After an Instagram post of mine last week generated quite a few inquiries on how to manage ulnar nerve hypermobility, I thought I'd record a follow-up video to dig in a bit deeper on the topic.

If you're looking to learn a bit more about the structure and function of the elbow (particularly throwing elbows), my presentation, Everything Elbow, would also be worth checking out.

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Here's some recommended reading from around the 'Net:

What Really Constitutes Functional Balance Training? -This is an old blog of mine that I'm "re-upping" here because of a conversation about specificity of balance training that I had with an athlete the other day.

How to Have Impossible Conversations - I just finished this as an audiobook, and it was outstanding - especially in light of recent events in the world. There are definitely lessons for every strength and conditioning/fitness and sports medicine professional.

Sport specialization is associated with upper-extremity overuse injury in high school baseball players - Here's (yet another) study demonstrating a drastic increase in injury rates in those who specialize in one sport. In this particular study, highly specialized high school baseball players from California, Alabama, and Michigan were 3.77 times more likely to have had an upper extremity injury in the previous year than their non-specialized counterparts.

Top Tweet of the Week

It's amazing that with all the remarkable metrics we have to track pitching and hitting characteristics, there are still coaches and players who overlook the fact that the most important number for baseball success - body weight - is the cheapest and easiest to monitor.

— Eric Cressey (@EricCressey) July 16, 2020

Top Instagram Post of the Week

 

 

 

 

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Ulnar nerve hypermobility: another thing you really only pay attention to if you train baseball players. It’s likely present to some degree in about 1/3 of the population, but not everyone does this repeated elbow flexion-extension 100 times in two hours at high velocity with a 5oz ball in the hand. You have to train the person AND the sport, and more importantly, the interaction between the two.👊#cspfamily

A post shared by Eric Cressey (@ericcressey) on Jul 13, 2020 at 12:34pm PDT

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Each time I run a Q&A, I get questions along the lines of:

If you could only pick one hip mobility assessment, what would it be?

If you could only pick one exercise to build pitching velocity, what would it be?

If you could only pick one shoulder exercise to fix my shoulder pain, what would it be?

You know what's awesome? With respect to all of these questions - and many more - I've NEVER in my entire career had to choose just one.

There may be no such thing as a stupid question, but there are stupid lines of thinking - and this reductionist approach to solving health and human performance problems is a big issue in our industry. In my experience, we see far more chronic issues develop because individuals fail to see the synergy among many factors, as opposed to their inability to hone in on the most important one. I'll give you an example.

Earlier this year, we saw a pitcher with a cranky ulnar nerve. He'd had mixed results with anti-inflammatory medications.

As it turns out, he had a subluxating ulnar nerve, which would predispose him to this issue during a motion like pitching that involves repeated flexion/extension, especially when combined with valgus stress (which stretches the nerve).

He did some extensive manual therapy with my business partner, massage therapist Shane Rye, who treated everything from his neck down to his forearm. This alone gave him a ton of relief - and he even commented that he felt a lot better with respect to some shoulder and neck issues he'd had previously.

In his movement screen, we'd noticed a lot of glaring scapular control issues. At rest, he sat in considerable anterior tilt and depression. Upon initiation of overhead reaching, he pulled into retraction instead of initiating smooth upward rotation. Most of his "external rotation" was actually scapular retraction and lumbar extension. In short, he was getting a lot of motion in the wrong places during several upper extremity assessments - and when we went to watch his arm care exercises, they were reaffirming all these faulty patterns. As an example, he was pulling down with the lat on horizontal abduction work, going into forward head posture on a lot of lifts, and banging out push-ups that looked a lot like this. 

