Three Years of Cressey Performance: The Right Reasons and the Right Way

Written on July 14, 2010 at 7:16 am, by Eric Cressey

Though a somewhat “normal” day at the gym, yesterday marked Cressey Performance’s three-year anniversary.

While my business partner’s blog post yesterday did an excellent job of doling out “thank yous” to a lot of the important people who have been so involved in our success – from clients to parents, coaches, interns, and significant others – I wanted to add my own two cents on the matter today.  More than anything, I really wanted to highlight a sentence that illustrates what makes me the most proud about where CP has been, where it is, and where it’s going.

We’ve done this for the right reasons, and we’ve done it the right way.

I read a business development blog post by Chris McCombs the other day where he wrote something that really hit home for me.  When he was talking about how he decides to accept or reject a new project/opportunity, here is one of his guidelines:

“Only Take on Projects That Are In Line With My Current Values and Fulfill Me Beyond Just The Money – A project must fulfill me in some way BESIDE just money…too many people spend their life JUST chasing a buck; to me, that’s no way to live.  For me, the money must be there, but it should fulfill me personally, be fun, help a lot of people, and build and be in line with my current brand and brand equity.”

Back in 2007, I had a tough decision to make.  My online consulting business had really taken off, and the Maximum Strength book deal was in the works.  My other products – Magnificent Mobility, The Ultimate Off-Season Training Manual, and Building the Efficient Athlete – were selling well and getting great reviews, and I’d just had a study published in the Journal of Strength and Conditioning Research.  This website was growing exponentially in popularity, and I had just wrapped up my first year on the Perform Better tour – so lots of doors were opening for me on the seminar front to present all over the world – and I could have stayed home and just written all day, every day.

I was getting really crunched for time, as I was already training clients 8-13 hours per day, seven days per week, as my in-person clientele had rapidly grown. My phone rang off the hook for about three weeks after Lincoln-Sudbury won a baseball state championship after I’d trained several of their guys, and one of my athletes was named state player of the year.  And, after being featured on the front page of the Boston Globe with a nipple so hard I could cut diamonds, I was in demand as a t-shirt model (okay, not really – but it made for an awesome blog post, The School of Hard Nipples).

I was exhausted and stressed – but absolutely, positively, “living the dream” that I’d always wanted.

To make matters a bit more interesting, I had just started dating a great girl (now my fiancee) who I really had a good feeling was “the one” after about three months.  The work days, however, were insanely long and I was worried that I’d screw up a good thing by not spending enough time with her.

Every business development coach out there would have seen a “simple” answer to all my problems: stop training people in person.  Just write, consult, make DVDs, and give seminars.  It would have cut my hours by 80% and still allowed me to earn a pretty good living – and enjoy plenty of free time.  There was a huge problem with that, though; as Chris wrote, it wouldn’t “fulfill me personally, be fun, help a lot of people, and build and be in line with my current brand and brand equity.”  I like doing evaluations, writing programs, coaching, sweating, training with my guys, cranking up the music, helping people get to where they want to be, collaborating with and learning from other professionals, and watching my athletes compete – whether it’s at some high school field or at Fenway Park.  Giving that up wasn’t an option; I guess I’d have just been a crappy business coaching client, as I would have been stubborn as an ass on giving that up.

Fortunately for me, Pete Dupuis, my roommate from my freshman year of college, had just finished his MBA and was in the midst of a job search.  And, during that MBA, he’d started to train with me and packed on a ton of strength and muscle mass – making him realize and truly appreciate the value in what I was doing (especially since he was and is a goalie in a very competitive soccer league).  Pete had also met and become friends with a ton of my clients – and taken a genuine interest in my baseball focus, as a lifelong Red Sox fan.  Almost daily, Pete would encourage me to do my own thing and let him handle all the business stuff for me.

Simultaneously, Tony Gentilcore was ready for a change of scenery on the work front.  Having been Tony’s roommate and training partner for almost two years at that point, I knew he was a genuinely great guy, that he’d read everything on my bookshelf, and that he could coach his butt off and “walk the walk.”  He, too, had met a lot of my clients – so there was continuity from the get-go.

So, on July 13, 2007, Cressey Performance was born.  Here is what we started with.

Boatloads of renovations and equipment additions later, it wound up looking like this.

Of course, we outgrew and demolished this space after about nine months and moved three miles east to a facility twice the size.  And, we’ve continued to grow right up to this day; June was our busiest month ever, and July should be busier.  We’ve got regular weekly clients who come from four states (MA, NH, CT, RI), and in the baseball off-season, I have college and pro guys who come from the likes of OH, AZ, CA, SC, NC, GA, FL, and VA.  And, we had 33 applicants for this summer’s internships.

