Every Wednesday morning at Cressey Sports Performance, we have a staff in-service.  It's an awesome chance for our staff and interns to exchange ideas, introduce new topics, standardize coaching cues, and explain strength and conditioning program design strategies.  Yesterday, I presented on the elbow - and we decided to video it, as not all our staff members could be there.

Not to toot my own horn, but it came out really well.  The elbow is right in my "wheelhouse," so when I get going on it, things seem to just roll off my tongue.  The end result was a 32-minute in-service where I didn't use any notes, but covered everything from functional anatomy, to injuries, to injury mechanisms, to strength training program modifications.  There are valuable lessons for both those in the baseball world as well as those who don't have any interest in baseball.  With that in mind, I decided to put it up for sale today, as I feel strongly that the elbow is a topic that doesn't receive a lot of attention in spite of its importance.

Click here to purchase Everything Elbow for just $12.99 on our 100% Secure Server.

You can see that Beckett is just short of stride foot contact here - which means that he's at just about maximal hip external rotation on the lead leg...in open chain motion.  The femur is rotating on the acetabulum.

Meanwhile, he's riding out his trailing leg...in closed chain motion.  The acetabulum is rotating on the femur.

When these structures get overused, they shorten - and as we discussed in Part 1, the zones of convergence (where tendons bunch up and create friction with one another) are where we develop some nasty soft tissue adhesions.

However, this doesn't just happen from gripping.  Think about what happens when you put the bar in this position to back squat:

That bar wants to roll off his back, and while the majority of the weight is compressive loading, a good chunk of it becomes valgus stress that must be resisted by the flexors and pronators that attach at the medial aspect of the forearm/elbow. It's not a whole lot different than the stress we see here; we just trade off the velocity and extreme range of motion in the throwing motion for prolonged loading in the lifting example:

As a general rule of thumb, the narrower the squatting grip, the more stress on the elbow.  Unfortunately, the wider the grip, the more shoulder problems we tend to see, as this position can chew up the biceps tendon.  The solution is to maintain as much specificity as possible with respect to one's chosen endeavor, but find breaks from the repetition of these squatting positions by plugging in options like front squats, giant cambered bar squats, and safety squat bar squats.

For these reasons, I also look at soft tissue work on the forearms - and particularly the medial aspect - as a form of preventative maintenance.  Regardless of the soft tissue modality you select, get some work done every few months and stay on top of your stretching in the area to maintain adequate length of these tissues.

We'll also see a fair amount of "underside" elbow pain in lifters, in most cases where the three heads of the triceps join up as a common tendon (another zone of convergence; does anyone see a pattern here?) to attach to the olecranon process.  The smaller anconeus - a weak elbow extensor - also comes in here.

Almost universally, the lifters who present with overuse injuries posteriorly are the ones who use loads of elbow-only extension movements like skullcrushers/nosebreakers/French presses/triceps extensions.  As a random aside to this, how can these movements have four different names, and not one of them begins with some Eastern European nationality?  "French" just doesn't get it done when we have Russian good mornings, Bulgarian split squats, Romanian Deadlifts.

Anyway, we vilify leg extensions and leg curls as being non-functional and overly stressful at the knee.  The knee is the joint most similar to the elbow, yet it's much bigger than the elbow, yet nobody contraindicates 4-5 elbow extension-only exercises per week in many routines as being inappropriate - or even excessive.  If you want to build big legs, you squat, deadlift, and lunge.  If you want to build big triceps, you bench, do weighted push-ups, overhead press, and do dips.  The absolute load is higher, but the stress is shared over multiple joints.

In just about every instance, when you drop the direct elbow extension work from someone's program, their elbow issues resolve very quickly and they don't miss a beat with training.

