In this blog, I’m going to tell you why your elbow hurts and what you should do about it!
Be sure to also check out our Rehab Programs!
Basic Elbow Anatomy
The two bones of the forearm are known as the radius and ulna, while the arm bone is known as the humerus. Together, these three bones form the humeroradial and humeroulnar joints, which make up the elbow. The radius and ulna also join here, and this is known as the proximal radioulnar joint.
If you feel the bony prominence on the inside of your elbow, this is a part of your humerus known as the medial epicondyle.
If you feel a similar bony prominence on the outside of your elbow, this is a part of your humerus known as the lateral epicondyle.
Many of the muscles that control the movements of your forearm, wrist, and fingers attach to the medial and lateral epicondyles via their tendons (because tendons attach muscles to bones).
The muscles that attach to the lateral epicondyle have 3 primary actions: wrist extension, finger extension, and supination, which involves turning your palm up toward the ceiling.
On the other hand, the muscles that attach to the medial epicondyle contribute to finger flexion, wrist flexion, and pronation, which involves turning your palm down toward the floor.
If you perform any of these actions or squeeze your hand into a fist, you should be able to see and feel these muscles contract.
Tennis Elbow
There are a lot of names used to describe pain at the location of the lateral epicondyle: lateral epicondylitis, lateral epicondylalgia, tennis elbow, etc. This can be confusing.
Lateral epicondylitis refers to inflammation of the lateral epicondyle, or more specifically, inflammation of the tendons that attach to the lateral epicondyle. However, lateral epicondylitis has fallen out of favor as a diagnosis because current research suggests that local inflammation is likely not the primary driver of the condition.
This is not to say that inflammation is never a contributing factor, but it likely doesn’t need to be the focus of management. This is important to know because most people associate inflammation with the need for complete rest, ice, and anti-inflammatory medication, which are not going to be the main recommendations in this blog.
As a result, the term epicondylalgia was introduced to replace epicondylitis. However, lateral epicondylalgia just means that the lateral epicondyle is painful, which is not very helpful.
We also shouldn’t call it “tennis elbow” because it doesn’t only occur in tennis players. In fact, it’s most common in manual workers who use their dominant arm for repetitive movements or forceful activities on a regular basis. Shiri 2006, Van Rijn 2009, Walker-Bone 2012, Descatha 2016, Vicenzino 2017, Aben 2018. And, as some of you reading may be aware, golfers also get tennis elbow.
So what should we call it?
According to Scott et al, lateral elbow tendinopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading of the lateral elbow tendons. Mechanical loading refers to any movements or activities that load the lateral elbow tendons, such as working with your hands, lifting weights, and playing sports.
The diagnosis is typically given when someone’s pain is reproduced with pinpoint pressure to the tendons, stretching of the tendons, or loading of the tendons, such as with resisted wrist extension, resisted middle finger extension, or gripping. The tendon most often involved is believed to be the Extensor Carpi Radialis Brevis.
Based on this information, lateral elbow tendinopathy is generally considered a clinical diagnosis, meaning that imaging, such as x-rays and MRIs, are not indicated unless there is suspicion of something like a fracture, dislocation, or instability.
Want to learn more?
Check out our full blog about Tennis Elbow Rehab!
Golfer’s Elbow
There are also a lot of names used to describe pain at the location of the medial epicondyle, such as medial epicondylitis, medial epicondylalgia, and golfer’s elbow.
However, for the same reasons mentioned above, medial elbow tendinopathy is the preferred label. It’s common in workers who do repetitive movements or forceful activities with their arms, wrists, or hands on a regular basis, as well as sporting populations other than just golfers (including tennis players). Descatha 2003, Shiri 2006, Wolf 2010, Walker-Bone 2012
The diagnosis is typically given when someone’s pain is reproduced with pinpoint pressure to the tendons, stretching of the tendons, or loading of the tendons, such as with resisted wrist flexion, resisted pronation, or gripping.
Like lateral elbow tendinopathy, medial elbow tendinopathy is considered a clinical diagnosis, so imaging is not typically necessary. However, it is important to consider other diagnoses in this region as well, such as an injury to the ulnar collateral ligament or involvement of the ulnar nerve. I’ll talk more about these diagnoses soon.
