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SKILLS: Treating Elbow Tendinopathies whilst in Lockdown

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 UKC Articles 06 Apr 2020
Tennis Elbow Improve Strength 1

Andy McVittie talks us through elbow tendinopathies and the first steps in solving them in the context of the Coronavirus lockdown:

It appears if we're not using lockdown to work out, hard, every day we're losers who will be weak and feeble when restrictions are lifted. As pointed out by Madeleine Crane you don't HAVE to. Live now, climb later! What about using this time to tackle those long-term issues that dog many climbers? This article is an accessible look at tendinopathies of the elbow and how to start treating them, with no equipment, during lockdown.



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In reply to UKC Articles:

From my experience, long term Tendinopathy (more than 12 months) nothing really works other than heavy mechanical load, isometrically or eccentrically, however isometrically you can exert the highest force and therefore work the whole of the tendon and get to the "damaged" part. Otherwise you just exercise the good part of the tendon, so basically a waste of time, at least it was for me. And I say "damaged" between brackets because it's not clear whether, say after 6/12 months of pain, the tendon is injured, scarred, it has gaps in the collagen structured and therefore making it weak or the pain is a nerve response (apparently the tendon has nerves on the outer sheath, according to Dr. Hakan Alfredson). I recommend the first thing to do if you think you have a serious tendon issue is to get an ultrasound scan, ideally by two different surgeons, to see what really is going on. However, by talking to vast majority of people, most tendon issues to majority of people go away on their own, no matter what they do as rehab, just stopping doing what aggravate it in the first place.

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 biscuit 07 Apr 2020
In reply to Ramon Marin:

Hi Ramon. There was so much i originally wrote that then got cut out, so it was still an article and not a dissertation. It's a huge subject. This is obviously a generalised approach, that's why i added at the end that the most effective treatment is an individualised one. 

My emphasis (hopefully) is on patients finding the spot that recreates 'their pain' and working there. Changing the position after re-testing as mentioned. You're quite right on that point.

What often causes pain to reduce is indeed to reduce the aggravating factors. But the tendon will not repair itself effectively without structured strengthening and a graded return to the activity that upset it in the first place. Without this it will be susceptible to re-occurring at a similar level of activity in future. A recent patient had been able to continue climbing for ten years with golfers, as long as he stayed below a certain threshold. Small interventions were all that was needed to set him on the right track to symptom manage and truly grade his return back to where he wanted to be and now, happily, beyond.

Ultrasound does definitely have its place, but my preference is not to go down that route until after 6-12 weeks of conservative treatment. And not so i get all the appointments. A thorough screening of differential diagnoses (such as rheumatological conditions) and consideration of intrinsic factors should factor out the need for an ultrasound and a confident diagnosis of a tendinopathy and nothing sinister. A program, which is tweaked as you go along, is implemented considering their goals and current capacity. If there is no improvements after 6-12 weeks then yes further investigation is needed and ultrasound could be one of the options as part of a treatment review. 

 owensum 07 Apr 2020
In reply to UKC Articles:

Whist is a great way to spend the lockdown

In reply to biscuit:

Yes of course the nature of the article has to be brief and to work for the majority and miss the more in-depth info. But my response was more about my experience with low loads which is what most articles online promote, and I thought there was a lack of mentioning the benefits of high mechanical loads and therefore that's why I commented, for the benefit of others who might ended up in many dead roads like myself. 

Why I meant on my last line, poorly explained, was that from my experience talking to a lot of climbers and professionals is that there seems to be a wide range of (low-load) interventions (therabands, low weight eccentrics, supinations, therabars, arm-aids, Randalls stretch for golfers...) that climbers attribute to their success to recovery. However that might just be a combination of accepting that the elbow needs attention and the consequential awareness, stopping aggravating elements and some of the exercises (if they correctly prescribed as you say). But that can be hit and miss depending on what specialist you talk to. I've done protocols for up to 3 months that were a waste of money and time. I've also amassed a collection of useless contraptions in the process.

I'm not a professional by any measure, but I just have to disagree with you that an ultrasound at an early stage is not advised. I'd probably say it might not be necessary for the vast majority of cases, but for those that the condition can complicate it can be invaluable. I for one wished the first thing I did was get an ultrasound, it would have saved me so much time and money. In fact it wasn't until I got two different scans with the same diagnosis (one by Chris Myers and the other the Hakan Alfredson) that I actually got the right answers and now I do have a protocol (tendon density training) that I'm finally seeing some progress with.

This is by no means a criticism of your article, but I've taken the opportunity of this article to give a side-note based on my experience that the general advise doesn't always work for everyone. 

1
 biscuit 08 Apr 2020
In reply to Ramon Marin:

And they are all very fair points Ramon. I didn’t take them as criticism and my response was just to explain why I hadn’t been able to write all I wanted. 
 

I’m glad you got there in the end, even if it did take a long time for you. 

 biscuit 08 Apr 2020
In reply to owensum:

Doh!

I’ll try and get that corrected. 

 Mike Nolan 08 Apr 2020
In reply to UKC Articles:

Great article Andy! Hope you're well. 

Mike

 biscuit 08 Apr 2020
In reply to Mike Nolan:

Cheers Mike. We’ll have to get out, whenever we can. Fancy some South Lakes lime? Chapel head may be open by the time we’re allowed out. 

 Tim Rodgers 13 Apr 2020
In reply to UKC Articles:

Hi Andy, as a sufferer of both tennis and golfers elbow in the same arm would you say the same rehab applies, ie. will the exercise loading for tennis elbow irritate the golfers tendon?

 dunnyg 14 Apr 2020
In reply to Tim Rodgers:

Also interested in Tims question...

 biscuit 15 Apr 2020
In reply to Tim Rodgers:

Hi Tim,

the loads on the opposing structures shouldn't be enough to flare them up. It's not uncommon to get it in both.

Doing it this way (with manually applied resistance) means you can alter it infinitely to suit. Give it a go and see what happens. If you do find one side more sensitive then treat that one first until it's settled enough to bring the other in.

Hope that helps. If you want any further info just drop me a line (free!).

Andy


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