Climbing to the top of your health: Elbow Talk

By Susan Leung, PT

Rock Climbing Injuries

Rock climbing has gained immense popularity over the past few decades. Last year, it was announced that rock climbing will be featured as a new Olympic sport in the upcoming Tokyo 2020 Olympic Games. This is an exciting time for both novice and expert climbers alike! But with every sport, there are risks. The most common injuries sustained in this sport include those affecting the shoulder, elbow and fingers. Studies have shown that more experienced climbers who are attempting harder routes and problems are more likely to develop injuries (Jones & Asghar & Llewellyn, 2008). That said, it is important to know when to keep climbing, and when to close that chalk bag to call it a day.

 

Rock Climbing Mistakes that lead to Injury

Can you recall how you felt a day or two following your first climbing experience? If you were like me, you would’ve felt as if your entire upper body had been run over by a massive truck (especially around the forearms). Most of us start off by “muscling it up the wall” using our biceps, constantly pulling in with our elbows when we should really be using more of our legs to push and ascend the walls. Overgripping is something that happens to all of us newbies. By gripping each hold for our dear lives, it gives us a false sense of security that if our foot were to slip, perhaps our arms would allow us to stay on the wall. However, not all of us have Spiderman’s genes, and the repetitive overgripping may later develop into an overuse injury that may prevent us from becoming better climbers. Depending on the type of hold that is present on the wall, you may want to try hanging your fingers and palms off it to decrease the amount of stress applied to your forearms, wrists, finger joints and tendons.

 

Rock Climbing and Elbow Pain

With all the repetitive gripping that is inherent to the sport, many rock climbers may develop what we call medial epicondylitis or medial epicondylosis (otherwise known as golfer’s elbow). Both conditions will cause pain along the inner part of the elbow and forearm. This is often noticed with gripping activities or lifting objects in a palm up position. These two conditions may sound quite similar, but will differ greatly in the way that they are managed therapeutically.

Medial Epicondylitis

Medial epicondylitis is an inflammatory condition whereby “itis” stands for inflammation in Latin. It affects the inside aspect of the elbow, where the muscles that are mainly responsible for gripping, transition to become a tendon (a rope-like structure). The tendon will eventually attach onto the medial epicondyle, which is a point on the arm bone. Since the actual tendon is actively inflamed, modalities and NSAIDs may be appropriate for use. A systematic review done by Hoogvlet et al. in 2013 found stretching and strengthening to be effective short-term relief (Hoogvliet & Randsdorp & Dingemanse & Koes & Huisstede, 2013).

Clinical treatment may include the use of ultrasound and acupuncture but should also focus on factors contributing to the injury including workspace ergonomics and muscle imbalances.

How this may affect your climbing

Early return to sport may:

  • prolong the inflammatory phase of healing to cause increased warmth, swelling, and point tenderness
  • hinder your ability to grip holds, and increase activation of your neck and shoulder musculature to compensate
  • initiate pain either immediately during, or shortly after your first climb

Therefore, consider taking a break from climbing, and spend your time cross-training instead! Try to chose activities that won’t involve too much repetitive gripping (e.g. ease off those pull-ups and deadlifts). You may want to opt for cardiovascular exercises to improve circulation, mobility work to remain loose and limber, and try resistance band exercises to target the shoulder girdle.

 

Self Treatment of Medial Epicondylitis

Ice packs can be used on the painful region for 10 minute on-and-off intervals, for 3-4 times in total.

Stretching the wrist flexors and extensors can also be beneficial.  This can be accomplished by keeping your elbow straight, try pulling your wrist up and hold for 30 seconds. Do the reverse by pulling your wrist down, and hold for 30 seconds. Repeat this 5-6 times. Now repeat the above with your elbow slightly bent.

Strengthen your rhomboids by having your arms straight in front of you to begin. Squeeze your shoulder blades to pinch them together nice and tight, and slowly pull your hands apart. Hold this for 5 seconds, and take at least 3-5 seconds to return to the starting position. Try this for 2-3 sets of 8-10 reps, or as tolerated.

 

 

Medial Epicondylosis

With medial epicondylosis inflammation is absent. This means that non-steroidal anti-inflammatory medications (NSAIDs), and the application of ice may not be of much benefit. Symptoms may begin more than a week after climbing.  Exercises that are aimed at lengthening and loading of the common flexor tendon will be appropriate during this stage of healing, such as eccentric wrist curls. Cervical and thoracic manipulation were also found to offer both short-term and mid-term relief as an adjunct therapy when combined with wrist and forearm mobilizations (Hoogvliet et al., 2013). Clinical treatment involves modifying the aggravating activities, specific strengthening emphasizing eccentric training, scar tissue mobilization/massage and functional training. Additionally, the use of proliferative therapies such as ultrasound therapy shockwave therapy and acupuncture may be considered to progress healing.