Want to learn more?
Check out our full blog about Golfer’s Elbow Rehab!
Triceps Tendinopathy
As you might guess, triceps tendinopathy follows similar logic.
The triceps brachii is a three-headed muscle that’s visible on the back of the arm. The medial and lateral heads originate on the humerus while the long head actually attaches up at the scapula, or shoulder blade. All three heads insert on the olecranon of the ulna via a common tendon and act to extend, or straighten, the elbow.
Since tendinopathy refers to persistent tendon pain and loss of function related to mechanical loading, triceps tendinopathy is characterized by localized pain at the back of the elbow that worsens with increasing demands on the triceps. For example, I would expect a 40lb dumbbell skullcrusher to cause more issues than a 20lb dumbbell skullcrusher because it’s a greater load. Similarly, a very fast repetition would likely be more problematic than a very slow repetition because tendons are also affected by the rate, or speed, of loading. Range of motion can play a factor as well.
Want to learn more?
Check out our full blog about Triceps Tendinopathy Rehab!
Distal Biceps Tendinopathy
The last tendinopathy to discuss is distal biceps tendinopathy.
The biceps brachii consists of two heads – a short head and a long head. Both heads originate on the scapula and come together to attach to the radial tuberosity of the radius. At the elbow and forearm, the biceps brachii contributes to flexion and supination.
The diagnosis is more likely when there is localized pain associated with loading of the tendon, such as with lifting, pulling, twisting, etc.
For all tendinopathies, rehab is the preferred method of management.
Ulnar Collateral Ligament (UCL) Injuries
The ulnar collateral ligament, or UCL, is located on the inner portion of the elbow and is made up of 3 distinct bundles: anterior, posterior, and transverse. The anterior bundle provides the majority of resistance to valgus stress while the posterior bundle is a secondary stabilizer. The transverse bundle does not actually cross the elbow joint.
Although injuries can happen traumatically, such as from falling on an outstretched hand (FOOSH), they are typically associated with repetitive overuse or relative overload in overhead throwing athletes, particularly pitchers in baseball.
Assessment of the injury may include a detailed history, palpation of the area, orthopedic tests, like the milking maneuver and moving valgus stress test, and imaging.
Depending on the severity of the injury, the stability of the joint, symptoms, and desired goals, surgery may be required in some cases (frequently referred to as “Tommy John Surgery” named for the pitcher who first had the surgery in 1974).
Little League Elbow
Little League Elbow, or medial epicondyle apophysitis, affects youth overhead athletes. As the name implies, it’s common in young baseball pitchers. It’s an overuse-type injury in which the soft-tissue structures that attach to the medial epicondyle, like the ulnar collateral ligament, cause irritation of the growth plate due to repetitive tensioning of the area.
Cubital Tunnel Syndrome (Ulnar Nerve)
As I mentioned earlier, any assessment of symptoms around the inner elbow should include an evaluation of the ulnar nerve. If you’ve ever hit your “funny bone,” you’ve actually hit your ulnar nerve. It runs just behind the medial epicondyle, so it’s easy to find, feel, and unfortunately, accidentally bump on a table or desk.
It’s possible for the ulnar nerve to be irritated in isolation, or for problems to co-exist with medial elbow tendinopathy or an injury to the ulnar collateral ligament. This is commonly referred to as cubital tunnel syndrome, but the ulnar nerve can be compressed or irritated in several locations along its path down the arm.
From a sensory perspective, the ulnar nerve supplies the pinky side of the hand so numbness, tingling, burning, or other sensory disturbances may be felt down into this region.
The ulnar nerve is also responsible for innervating many of the muscles that control the hand; therefore, atrophy, weakness, or changes in the appearance and function of the hand may occur if the condition progresses.
Symptoms are commonly felt at night or with any activity that requires sustained or repetitive flexion of the elbow.
Some people may also experience snapping or popping of the ulnar nerve as it rolls in and out of its groove behind the medial epicondyle during flexion and extension of the elbow.
