Article written by Seth Larsen
Unfortunately, “golfer’s elbow” and “tennis elbow” aren’t just for the country club crowd anymore. If you’ve been in the iron game for longer than a couple weeks, I can just about guarantee that you’ve experienced some kind of elbow pain. Moving heavy weight around beats all of us up, and few body parts (the lower back being one of them) take as much punishment as the elbows. Presses, rows, pullups, deadlifts, carries, loads, arm work, and even lifts we don’t think about as involving the upper body, such as squats, put significant pressure on the elbow joint, especially with the frequency that we train them. This repetitive stress on such a small joint can lead to a host of problems down the line if we don’t protect ourselves. Couple this with our jobs outside of the gym and we are in for trouble. If you work in a job requiring a lot of manual labor, this will replicate the stress placed on the elbows in the gym and compound upon it. Construction workers, welders, stockroom workers, grocery baggers, cleaning personnel, restaurant workers, and many others all have a significantly higher incidence of elbow pain than the general population. Unfortunately, with our increasing reliance on computers for our non-labor jobs, the incidence of elbow pain is increasing in the white-collar world as well. Sitting at a computer all day in a chronic position of elbow flexion, pronation, and wrist extension coupled with the repetitive finger movements of typing can make the forearms and biceps tighter than one might expect and puts a surprising amount of stress on the elbows.
As with any other body part, it all comes down to the anatomy. Similar to the knee, the muscles both proximal (closer to the torso than the joint) and distal (further from the torso than the joint) affect the elbow significantly. Because the elbow joint itself is fairly complex, I won’t go in depth into it’s anatomy, but will focus more on the muscles around it that can produce pathology, resulting in the pain we are all trying to avoid. There are five major muscle groups in the arm that we will delve into that affect the elbow: the extensors of elbow, flexors of the elbow, extensors of the wrist and fingers, flexors of the wrist and fingers, and the pronators/supinators. Imbalance in any of these muscle groups over others, just like I’ve talked about previously in relation to the shoulders and back, is what not only leads to pain, but compromises our abilities to move maximal loads. Yeah, I said it, not taking care of your elbows will make you weaker in the long term! Nobody wants that.
Let’s start with the forearm. There are 20 muscles here, so I won’t go into each one. Instead, we can separate them into intrinsic and extrinsic muscles. The intrinsic muscles act on the forearm, performing the actions of pronation, supination, and elbow flexion. So as not to go into to much detail, I’ll focus on the big gun of the intrinsic muscles, the brachioradialis. This is the large muscle belly you can see on the lateral side that crosses the elbow and assists the biceps with flexing it. It is one of the things you are training in hammer curls. Ever get that weird cramp in your forearms when doing front squats? That is your brachioradialis, and it is a major culprit in elbow pain. It gets hammered constantly during many movements, especially those in which the hand is pronated or in a neutral position. From controlling the speed of descent in a bench press, to holding the arm in place during squats, to flexing the elbow in rows, pullups, and olympic lifts, this muscle gets verytight. The tighter it gets, the more it pulls on the lateral aspect of the elbow, resulting in pain and point tenderness. If it becomes even tighter, the nerves supplying the extrinsic muscles of the forearm can become compressed, resulting in a loss of grip strength and wrist stability.
These extrinsic muscles are what act on the hand and wrist, and can be divided into 2 compartments: anterior (flexors) and posterior (extensors). These functional divisions are all the detail necessary for this article. They can also become extremely tight, and are why athletes tend to get elbow pain when they overtrain their grip. The extrinsic muscles take a beating from deadlifts, any type of loaded carry or pulling exercise, axle work, and of course, stones. Whether you are squeezing your fist tightly or have your fingers open as you would in a stone load, these guys are working hard. Pathology in the anterior compartment can result in medial epicondylitis (golfer’s elbow), while posterior compartment issues can result in lateral epicondylitis (tennis elbow). Unfortunately, the two are not mutually exclusive, so when I happened to develop both simultaneously, I decided to call it “lifter’s elbow.” Trust me, you do not want this.
Now for the upper arm. This is a bit simpler, but no less important. The major muscles here are ones we should all know at this point: the triceps brachii, biceps brachii, and brachialis. As you might expect, the triceps can cause posterior elbow pain and the biceps anterior. I don’t need to explain further about these two, but the brachialis is often an underrated muscle. Its muscle belly lies primarily on the medial side, deep to the bicep, where it originates on the humerus and inserts onto the ulna. It can create pain in a variety of places, from tenderness on the lateral aspect of the upper arm deep to the bicep that radiates to the medial elbow and vice versa, in addition to pain directly over the anterior aspect of the elbow, as it makes up the floor of that area. Similar to the brachioradialis, if it becomes too tight or inflamed, it can compress the nerves that travel through the elbow and supply the forearm.
So now that we’ve broken down the anatomy to a degree, where do we go from here? I could go into a bunch of complex case studies about neural tension and compression, kinematics of elbow movement, hypertonicity and weakness of upper extremity musculature, and all their effects on elbow pain and pathology, but that would just make for excess reading to get to a relatively simple point: we must keep our muscles balanced and relaxed! This may sound like something you’d hear at your local yoga studio, but it is of paramount importance to us meatheads as well. We can all agree that overly tight muscles are painful and less effective, but there is more to it than that. It is related to the concept of reciprocal inhibition, which can be applied in the case of elbow issues as the idea that if one muscle is overly tight, its antagonist will be weak. This means that if your extensors are tight, your flexors will be weaker.