So, as you probably inferred, it's very rarely a lack of strength that causes elbow pain in lifters.  Rather, it's generally poor tissue quality, a lack of flexibility, and overuse of a collection of muscles that have "congested" insertion points.  Simply changing the program around, getting some soft tissue work done, and following it up with some stretching can go a long way to both prevent and address these issues.  That said, there will be cases where elbow pain may originate further up at the cervical spine or shoulder or - as I learned from a reader in the comments section of Part 5 - from an abducted ulna.  So, there is definitely no one-size-fits-all approach.

That wraps up this series.  Hopefully, you've gained insights into some of what's rattling around inside my brain with respect to elbows.  Thanks for putting up with me for all six installments!

In a tennis population, "tennis elbow" emerges almost solely from backhands (with the one-handed version logically being much more problematic), which require huge contributions from the extensors of the wrist to not only hold the racket, but stabilize the wrist against the vibrations from the racket as it redirects the ball.  The path of the ball against the racket creates a destabilizing torque that wants to force the wrist into flexion, and it's the job of these extensors to resist that movement.

The logical question for many is why does the pain occur at the elbow when the forces are applied so much further down the arm?  The answer rests with the zones of convergence topic from Part 1: there are lots of tendons coming together in congested area, creating friction and negatively affecting soft tissue quality.  At the lateral epicondyle, you have the common extensor tendon, which is shared by extensor carpi radialis brevis, extensor carpi ulnaris, supinator, extensor digitorum, and extensor digiti minimi (the extensor carpi radialis longus and brachioradialis attach just superiorly).

If this doesn't convince you of both the preventative and rehabilitative role of soft tissue work, then you might as well be living life with a bag over your head.  Yet, it amazes me how many treatment plans for tennis elbow don't have even the smallest element of hands-on work.  Here's a little demo from Dr. Nate Tiplady, with Graston and ART.

Soft tissue treatments, flexibility work, and progressive strengthening exercises for these degenerative tissues get the ball rolling - and you can find thousands of foo-foo forearm exercises and stretches online.  Additionally, as Mike Reinold has reported, there is some research to suggest that elbow straps are slightly effective in expediting the process.

And, eccentric exercise for the wrist extensors tends to show the most promise for tissue-specific return to function. This is all well and good - but I think it sometimes overlooks a big fat white elephant in the room.

I worked at a tennis club for eight summers when I was growing up, doing everything from court maintenance, to racket stringing, to lessons, to scheduling court time.  Toward the end of my eight-year tenure (around the time that I started getting involved with the fitness industry), I started to notice some interesting patterns.

When I looked out on the courts, about 1/3 of the participants were rocking tennis elbow straps (the research actually shows that about 40-50% of recreational tennis players get tennis elbow).  Yet, when I was in the office with some professional tennis match on TV in the background, I NEVER - and I really mean that I can't remember a single time - heard of a professional tennis player missing time because of tennis elbow.  How in the world would a pro - who might spend about 5-6 hours a day on the court - not break down faster than an elderly woman who plays a) 5-6 hours a week, b) at a slower pace, c) predominantly in doubles matches (1/2 as many ball contacts), and d) against competition that hits the ball much more softly than a professional opponent?  It really didn't make sense - until I got involved with exercise physiology.  Why?

1. The members were largely over the age of 40 - meaning that they were obviously as an increased risk of degenerative issues like tennis elbow, especially in light of their activity patterns.

2. The pros were also younger, and the two-handed backhand is markedly more common in the newer generation of players.  The one-handed backhand still predominates in the "old guard."  Research has demonstrated markedly more complexity in the swing kinetics for the one-handed backhand - so there are more ways for things to go wrong in this older population.

3. This is the biggest one: the pros usually had a solid foundation of conditioning, meaning that they had the strength, power, coordination, footwork, and technical mastery to hit the ball in a biomechanically safe position.  Novice players with poor technique often hit the hit the ball with the wrists flexed and not neutral; in other words, they lead with the elbow instead of the racket, taking the wrist extensors outside of their ideal length-tension relationship.