 

 

 

 

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If you’re still doing push-ups like this two years after shoulder surgery, there’s a good chance your shoulder is still going to hurt. Many times, the biggest improvements come from cleaning up exercise technique, as opposed to adding new exercises. #cspfamily

A post shared by Eric Cressey (@ericcressey) on Jun 18, 2018 at 10:16am PDT

Morever, the exercise selection in his strength and conditioning programs were contributing to these aberrant patterns. His program was very lat dominant, and he wasn't doing enough work above 90 degrees of shoulder elevation to drive better patterns of upward rotation with good scapular posterior tilt. And, if that wasn't enough, he was using blood flow restricted training on his upper arm regularly in hopes of optimizing recovery. In reality, the compression was probably "snagging" his nerve even more.

We made a bunch of changes - picking lots of very easy, low-hanging fruit - and he hasn't had issues with the nerve all season. I can't tell you exactly which ONE of these interventions had the biggest impact on him staying healthy - but the good news is that it doesn't matter. Success is a function of over a dozen assessments and several interventions from multiple people.

With that mind, quit looking for a quick, easy, reductionist answer. It's not about a single assessment, exercise, or coaching cue any more than it is about a magic pill. Rather, it's about how all the pieces fit together. If you look around at the best coaches and rehabilitation specialists in the industry today, they're usually very well rounded in terms of their knowledge base, skill sets, and referral network. As a result, they can appreciating multiple disciplines and provide comprehensive care to the athletes, clients, and patients they serve.

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I talk a lot about how there's a difference between simply "training baseball players" and actually training baseball players with a genuine appreciation of the unique demands they encounter - as well as their bodies' responses to those demands.  Today's post will be a great example of how you can't just throw every throwing arm into a generic program.

One of the adaptations you'll commonly see in throwers is an acquired valgus carrying angle at the elbow.  For the laymen in the crowd, take note of how the throwing arm (in this case, the right arm, which is to the left side of the picture) has a "sharper" angle: 

This is an adaptation to the incredible valgus stress during the lay-back portion of throwing.

While the research on the subject isn't really out there, it's widely believed that a sharper valgus carrying angle predisposes throwers to elbow injuries, particularly ulnar collateral ligament (UCL) tears.  My good friend Mike Reinold actually has a lot of very good unpublished data on the topic, too. In my eyes, this verifies that we need need to treat throwers like this with extra care in light of this increased susceptibility to injury. 

From my perspective, I think it means more time off from throwing each off-season in order to regain passive stability, as the UCL is already stretched out more than in the normal pitcher.  Additionally, it may take longer for these athletes to regain good soft tissue quality, as the musculature at the medial elbow is likely working harder to make up for this loss of passive stability and the increased range-of-motion demands.  Another key point is that this valgus carrying angle may increase the likelihood of ulnar nerve hypermobility (snapping back and forth over the medial epicondyle during flexion/extension) or ulnar neuritis (irritation of the nerve from excessive stretch). If this nerve only has a limited number of flexion/extension cycles before it really gets irritated, then we need to use each throw wisely to put off the possibility of needing an ulnar nerve transposition surgery to set it where it needs to be.

Additionally, I think it means less aggressive throwing programs, particularly with respect to extreme long toss.  I think long toss has a ton of merit for a lot of throwers, but one concern with it is that it does increase valgus stress slightly as compared to throwing on a line at shorter distances.  With that in mind, these folks might respond better to other throwing initiatives, or simply less long toss than they otherwise might do.

From a training standpoint, we need to work to gain more active external rotation to ensure that more of the range-of-motion is occuring is at the shoulder than the elbow.  This should not be confused with simply stretching the shoulder into external rotation, which does much more harm than good in 99% of cases.  Rather, we need to educate athletes on how to get to lay-back without compensation. I like supine external rotation - an exercise I learned from physical therapist Eric Schoenberg - as a starting point.

Once we've been successful working with gravity, we'll progress this drills to prone to work against gravity, and then add in various holds at end-ranges of motion to strengthen athletes in external rotation closer to end-range.  Here's an example you can try at home:

In terms of contraindications, I can't say that it changes much as compared to what we avoid - back squats, Olympic lifts, etc. - with the rest of our throwers.  However, I think the fallout could be even more dramatic; just imagine these elbows catching a snatch overhead in the off-season after 200+ innings of wear and tear.

