Epicondylitis, elbow tendonitis, what to do?

[Lodestone]

I was climbing outside about four days week until it started getting rainy. In October I switched over climbing in the gym quite a bit (often three times a week). My elbows have become increasingly irritated since coming indoors. Usually the day after I climb I feel some mild pain in my elbows. Sometimes the irritation feels like an itch. I don’t feel physically limited by this problem (yet) but it is getting worse. In the last month I’ve slowed down on climbing at the gym. Bouldering and climbing the steep gym overhangs has been cut. I want to get this issue taken care of or at least have a game plan before going into the climbing season.

 

I did some web research as well as reading the applicable sections in Layton’s new book (Climbing Stronger, Faster, Healthier: Beyond the Basics). It seems that I have epicondylitis; Lateral or Medial epicondylitis, I’m not sure which, or if it matters. I’ve put together a little rehab and antagonist workout routine that I hope is appropriate (comments welcome).

 

 

I have not seen a doctor about this. I have iced my elbows after climbing sessions and have occasionally applied heat to them the follow day. I do not take NSAIDs for the pain because of what I’ve read about their propensity to inhibit tendon recovery. I take Omega 3 pills instead (hoping for a miracle). Before and after climbing I massage my forearms and elbows sporadically. The only good thing I’ve done consistently is staying hydrated, warming up, and stretching a lot before and after climbing.

 

Given the situation and my limited knowledge I have a few questions.

 

1) What would you add to/change about my workout routine?

 

2) Is it too early to be working out? Should I wait until I’m pain free?

 

3) Do I need to stop gym climbing? Lately I’ve been going about twice a week.

 

4) How important is it to see a doctor about this? I have insurance but am concerned about paying all the out-of-pocket expenses that come with basic insurance.

 

5) Are there any injections/meds I should me asking a doctor about? Cortisone, steroids?

 

6) When is it appropriate to ice or apply heat? How often?

 

7) Is it safe to massage my forearms and elbows while they are hurting?

 

8) What kind of recovery period am I looking at?

 

Please feel free to comment about any part of this post. I’m particularly interested to hear from those of you who have been through or treated this issue. I’m 31 years old, if that has any bearing on the situation.

 

 

Thank you.

 

Chad

 

Edited January 17, 2010 by Lodestone

[YocumRidge]

I wish your "antagonist" climbing routine last summer included the advice of your climbing partners to slow down and not to overindulge yourself in climbing harder grades non-stop

Arrgh!

[Mtguide]

Chad, if you're experiencing moderate to strong or severe pain,during or after gym climbing, and weight or other resistance training, you need STOP, and I do mean SSTTOPPP!!! working out right now. You have an inflammation which will continue to progress, if you don't stop, and can actually cause roughening of the periosteum (tissue covering the bone) under the site of the attachment of the tendon to the elbow, and eventually osteophytes or bone spurs will form beneath the periosteum.

 

When this happens, the only remedy is surgery, usually what's known as a "flexor slide", in which an anesthesiologist administers an "arm block" (deadening the entire arm), and then an orthopedic surgeon opens up the elbow and cuts the attachment of the tendon at the epicondyle. The periosteum is opened and peeled back and any and all bone spurs are scraped, sanded, chiseled, what ever has to be done to return the bone surface to it's formerly smooth condition. The periosteum is closed, and the tendon re-attached by stapling or other fasteners, to the bone, everything is closed up, and then you're looking at anywhere from 8 or 10 months to as much as two or three years for full recovery, depending on your age.It does help that you're just 31, however, you're not a kid anymore, bone and tissue growth have already begun to slow, and you won't heal like a 19-year old.

 

I know, because I went through all this at age 40. It took a long, long time to get back to normal, and I still have to watch it. Please don't, I repeat, DO NOT trifle, dawdle, hope for miracles or cures with Omega 3 supplements. Get an appointment with the best orthopedist you can find who specializes in Sports medicine and tendonitis/epicondylitis. Get it evaluated, NOW. And then DO WHAT HE SAYS. I can understand your reluctance to use NSAIDS, but THEY WORK if used properly, and may very well save you from my fate if you have caught this early enough.

 

ALEVE is one of the best. You need to get the inflammation down and stabilize the condition. You can be as aggressive as you want with ice. I use a 1 lb. bag of frozen peas, icing for 25 min., take it off, let the area warm up on its own, then repeat. you can do this 2 or three times an evening. You can also freeze ice in small paper cups,(make a whole bunch), then take'em out and peel the paper back to rub the tender area with the ice. You'll be surprised at how fast this gets the area REALLY cold. You can do this several times an evening, or during the day. Ask your doctor and physical therapist about if and when to use heat.