To be very candid, though, I don’t consider myself a very good “businessman.”  No offense to Pete or Tony, either, but I don’t think they even come close to the textbook definition of the word, either.  We just try to be good dudes. “We’ve done this for the right reasons, and we’ve done it the right way.”

We don’t allocate a certain percentage of our monthly revenues to advertising.  In fact, we haven’t spent a single penny on advertising – unless you count charitable donations to causes that are of significance to us.

We don’t search high and low for new revenue streams to push on our clients.  In fact, if I get one more MonaVie sales pitch, I’m going to suplex whoever delivered it right off our loading dock.  Rather, we bust our butts to set clients up for success in any way possible – and trust that those efforts will lead to referrals and “allegiance” to Cressey Performance.  We ask what they want from us and modify our plans accordingly.  It’s what led to us bringing in manual therapy, a pitching cage, and, of course, pitching coach/court jester Matt Blake’s timeless antics.

Along those same lines, we don’t measure our success based on revenue numbers; we measure it based on client results.  In three years of seeing LOADS of baseball players non-stop, we’ve only had three arm surgeries: one shoulder and two elbow.  All three were athletes who came to us with existing injuries, and in each case, we kept them afloat as long as we could and trained them through their entire rehabilitation.  I don’t want to toot our own horn, but this is a remarkable statistic in a population where over 57% of pitchers suffer some form of shoulder injury during each competitive season – and that doesn’t even include  elbows!  And, our statistics don’t even count literally dozens of players who have come to us after a doctor has told them they needed surgery, but we’ve helped them avoid these procedures.  The college scholarships, draft picks, state titles, individual honors, and personal bests in the gym are all fantastic, but I’m most proud of saying that we’ve dedicated ourselves to keeping athletes healthy so that they can enjoy the sports they love.

The same goes for our non-competitive athlete clients.  The fat loss and strength gains they experience are awesome and quantifiable, but beyond that (and more qualitatively), I love knowing that they’re training pain-free and are going to be able to enjoy exercise and reap the benefits of training for a long time.

We don’t penny-pinch during our slowest times of the month (late March through mid-May – the high school baseball season).  We see it as an opportunity to do more staff continuing education, renovate the facilities, and get out to watch a lot of baseball and support our athletes.  And, we adjust our hours to open up on Sundays and stay later on weeknights during the baseball season to make it easier for athletes to get in-season training in whenever they can.  If a pitcher wants to come in and get his arm stretched out before or after an outing, he stops by and we do it for him – but don’t charge him a penny for it.  It’s about setting people up for success.

We don’t try to just “factory line” as many clients through our facility as possible with everyone on the same program.  You might walk into CP and see 20 different clients on 20 different programs – because a 16-year old pitcher with crazy congenital laxity is going to have a markedly different set of needs than a 16-year-old linebacker with shoulder mobility so bad that he needs help putting a jacket on.  One program on one dry erase board for hundreds of athletes isn’t training; it’s babysitting.

Taking this a step further, we don’t boot clients out after a certain amount of time.  Clients take as long as needed to complete the day’s program. And, when they’re done (or before they even begin), loads of our clients spend time hanging out in the office just shooting the breeze and enjoying the environment.  As an example, Toronto Blue Jays Organizational Pitcher of the Year Tim Collins spends a minimum of five hours a day at CP all off-season.

Tim has sold girl scout cookies for the daughter of one of our clients, and he’s been our back-up front desk guy when Pete is out of town.  Yesterday, he was back to visit on his all-star break – and he said hello to every client he saw – and remembered them by name.  If you’re a 15-year-old up-and-coming baseball pitcher, how cool is it to get that kind of greeting when you walk into the office?  Well, at CP, kids get that greeting from 10-15 pro guys all the time.  And, if they’re lucky, they might even get to throw on a bobsled helmet and join these pro guys in a rave to Miley Cyrus, apparently.

At least once a week, I get an email from an up-and-coming coach asking for advice about starting a facility.  When I get these emails, I now think about how Rachel Cosgrove recently mentioned that more than 80% of fitness coaches leave the industry within the first year. In most cases, this happens because these people never should have entered the fitness industry in the first place – because their intentions (money) were all wrong.  They usually leave under the assumption that they could never make a living training people, but in reality, these folks are going to have a hard time making a living in any occupation that requires genuinely caring about what you do and the people with whom you work, and being willing to hang your hat on the results you produce.