In a non-tennis population, lateral elbow pain is almost always a function of overusing the grip and having some really nasty, fibrotic soft tissue accumulations at the lateral epicondyle.  In a tennis population, it isn't just an elbow problem; it's something that speaks to a lack of preparedness of the entire body, both physically and in the context of insufficient technical mastery.

In my eyes, tennis elbow rehabilitation should be treated much like a return to throwing program for a baseball pitcher.  The injured individual should take care of the soft tissue, flexibility, and strength issues at the elbow, but he/she should also get involved in a strength and conditioning program to improve ankle, hip, and thoracic spine mobility; core and scapular stability; and strength and power of the larger muscle groups at the hips and shoulders that should be creating the power instead of the smaller muscles acting at the wrist and elbow.

If you're slow to rotate your hips, you're going to hit the ball late (wrist flexed).  If you lack hip mobility to rotate to the ball, you're going to hit the ball late (or chew up your lower back).  If you lack core stability to transfer force from the hips, you're going to hit the ball late.  If you lack scapular stability or rotator cuff strength, you're going to hit the ball late.  Does anyone see a pattern?  This is about everything BUT the elbow!

Instead, what have we done?  We've done exactly what lazy people always does: created gadgets to avoid actually having to work hard!

In the 1990s, racket companies introduced oversized rackets, which have a larger surface area to minimize mishits (which increase vibrational stress) and increase power (at the expense of control).  Screw getting better at tennis or improving your physical fitness; we'll just make tennis easier!  As an interesting aside to this, strings break more frequently on oversized rackets as well - meaning that companies make more long-term on follow-up string purchases. This sucker is 125 square inches (as a frame of reference, Pete Sampras played with a 85-square-inch racket):

Also in the 1990s, the titanium tennis racket was introduced.  These things are insanely lightweight - to the point that it requires very little physical exertion to swing if you are a 60-year-old woman in a doubles match.  So much for exercise!

We've handed out tennis elbow straps like candy so that people can get back out to play as quickly as possible rather than getting their bodies right and then practicing with a qualified professional who can instruct them on proper technique as part of a return-to-hitting plan.  The straps can be very valuable if used appropriately - but not if used as a crutch to "get by" with poor movement patterns and a lack of physical preparation.

Is anyone else shocked at how comparable the rushed and careless return to action in adult tennis players is to what we see with young athletes trying to come back too quickly from ACL tears, rotator cuff strains, or stress fractures?  They say retirement is the second childhood; I guess they're right!

So, here are some take-home points on tennis elbow:

1. Take care of tissue quality at the lateral epicondyle alongside any flexibility and resistance training exercises for the muscles of the forearm.

2. Condition the entire body as part of rehabilitation.

3. Ease back into tennis participation, and do so under the supervision of someone who can correct the faulty mechanics in your backhand. Along those same lines, consider switching to a two-handed backhand if you have a history of tennis elbow.

Stay tuned for Part 6 to wrap up this series.

If the valgus forces are so crazy that they actually exceed the UCL's tolerance for loading, why don't we just rip that sucker to shreds on every pitch?

It's because the UCL doesn't work alone.  Rather, we've got soft tissue structures (namely, the flexor carpi ulnaris and radialis) that can protect it.  This is why cadavers don't usually pitch in the big leagues.  The closest thing I've seen is 84-pound Willie McGee, but he was an outfielder.

Keep in mind that it isn't just the UCL that's stressed in this lay-back position.  Obviously, the flexor-pronator mass takes a ton of abuse in transitioning from cocking to acceleration.  It's also a tremendously vulnerable position for the ulnar nerve as it tracks through some tricky territory.  That just speaks to the medial side of things; there is more to consider laterally.

In case you missed Part 1 of this series (Functional Anatomy), you can check it out HERE.

