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Injuries and Medical Advice

Dodgy Elbows Revisited

Ten years and a few thousand elbow patients ago, I designed a strengthening program to help climbers recover from tendinosis.

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Illustration by Steve Graepel. Ten years and a few thousand elbow patients ago, I designed a strengthening program
to help climbers recover from tendinosis. The regime was outlined in “Dodgy Elbows”[Rock and Ice, No. 156].
It’s the most downloaded article on, which speaks volumes for how common elbow pain is among climbers.

You may be surprised to learn that tendinosis is not the same as tendonitis! The former is a chronic degenerative condition, while the latter
is characterized by acute inflammation. That tendonitis is used as a blanket term, even by many medicos, to describe any discomfort within vague proximity
to the elbow belies the fact that the vast majority of elbow pain relates to tendinosis.

I can’t remember the last time a patient presented with actual tendonitis because most people will intuitively rest before making an appointment, during
which time it settles down. Tendinosis, on the other hand, will not yield to rest. Try it and the pain may subside (or not), only to rear its ugly
nubbin as soon as you resume climbing.

The fundamental premise of eccentric loading, which I detailed in the original program, is unchanged, but over the years I have refined how the program
breaks down in terms of load, angles, repetitions, sets and frequency. Other adjunctive therapies that I used to recommend, such as icing, have been
dropped altogether.


When you climb you increase your muscles’ physical requirements and the associated structures must adapt. Muscles such as the biceps, triceps and those
in your forearms can get stronger considerably faster than the tendons that anchor them to the bone.

The catalyst for generating this strength differential and subsequent injury is typically a change of habit. Ramping up your training program, for instance,

suddenly increasing the volume of climbing will cause your muscles to strengthen rapidly, often outstripping gains in tendon strength. Although the tendon
is unlikely to break, it is likely to degrade, causing cellular changes that result in tendinosis.

There is no wizardry that will make tendinosis go away. You strengthened yourself into this predicament, and you need to strengthen yourself out of it.



The almost religious adherence to using ice for the management of an acute injury has largely been debunked. Although great for pain management, ice does
not alter healing rates or even reliably affect inflammation. Heat, on the other hand, enhances blood flow. A hot pack for 15 minutes a day will speed
healing and make you feel warm and fuzzy.


Several decades ago this steroidal anti-inflammatory would have earned your doctor a pass for at least trying. These days it’s closer to unprofessional
conduct (although I still see at least one patient every week who has been recommended cortisone).


This masochistic dungeon master is not by itself a solution for tendinosis, but it greatly improves your chances of success. You could do the massage work
without it, but patients who have this vice-like forearm massager tend to be more compliant.

Ibuprofen (and all NSAIDS)

Like kids in a candy store, climbers just can’t help themselves. Tendinosis is not inflammatory. While ibuprofen does work wonders for deadening the pain,
it only masks the problem and can cause severe internal bleeding due to stomach ulceration. NSAIDS kill more people each year than car crashes. No


Pain is the catalyst formost people to become concerned. The pattern of the pain, however, is what differentiates tendinosis from other tendon conditions
such as tendonitis or a tendon tear. If your elbow has a burning pain around either epicondyle for up to a week following an aggravating activity,
you probably have tendonitis. At three weeks, that tendonitis is rapidly morphing into tendinosis.

Though most tendon conditions in the elbow will cause pain around either epicondyle, there is usually more bone sensitivity right on the epicondyle with
tendinosis. A good test is to tap the boney lump with a knuckle. The test is positive if you curse. Pain that is worst when you are warming up and
virtually disappears during your session, but then returns after cooling down, is classic tendinosis. Pain that increases or does not subside is likely
a tear in the tendon, tendonitis, or some other condition or injury.


When loaded, cells affected by tendinosis elicit pain (unless you have warmed up). A healthy aversion to pain has its place, but in this
instance pain is your radar for locating problem cells—avoid pain and your therapy will be ineffective.

Most cases of tendinosis occur in either the common flexor tendon, which attaches to the medial epicondyle, or the common extensor tendon as it joins the
lateral epicondyle. Each of these common tendons is fan-shaped, and hence loaded quite differently by muscles that attach to it. If the elbow angle
changes, the loading pattern will change, too. Ninety-five percent of medial epicondylosis cases involve flexor carpi ulnaris (FCU) and/or pronator
teres (PT). Lateral epicondylosis typically involves the wrist extensor on the thumb side called extensor carpi radialis longus. Although each version
requires a different exercise, the remainder of the protocol is much the same.

Testing Protocol

To target the affected tissue, you first need to locate it.

The muscles listed above all cross the elbow to anchor on their respective epicondyles on the humerus, so getting the elbow angle just right during the
curative exercises is paramount.

To test your medial epicondylosis, you will need to test both the FCU and PT. You may need to do one or both exercises depending on whether they are painful
during testing. For FCU, load a dumbbell with 12 to 20 pounds depending on your strength. Distribute the weight two-thirds on one side and a third
on the other. Note that your thumb in all exercises grips the bar on the same side as your fingers.