As such, the first advice, in a general sense, is obvious: do it for the right reasons, and do it the right way.  Sure, making a living is essential, but only open a facility because it would fulfill you “personally, be fun, help a lot of people, and build and be in line” with who you are and what your values are – which together constitute your “brand.” Making the move to start up this business was one of the most daunting decisions I have ever had to make, and all the efforts toward actually getting the business started were equally challenging.  However, in the end, it has been more rewarding both personally and professionally than I could have ever possibly imagined.

Thank you very much to all of you – clients/customers, parents, EricCressey.com readers, seminar attendees, and professional colleagues – for all your support over the past three years.  We couldn’t have done it without you – and look forward to many more years of doing things for the right reasons and in the right way.

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Mobilizing the Throwing Shoulder: The Do and Don’t

Written on June 18, 2010 at 7:32 am, by Eric Cressey

Q: I recently opened up my own place to train athletes, and wanted to thank you for all of the knowledge you have passed along, as it has been a big factor in designing my own training philosophy.  The majority of my athletes are baseball and football players in the high school and collegiate level, and I had question for you regarding my baseball players specifically.

Nearly every player I work with (and for the most part every pitcher I have worked with), has tight shoulders due to over-use, being imbalanced, and weak.  I have them performing a ton of upper back work in comparison to pressing movements, rotator cuff work, sleeper stretches, and myofascial release.  It helps greatly, but they still seem to never get back to a full range of motion or an actual natural throwing motion.  Because of this, I was wondering what you thought about adding in shoulder dislocations using a dowel rod or broomstick to help with shoulder mobility.

Because the players I work with are either in college because of their ability to play baseball, or have a chance at being drafted or getting a good college scholarship from their arms, I want to make sure that everything I do makes them better instead of hurting them in the long run for what looks like a quick fix when they are with me.

I’d love to hear any thoughts you might have on helping increase shoulder mobility and the shoulder dislocation exercise, in particular.

A: First off, thank you very much for your kind words and continued support.

Unfortunately, to be blunt, I think it would be a terrible idea and you would undoubtedly make a lot of shoulders (and potentially elbows) worse.

Most pitchers will have increased external rotation (ER) on their dominant side, and as such, increased anterior instability.  If you just crank them into external rotation and/or horizontal abduction, you will exacerbate that anterior instability.  Think about what happens in the apprehension-relocation test at the shoulder; the relocation posteriorly pushes the humerus to relieve symptoms by taking away anterior instability.

We are extremely careful with who we select for exercises to increase external rotation, and it is in the small minority.  Most pitchers gain ~5 degrees of external rotation over the course of the competitive season, as it is.  If we are going to have them do mobilizations to increase ER, it’s only after we’ve measured their total motion (IR+ER) as asymmetrical and determined that they need ER (a sign is ER that is less on the dominant shoulder).  And, any exercises we provide on this front are done in conjunction with concurrent scapular stabilization and thoracic spine extension/rotation – as you’d see in a side-lying extension-rotation drill.

Here, you’ve got supination of the forearm, external rotation of the shoulder, scapular retraction/posterior tilt, and thoracic spine extension/rotation occurring simultaneously on the “lay back” component.  And, the opposite occurs as the athlete returns to the starting position.  Again, to reiterate, this is NOT a drill that is appropriate for a large chunk of throwing shoulders who already have crazy external rotation; it’s just one we use with specific cases of guys we discover need to gain it.

With the broomstick dislocation, you’re going to be throwing a lot of valgus stress on the elbow – and as I noted in my recent six-part series on elbow pain, pitchers already get enough of that.  To read a bit more, check out Part 3: Throwing Injuries.

While we’re on the topic, be careful about universally recommending sleeper stretches.  There is going to be a decent chunk of your baseball players that don’t need it at all.  In particular, if you have a congenitally lax (ultra hypermobile) athlete (high score on Beighton laxity test), a sleeper stretch will really irritate the anterior shoulder capsule and/or biceps tendon.

These players don’t really need to be stretched into IR; they just need loads of stability training.  You’ll find that these guys become more and more common at higher levels, as congenital laxity serves as a sort of “natural selection” to succeed for some people.  So, universally prescribing the sleeper stretch becomes more and more of a problem as you deal with more and more advanced players and could be jacking up multi-million dollar arms.  You’ll even find guys who can gain 10-20 degrees of internal rotation in a matter of 30 seconds  - without any shoulder mobilizations – just with the appropriate breathing patterns.  It just doesn’t work for everyone.  Honestly, the only way to know is to assess; each pitcher is unique.