Radial Tunnel Syndrome (Radial Nerve)
Less frequently, on the outer portion of the elbow, compression of a branch of the radial nerve can masquerade as lateral elbow tendinopathy. Two key differences are the location and nature of the symptoms.
Radial tunnel syndrome, as it’s commonly called, will present as a deep, dull, diffuse ache that’s less localized than lateral elbow tendinopathy. Symptoms will also be experienced further from the lateral epicondyle than lateral elbow tendinopathy.
Two things to note here:
- I’m not going into extreme detail because the assessment of nerve-related issues can be a little more complex and it’s best to receive an appropriate evaluation and accurate diagnosis from a licensed healthcare provider.
- The shoulder and neck should always be evaluated when someone is experiencing elbow symptoms because the shoulder can refer pain down the arm into the elbow and irritation of a nerve in the neck, known as cervical radiculopathy, can present similarly to some of the diagnoses I’ve discussed so far.
Olecranon Bursitis
Moving on, olecranon bursitis refers to inflammation of the bursa on the back of the elbow. A bursa is a small, fluid-filled sac that helps cushion and reduce friction between structures.
Olecranon bursitis may occur following minor trauma or sustained pressure to the area. The first time I went snowboarding I used my elbow as a brake and developed this condition after hours of repeatedly falling on it. In my case, it was extremely swollen and painful.
Other causes of olecranon bursitis include gout, infections, and rheumatoid arthritis.
Fracture / Dislocation / Instability / Distal Biceps Rupture
A common cause of elbow injuries is trauma, such as falling on an outstretched hand, falling directly onto the elbow, or from a direct blow to the elbow. These traumatic instances can result in fractures, dislocations, and soft tissue injuries. As you might expect, this can lead to other issues as well, like instability of the elbow joint.
A distal biceps rupture also falls into this category of traumatic injuries.
What About Other Diagnoses?
What about other diagnoses that I didn’t mention?
Well, I can’t cover every possible diagnosis. For example, I didn’t discuss osteoarthritis of the elbow as it’s much less common than other joints like the knee and hip. However, I tried to review the diagnoses we most often receive questions about.
And hopefully this goes without saying, but this information should not serve as a substitution for a consultation with a medical doctor or physical therapist.
Why Did You Get Elbow Pain?
Trauma aside, you might be wondering why you developed elbow pain in the first place.
Lateral elbow tendinopathy is the most common of the elbow tendinopathies, so let’s use it as an example.
Think of it like this – you load your lateral elbow tendons every day when you’re working, lifting, playing sports, etc. However, if the intensity, frequency, and volume of that loading exceeds your capacity to recover and adapt from those loads appropriately, lateral elbow tendinopathy may occur.
Oftentimes, it comes down to doing too much, too soon. Here are three examples:
- You decided you wanted to get in better shape, so you started lifting weights every day without any prior experience.
- You’re a new tennis player who wanted to get good fast, so you joined a club to play after work each day.
- You took a week off of work to take care of a few projects around the house.
In these examples, you likely loaded your lateral elbow tendons more than what they’re used to. Therefore, the goal of rehab is pretty simple: it’s to initially reduce those loads to a tolerable amount and then make sure that your capacity is greater than or equal to the various loads you’re going to be experiencing on a day-to-day and week-to-week basis.
How To Rehab Elbow Pain
Based on this information, my first recommendation for rehab is to modify aggravating activities.
If you’re a gym-goer who can’t tolerate your current training program, you need to temporarily scale back by doing less sets per day or throughout the entire week, reducing the amount of weight you’re lifting, or making other adjustments to your routine. Here are five examples:
1. If upper body exercises that require significant gripping like pull-ups, pulldowns, and rows are provocative, an easy modification is to use lifting straps.
2. If leg exercises with weights in your hands are uncomfortable, like dumbbell lunges or split squats, use lifting straps, try a barbell, or perform a machine-based exercise instead.
3. If heavy deadlift variations are problematic, even with lifting straps, pick a different exercise that trains similar muscle groups without placing any demand on your grip, such as single leg hip extension on a roman chair.