When the dumbbell is in your hand, the heavier end should be on the little-finger side. Place your arm (palm up) across a table top with about half of
your forearm over the edge (Figure 1). Lean to the side, over your arm, such that the medial epicondyle rises an extra inch or so above the table surface.
With your elbow fully extended (0 degrees of flexion), lift the weight with your other hand (don’t weight the arm you are testing just yet) so that
your wrist is in full flexion (Figure 2). Slowly lower the dumbbell until the wrist is fully extended (Figure 3). Lowering the weight for this and
all repetitions for all tests and exercises should take five to seven seconds. There is no need to roll the bar down your fingers while you release
your grip, as the FCU is a wrist flexor only. Repeat this process at 45 degrees (Figure 4), 90 degrees (Figure 5) and 135 degrees of elbow flexion
(Figure 6). Go back to the position where you felt the most discomfort, then refine the angle to receive your diploma in Masochistic Tendencies. Eighty
percent of people will have maximum pain somewhere between the first two testing positions, and most of the rest of you sufferers will yelp at close
to full flexion.

Follow the same basic setup for pronator teres (PT) but don’t tilt your arm. Place four to six pounds on one end of the dumbbell. To get the correct amount
of load (such that it feels like depleted-uranium bullets are being shot into your elbow), simply move your hand on the bar to create more or less
leverage. Place your arm along a table surface with the elbow extended (Figure 7). Hold the dumbbell in a vertical position with the weighted end on
top. Lower the weight slowly to the outside until it is horizontal (Figure 8), not further, and then assist the weight back to the starting position
with your other hand. Test each angle.

Testing lateral epicondylosis can be a little tricky. Place weight on one end of the bar or use something similarly disproportionate—say, a cast-iron
skillet. This weight will be on the thumb side. Place the inside surface of your arm (the non-tanned side) flat against a table top with your elbow
fully extended. Your armpit will be against the edge or level with the table surface (Figure 9). Here’s the trick: with 12:00 being straight up, assist
the weight into position, pointing the weighted end to either 10:00 (if it’s the right elbow) or 2:00 (left elbow), and then start lowering. Follow
that angle all the way through the repetition as if the clock face was fixed to the weight and 12:00 stays in line with your forearm. Retest at each
angle by bending your elbow and sliding your forearm toward your chest (Figure 10).

If testing fails to elicit pain, you may need to increase the load. If the weight is difficult to lower in a controlled fashion, it is likely too heavy.
If you can’t isolate the pain, then you either do not have tendinosis or you have a different version. Tendinosis in the supinator or the distal end
of the biceps is less common, but I still see multiple cases every year. If you’re not sure of the diagnosis, see a medical professional.

The Program

A muscle lowering a load is roughly 40 percent stronger than one trying to lift a load. For instance, you may be able to lower yourself with one arm in
a controlled fashion, but you can’t necessarily do a one-arm pull-up. Remember that tendinosis is instigated by a strength differential that we don’t
want to propagate. By lowering the weight we are not necessarily pushing the muscle to further strengthen, but we are still forcing the tendon to adapt.

This program will usually take between four and 12 weeks, depending on how much you’ve ignored your elbow pain.

At the angle you isolated during the testing protocol, do three sets of eight repetitions, morning and night, every other day. As mentioned, the weight/resistance
should be high. Low-weight programs are notoriously ineffective.

There are many instances where this set/rep ratio is either slow or too aggravating. That does not mean the program will not work, just that you need to
tweak the program. Usually, this involves lowering the reps and increasing the weight. If your elbow is quite irritable, try starting with two sets
rather than three.

Take a week’s rest at the four- to six-week mark. Every second week, retest the elbow angle, as the location of pain will tend to become more specific
as the amount of tendinosis reduces and the affected area is therefore easier to miss. You can lose a lot of time hammering away at an angle that is
not hitting the target.

Soft-tissue work is imperative. The program will produce some muscle spasm and likely ramp up any tendonitis. Ten minutes of eye-watering massage over
the tendon and upper forearm a few times a week will double your chances of success. Note that massage alone is categorically ineffective. If healing
was as easy as rubbing it, we would have figured out how to cure our sore elbow soon after we discovered masturbation.

There is a small subset of people who, with significant and ongoing pain leading up to initiating the program, respond quickly, often recovering within
a couple of weeks. This tends to happen more with lateral epicondylosis than the medial counterpart. Though I’d like to believe there is a Wolverine
gene involved, I tend to think there is another pathology at play that presents like tendinosis and responds to eccentric loading. Perhaps it is some
kind of fiber deformation at the musculotendonous junction or possible fascial strain (the thin membrane that lies between muscle layers).



For Figures 1-3, which work the FCU, use a dumbbell with 12 to 20 pounds, with two-thirds of the weight on
one side. The heavier end should be on your little-finger side. Keep your thumb on the same side of the bar as your other fingers.

The purpose of all the exercises is to strengthen the tendons, so don’t lift the weight back into position. Instead, use your other hand to assist as shown
in Figure 2.

Changing the angle of your upper arm, as shown in Figures 4, 5 and 6, will help you pinpoint where you have the problem. If you don’t
have pain at a particular angle, you don’t need to do the exercise at that angle, except as a preventative.


Load a barbell with weight only on one side. Four to six pounds is about right. As you did for the FCU, test each angle of your arm, starting at 0 degrees,
then 45, 90 and 135. Only the 0-degree test is shown in Figures 7 and 8.


Figures 9 and 10 illustrate the exercise for lateral epicondylosis. These are similar to the other exercises, but with lighter weight,
or an iron skillet.

• Do the exercises for four to 12 weeks.

• Do three sets of eight reps, morning and night, every other day.

• At four to six weeks, rest a week.

• Retest, going through all the angles and exercises every two weeks.

This article was published in Rock and Ice 223 (January 2015).