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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.

lateralepicondyle1

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”).

golfers

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.

ulnarnerve

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.

stressfracture

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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9 Responses to “Understanding Elbow Pain – Part 2: Pathology”

  1. Simon Says:

    Great post Eric. Since I suffer from general hypermobility and some ulnar nerve problems this series is really helping me work things out. Question for you. How does one find a good manual therapist? What are some good certifications to look for?

  2. Jeremy Says:

    Really interesting. I wonder if the redness/bruising on the arm during Graston more from friction on the skin surface or more from the muscles below?
    Looking forward to part III.

  3. Steve Says:

    Excellent post Eric.

    Jeremy – The redness is the result of a controlled inflammatory response to the fascial layer between the deepest layer of skin and most superficial layer of muscle. Often and as is seen here – petechia – and ultimately a bruise – results from the mechanical friction. The skin is typically prepped with something to markedly reduce the friction coefficient (that is what is applied before the treatment begins).

    The resultant fibrogenesis will provide structure for realignment of the fascial layout. The new fibrin produces a proteoglycan gel that will improve the overall soft tissue quality of the region treated. The treatment reactions decrease in intensity and size with subsequent and consecutive treatments.

  4. Rock Smash Says:

    I pitched in college and still occasionally (in my upper 40s) for fun with other has-beens, and I find this kind of info not just fascinating and revealing, but incredibly valuable. Not to swing from Eric’s sack, but this is consistently and by far one of the most useful blogs of the dozens I follow.

    Thanks for the vids. Can’t wait for part 3.

  5. Walt Denkinger Says:

    That video definitely doesn’t have me rushing to add Graston to my list of treatments to receive, hah, hah. I thought I was watching the coming attractions for whenever they release another “Saw” movie!

  6. Jim Lenkowski Says:

    Any viable alternatives to Graston for those who can’t afford to have their skin get chewed up or don’t want it taking a beating?

    While some people might only care about the final result, I know that other folks may balk at that being the only choice.

  7. Jim Winterton Says:

    I was told at age 34 my competitive racquetball career was over due to tendonitis. I saw four orthopedic surgeons who wanted to operate. I would not let them and I finally met a physical therapist who put me on a regimen of daily rehab exercises, many of the same exercises you have outlined, plus the forearm massages. I was able to heal up and I played ten or more tournaments per year until I was 58 years old. Today I coach racquetball and see lateral epicondyle tendonitis, medial epicondyle and Some “snapping elbow” syndrome tendonitis. If there are no structural limitations and they have been cleared by their doctors, the rehabilition exercises with the active release tissue work, has been very effective if the client has committed to changing their mechanics which caused the problem in the first place. Thanks for excellent articles.
    Yours for excellence in sport,
    Jim “Coach” Winterton

  8. Eric D Says:

    Thank you for this elbow series Eric. I’m a longtime tennis player who is now experiencing some “golfer’s elbow pain” and now given my occasional finger tingling, I’m now wondering about the ulnar nerve issue you mention. I’m thinking that years of kick serves and perhaps prolonged laptop use w/poor posture may have done me in. This series has given me some insight into what may be going on inside my elbow and how to possibly improve the situation.

    Eric

  9. Casey Barnes Says:

    Thanks for the informative information. I just graduated college and I have been a four year starting pitcher at my schooln. I am currently looking to play independent league baseball, and I always having elbow pain. I have had ART done and it does feel great. And I have had many other treatments done as well. I like the stick idea, but I was wondering if there was anything else I could do on my own to help my elbow feel better when I dont have anyone to treat my elbow. Again my elbow pops sometimes, and It is always tight on the medial side. And another question, would weight lifting help? Such as forearm excercizes, tricep, and bicep exercizes to help it feel better? Again thank you for the information so far, it has been great!

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