4. If you have pain with dumbbell lateral raises, you can put a cuff around your wrist and do them using the cable column.
5. If a certain position of your forearm is problematic, whether it’s pronated, supinated, or neutral, try a different position. You can also try equipment or handles that provide you with more movement variability.
There are a lot of options.
If you’re a tennis player, or any other athlete, reduce how often you play, the total time you play each session, or the intensity at which you play. This can actually be a good time to focus on your technique.
Compared to your legs, trunk, and shoulder, your elbow should only be contributing a fraction of your overall power when you’re hitting the ball in tennis. Working with a coach might help you discover errors in your technique that are contributing to excessive loading of your elbow. This is true for tennis, golf, and other sports that may be contributing to your symptoms.
If you’re an office worker who spends a lot of time at your computer, you might have to adjust your workstation and incorporate periodic walking breaks. Set a timer on your phone or place a sticky note on your monitor as a reminder.
I understand that modifying aggravating activities may be more challenging for some individuals than others. For example, if your job requires repetitive bending and twisting of your elbow and wrist, you might need to get creative if you work for yourself or request modified duty if you’re employed by someone else.
I also want to highlight that most of these changes are meant to be temporary. The idea is that you’re taking one step back, so you can eventually take two steps forward.
What About Exercise?
Research demonstrates that individuals with lateral elbow tendinopathy have weakness of their hand, forearm, elbow, and shoulder muscles. This is a chicken or egg scenario because it’s possible that the weakness is secondary to pain and deconditioning from disuse as opposed to being the reason for the development of symptoms in the first place. Regardless, this still ties into the goal of improving your tolerance to various forms of loading and gradually restoring your function.
Fortunately, exercise prescription doesn’t have to be overly complicated. Oftentimes, 1-3 exercises performed a few times per week is a great starting point.
With regards to pain, some discomfort is usually acceptable during rehab. However, if you’re consistently pushing into unbearable pain and experiencing flare-ups, you probably need to temporarily scale back whatever it is that’s giving you problems. Once again, think of it as taking one step back so you can eventually take two steps forward. On the other hand, if you’re a person who has restricted yourself from all exercise and activities for fear of worsening your condition, you might just need to give yourself permission to move.
Is There Anything Else You Can Do?
Yes! There is a growing body of literature, including research related to lateral elbow tendinopathy, that tendinopathies are often associated with other lifestyle and metabolic factors, such as cardiovascular disease, diabetes, smoking, etc.
This is not to say that they are the cause of your symptoms or even a contributing factor, but if you’ve been meaning to positively influence your general health and well-being by changing your exercise, nutrition, and/or sleeping habits, this might be a good time to kickstart your journey.
One of the easiest methods for improving health is simply walking more. Something is always better than nothing, and short walks throughout the day can be a great way to help break up any repetitive tasks that you’re doing with your wrist or elbow.
Individualizing Rehab
All of this information also applies to medial elbow tendinopathy, triceps tendinopathy, and distal biceps tendinopathy, but the activities you need to modify and the exercises you choose to perform will likely differ between the diagnoses. You want to personalize your rehab to your specific goals and needs.
These overarching principles apply to most other diagnoses as well, although the exact implementation will vary. For example, someone with an ulnar collateral ligament injury may need to take 6 weeks off of throwing completely to give the ligament the best chance of healing. During that time though, the person will likely still be performing exercises for their elbow, shoulder, trunk, legs, etc. When they resume throwing, it’ll be a gradual process of ramping up the number of pitches and the speed of those pitches as they try to get back to their prior level of function while minimizing the risk of reinjury. Examining their technique with a coach may be part of the process as well. There may even be aspects of their health they want to address, like sleep and stress management.
With any diagnosis, there’s rarely a quick fix. Rehab often takes significant time, effort, and consistency.
Before wrapping up, I want to remind you know that we have full-length blogs dedicated to lateral elbow tendinopathy, medial elbow tendinopathy, and triceps tendinopathy, so check those out if you’re looking for more in-depth information.
Don’t forget to check out our Rehab Programs!
Thanks for reading. Check out the video and please leave any questions or comments below.
