Anterolateral elbow pain

Hello folks,

I know this topic has been brought up numerous times, so I wanted to give you all a little background on this "how to rehab injury" question prior to any prejudgments.

I am by training, a Physical Medicine and Rehabilitation physician with about 12 years of experience with respect to Aerospace medicine in the USAF, then traumatic brain injury/stroke/spinal cord/musculoskeletal injury rehabilitation, and now am currently in pain management.  I have a great working knowledge of the functional anatomy, which is a pre-requisite to be able to come up with movement programs to help these injured folks above regain some functional capacity in their future, now impaired, lives.  In fact, as a compliment to coach and his staff, the main reason I decided to become a member here is that I really appreciated the knowledge and plan Gymnastics bodies implements and their ethos on the body and its function.  I am also a very big proponent of the ancestral health movement to not only go beyond nutrition, but also to thrive on functional movement etc.  I do not think that any other program, to my knowledge,.has as good of a grasp and working knowledge of the functional human MSK system as does Coach Sommer and his team...

That said, I would like to draw upon him, his staff and the members here on some advice with elbow pain.  Now, I know this is a common issue and folks will start thinking distal biceps tendon/brachialis, but I am looking more for population information, sort of anecdotal information to this issue.  I personally have anterior/lateral elbow pain which sits just below (think more deep to) the distal biceps tendon when palpated.  I believe this started with a pullup workout routine several (6) months prior.  I have since stopped pullups about 2 months ago, but continue to have discomfort in this area during late exercise when I row and afterwards with simple functional, everyday forearm flexion.  My diagnosis is brachialis tendinopathy....

My question is, is this in fact brachialis tendinopathy (always like second opinions to eliminate bias esp when diagnosing myself)?   If it is brachialis tendinopathy, do folks who have a similar diagnosis, experience this pain lateral or medial to the biceps tendon (I usually hear this presenting as medial elbow pain where the brachialis tendon inserts which has me questioning my diagnosis)?  And most importantly, I have stopped all strength movements regarding those movement as suggested by Coach Sommer and backed off to following the program to strengthen the connective tissue as well as stretching exercises, but is there anything else anyone can suggest?  I normally wouldnt ask these questions based on my background and usually treating these issues as a physician, but I would appreciate outside "eyes",  so to speak, from a community that has substantial experience since I'd love to keep rowing....

Thank you all for your time to read this,

Alex

I would check the structures around the elbow to rule them out. I would in particular look at ulna-humeral, radio humeral and wrist joints. Check the muscles in the area as they most likely have tightness. If all those are ok then look at the shoulder and cervical spine. I often have patients who have alot of tightness in the subscapularis muscle that will cause elbow problems. Also check the median nerve tension test as it can cause elbow pain as well.

You are doing the right thing with training in that you are not training in pain. Elbow tendons like to be rehabalitated pain free. I like some of the bodybuilding exercises for tendon rehab. I perform alot of isometric and isotonic bicep and reverse curls, wrist curls and supination/pronation.

Have a listen to Dr Leanne Bisset on the physioedge podcast, who specialises in elbow tendon injuries.

I would still explore the other areas of the body and if there is a problem treat and reasess the elbow. Sometimes the problem is an area where you least expect. Unfortunatley it is not as easy as the problem being where the pain is.

On 6/23/2016 at 5:55 AM, Mark Collins said:

I would check the structures around the elbow to rule them out. I would in particular look at ulna-humeral, radio humeral and wrist joints. Check the muscles in the area as they most likely have tightness. If all those are ok then look at the shoulder and cervical spine. I often have patients who have alot of tightness in the subscapularis muscle that will cause elbow problems. Also check the median nerve tension test as it can cause elbow pain as well.

You are doing the right thing with training in that you are not training in pain. Elbow tendons like to be rehabalitated pain free. I like some of the bodybuilding exercises for tendon rehab. I perform alot of isometric and isotonic bicep and reverse curls, wrist curls and supination/pronation.

Have a listen to Dr Leanne Bisset on the physioedge podcast, who specialises in elbow tendon injuries.

I would still explore the other areas of the body and if there is a problem treat and reasess the elbow. Sometimes the problem is an area where you least expect. Unfortunatley it is not as easy as the problem being where the pain is.

Thanks Mark. 