The obvious question then becomes “why are you seeing shoulder “tightness.?”  Is it postural?  Is it an actual range of motion you’ve assessed?  Is it guarding/apprehension in certain positions?  And, what is a “natural throwing motion?” They said Mark Prior had “perfect mechanics” and he has been injured his entire career.

What is “natural” is not what is “effective” in many cases, so you have to appreciate that throwing is an unnatural motion that may be necessary for generating velocity, creating deception, and optimizing movement on a certain pitch.

It might seem like shameless self-promotion, but I would highly recommend that you pick up the DVD set Mike Reinold and I recently released: Optimal Shoulder Performance.

It covers all of this information in great detail, plus a ton more.  Baseball players – and particularly pitchers – are a unique population as a whole, and within that population, each one is unique.

I’d also strongly encourage you to check out Mike Reinold’s webinar, “Assessing Asymmetry in Overhead Athletes: Does Asymmetry Mean Pathology?”  It’s available through the Advanced CEU online store.

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The Fascial Knock on Distance Running for Pitchers

Written on June 9, 2010 at 2:42 pm, by Eric Cressey

A while back, I had the privilege to experience Thomas Myers in seminar for the first time.  For those who aren't familiar with Myers, he is the author of Anatomy Trains and a pioneer in the world of bodywork and fascial research.

There were a wide variety of attendees present, and Myers made dozens of interesting points - so the take-away message could easily have been different for everyone in attendance as they attempted to fit his perspective into their existing schemeta.

While I enjoyed all 150 minutes of his presentations, the portion of Myers' talk that jumped out at me the most was his list of the eight means of improving "fascial fitness:"

1.       Use whole body movements

2.       Use long chain movements

3.       Use movements including a dynamic pre-stretch with proximal initiation

4.       Incorporate vector variation

5.       Use movements that incorporate elastic rebound - this consists of cylic motions of a certain speed (for instance, cycling wouldn't count)

6.       Create a rich proprioceptive environment

7.       Incorporate pauses/rest to optimize hydration status

8.       Be persistent, but gentle (prominent changes can take 18-24 months)

A big overriding them of Myers' lecture was that the role of the fascia - the entire extracellular matrix of the body - is remarkably overlooked when it comes to both posture and the development of pathology.  He remarked that he doesn't feel like we have 600+ muscles in the body; he feels like we have one muscle in 600+ fascial pockets because they are so interdependent.  And, in this fascia, we have nine times as many sensory receptors as we've got in muscles.

Think about what that means when someone has rotator cuff problems - and treatment only consists of ice, stim, NSAIDs, and some foo-foo rotator cuff exercises.  Or, worse yet, they just have a surgical intervention.  It overlooks a big piece of the puzzle - or, I should say, the entire puzzle.

For me, though, these eight factors got me to thinking again about just how atrocious distance running is for pitchers.  I have already ripped on it in the past with my article A New Model for Training Between Starts, but this presentation really turned on a light bulb over my head to rekindle the fire.  Let's examine these eight factors one-by-one:

1.       Use whole body movements - Distance running may involve require contribution from the entire body, but there is not a single joint in the body that goes through an appreciable range of motion.

2.       Use long chain movements - Pitching is a long chain movement.  Jumping is a long chain movement.  The only things that are "long" about distance running are the race distances and the length of the hip replacement rehabilitation process.

3.       Use movements including a dynamic pre-stretch with proximal initiation - This simply means that the muscles of the trunk and hips predominate in initiating the movement.  While the hips are certainly important in running, the fundamental issue is that there isn't a dynamic pre-stretch.  This would be a dynamic pre-stretch with proximal initiation:

4.       Incorporate vector variation - A vector is anything that has both force and direction.  Manual therapists vary the force they apply to tissues and the directions in which they apply them.  There are obviously vectors present in exercise as well.  Here are 30,000 or so people, and pretty much just one vector for hours: forward (to really simplify things):

Here is one guy (and a good looking one, at that) in multiple vectors in a matter of seconds:

Incorporating vector variation into programs is easy; it just takes more time and effort than just telling someone to "run poles."  Take 8-10 exercises from our Assess and Correct DVD set and you've got a perfect circuit ready to roll.