 

As far as massage, vigorous cross-tissue massage (going across the length of the tendon) with a thumb or several fingers can be very effective at getting some flow of oxygenated blood into these areas, which are not very well perfused to begin with. Begin gently; if you have any extremely painful areas, again ask your doctor and physical therapist about this technique. But usually a moderate to firm pressure will be helpful without causing any problem.

 

If you're experiencing tightness, cramping, shooting pains or other discomfort in the larger muscles of the forearms, you have a problem, very likely osteophytes, or such a degree of inflammation at the site of the epicondyles that the nerves radiating into the forearm are referring the pain of constriction the inflammation is causing. While heat may feel better, it's ice that you want, at least in the initial stages, to get this to back off, if possible.

 

Your doctor may recommend injection of the site with a cortisone steroid depending on his evaluation and what he finds with x-ray or MRI imaging to determine if there are indeed any more serious conditions beyond mere inflammation. Ultrasound is sometimes used in physical therapy as well.

 

I would absolutely stay out of the climbing gym until this whole situation is resolved. For that matter, I really don't recommend climbing gyms at all. I know it's the winter, hard to get in much time on real rock, but I have never once, in over 40 years of climbing, been injured, or sustained tears or tendonitis from climbing on real rock outdoors. But it was the combination of weight training and the climbing gym that precipitated my bout with epicondylitis, and I have been injured a number of other times at climbing gyms, usually muscle pulls and tears, inflammations, etc. A lot of the routesetters are young guys trying to see how hard they can make it, are not thinking of potential force/load factors on human physiology, know nothing about movement dynamics or stress kinetics, and are trying to impress the girls.

 

Regarding the "recovery"/workout routine you show, I see nothing wrong with it per se, but in your present condition, RICE (rest, ice, compression, elevation) is what you really need to focus on until you can get to the doctor. Don't worry, at your age, your muscles won't melt. You may very well be overtraining anyway. Remember, MUSCLE GROWS WHEN YOU REST, NOT WHEN YOU TRAIN!!! Have you ever just knocked off the training for 3 or 4 days after a heavy cycle, and then looked in a mirror? Wow, how'd those arms, etc. get so big??!! I haven't been doing anything for 3 days! Right, dum-dum, the poor bastards FINALLY got some REST!! And they took advantage of it to GROW!!!

 

And tendon is no different, BUT: because it is white tissue with generally very low blood saturation, it takes LONGER to recover after heavy training. This is why we don't rain heavy, heavy, heavy, day after day. Instead we train heavy--Low reps(4 to 6), heavy weights, and then light--high reps (15 to 20), low weight, alternating every other workout, to allow the tendons to recuperate, and also to make sure that both muscle and tendon are progressing at a similar rate in strength and endurance. If muscle gets ahead of tendon--tendonitis. If tendon gets ahead of muscle-- serious muscle tears, or even detachment from the bone. Seen it happen with big guys and big weights; frightening and gruesome, extremely painful.

 

AND, we throw plenty of rest days in there for good measure. Research is showing more and more that fully recovered tissues perform and develop to a much higher degree than partially recovered tissue, and that full recovery may take much longer than previously thought. In one Oregon State study, it was found that full recovery from a heavy leg day was not reached until 9 DAYS(!!) after the workout.

 

Anyway, fucking GO SEE THE DOCTOR if you don't want to really get into trouble. This stuff is nasty, extremely persistent and time-consuming to heal, and can recur at the drop of a hat if you haven't allowed it to completely heal.

 

Finally, climbing is great- outdoors. Weight training and other forms of resistance training, is great-- but only when done properly, neither over- nor under-training, and with proper rest and recovery, and the right nutrition. After a training cycle of 8 to 10 weeks, I usually take an entire week or even two, completely off, don't touch a weight, don't go near the gym. I do stay active, but whatever's FUN, and as much as possible outdoors. And once or even twice a year, depending on how hard I've been training, I'll take an entire month off from training. It's sometimes absolutely amazing how much better I feel, having been way more tired and banged up than I'd realized. Your body likes a good vacation now and again.

 

Right now, your body is telling you, SHOUTING at you, "HEY, MAN!! STOP!! I'M INJURED!! If I were you, I'd drop that weight or come down off that climbing wall,and listen, and do whatever the body needs to get well.

