Climber’s elbow or medial elbow tendinopathy are terms used to describe pain around the inside of the elbow,
Climbers Elbow
Shoulder pain, pulley injuries, finger joint pain and elbow pain are the most common injuries we see in our climbing clinic. Today I want to dive into a common injury seen in many climbers which is presistant medial elbow tendinopathy or “Climber’s elbow”.
Climber’s elbow or medial elbow tendinopathy are terms used to describe pain around the inside of the elbow, where the tendons of the pronator teres (the muscle that rotates your forearm inwards) and the forearm flexor muscles (responsible for finger and wrist flexion) are located.
What is it:
Well this is a difficult question, because we are not entirely sure, and anyone who says that they are 100 % sure, you should be wary of! In years gone by the medical profession throught this was an inflammatory condition or an itis which was best managed with anti-inflammatory medication and rest……. But guest what? A lot of patients with this condition did not get better and so the medical profession had to re-think the mechanisms causing the pain and disability. However, advances in our understanding of the pathology causing persistant tendon pain has led to the demise of a primary inflammatory cause in favor of a degenerative non inflammatory cause. Now a days we think that the the primary problem is that the tendon because of frequent climbing is subject to micro trauma which fails to repair before the tendon is subjected to additional strain and load.
So why is this important?
Well it means that while anti inflammatory medication which is dished out by many healthcare professionals may provide you with some relief of pain, it wont fix the problem and neither will rest! The most current research and our experience tells us that patients with tendinopathy display tendons that are thicker (in a bad way!), weaker and have less capacity to deal with load.
This is the important bit !!!! Keep reading!!!
This means that when they pull hard on a hold the climber with a tendopathic tendon will exhbit higher strain or stress in the tendon than the climber with a healthy tendon. The cause of this is the degenerative changes that have taken place within the matrix of the tendon. A tendon is primarlly made up of Type 1 collagen fibres (proteins), a water based solution containing an extracellular matrix (or the glue that gells every thing together) and some other cells. When the tendon becomes degenerate there is dis-orginisation of the collegen fibres and loss of the very thick and robust Type 1 collegen fibres which are very good at dealing with tensile loads (see picture below). In its place we get the smaller Type 3 collegen fibres which is like scar tissue and so less robust and able to do the work that our Type 1 collagen fibres did. And to add insult to injury ( no pun intended) there is also often areas of cellular death in the tendon. So this means that we have tendons which are weaker because they has lost their strength and robustness. This we think gradually leads the tendon to become very sensitivity to load which makes pulling hard on holds and gripping very painful!
But is not all doom and gloom …… as this condition is treatable. We will explain how to do this in subsequent blogs !
How is it caused ?
The primary cause of Climber’s elbow is a repetitive stress or overuse of the flexor/pronator musculature due to climbing too often, too hard and/or with too little rest between sessions. Although repetitive overuse has been identified as the primary cause of persistant Climber’s elbow, a single traumatic event or a single hard move (or failed move) may result in the development of pain. This situation will be obvious and the signs and symptoms equally as obvious. Pain, swelling, redness and instant disability! But this situation is very uncommon when compaired to the long , slow and gradual onset of pain and disability associated with tendopathy.
What else?
In addition, muscle imbalance between the flexors (which are usually too strong) and the forearm extensors (which are usually too weak , because we don't train them) muscles of the forearm as well as, muscle adhesions (trigger points) in the tight forearm flexors can contribute to elbow pain.
How do we make the diagnosis?
The diagnosis of Climber’s elbow requires taking a careful patient history and physical examination. Medial elbow pain is characterized by pain of insidious (slow) onset along the inside of the elbow, which is worsened by resistance to forearm pronation (rotate the forearm inwards) and wrist and finger flexion. The origin of the tendons is usually tender when palpated or pressed or squeezed. The severity of the pain may vary, but is most often present during or after climbing. Initially the range of motion of the affected arm can be full but in later stages it may become limited resulting in restriction in wrist and finger movement.
Why a full examination is important?
As a rule it is important to do a full examination of the wrist , elbow and forearm joints to identify any joint or musculotendinous restrictions that could be contributing to the patients ongoing disability and symptoms. We also evaluate the cervical , thoracic spine regions and the median nerve function in patients that have had long standing symptoms or report a current or previous history of neck pain. This is because it is well recognized now from extensive research that neck pain and problems in the upper body (muscle imbalance ) is common in patients with persistant elbow pain.
Next week we look at how to manage this very difficult condition and share our top tips on how to rehabilitate this problem.
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References:
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