This picture also teaches us that one can simply be born with a more significant valgus carrying angle, but throwing during the adolescent and teenage years would make it more extreme.

Beyond training implications, for the reasons I noted above, it's also extremely important to take care of tissue quality at the common flexor tendon and pronator teres. I like a combination of instrument-assisted soft tissue mobilization and hands-on work like Active Release.

I hope this post brings to light an additional assessment and follow-up training principles you can use to give your throwers the quality training and (p)rehabilitation they need. If you're looking for more insights on training throwers, I'd highly recommend you check out our Elite Baseball Mentorships; the next course takes place on December 8-10.

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At the end of the day yesterday, I took a quick glance at my Facebook feed and was quickly drawn to a "highlight" video from a baseball strength and conditioning program.  The athletes' energy was great, and there was a ton of camaraderie.  The only problem was that if you had watched the video without first seeing the word "baseball" in the title, you would have never known it was a baseball team training. The exercises - and the way that they were/weren't coached - clearly didn't reflect the unique demands of the sport.

With that in mind, I thought I'd use today's post to quickly highlight the most important positions you need to understand when you're training throwing athletes: stride foot contact/full external rotation.

Stride foot contact occurs just before maximum external rotation takes place.  As the foot touches down, the pelvis has started rotating toward home plate while the torso is still rotated in the opposite direction to create the separation that will enhance velocity.  Maximum external rotation - or "lay-back" - signifies the end of this separation, as the energy generated in the lower extremity is already working its way up the chain.  Nissen et al. (2007) presented this tremendous diagram to illustrate the separation that takes place.  This image represents a right handed picture, where the top image is the hips, and the bottom image is the torso (right and left shoulder joint centers of rotation).

Source: Nissen et al.

Based on this image alone, you should be able to see where most oblique strains and lower back pain originate; this is ridiculous rotational stress.  Additionally, you can appreciate why hip injuries are higher in throwers than they ever have been before; it takes huge hip rotation velocities to play "catch up" so that the pelvis and thorax are squared up at maximum external rotation (if they aren't, the arm drags).  This just refers to what's happening at the lower extremity and core, though.  Let's look at the shoulder.

At full lay-back (maximum external rotation), we encounter a number of potentially traumatic and chronic injuries to the shoulder.  In a pattern known as the peel-back mechanism, the biceps tendon twists and tugs on the superior labrum. The articular side (undersurface) of the rotator cuff may impinge (internal impingement) on the posterior-superior glenoid, leading to partial thickness cuff tears. Finally, as the ball externally rotates in the socket, the humeral head tends to glide forward, putting stress on the biceps tendon and anterior ligamentous structures. 

Likewise, at the elbow, valgus stress is off the charts.  That can lead to ulnar collateral ligament tears, flexor/pronator strains, medial epicondyle stress fractures, lateral compressive injuries, ulnar nerve irritation, and a host of other isssue.  I don't expect most of you to know what much of this means (although you can learn more from Everything Elbow), but suffice it to say that it's incredibly important to train throwers to be functionally strong and mobile in these positions. 

And, this brings to light the fundamental problem with most strength and conditioning programs for overhead throwing athletes; they commonly don't even come close to training people to be "safe" in these positions. "Clean, squat, deadlift, bench, chin-up, sit-up" just doesn't cut it.  You need to be strong in single-leg stance to accept force on the front side with landing.

You need to be able to apply force in the frontal and transverse planes.

You also need to transfer this force to powerful movements.

You need to have plenty of rotary stability to effectively transfer force from the lower to upper body.

You need to be strong eccentrically in the 90/90 position.

You need to have outstanding hip mobility in multiple planes of motion.

You need to attend to soft tissue quality in areas that other athletes rarely have to consider.