[DanO]

Good clean fish, a few bites a day including the bones will help the healing process. I myself eat a little salmon often out of the can. I get salmon canned in BC, as the wild salmon from Alaska is often canned spoiled it seems to me and often the other is fish farm. I am getting lately the wild catch canned Salmon from BC. I find it in the Mount Vernon Co op.

 

I am at age 41 and one hard climbing trip to the gym a week is all I can handle and heal back up from.

 

When your younger it is hard to believe that a injury can

stay injured for forever and ever. As the above says, it is

best to make a full recovery. You can push it and really be

screwed up for a life time. So heal up totally, and then start to train carefully.

 

Dan

 

 

 

 

Edited January 17, 2010 by DanO

[W]

Hi Chad,

 

It seems like we are living parallel lives- I was climbing rock outside consistently from late May through end of October. Around early July I started getting the medial version- basically, mild pain and inflammation around the "funny bone" area and just below. For the rest of the summer I would ice it twice a day, occasionally massage it, and take Ibuprofen. It never seemed to get worse, but it never really got any better, either. For the most part, thankfully, it didn't hurt while climbing (cracks or face) but it would be sore after climbing and frequently hurt while doing other things- I was doing carpentry during the weekdays and I'm guessing this also contributed. Everyday things like, for example, taking wet laundry out of the washer where I had to "bear hug" items were painful. Then when I got back from Yosemite beginning of November I started hitting the climbing gym really hard, bouldering. Now, it really started to hurt, and this time it started to hurt while climbing. Not good. I kept at it as long as I could but finally at the beginning of December I stopped gym climbing altogether because I felt I was going to make it chronic. In preparation for spring climbing in Alaska I started focusing on cardio and some weight training instead. A few weeks resting it along with several acupuncture treatments and some deep tissue massages, along with continued ice and heat treatments seemed to really help. I did a little desert climbing over the holidays and it felt pretty darn good. However, it did get a little sore at times and since then it just seems to be in a day to day state, despite no climbing at all for the last 2 1/2 weeks. It's definitely better but it feels fragile. I really want to get back in the gym but I can tell it will flare up again quickly if I do.

 

Every case is different, but since this damn thing has occupied my mind for months now I have figured out a few things if not a cure, so here's some responses to your numbered questions that are based on my experience thusfar, your mileage may vary:

 

1)It should go without saying, but anything that is causing your elbow to hurt is probably something to eliminate from your workout. I have been including in my workouts (which are not just about my elbow issue...) doing the weight tied to a dowel and lowering the weight slowly, one crank at a time. I've been told this helps tendonitis and it tends to feel better after some initial soreness. I also ordered a "theraband flexbar" from Amazon, it is a large rubber dowel that does essentially the same thing. Dave Burdick found this article regarding this device, check this out:

 

http://well.blogs.nytimes.com/2009/08/25/phys-ed-an-easy-fix-for-tennis-elbow/

 

It doesn't seem that this thing has helped me that much, but then, I was using it while on a full on climbing trip in California for a month and then the gym climbing sessions probably undid every bit of good it might have been doing.

 

2) As long as what you do doesn't irritate it, it should be okay, but I wouldn't overdo it. Everyone seems to say rest is the best tonic.

 

That leads me to answer---

3) Gym climbing definitely screwed this thing up much worse for me, and quickly. As much as I want to go back in, I'm staying away until I'm sure it is healed. Everyone as well as my elbow was telling me to stop climbing, let it heal and focus on something else. I'm at the point where I feel like I could climb, but that it would likely come back. Given that it's January, seems like the more rest you give it the better, while focusing on non-irritating strength training. A lot of strong climbers assure that after a 6-12 week break it's likely you can come back quickly and even stronger.

 

6) I have found that heat makes it feel better than ice, and that frequency doesn't seem to matter with mine.

 

7) My wife is an LMP- she has been working on it. Surprisingly she found some bundled up tissue above the site (humerus side) that was knotted up badly, there was no pain in this specific area but when it released the pain on the opposite side of the joint decreased substantially. She cautions against doing cross fiber friction too frequently or when it is really inflamed. I've found that massage along the length of the forearm muscles and tendons is more doable but when it really hurts, leaving it alone and using heat/ice is a better bet.

 

8) I wish I knew! And for both of our sake I hope not too long.

 

If you find anything new or have any breakthroughs of your own I'd love to hear about them. I'll do the same. Good luck!

 

 

[W]

Chad, if you're experiencing moderate to strong or severe pain,during or after gym climbing, and weight or other resistance training, you need STOP, and I do mean SSTTOPPP!!! working out right now. You have an inflammation which will continue to progress, if you don't stop, and can actually cause roughening of the periosteum (tissue covering the bone) under the site of the attachment of the tendon to the elbow, and eventually osteophytes or bone spurs will form beneath the periosteum.