5.       Use movements that incorporate elastic rebound - Sorry, folks, but even though the stretch-shortening cycle is involved with jogging, its contribution diminishes markedly as duration of exercise increases.  And, frankly, I have a hard time justifying bored pitchers running laps as "elasticity."

6.       Create a rich proprioceptive environment - There is nothing proprioceptively rich about doing the same thing over and over again.  They call it pattern overload for a reason.  Pitchers get enough of that!

7.       Incorporate pauses/rest to optimize hydration status - Myers didn't seem to have specific recommendations to make regarding work: rest ratios that are optimal for improving fascial fitness, but I have to think that something more "sporadic" in nature - whether we are talking sprinting, agility work, weight training, or dynamic flexibility circuits - would be more appropriate than a continuous modality like jogging.  This is true not just because of duration, but because of the increased vector variation potential I outlined earlier.

8.       Be persistent, but gentle - This one really hit home for me.  Significant fascial changes take 18-24 months to really set in. I am convinced that the overwhelming majority of injuries I see in mature pitchers are largely the result of mismanagement - whether it's overuse, poor physical conditioning, or improper mechanics - at the youth levels.  Poor management takes time to reach the threshold needed to cause symptoms.  In other words, coaches who mismanage their players over the course of the few months or years they coach them may never actually appreciate the physical changes - positively or negatively - that are being set into action.

Distance running might seem fine in the short-term.  Overweight kids might drop some body fat, and it might make the practice plan easier to just have 'em run.  Kids might not lose velocity, as they can compensate and throw harder with the upper extremity as their lower bodies get less and less powerful and flexible.

However, it's my firm belief that having pitchers run distances not only impedes long-term development, but also directly increases injury risk.  Folks just don't see it because they aren't looking far enough ahead.

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Understanding Elbow Pain – Part 6: Elbow Pain in Lifters

Written on June 2, 2010 at 6:26 am, by Eric Cressey

Today, I’m going to wrap up this six-part series entirely devoted to the elbow.  In case you missed the first five, check them out:

Part 1: Functional Anatomy
Part 2: Pathology
Part 3: Throwing Injuries
Part 4: Protecting Pitchers
Part 5: The Truth About Tennis Elbow

In this final installment, I’m going to discuss elbow issues as they pertain to a strength training population.  Even though some of the treatments for these injuries/conditioning may be very similar or even identical to what we see in a throwing population, I separate lifters because their problems are almost always soft tissue in nature.  While we may see stress fractures, ulnar nerve issues, and ulnar collateral ligament tears in throwers, we are virtually always dealing with problems with muscles and tendons in folks who are avid lifters.  What gives?

Well, it’s very simple: they grip stuff a lot more than normal folks, and also perform a ton of repetitive movements at the elbows and wrists.  This difference also makes you appreciate why we often see elbow issues in those who work on factory lines, performing the same task for hours on-end.

Why is it that all these issues present at the elbow?  You see, many of the muscles involved in gripping originate at the superomedial aspect of the forearm, particularly on the medial epicondyle:

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!

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Understanding Elbow Pain – Part 5: The Truth About Tennis Elbow

Written on May 25, 2010 at 4:37 am, by Eric Cressey

Author’s note: This is the fifth part of a series specifically devoted to the elbow.  Be sure to check out Part 1 (Functional Anatomy), Part 2 (Pathology), Part 3 (Throwing Injuries), and Part 4 (Protecting Pitchers) if you haven’t done so already.

Today, I’m going to cover a pretty common, yet remarkably stubborn issue we see at the elbow: tennis elbow.

It’s also called lateral epicondylitis, although the -itis ending may not do it justice (as we discussed previously in this series) because it is likely more of a degenerative – and not inflammatory – condition in the overwhelming majority of those who experience it.  To take this naming conundrum a bit further, while the term “tennis elbow” is used to describe pain on the lateral aspect of the upper arm near the elbow, tennis players often experience medial elbow issues as well (golfer’s elbow) secondary to the valgus stress one sees with the forehand and serve.

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.

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Understanding Elbow Pain – Part 4: Protecting Pitchers

Written on May 21, 2010 at 5:53 am, by Eric Cressey

This is Part 4 of a series specifically devoted to elbow pain in athletes.  Be sure to check out Part 1, Part 2, and Part 3 if you haven’t already.

As I presented in Part 3 of this series, there is absolutely nothing healthy about throwing a baseball, as the body is being contorted to extreme positions as the arm accelerates in the fastest motion ever recorded in sports.  These outrageous demands warrant a multi-faceted approach to protecting pitchers from injury.  In my eyes, this approach consists of four categories, and that’s what I’ll cover today.

