6 February 2011

Golfers/Tennis elbow etc - what eccentrics do.


I’ve been asked a lot about eccentrics which are a really big part of successful rehab from tendonosis, in climbers that’s usually Golfer’s or Tennis elbow. What to they do? How do they work to heal the tendon?
There are no definitive answers, in fact, right now the various teams around the western world researching such things are arguing more about this subject now than they were a few years ago. Here is a little discourse on where things are right now.
The protocol of eccentric wrist curls was first brought to prominence by two Canadian physiotherapists (Stanish and Curwin) who reported very impressive and consistent success rates with their tennis elbow patients using a protocol that stopped short of provoking pain in the tendon. Since then, lots of studies have followed over the past decade and a half, also generally reporting good or excellent results with various protocols. These days, the evidence is mounting that nearly everyone with elbow epicondyle tendinosis should be able to get rid of it without resorting to surgery, so long as they do the exercises (the hard bit!), do them right and eliminate the original cause (the other hard bit!).
Protocol - The various different research teams have, generally speaking, had success with three different protocols. One is to do 3 set of 10 reps daily, with a weight that stops just short of provoking pain throughout the exercise. A second is similar, but at an intensity that provokes a little pain in the final set. The third protocol, favoured in a string of papers by a Swedish researcher Hakan Alfredson and his team, is to do 3 sets of 15 reps daily at an intensity that causes mild pain throughout. Several other teams replicated good results using eccentrics only three days a week.
The allowance for pain during the rehab exercises runs counter to much of orthodox sports medicine, even from researchers in the same field. Far from being settled, it’s a question that is only just being opened in tendon research right now. However, the successful healing demonstrated by Alfredson’s protocol does speak for itself. Briefly, the idea behind it is that tendons suffering tendonosis (degenerative tissue changes) grow numerous and sensitive new nerve endings that serve as a protective measure to self limit the condition. In order to stimulate the tendon enough to grow new collagen and remodel immature scar tissue, the exercise must be a little painful. If the exercise progression is correct, a little exacerbation in the first few weeks should give way to steady pain ratings while the exercise intensity gradually goes up.
So why eccentrics only? Well a lot of researchers were unsatisfied with the rather simplistic explanation that this mode of contraction (lengthening under load) preferentially loaded the tendon rather than the muscle, preventing the muscle from getting strong ‘too quickly’. It’s true that muscles respond better to a combination of concentric and eccentric loading. What tendon strength responds best to is nearly impossible to research (would you let a man in a white coat train you for weeks, chop your bicep tendon out and pull it on a strain gauge until it snaps?).
One idea from Alfredson was that the eccentric loading breaks up the adhesions of disorganised scar tissue, as well as abnormal blood vessels and free nerve endings that proliferate in degenerative tendons, allowing both pain free stimulation and collagen maturation. There are various other ideas about how the tendon responds biochemically to eccentric loading related to growth factors, inflammatory processes and other very complicated processes of cellular messaging.
An intriguing new hypothesis is emerging that tendonosis might be down to underuse, rather than an overuse injury as it’s traditionally been perceived. Research into painful achilles and patellar tendons is suggesting that unequal distribution of loading exists within tendons that are chronically loaded at a certain joint range. Some areas are overworked and strained, other areas ‘stress shielded’ become atrophied and weak, and eventually strain as well. This lends weight to the importance of technique, training design and posture as being the direct causes of these injuries in at least a proportion of cases. There is some evidence that eccentric loading allows more even loading in the tendon, stimulating both the overused and underused portions in a way that allows them to recover normal collagen content and arrangement.
Whatever the underlying mechanism, there is quite convincing evidence that these exercises are the thing to do and seem to get through to even the most unresponsive tendons, except in a few extremely advanced cases where the tendon has been trashed so severely it literally turns to bone. Which protocol you choose largely comes down to experimentation I’m afraid, as no studies have compared the effectiveness of each in a reliable way. Personally, I’ve found that either pain free, or with a little pain worked on all three of my injured epicondyles (two now symptom free, one more recent injury well on the road to complete recovery).
People tend to fail at this by simply not disciplining themselves to do the exercises. Simple as that. I’ve read a couple of studies that demonstrated clearly that tennis elbow sufferers tended to recover much better on identical protocols if they were done with the physio there. 
Remember that doing these exercises, although a gift to climbers who are suffering chronically, are only one part of the response. Unless your technique, posture, training all change to remove the reason you got injured in the first place, it’ll probably come back the minute you start trying to push your grade or training volume again.
This post is just a snippet about one aspect of elbow rehab. The above discussion should reinforce that healing a tendon for sport is a massive field and way more than a few blog posts. There is much more you should know - about the stretching, fitting the rehab in with climbing, and the detail of the changes to make in your technique, posture, training, lifestyle. Hence I’m writing the book. I know, I know, it’s not out yet… I’m working hard on it, but couldn’t resist a moment out to write this as I’ve been asked so many times…
Happy curling

22 comments:

Anonymous said...