 

When this happens, the only remedy is surgery, usually what's known as a "flexor slide", in which an anesthesiologist administers an "arm block" (deadening the entire arm), and then an orthopedic surgeon opens up the elbow and cuts the attachment of the tendon at the epicondyle. The periosteum is opened and peeled back and any and all bone spurs are scraped, sanded, chiseled, what ever has to be done to return the bone surface to it's formerly smooth condition. The periosteum is closed, and the tendon re-attached by stapling or other fasteners, to the bone, everything is closed up, and then you're looking at anywhere from 8 or 10 months to as much as two or three years for full recovery, depending on your age.It does help that you're just 31, however, you're not a kid anymore, bone and tissue growth have already begun to slow, and you won't heal like a 19-year old.

 

I know, because I went through all this at age 40. It took a long, long time to get back to normal, and I still have to watch it. Please don't, I repeat, DO NOT trifle, dawdle, hope for miracles or cures with Omega 3 supplements. Get an appointment with the best orthopedist you can find who specializes in Sports medicine and tendonitis/epicondylitis. Get it evaluated, NOW. And then DO WHAT HE SAYS. I can understand your reluctance to use NSAIDS, but THEY WORK if used properly, and may very well save you from my fate if you have caught this early enough.

 

ALEVE is one of the best. You need to get the inflammation down and stabilize the condition. You can be as aggressive as you want with ice. I use a 1 lb. bag of frozen peas, icing for 25 min., take it off, let the area warm up on its own, then repeat. you can do this 2 or three times an evening. You can also freeze ice in small paper cups,(make a whole bunch), then take'em out and peel the paper back to rub the tender area with the ice. You'll be surprised at how fast this gets the area REALLY cold. You can do this several times an evening, or during the day. Ask your doctor and physical therapist about if and when to use heat.

 

As far as massage, vigorous cross-tissue massage (going across the length of the tendon) with a thumb or several fingers can be very effective at getting some flow of oxygenated blood into these areas, which are not very well perfused to begin with. Begin gently; if you have any extremely painful areas, again ask your doctor and physical therapist about this technique. But usually a moderate to firm pressure will be helpful without causing any problem.

 

If you're experiencing tightness, cramping, shooting pains or other discomfort in the larger muscles of the forearms, you have a problem, very likely osteophytes, or such a degree of inflammation at the site of the epicondyles that the nerves radiating into the forearm are referring the pain of constriction the inflammation is causing. While heat may feel better, it's ice that you want, at least in the initial stages, to get this to back off, if possible.

 

Your doctor may recommend injection of the site with a cortisone steroid depending on his evaluation and what he finds with x-ray or MRI imaging to determine if there are indeed any more serious conditions beyond mere inflammation. Ultrasound is sometimes used in physical therapy as well.

 

I would absolutely stay out of the climbing gym until this whole situation is resolved. For that matter, I really don't recommend climbing gyms at all. I know it's the winter, hard to get in much time on real rock, but I have never once, in over 40 years of climbing, been injured, or sustained tears or tendonitis from climbing on real rock outdoors. But it was the combination of weight training and the climbing gym that precipitated my bout with epicondylitis, and I have been injured a number of other times at climbing gyms, usually muscle pulls and tears, inflammations, etc. A lot of the routesetters are young guys trying to see how hard they can make it, are not thinking of potential force/load factors on human physiology, know nothing about movement dynamics or stress kinetics, and are trying to impress the girls.

 

Regarding the "recovery"/workout routine you show, I see nothing wrong with it per se, but in your present condition, RICE (rest, ice, compression, elevation) is what you really need to focus on until you can get to the doctor. Don't worry, at your age, your muscles won't melt. You may very well be overtraining anyway. Remember, MUSCLE GROWS WHEN YOU REST, NOT WHEN YOU TRAIN!!! Have you ever just knocked off the training for 3 or 4 days after a heavy cycle, and then looked in a mirror? Wow, how'd those arms, etc. get so big??!! I haven't been doing anything for 3 days! Right, dum-dum, the poor bastards FINALLY got some REST!! And they took advantage of it to GROW!!!