1. Avoiding Injurious Pitching Mechanics

Let me preface this section by saying that I do not believe there is a single mechanical model that governs how one should pitch.  Everyone is different, and those unique traits have to be taken into consideration in determining what is or isn’t considered potentially harmful.  For instance, only a tiny fraction of the population could ever even dream about pitching like Tim Lincecum because of ideal blend of congenital laxity and reactive ability he possesses.

I’ve trained Blue Jays left-handed pitching prospect Tim Collins for the past three seasons.  At a Double-A game earlier this year, Tim introduced me to his good buddy Trystan Magnuson, a right-handed pitching prospect who is also in the Jays system.  While Tim was a whopping 5-5, 131 pounds when he was signed right out of high school (now 5-7, 170), Trystan stands 6-7.  Check out this picture I recently came across from spring training:

Anyone who thinks these two are going to throw a baseball with velocity and safety via the same mechanics is out of his mind. As an aside, if you’re interested in watching both of them throw, there is some decent warm-up footage of both HERE.

While we can never expect all pitcher to fit the same mechanical model, we can look to the research (a great 2002 study from Werner et al. is an excellent place to start) to educate us about certain factors that predispose pitchers to increased elbow stress.  To start, leading with the elbow too much  increases valgus stress by about 2.5N per degree of horizontal adduction that the arm must travel.  The problem with this is that every successful pitcher you’ll ever see leads with the elbow to some degree, so it becomes an issue of “how much” and “when.”

Getting to maximal external rotation too early also increases valgus stress on the elbow.  According to Fleisig et al. (1995), the typical thrower is going to have about 67 degrees of shoulder external rotation at stride foot contact.  The more external rotation there is, the more elbow stress you’ll see.  Unfortunately, this is one contributing factor to one’s velocity, so these results must be intepreted cautiously.  If you take away that external rotation, you may take away a few miles per hour.  Again, the same goes for horizontal abduction.

Lower extremity sequencing problems can also wreak havoc on an elbow.  Pitchers who fly open early tend to let their arm lag behind their body, increasing valgus stress in the process and making it harder to get good contribution from the lower half.

Likewise, guys who stay closed and throw across their body can wind up with medial elbow issues.  If a pitcher maxes out his shoulder internal rotation and scapular protraction in coming across his body, the only choice to continue getting that range of motion is the elbow.  If you create more range of motion, you have to slow down more range of motion.

This last point kicks off a brief, but important discussion.  Many pitchers stay closed to improve deception.  Others use it to help them get movement on sinkers.

Changing these mechanics could take away everything that makes these pitches successful, so you have to look to the other three factors to prepare them physically and protect them from these stresses.  It’s like making sure you give a guy a helmet if he is going to be banging his head against a wall!

All that said, finding the right mechanics is important for little leaguers and professionals alike – and it’s the first step in protecting the elbow in a throwing situation.  As we realize that the very issues that increase elbow stress happen to be the same ones that a) increase velocity and b) are often demonstrated by elite pitchers, we appreciate once again just how unnatural an act throwing a baseball really is!

2. Avoiding Acute and Chronic Overuse

One of our high school kids threw 188 pitches in a game last week.  I’d like to think that I’m pretty good at what I do, but nothing I can do to keep a kid healthy if his coach asks him to do that time and time again.

Acutely, fatigued pitchers put more stress on their arms.  There is less trunk tilt at ball release as the lower body gets more tired.  And, the usually elbow drops. “The next thing you know, there’s money missing off the dresser, and your daughter’s knocked up. I’ve seen it a hundred times.”

Gold star to those of you who caught that movie reference, but kidding aside, just about every case of elbow pain we see who comes through our door has been mismanaged in terms of pitch count – either acutely, chronically, or both.  They think they can pitch year-round.  They blow money on showcases.  They play on three teams team at a time.  They throw bullpens with their teams and with their private pitching instructors.  The research is out there and the answer is very clear: there is only so much stress an arm – especially a skeletally immature arm – can take.

3. Being Chronically Physically Prepared to Pitch

This is the topic of which I’ve written the most on this site, and it encompasses everything I’ve written with respect to strength training for pitchers and targeted flexibility work, not to mention my absolute hatred for distance running for pitchers.  Long story short, throwing a baseball is an action that takes its toll on the body; if you aren’t functionally fit to pitch, you’re just asking for an injury.

