by Gabriel Ariciu, DC

Elbow pain. Many of us have had it. Whether you play tennis and golf a lot or not, they are not the only cause to elbow pain. Elbow pain or more specifically lateral and medial epicondylitis are associated with tennis and golf, respectively. Due to the repetitive motions it can put strain on the tissues surrounding the elbow. In this article I will talk a little bit about what it is, what is going on, and what can be done about it.

Sports injuries are among the most common things we treat. We really enjoy helping people get back to the games and hobbies they love. It is always difficult when you start a new routine only to have a setback of an injury or the week is going great but you hurt yourself. I won’t talk about the proper techniques of golf and tennis, I will leave that to the pros. However, I will talk about the anatomy of the elbow and what is up the chain.

Anatomy of the Elbow

Our elbow is classified as a synovial hinge joint, so just like hinges on a door our elbow allows our arm to move in one plane. We usually use the terms of flexion and extension. However, this is a simplified view. With the ongoing work in fascia and biotensegrity, we learn that there much more going on. Dr. Jean-Claude Guimberteau has described our movements like stepping into a river. We do not step into the same river twice and likewise we do not make the same movement twice. It may look the same but under the surface your muscles, tendons, ligaments, and fascia have adapted and responded in such a way that makes the second movement different from the initial movement. Many things cause this and most of it has to do with your environment. You have adapted and responded to the environment. It is fascinating work that he is doing. If you want to read more about it, check out my fascia article.

The elbow is made up with the articulation of the radius, ulna, and humerus bones. There several muscles too with several different actions. The brachialis is our primary flexor. The biceps brachii and brachioradialis also assist in this action but they have other actions too. The triceps brachii is the primary extensor. Anconeus, a small muscle, assists it as well. In addition to these, you have your wrist and finger flexors and extensors. There are quite a few of these but here are few: flexor carpi ulnaris, flexor digitorum profundus, and extensor pollicis longus. There are a couple of other important muscles that help the forearm and hand supinate and pronate, they are aptly named supinator and pronator teres.

Each epicondyle have several muscles that attach to them. The medial epicondyle has many of the flexors and pronator teres. The lateral epicondyle has the extensors and supinator. But when we talk about attachments we must understand that though there is a specific anatomical attachment for the muscle itself, it also attaches broadly through the ligaments and fascia. Many anatomists are thinking all attachments are broad-based when it comes to muscular attachments. We do not to make isolated movements. Several muscles, fascia, tendons, and ligaments come into play. In fact, much of the body comes into play with each movement. But enough with the boring anatomy.

What Causes the Inflammation?

Inflammation? Yes, inflammation. The elbow is inflamed because it has been injured but how does this happen? There are many theories such as overtraining, poor form, posture, something upstream in the shoulder or elsewhere, or something deeper and more metabolic or organ related. In my experience, it can be any of the above and sometimes all of the above.

Golfer’s elbow is common amongst golfer’s because of the strain that the medial part of the elbow takes during a swing, that is the inside part or the part closest to your body. Same with tennis elbow but with the strain happening on the lateral part or the outside. Currently, I am treating someone who has pain on the medial side of her elbow making tennis and kettlebell lifting difficult. Wait you said medial is associated with golf? Hence the problem with these terms. Golf and tennis can cause both.

This particular patient had a previous neck injury along with her elbow pain. You will notice I don’t like to use a lot of the “diagnosis” terms because in the end it doesn’t matter as much as treating the underlying cause. We can spend hours trying to figure out what it precisely is with numerous orthopedic tests (that are highly fallible) and imaging to “make” sure there isn’t something more going on or we could do a trial of care and focus on treating the individual, which is what the research recommends. Another reason, I don’t like a lot of those terms is that it can become a label and then a crutch, a nocebo effect. How many friends or people do you hear say, “I can’t lift anything heavy because I a bulging disc” that was diagnosed 5 years ago? I hear it a lot. Yet, research shows that tissues heal within a few months and furthermore, many of us have bulging discs and other abnormalities without any pain. I don’t want to give anyone a crutch or a label. You are meant to move, and move well, no matter how old you are. That’s right. 80 year olds should be moving and moving well!