 

How this may affect your climbing

Early return to sport may:

  • cause adhesions to form around the muscle belly and/or tendon of the forearm extensors, secondary to repetitive strain
  • hinder your ability to grip holds (whether they be jugs or crimps)
  • initiate pain midway through your climb, near the end of your climbing session, or even the day following climbing

Therefore, consider picking routes or problems that are easier than what you normally attempt, and concentrate more on using more of your lower extremities. Traverse routes would be a great way to work on your technique and balance, without having to constantly use your maximal grip. So, stay away from dyno moves, and your body will love you for it!

 

Self Treatment of Medial Epicondylosis

Strengthening the weakened tendons is crucial to resolve your pain. Try holding a small dumbbell or a can of soup, and stabilize the forearm by resting it on top of a table. Slowly allow your wrist to drop, taking around 3-5 seconds to descend. Repeat 2-3 sets of 8-10 reps, or as tolerated. It is fine to feel a bit of pulling or discomfort around your elbow, but never pain.

Another eccentric training exercise for the forearm muscles is to use a bar with a weight. Place your hands around the handle bar, and slowly drop your wrist down using 3-5 seconds. Let the rope come completely undone, and drop the weight down on the floor to rearrange the rope back around the handle bar. Repeat 3-5 times, or as tolerated.

 

 

Don’t let Elbow Pain Limit You!

So, if you are currently suffering from an elbow injury (whether it be medial epicondylitis or epicondylosis), there are different treatment options and management techniques to help you feel better, stay better, and get you back to the crag with a smile on your face. Book an appointment to speak to one of our associates today!

 

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2300 John Street Unit #7 Thornhill, Ontario

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What is Shockwave?

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Extracorporeal shockwave therapy (ESWT) uses acoustic pulses to help to improve tissue healing and reduce pain. Pressure waves inside the shockwave unit are generated inside the unit balistically.   Compressed air rapidly speeds up a projectile in the transmitter of the unit.  The projectile is abruptly stopped by hitting the transducer head and the pressure wave is transmitted into the tissue using a water based gel.  Within the target tissue the mechanical energy is converted to chemical energy.

 

How does Shockwave help?

 

The common treatment sites treated by shockwave are the tendons.  In several areas of the body including the hips, knees, ankles, shoulders and elbows, these tendons do not have a good local blood supply.  Over time micro trauma, small injuries without proper healing, can create a situation where the accumulated failed healing can result in pain.  Research has shown that these tendinopathies areas do not respond well to techniques such as cortisone and anti inflammatory medication.  When the target tissue is the tendon research has shown that energy produced by the shockwave unit during a treatment session affects the tendon at the cellular level.  Through a chain of events at the cellular level, there is an increase in production of structural protein of the connective tissue known as collagen.   Circulatory changes also occur resulting in improved blood flow to the area.  This is dependent on the frequency used during the session as well as the intensity of the treatment waves.

 

What can I expect from a shockwave session?

Your physiotherapist will localize the area to be treated using a thorough assessment to determine if it is appropriate for you.  A water based gel is used to conduct the pressure wave into the tissue and is not moved around to the same extent as an ultrasound head.  Once the shockwave treatment has begun you will hear the noise of the projectile striking the transducer at a frequency determined by your therapist to maximize benefits and minimize discomfort.  Since pressure waves are being used there can be mild discomfort that is felt during the treatment session however this is usually temporary.  Your physiotherapist may increase the intensity of the shockwave slightly if the session is being tolerated well but will ask you before this is done.  The shockwave treatment is generally complete after a few minutes after which your physiotherapist will utilize other techniques to address movement or strength imbalances that may have contributed to the pain.  You may notice a slight discomfort or occasional reddening of the areas treated after the shockwave session.  You will be able to return to work and even continue with sports after the session, however for a few conditions you may be asked to refrain from certain aggravating movements.  Most conditions require between 3 to 8 treatment sessions usually spaced five to ten days apart.  There can be immediate changes in pain after the session; however tissue regeneration will take time.

Conditions that can benefit from Shockwave

Studies have shown shockwave to be a beneficial treatment approach for a variety of orthopaedic conditions including:

  • Tennis elbow
  • Calcific tendinitis of the rotator cuff
  • Achilles pain
  • Hip pain
  • Patellar tendinitis
  • Achilles Tendinopathy
  • Muscle pain
  • Myofascial pain and more

For more information or to determine if shockwave is appropriate for your condition talk to one of the physiotherapists at Family Physiotherapy.

 

The physiotherapists at Family Physiotherapy are trained in the safe use of Shockwave for orthopaedic conditions. We serve the areas of Thornhill, Markham, Vaughan and Toronto

 

References

Mani-Babu S., Morrissey D., Waugh C., Screen H., Barton C. “The Effectiveness of Extracorporeal Shock Wave Therapy in Lower Limb Tendinopathy” The American Journal of Sports Medicine 43 2014

Speed, C.  “A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence” British Journal of Sports Medicine 48 2014

Dreisilker, U. “Enthesopathies” Shockwave Therapy in Practice 2010

 

 

 

Breaking the Cycle of Injury: Treatment for Tendinopathies

By Brianne Burton, PT

 

What is a tendon?

A tendon is a tissue that connects muscle to bone. Unlike muscle, it does not contract, but it is connected to a muscle pic-1-235x300  that contracts so it sustains loading forces every time that muscle tightens. Tendons are made up of many bundles of fibers of collagen, which form a strong but flexible tissue.