4. Being Acutely Physically Prepared to Pitch

This is a very overlooked component of not only staying healthy, but also performing at a high level.  I’m amazed at how many young pitchers just “show and go” when it comes to pitching.  That is, they get to the field and just go right to throwing.  In other words, they throw to warm up.

We teach our athletes, “You warm up to throw; you don’t throw to warm up.”  I’ve spent the last 57 paragraphs (give or take a few) outlining how incredibly stressful the throwing motion is, yet some kids can’t wait to jump right into it before getting their body temperature up, optimizing joint range-of-motion, activating key neuromuscular connections, or doing anything that even vaguely resembles an appropriate “rest to exercise” transition.  We encourage athletes to go through 8-10 dynamic flexibility drills followed by some easy sprinting progressions before they ever pick up a ball.

It’s not just about what you do before an outing, either.  It’s also about what you do in the 24 hours after an appearance that determines how you’ll bounce back in your subsequent outing.  While the schmucks out there are doing “flush runs,” the #1 thing I am worried about after a start is regaining lost range of motion.  Reinold et al. found that pitchers lost both shoulder internal rotation and elbow extension range-of-motion during a competitive season when an adequate stretching routine was not implemented.  It’s no surprise, when you consider the overwhelmingly high eccentric stress that’s placed on the shoulder external rotators and elbow flexors as they try to decelerate the crazy velocities we see with pitching.  As such, following an outing, the first thing we want our guys to do is get back their shoulder and elbow ROM (and get the hips loosened up).  There are some athletes who don’t need to be stretched into internal rotation, so be careful about using this as a blanket recommendation (more on that in our Optimal Shoulder Performance DVD set).

For a bit more information on what we recommend for our pitchers between outings, check out A New Model for Training Between Starts: Part 2.

In closing, an important note I should make is that pitchers rarely get hurt because of just one of these factors; it’s usually a combination of all of them. So, when evaluating a pitcher’s health and performance, be sure to broad perspective.

We’ve got four down and two to go in this elbow series.  Stay tuned for more!

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Understanding Elbow Pain – Part 3: Pitching Injuries

Written on May 16, 2010 at 6:59 pm, by Eric Cressey

In case you missed them, check out Part 1 (Functional Anatomy) and Part 2 (Pathology) of this series from last week.  With that housekeeping out of the way, let’s move forward to today’s focus: elbow injuries in throwing athletes.  I work with a ton of baseball players and I know we have a lot of not only players, but parents of up-and-coming baseball stars that read this blog – so it’s a topic that is near and dear to my heart.  While my primary focus within the paragraphs that follow will be baseball, keep in mind that the many these issues can also be seen in other overhead athletes.  They just tend to be more prevalent and magnified in a baseball population.

Obviously, in dealing with loads of baseball guys, I see a lot of elbow issues come through my door.  The overwhelming majority of those folks are medial elbow pain, but we also see a fair amount of lateral elbow pain. What’s interesting, though, is that in a baseball population, most of these issues are purely mechanical pain; that is, the discomfort is usually only present with throwing, as it is tough to reproduce the velocities and joint positions present during overhead (or sidearm/submarine) throwing.

The question, logically, is why do some throwers break down medially while others break down laterally, or even posteriorly?

In other to understand why, we first have to appreciate the demands of throwing.  And, that appreciation pretty much always leads back to the valgus and extension forces (termed valgus-extension overload by many) that combine to wreak havoc on an elbow during throwing.

At late cocking – where maximal external rotation (or “lay-back”) occurs – there is a tremendous valgus force of 64Nm on the elbow, according to Fleisig et al.

As Morrey et al. determined, the ulnar collateral ligament (UCL) “takes on” approximately 54% of this valgus force – meaning that it’s assuming about 35Nm of force on each pitch.  This is all well and good – until you realize that in cadaveric models, the UCL fails at 32Nm.

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.

You see, the same valgus force that can wreak havoc medially also applies approximately 500N on the radioulnar joint during the late cocking phase of throwing; that’s about one-third of the total stress on the elbow.  In this case, a picture is worth a thousand words:

So, the same forces can cause a thrower to break down in multiple areas both medially and laterally!  What usually separate the medial from the lateral folks?

Let me ask you this: when was the last time you saw an 8-year old rupture his ACL?  Never.

Now, when was the last time you saw an 8-year-old break a bone?  Happens all the time.

This same line of reasoning can be applied to the pitching elbow.  The path of least resistance – or the area of incomplete development – will generally break down first.  As such, in a younger population, we generally see more lateral, compression-type injuries to the bones. These are your growth plate issues and Little League Elbows, usually.