I'll definitely take the advice on the rehab smaller exercises, especially the wrist pronation.  The real tightness and tenderness to palpation is in that area where the brachialis "crosses" underneath the biceps tendon from lateral to medial.  Thus, pronator teres may be a good thought too.  Mostly all joints and wrists have decent mobility and are without issues, but having been an overhead athlete for years, the shoulder does present compounding factors which include impingement and SLAP lesion (once repaired).  And like most overhead tyope athletes, external rotation is way more than the average individual, but internal rotation is severely limited, which I have been working on since injury.  All this translates to too strong anteriorly, tight and immobile posteriorly in that capsule.  

Mark, do you have any experience when you diagnose lateral elbow pain to be either brachialis or pronator issues?  This is definitely not lateral epicondylitis since resisted wrist and finger extension do not cause discomfort.  Median nerve also good to go (GTG).  Really mostly get that discomfort feeling on elbow flexion, right at the lateral distal biceps.  I don't mind slowing it down and rehabbing it without pain, but I figured rowing with minimal force wouldn't aggravate this as much as it does....Real bummer...

Anyway, thanks for the post and am curious about your past experiences and others experiences with this issue.

Alex

Hi Alex, 

Nice to meet you and interesting background. My advice borderlines the obvious, but have you considered doing a MRI?

I once had similar symptoms as you're describing in my "good" elbow and I was miss-diagnosed with a brachialis tendinopathy of sorts. After useless therapy, I, yes, I requested a MRI. It turned out to be a 1.6 cm wide intra-articular loose body at the anterior compartment of my joint capsule which was irritating the tissues, kinda like a knife stuck in there feeling. At the time, the pain was certainly annoying but not that bad (in comparison to my other issues) so I opted for not doing surgery to remove it. After all my ROM was good and my function not impaired (with the exception of limited end-range flexion at the top of a chin up). No to mentioned I was assured by several surgeons that the fragment could not move or grow. Worse case scenario, I would gradually lose ROM and die one day. Since I maintain a joint mobility practice, my ROM was not a concern.

One day out of the blue (while standing and talking), I felt something move inside my elbow (like a bite) and within one second I couldn't flex or extend my elbow. It was stuck at 18º of flexion. I knew instantly that that little sucker had moved. What i didn't know is what my next MRI revealed. In only 1 year, the bony fragment had grown from 1.6cm to 2.2mm! Theoretically feeding via the synovial fluid, which makes me wonder about the potency of my nutrition. Long story short, this happened last Summer. I had surgery to remove it as it was then impeding my normal functioning. Yours is probably a different scenario, but my point is it doesn't hurt to get some imaging.

Regarding rowing (I did crew rowing before College), based on the symptoms you're describing, I can only imagine rowing will certainly aggravate it. Keep in mind that rowing with your ER/IR shoulder imbalance will continue to "strengthen" your compromised joint arthrokinematics. Even if you're already taking steps to rebalance the joint since your injury, you know it's going to take a few years to undo or recalibrate your overhead pressing history.  

It sounds like your elbow could be the victim and the real suspects are hiding above and below, but it's impossible to tell without doing a whole body assessment. In my professional experience, it typically comes down to a complex individual pattern. My approach is always the same:

Bring that body back into balance. Address the most glaring deficiencies first, staring with joint mobility. Give back the joints their natural ROM. Make everything work nice so you can move better. In movement terms, "quantity" is possible after "quality" is achieved. The other way around is ultimately not sustainable (or doesn't work so well). "Real bummer" indeed and hard, hard lesson to learn. 

I generally find most people have an overactive pronator teres and get patients to do alot of supination. I like to get people rest on their knees and elbows, with forearms parallel and actively supinate the wrists so the thumbs touch the floor. I do this for 1-2 minutes.

Another good technique is from Kelly Starett where you wrap a compression band around the elbow. Then flex and extend the elbow for on to two minutes. It hurts quite alot but works wonders. I use this for crossfitters who have alot of anterior tightness. Look up voodoo floss of the elbow.

I also perform alot of deep soft tissue releases of the brachialis. 

If you row alot I would expect the pronators are very dominate and like Eva mentioned you need to restore the balance back to the elbow.

Thanks to both of you for the input!

Some quick points...

- I made an error in talking about pain being at the pronator origin, but being antero lateral, that would be the supinator origin.

- Interesting and most importantly, I actually noticed now that I wake up with this elbow pain.  I think mostly because I sleep on my side, sort of with my arms curled.  To me this signals some real tightness there.  When I wake, its painful to extend forearm.

Anyway, hope that helps with you folks insight into whats going on!

Thanks again

Alex