Complete Elbow Health

Dr. J addresses three questions regarding elbow health from three different readers.

This special section on elbow health appeared in the Medical Advice section of Rock and Ice issue 248 (February 2018).

By Dr. Julian Saunders | April 3rd, 2018

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I’m an older climber with serious medial elbow pain. MRI shows tendon tear. An orthopedic suggested a cortisone shot into the joint, saying that surgery is 50/50 success/failure. Your expertise would be valued.

– Jack


Ah, the intractable vice of age, doing its thing until there is no space left to live. That said, either the surgeon is losing the plot or you have only given me fragments of disparate information. Medicine is often Monet in appearance, a little blurry, but the picture you paint is more like Salvador Dali in that it makes only a little sense.

There is no reason for the joint to be injected with cortisone if the primary issue is a tendon tear. In fact, there is no reason to inject the tendon in the first place, though injections are too often undertaken, misguided as they are. I wonder if you are alluding to joint degeneration, in which case the doctor may float the idea of an intra-articular cortisone injection. That would buy some pain-free(er) time for several months, but is otherwise largely pointless.

Although being an “older climber” does not necessarily lead to elbow issues per se, you are, in more general terms, gallivanting down a path of reduced anatomical returns when it comes to training and healing. You could spend much time trying to slow that decline, or you could just relax and try to enjoy yourself.

Illustration by Steve Graepel.
Illustration by Steve Graepel.

If the medial elbow pain you mention is indeed a recalcitrant tendon tear then you have options. First and foremost is exercise rehab. Read “Dodgy Elbows Revisited” on my website www.drjuliansaunders.com for some direction with this. Bear in mind that, as you get older, tendons take longer to heal. What would take a 20-year-old a few weeks to recover from may take you a few months or longer.

Surgery is an option, but not before exhausting a more conservative rehab approach.

All injectable interventions, from PRP to prolotherapy, will appeal to non-science-based readers and desperados. Stem-cell therapy, the new oversized kid on the block, is for the aforementioned who happen to have loads of money. I got my science-o-meter out again this week and waved it toward “stem-cell injections.” The gauge reading was quite low. Reiki was higher since delusion (we’ll call it placebo) is now a recognized therapeutic force; a real win for the patchouli-oil mob.

I suspect that there is more to this case than just a tendon issue, probably some arthritis. There is no magic bullet that will transport you past the fiery cauldron of joint degeneration.


 

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I have had pain in my left elbow for 15 years and it has ended my climbing career. I have gone through the testing protocols you outline in the two Dodgy Elbows articles, and neither of the exercises elicits much pain. When I palpate deep into crook of the elbow, however, it’s extremely painful. My elbow crackles and pops when I flex it all the way. Self massage helps, while doing pullups creates immediate and lasting pain. I consulted an orthopedic surgeon and x-rays showed arthritis, which he said there’s nothing I can do about it. He didn’t do an MRI. I’m 47 but I have a hard time believing my elbows are arthritic when they started hurting when I was 31. My elbow hurts even when I ride a bike. What do you think?

– Torrey

One of my mates, Big Dave, is 40-something. For some unlucky reason his right elbow clapped out early as well. Had he bought that elbow at the shops there would be no question about returning it. He mostly attends Cuddle Club (aka Brazilian Jujitsu) now because climbing is not much fun when the main limiting factor is pain.

I’m not suggesting that arthritis is the sole source of your trouble, but it’s likely to be a major contributor at least.

Anterior elbow pain can be a few things. If it just hurts when you poke around, you may have an anterior bone spur, as this is a fairly common place to get them in a degenerate elbow. Distal biceps tendonosis is also possible, and is only briefly mentioned in the Dodgy Elbows Revisited article.

Cycling can be particularly aggravating for an arthritic elbow due to the way the joint is compressed. The synovial cartilage surfaces inside the joint will have a degree of injury that ranges from simple irritation—synovitis—to complete synovial erosion where bone is exposed to direct loading. Now imagine pushing the surfaces together and adding some high frequency shock load. Yowie!

The conundrum with arthritis is that strength is shown to generally improve function and stability and thereby slow the process. There is, however, a fine balance between strengthening and further wearing out the joint. Traversing this issue is akin to walking a tightrope with cataracts—it’s more about feeling your way than having a set formula.

