This is the third and final part of our series on climbers elbow. In previous blogs we have talked about the underlying cause of the climber’s elbow and how to prevent it (www.insideedgephysio.com/single-post/2018/03/13/Climbers-Elbow-Part-2-Prevention).
Today we will discuss the management or treatment of this rather disabling and performance sapping condition. However, before we get started it is important to set the terms of reference so all readers are clear on what we are, and are not dealing with.
We are talking about the management of climber’s elbow caused by over training which has led to degenerative changes within the tendon structure (https://www.insideedgephysio.com/Climbers-Elbow--What-is-it-Part-1). So we are not referring to a one off high load event which causes a traumatic injury such as a torn tendon.
Treatment and Management:
The aim of a comprehensive management approach should be to achieve the following:
To impart as much education into the climber as possible so they understand the diagnosis and the likely causes of the injury.
To reduce pain to allow purposeful rehabilitation.
To develop a tendon loading or strengthening programmed to improve the tensile strength of the tendon and force generating capacity of the muscle.
To improve any associated neck or thoracic spine or related dysfunctions which could be contributing to the underlying condition.
To provide a prescriptive approach to the climber’s eventual return to climbing by the gradual application of climbing intensity, duration and climbing grade.
The First Point!
Rehabilitation must be a methodical process or the climber will fail to reach their true potential and re-injure the degenerate tendon tissue. This failure to reach their true potential is normally because the climber stops the exercise therapy and tendon loading programme after the pain reduces and is cleared to start easy climbing. It normally goes’ something like this in the climber’s mind.
“Well I am climbing now and my symptoms are manageable so I don't need to see my physiotherapist any more and I will be able to get back to full climbing fitness under my own steam”
Now, this is not to say that some climbers can’t structure their own rehabilitation by themselves. However, consider this for a moment! Most climbers got injured because they pushed themselves too hard and did not listen to the signals, or understand the ideas about progressive tendon loading. So, there is an argument that if they did understand the science and practice of tendon loading they would not have got injured in the first place! So, just to hammer home the point your rehabilitation does not finish when the pain has gone. The tendon will not have regained its full tensile strength until you are back climbing fully. It is difficult to get back to full climbing and tendon fitness without a systematic and methodical approach. This is where a Physiotherapist that understands climbing and progressive strength and conditioning for tendons is GOLD!
The absence of pain does not mean, unrestricted climbing!
The phases of recovery:
So for convenience we can break the rehabilitation process into three distinct phases for ease. However, the phases are not meant to be prescriptive and there will be some cross over and overlap between the phases.
In phase one the immediate temporary cessation of climbing and climbing-specific activities is really important. At this stage it is important to get an accurate medical and physiotherapy diagnosis.
What is a Medical diagnosis?
Many of you will be looking slightly confused at this stage, thinking why do you need a physiotherapy and medical diagnosis. Well a medical diagnosis is designed to establish the pathological cause of the patient’s symptoms. A pathological diagnosis is concerned with what structures have been injured (e.g. tendon, muscles, nerves, joints or bursa etc.) because that is what the medical profession can direct their surgical or injection therapies towards. This is fine if you have something that needs an injection or surgery …. But many problems that affect climbers don’t!
What is a Physiotherapy diagnosis?
Now while a skilled physiotherapist can make a medical diagnosis in many cases and can request scans and expensive imaging in much the same way doctors can a physiotherapy diagnosis is different. A physiotherapy diagnosis is concerned with the consequences of the medical diagnosis. Or put simply, what has gone wrong and can’t be fixed by surgery or an injection. So for example, a climber with climbers elbow caused by tendopathic changes will have predictable weakness in the forearm flexor muscles and probably extensors because of muscle imbalance. There may be associated soft issues tightness in the forearm flexors and triceps muscles. A common associated problem in persistent elbow disorders is problems with the ulna nerve. The ulna nerve is positioned adjacent the flexor tendons as it courses around the elbow bones. To add insult to injury (no pun intended) the Ulna nerve is then sandwiched between the forearm flexor muscles as it extends down the forearm. This nerve often becomes highly sensitive because of its proximity to the flexor muscles. Its movement can also be restricted because of soft tissue tightness in the triceps muscles and joint stiffness in the neck. This can be a significant source of pain on top of the tendopathic pain from the flexor tendons.