The rotator cuff muscles of the shoulder connect to the

humerus or arm bone via tendons, shown above in white.

Image from Nucleus Medical Media / Getty Images

 

What is a tendinopathy?

The word tendinopathy refers to a non-rupture injury affecting a tendon. You may also hear people use the word tendonitis. There has been a shift in recent years favoring the word tendinopathy because it is a more general term, whereas tendonitis focuses the presence of inflammation, which may or may not be there. The two terms, however, are often used to talk about the same thing. Tendinopathies can occur at any tendon in the body. Some common sites include: rotator cuff tendons in the shoulder, tendons in the elbow (also known as lateral and medial epicondylitis), the hamstring tendons in the posterior thigh, patellar tendon in the knee, and the Achilles tendon in the ankle.

 

What causes a tendinopathy?

When a tendon is continually exposed to loading forces (such as compression, friction, or tension) that are beyond its capacity, a cycle of injury begins. The cycle of injury, inflammation, and repair happens repeatedly with each movement involving the tendon. This results in pain, swelling, and an accumulation of poor-quality tissue that never has the chance to fully heal. Overuse tendon injuries are common in athletes, but also common in less active people and people with jobs that require repetitive movements.

 

Why do overuse injuries happen?

It may be more correct to think about these injuries as ‘continued misuse’ injuries. Most often, overuse of the tendon in the wrong way is what actually leads to the injury. For example, if you have poor posture (slouched shoulders) and you continually reach overhead during volleyball, a tendon will be out of alignment; causing it to rub against the bone that sits above it. The repeated friction force starts the cycle of injury. This is what commonly occurs in a rotator cuff tendinopathy of the shoulder. The activity brings on the injury, but the root of the problem is improper positioning from poor posture.

Tendinopathies are also common with a sudden increase or change in load on a tendon, for example starting a new sport/activity or abruptly changing running surfaces. Use of improper equipment, for example worn out footwear or incorrect chair height in a workspace, also puts someone at risk for developing a tendon injury. Other risk factors for tendinopathies include smoking, obesity, hypertension, dyslipidemia and certain drugs like statins, flouroquinolones, and corticosteroids.

 

What happens to a chronically injured tendon?

When a tendon is chronically injured, some structural changes to the tissue take place. These changes lead to a disorganized, pic-2-263x300thicker, and weaker tissue that cannot withstand loading forces and continues to cause pain and swelling. Structural changes to a chronically injured tendon include:

  • Disorganized fibers
  • A higher number of a smaller, immature type of fiber (type III collagen)
  • Fewer mature fibers (type I collagen)
  • Increased number of vessels and nerves
  • More swelling in the tissue lining
  • Areas of dead cells

 

 

What are the symptoms of a tendinopathy?

Each person will experience symptoms differently, depending on the specifics of their injury. Most commonly people with tendinopathies experience pain and weakness with specific movements (whenever you use the injured tendon), localized pain and stiffness, and pain with increased activity.

 

What are the treatment options for tendinopathy?

Each tendinopathy is different and it is important to develop an individualized treatment plan; however some common elements include:

• Rest from aggravating activities. An early return to the aggravating activity will increase the risk of re-injury and could have negative effects on the structure of the tendon. Studies have shown that continued exposure to inflammatory chemicals contributes to the break-down of the collagen fibers and encourages scar tissue formation, which will set back recovery time.

• Electrotherapeutic modalities, like ultrasound therapy or Extracorpeal Shockwave Therapy. Shockwave therapy can be effective for stubborn injuries that are slow to heal.

• Manual Therapy to stimulate healing and encourage proper alignment of collagen fibers

• Eccentric strengthening. An eccentric contraction is a type of muscle contraction where the muscle is lengthening instead of shortening. For example, slowly lowering a weight with your arm is an eccentric use of your biceps muscle. Studies have shown that eccentric strengthening programs have produced better results than other programs because this type of loading stimulates tendon remodeling and leads to improved collagen structure and organization.

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Image from http://www.mdhealth.com.au/eccentric-based-strengthening/

• Your physiotherapist will assess your movements and address any contributing factors that are specific to each person (such as improper posture or poor joint mobility). These factors may have either contributed to the injury in the first place, or developed since the injury occurred.

 

At Family Physiotherapy, we pride ourselves on providing a comprehensive assessment and individualized treatment for your tendinopathy. Don’t hesitate to contact us if you are experiencing these symptoms, have had a recurring tendon injury, or feel you are at risk for developing a chronic tendinopathy.

 

 

 

References:

[1] Scott, A., Backman, L. J., & Speed, C. (2015). Tendinopathy: Update on pathophysiology. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 833-841.
[2] Murtaugh, B., & Ihm, J. M. (2013). Eccentric training for the treatment of tendinopathies. Current Sports Medicine Reports, 12(3), 175-182.
[3] Coombes, B.K., Bisset, L., Vicenzino, B. (2015). Management of lateral elbow tendinopathy: One size does not fit all. Journal