Written By: Kevin Cann
One of the most popular complaints I get at Total Performance Sports is “My elbow hurts.” When you think about it this makes quite a bit of sense. We write, text, type all day at work and then we go to the gym and grip a barbell or dumbbell to lift some weights. We are constantly flexing our fingers and wrists and do very little in the opposite direction.
The tricky part with the elbow is that it is stuck between two very mobile joints, the shoulder and the wrist. To make it even trickier, the shoulder is at the mercy of our spinal posture. So not only does texting, typing, and lifting weights negatively affect our elbows by overusing the flexor muscles, but it also puts us in a posture that is not ideal for our elbow.
The two most common elbow injuries are lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer’s elbow). In both of these conditions the muscle tendons and ligaments become inflamed from overuse. Tennis elbow involves the extensor tendons, and the pain is on the outside of the elbow. Golfer’s elbow involves the flexor tendons, and pain is felt on the inside of the elbow.
Performing rest, ice, compression, and elevation (R.I.C.E.) is enough to alleviate symptoms, but this condition can become chronic if it is not taken care of. When someone comes into my office with elbow pain the very first thing I do is check spine mobility. If this is lacking we perform soft tissue mobilizations and corrective exercise and then we retest.
That’s right, even if someone has elbow pain, I check the spine first and do not move on until that is corrected. The reason for this is that everything flows downstream from the spine. If the spine cannot get into a proper position, the shoulder cannot get into a proper position, and the elbow is going to be getting excessive valgus and varus forces that will continue to lead to pain.
Also, as coaches we are not physical therapists. I am not treating an injury here, but instead as Shirley Sahrmann labeled them, a movement impairment. Pain and dysfunction are results of these movement impairments. I am identifying them and correcting movement. The majority of the time this leads to a decrease of symptoms and a happy customer, even if it is not the reason they are in pain. The physical therapist can diagnose the injury and treat it accordingly.
After we clear the thoracic spine mobility we can move on to the shoulders. Once we get here I have some thoughts already established. In most cases people with tennis elbow are missing shoulder external rotation and people with golfer’s elbow are missing shoulder internal rotation. This is one of those movement impairments that Sahrmann talks about.
When we are missing internal or external rotation in the shoulder, the elbow will perform excessive internal or external rotation to make up the difference. Do this enough and we end up with some very unhappy tendons and ligaments. With that said, if we do not fix the shoulder range of motion, the elbow will continue to get this excessive stress and elbow pain will continue to be a problem.
After you assess and determine the ROM deficiencies of the shoulder, apply your corrective strategies. One thing about correcting ROM in the shoulder. The t-spine responds very well to soft tissue mobilizations. The shoulder will require a little more work. Applying soft tissue mobilizations to the tissues around the joint can be very helpful such as the pecs and the upper traps. Follow this with a stretch, preferably a banded distraction.
Unlike the t-spine, we need to train stability to lock the mobility into place. When the ROM improves quickly from corrective exercise it is not that the person doesn’t have the ROM. They do have the ROM, they just do not know how to use it. Not knowing how to use a joint is dangerous to the body, so the body tenses up to shorten the ROM and protect it. Once we take away this protection we need to teach the body how to use the ROM. I like using overhead kettlebell bottoms up carries after I mobilize the joint to teach stability and lock in that ROM.
One thing to keep in mind when mobilizing the shoulder is the fascial components. The arm has fascia on the lateral side of it, very similar to the IT band in the leg. It extends from the greater tubercle of the humerus down into the lateral epicondyle. Muscles such as the deltoids, triceps, and elbow flexors feed into it. Mobilizing this soft tissue can help to improve both shoulder internal and external ROM and should not be overlooked when performing soft tissue mobilizations. Often times I begin here and see how much of an improvement mobilizing it gives me first and then move on to other areas.
Once we have gotten the t-spine the mobility it needs, and the shoulder joint into a good position, we can now start working on the elbow. Like I mentioned before, the excessive forces on the elbow were due to the t-spine and shoulder being in poor positions. We have just taken care of that. Now we need to get stronger in these new and improved positions to make them stick with us.
Before we do that though, we may want to mobilize some tissue around the elbow joint. With tennis elbow we want to mobilize the tissue with our palm down, and with golfer’s elbow we want to mobilize the tissue with our palm up. Lacrosse balls and even barbells work very well for this. In both scenarios we want to mobilize the triceps, 2-3 inches above the elbow. This will give that tendon some slack and give our elbow some room to move properly.
From here we just need to be smart with our training. Fatigue and pain both alter movement patterns. Make sure that you are in the proper positions while you are training, otherwise the problems will only continue. We did a video for Murph’s coaching blog on EliteFTS.com that gives some examples of mobilizations for each joint here.