These demands are really just the tip of the iceberg, though, as you have to see how all the pieces fit together with respect to throwing and hitting demands at various times of year.  Training for baseball isn't as simple as doing the football strength and conditioning program and then showing up for baseball practice; there are far more unique challenges when dealing with any rotational sport, particularly those that also integrate overhead throwing.  Watch the sport, talk to the players, appreciate the demands, and evaluate each individual before you try to write the program; otherwise, you're simply fitting athletes to existing programs.

For more insights like these, I'd encourage you to check out one of our Elite Baseball Mentorships; we have two of these events scheduled for this fall.

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Quite some time ago, I met a pitching coach who made a bold statement to me:

"Most Major League pitchers have terrible mechanics."

I don't know if he meant that they were mechanics that could lead to injuries, or simply mechanics that would interfere with control and velocity development, but either way, I shrugged it off.  Why?

Their mechanics are so terrible that they're in the top 0.0001% of people on the planet who play their sport.  And, they're paid extremely well to be terrible, I suppose.

Kidding aside, this comment got me to thinking about something that's been "festering" for years now, and I wanted to run it by all of you today to get your impressions on it.  In other words, this post won't be about me ranting and raving about how things should be, but rather me starting a dialogue on one potential way to get the baseball development industry to where it needs to be, as it clearly isn't there yet (as evidenced by the fact that more pitchers are getting hurt nowadays than ever before).

The way I see it, mechanics are typically labeled as "terrible" when a pitcher has:

1. Trouble throwing strikes

2. Pitching velocity considerably below what one would expect, given that pitcher's athleticism

3. Pain when throwing

4. Mechanical issues that theoretically will predispose him to injury 

In the first three cases, anyone can really make these observations.  You don't need to be trained in anything to watch the walk totals pile up, read a radar gun, or listen when a pitcher says, "It hurts."  Moreover, these issues are easier to coach because they are very measurable; pitchers cut down on their walks, throw harder, and stop having pain.

Issue #4 is the conundrum that has lead to thousands of pissing matches among pitching coaches.  When a pitcher gets hurt, everyone becomes an armchair quarterback.  The two biggest examples that come to mind are Mark Prior and Stephen Strasburg.

Prior was supposed to be one of the best of all-time before shoulder surgeries derailed his career.  After the fact, everyone was quick to pin all the issues on his mechanics.  What nobody has ever brought to light is that over the course of nine years, his injuries looked like the following (via Wikipedia):

1. Hamstrings strain (out for 2002 season)
2. Shoulder injury (on-field collision - missed three starts in 2003)
3. Achilles injury (missed two months in 2004)
4. Elbow strain (missed 15 days in 2004)
5. Elbow injury (missed one month in 2005 after being hit by line drive)
6. Rotator cuff strain (missed three months in 2006)
7. Oblique strain (missed two starts in 2006)
8. Rotator cuff strain (ended 2006 season on disabled list)
9. Shoulder surgery (missed entire 2007 season, and first half of 2008)
10. Shoulder capsule tear (out for season after May 2008)
11. Groin injury (missed last two months of 2011 season)

By my count, that is eleven injuries - but four of them were non-arm-related.  And, two of them (both early in his career) were contact injuries.  Who is to say that he isn't just a guy with a tendency toward degenerative changes on a systemic level?  How do we know one of the previous injuries didn't contribute to his arm issues later on?  How do we know what he did for preventative arm care, rehabilitation, throwing, and strength and conditioning programs? We don't have his medical records from earlier years to know if there were predisposing factors in place, either.  I could go on and on.

The issue is that our sample size is one (Mark Prior) because you'll never see this exact collection of issues in any other player again.  It's impossible to separate out all these factors because all issues are unique.  And, it's one reason why you'll never see me sitting in the peanut gallery criticizing some teams for having injured players; we don't have sufficient information to know exactly why a player got hurt - and chances are, the medical staff on those teams don't even have all the information they'd like to have, either.

