Injury & Rehab: the gym junkie’s elbow

Overuse of the hand and wrist in pulling exercises can result in excessive movement, overstrain and micro-trauma in the forearm and elbow. identifies the causes and rehabilitation techniques for this common area of injury.

If any of your clients have elbow, forearm or wrist pain, they may have 'Popeye Syndrome'. Increasing numbers of personal trainers and clients who are participating in both traditional workouts and popular current alternatives, such as ViPR, CrossFit and kettlebell, are presenting with elbow pain (both medial and lateral). Despite frequently being extremely fit, closer postural scrutiny of these individuals often highlights the disproportionately large forearms in relation to their upper arms and shoulders (hence our affectionately labelling this development ‘Popeye Syndrome’).

By determining whether an injured client is exhibiting a classic muscle imbalance pattern, we can seek to restore balance in order to rehabilitate the injury.

Rather than looking at nerve entrapments and the vast spectrum of possible joint and muscle dysfunctions around the elbow, here we will focus on a common movement/muscle imbalance that is part and parcel of injuries to the elbow, forearm, wrist and hand.

Before we go any further, however, it is important to understand that these muscle imbalances;

  • are very common, often habitual and therefore feel ‘normal’
  • create overload of various nerve, joint and myofascial structures, leading to injury
  • result in tightness of the dominant agonist muscle, and weakness of the antagonist stability-muscle
  • need strong commitment to a rehab process in order to be fixed.

You may find that clients who experience elbow pain during workouts also play golf or tennis, participate in rock climbing, or regularly use laptops – all of which further exacerbate their symptoms. Occasionally they also complain of intermittent pins and needles and numbness when resting or at night in bed.

The issue: over-using the hand and wrist in pulling exercises

Most clients with wrist and elbow pain tend to overuse their forearm and/or wrist by ‘kinking’ their wrists into flexion or extension. This usually occurs at the expense of pure scapular retraction and thoracic rotation. They do not exhibit the smoother flowing movements that are seen when the whole shoulder and arm are synergistically working together. This results in excessive movement, overstrain and micro-trauma of medial or lateral structures in the forearm and elbow.

Example 1

One example of this overuse is a tennis player who plays a forehand incorrectly due to winding up for their stroke by extending the wrist rather than opening the shoulder (scapular retraction) and rotating through the thoracic spine. This may overload their common extensor muscle group, especially extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB), and result in lateral elbow pain.

Example 2

Another example of overuse is the gym-goer who habitually flexes their wrist during a bicep curl, seated row, lat pull down or chin-ups, which will often result in medial elbow pain. Exercisers should also be careful of increasing load and speed overly quickly during kettlebell training, as this places significant eccentric loads on the wrist and finger flexors. ‘Kipping’ during chin-ups is a classic exercise that many report as being the initial cause of their elbow pain, due to the high eccentric loads on the musculo-tendinous unit.

Rehabilitation techniques

If a client is suffering elbow pain, you have a few options for assisting in rehabilitation.

  • Loosen/massage the wrist and finger flexors or extensors, depending on which direction they overuse; this can be done daily in the relevant trigger points. In the example of the tennis player, the wrist extensors would need loosening. In the example of the ‘kipping’, the client’s wrist flexors would need attention. Depending on the severity of the case, you may need to engage the services of a physiotherapist, massage therapist or acupuncturist to help manage the tightness and pain.
  • Release the pectoralis minor muscle. There is no greater restriction to healthy scapular retraction than a tight and/or hypertonic pectoralis minor. In both examples above, a pre-exercise release of this muscle would open up the kinetic chain to improve scapular movement and immediately reduce the requirement to kink the wrist.
  • Teach the wrist not to ‘kink’ into flexion or extension (easier said than done!). In chronic cases the use of a wrist brace can be beneficial. Lessen the exercise speed and load of exercise until the wrist is able to stop kinking and neutral wrist position can be maintained habitually. Clients may even attempt to play tennis or workout in the gym with the wrist brace on.
  • Strengthen the scapular retractors, (most commonly mid-lower trapezius), to improve scapular retraction:
    • ‘Lower trapezius for dummies’. Keep arms straight and wrist free of kinking as you slide scapula down and to the centre of spine (see photos on previous page). Hold for 30 seconds or perform high repetitions to activate and strengthen lower trapezius in order to overcome the pectoralis minor dominance.
    • Straight-arm cable retraction. With a cable in front, perform high reps of pure scapular retraction with no elbow or wrist kinking. Encourage some thoracic rotation with the protraction–retraction, as part of the movement.
  • Blend the new scapular retraction movement back into their sport, exercise or function with effective cueing such as ‘open the chest as you pull or take your arm back behind your body’; ‘keep the wrist straight’; and ‘don’t kink the wrist’. Remember not to ask the client to lift too heavy a weight or move overly quickly during the exercise as this will cause them to default back to their kinking movement pattern.
  • Don’t rush back into the aggravating activity! If your client has to return to a sport or exercise that is inherently injurious to the elbows (e.g. ‘kipping’) then you also need to devote time to build the musculo-tendinous eccentric strength of the forearm flexors or extensors.

In a future article we will look at the second very common muscle imbalance of the elbow, which is involved in many injury patterns, i.e. pronator teres dominance over supinator – the rotary muscle imbalance of the elbow.

REFERENCES

1. ‘Stability and Movement Dysfunction Related to the Elbow & Forearm’ Orthopaedic Division Review Sept / Oct, 2001, S G T Gibbons MSc, MCPA, S L Mottram MSc, MCSP, M J Comerford B. Phty, MCSP, MAPA

2. Flip ‘n teach patient education manual for Wristiciser - PROplus system. Jemarkel Health-Tech; 2003.

3. ‘Carpal tunnel syndrome: a practical review’ Am Fam Phys, 1994;49:1371-1379; Katz, R T.

 

Ulrik Larsen, B Phty
An APA Sports Physiotherapist specialising in sports injury management, Ulrik has two decades of experience working with personal trainers and their clients, including elite athletes and their coaches. His passion for giving fitness professionals competence to manage clients with injuries led him to develop the Rehab Trainer course, which is now delivered internationally through his network of similarly-minded physiotherapists. Courses are coming up in most Australian capital cities from August to October. For more information visit www.rehabtrainer.com.au or call 0423 861 342.