Well this client had a previous neck injury as well. She is also not your typical American. She exercises a lot. She plays tennis, has a spin class, and lifts weights. But she has these acute and chronic pain issues. When I assess someone I ask a series of questions that involves the client’s whole health history. We ask a lot of questions, but that is part of being holistic. We have to see the client from a big picture view and how all the body systems are working together. With the physical exam I incorporate the gait pattern, functional movement assessments, and range of motion to get a general picture. Posture is always interesting to me mainly for the purpose of finding inhibited muscles. Sometimes there can be a drastic change depending on how bad the posture is, but we are all built differently so we can’t get too nuanced. Even with the way we walk or squat, some people will have feet turned out more than others. Here is a great video by Ido Portal on “improper alignment:” 

After the assessment, I begin testing muscles looking for inhibited muscles or muscle imbalances. I will often call these muscles weak but that is not precisely accurate just a simple term I use. For instance, when I test someone’s lats and I find that the client cannot resist my test on the muscle by holding their arm tightly to their side, I call that muscle weak. But what is really going on is that the muscle is neurologically inhibited. Our central nervous system controls most things in the body, I say most things because our gut contains its own nervous system and our fascia acts like a nervous system too. So our nervous system tells our muscles how much tone they should have and how to respond to stimulus. So a weak or inhibited muscle occurs when this is neuromuscular interaction is disrupted.

An inhibited muscle can happen from a variety of reasons but we can boil it down to 3 things. Something the founder of chiropractic used to say, thoughts, traumas, and toxins. Thoughts are emotional, spiritual, or stressful situations going on in someone’s life. Traumas are micro-injuries or actual injuries. A micro-injury is something that happens without us knowing about it. Our body compensates around it and we continue to move without noticing anything. An actual injury is when you feel the pain, often caused by a pattern of micro-injuries. It is the straw that broke the camel’s back scenario. You compensate until you can’t and the real injury takes place. Lastly, is toxins. Toxins are things we eat, things we are exposed to, etc. and they can inhibit your muscles due to the holistic nature of the body. All of our body systems are interdependent. There exists a muscle-organ relationship which can cause specific muscles to inhibit depending on the organ. Hence, elbow pain like all other pain can be cause by a variety of issues. I do find the majority to be musculoskeletal, but it is important to keep the others in mind.

What Can Be Done?

So I go looking for inhibited muscles as a form of diagnosis and treatment. I diagnose the muscular imbalance in general terms and use the inhibited muscle for treatment. Inhibited muscles are a great window into the nervous system. And since the nervous system is interconnected to everything throughout the body essentially, it is a great window to be looking into. Through neurological reflexes specifically our flexor withdrawal reflex (the reflex that causes you to pull away when you touch a hot stove) I find micro-injury and injury points throughout the body.

I then apply myofascial release to the injury points I find. It is usually fascia but sometimes there trigger points and other tissues at play. But in the end, everything is fascia right? Or at least that is what the research is telling us. Interesting tidbit. These points are almost always tender. After releasing them, I go on through the pattern of injury constantly rechecking the client’s pain to see if it is reducing. There are various other reflexes and techniques utilized but my goal is to have 80% reduction in pain before I let the client off the table. It is an incredibly rewarding experience for both client and doctor. I love it. I love helping people get back to what they love to do. This doesn’t mean treatment is over in one visit. There is always more to do at this point but typically a musculoskeletal pain patient treatment plan is 1-2 visits. But not everyone is typical so there is always a caveat.

So what happened with the elbow pain? I found several inhibited muscles in the arm leading me to injuries throughout the neck and both shoulders. At some point, the wrist and elbow finally came into play but by then the pain was mostly reduced. Often times the cause is distant to the pain. Another client had adhesive capsulitis or frozen shoulder. She was unable to lift her arm without a lot of pain. After a few injuries being released on the contralateral hip her shoulder returned to full range of motion without pain. Now this condition was in its early phase and other cases may take a bit longer, however it illustrates the point that a lot of the cause is distant to the pain.

A bit about overtraining and form. These do come into play. Sometimes we may feel behind or we think we need to prepare for a competition by getting extra training sessions in. However, this can lead to undue strain especially if you are not seeing a holistic practitioner to make sure everything is properly balanced. But most commonly I find form to be the issue which can due to a poor trainer, lack of a trainer, or muscle imbalance as explained above. Inhibited muscles can cause altered movement patterns which can lead to injury. For instance, I had some moderate pain in my left heel. I couldn’t figure what I was doing to cause it. In the end, I had several inhibited muscles in my left leg and hip causing it. Once that was fixed, the pain went away. A poor trainer or lack of one can easily lead to bad technique or if you are just plain tired. Exercises and sports require good technique. For example, I was deadlifting last week. It was decently heavy near 240 lbs. But I was tired and didn’t rest enough from the last set. So while I was lifting my form faltered and I felt the dreaded twinge in my lower back. I set the weight down and knew the next couple of days would be annoying but luckily I have a doctor I practice with who helped me out. But this injury was my fault due to poor technique from not resting enough between sets.

Here is an important reminder:

Remember this, pain is a sign of protection, and chronic pain is often a sign of over-protection.

So when you are in pain, remember that, and seek out the help accordingly.

Well I hope this was insightful! Elbow pain though irritating is definitely manageable. Whether it is medial or lateral, it is something we have seen great success in treating or we can direct you to someone closer to you if you are not near us.