Elbow issues can be really tricky at times from a diagnostic standpoint. Someone with medial elbow pain could have pronator and/or flexor (a.k.a. Golfer’s Elbow) soft tissue issues, ulnar nerve irritation or hypermobility, ulnar collateral ligament issues, or a stress fracture of the medial epicondyle – or a combination of two or more of these factors. All of these potential issues are “condensed” into an area that might be a whopping one square inch in size. Throw lateral elbow pain (commonly extensor overuse conditions - a.k.a. "Tennis Elbow" - and bony compression issues) and posterior (underside) pain in the mix, and you’ve got a lot of other stuff to confound things.

To make matters more complex, it’s not an easy diagnosis. The only way to recognize soft tissue restrictions is to get in there and feel around – and even when something is detected, it takes a skilled clinician with excellent palpation skills to determine just what is “balled up” and what nerves it may affect (especially if there is referred pain).

In these situations, I’ll stick with the terms “soft tissue dysfunction” and “tendinopathy” or “tendinosis” to stay away from the diffuse and largely incorrect assumption of “elbow tendinitis.” We’re all used to hearing “Tennis Elbow” (lateral) and “Golfer’s Elbow” (medial), and to be honest, I’d actually say that these are better terms than “epicondylitis,” as issues are more degenerative (“-osis”) than inflammatory (“-itis”).

Ulnar nerve pain patterns can present at or below the elbow (pinky and ring finger tingling/numbness are common findings), and may originate as far up as the neck (e.g., thoracic outlet syndrome, brachial plexus abnormalities, rheumatologic issues, among others) and can be extremely challenging to diagnosis. A doctor may use x-rays to determine if there is some osseous contribution to nerve impingement or a MRI to check on the presence of something other than bone (such as a cyst) as the cause of the compression. Nerve conduction tests may be ordered. Manual repositioning to attempt to elicit symptoms can also give clues as to whether (and where) the nerve may be “stuck” or whether it may be tracking out of course independent of soft tissue restrictions.

Childress reported that about 16% of the population – independent of gender, age, and athletic participation – has enough genetic laxity in the supporting ligaments at the elbow to allow for asymptomatic ulnar nerve “dislocation” over the medial epicondyle during elbow flexion. In the position of elbow flexion, the ulnar nerve is most exposed (and it’s why you get the “funny bone” pain when you whack your elbow when it’s bent, but not when it’s straight). Ulnar nerve transposition surgeries has been used in symptomatic individuals who have recurrent issues in this regard, and it consists of moving the ulnar nerve from its position behind the medial epicondyle to in front of it.

An ulnar collateral ligament (UCL) issue may seem simple to diagnosis via a combination of manual testing and follow-up diagnostic imaging (there are several options, none of which are perfect), but it can actually be difficult to “separate out” in a few different capacities.

First, because the UCL attaches on medial epicondyle (albeit posteriorly), an injury may be overlooked acutely because it can be perceived as soft tissue restrictions or injuries.  The affected structures would typically be several of the wrist flexors as they attach via the common flexor tendon, or the pronator teres.

Second, partial thickness tears of the UCL can be seen in pitchers who are completely asymptomatic, so it may be an incidental finding. Moreover, we have had several guys come our way with partial thickness UCL tears who have been able to rehab and return to full function without surgery. While the UCL may be partially torn and irritated, the pain may actually be coming to “threshold” because of muscular weakness, poor flexibility, or poor tissue quality.

Medial epicondyle stress fractures can be easily diagnosed with x-rays, but outside of a younger population, they can definitely be overlooked. For instance, I had a pro baseball player – at the age of 23 – sent to us for training by his agent last year as he waiting for a medial epicondyle fracture to heal.

While these are the “big players” on the injury front – particularly in a throwing population – you can also see a number of other conditions, including soft tissue tears (flexor tendons, in particular), loose bodies (particularly posteriorly, where bone chips can come off the olecranon process), and calcification of ligaments. So, long story short, diagnosis can be a pain in the butt – and usually it’s a combination of multiple factors.  At a presentation last weekend, Dr. Lance Oh commented on how 47% of elbow pain cases present with subluxating medial triceps ("snapping elbow"), but this is rarely an issue by itself.