 

And tendon is no different, BUT: because it is white tissue with generally very low blood saturation, it takes LONGER to recover after heavy training. This is why we don't rain heavy, heavy, heavy, day after day. Instead we train heavy--Low reps(4 to 6), heavy weights, and then light--high reps (15 to 20), low weight, alternating every other workout, to allow the tendons to recuperate, and also to make sure that both muscle and tendon are progressing at a similar rate in strength and endurance. If muscle gets ahead of tendon--tendonitis. If tendon gets ahead of muscle-- serious muscle tears, or even detachment from the bone. Seen it happen with big guys and big weights; frightening and gruesome, extremely painful.

 

AND, we throw plenty of rest days in there for good measure. Research is showing more and more that fully recovered tissues perform and develop to a much higher degree than partially recovered tissue, and that full recovery may take much longer than previously thought. In one Oregon State study, it was found that full recovery from a heavy leg day was not reached until 9 DAYS(!!) after the workout.

 

Anyway, fucking GO SEE THE DOCTOR if you don't want to really get into trouble. This stuff is nasty, extremely persistent and time-consuming to heal, and can recur at the drop of a hat if you haven't allowed it to completely heal.

 

Finally, climbing is great- outdoors. Weight training and other forms of resistance training, is great-- but only when done properly, neither over- nor under-training, and with proper rest and recovery, and the right nutrition. After a training cycle of 8 to 10 weeks, I usually take an entire week or even two, completely off, don't touch a weight, don't go near the gym. I do stay active, but whatever's FUN, and as much as possible outdoors. And once or even twice a year, depending on how hard I've been training, I'll take an entire month off from training. It's sometimes absolutely amazing how much better I feel, having been way more tired and banged up than I'd realized. Your body likes a good vacation now and again.

 

Right now, your body is telling you, SHOUTING at you, "HEY, MAN!! STOP!! I'M INJURED!! If I were you, I'd drop that weight or come down off that climbing wall,and listen, and do whatever the body needs to get well.

 

I wish I would have read this several months ago! thanks MtGuide!

 

The hardest part of this process has been facing the denial of reality that I had to stop climbing for awhile. And now I'm really enjoying my cardio training in the meantime; use the time to take advantage of something else!

[Lodestone]

Mtguide and W, thank you very much for the advice. It is greatly appreciated and well taken. I'll go see a doctor. Gym climbing isn't even all that interesting to me, I just wanted to "stay in shape". What a dummy.

 

Mtguide, do you have a recommendation for a Portland area doctor that can deal with this type of issue?

 

Dan, I had some great smoked salmon today. I'll have to make that a regular thing.

 

 

Thanks again everyone.

 

Chad

Edited January 17, 2010 by Lodestone

[ClimbingPanther]

I second Mtguide's gorgeous exposition on orthopedics, and especially his advice for seeking resolution. You just don't mess around with your joints. The amount of permanent damage and loss of time for climbing that can be caused by aggravating an injury is NOT worth the very temporary gains of pushing through the pain.

What you seem to be describing does not sound severe enough to warrant a doctor's visit, depending on what you mean by "mild pain" and "itching," especially since you're not taking any medication for it. You're likely to be told to try an NSAID first, along with cessation of the aggravating activity.

Athletes go back to work way too soon because they "feel better" and can't stand to be away from the action. Don't let yourself be tempted by this line of thinking. Whatever is going on in your tendon was enough to cause you to seek advice, so it is enough to warrant cessation of your routine for the time being. Knowing how long tendon and bone healing process take, a month would be wise.

I stopped exercising for several weeks after the Wonderland last summer due to knee pain, and my wife took several months before she could run without any pain. It is always worth the time to heal properly.

And remember, we are all different, so don't compare yourself with what other people can do without joint pain. Your body has communicated that you're over-doing it, so don't fight it.

[Mtguide]

Hi Chad;

 

One of the best orthopedists I know of in the Portland area is Dr. Ira Weintraub, he's the very last listing in the Yellow Pages under Orthopedics. He's also in the white pages, and is located on 1515 NW 18th, phone is 503-224-8399. He's a climber and skier himself, so he'll have an understanding that is very helpful. And in my experience, he'll spend the time it takes with you to make sure he fully understands the symptoms you're experiencing, and where to take it from there. Great guy, really knows his stuff.

 

Another option that may be helpful, and a little less expensive initially, is Portland Adventist Hospital out near Mall 205. They used to have a walk-in Sports Medicine clinic on Tuesday evenings, where you could go and be evaluated for a nominal fee, around $35.00. The clinic has a very respected reputation. They could also prescribe medications and treatment, and they have a state-of-the-art Physical Therapy facility. I haven't been out there for years, but give 'em a call and see if they still do that. The doctors are excellent, and they'll steer you right.

Edited January 17, 2010 by Mtguide