As athletes mature and the bones become sturdier, we get more muscle/tendon, ligament, and nerve issues on the medial side.

This isn’t always the case, of course; you’ll see young kids with medial elbow pain, and experienced throwers with lateral issues as well. It generally holds pretty true, though.

The issues at the cocking-to-acceleration transition would be bad enough by themselves, but there is actually another important injury mechanism to consider: elbow extension.

This lateral area also takes on about 800N of force at the moment arm deceleration begins with elbow extended out in front as posteromedial impingement occurs between the ulna and the olecranon fossa of the humerus.  This bone-on-bone contact at high velocities (greater than 2,000 degrees/second) can lead to fractures and loose bodies within the joint.

This wraps up the causative factors with respect to elbow pain in throwers – but I need to now go into further detail on the specific physical preparation and mechanical factors one needs to consider to avoid allowing these issues to come to fruition.  Stay tuned for Part 4.

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Understanding Elbow Pain – Part 2: Pathology

Written on May 12, 2010 at 6:16 am, by Eric Cressey

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…

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Understanding Elbow Pain – Part 1: Functional Anatomy

Written on May 9, 2010 at 6:29 pm, by Eric Cressey

Today’s piece kicks off a multi-part series focusing specifically on the elbow.  I’m going to start off this collection by talking about the anatomy of the elbow joint, but in appreciation of the fact that a lot of you are probably not as geeky as I am, I’ll give you the Cliff’s Notes version first:

The elbow is the most “claustrophobic” joint in the body; there is a lot of stuff crammed into very little space.  This madness is governed not just by the joint itself, but (like we know with all joints) by the needs of the forearm/wrist and what goes on at the shoulder and neck.

Even for the geeks out there, in the interest of keeping this thing “on schedule,” I’m just going to focus on your pertinent information.  I would highly recommend The Athlete’s Elbow to those of you interested in learning more; it’s insanely detailed.

Your big players on the osseous (bone) front are going to be the humerus, ulna, and radius.  At the humerus, in the context of this discussion, all you really just need to pay attention to are the medial and lateral epicondyles, as they are crucial attachment points for both tendons and ligaments (as well as sites of stress fractures in younger athletes).

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.

As any good manual therapist, and he’ll tell you that soft tissue restrictions occur predominantly at:

A.       Areas of increased friction between muscles/tendons

B.       Areas where forces generated by a myofascial unit come together (termed “Zones of Convergence” by myofascial researcher Luigi Stecco): this is generally the muscle-tendon-bone “connection,” as you don’t typically see prominent restrictions in the mid-belly of a muscle.

This is a double whammy for the muscles acting at the elbow.  In terms of A, you have many muscles in a small area.  Most folks overlook the importance of B, though: a lot of them share a common (or at least directly adjacent) attachment point.  The flexor carpi radialis, flexor carpi ulnaris, palmaris longus, and flexor digitorum superficialis all attach video the common flexor tendon on the medial epicondyle, with the pronator teres attaching just a tiny bit superiorly.  There’s ball of crap #1.

Ball of crap #2 occurs at the lateral epicondyle, where you have the common extensor tendon, which is shared by extensor carpi radialis brevis, extensor carpi ulnaris, supinator, extensor digitorum, and extensor digiti minimi – with the extensor carpi radialis longus attaching just superiorly on the lateral supracondylar ridge.  Ball of crap #3 can be found posteriorly, where the three heads of the triceps converge to attach on the olecranon process via a common tendon, with the much smaller anconeus running just lateral to the olecranon process. You can see both balls of crap (double flusher?) coming together here:

Ball of crap #4 is a bit more diffuse consisting of the attachments of biceps brachii (radial tuberosity), brachioradialis (radial/styloid process), and brachialis (coronoid process of ulna) on the anterior aspect of the forearm.

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.

Related Posts

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A Somewhat Overlooked Cause of Elbow Pain

Written on May 4, 2010 at 7:02 pm, by Eric Cressey

I have written a bit in this blog about elbow pain – both in throwers and lifters – but will be devoting some very specific, detailed articles to it in the near future.  In the meantime, however, here is an interesting population-specific fact.  Many baseball players wind up with elbow issues secondary to shoulder range of motion deficits.  Most lifters run into trouble because of excessive gripping and terrible tissue quality in the region.  Apparently, though, certain NBA players run into elbow issues because of KARMA.

Huh?  Well, apparently if you treat ballboys like crap, it comes back to haunt you sooner than later.

Go Celts!