In the elbow, this results in overcompensation with certain muscle groups to make up for it, ultimately making those muscles do more work than they are intended to. This is problematic for multiple reasons. First of all, when a smaller muscle and its tendons have to take on more load than they should, one or both can tear. Good luck trying to grip anything if you rupture your flexor pollicis longus, the muscle that flexes your thumb. Second, these smaller muscles are easier to overwork, causing them to become tight and start our vicious cycle of reciprocal inhibition again. You’ll soon run out of muscles to overcompensate with, meaning you will be able to do essentially nothing. The third reason, and arguably the most important from a performance standpoint, is that these smaller compensatory muscles that you have now pressed into service are not nearly as strong as their larger counterparts. This means you will be weaker. It would be like trying to squat without glutes. I don’t see that leading to any kind of impressive performance at a competition.
Curing and prevention of elbow pain can be time-consuming and frustrating at times, but it is relatively simple once you get going. First and foremost, if you are having pain right now, whether it is acute or chronic, go get it evaluated in person by a professional! I can not be more adamant about this. There may be other underlying issues involved that are leading to this pain, or structural issues within the joint that are causing it. Neither of these things can be properly assessed in an online forum! If you have a slight tear in your ulnar collateral ligament, and you start over-stretching it in the hopes of reducing your pain and it ruptures, you are in for likely surgery or at best a long, painful recovery. Neither you or I want you to be in that situation, so be smart. Even if there is no significant injury found when you get evaluated, there may be other factors contributing to your elbow issues. For example, up to 70% of elbow pain patients also report pain and dysfunction in their cervical and thoracic spines. Elbow tendinopathies have also been linked to weakness in the middle and lower trapezius, along with scapular dysfunction. So the problem with your elbow could actually be a result of issues with your neck and back!
Once an exam is performed, we can start attacking your elbow issues. First and foremost, take a look at your training program. Some lifts make you more prone to elbow problems than others. Skullcrushers, dips, heavy dumbell rows, carries, stone loads, olympic lifts, and front squats can all be elbow killers. I have noticed this more than once in my own training. This isn’t to say you shouldn’t do them ever (you should know by now that I think absolutes in training are idiotic), but you may want to back off on the intensity, the volume, or both for some time while you rehab your elbows. There are also ways you can adjust some of these lifts. For the skullcrushers, try them with an EZ-curl bar on an incline bench and don’t go back as far. For the dips, play around with your hand positioning and weight distribution, as leaning too far forward or too far back can change the stress on your individual muscles and joints. When training stones, stop being a hero and use some tacky. This will place less stress on your elbows and your biceps. Front squats put far less stress on your elbows if you do them with a barbell grip vs. an olympic grip. And if the lift isn’t essential to your goals and causes you a significant amount of pain? Scrap it! There’s no reason to keep doing something a magazine told you to if it does nothing but increase your ibuprofen intake and piss you off. The second thing to do is to roll your biceps, triceps, and forearms before every training session, and even when you are at home relaxing. Buying a little $20 trigger point roller and scraping my forearms and biceps with it while watching TV has been huge in treating my elbow pain. Preferably do the rolling with something very stiff like a PVC pipe, because it generally takes some real pounding to break up the adhesions in these areas. The third part is stretching. Stretching the biceps and triceps is pretty self explanatory, and the forearms aren’t much different. If your anterior/flexor compartment is tight, pull your wrist back towards you with both a flexed and extended arm and in multiple directions medially and laterally. If the posterior/extensor compartment has problems, simply do this in the opposite direction to stretch it out. Never neglect good old fashioned icy hot (or whatever your liniment of choice is) on your elbows before you throw on your sleeves either. This all probably seems really basic, but some subtle changes can really aid in prevention and management of chronic elbow issues from lifting.
If none of this stuff works, don’t freak out. Your elbows are not beyond repair. My own personal battle with elbow pain has been a long and arduous road, but I can tell you there is a light at the end of the tunnel. Sometimes, we just have to suck it up and get treatment from a professional. Active Release Therapy (ART) was the silver bullet for my elbow problems. It didn’t fix it immediately, but it has made a huge difference. ART and other soft tissue techniques such as osteopathic manipulative therapy, sports massage, fascial distortion therapy, and Graston are powerful tools. Acupuncture and trigger point injections are other options that myself and other athletes have had success with. If you’re still struggling with elbow issues and have been told there are no structural abnormalities, I recommend looking into one of these. Don’t let your ego or misguided beliefs about alternative treatments keep you in pain longer. Protect those ‘bows and you will be rewarded with PRs. I guarantee it. If nothing else, at least you’ll have one less excuse for missing lifts.
Seth Larsen has a Bachelor’s of Science in Biology and Neuroscience and is a Doctor of Osteopathic Medicine candidate for 2015 at Midwestern University. He is a former NASM-CPT and student athletic trainer. He currently serves as a reserve officer in the US Navy Medical Corps while he finishes medical school with a specialization in primary care sports medicine. Seth is a former NCAA football player who now competes as a LW (105kg) strongman, Highland Games athlete, and powerlifter.
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