Hey Dave.
Will there be any advice in your book on the prevention of shoulder injuries?
Also in your recent post about "base training detail" you mentioned exercises to prevent the hunched shoulders which climbers tend to get. What kind of exercises are these?
Thanks
James Oswald (sorry, I don't have a google account)

David Bulley said...

That only really mentioned tennis elbow. How would wrist curls help golfers elbow? If I'm mistaken, isn't golfers elbow abover the forearm? So wrist curls that work the muscles in the forearm wouldn't have any effect on the brachiallas, which is the muscle associated with golfers elbow?

Please reply! I greatly look forward to your book on injuries!

Dave MacLeod said...

Shoulders - yes there will be advice. The problem is diagnosis of which muscles are short. There will never be any substitute for your physio giving you a thorough manual muscle examination and identifying the muscles needing lengthened/shortened/strengthened/educated.

David - Golfers elbow is the wrist flexor. wrist flexor curls for this and extensor curls for tennis.

Anonymous said...

Dave, have you found any research indicating a mindbody connection to elbow epicondyle tendinosis. There is much to show that if no structual abnormalities exist this is the case.

Often athletes will obsess to greatly about the severity of injuries sustained.

Of course get the film and mri and if no strucrual cause treat as a mindbody disorder.

cheers

David Bulley said...

Thankyou for the reply.

I think I'm confusing golfers elbow with a problem with the brachialis.

Have you got any tips on exercises/stretches for the brachialis (deep elbow pain, usually spurred on by deep locks) muscle?

Tom Hutton said...

Hi Dave
Seem to have made mild tennis elbow (chainsawing and winter climbing over christmas) into really bad tennis elbow by trying eccentrics with an 8kg weight. It finally gave up altogether last week in the Cairngorms. I've seen a physio, who suggests at least 4 weeks of nothing, and at the moment it's too sore and swollen to even stretch, so I am icing it and taking a fair bit of ibuprofen.

Any advice? At what point should I try mild stretches and excercises? Thanks

Jules said...

Dave, thanks a lot for posting this - I've been rehabilitating my tennis and golfers elbows (yes, all four epicondyles at once!) with eccentric curls and am now slowly getting back into the climbing with apparent improvement. There's so much advice around, but a lot of it seems only to be adequate to get back to square one - i.e. no pain, but no activity either.

Everyone else: have a read of the articles here: http://www.athlon.com.au/media_articles.htm, some useful pics on how to do eccentric curls

Sean Ferrell said...

Delighted by this post, and eagerly awaiting your book!
Thanks from Minnesota. -Sean

Pepijn said...

Is the tendonosis spoken of in this article in any way comparable to the one in a finger tendon?

If so, I would think that tendononis in a finger could be treated with eccentrics as well, but are there any known excercises for the fingers?

I have been suffering from t'nosis in my left ring finger for about 8 months now and it is making progress, but I'd definitely like to give something like this some thought in the hope that it may help someone else in the future as well...

waldorf said...

Hey Dave,

As for unscientific proof of a prevention-cure for most elbow and shoulder pain, a small amount of push-ups after each workout has kept my partner and I free from pain over the last few years.

Emphasis should be on doing push-ups, not doing a lot of them.

Erik

Peter Beal said...

I would really second what Erik has said. Around 40-60 pushups after a climbing session seems to really make a big difference. There is a strong flexor stretch component and extensor use as well if done with a bit of push off the fingers with each rep.

Anonymous said...

Hey Dave.
I have started having some problems with my elbows, and after much research, I know it is golfer's elbow. I have started doing eccentric curls as prescribed by Dr. Julian Saunders' article "Dodgy Elbows", and it truly makes them feel somewhat better. After reading many of your other posts, I would guess that you recommend not completely laying off climbing but climbing easier and differently in regards to technique and terrain. Does this seem correct and should I ice the elbows too?

Thanks,
Phil

klimbart said...

I had a serious golfers elbow, that was so bad it hurt at pretty much everything I did, including washing my hair, or closing a car door. Early 2008 I found out about eccentric training, and after a few weeks I noticed very real improvements.
In about half a year I was completely cured, and still am. I'm now on a year long climbing trip, and I've recently put together a site with a small movie on how I did my exercises: here it is. It is already helping a few people that I know of.

Anonymous said...

I had fairly bad tendonitis - went to get help, did exercises etc. Didn't help much. Then I started doing Bikram Yoga and my elbows don't hurt any more. Best cure ever! (Mind you, the yoga is hard work...)

Anonymous said...

I think that flexion and extension ate valuable but its also important to work supination and pronation. Tendonosis can also flare up in these areas as well. Maybe eccentrics in multiple planes would be ideal? I like a sledgehammer for these. Anyways very good article!

Anonymous said...