Early joint degeneration as an athlete sucks. As a relatively young athlete you can rightfully feel a little gypped albeit there’s no one to take it up with. Can you go climbing? Sure. Will it be painful at times? Yep. Is that the whole story? Definitely not. See Rock and Ice Issue 237 for more information on arthritis. There are certainly other issues that can contribute to elbow pain, like the aforementioned distal biceps tendonosis, which are worth exploring given the profound effect on your climbing.


 

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Embarrassing as it is, I fell off my bike while it was stationary, hitting my elbow on the edge of the gutter and royally phuked it. I fractured the radial head and through the ulna in the joint. What’s my chance of climbing again?

– Simon

As I stood on the top of the slide, victorious, having just run straight up the dauntingly steep ramp, I really did feel I had achieved something that Saturday at my mate’s house. I was 11. Such athletic prowess seemed important. Still does! The view was excellent. As the rusty old ladder snapped just below my feet, the excellent view became a blurry less excellent view. When I was able to focus again my elbow resembled a carpenter’s T-square, the ulna now poking out the back. My mate’s dad, a horse trainer, declared it “only dislocated” (which ironically may have been true at the time), wrapped it around his knee and wrenched it back into place. After the relocation, at least, my radius and ulna were fractured in several places, and my forearm took on the appearance of an oompa loompa’s thigh.

Although fractures do happen, ligament and tendon injuries are far more common. Snapping the medial collateral ligament (aka ulna collateral ligament) on the inside of your elbow, acute tears in the common flexor tendon, distal bicep tendon rupture, and even avulsing the tricep tendon from the back of your elbow are all part of the injury spectrum in climbing. Luckily, the majority of injuries around the elbow heal extremely well, even if they do need surgery to be reattached, and virtually all climbers can return to previous levels of climbing given enough patience and desire.

Radial head fractures, as is the case here, are fairly common in the general population. It’s as easy as falling onto an outstretched arm. Although you did this falling off your STATIONARY bike, you could have just as easily done this pitching off a lowball boulder problem or swinging in on a roped fall with your arm out by way of protection. Breaking the ulna, however, takes a bit more effort in terms of force.

Climbing may well be one of the few activities that will get your elbow back to the best shape possible. Alternatively it could be completely horrible and way too much to expect. Although climbing does not irritate my elbow, whether you have pain while climbing depends on the extent and location of damage, and how well it heals. Certainly climbing is easy to control in terms of load, and it will improve functional range of motion and help you regain strength. And it’s fun, i.e., good for your head. Being injured and thus inactive can be depressing.

Before you get to pull your shoes back on, however, your primary concern will be bending your elbow at all. After 12 weeks of immobilization, it will look and feel like a piece of fossilized wood. Find a manual therapist to help you regain as much range as you can. Be patient; it’s O.K. to cry a little. There will likely be some reduced capacity, both in forearm rotation and flexion/extension of the elbow, though this is typically less than 10 degrees in any direction and won’t really affect you while climbing.

I’m not sure what steel work is in the elbow—screws and plates—or how it will play into your rehab. Certainly internal fixation can cause some issues and may need to be taken out down the track.


 

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1. Avoid the ups-and downs of training intensity. As much as you can keep it consistent and well structured such that you are not asking more from your elbows than they are capable of.

2. If you’re prone to elbow tendonosis, try doing a few sets of eccentric exercises a couple of times a week. You can read more about these in the Dodgy Elbows Revisited article archived on my web site.

3. Any type of repetitive, high-stress finger training is potentially problematic. Campus boards, Bachar ladders and finger boards can devour your elbows like a diesel wood-chipper gone feral. Even changing your training style, say from long bouldering to the fingery Moon Board has a vast capacity to cause trouble.

4. Engineers, web designers, architects, and other avid mouse users, beware. Continually lifting the mouse to reposition it on the table surface is a major catalyst of lateral epicondylosis. If you can’t keep the mouse attached to the desk surface —sliding it rather than lifting it—try using a stylus and pen setup like a Wacom. Having an ergonomic mouse for each hand is a good way of spreading the load.


This special section on elbow health appeared in the Medical Advice section of Rock and Ice issue 248 (February 2018).


 

Also read

Medical Advice: No Zs No Send

Medical Advice: A Shoulder to Cry On

Medical Advice: Stiff Fingers After an Accident?

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