research 25, 1651-1657
Bhatt JB et al (2013) Middle and lower trapezius strengthening for the management of Lateral epicondylalgia: A case report. Journal of orthopaedic and sports physical therapy. 43, (11) 841 846
Brooke K et al (2015) Management of lateral elbow tendinopathy: One size does not fit all. Journal of orthopaedic and sports physical therapy. 45, (11) 938-950
Horst E (2016) Training for climbing. Falcon. Connecticut
Scott et al (2015) Tendinopathy: Update on Pathophysiology. Journal of orthopaedic and sports physical therapy. 45, (11) 883-842