Strasburg has been labeled the best prospect of all-time by many, and rightfully so; his stuff is filthy and he's had the success to back it up.  Of course, the second he had Tommy John surgery, all the mechanics nazis came out of their caves and started berating the entire Washington Nationals organization for not fixing the issue (an Inverted W) proactively to try to prevent the injury.  Everybody is Johnny Brassballs on the internet.

To that end, I'll just propose the following questions:

1. Did Strasburg not do just fine with respect to issues 1-3 in my list above?

2. Would you want to be the one to screw with the best prospect of all-time and potentially ruin exactly what makes him effective?

3. Do we really know what the health of his elbow was when the Nationals drafted him?

4. Do we know what his arm care, throwing, and strength and conditioning programs were like before and after being drafted?

There are simply too many questions one can ask with any injury, and simply calling mechanics the only contributing factor does a complex issue a disservice - especially since young athletes are growing up with more and more physical dysfunction even before they have mastered their "mature" mechanics.

The Inverted W theory is incredibly sound; Chris O'Leary did a tremendous job of making his case - and we certainly work to coach throwers out of this flaw - but two undeniable facts remain.  First, a lot of guys still throw with the Inverted W and don't have significant arm issues (or any whatsoever).  They may have adequate mobility and stability in the right places (more on this below) to get by, or perhaps they have just managed their pitch counts and innings appropriately to avoid reaching threshold.  I suspect that you might also find that many of these throwers can make up for this "presumed fault" with a quick arm combined with a little extra congenital ligamentous laxity, or subtle tinkering with some other component of their timing.

Second, a lot of guys who don't have an Inverted W still wind up with elbow or shoulder injuries. Good research studies bring issues like these to light, and nobody has really gotten a crew of inverted W guys and non-inverted W guys together to follow injury rates over an extended period of time while accounting for variables such as training programs, pitch counts, and pitch selection (e.g., sliders vs. curveballs). We don't know if some of these other factors are actually more problematic than the mechanics themselves, as it's impossible to control all these factors simultaneously in a research format.

As such, here we have my first set of questions:

Don't you think that pitching coaches need to make a dedicated effort to understand research methods so that they can truly appreciate the multifactorial nature of injuries?  And, more importantly, wouldn't learning to read research help them to understand which mechanical issues are the true problem?  

The Inverted W is certainly an issue, but there are many more to keep in mind. Just my opinion: I think the baseball industry would be much better off if pitching coaches read a lot more research.

Now, let's move on to my second question.  First, though, I want to return to the Inverted W example again. I have not met more than a few pitching coaches who can explain exactly what structures are affected by this mechanical flaw because they don't understand what functionally is taking place at the shoulder and elbow.  They don't understand that excessive glenohumeral (shoulder) horizontal abduction, extension, and external rotation can all lead to anterior glide of the humerus, creating more anterior instability and leading to injuries to the anterior glenohumeral ligaments and labrum.  Meanwhile, the biceps tendon picks up the slack as a crucial anterior stabilizer.  They also don't appreciate how these issues are exacerbated by poor rotator cuff function and faulty scapular stabilization patterns.  And, they don't appreciate that these issues are commonly present even in throwers who don't demonstrate an Inverted W pattern.

At the elbow, they also can't explain why, specifically, the Inverted W can lead to problems. They don't understand that the timing issue created by the "deep" set-up leads to greater valgus stress at lay-back because the arm lags.  They can't explain why some players have medial issues (UCL injuries, ulnar nerve irritation, flexor/pronator strains, and medial epicondyle stress fractures) while other players have lateral issues (little league elbow, osteochondritis dissecans of radial capitellum) from the same mechanical flaws.  They can't explain why a slider thrown from an Inverted W position would be more harmful than a curveball.

I can explain it to you - and I can explain it to my athletes so that they understand, too. I've also met a lot of medical professionals who can clearly outline how and why these structures are injured, but we aren't the ones coaching the pitchers on the mounds.  The pitching coaches are the ones in those trenches.