Oh and there is more!
Then then we have factors up steam in the neck ,the shoulder girdle and rotator cuff muscles that can contribute to ongoing symptoms and reduced climbing performance. So there is a lot to do to get the climbers rehabilitation spot on, so that the underling condition is treated appropriately and its recurrence reduced.
Now hopefully you can see why it is not recommended to recommence climbing without a physiotherapists guidance even when the pain is better.
Phase 1 continued:
Phase 1 could last from two weeks to a month or longer depending upon the severity of the condition. If the soft tissues are restricted and contributing to sensitivity of the ulna nerve and pain transmission, then it is a priority to treat it. Equally, it may be wise to begin improving rotator cuff and scapular muscle strength while waiting for the acute tendon pain to settle.
As soon as symptoms have improved a guided rehabilitation program should be initiated and is the hall mark of a successful outcome. The first goal of rehabilitation is for the climber to re-gain full and painless wrist/ elbow range of movement. At this point, stretches and progressive isometric exercises are introduced to the rehabilitation program. Initially the elbow should be extended during these exercises to minimize the load applied to the tendons, but as the climber progresses, greater elbow flexion should be increased. As pre-injury flexibility and strength return, a progressive increase in load with concentric and eccentric resistive exercises should be added to the training program. The aim of this phase is to make the climber stronger and more robust than the pre-injury level, because pre-injury muscle and tendon strength proved vulnerable to overload.
In this phase the aim of the programme is to enable the climber to return to climbing safely with a graduated climbing programme in terms of duration and climbing grade. This is where many climbers get it wrong! The pain gets better and they return to climbing without a load management schedule and wing it! This often leads to a gradual increase in symptoms over several weeks. Or the climber is stuck climbing easy grades at or below their on sight indefinitely, because every time they try to push their grade the pain returns. Often, many climbers need a longer period of low intensity climbing under the watchful guidance of a physiotherapist for longer than they think! The climbers weekly climbing schedule is a part of their tendon loading programme in addition to formal tendon load training with specific exercises. The programme must be customized to the needs of the climber and their climbing goals (e.g. bouldering, sport climbing, climbing holidays planned and competitions etc.).
IT IS NOT ENOUGH JUST TO GET BACK TO CLIMBING, IF YOU WANT THE BEST OUTCOME!
A physiotherapist who understands climbing should always analyze the climbers climbing to identify technical flaws that may have caused the problem or are contributing to ongoing symptoms. The question at the forefront of the physiotherapists mind should always be why hasthat climber developed climber’s elbow in the first place?
Are they too reliant on their fingers and forearm flexors when you climb?
How good is their footwork at critical stages?
Are the muscles around their shoulder blade resilient enough to function as an optimal bridge between their body and their arms?
Do they have enough leg and hip strength to get out of a high knee positions or do they compensate with their finger strength?
This analysis and clinical interrogation of the climber should be at the core of a comprehensive rehabilitation approach. The body is a kinetic chain and the development of pain is never the result of failure of a single part of that chain.
TREAT THE WHOLE CLIMBER; DON’T JUST TREAT THE ELBOW!
Most often Climber’s elbow is the result of overuse or a strength imbalance between the forearm muscles.
The goal in Phase 1 is the reduction of pain and the correction of contributing factors when possible.
In Phase 2 the rehabilitation is directed towards re-gaining of full and painless range of motion in wrist and fingers. Specific soft tissue techniques are extremely helpful at this point of the treatment (see https://youtu.be/4bxtflNYPD8)
A progressive tendon loading programme is the cornerstone of an effective rehabilitation programme to improve its robustness and resilience to climbing.
Phase 3 is the return to climbing phase. A structured climbing programme in addition to a tendon loading programme although critical to a good outcome is often omitted by climbers.
A detailed and thorough assessment of a climber’s technique is essential to reduce the risk of injury recurrence.
References: 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