That’s one important note. However, there is a much more important note – and that is that many rehabilitation programs are outrageously flawed in that they only focus on strengthening and stretching the muscles acting at the elbow and wrist.

As I’ll outline in Part 3 of this series, a ton of the elbow issues we see in throwers occur secondary to issues at the glenohumeral and scapulothoracic joints. And, more significantly, not providing soft tissue work in these regions grossly ignores the unique anatomical structure of the elbow and forearm and its impact on tendon quality. If you’ve got elbow issues, make sure you’ve got someone doing good soft tissue work on you. Just to give you a little visual of what I’m thinking, I got a video of Nathaniel (Nate) Tiplady, D.C. (a great manual therapist who works out of Cressey Performance a few days a week) performing some Graston Technique® followed by Active Release ® on my forearms.  Here's the former; take note of the sound of his work on the tissues; the instruments actually give the practitioner tactile (and even audible) feedback in areas of significant restrictions.  You'll see that it is particularly valuable for covering larger surface areas (in this case, the flexors of the anteromedial aspect of the forearm):

As for the ART, you'll see that it's more focal in nature, and involves taking the tissue in question from shortened to lengthened with direct pressure.

As you can probably tell (even without seeing me sweat or hearing me curse), it doesn’t feel great while he’s doing it – but the area feels like a million bucks when he’s done.

While there is no substitute for having a qualified manual therapist work on you, using The Stick on one’s upper and lower arms can be pretty helpful.

More on that in Part 3…

Posteriorly, you'll see that olecranon process of the ulna sits right in the olecranon fossa of the humerus.  This is a pretty significant region, as it gives the elbow its "hinge" properties and prevents elbow hyperextension.  Fractures of the olecranon can occur and leave loose bodies in the joint that will prevent full elbow extension.  And, not to be overlooked is the attachment site of the triceps (via a common tendon) and anconeus on the olecranon process.

The "elbow" may just be a hinge to the casual observer, but in my eyes, it's important to distinguish among the humeroulnar joint (described above) and the humeroradial (pivot) and proximal radioulnar joints - which give rise to pronation and supination.

Likewise, the wrist (and the fingers, for that matter) is directly impacted in flexion/extension, radial deviation/ulnar deviation, and pronation/supination by muscles that actually attach as far "north" as the humerus.  Muscles aren't just working in one plane of motion; they're working for or against multiple motions in multiple planes.

In all, you have 16 muscles crossing the elbow.  For those counting at home, that's more than you'll find at another "hinge" joint, the knee, in spite of the fact that the knee is a much bigger joint mandating more stability.  More muscles equates to more tendons, and that's where things get interesting.

This last graphic demonstrates that there are a few other factors to consider in this already jam-packed area.  You've got fascia condensing things further, and you've also got a blood supply and nerve innervations - most significantly, the ulnar, median, and radial nerves - passing through here. The median nerve, for instance, passes directly through the pronator teres muscle.

Oh, and you've also got ligaments mixed in - some of which are attaching on the very same regions that tendons are attaching.  The ulnar collateral ligament attaches on the medial epicondyle in close proximity to the flexors and pronator teres, for instance.  These ligaments are heavily reliant on soft tissue function to stay healthy.  As an example, flexor carpi ulnaris is going to be your biggest "protector" of the UCL during the throwing motion.

So what's the take-home message of this functional anatomy lesson?  Well, there are several.

1. Lots of stuck is packed in a very small area.

2. When things are stuck together, they form dense, fibrotic, nasty balls of crud.

3. These gunked up muscles/tendons can impact everything from nerve function to ligamentous integrity - or they can just give out in the form of a tear or tendinopathy.

4. Diagnosis can be tricky because all the potential issues take place in a small area, and may have very similar symptoms.  Different pathologies take place in different athletic populations, too.  We'll have more on this in Understanding Elbow Pain - Part 2: Pathology.

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