To that end, I propose my second set of questions:

Don't you think pitching coaches ought to make an effort to learn functional anatomy in order to understand not just what gets injured, but how those injuries occur?  Wouldn't it give them a more thorough understanding of how to manage their pitchers, from mechanical tinkering, to pitch selection, to throwing volume?  And, wouldn't it give them a more valid perspective from which to contribute to pitchers' arm care programs in conjunction with rehabilitation professionals and strength and conditioning coaches? 

The problem with just saying "his mechanics suck" is that it amounts to applying a theory to a sample size of one.  That's not good research.  Additionally, this assertion is almost always taking place without a fundamental understanding of that pitcher's functional anatomy.  It amounts to coaching blind.

To reiterate, this was not a post intended to belittle anyone, but rather to bring to light two areas in which motivated pitching coaches could study extensively in order to really separate themselves from the pack.  Additionally, I believe wholeheartedly in what Chris O'Leary put forth with his Inverted W writings; I just used it as one example of a mechanical flaw that must be considered as part of a comprehensive approach to managing pitchers.

With that said, I'd love to hear your opinions on these two sets of questions in the comments section below. Thanks in advance for your contributions.

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My good buddy Alan Jaeger has gone to great lengths to bring long tossing to the baseball world.  I discussed why I really like it and what some of the most common long toss mistakes are in two recent posts:

Making the Case for Long Toss in a Throwing Program
The Top 4 Long Toss Mistakes

However, one thing I didn't discuss in those previous blogs was the status quo - which is essentially that long toss distances should not exceed 90-120 feet.  These seemingly arbitrary numbers are actually based on some research discussing where a pitcher's release point changes and the throwing motion becomes less and less like what we see on the mound.  Alan looked further into the origins of the "120 foot rule," and informed me that these programs began in the late 1980s/early 1990s and were based on "post-surgery experience" of a few rehabilitation specialists.

Yes, we're basing modern performance-based throwing programs for healthy pitchers on 20+ year-old return-to-throwing programs that were created for injured pitchers.  It seems ridiculous to even consider this; it's like only recommending body weight glute bridges to a football player looking to improve his pro agility time because you used them with a football player who had knee or low back pain.  It might be part of the equation, but it doesn't improve performance or protect against all injuries.  Let's look further at how this applies to a throwing context, though.

A huge chunk of pitching injuries - including all those that fall under the internal impingement spectrum (SLAP tears, undersurface cuff tears, and bicipital tendinosis), medial elbow pain (ulnar nerve irritation/hypermobility, ulnar collateral ligament tears, and flexor/pronator strains), and even lateral compressive stress (younger pitchers, usually) occur during the extreme cocking phase of throwing.  That looks like this:

It's in this position were you get the peel back mechanism and posterior-superior impingement on the glenoid by the supra- and infraspinatus.  And, it's where you get crazy valgus stress (the equivalent of 40 pounds pulling down on the hand) at the elbow - which not only stresses the medial structures with tensile force, but also creates lateral compressive forces.

In other words, if guys are hurt, this is the most common spot in their delivery that they will typically hurt.

So, logically, the rehabilitation specialists try to keep them away from full ROM to make the surgical/rehab outcomes success - and you simply won't get full range of motion (ROM) playing catch at 60-120 feet.

Effectively, you can probably look at the "progression" like this:

Step 1: 60-120 ft: Low ROM, Low Stress
Step 2: 120+ ft: Medium ROM, Medium Stress
Step 3: 240+ ft: High ROM, Medium Stress
Step 4: Mound Work: High ROM, High Stress

In other words, in the typical throwing program - from high school all the way up to the professional ranks - pitchers skip steps 2 and 3.  To me, this is like using jump rope to prepare for full speed sprinting.  The ROM and ground reaction forces (stress) just don't come close to the "end" activity.

Only problem?  Not everyone is rehabbing.  We're actually trying to get guys better.

Long Toss.  Far.  You'll thank me later.

Want to learn more? Check out Alan's DVD, Thrive on Throwing, to learn more.  He's made it available to my readers at 25% off through this link.

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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 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…