Hi Dave, big thanks for help here. Just thought id mention for others something recomended to me that worked well. Applying pressure and massage to the indside elbow, the joint and tendon area of pain. About the same pressure and slow technique you would use on a knot in the back. Supposedley the increased blood flow afterwards improves the limited flow in ligaments/connective tissue. Also mild damage to conective fibers stimulates new collagen growth, like in the exercises mentined. I thought i needed to combine this with extensor curls/slow pushups to make shure the collagen growth was with the "grain" of the tendon fibers. Sorted it in about a month after 3 months of injury, though i keep on doing the pushups. I wouldent try this unless you are in a recovery stage though. glucosamine, chondroitin, msm, and fish oil a good idea too for conective tissue healing and general joint health.

Jamie foxen

DocP said...

Hi

I read your last article in Climb regarding injuries. I was interested in your comments regarding epicondylitis and shoulder girdle dysfunction as it seemed to mirror problems I had associated with bilateral painful upper trapezius.

Without going into detail a good physio has helped sort the problem out but I would be keen if you any references to this issue. Once the shoulder problems where corrected the bilateral medial and lateral epicondylitis went!

You might be aware but there was a recent review article in the BMJ regarding the current evidence base for treatment of tennis elbow.

I look forward to any future book on sport injuries. One piece of advice I would add is if you do the excercises and follow the advice of a physio and the problem remains it's probably time to find another physio.

Cheers

Mark

тендеры на строительство и ремонт said...

Very helpful info, much thanks for your post.

brendan said...

Dave,
You clearly show that eccentrics help people who already have tendon issues, but do you think they have a prophylactic effect for people without symptoms?

Are they worth doing at the end of every session to prevent the dreaded and debilitating fire-elbow?

Thanks for your response.

billbow said...

Dave,

Thanks for the article. I am looking forward to your book.

I just wanted to add something. I had tendonitis off-and-on for about two years in the early 90's. I had been climbing/training with Francois Legrand, Yuji Hirayama, my twin brother, etc. quite hard during this entire time and I tried many forms of elbow rehab. NOTHING worked. Finally, at Francois' wedding I was talking with Laurent Jacob and, after basically calling me an idiot (politely, but still..), he said that I should have asked him how to fix the problem sooner. He had been a top-level climber for 25+ years AND a physician for 22+ years at that point. The fix was simple he said.

As climbers we use our biceps WAAAAAY too much and we do not use our triceps in any sort of balanced manner (this was before bouldering top-outs and cross-training that includes push-ups, dips, etc., which seem to help balance things out for some people). Laurent's suggestion was to pinch a (relatively) heavy book, like a dictionary, and to do triceps extensions while making sure to roll your palm to face the ceiling/sky when you reach maximum extension. 3 sets of 10-15, 3 times a day for around a week should completely resolve the problem (if there is no structural damage that is). Then you just do 3 sets once or twice a week to maintain balance.

The trick here is to make sure that you are stretching the brachioradialis while doing these exercises AND to use a book that is heavy enough to pump you out a bit, but not so heavy as to make you strain to complete the exercise. This exercise works the muscles in a slightly different way than straight push-ups or dips and is necessary once you have begun to have balance problems and your elbows have begun to hurt. (There may be some connection with the fact that when you tense your triceps at maximum extension you are engaging the anconeus, which is otherwise not doing much in most humans. This might help stabilize the elbow and stop it from over-pronating/pinching the ulnar nerve)

I know that this seems too good to be true, but I used these exercises for 3 DAYS and my two years of elbow problems went away. By the 7th day I was climbing at my maximum level again and I have not had a relapse in almost 20 years. I still climb quite hard (13a on-sight) and I pull more weight than ever before (being naturally heavier/fatter :). All without a single problem, as long as I stick to balancing my elbows out (I slack-off sometimes for a month or two and everything is fine, but then I remember the pain I used to go through and I get back to doing the exercises once a week).

I have mentioned these exercises to all of my friends that have had elbow issues and almost all of them have had good results, UNLESS they had structural damage.

Will Gadd and I have talked about this issue. He seems to have structural problems, after all of his years of severe strain, which prevent these exercises from completely solving his elbow problems. That said, I think that many people, particularly younger climbers, will benefit greatly from this advice and I felt compelled to make this long post. As a matter of fact, I have found that finding balancing exercises for any NON-TRAUMA injury is an effective method of healing/prevention. Shoulders and, particularly, fingers react well if you can find the proper balancing exercise (fingers are the most difficult and require balancing exercises that generally focus on the back of the hand (i.e. opening hands in sand) or the fine muscles in the palm of the hand).

I hope that this will help someone out there.

Thanks,
Kevin Wilson

(I am using my wife's google account, but you can contact me through this address if you need to berate me for the long post, haha :)

Mika said...

Kevin´s intructions healed my tennis elbow in a week, after being really painful for a month despite intensive rehab. Doesn´t fall short of a miracle for me. Give it a try!

Lars Ole said...

Hello

Can someone please explain me Dave`s method "heavy book, like a dictionary, and to do triceps extensions while". I did not understand.., and I have pain..